You are here: Home / Archives for private practice

Thinking, and Just Thinking

March 20, 2012 by 5 Comments

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

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

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

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

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

They listen and say they’ll think about it.

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

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

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

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

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

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

Filed Under: Gamer Therapy Tagged With: , , , , , , , , , , , , , ,

Why Therapy Is Like A Game

February 25, 2012 by 15 Comments

Game-playing often has negative connotations in the field of psychiatry.  We have all sorts of erudite ways of describing what laypeople call “mind games.” A great example is in the language of Axis II personality disorders.  People are borderline, dependent, avoidant, narcissistic, antisocial, and the most FABULOUS of them all, histrionic.  These words attempt to describe the psychological conditions which motivate problematic behaviors.  Serious business indeed.

But come right out and say that therapy is like a game, even a kind of game, and that gets a lot of hackles up.  Therapy is serious business, and games are anything but serious, right?  Wrong.

To describe something as a game is not to minimize it or take it less seriously, but I suggest to describe what Bernard Suits calls the “lusory attitude.”  This is the state of mind, the psychological attitude, required of any player when they play a game.  The most succinct way Suits describes the lusory attitude is to say that it allows the “voluntary attempt to overcome unnecessary obstacles”

An example of this, not mine originally, is that of golf.  The activity is directed at achieving the goal of getting a ball into a hole.  But instead of just creating an activity where we find a ball and drop it into a big hole, we take the hole, make it small, say you can’t use your hands to drop the ball in but must use a metal club, and start you off hundreds of feet away from the hole.  That’s golf, and it is so full of unnecessary obstacles!  There is no reason to make it so challenging, EXCEPT that that challenge is what makes it fun, and frustrating, and more fun.  And nobody drags you into the wilderness, gives you a golf club and points a gun at your head to golf.  It is a voluntary act.  People love to, choose to, spend hours with sticks hitting balls from great distances with the hope of getting them into little holes.  Why choose to do something so weird and difficult?  Because they are playing.  They have voluntarily attempted to overcome unnecessary obstacles.  They have adopted a lusory attitude.

Life is hard.  And for many of therapy patients, life has been extremely hard, and cruel.  And yet, how often do we notice that they are making life even harder on themselves in some ways?  Perhaps unconsciously, perhaps subtly, but more difficult nevertheless.  That neurosis, the reenactment of the past, is what I would suggest is the unnecessary obstacle.

For example let us take PTSD-precipitated by child abuse.  The abuse was serious, hurtful, sadistic, real.  It happened.  But in the case of the adult patient, the abuser is no longer there.  The introjects, the learned stuff, the unconscious stuff, that is all there, but the perpetrator has fled the seen of the crime long ago.  They were real obstacles, but trauma recreates them as unnecessary obstacles in the here and now.

Another example would be a phobia.  Why not be fearful of everything?  Spiders aren’t the only thing that we could fear:  There’s death, and hurricanes, and black cats, and dirt, and blindness, and the next presidential election.  But we don’t fear everything in the world that is or is perceived as harmful to us.  Phobias are very specific, that is why there are so many clever names for them.  They are again, unnecessarily specific obstacles.

Again, I want to stress that by calling these unnecessary obstacles that I am not at all saying that phobias or PTSD or not serious, painful, debilitating, conditions.  What I am saying is that they are unnecessary to the life of the patient.  Even as compromise solutions they have outlived their usefulness if the patient is in the here and now experiencing distress as a result of trying to defend against or cope with the past encroaching on their present.  The repetition compulsion is a game of both danger and optimism.  We do the same things over and over, often with disastrous results, true; but we keep doing it because on some level there is an urge to get it right.  And like a video game, the repetition compulsion doesn’t just get defeated one day; rather we get progressively further in the game, acquire new levels and skills.

When our patients arrive at our office, they are in a state of lusory attitude, they are really trying to resolve the problems the best they can, and they have sought out our help to that end.  If they are mandated to treatment, this is less likely to happen.  But for a majority of patients, they choose to show up.  And from a psychological point of view, showing up must be voluntary for therapy to work.

In order to do therapy, we also have to adopt together a lusory attitude.  Both therapist and patient volunteer to work together to overcome the unnecessary obstacles.  The therapy time and space are in some ways unnecessary obstacles: we choose to limit the session to the 45-50 mins, in a specific office, with only two “players” if it is individual therapy.  These may be the warp and woof of therapy but they are also arbitrary distinctions that create unnecessary obstacles.  We could rotate different therapists in, or meet for varying times whenever we both want, and hang out at Dunkins, but that would be therapy in the sense we are talking about would it?  No, therapy, like games, must have agreed-upon rules.

Although I’m speaking in clearly psychodynamic terms here, doesn’t it seem that more behavioral approaches would find the concept of lusory attitude applicable as well?  Surely we don’t try to extinguish behaviors we think are necessary.  The behavioral approach also implies that the obstacle (behavior) is unnecessary and tries to over come it.

Having a lusory attitude is not always about being lighthearted, although it can be, but it is about taking play very seriously, engaging in it and often having an immersive experience.  Psychotherapists who engage in play therapy with children often have an easier time understanding this than those who do adult psychotherapy.  There is a general tone from our profession of, “we need to be taken seriously,” which I think has lots of its roots in the tendency of the medical profession in the past to have considered it less important.  And somehow being taken seriously becomes equated with being important or being valuable.

