ROI

Social Justice & Technology Revisited

March 15, 2014 by langloimsw 1 Comment

I have written before about how technology often makes life easier for a large number of the population while simultaneously disenfranchising others. The good news is that this does not have to be the case.

The example I used in the past was the Starbucks App which allows customers to use, gain rewards for, and reload their account on their smartphone, while making it more cumbersome and difficult to tip baristas. This again does not have to be an inevitability, but requires Starbucks to enhance the functionality of its App.

So I was pleased to discover (special thanks to my student Marissa for bringing this to my attention) this week that come Wednesday March 19th, Starbucks will be rolling out an update to their smartphone App which allows just that. You can read more about it at Forbes here. You will be able to download the update from places like iTunes, and include your tip easily.

While some may dismiss this as a first-world problem, I cannot emphasize how powerful a shift I consider this to be in terms of workers’ rights in the service sector. I am convinced it comes in part as a result of advocacy by and for workers, and sets the bar higher and yet attainable for corporations to maximize their value to customers while not disenfranchising their employees.

How can you help advocate for social justice in the technology you use? First, simply by mindful usage. Take a few minutes today to open your smartphone and make note of the Apps you use most frequently. Next, ask yourself, who, if anyone is disadvantaged by my using this App? Just thinking about the connections can be a powerful mental exercise. Notice how complicated it can get fairly quickly: If I use Evernote frequently, I am less likely to write things down on paper, which may be good for the environment but may also disenfranchise industrial workers in paper mills. Hold on, did I say that you had to stop using Evernote or lobby for paper mills? No, I’m asking us to sit with the complexity of a problem here for a minute to see the larger systems at play. Technology has always resulted in job loss for some even as it may provide workplace improvements or quality of life for others. It’s when we don’t think about these things in a more complex way that we stop innovating social justice itself.

Part of what I’m trying to encourage us to see is that social justice, workers’ rights, unions, and any person or group committed to social justice needs to keep pace with innovation and in fact keep innovating themselves. Technology always runs the risk of disenfranchising people, especially workers. If the McCormick reaper in a few hours does the day’s job of three workers, what happens to those three workers? We are still living in a capitalist society in the US, and it is unlikely that as technology improves and reduces the need for human workers that all of these people will be able to afford to turn their minds and lives to the pursuit of art and culture. Everything isn’t always getting better for everyone in the current system, and we are seeing overcrowding in occupations ranging from factory to legal work.

If social justice advocates, and social workers are to continue to help the disenfranchised, they are going to need to keep pace with technological developments and continue to think innovatively about 21st century equity in complex and sustained ways. And by the way, thinking, “the gap is just going to get wider, the social fabric is unraveling,” is not an example of innovative thinking, but defeatism that exempts us from the work of innovation.

This brings me back to my social work colleagues, and my continued urging for them to keep pace with emerging technologies, especially if you are touting the concept of social innovation. Social innovation without leveraging emerging technology will ultimately lead to future disenfranchisement. If you have a social innovation department in your social work program that doesn’t leverage technology you are not being socially innovative. I certainly don’t have all the answers, but I know that the answer to social injustice will inevitably need to integrate emerging technology into it.

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Filed Under: Gamer Therapy Tagged With: activism, behavior change, building your business, digital literacy, education, marketing, ROI, social justice, social media, technology, twitter, video games, Web 2.0

Works, Life and Marshmallows: Iterative Design

February 13, 2014 by langloimsw 2 Comments

They say the journey of a thousand miles begins with a single marshmallow. Ok, I say that, and more specifically I am talking about your life, job or relationship rather than a journey. I am coming back to my practice from a brief sabbatical, and have been noticing that while many things are going to stay the same, a few are changing as well. I’ll get back to the marshmallow in a minute.

One thing I learned on my sabbatical is that I definitely want to continue my therapy practice. As I said to some friends on Facebook this week, “You know, I’m kind of grateful that I get to challenge the self-hatred of others for a living.” As a clinical social worker and psychotherapist I get paid to do that. One thing I also decided on my leave was to withdraw from the last managed care insurance panel I was on. It made no sense to continue to decrease the time I could be seeing people due to paperwork and bureaucratic hassles, and it made no financial sense to have a waiting list of people who are willing to pay my full fee and also deserve treatment just so I could work at half my rate. I have always built pro bono or sliding scale slots into my practice because I have a commitment to serving a diverse population, so why was I doing that and letting an insurance company slide the remaining hours of my week?

Part of the answer to this and most “why-have-I-been-doing-this-this-way-when-it-doesn’t-work-in-my-favor?” questions is fear. Most of us are afraid of change. Whether we are staying in an abusive relationship, having difficulty getting sober, flunking out of college or missing days at work, most of us have moments when we see what we are doing to ourselves and ask the above question. And then we often resume whatever the pattern is, leaving an interesting question unanswered and instead turning it into self-recrimination, which is really just evasion. Another part of the answer is that we often act is if we only get one shot at answering the question of life satisfaction. Here comes the marshmallow.

Invented by Peter Skillman of Palm, Inc. and popularized by Tom Wujec of Autodesk, the Marshmallow Challenge may be familiar to some of you: “It involves the task of constructing the highest possible free-standing structure with a marshmallow on top. The structure must be completed within 18-minutes using only 20 sticks of spaghetti, one yard of tape, and one yard of string.” (per Wikipedia) You can call it an exercise, or play, but in either event the creators of the challenge have observed something very interesting about how different groups tend to approach it. Children tend to make a first structure, stick the marshmallow on top, and then repeat the process over and over, refining it as they go. Adults tend to engage in group discussions, arguments, power plays and plans to produce one structure built once to which the marshmallow is added. In other words they tend to approach it derivatively rather than iteratively.

Iterative design is a method of creating a thing or addressing a problem by making a prototype (first attempt,) testing it, analyzing the prototype, and then refining it. Rinse and repeat. Iterative design isn’t good for everything: As parents know, often there is not time in the world for everything to get done in 18 minutes or before the school bus gets here. But a life built on derivative design alone is destined for stagnation and rigidity.

Derivative design, as the name suggests, takes something from a pre-existing something-else, whether it be a rule, materials, social construction or interpretation of the something-else. When you psychoanalyze a patient’s dream and interpret it as a manifestation of their Oedipus Complex, you are deriving your interpretation and their dream from the something-else of Freud, who in turn derived his Oedipal Conflict theory from the something-else of Greek mythology. Derivative design can save time and effort in many important ways, by collapsing cultural memes and thinking and transmitting them forward through time from Sophocles to your office. But as feminist thinkers and cultural critics have shown us, we might have arrived at a different “complex” if Audre Lord et al had been in on the prototyping of it.

