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So, for the time being, I’m quite happy with the solution I cobbled together.

I subscribe to Simplepractice, but I don’t think I’m going to use them until they have a more seamless imaging solution. Here’s what’s working really well for me:

Quickbooks Online – I key the session in the timecards section, and the system sends an email to the client with a link they can click to pay – which is then automatically credited to their account. My bookkeeper is quite happy with QuickBooks, to do all the mystical things that she does, so I’m happy too.

Outlook – When I schedule a session, I send an “invitation” to the client’s email address. Many EMR products include a session reminder sent to the client. That would be helpful occasionally, but only occasionally.

Evernote – Here’s my latest thrill. I take notes throughout a session, and at the end of the session scan the note into Everlink. The note is titled with the date automatically. Once a day I take less than a minute and drag each image into that client’s Notebook in Everlink. There’s something compelling about Evernote. (“Stop me before I scan again!”) Security up the wazoo, through them and also through Dropbox.

iPad – To refer to previous notes during a session, I have them right in front of me on the iPad through Everlink. If I want to mark up a previous note, like a dream, I can do that on the spot with a stylus. Okay, so far the stylus is so funky that it’s not useful. But I can just type comments above or below the image.

I’m quite pleased with my solution. But I don’t do insurance billing, and rarely have to type up progress notes. If I did those two things, I’d probably use a combination of Simplepractice and Evernote. But for now, whew. These things are working!

SimplePractice

I’ve kicked around building a practice management system with my brilliant programmer buddy from my consulting days. Everything I could find out there was overbuilt, and hence too complicated for a ten-minute break that includes saying good-bye, going to the bathroom and making a cup of tea. But we learned some years ago that a bright idea is a minuscule fraction of what’s required for success in the software market. You have to be ready to knock yourself out for years getting it right, serving customers, and selling selling selling. No, thanks. I like my current job.

But what we had in mind has been nailed, I think, by SimplePractice.com. They’ve built a simple user interface, just the meat-and-potatoes for the individual practitioner. They’ve got scheduling, billing, progress notes. I don’t care about insurance billing, but they’ve got that. They’re working overtime to provide good customer service, and their prioritization of new features (the order in which they roll them out) is sensible.

Unfortunately, they don’t have a piece that I require. I take my notes on paper during a session, and want to scan them post-session. During a session, I want to be able to look up past notes REALLY quickly. They took a first pass at imaging, but their imaging solution isn’t really there yet for what I need. They found some capital somewhere, because they’re buying ad space with various online markets. And yes, it creeps me out that somehow Yahoo knows I’m interested in them and keeps trying to sell me their software.

I went ahead and bought their product, and I won’t be surprised if I convert to them in a year or so, once they’ve grown the product some. But I’m content for now with the solution I’ve finally cobbled together, which, if you’re interested, you can read about in a post named accordingly. “Cobbled together?” I suppose it has to do with making shoes, right?

All I want is a piece of therapist software that:

1. Allows me to enter the cash and checks I receive, and print statements.
2. Keeps my calendar, allows people to book appointments online, and sends reminder emails.
3. Lets me enter reminders for the next session.
4. Provides a way to enter session notes.
5. Runs across the Internet in a secure browser connection.
6. Cuts directly to the chase, and doesn’t do a bunch of other stuff that makes screens complicated and navigation ponderous.

Software vendors, in order to compete, imagine that they need to keep adding features. But I just want something really simple!

If my buddy Steve-the-software-genius gets motivated, he’ll stay up nights for a couple weeks and whip it out. We used to make hospital software together, and he could do an amazing amount of coding in a few weeks, given enough coffee and donuts. Whenever we were worried about project progress, I’d remind him of the character of Boxer in Orwell’s Animal Farm, who would simply say, “I will work harder.” (I didn’t mention that Boxer ends up in a truck headed for the glue factory.)

We were younger then.

Meanwhile, I’m making do with Outlook and QuickBooks.

My needs as an individual therapist in a private practice are so simple. I just want to keep track of appointments and money, and keep simple notes about each session. There are dozens of software packages for therapists out there, this should be a slam-dunk.

But it isn’t.

I’ve now looked at 15 or 20 packages and I’m not happy. Now, I do require that it be a highly secure internet-based therapist software package, which eliminates most of the vendors. The problem with all the others is that they DO TOO MUCH. Most recently I took at look at TherapyCharts. They met my criteria, they have a nice website, they look substantial. When I tried to register for an evaluation account they reminded me that I had already done so – several times! Then I remembered the problem, which is a familiar one. I want a simple screen to register clients and track appointments and payments. To do that in their software meant digging through multiple screens.

I’ve got ten minutes between clients, and that has to include making my tea, going to the bathroom, and returning urgent calls. I need a therapist software package that I can use in ONE or TWO minutes.

So, now I’m trying MyClientsPlus. I’m working at maintaining an optimistic attitude.

Dan Quinn, Psy.D. Psychotherapist
www.DanQuinn.Info

Oy vey, I’ve been combing through the (many, many) software packages which offer to make my life much simpler as a psychotherapist and automate psychotherapist tasks, and so far they’ve all gotten carried away with all the EXTRA neat things they could help me do – except I DON’T WANT TO! I just want to put in a few pieces of information about my clients in a highly secured piece of software, capture a progress note and a session date/time, and get back to thinking about my clients!

Any ideas for simple software for psychotherapists would be GREATLY appreciated.

Posted by Dan Quinn, Psy.D. Psychologist in Berkeley California. www.DanQuinn.Info

Neat idea from therapick.com – they hail from Hollywood, and are professional film editors. They’ll interview you on camera for a half hour about how you work, edit the result down to several minutes, and then post the video on their website. They are working toward being a therapist selection site for prospective clients who want to see videos of their options for therapist. Therapick charges $150/year, and they’ll provide the video link to you on Youtube, so you can embed it on your own website.

Here’s a summary from their website:

Founder and CEO David Brundige, an award-winning filmmaker turned web entrepreneur, created Therapick after witnessing a loved one visit five different therapists over the course of two years before quitting. It made sense to build a website that would allow her and other potential clients to get a sense of a therapist before spending the money and time to go in for that first visit.

Pick a Therapist on Therapick!
Your relationship with your therapist is important. Research indicates that success in therapy is highly dependent on a strong relationship with your therapist. That’s why Therapick believes that the best person to choose your therapist is YOU!

Finding a therapist is a personal experience. On Therapick, you can search videos, read profiles, and email therapists you might want to work with. If you don’t like the vibe of a psychologist, counselor, or psychiatrist, move on to the next one. It’s that simple. Our videos let you choose.

We’ve interviewed hundreds of licensed psychotherapists in Los Angeles and Orange County to give you the best selection for individual, couples, and family counseling in Southern California. Whether you’re looking for psychotherapy, marriage counseling, or even hypnosis, Therapick’s videos give you a better sense of who a therapist is before going in for your first visit.

www.therapick.com

Here’s a great little summary of one therapist’s approach to growing her practice. She’s got an organized approach, and she clearly has a handle on psychotherapy finances. It speaks to the question of whether or not to create a narrow focus in one’s practice.

A narrow focus on special populations keeps a therapist busy

Last month we profiled a practice that was prospering as the result of a diverse, something-for-everyone approach. The two therapists in that article have several niches, and work in many different ways–including online.

Joan Unruh’s practice is 180-degrees away from that. She serves just two niches in her Boulder, CO, practice: anxiety and eating disorders, with a sub-niche working with college students. She’s 75% self-pay, does little or no telephone work, and doesn’t employ a sliding scale.

Most clinicians probably can’t–or won’t want to–adopt all of Unruh’s approach. But almost everyone can pick up one or two good ideas based on her experience. Below, we go over the key facets of her practice.

l Overall, her practice mix is young, female, and willing to pay cash. “About 85% of my clients are women,” she tells us. (Male clients are generally seeing her for anxiety, she adds.) “A majority of them are in their 20s, then there are some in their 30s. My oldest client is 55–I’m seeing him for social anxiety disorder.

“My out-of-state college students tend to have parents with money,” Unruh goes on. But in many cases, it’s motivation rather than simply the ability to pay cash that brings clients to her door. “I find that most of the people who find me have tried many other therapists, and are looking for my specialties. So I haven’t had to slide very much.”

l She was narrowly focused from the start. “It was a conscious choice. I knew there was a need for eating disorder specialists in the Boulder area–it’s such a weight and fitness conscious environment. There are a lot of triathletes, and a lot of people who’ve moved here specifically for the outdoor, fit lifestyle.

“I’d started out in substance abuse. There wasn’t really any certification for eating disorders, but I felt I had a lot of good experience in motivational interviewing, and substance abuse theory. So I transitioned almost 100% to eating disorders to start. That was in 2000.” Unruh maintained a part-time practice, keeping her day job with Kaiser Permenente until 2007, when she entered full-time private practice.

l On average, Unruh’s patients stay in therapy for over six months. “I keep a spreadsheet on that,” she tells us. Almost all of her patients come in weekly, she goes on, and a majority are self-pay, paying her full fee of $120. “I started out 100% self-pay, and it wasn’t until 2007 when I quit working part-time at Kaiser that I decied to add some padding…I work with Anthem Blue Cross/Blue Shield. That’s it. (See details in the box, above.)

l Roughly a third of her clients are college students. “My office is walking distance from the University of Colorado at Boulder campus–I chose it specifically to accommodate that population.” Many of these clients have eating disorders but “anxiety and stress are huge” in this group.

“Sometimes you have students who are just trying to acclimate, who are away from their parents for the first time…With other kids, they had a therapist at home, and they’re continuing their work with anxieties, OCD, panic, or eating disorders…Very often, I get a call from parents who say, ‘My kid’s a freshman. Can we come in for a consult on parent’s weekend?’ And we go from there.”

Parents frequently find her online, through her website, www.joanunruh. com, or through therapists directories at PsychologyToday.com and Network Therapy.com.

Students sometimes find her on their own, “referred by one of their sorority sisters…And I go to monthly meetings at the university. There’s a task force on eating disorders. So I have a presence there, and I’m on their list as a referral resource. The university provides students with a certain number of sessions in-house and then they refer out.”

l She makes it easy to pay her–offering a credit card option online. “You can go right on my website and pay there…Parents especially love that. A lot of the students are from out of state, and it’s the parents who are paying.”

l She’s a steady marketer, making good use of her website, as well as meeting roughly four times per month with a colleague or allied professional. “It’s not a formal thing,” Unruh says. “I just call around and see who wants to do something–coffee or lunch.” In addition, she puts a lot of stock in offering potential clients a free initial interview, to make sure they’ll be comfortable with her. (Unruh was featured in our April, 2010, “Marketing” article on free first sessions.)

“And I coordinate with registered dietitians, primary care physicians, as well as psychiatrists…I’m in touch with at least one of those, once a week. And when there’s a critical patient situation, we might talk two or three times a week.”

You can contact Joan Unruh in Boulder, CO, at (303)668-9024, www. joanunruh.com. Medicare,” she says. “That’s why for now, Medicare is our main concern.”

Nuts & bolts: Seasonal concerns

Joan Unruh is in solo practice, sharing an office suite with four other unaffiliated professionals. Two of her suite-mates are therapists, another is a career counselor, and the fourth is a psychodramatist. She pays $925 per month for her own 350-square-foot office.

Which of her two niches is more important? “It depends on the time of year. When school starts in the fall, I see a lot of anxiety, and stressed-out students. Then in the summer, you see people who are getting concerned about weight issues with all the summer activities.”

Her typical caseload is 30-35 sessions per week. “It got as low as 20 over the summer,”she tells us. But since school started, it’s back up again.”

Patient sessions are grouped into three long days: Tuesday through Thursday, with some spillover onto Saturday. But she plans to spread that out a bit when her son enters kindergarten

The only insurance she works with is Anthem Blue Cross. They pay $76 for a 90806 and “about $100” for a 90801. Unruh’s out-of-pocket rate (paid by 75% of her clients, she says) is $120.

About half her clients pay with a credit card. She processes through PayPal, paying them about 2.9%. She uses a small local billing service to chase insurance payments, “and I maintain an Excel spreadsheet to keep track of the folks who are full fee.”

All client calls go to her iPhone. “I encourage patients to text. Most calls involve scheduling conflicts, anyway, and it’s easier to deal with it that way than by phone…And when I get home I turn it off.”

www.psyfin.com

I’m told it’s rare, but I haven’t seen any data. Here’s a quote from a NY Times article way back in 1983:

- Although precise numbers are unobtainable, it appears that a few psychiatrists are murdered by patients each year. In a six-week period in the summer of 1981, four psychiatrists, one each in Massachusetts, Florida, California and Michigan, were murdered by patients.

Here’s a current, tragic story about a schizophrenic man who murdered his therapist.
As Sergeant Esterhaus used to say on Hill Street Blues, “Let’s be careful out there.”

NEW YORK (AP) – A schizophrenic accused of murdering a psychotherapist with a meat cleaver was ruled mentally unfit Tuesday for trial, indefinitely delaying a trial that came close to starting but has long
been rocked by uncertainty about his mental state.