I often supervise interns who repress any sense of enjoyment that comes from making an interpretation that moves a patient forward, or seeing theoretical elements manifest in the treatment, and try to help them see that enjoying the process of learning psychotherapy and learning about the patient is not the same as having fun at her/his expense.  As Sutton-Smith says, “The opposite of play isn’t work.  It’s depression.”  In this regard I agree with him:  When engaging in a lusory attitude with patients we are working with them.  Removing those obstacles is very hard, dangerous work, and it is deeply and seriously playful.

To add gamers and video games into the mix, I would suggest that approaching video games as an addiction is a step in the wrong direction.  This is not to say that I don’t think that some people play video games to the detriment of their lives and relationships.  I do think that happens, just like I think people engage in a number of activities at times to the detriment of their lives and relationships.  But to label them as pathological is to miss the point.  Even if we rule out the cultural incompetency of the clinician around video games which often masquerades as dismissal or villainization, we need to understand that we are in essence asking the patient to adopt the same lusory attitude with us that is often there already for them with video games.  We are saying, “don’t play that game, play this game of therapy instead.”

(Unless you have this view of psychotherapy:

 

Psychotherapy needs to stop taking the lusory attitude for granted.  What if we became more mindful of our lusory attitude?  We all have them, over coffee with a colleague when we look at each other and say, “this is such a weird profession!”  It’s like golf in that respect, it seems; so intricate and complicated with rules we take for granted that make a particular human relationship much more complicated than it has to be.  Try that on the next time you are trying to discuss your fee with someone:  “I charge you $150 an hour because this is a weird relationship that has intricate rules and is much more complicated than human relationships have to be.”

I think that there are strong parallels between therapy, neurosis, and games, and that the thread that links them together may be the lusory attitude.  In games, the design always boils down to a voluntary attempt to overcome and unnecessary obstacle.  In neurosis, the attempt to repress intolerable conflicts and feelings creates an unnecessary obstacle even as the patient tries to remove the unnecessary obstacle of those same conflicts and feelings.  (Game designers may recognize an interesting resemblance to the concept of iterative design here.)  Finally, in therapy, the neurosis or symptom becomes the unnecessary obstacle that the therapist and patient voluntarily attempt to overcome.

What do you think?  Does this jibe with your experience as a therapist, patient, gamer or game designer?

 

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

Filed Under: Gamer Therapy Tagged With: , , , , , , , , , , , , ,

When They Hate You.

February 22, 2012 by 5 Comments

Many therapists I work with dream of expanding their practice to being a consultant and presenter. In our initial appointments they ask me with a lot of excitement about my experience doing these things. And I am usually very positive and optimistic about it. But although I am “living the dream,” there are many rude awakenings along the way.

One such awakening came this week when I received my evaluations back from a recent talk. Out of the 760 people who attended, 566 of them did evaluations. It isn’t often that I have a chance to get feedback from 566 colleagues at once. What struck me is how I tended to react to them and how I had to fight the urge to focus on the negative. If 535 people rated me as good or excellent, my eye was drawn more often to the 2 “poor” ones. No matter that .35% is a really small percentage, that fraction of a percent that delivered a poor rating was hard to overlook.

The comments were even more challenging, as I noticed that my eyes flew over comment after comment describing me as interesting, great, edgy, fresh, thought-provoking, relevant, a gem, and passionate. But boy did they stop when I read this: “His bias towards media enraged me,” or this: “Seems like he has a chip on his shoulder, perhaps because he was told he had poor social skills.”

Ouch.

Would-be presenters please take heed. When you put yourself out there, people will take shots at you. This will hurt, even when it is a fraction of a percent. Part of what hurts is the asynchronous and anonymous nature of these comments, because you have little recourse to respond, correct an error you may have made, or just plain defend your point of view. But if you want to do public speaking, you’ll need to get a thick skin.

Part of why you need a thick skin is to allow for the accurate appraisal of your work. Here’s how I do it:

I divide the critical comments into one of three categories: Absolutely Useful, Fair Enough, and No ROI.

  1. Absolutely Useful: These comments are ones that don’t make me defensive, where I can imagine myself saying to the person, “absolutely.” An example of this kind is “it was somewhat difficult to follow along in the booklet because he seems to have changed the order of slides.” This comment was extremely useful, as I can put more emphasis in my prep to not change my slides at the last minute. This is an easy fix, and will benefit the audience.
  2. Fair Enough: These comments do make me a little defensive, but there is some benefit in spending time to acknowledge or address them. I can imagine myself saying “your point is well taken, however…” For example the comment “limited research” is fair enough. Your point is well taken, however I was only allowed 45 minutes to present, and needed to choose from my copious slides only 60. Another commentator expressed that they wished I had spoken more about the impact of violent video games and how they are a problem. This is fair enough, however there are plenty of places people can get that information or misinformation, and few places that they can get my take. What I can take from these comments are points to consider weaving in or addressing when there is more time.
  3. No ROI. These are the comments that are clearly ad hominem arguments. A good clue is if they hurt my feelings or make me feel extremely defensive. “Seems like he has a chip on his shoulder, perhaps because he was told he had poor social skills” is an example of this sort. There is little return on investment of time or energy I should expend on this. Who knows why a person would think that comment would help anyone, but more importantly, how would it help make a presentation’s argument more effective? These need to be set aside ASAP to focus on more helpful comments.