Derivative thinking left unchecked can get you in a rut. One of my most recent examples of this comes from The Little Prince, where he encounters the drunkard:
“- Why are you drinking? – the little prince asked.
– In order to forget – replied the drunkard.
– To forget what? – enquired the little prince, who was already feeling sorry for him.
– To forget that I am ashamed – the drunkard confessed, hanging his head.
– Ashamed of what? – asked the little prince who wanted to help him.
– Ashamed of drinking! – concluded the drunkard, withdrawing into total silence.
And the little prince went away, puzzled.
‘Grown-ups really are very, very odd’, he said to himself as he continued his journey.”

Everything derives from the previous thing, but in the end it sometimes gets us nowhere.

We all get in these difficult spirals. A good therapist or supervisor can point them out to us and then encourage us to become iterative in our design:

So what are you going to do this time?
How did that work out?
So what are you going to do differently?

Therapists starting their private practices also come to see me, often stuck in derivative thinking:

-I need my NPI number.
-Ok, why?
-To get on Medicare.
-Ok, because?
-So I can get on insurance panels.
-Ok, why?
-So I can get patients who will pay me so I can rent an office so I can have an address to register for my NPI.

If you are one of my consultees reading this rest assured I am NOT talking about you in particular: I have had this conversation a hundred times with people. We get indoctrinated into the world of managed care and get, well, managed. In this case, I usually recommend the consultee start by imagining what kind of office space they want. Answers have varied and included: Sunny, exposed beams, plants, yellow paint, toys, music system, waiting room with receptionist, friendly colleagues in suite, accessible to public transportation, elevator, warm colors, cool colors, and all sorts of other iterations.

Once you have a mental prototype you can either build or design your office, or find and rent it. Again I tell folks to walk around the areas they want to work in, find buildings that look interesting to them, then walk inside and ask to speak with someone about seeing a unit. Testing involves going to see several spaces. Then they can analyze the results: Does the space look like it would become what they imagine it to be furnished? Are there things about their ideal that need to be discarded? Do they now realize that they could be even more wild in their expectations?

This is just one example of the ways that iterative design can open up possibilities. But be warned, iterative design can be daunting for many of us raised in our current education system. We have been trained to create one product presented in final form with the expectation that we will be graded on that product alone. Everything becomes about that one paper or exam, which is often more about regurgitation rather than innovation.

I have colleagues who take my breath away with the number of projects and ideas they are consistently throwing out there to see what happens: It takes guts to do that. I myself often am afraid that the Project Police are going to pop out and say, “What happened to your idea of a Minecraft group? Shame on you for proposing it and not completing that project! You are not allowed any more ideas until you show us you can carry that one out.”

Sound ridiculous? Of course it is, but does it sound familiar to you as well? If it does, go out and buy yourself some spaghetti, tape and marshmallows: The quality of your job, relationship and life may depend on it.

Interested in setting up a consult for your practice? I have some openings come March. Like this post? I can speak in person too, check out the Press Kit for Public Speaking info. And, for only $4.99 you can buy my book. You can also Subscribe to the Epic Newsletter!

Filed Under: Gamer Therapy Tagged With: addiction, behavior change, buddhism, building your business, children, education, gamers, games, gaming, marshmallows, mindfulness, play, private practice, psychoanalysis, psychodynamic, psychology, psychotherapy, ROI, social justice, technology, therapy, video games, Web 2.0

No Matter How You Feel, You Still Failed

January 14, 2014 by langloimsw 4 Comments

Psychotherapists are often people who prefer to deal with feelings in their workings with people. Feelings are important, and being empathically attuned to how patients are feeling is equally important. We are taught to explore the patient’s feelings, imagine ourselves into their lived experience, and validate that experience.

This is often where we become disconnected from other professionals we collaborate with, such as educators. Be it Pre-K or graduate school, educators are charged with working with students to learn and grow as a whole person. It’s not that they aren’t concerned with feelings, they just can’t get hung up on them to the exclusion of everything else.

To be fair, psychotherapy has a long history of taking a broader view on the individual as well. A famous psychoanalyst, Winnicott, once responded to a patient of his who was expressing feelings of hopelessness by saying something to the effect of “sometimes when I am sitting with you I feel hopeless too, but I’m not going to let that get in the way of continuing to work with you.”

But often in the past decade or two, feelings have held sway over everything. Students don’t complete their assignments because they felt overwhelmed and still expect to pass the course. Adults feel emotionally exhausted and miss work or are late to it. Children feel angry at the injustice of chores and don’t do them but still want their allowance.

A criticism I often hear toward video games is that they encourage people to believe that they can always just reset, do over and have another shot. But implicit in this criticism is the fact of something I feel video games actually do better than many of us sometimes: They acknowledge the reality of failure.

When we play video games, we are failing 80% of the time. Failing in the sense of Merriam Webster’s definitions including:

to not succeed : to end without success
to not do (something that you should do or are expected to do)
to fall short <failed in his duty>
to be or become absent or inadequate
to be unsuccessful

In video games the reality of this is driven home to us by a screenshot:

You can feel any way you’d like about it, angry, sad, annoyed, blase, frustrated with a touch of determination. But no matter how you feel you still failed.

In life outside games, many of us have a hard time accepting the reality principle when it comes to failing at something. We think we can talk, think, or feel our way out of failing to meet expectations. My own predilection is that of a thinker, which is probably why I became a psychodynamic psychotherapist and educator. I often waste a lot of time trying to think (or argue) myself into a new reality, which just boils down to not accepting the reality principle. I notice the same with patients, colleagues and students, who miss deadlines, avoid work, come late to class and then try their best to think or feel their way out of it.

The first class each semester I tell my students, who are studying to be social workers and psychotherapists, that the most frequent complaint I get as an instructor is “I feel put on the spot by him.” I assure them that this is a valid feeling and actually reflects the reality that I will put each and every one of them on the spot. I will ask them tough questions, I will point out that they are coming late to class, I will disagree with ideas that seem erroneous to me. Because if they think it is ok to be late or avoid thinking through a problem or confrontation in class, how in the world will they ever be a decent psychotherapist or social worker? If the single mother you are working with wants to know how to apply for WIC, and you say you feel put on the spot by her question, that is a valid feeling AND you are useless to her. If your therapist was 15 minutes late every week I hope you’d fire him. And when you are conducting a family session and someone discloses abuse it is unprofessional to say “I’m feeling overwhelmed and sad right now, can you ask somebody else to go next?”

These sort of disconnects doesn’t happen overnight. It comes from years of being enabled by well-intentioned parents and yes, mental health providers who focus on feelings to the exclusion of cognition and behavior, and worse, try to ensure that their children grow to adulthood feeling a constant sense of success. When I hear self psychology-oriented folks talk it is almost always about mirroring and idealizing, and never about optimal frustration. And I suspect that this is because we have become so focused on feelings and success that we are preventing people from experiencing optimal frustration at all.

The novelist John Hersey has said “Learning starts with failure; the first failure is the beginning of education.” We commence to learn because reality has shown us that we lack knowledge or understanding. That’s the good news. We’ve woken up! In this light I regard video games as one of the most consistent learning tools available to us. When that fail happens and that screen goes up you can try to persuade it to cut you some slack, flatter or bully it, weep pleadingly for it to change to a win, but no matter how you feel, you still failed. And because that reality is so starkly there, and because the XBox or PS3/4 doesn’t get engaged in your drama, that feeling will eventually dissipate and you will either try again, or give up.