The decision means David Tarloff will be sent to a state hospital for treatment until doctors find he has improved enough to stand trial _ if they ever do. He has varied between findings of fitness and
incompetence since his 2008 arrest in Kathryn Faughey’s death in her Manhattan
office.

The ruling came after two psychiatrists found Tarloff incompetent for trial, and a prosecutor said he refused to cooperate with a third exam, leaving that doctor unable to reach a conclusion
about his fitness and prosecutors unable to challenge it.

“Consequently, I have to commit Mr. Tarloff,” state Supreme Court Justice Edward McLaughlin said. “There is little doubt that … Mr. Tarloff has had documentable periods of unfitness.”

Tarloff, 42, is accused of killing Faughey as part of a peculiar robbery plot targeting her office mate. Tarloff has planned an insanity defense, which involves different standards than mental
competence for trial.

Given to delusions that he’s the Messiah and that God and the devil speak to him, Tarloff has a long history of psychiatric hospitalizations, his lawyer and psychiatrists have said.

He told police he went to Faughey’s office to rob the psychiatrist who shared it, Dr. Kent Shinbach. He’d been involved in Tarloff’s first hospitalization – 17 years before.

Tarloff’s goal was to get $50,000 from Shinbach to whisk his mother out of a nursing home and take her to Hawaii, he said in a video-recorded statement.

He encountered Faughey first and believed she was going to kill him, he told authorities.

Faughey was slashed 15 times, and Shinbach was seriously hurt trying to help her, authorities said. The attacker fled; investigators ultimately matched Tarloff’s palm prints with some found on a
suitcase – filled with women’s clothing and adult diapers – left in the
building.

He was deemed mentally incompetent for trial for about a year after his arrest, but doctors said last year that his condition had improved.

Being competent for trial means being able to understand court proceedings and help in one’s defense. It doesn’t rule out an insanity defense, which requires showing that a person was so mentally ill
when committing a crime that he or she didn’t know it was wrong.

Jury selection was nearly finished last month when Tarloff refused to leave a courthouse holding cell or respond to questions, his lawyers said. After being taken back to Bellevue Hospital, he
stripped naked and ran around a psychiatric ward, according to his lawyer.

Two court-system psychiatrists found Tarloff mentally unfit to proceed, and then prosecutors had another expert evaluate him.

During that exam, Tarloff “shut down” and stopped speaking, Manhattan assistant district attorney Evan Krutoy said. Tarloff’s lawyer, Bryan Konoski, said his client had started talking to himself
and then abruptly froze, wide-eyed, during the exam.

As for the future, “I think it’s possible that he’ll be found fit enough to return to court” at some point, Konoski said. “But I’m not sure he’ll ever be fit enough to withstand the stresses of a full
murder trial.”

Faughey’s relatives said Tuesday’s developments wouldn’t diminish their determination to see the case through; some of her siblings have attended every one of Tarloff’s court appearances.

“We’ve been through this a few times,” brother Owen Faughey said.

Kathryn Faughey, 56, specialized in helping people with relationships.

http://www.therapynetworking.com/forum/topics/man-found-unfit-for-trial-in

Gung-Ho Marketer

I appreciated this entry in a therapist’s blog. It’s nuts that we’re not taught how to do marketing in grad school along with CBT and Child Development. It’s one of the key reasons why psychological services are so widely under-utilized. Marketing therapy is a gift to the community.

The reason I have so many referrals is because I worked long and hard to develop multiple referral streams. I join EAPs on the other side of the US so I could be their only provider in MA. I advertise in every free online venue I can. I have a presence online in Psychology Today, on Google and HelpPro. And in real life I am constantly talking with my colleagues, networking, sending out newsletters and giving workshops. This all occurred during those hours I had vacant in my practice to start with, and still occurs, sometimes at 2:00 AM! I’ve got my own hell to raise, so when I pass along a referral, don’t expect me to do your footwork for you.

We therapists need to cultivate our aggression when it comes to getting patients. No, I don’t mean going out and clubbing them on the head to drag them to our office. I mean that we need to be willing to spend hours marketing ourselves, refining our strategies; hours and dollars on consultants and coaches if we need to learn how to do this. We undervalue that part of the business, worse, we sometimes act as if we think it is below us.

In another section he makes a compelling case for therapists to not just become marketing savvy, but to become adroit in the use of technology to reach out to therapy clients. Again, not just because therapists need the money, but because all these people who could benefit are not getting help.

You may think by the above tirade that I am exempting myself from this, but I am not. I still catch myself shying away from talking about online gaming because I worry we won’t talk about the “serious stuff.” I still struggle to refrain from interpreting that conversation about blogging as avoidance. I still send dozens of nonverbal cues that shape the expectations about what can and cannot be considered important in the therapy room. I do it too, and this is a work in progress.

You may also think that I’d be happy as a businessman to have found a niche that few of my colleagues are tapping into.

I’m not.

I used to be, but now my practice is mostly full, and when I have a request to take on a patient who wants a gamer-affirmative therapist, or a therapist who does not view blogging as social phobia, or a therapist who takes virtual affairs in Second Life seriously, I don’t know who to refer them to. I have many names to offer for EMDR, IFS, CBT, DBT, psychoanalysis. I have many trusted colleagues who have years of dealing with mood disorders, anxiety, trauma and bereavement. But I have only a handful of peers who I can refer to and trust that technology talk will not be taboo or overlooked.

I need your help, and I need you to care enough to learn. People are dying, or living alone in pain, because not enough of us are staying in learning mode. People are flunking out of school, losing jobs, ending good relationships and beginning bad ones, and they don’t have time to explain to you and I what Twitter is on their dime. Please begin to push yourself. Download a new iPhone App for the DSM IV ($.99,) , or surf over to Technorati (free) and read a few blogs, or create a free character in Second Life.

This is continuing your professional education: This is important.

http://mikelangloislicsw.wordpress.com/

Ah, sweet relief! You’d think a therapist would know when to get help, but it took me YEARS of messing around with websites and trying to learn Adobe Illustrator before I realized: I need people who actually know how to do these things. So I found a graphics designer, a programmer, and the Best Marketing Coach, Lynn Grodzki (www.privatepracticesuccess.com). I dug around, looked at a half-dozen of the coaches who specialize in therapy practices, and settled on her, and am I glad.

She asked me a whole lot of questions, and then started dictating things to do so fast I had trouble writing them all down. I’m convinced that if I JUST DO WHAT SHE SAYS I will have no problem reaching my particular niche market.

If you’ve been reading these pages you know that I am convinced that outreach is a big responsibility of every therapist, and it should be taught in every graduate program, and should be part of licensing exams. The population is going largely un-served because of our failure to reach them, and tailor what we do to methods that they will embrace.

I’m convinced that there is a huge opportunity for therapists to fill their practices and serve the public. Now I’ll put that hypothesis to the test.

Here’s some info from Lynn’s site:

Are you a psychotherapist, counselor, healer, coach, in private practice? Are you a professional or executive in business?

Do you wish you had a business coach – an expert in the field — who could help you set and meet your private practice or business goals, someone who would stand behind you as you reached for more success? Want to brainstorm, resolve difficult situations, develop confidence in your business ability — and hate to go it alone? It’s time to partner with a coach!

Meet Lynn Grodzki, nationally-known, Master Certified business coach, senior psychotherapist, former executive and entrepreneur. She can support you or help you think through your goals. Lynn can strategize with you or show you how become more profitable and purposeful!

Book single or monthly coaching sessions by phone or in person today!

Start with Lynn’s “Living Brochure” — a 30 minute free introductory session to help you see if business coaching with Lynn is right for you. Click here to learn more!

What others say:

“In person, Lynn Grodzki is even better than her books. She models integrity and authenticity and shows you how to market yourself without selling out!”
TR, Marriage and Family Therapist, California

“I am off all managed care, seeing only those clients that are ideal for me. My income has doubled in the past year. Lynn really gets me and helps me identify and overcome the negative belief systems that used to keep me stuck.”

AV, Licensed Professional Counselor, Virginia

I’ve also been impressed by the podcasts of these guys, Joe Bavonese and Mel Restum. I might get them to review what we come up with, once the foundation is in place:

If you’re like us – and most clinicians – you learned little or nothing about business or marketing in graduate school. In contrast to the confidence you probably feel about your clinical skills, you may feel inadequate or uncomfortable in knowing what to do or how to proceed in promoting, marketing and growing your practice. Or you may know what to do, but just really dislike doing it.

We’ve also found that today there are a number of factors making it harder for psychotherapists in private practice to succeed than ever before. We are all dealing with things such as:

* Managed care

* The rise of free non professional help

* The rise of the coaching industry

* The increased use of antidepressants to address mental health issues

* The rise in alternative therapies such as bodywork, yoga, Pilates, herbs, vitamins etc. to deal with emotional concerns

* The ubiquity of the Internet, offering tons of information and advice only a click away

We took an uncommon approach to dealing with these challenges, studying with very successful, nationally-renowned small business marketing consultants, who were NOT psychotherapists (see Our Story for more details).

The results were remarkable: within four years, we had filled up our practices and had extra referrals we couldn’t handle – enough to allow us to expand to group practices which have generated passive income for us ever since. We’ve created practices that are within the top 1% of all mental health practices, and seen our incomes rise every single year, despite changing economic conditions.

Here’s a graph that clearly demonstrates what happens when you add solid business knowledge to your practices. Note that this data represents a time when the economy was doing well! The following data from Psychotherapy Finances newsletter shows the percentage change in income for various therapy degrees from 2000-2005, along with our changes:

And our practices have even done well during the recent severe recession – living in Michigan no less, with the highest unemployment rate in the country.

And the reassuring thing to know is that these business ideas and practices are not rocket science – they’re not conceptually difficult – it’s just that we in the mental health field have just never had training in them. Once you learn them, it’s like the difference between riding up a hill on a bicycle with or without gears – with the gears, you get where you want to go more quickly, and with much less effort. We learned (the hard, expensive way) that working harder only makes you more tired, whereas working smarter makes you more successful.

One bonus from our success is that we’ve also found that the work itself becomes much more rewarding when you don’t have to worry where the referrals are coming from. The original reasons you went into this field – to do stimulating, creative, rewarding work which helps people – comes back to the forefront of your work.

Which leads us to another point: we’re not some armchair therapists who have left the field or are encouraging you to go into coaching. We love doing psychotherapy and believe it is still a vital, necessary service in our world. We still practice psychotherapy and run psychotherapy businesses full time. We know exactly what you’re dealing with – we deal with the same issues every day.

So our Mission is to take the best of what have learned the slow, expensive, hard way – and teach it to private practitioners who have a sincere desire to succeed in private practice. We have great respect for the traditions of psychotherapy and counseling. We believe that they are extremely important, valuable and at times life-changing services that are much needed in our communities.

Our goal with this business is to provide psychotherapists and counselors with the best resources, information, tools, support, guidance and accountability to help you:

*

provide the best service to the greatest numbers of people you desire to serve;
*

create you own Ideal Practice, in whatever terms that may be, including financial, lifestyle, and other factors;
*

master a marketing and business mindset that you can utilize for the rest of your career; and
*

create a balanced, healthy, fulfilling life for yourself.

Furthermore, we are committed to:

*

Using the latest technology available to make access to our information convenient, understandable and stimulating;
*

Making the process of learning, change and growth into a marketing mindset an enjoyable and intellectually stimulating experience; and
*

Sharing all of the latest ideas, trends and practices in marketing and business as they become available.

http://www.uncommonpractices.com/about.html

Hey, get a Skype session going and provide therapy anywhere in the state! Sounds easy enough. But there are a lot of ways things can go wrong. For example, how do you know that the “container” at the client end is in fact private? Or, if a client across the state rapidly declines and then hangs up on you, what do you do?

Now it looks like Skype is getting the willies about possible litigation stemming from the use of Skype as a therapy container, at least for their “Skype Prime” directory of service providers (referred to as “Call Providers”).

The Admin for the Skype community comments:

Call providers are not permitted to offer services relating to the following categories:

• Content or Service, which is adult, sexual , pornographic or paedophiliac;
• Content or Service which is offensive or promotes or legitimates racism, revisionism, or any other form of discrimination;
• Content or Service relating to the offering of gaming, betting and lotteries;
• Content or Service provoking violence
• Content or Service provoking or encouraging reprehensible or illegal actions.
• Content or Service relating to health and therapy
• Content or Service relating to legal or tax advice
Call providers must not promote their service or content on web pages which may be contrary to public order or good morals or likely to violate any law or to constitute a criminal offence.
The following categories are currently available to describe service calls:

Astrology & Spiritual
Business & Finance
Computing
Creative services
Coaching and tutoring
Relationships
Sport
Others

Skype has a special category of users they call “Service Providers,” using “Skype Prime,” for whom they provide a wraparound billing service. Nothing about therapy is said in the basic EULAs for users; it looks like the only agreement to comply is required if you wish to use Skype Prime services. Here’s their EULA:

Service Provider Agreement
IMPORTANT – PLEASE READ CAREFULLY

Entering into this Agreement: This Service Provider Agreement (the “Agreement”) constitutes a valid and binding agreement between Skype Communications S.a.r.l and You, as a Premium Call Services Provider (“the Service Provider”). You must enter into this Agreement by clicking on the ACCEPT button. You hereby agree and acknowledge that this Agreement covers all the provision of Contents and/or Services through the Skype Software, by You. You must be 18 years old or older to enter into this Agreement.
Preamble

Skype wishes to offer its end users a new chargeable service over Skype Software, allowing Service Providers to provide chargeable products or services to its users through the Skype Software.
1. Skype Software,Content, Service and Support

1.1 Capitalised terms that are not defined in this Agreement shall have the meaning given to them in the EULA, Terms of Service or any other Additional Terms (as applicable).