The irony is that the most useful comments are usually not the ones that are extremely validating or invalidating, but matter of fact, like the slide order comment. The job of a presenter is to become a better presenter. Whether you like the information and opinions I present is none of my business really, my job is to present it.

In my opinion, part of what makes a person an effective speaker is also bound to make them hated: namely, their passion and conviction. Of course I am biased, of course I think that my point of view is important. Would you really want me up there talking about things I don’t feel or think strongly about? At an old internship of mine a colleague once asked me, “have you ever been hated by somebody?” At the time I thought I hadn’t, and said so. “That’s too bad,” she replied, “It’s very defining.”

Since then I have come to realize that I, like most of us, have in fact been hated. Merriam Webster defines the noun hate as “intense hostility and aversion usually deriving from fear, anger, or sense of injury.” People are hated because they are black, or white; LGBT or straight; rich or poor; Nazi or Jew. In everyday affairs we like to pretend this is not true, and when we do so it is crazy-making. It is often a bittersweet relief to a patient when we say, “you weren’t crazy, you really were experiencing hatred.” Finally, someone told the truth.

When I present about technology and video games, I speak out explicitly or implicitly about adultism. This comes across when I challenge people around the concept of screen time. One very prescient member of my audience stated that my message seemed to be focused on changing adult behavior, not child behavior. Bingo.

When it comes to gaming, technology, and education, we need to take a good hard look at how adultism is implicit in many of our practices. We think we know better than our youth, and we think we know better than they how they should spend their time. Back in grade school, well-meaning adults decided that my time would be better spent memorizing multiplication tables, drilling them into my mind, giving me A’s for knowing them. Yet, now I live in a world where I am never more than few feet away from my phone, laptop, or dedicated calculator, and I have to question whether that time couldn’t have been spent better learning other things. What we are taught as important is bound by the history and culture of the adults in power at the time, and it isn’t always a good thing. In retrospect, I’d have been more prepared for life if I’d learned about the subjugation of indigenous people in school rather than drawing hand turkeys.

So if you are passionate about something, it will give you the passion to devote time and energy to it, go above and beyond the workaday life that we often lead. But it will put you out in front of people who don’t agree with you, see you as a threat to what they believe as good and true. You will be hated. You will get tired and hurt and frustrated. And when that happens I recommend that you take some solace from loved ones and friends, and then get back to work.

Some posts, like this one, are written for me as much as for my colleagues and consultees. We all get discouraged and need to be reminded that we are choosing to strike a blow for freedom in whatever path we choose. But I want to give the last word to one of my commentators, who said exactly what I need to hear when I have moments of flagging confidence and doubt: “Mike’s presentation changed my outlook on technology in my professional and parenting roles. Thank you so much, from a FORMER technophobe!!”

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

 

Filed Under: Gamer Therapy Tagged With: , , , , , , , , , , , , , ,

Protect Your Online Privacy: Start Blogging!

February 9, 2012 by 8 Comments

Many therapists have lamented about the lack of privacy the internet has created.  More to the point in my view, the internet has taken away the veil of secrecy psychotherapy has frequently sought refuge behind.  It used to be that the anonymity of large urban areas, or the possibility of a commute to the suburbs insulated therapists from their patients after the analytic hour came to a close.  I friend of mine once went for years before discovering that Therapist A, who had referred him to Therapist B when treatment was stymied, was actually married to Therapist B.  They did not share last names, but my friend in a moment of high curiosity and low impulse control drove over to Therapist A’s home address and discovered Therapist B’s name there as well.  He terminated therapy thereafter.

For myself, I learned that privacy is to a large extent illusory, not from the internet, but from my first job.  I worked in a community mental health center on a 13 mile long by 7 mile wide island which was 2 1/2 hours by boat from the mainland.  You get used to a diminished sort of privacy on an island.  I couldn’t avoid my patients if I wanted to, unless I wanted to avoid the library, most restaraunts, coffeeshops, the beach, or the one movie theater we had in the winter.  Nor could I find privacy in limiting the type of work I did there.  The Community Mental Health Center was the only one on the island.  We were responsible for, and I did, school counseling, Psychiatric hospitalizations (which involved flying with often psychotic people in a Cesna six-seater airplane,) outpatient therapy, Alcohol counseling and DUI classes, drug testing, and court-ordered counseling for domestic violence perpetrators.  I can still remember how when a colleague and I went out to dinner at a local pub one night one-third of the people at the bar left.  It wasn’t just my privacy that was affected here.

You have a choice in situations like that.  You can hide out in your house with a cat and television (which I did at first) or you can start living your life in the community and negotiate boundary crossings on a case by case basis (which I settled upon as my strategy.)  I learned to cultivate a sense of never-too-uptight-never-too-relaxed when I was in public.  It became second nature in many ways.

When I moved to Cambridge, MA, it felt very anonymous by comparison.  But as many practitioners in “The most opinionated zipcode in the US” will tell you, Cambridge is really a village in many ways.  I still ran into people, and by this time, technology was becoming more of a factor.

As Thomas Friedman has observed, “The World Is Flat” in the 21st century.  Globalization and technology have removed many of the barriers to, and some would say protections from, knowing each other.  Our patients can Google us, Yelp hangs up a business page of us whether we like it or not, and are often only one Facebook friend away from connecting with us.

Even if you want to make the poor business decision of staying off the internet in terms of a website, eventually your contributions to the Democratic Party, your address, and notes about you in your alumni magazine are still going to find their way out to the world.  We’re all on an island today.