Because that is in a lot of ways the conflict we’re trying to avoid isn’t it? We want to avoid looking reality square in the face and taking responsibility for what comes next. We want to keep the feelings flowing, the drama going, and we are willing to take entire groups of people and systems with us. If we are lucky they put their feet down, but more often then not they want to avoid conflict too, and the problem just continues.

So here’s a confession: I have failed at things. I have ended a task without success. I have not done things I was expected to do. I have fallen short, been inadequate and been unsuccessful at stuff. And nobody took away my birthday. I’m still around doing other things, often iterations of the previous failures, quite successfully.

If you are a parent or educator please take a lesson from video games. Start saying “Game Over” to those in your care sometimes. If they can try again great. If they want to read up on some strategy guides or videos to learn how to do it better, awesome. But please stop capitulating to their desire to escape reality on the illusory lifeboats of emotional expression, rationalization or verbal arguments. As Mrs. Smeal says in “Benny and Joon,” “when a boat runs ashore, the sea has spoken.” Reality testing is probably the most important ego function you can help someone develop, please don’t avoid opportunities to do so.

Nobody likes to experience failure, I know it feels awful. But to move through it to new realizations can be very liberating, and in time become more easily bearable. And I truly believe that success without past failures feels pretty hollow. When I play through a video game from start to finish without a fail I don’t feel like a winner. I feel cheated.

Like this post? I can speak in person too, check out the Press Kit for Public Speaking info. And, for only $4.99 you can buy my book. You can also Subscribe to the Epic Newsletter!

Filed Under: Gamer Therapy Tagged With: addiction, adolescents, behavior change, buddhism, building your business, children, digital literacy, education, ego psychology, failure, Freud, gamers, games, gaming, Kohut, mindfulness, minecraft, optimal frustration, play, private practice, psychoanalysis, psychodynamic, psychology, psychotherapy, reality testing, ROI, self psychology, social justice, social work, stress, technology, therapy, video games

Evocation and Mindfulness: Or, How to Think Better

October 16, 2013 by langloimsw 2 Comments

Like other art forms, video games can be both a mirror and a candle held up to our culture, at times reflecting it and at times revealing things about it. Normally I direct my posts primarily at people: therapists, gamers, educators, parents. But today I want to include the company that produces World of Warcraft as well. We have a crisis regarding thinking, and although I don’t think WoW created it at all, it has reflected it in a recent game mechanic change.

I am referring to a change mages that happened recently, where the spell Evocation was replaced by Rune of Power. For people not familiar with the game, here’s a simple explanation. Mages cast spells, but spells require an energy called mana, which gets used up gradually as you cast spells. How much mana you start with depends on your character’s intellect, and once you have used up your mana, you can’t cast any more spells until it is replenished. To replenish it you can either wait and it will gradually return (not the greatest idea in combat,) or eat and drink (not possible while you are in combat.) Or you could in the older days cast Evocation, which meant you stood in place as the spell was going, gain 15% of your total mana instantly and another 45% of your total mana over 6 sec. Move or get attacked, and the spell broke.

This recently was replaced with Rune of Power, which places a rune on the ground, which lasts for 1 min. While standing within 5 yds of it, your mana regeneration is increased by 75% and your spell damage is increased by 15%. You have to keep remembering to replace it every minute, but that’s not the problem. It may even be an easier game mechanic, but that’s not the problem either. My problem with it is how it reflects our dysfunctional attitude about thinking, and specifically our tendency to think of thinking as separate from doing something.

We live in a culture where people frequently worry about things, and in fact have ruminations that are intrusive. Many people report feeling hijacked by their minds with worrying or intrusive thoughts. And yet at the same time, few of us seem to mark our time and set it aside specifically for thinking. We schedule appointments to do things, but thinking isn’t one of them. We treat thinking, which is intangible, as if it can occur in the same space as doing other activities that are more observable and tangible. And then we are surprised when our minds rebel and hijack our thinking with thoughts and feelings that come unbidden, when all along we have been failing to cultivate the practice of intentional, mindful thinking about things.

This is where I think Blizzard and Wow initially had it right with Evocation. It was acknowledging an important truth, that Thinking IS doing something, and when done intentionally it occupies time and has benefits. Sure you weren’t able to do other things while casting Evocation, but isn’t that the point? In the real world, when you want to think deeply and seriously about something, you really do need to be intentional about it, and make a space in your day to do it. Rune of power definitely embraces the multitasking model, which encourages you to set up a rune and then go about your other business while keeping half an eye on it to know when to refresh. Multitasking is not inherently a bad thing, but there are times and places that intentional thinking may be more appropriate and less anxiety-provoking.

Part of helping patients learn to manage worrying is often to help them set up a specific time for worrying about things. This “worry time” can be a placeholder in the day or week which the patient uses when an intrusive worry enters into their thinking: They can dismiss it by deciding to put that on the agenda for the scheduled worry time. This is a way of training your mind to be intentional about what you choose to think about and when. But implicit in this is the idea that training your mind to think about things intentionally is a learned skill.

You can apply this to many different aspects of your life and work. If you are growing your private practice, when was the last time you set aside an hour to think deeply about your business plan or clinical focus. I’m not talking about daydreaming here, I’m talking about sustained intentional thought. Clinically, do you set aside supervision time to think deeply about patients? As students do you take 15 minutes after each article to think specifically about the reading? As parents, when was the last time you said to your co-parent, let’s make a time to think together about how our child is doing in life at home and school. Classroom teachers, when was the last time you asked students to take 5 minutes and think quietly about the classroom topic?

Another challenge here is the confusion of tongues around the concept of thinking. Self-help gurus often exhort us to stop thinking about things and JUST DO IT. But I don’t think they are talking about intentional thinking, I think they are talking about reactive or intrusive thinking. Procrastination is reactive thinking, worrying can be intrusive thinking. Those are often roadblocks to success, but the form of thinking I have been referring to is perhaps better described as a form of concentration meditation. Concentration meditation has come to be seen by many of us as concentrating on an image, or a candle, or chanting, or a revered object, but that is not necessarily the case, and in fact it is limiting.

What if your idea is the revered object? What if your thought process about your work, child, patient, class is worthy of your undivided attention? What if you were to schedule a specific time to think about a certain project?

If you are one of those detractors who say, “I just don’t have time to think,” I don’t buy it. Thinking time is not a luxury item, although it may be a learned discipline to set aside a few minutes at a time to do it. So please take a second and schedule a time on your calendar to think about an idea that is important to you. Schedule a time to hold your random worries and thoughts and show up at that appointed time to seriously consider them. I suspect this will free up more mental space and time than you may imagine.