1.2 The “Content” shall mean any and all content consisting of text, sounds, pictures, photos, video and/or any type of information or communications.

1.3 The “Service” shall mean the provision of Content by the Service Provider to the end users of Skype Software (the “Users”) via the Skype Software whether such Content is generated by the Service Provider or by a third party content provider.

1.4 “IP Rights” shall mean (i) patents, pending patent applications, designs, trade marks and trade names (whether registered or unregistered), copyright and related rights, database rights, knowhow and confidential information; (ii) all other intellectual property rights and similar or equivalent rights anywhere in the world which currently exist or are recognised in the future; and (iii) applications, extensions and renewals in relation to any such rights.

1.5 To provide the Service, Service Provider must download the Skype Software, accept the EULA, Terms of Service and privacy policy and register for a User ID. Service Provider shall provide the Content and Service to the Users through Skype Software and through Service Provider’s User ID, in accordance with the terms of this Agreement.

1.6 Service Provider represents and warrants the accuracy and completeness of information it has provided to Skype upon subscription and shall notify Skype without delay of any changes in such information. Service Provider acknowledges that all such information may be publicly displayed and communicated to third parties by Skype, including to the Users, and permits such disclosure.

1.7 The “Skype Prime API” means the application programme interface that enables users to interact with Skype Prime for the purpose of retrieving Content relating to a Service from the directory owned and operated by Skype in respect of Skype Prime which is featured on the Skype Website and on the Skype client application (“Directory”), and displaying such Content on their website, webpage, software application or program (“Website”).Service Provider acknowledges and agrees that the information included in the Content submitted by Service Provider (including without limitation personal information such as the Service Provider’s User ID) in accordance with this Agreement may be accessed by users of the Skype Prime API and displayed on their Website and viewed by the general public.

1.8 Service Provider may provide the Content or Service in the following languages only: English, French, Italian, German, Spanish, Japanese.

1.9 In the event of any issues, claims or questions from Users relating to the marketing, promotion, pricing, communication problems, or generally any issue in connection with the provision of the Content and/or Service (the “Service Issues”), Skype will be the first level of customer support. Customer support will only be provided in the languages listed in section 1.8.

1.10 In the event of a refund request, Skype shall decide, in its sole discretion whether to pay a refund to the User. Skype may contact Service Provider at any time by email or by telephone to investigate any matters regarding a Service Issue or to ask for Service Provider’s cooperation to resolve the Service Issue. Service Provider will cooperate and abide by any requirements from Skype to resolve the matter.

1.11 Service Provider solely is responsible for promoting the Service.
2. Fees and Payment Terms

2.1 The price at which the Service is offered will be determined by Service Provider upon registration and can be changed from time to time. The permitted limits for the fee shall be between 0.1 EUR or 0.15 USD and 2 EUR or 2.5 USD (excl. 15% VAT) per minute and between 0.1 EUR or 0.15 USD and 10 EUR or 12 USD (excl. 15% VAT) per call. Service Provider shall be responsible for monitoring that such limits are not exceeded. Fees shall be expressed with and without VAT (15%) in all promotional and marketing communications, and Skype shall charge 15% Luxembourg VAT when applicable.

2.2 Skype shall either (i) enable Service Provider to communicate such fee to User through the Skype Software, prior to the provision of Service or (ii) communicate the fee defined by the Service Provider through the Skype Software or otherwise, in a way that User has necessary knowledge of the fee, prior to the provision of chargeable Service.

2.3 The duration of the chargeable Service shall be from the moment a User requests for the Service and approves the applicable fee, until the termination of the call by User or Service Provider. The total fee is calculated in one-minute increments, and fractions of minutes will be rounded up to the next minute after 5 seconds.

2.4 Skype shall collect fees from Users. Service Provider shall be entitled for a service fee for the provision of the Service (the “Service Fee”) as a percentage of Gross Adjusted Revenue. Skype reserves the right to change the Service Fee from time to time by publishing the revised Service Fee on the Skype Website. The revised Service Fee shall become effective within thirty (30) days of such publication. The express acceptance or continued provision of the Service or Content by Service Provider after expiry of the 30-day period shall constitute Service Provider’s acceptance to be bound by the revised Service Fee. You can find the current Service Fee(s) at: www.skype.com/go/skypeprimefee

2.5 For the purposes of this Agreement, the “Gross Adjusted Revenue” shall mean the aggregate fees paid by Users for the Service less (i) applicable value added, sales or similar tax, (ii) amounts refunded in accordance with paragraph 1.10 and (iii) any payment from a User that has been charged back for any reason whatsoever. Further, no Service Fee shall be paid (i) for fees charged over and above the permitted limits (per minute and per call) defined in paragraph 2.1 (ii) if Skype reasonably believes that Service Provider is in breach of this Agreement. The Service Fee shall be calculated solely based on invoicing records maintained by Skype and the statements of Service Fee issued by Skype are final.

2.6 The Service Fee will be paid no later than four (4) months after the end of the calendar month during which the Service is provided to the User, by day 15 of the applicable month. The Service Fee may be paid in the following currency only : EUR, USD.

2.7 The Service Fee will be paid exclusively into the Service Provider’s PayPal account. Service Provider shall open and maintain a valid PayPal account and shall provide Skype with the email address registered with their PayPal account. The Service Provider understands that PayPal supports receiving and withdrawing money only within certain countries, and under certain conditions as set out in PayPal’s user agreement. Service Provider is responsible for checking that the Service Fee has been received into their PayPal account. If the Service Provider has not received payment or has received insufficient payment, they should visit Skype support at https://support.skype.com/. If for any reason whatsoever the payment of the Service Fee cannot be received by the Service Provider’s PayPal account, the amount will be held for a six (6) month period. At the end of this period, the debt will expire and no payment will be issued for the expired debt. Any costs, loss or fee associated with the payment of the Service Fee, including any fees charged by PayPal or conversion costs, shall be borne exclusively by the Service Provider.

2.8 In the event of a Service Issue, or if Skype suspects any abusive (for example, but not limited to, artificially increasing the Gross Adjusted Revenue), fraudulent or illegal activities, or if Service Provider breaches this Agreement, Skype will have the right to retain the payment of applicable Service Fee until there has been a complete settlement of the matter. If the applicable Service Fee has already been paid and claim results in a refund, Skype is entitled to either deduct such refund from the future invoice for Service Fee or charge it to the Service Provider directly.

2.9 If the Service Provider is based in Luxembourg they may have to charge VAT on the Service Fee. Invoices should be sent to Skype Communications Sarl, 23-29 Rives de Clausen, 2165 Luxembourg, VAT number (LU 20981643).
3. Skype’s Undertakings

3.1 During the term of this Agreement Skype shall provide the Skype Software and enable the Service Provider’s provision of the Service from its Skype ID as set out in this Agreement.

3.2 Skype shall use reasonable endeavours to keep the Skype Software available for the provison of the Service. Skype is entitled to suspend the Skype Software or a part thereof in case it is necessary for the repair, improvement, and/or upgrade of the Skype Software. Further, Skype may change the technical features and/or otherwise adjust the Skype Software at any time in order to comply and keep pace with the latest demands, requirements and technological developments, at its own discretion.
4. Service Provider’s Undertakings

4.1 Service Provider shall provide the Service pursuant to the terms and conditions set forth in this Agreement.

4.2 Service Provider represents and warrants it is entitled to provide the Service under the laws and regulations applicable to the Service, Service Provider and/or its operations.

4.3 Service Provider declares that it has never been subject to investigation or criminal complaints in connection with the provision of Service, other types of services similar to the Service, or any types of services provided through public switched telecommunications networks.

4.4 Service Provider undertakes to comply with all laws and regulations applicable to it and to the provision of the Service. In particular, Service Provider undertakes (i) not to make available Service or Content, (ii) or promote your Service or Content on webpages, which may be contrary to public order or good morals or likely to violate any law or to constitute a criminal offence and, in particular a:

4.4.1 Content or Service, which is adult, sexual or pornographic;

4.4.2 Content or Service which is offensive or promotes or legitimates racism, revisionism, or any other form of discrimination;

4.4.3 Content or Service relating to the offering of gaming, betting and lotteries;

4.4.4 Content or Service provoking violence; or

4.4.5 Content or Service provoking or encouraging reprehensible or illegal actions.

4.4.6 Content or Service relating to health and therapy.

4.4.7 Content or Service relating to legal or tax advice.

4.4.8 infringes the IP Rights of any third party; and/or

4.4.9 breaches the terms of this Agreement, the EULA, Terms of Service or any other applicable Additional Terms.

4.5 Service Provider warrants, represents and undertakes that the Service and Content will not infringe the rights of third parties, including the right to privacy, the right to personal data protection, copyrights, trademarks and patents, software licenses or any other industrial or IP Rights.

4.6 Service Provider undertakes to respect the security and the confidentiality of the network that allows the provision of the Service. Service Provider will not use the User ID or its access to the Skype Software to misappropriate or otherwise negatively affect Skype Software or other products offered by Skype.

4.7 Service Provider warrants the harmlessness of the Service and Content that it offers, and undertakes to use, inter alia, efficient and up-to-date protection systems against third-party intrusions and computer viruses.

4.8 Service Provider undertakes not to transmit to the Users, via Skype Software, Service or by other means, unsolicited data including but not limited to, chain mails or unsolicited advertising messages (spam). The Service Provider will not collect personal information from the User unless it is absolutely necessary to provide the Service. The Service Provider should process the collected personal data in accordance with any applicable law and shall use the collected data only for the purpose of providing the Service requested by the User.

4.9 The promotion, marketing and provision of the Service and Content must comply with applicable laws and regulations including consumer protection, protection of minors (including age limits), e-commerce regulation and data protection. Service Provider shall make all reasonable efforts to promote the Service and Content in such a way that it does not reach such Users to whom the Service or Content could be regarded harmful or offensive or otherwise forbidden.

4.10 Service Provider undertakes that in all customer communication to the public, prices shall be accurate, clearly and visibly indicated, and that the Service shall be clearly defined as payable to the Users, and that such communications shall not contain misleading advertising or representations.

4.11 Service Provider undertakes to immediately bring to the attention of Skype any claim, action, lawsuit or other proceedings brought against it relating to any part of the Service and/or Content it supplies hereunder.

4.12 Service Provider will not transfer or assign to another natural or legal person the rights or obligations arising from this Agreement and any attempt of such transfer or assignment shall be considered null and void.

4.13 Service Provider may post Content, including a description of the Service Provider’s Service, on the Directory. Service Provider shall not:

4.13.1 include any prohibited weblinks in the Content (as such prohibited weblinks are defined in paragraph 4.14 below);

4.13.2 post or upload Content in a category that is not representative of the Service;

4.13.3 create a Service title or description that does not accurately describe the Service, or that includes information that could mislead users as to what the Service actually is;

4.13.4 include any information in the Content that does not describe or is not directly relevant to the Service, is intended to misrepresent the Service, or includes brand names or other inappropriate keywords in a title or description of a Service;

4.13.5 offer the opportunity through Skype Software to purchase the Service outside of Skype Prime (e.g. by including contact information e.g. email addresses, telephone numbers in the Content);

4.13.6 promote services outside of Skype Prime or other prohibited products or services;

4.13.7 do any other activity for the purpose of inappropriately gaining attention or diverting users to a Service. Service Provider shall ensure that each listing accurately reflects the Service and that Service Provider does not use any unfair methods to divert members to a Service, including but not limited to a title or description; and

4.13.8 report another Service Provider for infringing Your IP Rights unless You own the IP Rights to the Content you are reporting for unauthorised use or for infringement. You must not report Content or a Service as inappropriate or prohibited in any way unless you have genuine grounds to do so.

