You’re The Reason Building Your Business Is So Hard


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

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

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

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

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

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

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

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

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

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

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


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What It Means To Make A Referral

referral cartoon

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

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

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

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

Please accept my invitation below. Thanks!

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

That’s not how you make a good referral.

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

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

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

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

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

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

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

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

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

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

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

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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.

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

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

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

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

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

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

They listen and say they’ll think about it.

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

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

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

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

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

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A Tale of Two Conferences

Many consultees ask me how to get speaking engagements, and certainly that’s an important question.  But this is also not the most important question.  It is akin in many ways to the conversations around the question, “How do I get a job?”  The focus is often too much on how to make a good impression on the interviewer, how to present as a good fit for the workplace in question.  If you are only asking those questions and wanting to be a successful entrepreneur, I suggest you are barking up the wrong tree.

Because the questions that are equally important, if not more important, are the on the surface the less humble and self-effacing ones:  Do I want to work for this person interviewing me?  Would I enjoy this work environment?  Are these people making a good impression on me?  These are the questions which come from the perspective that you are a valuable commodity, and that perspective to a large extent needs to come from within.  And let me be clear, not all workplaces, even those who purport to be empowering, want you to approach them from that perspective, because it lowers their bargaining potential when money (there he goes again with the money!) questions arise.

So too with public speaking engagements.  There needs to be at least a sense of mutual value, mutual ROI that has to come from the speaker and the speaking engagement.  Let me give you an example:

I am doing in the next year an engagement with conference A and conference B.  Conference A approached me with a request, because they had had a personal referral to me.  I will be speaking to a group of several hundred people at an event where I am one of several presenters.

Conference B sent out a general call for presenters and ideas.  Several years running I have been nudged by some of the folks in charge to apply to present, so this year I did.  Again, the conference will have an attendance of several hundred people and I will be one of several presenters.

Neither conference A nor conference B have an honorarium, but that is acceptable to me for a couple of reasons at this point in my career.  One reason is that I now allot one pro bono presentation per month.  But the other reason is that there is some clear ROI in both conference A and B:  I will get exposure which leads to more paid speaking engagements; I will have a venue to make my book available for sale; and I will get my pro-gaming, pro-tech message out.

So far, so good.  I should add here how both Conference A and B frequently include language in their letters to me about how valuable my contribution is and how much they appreciate me.  But over the past few months I have received communications from both conferences that show how different they are in their attitudinal stance towards speakers.

Conference A sends me a paper letter with the details of registration for the conference.  I am given the name of a specific person who handles presenter registration, told I am welcome to attend the entire conference for free and invited to a special luncheon for presenters on the day.

Conference B sends me a registration form, offers me a discount, and lets me know that they can only “give” me free admission to my presentation.


I am being given free admission to my presentation?  I’m confused.  Is the implication that normally I should be paying for the privilege of presenting my expertise, but as a special gift I get to work for free?  And are they really asking me to pay to attend a conference that I am donating my time and expertise to?

Guess which conference I will continue to work with in upcoming years?

If you guessed Conference A, bingo!  Because they have the right attitude in my opinion.  Their behavior is as valuing as their words.  It costs them virtually nothing to get the group of us presenters in a smaller room for lunch and call it a special lunch, and it costs them virtually nothing for them to give me free attendance to the larger conference.  And by assigning a specific person to handle my registration, they have made things even easier for me.  What’s more they have in a few gestures given me what Chris Brogan calls that VIP Feeling.

Conference B has done none of that for their presenters.  And think of all the value they are losing!  They could have all of us experts in the field adding to the conference beyond our sessions.  Asking questions or making comments at other presentations, networking with others, and being a free resource to other attendees at lunch, breaks and other down times.

Here is where word and deed don’t connect.  What message are you sending when you ask people to work for free and then charge them?  The irony is that Conference B will probably have some organizers who don’t understand why they end up getting a bunch of “hit and run” presenters and resent our not signing up for the conference.  It’s a lose-lose situation for everyone, and it comes from a poverty perspective, not an abundance one.

So if you want to be a presenter, please remember this:  You’re an expert in your field, act like one.  Your time is valuable and limited, and you need to set the tone for that.  Finally, pay attention to how potential presenting clients treat you.  After talking with them, do you feel like a VIP, or do you feel like Oliver Twist?