And please Blizzard, bring back Evocation. I miss it, and the important life lesson in mindfulness it has to teach us.

Like this post? I can speak in person too, check out the Press Kit for Public Speaking info. And, for only $4.99 you can buy my book. You can also Subscribe to the Epic Newsletter!

Filed Under: Gamer Therapy Tagged With: behavior change, building your business, digital literacy, education, game theory, gamers, games, gaming, mindfulness, private practice, psychoanalysis, psychodynamic, psychology, psychotherapy, ROI, stress, video games, World of Warcraft, wow

Guild Wars: The Conservative Attack on Online Therapy

August 4, 2013 by langloimsw 11 Comments

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

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

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

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

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

I have several concerns about this.

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

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

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

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

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

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

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

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

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

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

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

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

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References

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

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

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

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

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

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

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

You’re The Reason Building Your Business Is So Hard

May 31, 2013 by langloimsw 22 Comments

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

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

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

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

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

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

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

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

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

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

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

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

What To Do When Your Therapist Turns Into A Kitten

May 1, 2013 by langloimsw 10 Comments

I have been working with patients online for about 6 years, and even now I have some interesting surprises in the work. Recently I was meeting online with one of my long-term patients for their regular session. I use my laptop but have a better web camera and monitor hooked up to it. The bigger monitor allows me to see the patient’s image, but also keep an eye on my image so I can see what the patient is seeing. The laptop monitor stays dark, and the laptop’s built-in webcam goes unused, at least most of the time. But this particular day the laptop webcam decided to switch on 15 minutes into the appointment, and hijacked the webcam I was using. So from what my patient could see, one minute I was there listening empathically, and the next minute I had disappeared.

Those of you who enjoy object relations theory should be enjoying this story by now. Wait, it gets better.

As I was explaining to my patient why I’d disappeared, I was trying to turn off the laptop’s built-in webcam. Instead I turned on a special program the laptop has that replaces the screen with the image of a kitten, the one seen above in fact. Suddenly I was not invisible, but a kitten. Better yet, the kitten was lip synching and moving its mouth when I spoke. Fortunately this wasn’t happening at a particularly delicate moment in the therapy, and we both had a good laugh at it. I apologized to my patient and said, “you know, I studied a lot of things at grad school, but they never taught me what I’m supposed to do if I turn into a kitten when I’m with a patient.”

Many psychotherapists have the sort of relationship with technology that resembles the folks they treat with Borderline Personality Disorder: They alternately overidealize and devalue tech, often in the same breath. “Skype” will be the way we salvage our dwindling practices, we’ll be able to reach people all over the planet, make our own hours and go completely self-pay because most insurance doesn’t cover it. It will be wonderful. That’s the overidealizing part, the devaluing part is more subtle.

Because I do a growing amount of therapy and supervision online, I often get requests for a consultation session to help therapists who want to do online therapy and “need my help getting on Skype.” At this point I try to explain that Skype is not HIPAA-compliant, and that there is more to it that getting a webcam, but here’s where the devaluing of technology comes in. It’s as if some folks think that the only thing one needs to know in order to be an online therapist is how to download a program and turn on the camera.

Most therapists who decide to get Basic EMDR training wouldn’t bat an eye at needing to go through two weekend trainings and a minimum of 20 didactic and 20 hours of supervised practice in order to be certified. And yet many therapists don’t consider that working online and with emerging technologies requires more than learning how to flick a switch. It’s sort of the way people often treat the IT guy at the workplace: With one breath we describe ourselves to him as “clueless” about technology; and yet we really want him to stay in that basement office until we need him to come up and fix our email.

Graduate programs teach us next to nothing about how to use technology in our practice, except perhaps to warn us to avoid it at all costs. Think about it. Do you know what to do if you disappear in the middle of talking with a patient? Do you know what to do if you turn into a talking kitten? More importantly do you know how to prevent yourself from turning into a talking kitten, or turn yourself back from one if you do? And perhaps most importantly, do you know how to help patients anticipate the glitches with virtual therapy, process the unique empathic failures that can arise, and create a good-enough holding environment online?

People like my colleagues DeeAnna Merz-Nagel and Kate Anthony founded the Online Therapy Institute for just this reason. They offer dozens of different 5 hour courses on various technologies, from video conferencing to text chat to conducting therapy in virtual realities like Second Life. The takeaway here is that there is a lot more to learn about online therapy than downloading Skype.

Look, I am not trying to discourage people from doing online therapy, in fact the opposite. I know that it can be a very effective treatment modality, and easily accessed by a growing global population. I’m not even trying to get you to sign up for consultation with OTI or me or anyone in particular. The point I am trying to make is that it is an additional skill set that needs to be learned and integrated into your clinical repertoire.

Psychotherapists don’t just buy chairs and a couch and start talking. EMDR isn’t just wiggling your fingers in traumatized people’s eyes. Both take time, case supervision and specialized training.

Online therapy, and integrating social technologies into your therapy practice is no different.

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Filed Under: Gamer Therapy Tagged With: avatar, building your business, digital literacy, education, facebook, kitten, mindfulness, online therapy, private practice, psychoanalysis, psychodynamic, psychology, psychotherapy, ROI, skype, social media, therapy, Web 2.0

How to Get Taken Seriously as a Mental Health Professional

August 8, 2012 by langloimsw 8 Comments

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

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

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

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

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

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

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

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

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

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

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

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

If not, get thee to a photographer.

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

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Filed Under: Gamer Therapy Tagged With: building your business, education, linkedin, managed care, marketing, private practice, psychoanalysis, psychodynamic, psychology, psychotherapy, referrals, ROI, self-promotion, social media, technology, therapy, twitter, Web 2.0

The Perilous Price of a Good Living

June 30, 2012 by langloimsw 6 Comments

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Thinking, and Just Thinking

March 20, 2012 by langloimsw 5 Comments

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

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

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

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

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

They listen and say they’ll think about it.

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

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

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

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

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

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: behavior change, building your business, business, managed care, marketing, mindfulness, private practice, psychoanalysis, psychodynamic, psychology, psychotherapy, referrals, ROI, self-promotion, therapy

When They Hate You.

February 22, 2012 by langloimsw 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.

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.
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.
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: adolescents, adultism, education, gamers, gaming, private practice, psychodynamic, psychology, psychotherapy, public speaking, ROI, self-promotion, social media, therapy, video games

How To Get An Epic Supervisor

January 25, 2012 by langloimsw 6 Comments

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

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

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

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

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

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

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

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

3. Do your research

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

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

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

4. Know what is important to you

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

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

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

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

No, you may not.

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

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

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

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

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

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

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

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

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

7. Kick the tires

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

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

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

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

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

A Tale of Two Conferences

January 21, 2012 by langloimsw 3 Comments

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.

What?

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.

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: behavior change, building your business, chris brogan, education, marketing, mindfulness, psychotherapy, referrals, ROI, self-esteem, self-promotion

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

January 7, 2012 by langloimsw 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: behavior change, building your business, DCU, marketing, money, private practice, psychology, psychotherapy, ROI, social justice, Web 2.0

Occam’s Oyster

December 7, 2011 by langloimsw 2 Comments

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

You are not an oyster.