4.14 Skype allows Service Providers to post only certain types of links within their Content. A link is a mechanism used to take a User off the Content, whether static or clickable. This applies to any format used for a link that includes but is not limited to text, images, logos or icons. Permitted links are links to a Service Provider’s website or blog telling Users more about the Service Provider’s Service or business, or to a website that provides information about the Service Provider’s experience or qualifications relating to the Service. Prohibited links include, but are not limited to links to websites or webpages that offer to provide services or products outside of Skype Prime and links to websites that solicit User IDs, passwords or any other personal information from Users.
5. Disclaimer, Idemnity and Limitation of Liability

5.1 Service Provider is solely responsible for the Service and Content made available to the User.

5.2 IT IS EXPRESSLY UNDERSTOOD AND AGREED BY THE PARTIES, THAT SKYPE IS NOT RESPONSIBLE FOR THE SERVICE OR CONTENT. FURTHERMORE, SKYPE SHALL NOT BE RESPONSIBLE FOR THE CONTENT OF COMMUNICATIONS SPREAD BY MEANS OF SKYPE SOFTWARE OR ANY OTHER USE OF SKYPE SOFTWARE BY USERS OR ANY THIRD PARTY.

5.3 AS THE SKYPE SOFTWARE OPERATES THROUGH THE PUBLIC INTERNET, SERVICE PROVIDER UNDERSTANDS THAT SKYPE SOFTWARE IS SUBJECT TO POWER OUTAGES AND INTERNET SERVICE DISRUPTION AND HARDWARE OR SOFTWARE FAILURES ON THE EQUIPMENT USED BY THE USERS AND THAT SERVICE PROVIDER AND USERS MAY EXPERIENCE DISRUPTIONS IN THE COMMUNICATIONS OVER SKYPE SOFTWARE, E.G. PACKET LOSS AND DELAY, AND SKYPE WILL NOT BE LIABLE FOR ANY NON-AVAILABILITY, DISRUPTION, DELAYS, FAILURES OR OTHER OMISSIONS IN THE SKYPE SOFTWARE. THE SKYPE SOFTWARE IS PROVIDED “AS IS”, WITH NO WARRANTIES WHATSOEVER, IN ACCORDANCE WITH THE TERMS AND CONDITIONS OF THE EULA.

5.4 SERVICE PROVIDER AGREES TO INDEMNIFY, DEFEND, AND HOLD SKYPE HARMLESS FROM ANY THIRD PARTY CLAIMS, LOSSES, LIABILITIES, CAUSES OF ACTION AND COSTS INCURRED BY SKYPE ARISING OUT OR RELATED TO SERVICE AND/OR CONTENT, INCLUDING WITHOUT LIMITATION DAMAGES CAUSED TO THIRD PARTIES BY REASON OF THE VIOLATION OF ANY CLAUSE OF THIS AGREEMENT OR A LEGAL PROVISION BY SERVICE PROVIDER, DEFAMATION, INVASION OF PRIVACY, UNLAWFUL USE OF USER’s PERSONAL DATA OR INFRINGEMENT OF INDUSTRIAL OR IP RIGHTS OR ANY OTHER THIRD PARTY RIGHTS.

5.5 Neither Party shall be liable for any breach of this Agreement caused by a force majeure event. A force majeure event means an event beyond the control of that Party such as act of God, insurrection or civil disorder, war or military operations, national or local emergency, flood, subsidence or weather of exceptional severity.

5.6 SKYPE WILL NOT BE LIABLE FOR ANY LOSS OF BUSINESS OR PROFITS, OR FOR ANY CONSEQUENTIAL, INCIDENTAL, PUNITIVE, OR SPECIAL DAMAGES, REGARDLESS OF THE FORM OF ACTIONS, WHETHER IN CONTRACT OR IN TORT, INCLUDING NEGLIGENCE, EVEN IF SKYPE HAS BEEN ADVISED OF THE POSSIBILITY OF SUCH DAMAGES. IN ADDITION, SKYPE WILL NOT BE LIABLE FOR THE CONSEQUENCES OF ANY INTERRUPTIONS OR ERRORS, OR FOR ANY LOST DATA OR CONTENT. UNDER NO CIRCUMSTANCES SHALL SKYPE’s TOTAL LIABILITY EXCEED THE AMOUNT OF 100% OF SERVICE FEES GENERATED UNDER THIS AGREEMENT DURING THE IMMEDIATELY PRECEDING PERIOD OF TWELVE (12) MONTHS.

5.7 NOTHING IN THIS AGREEMENT IS INTENDED TO EXCLUDE OR RESTRICT OR SHALL BE CONSTRUED AS EXCLUDING OR RESTRICTING THE LIABILITY OF SKYPE FOR (I) THE DEATH OR PERSONAL INJURY CAUSED BY THE NEGLIGENCE OF SKYPE, THE SKYPE STAFF OR ITS AGENTS, OR (II) ANY LIABILITY WHICH CANNOT BE LIMITED OR EXCLUDED BY LAW.
6. Term, Termination and Suspension

6.1 The Agreement will be effective as of the date of Service Provider’s acceptance thereof and will remain effective until terminated by either party.

6.2 Service Provider may terminate this Agreement at any time. Any Service Fee due at the time of termination will be paid in accordance with paragraph 2.5.

6.3 Without limiting other remedies, Skype or its Affiliates may with immediate effect and without recourse to the courts: (i) limit, suspend, or terminate this Agreement; (ii) suspend the provision of the Service; (iii) terminate or block the Service Provider’s access to Skype Software; (iv) remove hosted Content; and/or (v) take technical and legal steps to keep Service Provider off the Skype Website, if Skype deems in its sole discretion that Service Provider is in breach of this Agreement or if: there are repetitive Service Issues, refund requests, charge backs of payments related to the Service; if Service Provider is creating problems, possible legal liabilities, acting inconsistently with the letter or spirit of Skype’s policies, infringing someone else’s IP Rights, engaging in fraudulent, immoral or illegal activities; or for other similar reasons. Skype shall effect such termination by preventing the Service Provider from accessing their User Account and/or by removing Service Provider’s Content from the Directory. If the Service Provider provided a valid email address, Skype may provide notice by email in its sole discretion.

6.4 All provisions which must survive in order to give effect to their meaning shall survive any expiration or termination of the Agreement, including without limitation, all representations, warranties and indemnification obligations.

6.5 The terms of paragraphs 2, 4.2, 4.5, 4.7, 5, 6, 7 and 8 and any other provision of this Agreement which is expressed to survive or operate in the event of termination, shall survive termination of this Agreement for whatever reason.

6.6 Skype reserves the right to modify this Agreement at any time with a thirty (30) days notice by email, unless Service Provider expressly accepts the revised Agreement earlier by clicking on the accept button. Continued provision of Service or Content by Service Provider after expiry of the 30-day period shall constitute Service Provider’s acceptance to be bound by the terms and conditions of the revised version of the Agreement. If Service Provider does not wish to accept this revised Agreement, Service Provider is entitled to terminate this agreement at any time, in writing or by email by contacting our customer support team.
7. Intellectual Property and Removal of Innapropriate Content

7.1 All IP Rights regarding the Skype Software, Content and Service and any related documentation which are developed and/or owned by a Party shall be and shall remain the sole property of that Party. Subject to paragraph 7.2 below, nothing in this Agreement implies any transfer of IP Rights or grant of any licenses thereto.

7.2 The Service Provider hereby grants Skype a non-exclusive, worldwide, perpetual, irrevocable, royalty-free, sublicensable and transferable licence to use, reproduce, distribute, modify, adapt, translate, create derivative works from and display the Content in any media in connection with Skype Prime, the Skype Website and Skype’s (and its successors’s and Affilates’s) business. The Service Provider also hereby grants each user of the Skype Prime API a non-exclusive, worldwide, perpetual, irrevocable, royalty-free licence to access Service Provider’s Content through the Skype Prime API and to use, reproduce, distribute, modify, adapt, translate, create derivative works from and display such Content on the user’s Website in accordance with the terms of service of the Skype Prime API.

7.3 The Service Provider shall not copy text, photos, pictures or images from the Content of any other Service Provider on Skype Prime or from any third party or source without specific permission from the owner. Such content may be protected by copyright laws and copyright owners may object to the use of content that they own or have created. If the Service Provider wishes to use any third party content, Service Provider must first ask the permission of the owner of the IP Rights in such content (”Rights Owner”). If the Service Provider breaches this provision and/or Skype receives a report by a Rights Owner or any other third party that the content is being used without their permission or infringes their IP Rights in any way (”Infringement Report”), Skype reserves the right to automatically remove such content immediately or within such other timescales as may be decided from time to time by Skype in its sole discretion. The content shall be taken down without any admission as to liability and without prejudice to any rights, remedies or defences, all of which are expressly reserved. Service Provider acknowledges and agrees that Skype is under no obligation to put back such content at any time regardless of whether or not the Infringement Report is valid.

7.4 If any Content submitted by Service Provider is the subject of any report that it is inappropriate (other than an Infringement Report) Skype reserves the right to remove such Content within such timescales as may be decided from time to time by Skype in its sole discretion whilst Skype investigates the complaint. The outcome of any investigation shall be decided by Skype in its sole discretion and Service Provider acknowledges that Skype is under no obligation to put back any Content which is the subject of such investigation.

7.5 If any photo, picture or image included within any Content submitted by a Service Provider is taken down from a listing by Skype as a result of a report that it is inappropriate or for any other reason, Service Provider acknowledges and agrees that Service Provider is prohibited from posting any further photo, pictures or image within their Content at any time.

7.6 If Service Provider puts back any Content at any time after it has been removed by Skype, such action may result in the cancellation of the Service Provider;s Service and/or the suspension, termination of this Agreement and the Service Provider’s User Account.
8. Confidentiality

Service Provider acknowledges and agrees that by reason of its relationship to Skype under this Agreement it may have access to material, data, systems and other information concerning the operation, business, products, customers and intellectual property of Skype that may not be accessible or known to the general public (“Confidential Information”). The Service Provider agrees that Confidential Information shall remain the sole and exclusive property of Skype and agrees to maintain the Confidential Information in strict confidence and to use the Confidential Information solely for the purposes set forth in this Agreement. Confidential Information shall exclude any information that (i) has been or is obtained by Service Provider from a source independent of the Skype and not receiving such information from the Skype, (ii) is or becomes generally available to the public other than as a result of an unauthorized disclosure by Skype or its personnel, (iii) is independently developed by Service Provider without reliance in any way on the Confidential Information provided by Skype, or (iv) the Service Provider is required to disclose under judicial order, regulatory requirement, or statutory requirement, provided that the Service Providers provides written notice and an opportunity for Skype to take any available protective action prior to such disclosure.
9. Governing Law

The Agreement shall be governed by and construed in accordance with the laws of Luxembourg. Any disputes arising out of or relating to this Agreement shall be subject to the jurisdiction of the courts in Luxembourg.
10. Miscellaneous

The Agreement, the TOS and the EULA constitute the true and entire agreement between parties with respect to the subject matter hereof and shall set aside all prior arrangements. The invalidity or unenforceability of any provision of this Agreement shall not affect the validity or enforceability of the remaining provisions thereof. No amendment to this Agreement shall be valid unless they are made in writing and signed by both Parties. The failure of either party to enforce any of its rights under this Agreement shall not be considered a waiver of that party’s right to enforce said provision or any other provision included herein.

YOU EXPRESSLY ACKNOWLEDGE THAT YOU HAVE READ THIS AGREEMENT AND UNDERSTAND THE RIGHTS, OBLIGATIONS, TERMS AND CONDITIONS SET FORTH HEREIN. BY CLICKING ON THE ACCEPT BUTTON OR BY USING SKYPE PRIME YOU EXPRESSLY CONSENT TO BE BOUND BY ITS TERMS AND CONDITIONS AND GRANT TO SKYPE THE RIGHTS SET FORTH HEREIN.

© Skype – Last revised: August 2010

Great, quick clip on “How to be a man,” which delves into traditional masculine stereoptypes in our culture:

Found an entire blog devoted to reporting the sexual misconduct of therapists.  I’m left with that dirty feeling I got as a kid, after spending an afternoon reading my sisters True Crime magazines.  It’s one area in which growing public awareness of this danger no doubt helps police our profession… and probably also discourages people from seeking the help they need.

So, here you go, some bizarre and disturbing tales:

 

Court awards patient $900K against psychiatrist who set up “voyeuristic” patient datesPosted on October 11, 2010 by psychrapereporter| Leave a comment

She went to a highly respected Manhattan shrink to help her cope with years of sexual abuse — and his twisted treatment was to set her up for sex trysts with other patients.

Or in another case:

“I am a psychologist and I work in local schools, but the money is terrible. I am thinking about taking photos of young girls for extra money.  Would it bother you if I took photos of your daughter for the internet…photos for dirty old men?”

http://psychrapereporter.wordpress.com/

I’m glad to see this blog post on this important issue.  Men in particular are underserved by our profession, and it’s our responsibility to find ways to re-package or re-tool what we do so that they can benefit more.

Counseling is for wimps

 On any given day, most therapists’ waiting rooms will reflect the same thing: counseling is something that is sought disproportionately by women.  While it may be tempting to think this reflects greater need or emotional instability in women, this imbalance between the genders may have more to do with men themselves.  In fact, men experience depression, anxiety, substance abuse problems and stress (particular during the current recession) at levels that are either similar to or even greater than women.