Some of the old guard have told me that this is the industry standard.  To which I say two things:

1. If that is true, the standard is wrong and needs to be changed.

2. This is one big reason why our profession is consistently undervalued and under-appreciated: Other people take our cue.

Also, someone should tell Conference A that they aren’t keeping lockstep with the industry standard by giving speakers the VIP treatment.

Oh, never mind, I’ll tell Conference A myself: Because they’ve earned my loyalty and I hope to be a presenter and attendee for years to come.


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Why Ursula the Sea-Witch is My Guru

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

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

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

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

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

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

It’s not.

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

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

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

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

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

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

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

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

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


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Save and Continue

Recently I was playing God of War III, and noticing something I take for granted much of the time, the savepoint. This is something that has become so integrated into video games that gamers hardly notice it after we discover what the particular “savepoint” looks like in the game we are playing. The saved game has been around for decades, and has become increasingly important as games have grown in length and complexity. I was reminded recently by Nancy Rappaport, a colleague and attending psychiatrist at Cambridge Health Alliance about how the concept of the saved game may not be taken for granted. I was trying to explain to Nancy during a workshop certain gaming concepts, and she was explaining that her point of reference in playing video games was Pac-Man, and in a general sense video games from an arcade setting that early on didn’t always have savepoints, where the player was asked if they wanted to “Save and Continue.”

This may be useful to remember when you are becoming frustrated with a gamer who is not as concerned with the quantitative time (bedtime, for example) as they are with the qualitative time of getting to the savepoint. But that actually isn’t what this post is going to be about. Instead I want to return to the concept of what makes an Epic Therapist here:

Epic Therapists remember the importance of saving and continuing.
To start with, therapy is in many ways a savepoint. At certain times in their lives or week our patients arrive at our office, pause, and take stock of things. In his 1914 paper “Remembering, Repeating and Working-Through” Freud alludes to this when he remarks that “In these processes it particularly often happens that something is ‘remembered’ which could never have been forgotten because it was never at any time noticed–was never conscious.” Like the savepoint in a game, the patient arrives at the place for the first time, understands how important it is to hold on to that progress, and remembers or saves it from repression. But part of what makes therapy therapy is the therapeutic frame, and at some point the session ends, and the patient goes back out into the rest of their life. They can’t just stay at the savepoint, they have to continue.

Readers have probably noticed by now that I draw frequent parallels to psychoanalytic theory and video games, and this is no exception. Our profession has a rich theoretical history that has grown from individual therapists learning from each other, disagreeing with each other, building on the prior work of each other and diverging from each other. Psychology as a field to flourish has had to frequently “save and continue” by writing these theories down in journals and now blogs, to take stock of what we have learned, but we’ve also had to move forward and continue to challenge pre-existing models. It can never be just save or just continue: To just save would stagnate our thinking and practice, and to just continue would mean we never consider thoughtfully the work we are doing.

In many ways, the problem with healthcare has been few if any savepoints, discouraging providers from taking time between patients to reflect before continuing on to the next patient. Interns in mental health agencies have many no-shows, and with no infrastructure to hold patients responsible to keep their appointments, these interns “continue” through the years where they should be receiving the most training with a fluctuating and diminishing number of patients to practice their craft under supervision.

Ask yourself this: If you were about to have open heart surgery and the doctor told you that he had only had the opportunity in medical school to practice the procedure 3 times because most of his patients cancelled or no-showed, would you feel confident in their ability? And yet we crank our interns through graduate programs based on the number of years rather than skills acquired, because the healthcare system is flawed and and patients are not held accountable for missing/cancelling appointments. This isn’t the interns’ fault, they are trying to get through to their knowledge and experience “savepoint,” but graduate schools and placements inadvertently become the parent shutting off the light because its “bedtime,” and we are producing generation after generation of clinicians who have had inconsistent or insufficient practice. This is continue without the save.

On the other hand, let’s take a look at the radical save mentality that permeates our profession. There are certain parts of the way many of my colleagues practice psychotherapy which have become extremely fixed, and I too fall prey to this at times. The 45-50 hour, a certain therapeutic stance, and my favorite, shunning technology. They bar their adolescent patient’s cellphones at the door rather than exploring who is texting them, refuse to consider Skype as an option let alone suggest it to their patients.