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

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

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

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

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

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

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

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

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

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

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

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

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: behavior change, building your business, insurance, managed care, mindfulness, private practice, psychoanalysis, psychodynamic, psychology, psychotherapy, ROI, stress

Epic Guest Post: Newbie Therapist Esther Dale on Staying Determined

November 3, 2011 by langloimsw 7 Comments

Every once in a while I receive an email that reminds me that the work I am doing is making a difference. Today I received this from a new colleague to our field, and with her permission I share it in its entirety. I hope that you will comment on it and show her that she’s not alone:

Hello Mike,

I am a newbie therapist, having entered the licensed profession less than a year ago. Though despite my newbie status, despite the fact that I currently have no clients, no office, no firm job prospects, with a website and business plan that are both still in the initial stages, I still feel that I am an Epic Therapist. Or, at the very least, I am in training to be one!

Anyway, I just wanted to let you know how truly, truly, refreshing I found your blog. In the past, I have spent many, many, many hours skimming one random psychotherapist website after another. More often than not, I get so bored to tears reading the same drivel. I can’t understand how so many of them stay in business. From their websites, I feel that often there is no real spark or passion for their profession, and that they are all trying so hard to play it so safe, that so many psychotherapists end up sounding so cookie cutter. Not to mention the rather pretentious attitude that comes with, “I specialize, well, in the whole DSM-IV. What is your disorder? How may I help you in your disordered state?” Or my personal favorite, “Are you anxious? Depressed? Do you find yourself worrying a lot? Do you sometimes find yourself feeling lonely?” My thinking after reading that is always, “Yeah, I am depressed and anxious just from reading that!” After exhaustive online research, I felt rather alone in feeling like a therapist could dare to have their personality shine online. And then I found your site, and I was like, “Someone who dares to break the mold!” YAY! 🙂

So I have basically spent my free time the past couple of days reading as many of your blogs as possible. I know that you must get many, many e-mails. And I am trying my very best to have my e-mail be worth your time. I am hoping at the very least that what I have to say might spark a possible interest for a blog response.

When I am in my Secret Headquarters, well, ummm, Head(corner) more like it, I feel like anything is possible. I feel the passion and excitement and knowledge for my blossoming niche, Sandplay/Play Therapy. I feel my passion and excitement for my professional focus on the more non-verbal approaches to psychotherapy, for the times when individuals just can’t seem to find the right words to truly express everything that is going on inside of them. Even right now, I feel myself fumbling around for words, and wish I didn’t have to rely solely on words at this moment in time to captivate my Epic Therapist passion. So when I am in my Secret Head(corner) I feel rather invincible. I feel like I can make it. I feel like I have the ability to design the website I want, and set up shop the way that I want. Though the moment I step out of my Secret Head(corner) I am immediately flooded with all these scripts of why I can’t do this. I feel like there are so many “voices” telling me I can’t succeed on my own terms quite yet because I haven’t paid my dues to the system. The current system that exists between many CMH, Non-Profit establishments and insurance companies, make it near impossible for newbie therapists to get a traditional job. From my own experience, I didn’t even qualify to apply for the clinical position for which I interned. When this happened to me, I acknowledged to myself that the current system is way out of joint, and that deep down inside, I have no real desire to associate with that kind of business structure. Though still I feel so many professionals trying to taint my passion for a private practice with their venom of, “Well, you need to walk, crawl, climb your way through Mordor, in order to finally be able to sever your newbie status ring into the fiery pits.” Though I tend to see another option rather than the traditional route: http://www.youtube.com/watch?v=1yqVD0swvWU (I love this video, two minutes of LoTR epic-parody goodness.)

In their eyes, I am trying to take a short-cut. Though I am not trying to take a short-cut, merely a different path. I have checked the policies and procedures regarding private practice, and even with my Limited License Professional Counselor (LLPC) status, I am able to set up shop. I have a qualified supervisor and seek out as many mentors as possible; I am constantly researching to gain as much knowledge as possible; I spent much time and effort in receiving professional training in Sandplay/Play Therapy. I feel like I am a blossoming professional in my field. I am determined to have an ethically driven, professional private practice, with a strong niche, and a strong professional voice. Though, every time I think of my “Limited License” status, or I think of all the things I still need to learn, I sometimes feel myself retreat into this defeated status. So I guess my question is this, how does one continue to build up and defend their Epic Therapist status, when so many naysayers want to tear you down because you are forging your own path?

If this sparks a possible blog/e-mail response that would be awesome. If it doesn’t, that is okay too. I know your time is valuable. I am just grateful if you took the time to make it to the end of my letter. Best of luck in all your efforts!

Sincerely,

Esther Dale, MA, LLPC

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

Filed Under: Gamer Therapy Tagged With: building your business, gamers, gaming, marketing, newbie, private practice, psychodynamic, psychotherapy, ROI, self-promotion, Web 2.0

Why Ursula the Sea-Witch is My Guru

October 29, 2011 by langloimsw 8 Comments

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

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

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

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

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

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

It’s not.

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

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

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

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

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

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

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

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

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

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

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

Why Therapist Directories Are A Waste Of Time

August 11, 2011 by langloimsw 56 Comments

This post is for all of you who have been considering or actively using listings in therapist directories. I frequently get asked from consultees which directories they should list in. I also frequently see colleagues debating on bulletin boards and listservs the merits and demerits of individual directories. So I figure it’s time to offer you my perspective. Please bear in mind that I am sharing my experience and opinions here, and if you’ve had a different one, hopefully you’ll mention it on the comments. If you own a directory service, I hope you’ll disclose that as well.

When I started building my practice, I had a lot of time to spend filling out various online directories. I literally spent hours filling out profiles that promised to make me visible to potential patients. To be fair it gave me the opportunity to hone my bio and elevator speech, but other than that I now think that I was wasting my time. But let’s talk a little about why directories may be a waste of your time, because I think it points to a larger misconception about marketing your practice online.

Billboard in a bottle.

Many therapists still approach the internet as if it was a giant Yellow Pages. We often create static content, the equivalent of a business card, cover letter and resume, and then slap it up on a website, or a directory. Then we sit back and wait for the phone to ring. It’s like we imagine that we created a giant billboard and threw it into the world wide web. But in reality, it’s more like a message in a bottle, thrown in a vast ocean. We imagine that that will get us recognized. It usually doesn’t, and here’s why.

If you google “find a therapist” you will literally find dozens of website directories guaranteed to help patients find the right provider. If you’re ambitious you could spend hours and days finding all of them and entering your information. Many of them are free, some charge money, and a few don’t let you know whether they will charge or not until you’ve entered all of your information. One of the main problems with directories is exactly that there are so many of them.