Men may be less likely than women to seek help for psychological needs not because they are “wired” differently, have fewer problems, or are less emotional than women on a biological level.  Rather, it may be the social messages men receive from childhood on about what men and boys should do and what they should not do, that may be to blame.  These expectations hold that men should not be emotional, should be independent and self-reliant, physically distant from other men, take physical and sexual risks, and value work, success and power over intimacy with others.  Any show of need is often met with teasing and social disapproval from both men and women, making it difficult for a man to acknowledge he may need help with mental health problems.  

Not to mention, most men perceive themselves as less manly than the men around them and are dissatisfied with this perception of themselves.  The desire to enhance and prove one’s level of “manliness” then becomes a central preoccupation in many men’s lives—a preoccupation with a goal that is seldom achievable, and often dangerous.  In fact, men who have more traditional attitudes about women, work and emotional intimacy tend to also have more mental and physical health problems, while also being less likely to seek help for these problems.    

So while men may still enjoy privileges in the wider society when it comes to higher pay and political status, that privilege may be maintained at the cost of personal mental health care.  Would men be as likely to seek the traditional male ideal if they knew that being stoic, refusing help and taking physical risks came at the cost of their physical, social and emotional well-being?  

Many researchers in the psychology of men and masculinities would answer this question with an emphatic, “yes.”  Multiple programs have arisen to challenge these long-held notions that real men do not seek help when needed.  Different types of therapy, such as wellness coaching, men’s groups, and other approaches that emphasize understanding men’s unique experiences have also shown promise.  These approaches to providing more appropriate therapies for men, along with wider social changes in what we expect from men, may help more men to get needed help. 

Submitted by Kim Jones on October 11, 2010 – 6:18pm Mind Blogging

http://jacksonville.com/opinion/blog/437666/kim-jones/2010-10-11/counseling-wimps

Get More Clients

Here’s a nice summary of some of the bad habits to avoid if you are struggling with outreach.

3 Things To Avoid

Hiding Out: I’m not suggesting that there is not a lot of tasks that need to be done at your desk or on the phone. What most people that don’t have enough clients yet do though, is stay in their office (perhaps that’s at home), and hide behind their computer, their e-books, their info-in-a-boxes. As they shuffle paper work from one side of the desk to the other they can kids themselves that their ‘busyness’ means they have a sustainable business.

Talking About Yourself: When you do nothing but talk about yourself, your products or your services, this is the quickest way to have prospects roll their eyes and switch off. This is a common mistake when you are operating from a place of fear, if you appear to need your clients more than they need you. The people you speak to will sense this, and categorize you into the section they keep for ‘sales’ people.

Lacking confidence: If things are happening as quickly as you would like them to, it is easy to start to lose confidence in your skills, your ability to offer them for a price, or to speak about them confidently. Sometimes it only takes one small set back to send you reeling back into hibernation, or a feeling of inadequacy in your abilities to create the success you so badly want.

What to Do

Get out there in a big way: Every month, make sure you have some events on your calendar that you attend in person. These might be local networking events, charity events, fundraisers, meeting people of influence in their space, workshops or conferences. These are prime opportunities for you to meet potential clients and spread the word about what you do. Make sure you then have a great follow up system in place too.

What’s in it for me? This is what everyone really wants to know. So, make it your intention when you are next in a group of people to find out what it is that is bothering them, what are their frustrations, what are they having trouble with. Then decide whether or not you have something that can help them solve their problem, or perhaps be a referral to point them in the right direction. Your honesty and openness will be rewarded with respect and trust. This will automatically make you a person of choice should you and your prospect be a good fit at some stage.

Trust in your own abilities: Take some time to recall when people have told you how great you are at doing what it is you do. You might have some emails, cards or small notes that people have given you over time in acknowledgement of your abilities. Take a look at where you have come from, rather than where you have not yet go to. I keep a folder both in my emails, and on my desk, where I past any kinds words that get sent to me. Sometimes this is a card, sometimes just a comment put on Facebook. Then, when you are having times of self doubt, you can refer to these for support and encouragement. You do have great skills and belief in your abilities or you wouldn’t be reading this article right now. Trust in yourself, and then GO DO IT!

And now I would like to invite you to claim your Free Instant Access to my audio and transcript “7 Steps to Attract More Clients, Make More Money Quickly and Consistently” when you visit http://www.TheAussieBusinessCoach.com.

http://ezinearticles.com/?Get-More-Clients-Quickly&id=5130039

I first trained in the 70′s, and I must say it was the Wild West.  Here’s a great example from a blog called “Neatorama,” of a psychologist who “pioneered” therapy without your clothes on.

Never really caught on.

In the 1960s (of course), psychologist Paul Bindrim, building upon the work of Abraham Maslow, invented a form of psychotherapy that involved everyone getting naked:

Nude therapy was based on the idea of the naked body as a metaphor of the “psychological soul.” Uninhibited exhibition of the nude body revealed that which was most fundamental, truthful, and real. In the marathon, Bindrim interrogated this metaphor with a singular determination. Bodies were exposed and scrutinized with a science-like rigor. Particular attention was paid to revealing the most private areas of the body and mind-all with a view to freeing the self from its socially imposed constraints. “This,” Bindrim asserted gesturing to a participant’s genitalia and anus, “is where it’s at. This is where we are so damned negatively conditioned” [...] Determined to squelch the “exaggerated sense of guilt” in the body, Bindrim devised an exercise called “crotch eyeballing” in which participants were instructed to look at each others genitals and disclose the sexual experiences they felt most guilty about while lying naked in a circle with their legs in the air [...] In this position, Bindrim insisted “you soon realize that the head end and the tail end are indispensable parts of the same person, and that one end is about as good as the other.:”

From the Annals of the History of Psychology: Nude Psychotherapy

By John Farrier in Society & Culture on Oct 2, 2010 at 1:57 pm

I treated a man for 10 years.  Ten.  Years.  He had an attachment disorder, horrifically deprived as a child, and dissociated into a “spiritual bypass” state of Buddha-like sweet, calm, not-entirely-there loveability.  He was a genius, and it often worked in getting him what he wanted.  But as we worked he was increasingly able to ask his partners and friends for what he wanted, to see himself as a normal guy who had normal needs and could actually be loved as a normal person.  He was definitely getting better, and, as is so often the case, it was taking a long, long, long time.

Then he died, and I learned from his partner about the years of domestic violence.  After he was gone she went through his computer and learned that he had been serially cheating on her all along.  He was an abusive sex addict.

How humbling, that I could be so hoodwinked for so long.  How grievous, that, had he brought all these split-off, shameful things to me, we could have worked through them, and changed his life to be so much more satisfying.  These dramatic symptoms could have been so helpful in moving the work forward.  Symptoms have to live forward the way that, as Hillman says, dreams have to be, “dreamed forward.”

But he never felt safe enough to bring me his secrets.  I’m left pondering, what could I have done?  How can I better become a therapist who is a safe-enough container for the things my clients are absolutely sure will get them thrown out or attacked?

It’s the hidden self that we build this container for.  So sad when they don’t show up.

In California, we’re supposed to have the bluntly named pamphlet displayed in our waiting room.  Except I share a suite with psychoanalysts, and there is no way they want to introduce that into the “field,” every time a patient sits down in the waiting room.  I left a note with a copy of the pamphlet by the check-in board, and promptly got a note back from an octogenarian Jungian analyst: “I’d prefer that each of us be responsible for dispensing these.”  In other words, no way am I going to let you leave these laying around the waiting room.

So, great, now I’m going to display them in my office, so that all through sessions, any time a client’s mind wanders, they will be reminded: NO SEX.  This is one of those situations where I am glad the rule exists, I just don’t want it to apply to me.

Time to bend a rule.  Into the file cabinet they go.  The other rule is that, if we learn of a client previously being inappropriately treated by a prior therapist, we’re to give them the pamphlet immediately and discuss their options, including a report to the Board of Psychology.

That I will do without hesitation.

This looks like a promising, more up-to-date guide book for the therapist in private practice.  She gets into office operations, agreements, psychotherapy finances and more.

Here’s her blurb.

Book Overview

Are you planning to be or already in private practice? I decided to write this book to share some strategies that have worked for me over the years in the hopes that they will help you too. The following chapters offer practical ways to streamline your practice by increasing day-to-day efficiency and eliminating unnecessary costs. Whether you are just starting out or have been at it awhile, these steps aim to help you thrive in your business so you can do the therapy work you want as long as you choose. They have worked so well for me that I can now support myself seeing clients one to two days a week.

If you find yourself in any of the following circumstances, this book may be especially appealing to you: Are you in graduate school and already dreaming about having your own practice? Are you newly-licensed and ready to be your own boss soon? Are you are already working hard in someone else’s practice that reaps a healthy profit while your compensation is much less? I’ve been there, too. After joining my first group practice when I became licensed, I realized the financial agreement would quickly lead to a diminishing return for me. Although self-employed, I still paid a tiered percentage of income to the group. Even though my percentage rose the more I made, I figured that I would be making much more if I left the group.

Perhaps you are working more hours and feeling more tension in your own practice, but your take-home pay seems to be shrinking instead of growing. Count me in on this one, too. After eight months I left my first group and joined others in different expense-sharing arrangements for the next ten years. I definitely felt more pressure and less pay during these years, as managed care pushed out higher paying indemnity and PPO (preferred provider organization) insurance, panels began to close, and contracted fees were regularly slashed. More non-paid work was added, too, including treatment reports, case reviews, and special billing instructions for different managed care companies. Client stressors added to the mix, things such as no-shows, last-minute cancellations, and calls at all hours.

Perhaps you have a busy practice and are ready to scale down to pursue other interests, but still need to earn enough to pay your bills. I’m right with you on this one as well. After ten years of expense sharing with others, I moved to an office by myself where I have been ever since. I decided to reduce my practice hours so I could write this book, but, I still needed to earn enough to support myself.

The strategies in this book emerged from these years of different practice arrangements and assorted trials and tribulations. I pass them along to you as your colleague and ally, right beside you in the trenches of daily practice, hopefully saving you time and frustration in your own efforts.

The good news is that regardless of your current circumstances, you can have the practice you want with less stress and more income. The following chapters emphasize three main strategies to achieve these practice goals: lowering overhead expenses, simplifying daily procedures, and implementing efficient client policies. These organizational and business aspects of our work can be easily overlooked, but are crucial to a successful practice.

If you are in graduate school, you probably already have a good idea how to conduct therapy based on experiences in your classes, practicum, or internship. However, you may not have much familiarity with the business of private practice. Although there are many resources available that focus on the therapeutic side of our work, there are fewer devoted to setting up and operating our private practices.

If you are just beginning or already have a practice, you may not know where to go for assistance in your efforts. When I was starting out, I had no business training and did not know how to set up an office or develop daily procedures and policies. It was a daunting task to blend hard business matters with the caring and therapeutic approach inherent to psychotherapy.

This book aims to fill this gap and, in so doing, offer you a practice management resource. It is written directly for you, with your unique, dual status as both therapist and proprietor in mind. You will gain knowledge and skills about how to blend both of these roles, lower your strain, and increase your financial return within your daily practice. Your clients will also benefit from your increasingly well-run practice.

Private practice has definitely changed over the years, with economic concerns more dominant now than ever before. If you are a new practitioner, you enter a world in which most of the insured population is covered by some form of managed care. If you are an established practitioner, you have probably experienced the reduction of therapy fees while your overhead expenses have remained constant or have increased.

Many in practice have responded by increasing client loads to compensate for lowered rates. Others have added marketing efforts geared towards the self-pay population. While both of these strategies can be effective, they do require money, time, effort, and can become an increased burden to you. Consider also that when you are in need of more income, your prospective clients are likely to be struggling too. They may forgo self-pay therapy when basic expenses like mortgage, food, and clothes become a priority. This climate leads to more therapists competing for fewer and fewer cash-pay clients, creating more marketing work for you with less potential return on your time and energy investment.

This book presents other alternative methods to preserve and expand your income through cutting costs and improving efficiency. Whether you market a little or a lot, whether you desire a small or large practice, these strategies can make your work easier while actually increasing take-home pay. They will allow you to see managed care clients if you choose to and still earn a good income. By retaining a base level of income in the lean times, you will add a layer of protection during any unexpected shifts in client loads. You will also boost quality care to clients, enhancing rather than detracting from the therapeutic process and outcome.

As you read the chapters that follow, please note that to preserve confidentiality, I’ve changed client and practitioner names as well as identifying information. The first major streamlining strategy of reducing overhead expenses is covered in Chapters 1 through 3. Since we are often less knowledgeable about the business part of our work, we can easily lose potential profits through unchecked expenditures. You will learn ways to cut costs when arranging your practice, selecting your office, and choosing a communications system. By designing your practice with lower overhead in mind, you can ensure savings and increased earnings independent of your client load.

The second major strategy of this book involves streamlining routine procedures. Many clinicians in practice lose time, energy, and income through disorganized daily operations. Chapters 4 through 6 will help you simplify daily procedures to prevent these drains. You will learn how to efficiently arrange for initial appointments, verify insurance benefits, bill insurance carriers, and get paid quickly. These suggestions will help maximize your pay with minimal effort, allowing you to provide higher quality care to clients. Although my recommendations have you in mind as the person performing these daily operations, if you decide to have someone else do any of these services, you can also adapt this information to use in training your support staff.