So what can you do?  Well, my advice is to start blogging.  I know sounds counterintuitive, but it makes sense on a number of levels:

1.  Buddhism tells us to move into the places that scare you.  We exert so much energy trying to avoid things, find a spot where we can stay safe and stop the awkward and uncomfortable learning process.  And yet we ask our patients to do the exact opposite so often: to look underneath those rocks, descend into the depths of the psyche, face their fears.  Our obsessive quest for privacy is perhaps not that different.

2.  Make the internet work for you.  One of the best ways to protect your privacy is to generate a lot of content that you consciously know is public-facing.  Google “Mike Langlois, LICSW” for example.  Go ahead, I’ll wait.  What came up probably is pages of my website, professional picture, Youtube videos, and blog posts.  Dig a little deeper and you’ll see me commenting on a few blogs.  This is the practice of radical transparency.  All of that content was written with all of you in mind, my patients, colleagues, friends, family members, potential coaching clients, high school classmates, potential employers, my future children and grandchildren and the FBI.  The way Google and other search engines work, the more content I put out there that is public, the further back any unintentional pieces about me will be.  By embracing that the world is flat I have learned to cultivate a style that I can negotiate in my work life while still feeling authentic.  And it is great advertising, or fair warning, if you are considering working with me.

3.  Radical transparency protects your patient’s privacy as well.  Whether we like it or not, therapists are finding themselves on review sites like Yelp.  Yes, anyone can post a review, and no, Yelp will not taking it down if you ask.  More importantly, your patients might not understand the ramifications for their privacy or PHI if they post a review.  Keeley Kolmes has great resources on this, and you are welcome to use my version of her version as well.  Take a look:

Notice that half of my allotted space is not advertising, but a direct message to any potential commenters.  Rather than hide out and try to get Yelp to take my name down, I have used it as a platform to market my business, model what I feel is ethical professional standards, and provide some information to patients in the spirit of informed consent.  Do I want to get bad reviews?  Of course not, who does?  But that is not an excuse to hide my head in the cybersand.

4. Last, but not least, get over your bad self.  Sometimes listening to our colleagues you would get the feeling that they are dealing with the paparazzi, not the public.  Sure patients and others may be curious about your life, but really most people in the blogosphere just aren’t that interested.  On a good day, my blog gets 200 views, on an amazing day last August I got 689 views.  There are 7 billion people on the planet.  Feel free to correct my math here but according to my calculations that means on a busy day 0.000009842857142857142% of the people on the planet are checking out my most visible presence on the internet.

Am I saying you should blog for the sake of blogging? No.  I am saying that there is a Copernican revolution going on in the 21st century, and therapists need to join it.  Rather than avoiding technology and the internet we need to start understanding it and harnessing it.  You can be googled whether you like it or not.  Yelp doesn’t care about contaminating your transference.

Being professional is about how we rise to the occasion of Web 2.0, not deciding to skip out on the party.

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

Filed Under: Gamer Therapy Tagged With: , , , , , , , , , , ,

How To Get An Epic Supervisor

January 25, 2012 by 6 Comments

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

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

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

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

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

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

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

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

3. Do your research

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

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

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

4. Know what is important to you

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

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

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

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

No, you may not.

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

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

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

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

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

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

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

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

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

7. Kick the tires

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

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

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

 

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

Filed Under: Gamer Therapy Tagged With: , , , , , , , , , , , , , , ,

Money: The Post You Don’t Want To Read But Should

January 7, 2012 by 8 Comments

First off, not only am I not a financial advisor, an economist or an accountant, I have never been the poster-boy for “financial whiz.”  I say this out of neither pride or shame, but for two other reasons.  First, as a caveat to the reader that all of this is based on personal learned experience and therefore as limited as it is true for me.  And second, because if I can do this, I think you can too.

Money is the Achilles heel of many therapists.  We are averse to think about or speak aloud about it, and we come by this aversion honestly.  At least in the US, we are raised and educated without a single class or course in financial planning or money management.  Ask yourself, what subject have I ever learned about in life that I avoided thinking or talking about?  But in the case of finances, many of us emerge into adulthood with huge blind spots about how to function in a capitalist economy and society.

In my coaching and clinical supervision with therapists, and in my talk with colleagues, I have heard some amazing examples of these blind spots.  I once heard a colleague justify not charging a patient for a missed appointment because if she has to miss an appointment the patient doesn’t charge her!  These statements bely an ambivalent and confused statement about money.  Patients are hiring us, we aren’t hiring them.  As uncomfortable as this assymmetry is, the fact is that we don’t pay patients to help us and they do pay us to help them.

I have launched into general diatribes before, but today I want to be really specific and concrete.  I want to share with you one pointer I share with all my coaching clients about how to make more money and how to manage it better.  I’m even going to give you a specific vendor link.

The pointer is this, if you want to make more money, take a look at the bank you’re using.  Making money isn’t just about your fee or caseload, but the fees you may be paying out.  (I know, some of you who’ve made it this far are already getting ready to click away, hang in there.)  One of the things large banks have is large overhead.  They are, for reasons too numerous and obvious, in a lot of distress these days.  For example, Consumer Reports estimates that the government legislature that required them to cap their fee each time you use your debit card at 24 cents a transaction is going to cost banks 6 billion dollars in revenue lost.  So to recoup their losses, they are finding other fees to levy on you that are legal.