One thing I’ve learned from starting up social networks for other companies is that you always need a critical mass of members as quickly as possible. If you launch a site you have a few days to a week to achieve this in most cases. Otherwise potential members will log in to your site, look around and see little activity, and leave. So low enrollment of providers in a directory will drive little traffic to it.

On the other hand, if you take a directory like Psychology Today’s you will see that they did achieve a critical mass, and have more traffic. But the problem here is that this is because every therapist and her maiden aunt is now listed there. So the problem becomes how to set yourself apart from the rest. If you are determined to spend time on listing yourself in a directory, I’d suggest that you pay for the PT one and try to distinguish yourself as best you can. In fact, the Psychology Today site is the only directory I even try to keep current and pay for anymore.

Speaking of keeping current, here’s the other potential pitfall of directories: The more you participate in, the more you’ll need to update your content, remember more passwords, and check back in. Some directories require you to log in any time you get a message from a potential client (or spam) in an effort to drive up their traffic. It’s a lot of hassle for little ROI.

If you are determined to list yourself in directories, please consider the following:

If you are planning on practicing online, does the directory have global traffic?
If you are planning on practicing in a certain geographic location, does the directory get traffic from your part of the world?

One way to research this a little is to run the site’s address on Alexa, which will often tell you some information about traffic or rankings by country.

But while we’re talking about Alexa, let’s talk about how those numbers can be misleading. Alexa allows you to download the Alexa toolbar, which allows you to check a site’s alexa traffic rank, but it also allows Alexa to tabulate traffic to any site your browser visits, which is part of how they get those numbers. So it is very easy to drive traffic numbers up artificially. How? Easy, set your homepage to your website, and every time you open up your browser, it opens to your site, and adds to your number of visits. Not enough? No problem, have all of your family members do the same on their computers. Within days, your ranking will rise dramatically, without any real rise in potential referral visits. So keep that slight-of-hand in mind when you look at a therapist directory’s traffic. Maybe they do have 100s of visits a day, or maybe they have 10 people who have that site as their home page to drive up traffic.

So Now You Know.

When I review my practice referrals, I received probably %10 of them from a directory, usually Psychology Today. The majority of my referrals came from word of mouth, insurance company lists, and increasingly my blog and articles. By now, many of you will know where I am going with this: It is content and interaction that convert visits to your website into referrals. There is not a similar conversion rate from visits to your directory profile and calls to you, or even visits to your website.

Some may disagree with me, but my take on directories is that they are a waste of time, and that they capitalize on therapists’ reluctance to generate interactive and dynamic content. Put simply, people want to hang up their cybershingle and then go back to passively waiting for the phone to ring.

To spend a lot of time finding and listing yourself in a therapist directory is to confuse worry with effort. What you should be doing (Oh Nos! A therapist used the word “should” 😉 ) is generating content and creating opportunities for interaction with colleagues and potential patients. Examples of generating content include:

writing brief informative blog posts
tweeting links to articles that you find interesting to establish your “brand”
offering a free hangout on Google+ on your niche topic
creating a meditation podcast that people can download from your site
networking in Second Life or attending the Online Therapy Institute’s open office hours
doing a five-minute vblog on a CBT technique

I’ve done many of the above, and this blog post is another example. I guarantee you that this post will generate a new referral for me at some point soon, much sooner than my Psychology Today profile will.

So please take the time you could be playing it safe cutting and pasting your info into yet another directory, and instead take some risks, create some new content, or join in a conversation online. Web 2.0 is not about being a digital classified ad. Use your time marketing to do what therapists do best: Relate.

Filed Under: Business Tagged With: building your business, HMOs, insurance, marketing, private practice, psychology today, psychotherapy, ROI, self-promotion, social justice, social media, therapist directories, Web 2.0

Integrity Is Your Brand.

August 2, 2011 by langloimsw 7 Comments

Recently I had two experiences which took me a bit by surprise. The first was when a representative from an online gambling site contacted me and asked me to consider affiliating with their website. Apparently they had read several of my blogs and found my site and the posts to be in their words “respectable” and “well written.” They wondered how much I’d charge for them to be able to include a link to their site in my next blog.

As many of you can guess, I derive no direct monetary income from this blog. The revenue I do get comes in requests for consultation, workshops and speaking engagements from people find me through this site, and summer is slower in those areas. Needless to say the idea of making some money from the blog is always tempting. And I have nothing against online gambling per se. But I declined, and at this point I can’t imagine accepting advertising or affiliating. It might be more tempting if Blizzard or Nintendo were to call, but even then I would have to decline. Not because I think affiliate marketing is inherently wrong, but because in this case something more valuable is at stake.

The second experience didn’t involve money, but it was actually an even harder decision. Not long ago I had the privilege of being elected to the board of a professional organization. I’ve been on several boards, so I was expecting to commit a lot of time and work to this one. What I wasn’t expecting was to get a call from the chair about my blog. Seems that someone had forwarded a post where I criticized several organizations for their stance on technology, including this one. I was told that I’d have to retract the post, and refrain from making any future critical posts about the group.

This is an organization I think highly of, and I can tell that the members of this group are not just in it for the title. I’m sure I could have done a lot of good serving on it.

But again, I had to decline.

Neither money nor a titular position is more important than my integrity. In fact, I’d go so far as to say to you that integrity is your brand.

It’s important not to make the mistake of demonizing either of the two parties in the examples. There is nothing inherently wrong with marketing or in my opinion online gambling. But I have not built my reputation on being an expert on gambling, and I’m not one. So even though the website might derive benefit from having a respectable blog link to them, I wouldn’t. Sure money is great, but as I said, something more valuable, my integrity, might be lost. I have worked too hard and too long to risk losing that.

I can also understand the board’s point of view: As an ambassador of the organization, whatever I say about it, critical or otherwise could be problematic for them. I don’t agree with them entirely, but when I understood what was expected my choice was clear. This blog isn’t Mashable, but many of you have been reading it for as long as it has been up. And people expect me to tell it like it is, whether it be about technology, gamer-affirmative therapy, or growing your private practice. If you’ve read the comments you know that everyone doesn’t always agree with my point of view. But many people have come to find the blog, and me, consistent and honest. There are other people who can do board work, but without my integrity there is no blog.

At the risk of sounding self-righteous, I know that writing this has made a difference in the lives of therapists and the patients they treat. It has allowed me to gain access to publications and groups to spread the word that technology is not incompatible with therapy, and that gamers need therapists who are culturally competent in gaming rather than contemptuous prior to investigation. Seasoned clinicians have told me that they have begun to rethink some of the cherished ideas our field holds about addiction, and fledgling therapists have sought me out for supervision on how to grow and market a profitable and socially just practice. And of course writing for all of you has helped me feel “powered-up” to continue to do the work even when there’s pushback from colleagues and our field.