The third major strategy involves implementing efficient client policies. Most of us enter this field with a primary desire to offer therapeutic services. We are typically sensitive, empathic, and intuitive, with much to offer as healers. These very qualities also make us vulnerable to exhaustion from the rigorous emotional needs of our clients. Chapters 7 through 9 will guide you in preserving your therapeutic gifts by establishing firm and caring policies–policies that will help both your clients and you at the same time. You will learn how to manage your finances wisely and efficiently collect the client fees you earn. You will read how to create and implement a successful cancellation policy to minimize violations and preserve your income if they do occur. You will also learn effective phone practices and policies to enhance client treatment and ensure payment for services you provide.

The strategies and skills you will learn in this book will work regardless of changes in insurance policies, the economy, or other unforeseen circumstances, enabling you to survive and thrive in practice. I experienced this directly soon after beginning my own practice in 1990. I had no idea then that the insurance industry was poised for a drastic overhaul. The next several years became a whirlwind of managed care takeovers, fee reductions, micromanagement, and bankruptcies. These and many other unexpected changes threatened my practice over the years, but I prevailed by using many of the strategies that I now offer here. Whether you desire a full- or part-time practice, they will also help you to thrive, even when the most unexpected occurs.

Copyright 2004-2010 Holly A. Hunt

http://www.essentialsofprivatepractice.com/overview.html

Copyright 2004-2010 Holly A. Hunt

The Psychotherapy No-Show

Empty waiting room.  Wait 10 minutes.  Call the client.  Get voicemail, or, “Oh, geez, I forgot, I’m all the way across town, guess I’ll just see you next week.”

You have to charge for missed sessions.  You just have to.  Heck, my OWN analyst charges me for a session every week, and it’s up to me whether or not I show up!  (He lets me shift the time when I need to.  I’m more impressed than resentful.  Actually I’m not resentful at all.  You mean you’re not conscious of any resentment?  Anyway.)

Good article from the Psychotherapy Finances website summarizing some guidelines on how to enforce a no-show policy without being a hard-nose.

8 steps for eliminating no-shows and cancellations

An empty therapy hour is like an empty airline seat–it represents lost income that can never be recovered. And while most clinicians employ written policies making clients responsible when they cancel appointments without notice, in our experience the rule is frequently waived.

A better strategy is to nip the problem in the bud by adopting policies that cut down on no-shows. In this report, we offer advice for doing just that from three practice consultants quoted frequently in PsyFin.

1. Explain your policy on the phone when clients make their first appointment, says California clinician Holly Hunt. It might seem that starting the therapeutic relationship that way would be a turn-off–but Hunt says her first-session no-shows actually decreased after she started doing it.

2. Try to establish a connection with the client over the phone at first contact, says Wisconsin’s Karen Carnabucci, rather than just covering the basics and making an appointment. “When they arrive, it feels like our second appointment rather than our first,” she says. “I also refer them to my website so they get another connection in addition to my voice.”

3. You can be firm without being hardnosed. In Florida, Dwight Bain does it this way: A) clients get one free cancellation; B) thereafter, they must give 24 hours notice; C) a missed session has a $75 price tag–not the full fee–which for Bain is $165. The policy is spelled out clearly at intake, both in writing and verbally.

4. Do some trouble-shooting. If clients seem to have trouble making it to their appointments, says Carnabucci, try changing the day or time. “They may have issues around child care, or late hours at work. I try to address that. I tell them, ‘Maybe we should consider a different time.’”

5. Follow the lead of many physicians and dentists: Call patients a day in advance to remind them. Bain hired a college student to make these calls, and reports that his no-shows fell by 30%-40% almost immediately. Of course, clients need to sign off on that. Your intake form can include language like this: “I understand that [the therapist] will make a discreet phone call to remind me of my appointment 24 hours in advance. I prefer that the following telephone number be used for this purpose: ________.”

6. Don’t put off collecting for missed sessions. As with any collection job, the longer you let it go, the less likely you are to collect. Ideally, clients should pay at the next session. So after no-shows, you should have that bill ready and waiting. (That’s a big reason why we recommend that you accept credit card payments. It allows you to say, “Forgot your check book? No problem–I take Visa and Mastercard.”)

7. Make up your mind how tough you’re going to be if clients just won’t pay. Not very, Bain recommends. He says he collects for no-shows “about 95% of the time,” but never uses a collection company. Remember that many lawsuits and board complaints have their genesis in hurt feelings over money.

Hunt advises clinicians to send one bill after a no-show–but then drop it. “My experience is it doesn’t add anything to send two or three or more bills. Usually if a client doesn’t follow through on the first bill, it’s just a lot of effort with diminishing returns.”

8. With managed care clients, you may be able to bill the client directly for missed session. But you should check with the company first. (Many managed care plans do allow this, but most EAPs don’t.) And remember that you have to bill the managed care rate–not your full fee.

Contacts: 1) Dwight Bain, Winter Park, FL, (407)647-3900            (407)647-3900     www.lifeworks group.org; 2) Karen Carnabucci, Racine, WI, (262)633-2645 (262)633-2645      www.lakehouse center.com (Carnabucci is also quoted in the “Marketing” article beginning on page 4); 3) Holly Hunt, Long Beach, CA, (562)987-8947 (562)987-8947      www.essentialsofprivate practice.com.

http://www.psyfin.com/articles/1209_noshows.htm

I was standing naked in front of a mirror at the gym shaving, and I asked the naked guy standing next to me how he was doing.

“Not so good.”

I was surprised by his candor, we hadn’t talked much before.  “Really?  What’s going on?”

“I came home last night and found my wife in bed with another woman.”

We talked for a few more minutes.  He was upset, grieving more than anything, confused.  So, me being me, I asked him, “Have you got a therapist you can talk to?”

“Oh,” he replied, “Things aren’t THAT bad.”

Wow.  How bad do things have to get before many men are willing to ask for some help?

Think of what we typically ask a man to do in therapy settings: recognize that something is wrong with him, admit that he needs help, openly discuss and express his emotions, get vulnerable, and depend on someone else for guidance and support—all extremely challenging tasks in Guy World.  (David Wexler, Ph.D., in Psychotherapy Networker)

Really?

Here’s a link to a discussion a woman started after her former therapist sent her a friend request on Facebook. She accepted, and then felt worried about it, realizing that she wishes she hadn’t.

This made me laugh at first until I started to think about how low the standards sometimes are for the licensing of therapists. Then it worried me.

Here’s the link:

http://community.thenest.com/cs/ks/forums/43131820/ShowThread.aspx

When Therapists Die

I recently inherited several clients from a therapist in our area who suddenly died. It reminded me that I don’t have a “Therapist’s Professional Will.” Synchronously, a friend emailed me a link to a guide to creating them on Ken Pope’s site. Ken Pope is THE BEST information curator working in psychology. More on him later, but reading his guide and woke me up:

Holy cow there will be a lot to think about for whomever picks up the pieces when I’m gone!

Of course, a friend of mine has an (out of date) list of clients and their phone numbers to contact. But Pope asks, who has a copy of your office keys? Who will tell your colleagues? Is it in your informed consent that your executor may access client records?

Here’s an excerpt from this excellent guide to making a therapist’s professional will:

Therapist’s Guide For Preparing a Professional Will

Kenneth S. Pope, Ph.D., ABPP & Melba J.T. Vasquez, Ph.D., ABPP

Only therapists who are invulnerable and immortal don’t need to bother preparing a professional will.

We all share many vulnerabilities. We can’t wall ourselves off from the unexpected. At any time a drunk driver, stroke, mugger, heart attack, fire, plane crash, and countless other unwelcome surprises can strike us down. It is an ethic of both personal and professional responsibility to take our mortality and vulnerability into account in our planning.

A professional will is a plan for what happens if we die suddenly or become incapacitated without warning. It helps those whom we designate to respond promptly and effectively to our clients’ needs and to the unfinished business of our practice. It gives others the basic information and guidance that can be so hard to come by at a time of shock and mourning.

We recommend preparing a professional will as early as possible. We cannot schedule our personal misfortunes or postpone accidents so that they happen only late in our careers. We must prepare for the possibility that something can happen to us–robbing us of our ability to function–at any time, without warning.

No standardized one-size-fits-all professional will works well with every therapist or situation. The next sections provide a set of steps to help you create your own professional will so that it fits your needs, resources, setting, and practice.

Here’s the URL: http://kspope.com/therapistas/will.php

It’s from a book that also looks great:

I worked in a clinic once where I SCANDALIZED the other therapists by allowing a CLENT to go into the STAFF kitchen. It exposed a deep, common rift in therapists thinking: there’s something wrong with them, but not with us.

Compare that to R.D. Laing’s therapeutic communities, big ramshackle houses full of people doing whatever they wanted, and where you could wonder for days if a particular person was “staff” or “patient.”

NPR ran an article today about recent research on stigma associated with mental illness. For example, 74% of the people surveyed said they would not want to work with someone with schizophrenia. This stigma, which extends into people’s willingness to get help for anxiety or depression, or just get help getting HAPPIER than they already are, or improving their relationships, and so on, is perhaps the biggest impediment to our reaching my goal, which is that EVERYONE WILL BE IN THERAPY of some kind or another.

Here’s the link:

http://www.npr.org/blogs/health/2010/09/17/129937437/still-a-stigma-for-mental-illness?ft=1&f=1001

And here’s an excerpt:

Knowledge is power. And some research has suggested that emphasizing the science behind mental illness — that it’s a brain disorder and not a defect in character — could be powerful enough to help shake the stigma of the condition.

But a study just published online by the American Journal of Psychiatry found that isn’t paying off all that well.

Researchers found that while more people understand mental illness is caused by brain biology, that hasn’t translated into a decrease in stigmatization.

Also, here’s the abstract of the recent study, published in the American Journal of Psychiatry.

http://ajp.psychiatryonline.org/cgi/content/abstract/appi.ajp.2010.09121743v1

“A Disease Like Any Other”? A Decade of Change in Public Reactions to Schizophrenia, Depression, and Alcohol Dependence
Bernice A. Pescosolido, Ph.D., Jack K. Martin, Ph.D., J. Scott Long, Ph.D., Tait R. Medina, M.A., Jo C. Phelan, Ph.D., and Bruce G. Link, Ph.D.

From the Schuessler Institute for Social Research and the Department of Sociology, Indiana University; and the Mailman School of Public Health, Columbia University, New York.

Objective: Clinicians, advocates, and policy makers have presented mental illnesses as medical diseases in efforts to overcome low service use, poor adherence rates, and stigma. The authors examined the impact of this approach with a 10-year comparison of public endorsement of treatment and prejudice. Method: The authors analyzed responses to vignettes in the mental health modules of the 1996 and 2006 General Social Survey describing individuals meeting DSM-IV criteria for schizophrenia, major depression, and alcohol dependence to explore whether more of the public 1) embraces neurobiological understandings of mental illness; 2) endorses treatment from providers, including psychiatrists; and 3) reports community acceptance or rejection of people with these disorders. Multivariate analyses examined whether acceptance of neurobiological causes increased treatment support and lessened stigma. Results: In 2006, 67% of the public attributed major depression to neurobiological causes, compared with 54% in 1996. High proportions of respondents endorsed treatment, with general increases in the proportion endorsing treatment from doctors and specific increases in the proportions endorsing psychiatrists for treatment of alcohol dependence (from 61% in 1996 to 79% in 2006) and major depression (from 75% in 1996 to 85% in 2006). Social distance and perceived danger associated with people with these disorders did not decrease significantly. Holding a neurobiological conception of these disorders increased the likelihood of support for treatment but was generally unrelated to stigma. Where associated, the effect was to increase, not decrease, community rejection. Conclusions: More of the public embraces a neurobiological understanding of mental illness. This view translates into support for services but not into a decrease in stigma. Reconfiguring stigma reduction strategies may require providers and advocates to shift to an emphasis on competence and inclusion.

Hello, Technorati!

Welcome, Technorati. D6YJJ7VT9TJ3

The *excellent* psychology blog, PSYBLOG, has an article on 10 problems with the use of email. One study found that 59% of email users check mail from the bathroom. The NY Times ran an article last week about how overstimulated we’ve gotten, but it hadn’t exactly occurred to me that by extending psychotherapy to the Internet we were taking the work into the NOISE STORM that is our experience at the computer.

By using email in psychotherapy we are extending the work into an medium that is conducive to a lower rapport, in which people feel less cooperative, and emotional communication is drastically reduced.

I don’t know what to do with that thought, yet.

Here’s the link:

http://www.spring.org.uk/2010/09/emails-dark-side-10-psychology-studies.php

Here’s an excerpt:

Email is a fantastic tool, but these ten psychology studies remind us of its dark side.
Like the telephone or the TV, email is a technology so embedded in our lives, we think nothing of it. Both help and hindrance, on one hand it’s the internet’s original ‘killer application’ and on the other it’s a spam-spewing slave-driver.