What banks are banking on is that we’re afraid of change.  And let’s face it colleagues, most of us want to find a place to “park” when it comes to money management.  We want to find the fee we can set and not look at again rather than adjust it over time.  We want to program our billing into computers or contract it out to services so we can not deal with it.  And we don’t want to compare interest rates and fees, but rather find a bank and stick with it.

And the larger banks don’t just gouge you with fees, they use you in another way.  Maybe you’ve noticed that when you do use your ATM or the bank website advertisements come up that are eerily resonant with what you spend your money on.  This is because banks value your patronage for data mining purposes as well.  Many of them are selling this data to big business.  I am often struck by the irony that a profession which values privacy and confidentiality for our patients turns a blind eye or accepts the violation of their own financial privacy.  So if nothing else, do a little research about whether your bank sells your debit transaction or other data, and if they do, move.

Since 2009 I don’t think I have set foot in a bank to do actual banking.  The last time I went in the building was to have something notarized.  By the same token, my deposits have become much more quick and efficient in my business, and my fees have been minor.  Why is this?

It is because I use an online credit union, Digital Federal Credit Union in fact.  DCU is a completely full-service credit union with the emphasis on online banking.  This is not surprising since it began in 1979 as a charted credit Union for Digital Equipment Corporation.  The eligibility requirements are not at all onerous, in fact your interest in social justice can make you eligible.  I say this because my eligibility came from being a disability rights ally.  I joined the American Association of People with Disabilities.  That was it:  Fifteen bucks to a great cause and I was eligible to join DCU.

As an online credit union, DCU is actually more portable than my licensure!  I can move to any state, bank from any state, online.  Their technology and website are in my opinion excellent.  I can transfer funds easily from my account to other family members’ accounts at DCU, and interbank exchanges are almost as easy.

They have a great bill-paying feature that allows me to schedule payments electronically, either one-time or recurring.  The bill-pay feature has also been a lifesaver for me when I need to dispute something with a vendor or track how much I have spent on utilities for my practice or home in a given amount of time.

And at tax time, house closing, or any other time you need financial documentation quick, DCU allows me to download check images, statements, etc. into PC files.  Or if I am trying to sort my expense deductions for the year I can import the entire tax year into an Excel or other software spreadsheet to sort, locate, and calculate expenses.

But the thing about DCU that makes me go absolutely blissful is their iPad and iPhone app, because it allows me to take photos of checks and deposit them from my office, living room, wherever there is, well, the internet.  No more hoarding checks to make a trip to the bank, no more waiting in lines at the bank.  In fact, I often do my deposits late at night or on weekends, because banking hours aren’t really an issue.

Think about all the time you are spending, which is money you’re spending, on your banking.  Do you spend 30 minutes running to the bank each week?  That’s time you could see a patient.  Is your income stream stuttering because you avoid depositing check until you have to?  And clinically, what message(s) may you be sending your patient that you haven’t cashed their check yet?  If you want to be a better therapist, get better with your money.  And if you want to get better with your money, use an online credit union.

Oh, I have lots of thoughts and opinions on how to use technology to improve your therapy practice clinically and financially, maybe you want to work with me online or in person?

 

 

Filed Under: Gamer Therapy Tagged With: , , , , , , , , , ,

Occam’s Oyster

December 7, 2011 by 2 Comments

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

You are not an oyster.

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

 

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

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

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

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

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

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

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

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

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

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

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

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

Filed Under: Gamer Therapy Tagged With: , , , , , , , , , , ,

Not All Failure Is Epic

December 4, 2011 by 5 Comments

In gaming there is a concept known as the “Epic Fail.”  Roughly translated this means, a failure so colossal, so unbelievable in its nature, that it will go down in history as epic.  Epic failure can be extremely frustrating in the moment, but is almost always funny in retrospect.

Recently I was playing Dark Souls, and I was trying to down two bosses known as the Belltower Gargoyles.  Just as you get one down to half health, the other, who likes to breathe fire on you, shows up.  Oy.  I kept getting killed, which sent me back to a save point, running back up the belltower, and trying again.  What kept me going up there was that each time I was surviving a few seconds longer, and each time I was getting the gargoyle’s health down a little more.  At one point I started to consistently kill the first gargoyle before the second one finished me off.  Finally, through an unbelievable feat of mashing all the buttons, luck, and strategy, I beat them both.

The failure that kept happening was not what I would call Epic Failure.  It was certainly what Jane McGonigal et al call fun failure though.  It was failure with just enough progress mixed in that I’d say, “Oooh, you’re going to get it,” to the gargoyles and try again.  And again.  Fun failures in video games are designed to work that way.  The game can’t be so hard that the person gives up, but can’t be so easy that you don’t feel challenged.  Because if you don’t feel challenged then there is little or no sense of accomplishment.

Heinz Kohut, one of my favorite psychoanalytic thinkers, would probably have a lot to say about video games if he were alive today.  Kohut knew that failure was a part of life and human development.  In fact, he thought that therapy was full of failure.  He talked about empathic failure, when the therapist fails to respond empathically to the patient in some way.  Maybe we don’t pay attention enough to a story, or don’t remember something, or start 5 minutes late.  These are all parts of the therapist being human, and therefore being unable to stay absolutely in empathic attunement with the patient.  This kind of failure is inevitable.

Kohut goes on to say that it is not necessary to deliberately make mistakes and empathically fail our patients, because we are going to do so naturally in the course of our work with them.  In fact, to deliberately fail our patients is rather sadistic.  But usually we aren’t being sadistic when we forget something, or run late a few minutes, even though the patient may experience it that way.