I’m not telling you this just for catharsis. And I don’t have that “Blog With Integrity” badge on the blog just for show. Here’s what I want to make sure you know:

One day, maybe very soon if it hasn’t already happened, you’re going to realize you’re a success. You’ll realize that you haven’t been worrying about your practice as much, or that your caseload is full, or that you’re being asked to teach on your expertise. One day, you’re going to be a success. And when that happens, you’re going to have opportunities that require you to make tough choices. Because people will notice you’ve become successful. Whether it be those word of mouth referrals or podcast interviews, you’re going to have become more influential. Some people will want to harness your influence to help them, others will want to harness it to control it. And the only person who can decide what choice to make is you.

If you don’t feel comfortable seeing yourself as successful or influential, that’s your problem. Ignorance is always a vulnerability. You matter. The work you do matters. Your thoughts and opinions matter. Its when we don’t think we have an impact that we hurt our patients, our families, our business, in fact our world.

Immanuel Kant once said, “Act only according to that maxim whereby you can at the same time will that it should become a universal law.” I take this to mean act as if anything you were about to do in your life would become a universal law for how to do it. That’s heavy stuff. It’s not easy to decide how to act in a way that you’d be willing to have be the way to act for the rest of your life. In this case, blog with integrity.

Integrity is your brand. Are you willing to do what keeps you whole and constant in your therapy, business and life? Do you stand up for the things you believe in even when they cost you money, comfort or being liked? And perhaps most difficult, are you willing to notice your success, admit that you matter, and live with the knowledge that you have an impact on the world?

Filed Under: Business Tagged With: branding, building your business, gamers, integrity, kant, marketing, private practice, ROI, self-promotion, social justice, social media, Web 2.0

How To Learn About Video Games & Why You Ought To

July 29, 2011 by langloimsw 1 Comment

http://www.youtube.com/watch?&v=JY8h-U7rE6Y

Filed Under: Gamer Therapy, Games Tagged With: adolescents, building your business, gamers, gaming, LGBT, play, psychodynamic, psychology, psychotherapy, ROI, social media, Web 2.0, Wizard 101, World of Warcraft, wow

Five Tips For Your Practice This Summer

July 15, 2011 by langloimsw 10 Comments

Filed Under: Business Tagged With: building your business, marketing, private practice, psychotherapy, ROI, social media, Web 2.0

Don’t Run Your Practice Like An HMO

June 18, 2011 by langloimsw 9 Comments

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

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

So why are we just like them?

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

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

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

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

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

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

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

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

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

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

Therapist Websites Are Not Enough

May 22, 2011 by langloimsw 25 Comments

Last March a friend and former graduate student I supervised was visiting me from out of town. He was telling me about a call he got that went something like this: “Hi Bob, great website! Would you like to do a workshop on creating a online presence for our chapter of NASW? You won’t be paid for this, but you’ll get exposure, what do you think?”

This sort of exchange contains every element you need to have to teach a lesson on how not to do things as a Web 2.0 therapist. Let’s break this down:

1. What you are doing is so valuable we’d rather not pay you for it. Anything that you would go to a workshop to learn is something you should be willing to pay for. Even if it was only $20, a small amount or honorarium is something you should offer when you recruit someone to help you. Offering a rationalization is not the same thing; if my former student needed exposure the last place to look for it would be from this cheapo crowd! I know we have had a longstanding tradition in the psychotherapy disciplines to expect that we will present papers or talks at big yearly conferences for free, and that kind of thing seems a little different in my mind, because they are national conferences or Symposia and have many presenters. But to recruit someone specific for a specific workshop and not pay them any honorarium seems both cheap and arrogant to me.

2. Online Presence=Having a web site. Wrong! A website is just one small (important, but small) part of having an online presence. Having a website is something you should have prior to trying to launch your online presence. Now opinions vary on how to get one. I have some colleagues who know this space who believe that Therapists need to hire someone to build a website for them, and I can see the merit of this. My own opinion is that WordPress and our current technology have made it possible to have a very professional website for a fraction of that price if you are willing to spend some time and a little extra money to get a framework like Genesis. That is the one I use, and this site is one that I was able to design and launch pretty quickly. I have an older site that is still out there, but doesn’t get anywhere near as many hits now. That being said, I do think that whether you build one or have a professional do that, you definitely ought to have a professional critique it. My colleague Juliet Austin has a expertise doing this, and having been in the market for a while, she has a great eye for dos and don’ts.

But having a website is not an online presence in 2011, it is a colorful classified ad. Yes it is necessary now that potential patients want to see and meet you before they see and meet you, but now that there are thousands of Therapists with websites it will not distinguish you much more than a Psychology Today profile. Having an online presence requires you have a vibrant combination of interactive dialogue, recommendations that establish your “brand” as a therapist, multiple forms of media to see, hear and read you, and some amount of change over time.

I’m not trying to discourage any of you from getting started online with a website, I just want to make sure you see it is only one component of having an successful online presence.

3. Professional Organizations need to become more professional when it comes to business and social media. Asking your constituents to take the lead without compensating them is just lame. But even more concerning are the attitudes I see many organization taking towards social media. One example recently was a workshop NASW was promoting on HIPAA and Social Media. The flyer began with the bold red words “Protect Yourself!” The workshop like many others I have seen approaches the Internet and Web 2.0 from the point of view of fear-mongering, if the advertisement is accurate. Be scared of social media. Don’t learn how to use it for marketing your business, let alone your clinical work. This is not the message we need from our leadership. Include a component on social media in a general ethics course, sure. But please stop fostering the association of technology with ethical risk, social media with liability.

Our professional organizations also need to put the same thought and care in finding expertise when it comes to Web 2.0 as they would other workshop topics. Would we ever email a colleague and say, “Hey, want to do a workshop for NASW on EMDR?” based on information as limited as a website? I doubt it. As leaders of our profession, our professional organizations need to treat the topic of social media and health care with the same care as other topics. Their endorsement gives an imprimatur. If they say, the only thing you need to know about social media is to avoid it or you’ll be sued, we learn nothing but fear. If they say, social media requires no expertise or experience, we underestimate the skills we all need to learn to use it.

Bob is a great guy and an excellent clinician, but his having a website doesn’t make one an expert. Being on Facebook or Twitter doesn’t make one an expert. Having 5-15 years of experience working in the space of Web 2.0 like Juliet, Susan Giurleo, or myself does. These are peer-vetted experts, experts vetted by peers in both the clinical and Internet fields. I used to be hesitant to say this, because even though I teach people how to self-promote as part of their business I still feel uncomfortable with it myself. But I feel it is important to make a distinction between people who have spent years and thousands of dollars learning how to integrate clinical practice and Web 2.0, and your colleague who has a nice website.

Look, we need to start taking social media seriously, 97% of our patients and other human beings use it. I applaud our professional organizations for trying to offer something. But the above approach reminds me of having your grandson hook up your DVD player when he comes home from college. It is shortsighted and underestimates the complexity of the matters at hand. At some point Therapists need to strike a balance between a healthy respect for the growing importance of social media and avoidant fear. And at some point we’re going to need to invest time, money, and serious thought into how, not if, we use it in our practice.

