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Social Justice & Technology Revisited

March 15, 2014 by 1 Comment

mccormick_reaper

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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Works, Life and Marshmallows: Iterative Design

February 13, 2014 by 2 Comments

marshmallow

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:

  1. So what are you going to do this time?
  2. How did that work out?
  3. 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!

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No Matter How You Feel, You Still Failed

January 14, 2014 by 4 Comments

Game_Over

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:

minecraft71

 

 

warcraft

 

 

pac man

 

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!

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Evocation and Mindfulness: Or, How to Think Better

October 16, 2013 by 2 Comments

evocation

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!

 

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Guild Wars: The Conservative Attack on Online Therapy

August 4, 2013 by 11 Comments

Commercial-routes

“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:”

 

  1. 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.)
  2. 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.
  3. 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.
  4. 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.

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You’re The Reason Building Your Business Is So Hard

May 31, 2013 by 22 Comments

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

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

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

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

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

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

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

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

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

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

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

 

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What To Do When Your Therapist Turns Into A Kitten

May 1, 2013 by 10 Comments

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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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How to Get Taken Seriously as a Mental Health Professional

August 8, 2012 by 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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The Perilous Price of a Good Living

June 30, 2012 by 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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Thinking, and Just Thinking

March 20, 2012 by 5 Comments

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

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

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

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

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

They listen and say they’ll think about it.

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

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

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

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

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

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