So first a note to therapists here.  In the course of your work with patients you are going to fail a lot.  But not all failures are epic.  That is not to say that your patients won’t experience it that way.  That vacation you’re going on may be an epic failure on your part, as far as they are concerned.  Does that mean you cancel your flight plans?  Of course not.  Our job is initially to help the patient by understanding by empathy the epic nature of our failure from their point of view.  We try to imagine ourselves into that moment they are having.

But that doesn’t mean that we stay there.  We need to maintain some perspective, have some sense of fun failure, to keep doing our work.  By that I don’t mean have fun at our patient’s expense, but rather be able to be lighthearted enough in our introspection to say “Oops, I missed that one,” or “there I go again.”  If we can do that we are able to then refocus on the patient.  If we instead get sucked into the idea that this is an Epic Fail we will lose all perspective, and actually start focussing on ourselves rather than the patient.

Do you ever say to yourself, “I’m such a bad therapist?”  I don’t.  Of course, I also don’t say, “I’m such a perfect therapist” either.  I do frequently think, “I was not at my best today,” or, “oooh, how come I keep missing that with patients!”  This helps me keep perspective so that I can get back in the game as soon as possible.

Whether you are a therapist, a gamer or someone else who is still breathing, chances are that you are failing sometimes.  In fact, this time of year with all its’ hype and expectations about being joyful and loving families can make you feel even more like a failure.  Some examples of Epic Fail statements that we think consciously or unconsciously include:

  • I’m a terrible parent.
  • I’m a terrible daughter/son.
  • I’m a terrible sex partner.
  • I’m a terrible worker.
  • I’m a terrible cook.
  • I’m a terrible student.

and the list could go on.

If any of those sounds like you, take a moment to reflect.  Is this really an Epic Fail?  Or are you distorting things?  Chances are you are not a perfect parent, child, worker, sex partner, student or anything else.  But if you really identify this as an Epic Fail, chances are you are solidifying a form of self-identity rather than accurately appraising yourself.

Why would we do that?  Well, one reason is that we learned those messages of Epic Failure as a child.  You probably still remember a few failures that can make your stomach churn if you think of them.  But as often, I think we grasp on to solid identities, even negative ones, so we can stop working on ourselves.  I’m just X, I’m the kind of person who can’t Y, Nobody ever thinks Z about me:  These all kill our curiousity about ourselves and help us stay stuck.

Mindfulness is about fun failure.  It is about being able to look at ourselves and reflect on ourselves without going to extremes.  Mindfulness is about being able to be curious rather than judgmental, having roominess in our minds and souls rather than rigidity.  This perspective leads to “Ooooh, I’m going to get that boss down this time.”  The other leads to hopelessness.

So try to remember this as the days are getting shorter and tensions may be rising:  Not all Failure is Epic.  And if we can be right-sized about our failures we can learn from them.  We can take an interest in our thoughts, feelings and behaviors rather than judge ourselves.  If we catch ourselves saying “what kind of monster I must be to hate Aunt Myrtle,” we can perhaps think, “oops, there I go again. Isn’t it odd/interesting that I feel hatred towards Aunt Myrtle, what’s THAT about?”

Eighty-five percent of the time gamers are failing.  And yes some of those are Epic, but the gamer attitude is to view those Epic Failures as moments of camaraderie and learning.  In life outside the game, do you treat the Epic Fail that way?  Do you seek out others and try to learn from the experience, or do you isolate?  There is always some observing ego in the game Epic Fail that is often lacking in our non-game life.  And in some ways that is understandable, you can’t always reset in life outside video games.

But consider this:  Where there is life there is hope.  If this was a true Epic Fail in your life you can still learn from it in time.  Failures are inevitable, but with time and perspective they can be instructive as well.  In the end I’d say that whether you think you’ve had an Epic Failure or not what matters most is how you move on from it.  Who knows, maybe the only real Epic Fail is the one where you give up..

Note:  No real Aunt Myrtles were hated in the writing of this post.

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

Filed Under: Gamer Therapy Tagged With: , , , , , , , , , , , ,

Skyrim, Stealing & Sadism

November 28, 2011 by 13 Comments

If you have been a therapist for at least, oh, say three months, you’ve probably had a conversation with a patient who steals. Sometimes it is mandated counseling as a result of a criminal charge or EAP referral; sometimes it is the confession of shoplifting. But if you haven’t talked about stealing yet, chances are you haven’t asked.

Stealing is always a metaphor and enactment. It may be other things as well, a means of survival, an indication of impulse control: But for the patient it always means something consciously, preconsciously or unconsciously. (If you don’t believe in the existence of the unconscious, why are you reading my blog?? No good can come of it.. 🙂 ) Sometimes the stealing is a symbolic expression of the desire to possess something that one feels was stolen from one: for example, a survivor of sexual abuse who steals toys to express the experience that her childhood was stolen. Sometimes it is to express the fear of being deprived; for example someone who steals and hoards food or clothing. I’m sure you could come up with plenty of examples, but let’s move on and discuss it in terms of narcissistic rage.

The difference between anger and narcissistic rage, according to some psychoanalytic thinkers like Kohut, is time and revenge. If a situation makes one angry, it usually has a short time span, and little to no accompanying desire for revenge. If a narcissistic injury occurs, the accompanying rage can last for a lifetime, as can the accompanying desire to have vengeance upon the person responsible. We experience both forms of feeling in our lives, and I’d say they’re different rather than better or worse for someone. And both are very useful sources of information about a patient’s inner world.