I frequently get referrals emails from several listservs, looking for therapists in Seattle, London, or Singapore. I enjoy practicing in-person therapy immensely, but does it ever occur to these colleagues to consider beginning to practice online as well? Why refer a patient to someone in Taiwan based on location when you could have one of your colleagues whom you know and respect take the patient on? On occasion I reply to these referral requests asking if the patient would be interested in Skype, but for the most part I’ve become reluctant to do that because I am pretty sure it doesn’t go anywhere. In terms of technology these psychotherapists are often in a lock-down save mode, and I foresee that they will resist change as the world continues without them.

My friend and colleague Susan Giurleo and I often find these things frustrating, and I realized today one reason why we may have this in common. We both went to Connecticut College in the late 80s early 90s, between the college presidency of Oakes Ames and Claire Gaudiani. In fact our graduating class became known as “the folks who knew Oakes.” And during this time our college had a motto that was drilled into all of us: Tradition and Innovation. Everywhere we looked, in all the college information and stationary were those words, tradition and innovation. Save and continue.

I have definitely tried to live that in my profession and my life of the mind. I’m a psychodynamically oriented therapist who uses Twitter and plays video games. I teach my students about Freud and Facebook. And I think that perhaps the affinity I find in the fin de siecle of the 19th century is how its denizens struggled to save and continue, to embrace the advances of technology then as we do now in the 21st century. In a recent article at Chris Brogan alluded to this when he said, ““The excitement for me about [social media] is, it’s gone from ‘Gee whiz!’ to ‘Now what?’ ”

Technology is here to stay and embedded in our lives, and today, like after the Industrial Revolution, we must learn the “now what?” To do this we can’t just rush forward and forget everything we ever knew, but we can’t stay stuck in a mindset from the pre-IBM world. Web 2.0 has arrived, and we need both tradition and innovation if we want to progress.

We must save and continue.

(Un)Desperate Times, or Know Your Talent Trees

Recently I was given a referral for an evaluation, and upon some reflection I declined it.  This is not something I am often in the habit of doing, but in this case the evaluation would have involved a clinical situation that did not fit with my integrity.  So it got me thinking about the relationship between building your business and professional integrity.

The referral would definitely have been lucrative, and within my scope of experience and skill.  And most of us these days certainly cannot afford to turn away business.

Or can we?

If I had taken this evaluation on, I would have most likely have been called on to testify about something that I was not entirely behind.  This would have compromised my ability to be an expert witness.  As I weighed the pros and cons I was quickly aware of my feeling of “halfheartedness” about the whole thing.  And that was what clinched it for me.  No patient deserves anything less than a wholehearted therapist as far as I am concerned. And I believe that when we catch ourselves trying to make something “fit” with our practice, we should probably stop right there.

Most of us were trained in clinics or hospital settings where we did not choose our patients.  We were there to help everyone, and the idea of a good clinical fit was something we were usually reluctant to give voice to.  Social workers in particular are often encouraged to be little mental health Statues of Liberty, treating any of the huddled masses that get sent our way.  But no one of us is supposed to treat everyone in my opinion.  And believe it or not, there are therapists who want to work with every segment of the population.  I have met therapists who love working with borderline personality disorder.  Others feel invigorated by working with substance abusers.  There are people who really enjoy working with schizophrenia, like me.  So in the long run, I think it is important to notice who you like working with, especially if you want to be in private practice.

Being clear on this is hard enough when we are starting or growing our practice.  Turning down a referral can be terrifying and guilt-inducing.  Somebody needs our help, we need to earn money, and we’re going to decline a referral?  Sometimes, yes.  Sometimes we need to hold a space open in our practice for a bit.  And always the patient deserves a therapist who is 100% committed to the therapeutic relationship.  So if we are lucky and have a good coach or supervisor we brave our fears and hold open the space for a while.

But later on in the development of a private practice, you may encounter a slightly different issue, what can be called an “embarrassment of riches.”  The phone starts ringing with calls from potential patients, requests for court or special education evaluations, or maybe your old employer wants you to come back and do a workshop for your old agency.  It can be tempting to overextend yourself, but I would suggest the following when this happens:  Don’t just do something, sit there.  Give yourself time to evaluate whether this opportunity is the best opportunity for you after the initial shine or honor of being asked has worn off a little.  Because only you know your business plan, and which of the opportunities presenting themselves to you is the best one for furthering your practice.

The picture at the beginning of the blog is what World of Warcraft veterans will recognize as a talent tree.  Each character class has three talent trees they can choose from to put their talent points into.  The more talents points you put into one tree, the more access you have to higher powers and abilities of a certain kind.  At the same time, since you have a finite amount of talent points, putting talent points deep into one tree makes it impossible to put them deep into another.  So for example, if I am a mage, I can choose to put my talents in Fire, Frost, or Arcane trees.  If I put most of them in fire, I won’t be as powerful when I need to use frost spells.

