Bringing Emerging Technology into the Clinical Process: Implications for Engagement and Treatment

If you have ever wondered how to begin attending to, listening for, and asking questions about a patient’s use of technology, this video might give you some ideas.  In it my colleague Lesa Fichte, LMSW, University at Buffalo School of Social Work, and I, discuss the role of technology, people’s relationship with technology, and how to integrate it into the treatment process by listening, inquiring, and learning.

 

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The Changing Landscape of Social Work

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Recently I had the great opportunity to be a scholar-in-residence at The University at Buffalo’s School of Social Work.  For three days I met with students, faculty and staff to speak about emerging technologies ranging from Twitter to video games.  During one morning, Dean Nancy Smyth and I sat down for a series of informal discussions around various topics, and the University was kind enough to let me share these videos with you.  If you want to learn more about how I can come to your institution to do the same thing, please contact me.

How to Use Social Media and Technology to Develop a Personal Learning Network:

 

 

If I Don’t Use Social Media and Technology in Social Work Practice What Am I Missing?

 

 

Social Work is Changing:  Integrating Social Media and Technology Into Social Work Practice

 

 

 

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Guild Wars: The Conservative Attack on Online Therapy

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 Practice42(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.

Bio Breaks

 

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The Perilous Price of a Good Living

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

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

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

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

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

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

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

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

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

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

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

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

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

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Worth a Thousand Words?: Infographics on Video Games

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

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

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

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

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

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

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

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

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But Not Your Thoughts: Social Media & Children

 

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You Are Not A Non-Profit.

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

  1. Print out this page.
  2. Cut out the title to this blog post.
  3. Find a picture of your child, partner, parent or other loved one.
  4. Tape the title to the picture.
  5. 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.

Tweaking 2011

photo courtesy of profalbrecht.wordpress.com

This is my first blog entry on Evernote.  I’m excited about that because learning and trying out Evernote is one of my 2011 goals.  More about that in a sec.

One of the reasons I love supervising therapists is that it keeps me honest and focussed on innovation.  The other night I was talking with a supervisee about scheduling our time for the upcoming year.  Would an evening time on another day work better for me? (Quite a thoughtful supervisee, not an uncommon experience given our field.)  I found myself answering that I wasn’t sure yet, because I needed to re-evaluate my evening time.  I have been noticing a drop-off in my work with adolescents, and have been coming to the conclusion that if I want to keep working with adolescents I’ll need to give up some of my evening time.

This time of year is an excellent time of year to give your practice and your career the lookover.  In the past several years I have gravitated to more traditional hours so I could pursue other projects.  For example, my professional development and networking goals for the past year and a half have been fulfilled by my Fellowship appointment at the Massachusetts Institute for Psychoanalysis.  In 2009 I identified the need for more collegial contacts and friendships as well as wanting to have CEs for my license.  The Fellowship has provided me both in abundance.  Like many of my actions to meet my goal, the MIP Fellowship was a “twofer.”

I always try to have as many twofers or threefers as possible, so that I don’t overwhelm myself with actions to meet the multiple goals.  Twofers are important to me because I want to consolidate my actions, but not my goals.  So I list my current goals and then put the actions under the goal(s) it fulfills.  I also rate it hot or backburner.  That way if I have a few actions I make myself evaluate the relative strength of my interest to do each.  So follow me along for an example:

Professional Development Goal

  • MIP Fellowship- heading towards backburner.  This is my last year of it, and I’m ready to move on to a different structure and get my Monday night back.
  • Program Exploration – hot.  I need to begin planning on what I will do to replace the Fellowship, which means taking a look at workshop or mini-course offerings or webinars that happen during the day.  Am I willing to give up my weekends yet?  Traditionally I have balked at Saturday workshops, so I am revisiting this.
  • Continuing Ed on cultural competency working with transgender population- hot.  My practice has been trending towards an increase working with this population, so I need to invest time in updating my skills in theory and best practices.