Skyrim is the latest video game in the Elder Scrolls series. This much-anticipated game has shipped 7 million copies worldwide its first week garnering $450M. Within the first 24 hours 280,000 PC players were downloading it, and within 48 hours Bethesda reported 3.5 million copies sold. It is looking to be one of the most popular video games this holiday season, if not Game of the Year.

Skyrim is a single-player game, not an MMO, but one of the things that makes it impressive is its scope, which is closer to MMO games than traditional single-player games. It has an immense game world, the province of Skyrim, and has an open-ended quality to it, in that you can play the game to your heart’s content without ever completing the main quest line. There is a main story, but you can choose to ignore it, and focus on doing other things. There are side-quests to train at Mage or Bard College, there are achievements to unlock and crafts like mining and smithing to learn.

And then there is stealing.

In Skyrim, there are lots of things lying around for you to take. If they are in a cavern or the world at large they are usually loot. But go inside someone’s shop or inn and you’ll see in red the option to steal them. If you do steal something, you may get caught or not. You may get caught and persuade the guard to let you go. You may get thrown in jail and forced to pay bail. Or you may get killed. The same applies to any lockpicking you do to break and enter someone’s real estate.

The more you steal, the higher the bounty on your head in each city gets. And each city has its own record of your crimes, meaning you can have a different reputation in each city. In fact, if your do enough criminal activity, the Thieves Guild, an invite-only thieves guild, may recruit you.

Not every video game allows for stealing, and by now some of you may be asking, “Why would anyone want to play a video game where they steal things?” Good question, let’s not dismiss this phenomenon: This game is 5th in a popular series which has consistently allowed theft in the game world, and developers don’t create and keep dynamics that nobody wants or plays. But to return to my earlier assertion that stealing is always a metaphor and enactment, we can begin to see the importance of asking our gamer patients about it in the particular, i.e., “What makes you steal in Skyrim?”

One of the advantages to taking a gamer-affirmative approach with patients who play video games is that you look at the video game as meaningful, rather than as merely a symptom or pathology. Once you do that the questioning loses it’s dismissive tone, and can become a useful part of the treatment. Why does the patient or gamer steal in Skyrim? Are they acting out a loss? Are they trying on a new way of being in the world? Or are they allowing some part of themselves to be expressed in the game that they try to hide from themselves in real life?

For example, did one of Skyrim’s NPCs with their Schwarzenegger accent say something insulting to you when you went in their shop? Maybe the fact that they sound like Schwarzenneger means something to you, and you like the idea of taking some tough bodybuilder down a peg. If you feel slighted, and steal from the innkeeper to “teach them a lesson,” this is an example of narcissistic rage. Having seen this in the game, can you begin to see any connections with people in your world outside the game whom you’ve felt insulted by, whom you wish you could teach a lesson?

It is often easier to look at our sadism and our narcissistic rage in the symbolism and displacement of a dream or art. Video games, which are social media and art forms with elements of dreams, are rife with opportunities to do this. The gamer-affirmative therapist can ask if your stealing to become noticed and recruited by the Dark Brotherhood might have any connection to the rage you feel that the girls/women/boys/men in your life only seem attracted to “jerks,” not “nice guys” like you. Or do other interesting (to a therapist) patterns emerge? Do you only steal from male NPCs? Do you ever regret stealing? Does whether you steal during gameplay depend on your mood that day? Do you think it is wrong to steal from the NPC? Why or why not?

Therapists: Don’t take the excuse, “it is only a game,” because any gamer knows, in fact we all know on some level, that play is not meaningless. You don’t accidentally steal, ok wait, scratch that–you can inadvertently click on something and steal it in Skyrim, and then all hell breaks loose. But if it was an accident, did you feel anything after it happened? Do you do it again? What does this say about your learning style, or repetition compulsion?

And sometimes, people steal in Skyrim to experience a conscious, guiltless pleasure and awareness of their own sadism. In video games, like in all fantasy, we get to do things we’d never do in real life, and enjoy them. If you’re recoiling at the idea of taking a loaf of bread from a little girl in a video game, stop and reflect: Might you have an overactive superego? Might you be splitting off and disowning some sadism here? Or was Oscar Wilde wrong when he said, “One must have a heart of stone to read the death of little Nell without laughing.”

There is a reason why the Germans have the word Schadenfreude in their vocabulary: There is something archetypal about taking joy in the suffering of others. In real life it can be more problematic than satisfying for us, or it can be an ethical dilemma. But in fantasy and in psychotherapy, exploration of sadism is often meaningful and important.

Gamers might worry that talking about the joy they experience stealing from or even killing characters in Skyrim will have adverse effects on them. In one direction, you may worry that exploring these fantasies and the satisfaction you feel might demystify and ruin the game for you. I doubt that will happen, understanding the meaning of an unconscious fantasy doesn’t have to spoil the fantasy, in fact it might enrich it. Or you may worry that talking about these fantasies will be trivialized or pathologized by your psychotherapist. To that I say, if they do, perhaps it is time for you to get a new one.

Enjoy the blog? Maybe you want to write one yourself?

Upcoming Webinar!