We’re used to hearing about the negative side of the balance-sheet, about email’s addictive nature and the unnecessary stress it injects into the modern worker’s life, but we downplay these problems because it’s so incredibly useful.

Now that email is well into middle age (the first emails were sent in 1965), let’s take stock of what we know about the darker side of email.

Google Health is expanding their services to allow users to track “wellness” data. They have been providing a place to keep your medical record (if you’re willing to enter all that information off of reports from your doctors, hospitals, etc.), but they’ve added a feature so users can track things like exercise and diet. Why not track a depression inventory, or psychotherapy homework assignments, allowing access by the therapist to the client’s record?

We are way behind in using the power of the Internet to extend the psychotherapy container, but this sort of thing takes a part of the way down the track.

Here’s Dean Ornish, in the Huffington Post, on Google Health:

These design changes are important, as they now make Google Health a new tool for anyone looking to improve their health through lifestyle change. For example, you can create customized Google Health trackers for different aspects of your lifestyle and keep a record of where you are day to day and how you progress over time. For those who like to set goals and monitor progress toward them, the newly designed product offers that too. And it looks like Google has given you a way to see how medical tests and conditions can track with your personal wellness goals.

Will the new and improved Google Health be enough to make Internet-based tracking a daily part of people’s health and lifestyle activities or a catalyst for better health through lifestyle change? It’s too soon to tell, but the steps that Google has taken today to improve this product are clearly in the right direction. They are offering a set of new features for consumers to engage more with their own health and wellness.

We’re clearly still at the beginning of a revolution in health and Internet-technologies, but I’m excited to watch what develops as more and more companies find ways to help consumers empower their lives and take control of their own health.

Okay, that’s bold, but I am really impressed with the depth of information about the money side of therapy at this site:

http://www.psyfin.com/wordpress/

I first started reading them when these folks just had a paper newsletter full of interesting tidbits, stretching back at least 5 years. They still have the newsletter, for paid subscribers, but their website and blog is full of good stuff too. For example, they quote a study finding that 12% of E.R. visits are due to psychological problems. And have you ever thought about a specialty treating couples in which one partner has ADHD? (My wife will testify to the potential value of that marketing angle.) Did you know that the military is expanding its online counseling program?

While they put good tastes in their online presence, they say their website contains less than 10% of all their articles. so I do recommend a subscription to the newsletter.

Here’s a sample of their many great ideas for therapists wanting to reach out to new markets:

A new mini-niche: bullying in the workplace
Filed under: Uncategorized — Administrator @ 8:40 pm

We often publish articles on niche markets at Psychotherapy Finances, and we’re in the middle of preparing a new one for an issue this fall. It’ll be a comprehensive look at some of the standard niches for therapists, with a focus on specialties that have gained traction because of their timeliness.

In our research we stumbled upon a rather interesting issue that is being called to the attention of more and more EAP providers – adults being bullied at work.

We’ve featured articles about therapists who work with children being bullied at school (and there are also some consulting possibilities here, as most schools have anti-bullying programs.)

But now the managed care giant ValueOptions reports that employees who are being bullied on the job are seeking help through their EAP.

“When you see it on the playground, it’s clear,” Rich Paul, vice president of Health & Performance Solutions at ValueOptions, said in a news release earlier this week. “At work, bullying can be less obvious and occur over a long period of time, resulting in extreme stress and anxiety for the employee.”

And as he also notes: “Workplace bullying doesn’t just affect the person being bullied. It divides work teams, distracts from the job and causes untold hours and days of lost productivity for the employer.”

It can take different forms, including falsely accusing co-workers of errors, giving another employee “the silent treatment,” or ridiculing someone’s point made at a staff meeting.

In addition to EAP work, this could be worked into a private practice mini-niche. It would seem to offer additional opportunities for consulting as well – and businesses tend to pay better than schools.

Found another outfit that is working on the policy issues related to “telementalhealth.” They are at the University of Colorado, Denver, and they’ve keyed on this central issue of OUTREACH. Their mission is to use technology to make mental health services more available to the under-served. I like they way they think!

“The telepsychiatry developmental model described in this section is intended to help you go through the process in a systematic way of setting up a telemental health clinic from the beginning. This model draws and expands upon the work or Drs. Jay Shore and Spero Manson for an article entitled “Developmental Model for Rural Telepsychiatry.” The telepsychiatry developmental model that is discussed identifies six steps that can be used to create a successful telemental health clinic.”

They’ve created a document, a guide, to help set up these services:

Their very useful guide introduces the concept of telemental health:

* An overview of what telemental health is and how it is being used to improve mental health services,
* The steps necessary to develop and implement a telemental health program,
* How best to use these services once implemented and how to take advantage of this unique service delivery tool,
* How to fund and sustain a telemental health program, and
* How to market telmental health services to a wide range of stakeholders.

Find them at: http://www.tmhguide.org/

“I called over 16,000 people.”

There’s a brief video on the NY Times website about a couple of therapists who started a center for the training and supervision of therapists. They made a great website, and sat back waiting for the calls to start. Silence.

So one of them got brave, and started calling therapists one at a time, inviting them to come. “Thousands called back,” he says, and now their center is thriving.

Sometimes we hide behind our websites and fliers. The population is grossly underserved by therapists, and there are too many therapists for those people who do seek out therapy. Not sure how to translate what they’ve done to reaching out to prospective clients, but it underscores the importance of making a personal connection to encourage people to come in and work with us.

URL:

http://boss.blogs.nytimes.com/2010/08/06/how-i-saved-my-company-the-new-center-for-advanced-psychotherapy-studies/

NY Times Story:

The New Center for Advanced Psychotherapy Studies is a training institute for psychotherapists and psychoanalysts. It offers supervision and consultation and study groups by telephone — and tries to help therapists succeed financially in their practices.

The center, which is based in Key Biscayne, Fla., opened near the end of 2007 with high hopes that it would succeed if it could attract only a tiny percentage of the approximately 130,000 mental health professionals in the United States.

It invested thousands of dollars in a sophisticated Web site with billing software and credit card capacity, and it produced an advertising campaign. But after two months, it had attracted precisely two customers. It decided to shut down the Web site and opted instead for a decidedly old-school approach to finding customers. Please watch the video below to see how the company turned things around.

Many therapists, if they walk into a restaurant and see that a client is in line in front of them, will turn around and go find somewhere else to eat. I once sat down at a movie and realized that my analyst was sitting a couple rows ahead of us eating popcorn. We stayed… and I spent the whole two hours wondering what she thought about the movie, watching her reactions, and activated with all the emotional content that got activated when we were in a session. I don’t want to go to the movies with my analyst. Except for the part of me that does, that often dreamt I was living in her house with her family. I mean, wouldn’t it be great if SHE were my mother?

So if I establish a Facebook presence, I’m inviting my clients into my living room, where I am giving a party for all the people who know me best. What a terrible idea! I’ve gone back and forth, establishing a Facebook page and then taking it down again. The problem is, it’s an excellent way to keep up with what’s happening in my daughter’s life! So I’ve created a Facebook presence under a pseudonym, and I just use it to connect with a few people.

Here’s a link to a good policy statement regarding therapy and social media, something to hand to clients regarding the therapist’s policy on social media.

http://www.drkkolmes.com/docs/socmed.pdf

I regret not being able to keep up with my extended community through Facebook. It’s hard to walk out of that restaurant, too.

Here’s a quote from a good policy statement by Keely Kolmes, Psy.D., regarding therapy and social media, something to hand to clients regarding the therapist’s policy on social media.


FRIENDING
I do not accept friend or contact requests from current or former clients on any social networking
site (Facebook, LinkedIn, etc). I believe that adding clients as friends or contacts on these sites
can compromise your confidentiality and our respective privacy. It may also blur the boundaries
of our therapeutic relationship. If you have questions about this, please bring them up when we
meet and we can talk more about it.
FANNING As of 4/14/10, I deleted my Facebook Page after concluding that the potential risks of maintaining such a Page
outweigh any potential gains. This section has been retained for those wishing to view the original document.
I keep a Facebook Page for my professional practice to allow people to share my blog posts and
practice updates with other Facebook users. All of the information shared on this page is
available on my website.
You are welcome to view my Facebook Page and read or share articles posted there, but I do
not accept clients as Fans of this Page. I believe having clients as Facebook Fans creates a
greater likelihood of compromised client confidentiality and I feel it is best to be explicit to all who
may view my list of Fans to know that they will not find client names on that list. In addition, the
American Psychological Association’s Ethics Code prohibits my soliciting testimonials from
clients. I feel that the term “Fan” comes too close to an implied request for a public endorsement
of my practice.
Note that you should be able to subscribe to the page via RSS without becoming a Fan and
without creating a visible, public link to my Page. You are more than welcome to do this.

http://www.drkkolmes.com/docs/socmed.pdf

It seems obvious that these online counseling websites are the refuges of hucksters and snake-oil salesmen, right? You can go online, start chatting with a “counselor,” and pay by the minute. (Are these folks licensed? Sometimes.) When you’re done, you rate the counselor the same way you rate a bookseller on Amazon.

The problem is that we are reaching, maybe, 10% of the population. I think we ought to be providing therapy to just about everybody.

So this kind of web-based drive-through therapy may be a big part of the therapy of the future. According to the testimonials, people find it helpful. I saw one startling study that found that depressed folks who were “seeing” a therapist via phone were much more likely to stay in therapy vs. clients who came into the office (I’ll look for the reference).

Something like these websites will provide more and more of the therapy that people use, so we may as well figure out how to be our best at helping (and protecting) people who come to therapists that way.

Hoo boy. Marlene Maheu, Ph.D. presented at APA last week, partly covering all the different ways you could get into serious hot water doing online or remote psychotherapy. Like, how do you know the patient is who she says she is? What if, this session, it’s actually the patient’s KID at the other end, sitting around the computer with some friends cracking up and inventing problems? Intricate legal issues depending upon which states you are licensed in. (Really? We’re going to have to license in MULTIPLE states?). Oh, and is a text message thread between you and your client part of the legal record? (Now that you mention it, of course it is.)

They offer multiple-day-long courses on all the details. My ADD kicked in after about 20 minutes, but I was left with a certain amount of awe for the exceptional level of specificity she sustained.

Go to TeleMentalHealth.com for more info.

And of course there’s a book!

I was impressed by Joseph McMenamin, MD, JD, when he presented last week at APA on the laws related to providing therapy online. Like, one therapist asked, “What if I’m providing therapy to someone who lives in a neighboring state?” I thought, geez, obvious, you have to follow the laws of that state (and probably be licensed in that state). No. In fact, you might have to follow the laws of BOTH states, your state and your client’s state. This attorney was recommending that you include in your paperwork an attestation from the client that s/he does, in fact, live in the state they say.

Also, there are some regulations proposed in California which will include direct liability for the therapist if a business associate discloses client information. More to worry about, but I’m not clear what’s to be done except to be extra careful in picking those associates (like bookkeepers, for example), and get them to sign statements of responsibility.

Some interesting arcana, for example if the security of your records is breached, you’re required to contact all your clients AND TAKE OUT AN AD in a newspaper announcing it has happened. There’s an encouragement for psychotherapy notes security. Interesting, too, to hear that there have only been six cases of malpractice nation-wide related to breach of confidentiality, and all six have settled with a clause forbidding the parties from disclosing the settlement terms.

Came across an online course that investigates a lot of these topics, including things like “To friend or not to friend,” (I don’t think so, no) and digital record keeping (waaay past due in psychotherapy). Here’s something from the course description:

“The first section of the course is an Introduction to the clinical and ethical issues that get raised for psychotherapists using Social Media. The second section addresses online transparency of both clients and therapists, inclusive of what therapists may intentionally or unintentionally make available online, and whether they should access client information online. Section three looks at friend and contact requests on sites such as Facebook, MySpace, and LinkedIn, and also examines the challenges of Facebook business pages and the blocking feature on such sites. The fourth section addresses Twitter, Status Updates, and Location-based check-in sites. The fifth section discusses the ethical issues that are raised by consumer review sites and business listings. Section six focuses on email exchanges between therapists and clients, record keeping, and digital security. Section seven provides sample Social Media Policies, and section eight, the last one, includes links to ethics codes for psychotherapists, and additional online resources.”

http://www.zurinstitute.com/digitalethicscourse.html

DSM IV TR Lookup Tool

This will give you the name of the diagnosis and the numeric code, but it won’t give you any of the criteria. I’m guessing that the reason for that is that the American Psychiatric Association charges software vendors on a per usage basis for displaying that information. In other words, every time someone clicks the diagnosis name, the software vendor gets charged something like $1.00.

Makes it inconvenient.

Anyhow, here’s the lookup tool for the DSM:

http://doctorcodes.com/dsm-iv

CPT Code Lookup Tool

Wow, this is great:

https://catalog.ama-assn.org/Catalog/cpt/cpt_search.jsp?checkXwho=done.