Sometimes newbie gamers decide to spread their talents across all three trees.  They divide up the points and suddenly notice that they are at a high level but aren’t doing that well in the game.  At some point someone will notice their talent trees are a mess, and explain to them the importance of specifying their talents.  Sometimes therapists do the same thing:  We try to be everything to everyone and learn to do a little of this and a little of that.  This is often where the diabolical word “eclectic” comes up.  We’re not frost mages OR fire mages, instead we’re hurling bolts of lukewarm water, and who needs that really?

If you have been building your practice for a while, you have probably noticed that your phone is starting to ring more, or your website is getting more hits, and this can be so exciting and intoxicating you’ll lose sight of your business plan.  This week I had a day like that, where I got 2 referrals for psychotherapy, an extended evaluation, and invited to teach 2 classes!  You bet that feels good (and overwhelming!)

But I needed to spend my talent points wisely.  If I load up on patients, I won’t have time to do my writing or workshops and ultimately develop passive revenue streams.  What’s worse, the patients will get an overworked overtired therapist who is not wholehearted. If I teach two classes, I won’t have enough time to do something else, and if I take on an eval that has me interviewing, writing and expert witnessing, same thing.  Time to refer back to my Tweaking 2011 plan.  So everything went on hold for a day (remember, we’re running a private practice, not an ER:  If something seems so emergent that it can’t wait a day, it may not be something to take on) and  I ended up declining half of the embarrassment of riches, offered alternate referrals, and hopefully everyone will be the better for it.

Have you started to specify your talents yet?  Have you chosen the talent tree you’ll put the majority of your points in?  The secondary one that enhances the first?  Does what type of work you accept clearly map to the business plan you’ve made for yourself?  I’ve written before about being an Epic Therapist and this is one of the qualities that makes a therapist Epic:  Epic therapists specify and hone their talents in one main area. And because they do that they can explain what kind of therapist they are at parties.  And they can do solid work and reading in their area so the patient gets excellence.  Excellence is what will keep your business afloat in the coming years, so spend your time and talents wisely!

How Do You Want to Be Remembered?

photo courtesy of

Recently, a bulletin board I participate on had a thread that really made me think.  A colleague posted a copy of an email she’d received from a third colleague.  The email was basically an introduction, a brief explanation of the therapist’s practice, and concluded with an invitation to visit her website and hoping to receive referrals.  The string of comments that ensued were mostly, although not completely, negative.  But I was struck by how openly critical many of the folks who replied were.  And what was even more striking than people referring to the email as unprofessional was how quickly several of these professionals began to say hurtful and insulting things to each other.  Personally I always applaud emails like the one in question, as I think it takes guts to self-promote, but I accept that other people have variations in opinion.  What I had a harder time accepting is the negative quality of the discussion.

A related incident occurred over the past few weeks with my blog.  A colleague began emailing me after each blog pointing out typos or grammatical errors.  I was a bit surprised, but at least she was taking the time to read it.  The last email was a bit more frustrating, in that she started the email criticizing my latest post and then asked for free consultation!  Still, I replied with a brief and polite answer to her question.  I wasn’t expecting a thank you or anything, but I was really surprised at what happened next.  When I posted a note to a listserv I am on with a link to my next blog post, which said, “You may find this blog post of interest,” she posted to the listserv saying simply, “No Mike.”

I tell you these two incidents to remind you that every time you post anything with colleagues you are also building your online presenceEverything we read tells us something about you. If you post something sarcastic you let us know that you are sarcastic.  If you post something clinically astute we know you are clinically astute.  When you post an article link you tell us that you are keeping abreast of research, as well as your areas of interest.  When you post online about a patient you tell us that you talk about your patients online.  And when you don’t play well with others you tell us about how it might be to collaborate with you on a case.

If you are mindful of this and are doing things the way that is in keeping with your professional style and identity, great.  There are lots of different ways to be in the world.  My point is to make sure you are mindful about how you are presenting yourself, because your online presence is everything out here!