WEDNESDAY, NOVEMBER 30th

7:00-8:00 PM EST online

Blogging for Therapists

Are you considering writing a blog? Whether it is for marketing your practice, expressing a passion, or providing content for patients and colleagues, blogging can revitalize your work and bring many rewards. If you are looking for help focusing your posts, deciding what level of personal disclosure works for you, or looking for some tech tips to get started, this introductory webinar is just what you need. Email me to sign up today.

Filed Under: Gamer Therapy Tagged With: , , , , , , , , , ,

Dopey About Dopamine: Video Games, Drugs, & Addiction

November 8, 2011 by 23 Comments

Last week I was speaking to a colleague whose partner is a gamer. She was telling me about their visit to his mother. During the visit my colleague was speaking to his mother about how much he still enjoys playing video games. His mother expressed how concerned she had been about his playing when he was young. “It could have been worse though,” she’d said, “at least he wasn’t into drugs.”

This comparison is reminiscent of the homophobic one where the tolerant person says, “I don’t mind if you’re gay, as long as you don’t come home with a goat.” The “distinction” made actually implies that the two things are comparable. But in fact they are not.

Our culture uses the word addiction pretty frequently and casually. And gamers and opponents of gaming alike use it in reference to playing video games. Frequently we hear the comments “gaming is like a drug,” or “video games are addictive,” or “I’m addicted to Halo 3.” What muddies the waters further are the dozens of articles that talk about “proof” that video games are addictive, that they cause real changes in the brain, changes just like drugs.

We live in a positivistic age, where something is “real” if it can be shown to be biological in nature. I could argue that biology is only one way of looking at the world, but for a change I thought I’d encourage us to take a look at the idea of gaming as addictive from the point of view of biology, specifically dopamine levels in the brain.

Dopamine levels are associated with the reward center of the brain, and the heightened sense of pleasure that characterizes rewarding experiences. When we experience something pleasurable, our dopamine levels increase. It’s nature’s way of reinforcing behaviors that are often necessary for survival.

One of the frequent pieces of evidence to support video game addiction is studies like this one by Koepp et al, which was done in 1998. It monitored changes in dopamine levels from subjects who were playing a video game. The study noted that dopamine levels increased during game play “at least twofold.” Since then literature reviews and articles with an anti-gaming bias frequently and rightly state that video games can cause dopamine levels to “double” or significantly increase.

They’re absolutely right, video games have been shown to increase dopamine levels by 100% (aka doubling.)

Just like studies have shown that food and sex increase dopamine levels:

This graph shows that eating food often doubles the level of dopamine in the brain, ranging from a spike of 50% to a spike of 100% an hour after eating. Sex is even more noticeable, in that it increases dopamine levels in the brain by 200%.

So, yes, playing video games increases dopamine levels in your brain, just like eating and having sex do, albeit less. But just because something changes your dopamine levels doesn’t mean it is addictive. In fact, we’d be in big trouble if we never had increases in our dopamine levels. Why eat or reproduce when it is just as pleasurable to lie on the rock and bask in the sun?

But here’s the other thing that gets lost in the spin. Not all dopamine level increases are created equal. Let’s take a look at another chart, from the Meth Inside-Out Public Media Service Kit:

This is a case where a picture is worth a thousand words. When we read that something “doubles” it certainly sounds intense, or severe. But an increase of 100% seems rather paltry compare to 350% (cocaine) or 1200% (Meth)!

One last chart for you, again from the NIDA. This one shows the dopamine increases (the pink line) in amphetamine, cocaine, nicotine and morphine:

Of all of these, the drug morphine comes closest to a relatively “low” increase of 100%.

So my point here is twofold:

1. Lots of things, not all or most of them drugs, increase the levels of dopamine.

2. Drugs have a much more marked, sudden, and intense increase in dopamine level increase compared to video games.

Does this mean that people can’t have problem usage of video games? No. But what it does mean, in my opinion, is that we have to stop treating behaviors as if they were controlled substances. Playing video games, watching television, eating, and having sex are behaviors that can all be problematic in certain times and certain contexts. But they are not the same as ingesting drugs, they don’t cause the same level of chemical change in the brain.

And we need to acknowledge that there is a confusion of tongues where the word addiction is involved. Using it in a clinical sense is different than in a lay sense– saying “I’m hooked on meth” is not the same as saying “I’m hooked on phonics.” Therapists and gamers alike need to be more mindful of what they are saying and meaning when they say they are addicted to video games. Do they mean it is a psychological illness, a medical phenomenon? Do they mean they can’t get enough of them, or that they like them a whole lot? Do they mean it is a problem in their life, or are they parroting what someone else has said to them?

I don’t want to oversimplify addiction by reducing it to dopamine level increase. Even in the above discussion I have oversimplified these pieces of “data.” There are several factors, such as time after drug, that we didn’t compare. And there are several other changes in brain chemistry that contribute to rewarding behavior and where it goes awry. I just want to show an example of how research can be cited and misused to distort things. The study we started out with simply found that we can measure changes in brain chemistry which occur when we do certain activities. It was not designed or intended to be proof that video games are dangerous or addictive.

Saying that something changes your brain chemistry shouldn’t become the new morality. Lots of things change your brain chemistry. But as Loretta Laroche says, “a wet towel on the bed is not the same as a mugging.” We need to keep it complicated and not throw words around like “addiction” and “drug” because we want people to take us seriously or agree with us. That isn’t scientific inquiry. That’s hysteria.

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

Filed Under: Gamer Therapy Tagged With: , , , , , , , , , ,
« Previous Page
Next Page »