Filed Under: Business Tagged With: behavior change, building your business, marketing, private practice, psychotherapy, ROI, social justice, social media, twitter, Web 2.0

You Are Not A Non-Profit.

March 5, 2011 by langloimsw 16 Comments

Please do this for me; even if you never contact me and ask for a consultation or supervision, just do the following.

Print out this page.
Cut out the title to this blog post.
Find a picture of your child, partner, parent or other loved one.
Tape the title to the picture.
Place it on your office desk, where you can see it every day.

Huh?

This week in MA, we had further seismic tremors in the land of health care. Two tremors in fact. First, the news broke that our three biggest insurers Blue Cross, Harvard Pilgrim, and Tufts had reported financial gains this past year and strong investment income. In addition, the story reported that the CEOs of these companies made salaries ranging from 780K to 1.2 million dollars. News also revealed that BCBSMA’s board members collected an average of $68,000 last year to attend board meetings. That’s roughly $1,100 an hour.

The other big insurance news was that Tufts and Harvard Pilgrim decided to call off their merger. The reasons cited were that there wouldn’t be enough savings to offset the cost. Translation: They just wouldn’t make enough money to make it worthwhile.

What does this have to do with anything? Lots.

First, the salaries and board stipends underscore that Blue Cross Blue Shield is a non-profit business. That is why if you look at this list of BCBSMA’s Board of Directors, you will see top-ranking business-people and government officials. Put simply this means that it can dispense its surplus to reward board members and top management. They are a franchise, and in many cases, publicly-traded companies.

Second, and this is a reiteration of the first in a lot of ways, health-insurance companies are designed to make money, not just break even. They are a Non-Profit not because they don’t make money, but because of the way they disburse the money made, to their managers and board members (who incidentally are some of the people who have legislative power when it comes to healthcare reform.)

Back to your picture and my post title.

You are not a non-profit. You don’t even have to play the shell game with board members and management, because you are the management. It is understandable and easy to get distracted by the rage and yes, envy, that one feels at these “fat cats” making so much money. But let’s get real honest now. Here, I’ll go first:

1. I’d love to make 1.2 million dollars a year.

2. I live in a capitalist system, not a caste system, which means that just because I was born in a capitalist system I don’t have to live here, or, I can try to alter the system to be more in keeping with my socialist goals. But as long as I live in a capitalist system, money is an inevitable fact of my existence.

Now the hardest one, at least for me:

3. The minute I accept insurance reimbursement I become part of the medical establishment, and that means that the sickness and suffering of others is what creates a need for the commodity of psychotherapy. In other words, I need a steady stream of unwell or hurt people in order to make my living. If I do my job well enough, people won’t need me any more, and I’ll need to attract other hurt or unwell people. And even if I try to gussy it up in the form of “self-help,” I’ll still need people who need help.

Now I am not going to try to justify this to you, gentle reader, by saying I only make as much money as I need. I don’t believe greed is good, but I do want an iPad, and I don’t need an iPad. So I have to come clean and admit that I am not an non-profit.

I consult so often with therapists who take great pride in the amount of “slide” they have in their sliding scale. They are willing to give up that money without a lot of regret. Until they take out that picture of their family that I ask them (and now you) to put on the office desk. Look at it, at them. Those are the people you love, they are also being affected when you don’t charge full fee to someone who just got a new job, or when you don’t enforce your cancellation policy. They are the ones who are depending on you to help keep your family afloat. They are the ones who embody the best care you can give, and they will be with you and counting on you the rest of their lives in one way or another, often financially.

You are not a non-profit. You need to make a profit, and you need to stop pretending you don’t, and minimizing the profit so that you can pretend. I hate insurance companies and a lot of our healthcare system, and I am fighting for social justice when I am not working in my practice. But these companies get it, they get that they are in business.

We need to get that too.

Filed Under: Business Tagged With: building your business, HMOs, insurance, mental health parity, private practice, ROI, social justice, Web 2.0

Is your Practice Busy or Hectic?

December 10, 2010 by langloimsw 5 Comments

This time of year the reply I often get from colleagues when I ask how their business is going is “Busy!” This is often said with shortness of breath, decreased blinking, and other physiological signs of anxiety. At the college I teach at, I often see my fellow faculty members commiserating with each other about how busy they are there. I think lots of us are busy, but I think it is time to re-evaluate if we are really busy, or hectic.

The way I differentiate between busy and hectic is simple: ROI and organization. When I am busy, I have most of my clinical hours filled, am up to date on my billing, know which week I am teaching on the syllabus, and returning phone calls or emails within 24 hours. I am also eating and sleeping well. That’s “busy.” When I am “hectic” I am thinking “oh my god I have too many patients to see;” forget to do my billing (or avoid it;) unfocussed when I get ready to teach; and start “saving” (read sitting on/avoiding) voicemails and emails. I also feel more of a pull to commiserate, to tell people how “busy” I am. For me, talking about how busy I am when I could be doing something more productive is usually a sign that I am hectic, not busy.

Once you have started to feel more stress in your practice, pause immediately and ask yourself if this is a prod from your psyche to take care of yourself. Have you done that? Good, if the answer is you haven’t, and that you don’t have time to because you are too busy, you’re being hectic.

Now knock it off.

Really, I am suggesting it is that simple. Other than an opportunity to review for self-care there is NO ROI on being hectic. You won’t get more patients, you’ll get less. You won’t have more time by worrying or commiserating, you’ll have less. You may derive a sense of self-importance from how crazy things are, but you aren’t really impressing anyone, including if you are honest, yourself. So put down the cross, we need the wood.

Here’s a suggested checklist if you are still unsure whether you are being “busy” or “hectic:”

I miss appointments or double-book
I haven’t eaten today
I am avoiding the phone and email
I have complained to 2 or more people that I am busy
I feel like I am working too much, and making less than I usually do
I am behind on billing patients
I have open times for patients but can’t find the time to schedule intakes
I hate my office
I’m feeling cranky and dissatisfied with my clinical work
I can’t remember the last time I had a non-therapy conversation with a friend, or if I can it was over 24 hours ago
I feel a sense of dread when I think about work

You may notice that some of these can also be signs of burnout: This is not a coincidence. I firmly believe that if you don’t learn to distinguish between being hectic and busy, your business will fail. It will fail because you burn out, and or because you sabotage your income streams to the point where you have to close up shop and go work for someone else. And if you do that, you can guarantee they’ll help you learn the difference between busy and hectic the hard way.

So this weekend, take 15 minutes to sit and reflect, is my practice busy or just hectic? And if you don’t think you have 15 minutes to do that this weekend, you already have your answer. 🙂

Filed Under: Business Tagged With: building your business, mindfulness, private practice, ROI, stress

Many Happy Returns

August 1, 2010 by langloimsw Leave a Comment

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

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

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

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

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

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

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

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

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

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

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

with a third party.

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

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

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

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

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Is your Practice Busy or Hectic?

Many Happy Returns

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