Sometimes I get the impression that the same sense of narcissistic invulnerability we acquire when we get behind the wheel of our car happens when we get online.  We feel protected by a sense of anonymity and the asynchronous communication.  We say things that we might never say to the colleague’s face if we were in the same room.  We sacrifice sensitivity for the opportunity to seem witty or clever in front of our peers, even if it hurts someone.  We forget there are people behind the screens, or we decide we don’t care.  I am sure I have done it too, nobody is perfect.  But please think about what you are doing, because it can be really detrimental to building your business.

Take a look at the last 5 posts you made out here in Web 2.0.   What do they say about you?  If they were the only things a potential colleague or patient knew about you what might they think?  How do you want to be remembered?

Psychotherapy and Web 2.0

Recently, I had two referrals to offer to colleagues.  Although I like to make personal referrals, these patients had already had problems finding in-network providers.  So I mailed a general query to a listserv I am in.  Within an hour I received 5 emails back from therapists saying they had availability and providing phone numbers and their emails.  Only one had a website however.  I cut and pasted all five into a note to my patients, and I can guarantee you they will only call the therapist with the website initially.  This event provides us with a perfect example of the difference between Web 1.0 and Web 2.0

Web 1.0 refers to websites and internet technologies that were historically non-interactive, sites that we can read but not actually actively interact with.  Remember those?  Nowadays it is hard to find any examples of them.  Email and listservs, while still VERY valuable, and not at all disposable, would probably be considered Web 0.5.0 .  They are not going anywhere soon according to the recent tech experts I’ve read, but they are more limited in their nimbleness.  They also tend to give people burnout more quickly, as many experience them as intrusive emails from strangers who lob their opinions into the group, then someone lobs back an equally long rebuttal, and so on.  The majority of folks on listservs quickly become passive and resentful, and soon create that sort rule which sends all of the information into the infamous “folder” many of us have.

First let’s look at what all five therapists did that was marketable, in terms of 1.0  They are on listservs, they respond rapidly and include email as a way to be in touch with them.  These are great things, they position these 5 therapists ahead of the pack.   They are responsive and accessible in the manner needed for growing or maintaining a practice.  Anyone who responds after two hours is too late.  When I told my patients I would gladly forward other names if they came in, they basically said, don’t bother.  So that is the power of Web 1.0, that is what these clinicians are doing right, and that is the barest minimum, the barely bare minimum of where you should be with technology if you want to have a private practice in the next 2 years.

If you are reading this, you are at least at Web 1.0, so now let’s look at the therapist above who has begun to make the jump to Web 2.0.  But first, what is Web 2.0?

Web 2.0 basically refers to web-based social media and social networking websites, like Facebook, and LinkedIn.  What makes it 2.0 is the interaction.  We don’t just read what someone somewhere put up on a site, we participate.  We respond to information; comment on videos; share links with friends and colleagues; post blogs; make podcasts for websites or continuing education that others can download; host webinars; IM with friends while we share news or music.  In particular to LinkedIn, which is designed for our work world, we can sign up for discussion groups (and there are hundreds) but also create an online profile which can be as specific or vague as one likes.  The profile can include publications, and links to them, and a professional version of Twitter called your status.  Mine sometimes says “Michael Langlois is accepting new patients.” Folks looking at my profile can see that I have experience in gamer-affirmative therapy and learning disabilities, which makes it easier for people to refer to me or ask me different questions.

The therapist above has much of that.  He has a website, it has an interactive copy of his book, a picture of him, links to other sites and information.  He even has links for professionals and I joined a email list as a result of his site.  If I were providing consultation to this guy, we would be able to devote a lot of time right from the start on webinars and podcasts, because he has a lot of Web 2.0 down pat!  He gets that the rules of engagement for therapist and patients have changed significantly.  Patients want to see your face, hear your voice, think about what you have written, read recommendations from colleagues about you.  And they want to do all that before they meet you.  Remember the saying that therapy begins when you say “hello” to a potential patient on the phone?  Well, in a Web 2.0 world therapy begins before you even get the phone call.

So you need to become familiar with Web 2.0 ASAP.  And not knowing how yet is not an excuse, because as one of my colleagues said “people don’t go around nowadays saying, ‘the telephone, I don’t know how to use that.’”   The telephone has become much more a part of our daily world and Web 2.0 has become much more part of our patients’ world.  Technology is constantly evolving, in some ways like psychoanalytic theory.  Even 100 years ago we might have heard ourselves saying, “free association, what’s that?  I don’t know how to use that.”

So please, because I really do want you to succeed, please start gearing up for Web 2.0 and beyond.