Clinical Therapy Goal

  • Adolescents- hot.  I have noticed that I am trending downward in my work with adolescents, a population I love.  Most adolescents require parental transportation and can’t miss school regularly, so I need to revisit my giving an evening up.  Saturdays? No.  (This is an excellent example by the way, of how there is no one right answer for this.  My colleague Susan Giurleo regularly works an evening and Saturday, and there are lots of good reasons for doing this.  I have consciously chosen the last 2 years to not have an evening because the evening time was more valuable to me than the money I was choosing not to make.  Choosing not to make money is different than saying, “why can’t I fill my practice, whoa is me.”  Money is one item of value, time is another, it is up to you to choose what you want to give up.
  • Gamers- hot.  I want to continue to focus on working with more gamers.  I need to revisit where and how to get referrals.  This year I will try to offer more public speaking opportunities to colleagues to increase awareness of gamer-affirmative therapy.  Also will use Twitter to remind my followers of my interest in working with this population.
  • Couples work- backburner.  Even on my best day, this is not my preferred modality.  I will maintain my “no more than 3” couple limit, but am tweaking it to focus on private pay, gamer couples or online therapy.

Technology Goal

  • Twitter-hot.  I continue to find Twitter useful, but am tweaking it a lot.  I will use it to Tweet blog articles or RTs and hold to my goal of 2RTs and 2 salient tweets (i.e., tweeting something I think is relevant professionally rather than for the sake of Tweeting.  Recently I have fallen short of this goal because of the magnitude of tweets that come my way.  Will add this to my Epic Win program and scale back on how much time I spend reviewing.  Will keep an eye out for Tweet-management software to see if I find any I like more than TwInbox.
  • Evernote- hot.  I have heard about how great Evernote is for too long from too many people I respect to ignore it.  I will familiarize myself with this program and try using it for blogging, as well as exploring which other goals it might further.
  • Game exploration-hot. I have been focussing on WoW and Second Life.
  • Rockmelt-backburner.  Still in beta and having some bugs.  Still limiting access so limited as social media.  Shut down and I lost a whole blog post!  I am continuing to play with it a little but relying on Firefox until it gets a little more stable.

Social Justice Goal

  • Give an Hour-hot.  I still find this a meaningful way of donating clinical time to fulfill the gap for returning vets.  There is an increasing number of vets and active duty gaming, and this is a potential twofer with the Clinical goal.
  • Diversity Class- hot.  I continue to find teaching this worth the “pay cut” I take by giving up those clinical hours.  This is a twofer a teaching goal and writing goal on rethinking how we teach Diversity.
  • Masshealth-backburner.  I am opting out of taking Masshealth due to the high cancel rate I’ve experienced in the past.  This is a twofer with my business Goal below of decreasing my involvement with insurance and diversifying revenue.

Business Goal

  • Reduce dependence on insurance-hot.  The writing is on the wall for decreased revenue and increased hassle as Health Care Reform takes effect.  Leave Masshealth and UBH networks.
  • Increase online therapy-hot.  I need to focus on increasing marketing for this modality, it is all private pay and more flexible in time to meet patients and my needs.
  • Increase consultation and supervision-hot.  Supervision and consultation was the biggest growing area of my practice last year.  Need to poll current consultees about what they find most valuable so I can emphasize that.  Be willing to slide down to my bottom line to attract supervisees in early stage of their career.  Make and post more video on supervision and consultancy.
  • Advertising-backburner.  Google Ads not yielding much ROI, decrease ad bids.  Stay on Psychology Today for next year but focus marketing/advertising through speaking engagements.

Teaching Goal

  • Additional psychodynamic class-hot.  New syllabus written and course approved.  Hopefully this will be offered this summer, will apply to teach it.
  • One class per semester-hot.  This tweak from two classes one semester and one the next was a big improvement.  Evaluations better, enjoyed work more.  Will consider whether to make up third class by committing to summer course regularly.
  • Offer visiting lecture or workshops to universities-hot.  This year I want to get out to more college health centers and schools for social work to present on gaming.  Tufts very successful, will look for opportunities to present at other universities.   Put the word out, twofer with business and professional development goals.

Writing and Research Goal

  • Newsletter-hot.  The readership response has been positive and begun to generate revenue.  Need to stay focussed on keeping newsletter relevant and yet distinct to my niche.  Review of clicks indicates that the psychoanalytic topics are more popular than the gaming ones.  How can I increase traffic to those stories?
  • Blog-hot.  Now have over 100 readers subscribed, and growing.  Need to continue to make this a focus.  2-3 posts weekly remains doable and will maintain 2 minimum.  Again, the practice/business posts are more popular than the gaming ones, need to consider how to increase interest in those articles.  This is a threefer with business and clinical goals.
  • Journal article-backburner.  The style and tone of blogging is much more satisfying currently, will revisit later in the year to see if this changes.

So that’s my beginning of 2011 review and tweak.  It took me 40 minutes to think and write about this.  Don’t you think it would be worth 40 minutes of your time to do the same?  What are your goals for this year, feel free to use the blog comment to get started!

Self-Promotion, No One is Gonna Do It For You..

When I am doing workshops with colleagues or consultations on building a practice, I am often struck by how mortified they become at the thought of self-promotion.  And yet, I know too well what they are up against.  I have been marketing myself for a while now, in a dozen different venues in multimedia, and it is only recently that I have begun to do so without the negative self-talk or twinges of guilt.

What was I worrying about?  Well, in the past I worried that people would say to themselves, “I am so sick of Mike tooting his own horn” or think of me as a narcissist or superficially greedy, etc.  Boy did I have to get over that, and if you want to be a successful business owner, you will too!

Back when I worked in a large institution it was fine to hide out, do good work with my patients and bring home a paycheck week after week.  But when you decide to start a private practice, you are basically committing to becoming a business.  And businesses need marketing.

One of the great things about being a solo practitioner is that your research and development department and your marketing department is the same person, you!  Self-promotion is much easier when you have a product or services that you believe in.  So I look for opportunities to do the things I enjoy, and then show my colleagues and clients how this adds to my value.  When a recent insurance company began stepping up its efforts to bully clinicians, I had no trouble rising to the occasion.  I like reading up on parity, researching and educating myself about the business climate, and thinking about how language can be used by HMOs to disempower therapists.  And after a few conversations with colleagues, who were clearly looking for a fresh approach to that problem in their practice, I realized that I had something of value to offer.  So now I’m doing workshops on the subject and loving it.

It is very tempting to trade the structure of an institution for the imposed structure of managed care.  Don’t do it!  If you do you have only yourself to blame.  As I tell my consultancy clients, you need to remember that the most important difference between you and the insurance company reviewer is that you have better things to do with your time.  The reviewer is a salaried employee who is paid to call you and conduct these clinical reviews.  Whether you are on the phone 5 minutes or 50 minutes, they get paid.  You don’t.  In your time you could be:

  • Seeing another patient.
  • Devising a workshop strategy
  • Networking with a colleague
  • Being the first to call a potential referral back
  • Writing your newsletter or blog
  • Designing your website
  • Writing your google ad
  • Writing an article for your professional magazine
  • Depositing checks in your bank
  • And more!

The way the intimidation tactics work is that HMOs are banking on your need to buy into a system, even a system of oppression, rather than your own.  Yes, they may say they are not going to pay for any more sessions, that’s their mission.  So make the call brief, and use the time to self-promote some other part of your business.

Self-promotion scares many of us even more than HMO reviews, but self-promotion ultimately pays better and gives you more freedom, motivates you to stay current and innovative, and puts you back in the driver’s seat rather than the victim seat.  I want to know:  What can you do to toot your own horn today?