I just spent a disturbing and engaging half hour reviewing the latest edition of The Therapist, the publication of the California Association of Marriage and Family Therapists (www.camft.org). They devote an entire section to detailed descriptions of the ways that California MFTs got themselves into hot water last month. Two fellows, for example, thought it would be a good idea to tell their female clients that they had starring roles in their masturbation fantasies. One therapist stole a car while under the influence of pharmaceuticals, another got drunk and attacked her neighbor.

Sexual misconduct is the number one reason for loss of license. It’s usually perpetrated by male therapists on female clients who are signficantly younger than themselves. We know that if a therapist gets consultation when the urge strikes, it greatly improves his chances of getting through it without acting out.

Consultation. Therapy of my own. I wouldn’t want to do this job without both.

To Coach or Not to Coach

When a therapist decides to label himself a “coach,” is it much more than packaging? It seems to depend. Coach training organizations, for the most part, seem to have repackaged cognitive-behavioral therapy tools to help people attain specific goals, versus alleviate symptoms.

So who would want to see a therapist who isn’t also a coach?

I did coach training with a different sort of organization, the Values In Action Institute, which is devoted to the development and application of Positive Psychology. It’s a strengths-based model, and the emphasis clinically is on the strengths of the client and the goals of the process. It’s also firmly grounded in work to empirically validate interventions. Again, I hope every therapist gets trained in this approach, and I know I wouldn’t want to work with a therapist who wasn’t focused on leveraging my strengths to achieve my goals, among other things.

As far as I can tell, the coaching movement has done two things. It has let people get into the talking cure profession without much training. As far as I can tell this has not led to any particular problems, so if they are out there talking to people and, more importantly, letting people talk to them, so much the better. The other accomplishment of the coaching movement is that it has been part of a movement to re-label psychotherapy to make it more palatable to the general population.

I haven’t been able to find any utilization stats on coaching, but as far as I can tell there actually are few people out there actually employing coaches. So the re-packaging of therapy, thus far, hasn’t had much effect. But I think the trend is critical, to make the case to all those folks out there who would benefit that they won’t have to lie down on a couch and regress to a childlike state. If they don’t want to.

Found a practical, thirty-year-old guide to all this called The Business of Psychotherapy by Robert L. Barker. It looks like it was intended as a text book for a class on setting up a private practice. And by the way has anyone ever seen a school offer that? It’s rare to hear about CE courses on the topic. Anyway, this book includes chapters on setting up the therapy office, building up a therapy client load, etc. and he makes it a lively read with illustrative anecdotes. Not a lot of surprises here, but I was interested to note that only one factor correlated with success in passing the LCSW licensing exam at the time. Not training, not age, not years of experience… If a therapist had been in personal therapy herself, she was significantly more likely to pass the exam. Of course, in those days they were still using oral examinations as part of the licensure process, which ended when lawsuits ensued charging that they were overly subjective and subject to bias.

His sample contract (page 102) includes a statement of the agreed upon therapy goals, which I haven’t seen in the others I’ve been reviewing.

Comparing the therapy market of the times to the pre-1929 crash, Barker warns that their heady days of relatively unchecked insurance reimbursement for therapy were endangered, and that the “bubble” may pop. “It can happen when there are very many more therapists than there is demand for them, when many therapists find they must leave the work for which they were trained and which they struggled to enter. It will happen if the insurance companies decide they can no longer pay for therapy services that aren’t proved effective and if government funding is cut back to cover only treatment of the seriously disturbed (page 280).”

Ahem. Duly noted.

Here’s a link if you’re interested:

The First Therapist

Long before the 50-minute hour (which Anna Freud devised to fit more patients into her father’s schedule), Asclepiades set up a private practice in Rome. It was around 100 BCE, and he annoyed all the other physicians by departing from medical standards and prescribing catharsis and exercise for depression, and wine and a hot bath for anxiety. Physicians at the time worked only in institutions, so they were scandalized when Asclepiates accepted money from his patients, making him also the first therapist who did not accept insurance, and placing him socially in the same ranks as a barber, busker or street juggler. He was seen as a weirdo. Things went very well for Asclepiades and his talking cure, though, and his practice thrived, with a schedule that included Marc Antony and Cicero.

Fast forward a few centuries, when the priests set up their tiny booths in churches, and Western culture entered its confessional period, which I think of as an evolutionary step.

Sharing a Therapy Office

So one of my best friends needs an office for a couple days a week, and that will work right now because I’m working out of the office some of the time, it’s just for a couple months, he can help with the rent, sure why not?

You’re waiting maybe to hear that something bad happened? Nah. It’s a good feeling to walk in and know that he’s been in here, doing this remarkable spiritual healing that he does (www.empoweredhealing.com).
But it’s still my office. He takes down my diploma, and hangs his diploma, and I reverse the process when I come in.

I noticed that I was reluctant, afraid to turn over blocks of time to him, to know that these are times that my office is not available. Yes, Mrs. Klein, it is like an infant who wants his mother constantly available.

But it’s worked out well. I remember, too, that I enjoyed sharing my friend Gilbert’s office. He had nice taste, quite unlike mine, but it was a fine work environment.

So, developmentally, I seem to have advanced to preschool age, when we learn that it does not destroy us to share toys. In fact, it can make us feel connected, like playmates.

I’m coming across a rich panoply (“a wide-ranging and impressive array or display,” according to www.dictionary.com, and why didn’t I just say “array”?) of websites that consolidate web material on this topic.  One that I like is: http://www.wheretheclientis.com, which is curated by Will Baum, LCSW (www.willbaum.com).  He has wide-ranging interests on office practices.    Also, the Online Therapy Institute, http://www.onlinetherapyinstituteblog.com/ tackles some issues related to electronic therapy, including an interesting code of ethics.  It doesn’t address the issue of security for email therapy, which I think is the most important issue we currently face in using the web to extend the therapy container.

Psychology Today remains the Godzilla of online resources for therapists, and they have a spirited online community.  You have to be a therapist, and join (it’s about $30/month), to gain access: http://www.psychologytoday.com/.

In a couple of my men’s groups, the members have put together listserves and communicate a lot via email.  It gives me the willies, because those emails could end up anywhere, for anyone’s eyes, but they all know that.  It means that the group has a way to stay in touch throughout the week, between meetings, because of course the work keeps happening for all of us while we “cook” what happened, and this extends the container. 

Right now one of us is suddenly facing a brutal cancer, and achingly beautiful expressions are being flooded across our IN boxes, as he talks about his process and we all work to face it with him as best we can. 

A new savoring of life is happening, and I’m grateful for the emails.  At one point this Mary Oliver poem found its way into the mix: 

Mockingbirds

This morning two mockingbirds in the green field were spinning and tossing the white ribbons of their songs into the air. I had nothing 

 better to do than listen. I mean this seriously. 

 In Greece, a long time ago, an old couple opened their door 

 to two strangers who were, it soon appeared, not men at all, 

 but gods. It is my favorite story– how the old couple had almost nothing to give 

 but their willingness to be attentive– but for this alone the gods loved them 

 and blessed them– when they rose out of their mortal bodies, like a million particles of water 

 from a fountain, the light swept into all the corners of the cottage, 

 and the old couple, shaken with understanding, bowed down– but still they asked for nothing 

 but the difficult life which they had already. And the gods smiled, as they vanished, clapping their great wings. 

 Wherever it was I was supposed to be this morning– whatever it was I said 

 I would be doing– I was standing at the edge of the field– I was hurrying 

 through my own soul, opening its dark doors– I was leaning out; I was listening 

- Mary Oliver

Psychologist Ed Zuckerman has a book that includes an exhaustive collection of the forms we use:

I still want to do it all electronically, though…

I’ve just moved into a beautiful new office.  2nd floor, big tree and the rooftops of Berkeley out the large windows.  So many therapists I know keep a “blank slate” office but it’s just not me, I’ve crammed my office once again with paintings by my friend Stan Washburn, with African tribal statuary, a special painting a client gave me and on and on…  There’s a big mortar and pestle that was used by a Pomo woman all her life to grind things into digestible form, a lot like the work we do here.  I did bow to reason and took out the extra bookshelves but I miss having most of my books right here! 

I walk in every day and, I really do, I breathe in with a happy glow.  It feels so good to be here.  My men’s groups have been patient with me, they sort of do have to cram in here when we get past 10 guys.  But I’m struck, once again, by how profoundly I am affected by my environment, and I think these good feelings affects the work in positive ways.

I’m happy to see that the APA meeting in San Diego (www.apa.org) next month will have a couple sessions taking up these questions related to extending the frame electronically.  One session, Computers and the Couch—New Norms of Information-Age Practice , will address email as well as the use of social networking tools.  A plenary session intriguingly titled,  “r u rede 4 ths? The Practice of Psychology in the Digital Age” will also be offered.

Therapy Emails and HIPAA

We want to extend what we do using email, but HIPAA (and good sense) requires that we take responsibilty for, “”securing patient records containing individually identifiable health information so that they are not readily available to those who do not need them.”

I think most therapists address this problem by restricting email communication to scheduling.  But what a waste!  We have the opportunity to keep the process more alive throughout the week by being in touch this way, and I’ve found it’s been helpful with certain clients. 

I see now that I have to stop until I’ve found a secure way to do it.  I don’t want the wrong eyes seeing these exchanges, and, once something is out in the unsecured wilderness of the internet, it can go anywhere.  This is deeply frustrating to me, because I can be more help to my clients if I can use these tools.

APA had a session on therapy and the web 10 years ago, and it excited a lot of conversation at the time, but it was mostly heat with little light.  Still no safe way to do therapy on the Internet.  Not good enough!

Weird.  Many of the therapists I know (especially those under 60) use email to communicate with clients.  I use it with some to schedule.  Then I had one start sending me dreams, and something stopped me from saying, “Let’s wait and talk about those in our sessions.” 

This raises some hair-raising questions.  Sure, my email is secure (although it’s not encrypted), but is his?  Where does this fall in HIPAA?  What if he sends me a message that communicates an emergency, and it sits in my IN box for hours.  (Actually, I check my email CONSTANTLY on my iPhone, it’s become a bit of a problem, but that’s another story.)  Do I want to have an email conversation throughout the week as a part of the therapy?   In this case, I do!

Another way that email plays a role in my practice, a lot more nerve-wracking: two of my men’s groups have set up email listserves, restricted to them and me.  A lot of very personal stuff goes out across the wire, and ends up sitting in the IN boxes of every one of those guys.  How often does a wife or a kid walk by and take a peek?  On the other hand, for both groups those listserves have become a dynamic part of the process.

I don’t want to give it up.  But it worries me.

Where I went to school  and now teach, The Wright Institute, our slogan is: Clinicians to Society.  The school was started by some very lefty folks in the sixties, visionary in this regard: psychology cannot sit in its office waiting for people to show up for sessions.  Our skills are needed anywhere there are people, from the schoolyard to the factory floor, and it is essential that we find ways to extend the psychotherapy container to encompass every part of contemporary life. 

Some friends built a company (Hummingbird Coaching) that put coaches to work communicating with parents who needed advice, via email.  I’ve been having great experiences doing sessions using Skype for video conferencing.  Some of the most compelling “sessions” I’ve had have been around a table with a bunch of executives.

If you still think of psychotherapy as something confined to the 50 minute hour, do you think it’s time to stretch the container in your head?

The Hungry Therapist

I had a client tell me that he’d overheard his previous therapist on the phone, just before their session began.   ”I’ve got to go make some money now.”

Ow.

Part of what we have to contain in the business container is our own greed.  Of course we have to make money but it would astonish me to meet many psychotherapists who went into this because of the pay.

It helps me to think of “marketing” as “outreach.”  I think everybody should have a therapist, with whom they meet at least weekly.  Forever.  I just think this kind of conversation is a necessary component of The Good Life.  Look at the California statistics alone: 471 people for every therapist, that means a whole lot of people are not seeing a therapist, and I think the world would be a better place if they were. 

So we owe it to society to be experts at outreach.  I learned in my previous incarnation running a consulting firm that generating business came from being in relationship with lots of people.  This is a problem for introverted psychotherapists who want to sit in their offices and have one person after another just come in and go to work.

One of my many marketing gurus when I was consulting was Jay Abraham, and I was pleased to find an excellent article by a psychotherapist, Joe Bavonese,  who has been applying his ideas (and others) to his outreach with fabulous results.  He tells the story of changing his practice from limping along to overflowing with new clients, and he breaks it down to some very practical ways of getting connected to people who need what you do.  He’s a marketing coach for therapists, too.

“So maybe the sky isn’t falling after all. Private practice is alive and well—but only if you realize that excellent clinical skills are a necessary, though not sufficient, condition for success. To have a successful practice and serve more people, you have to learn how to run a small business, tolerate risk, and be comfortable spending money. Much like our clinical training, building a small business is a complex, ever-changing discipline that takes a commitment of money, time, and feedback from successful mentors to fully master. But if you’re serious about being successful in your private practice and helping more people, investing money and time will reward you handsomely for the rest of your career. You just have to remember always that your work is your business, your business is your work, and you are as much businessperson as therapist. These days, to be successful at one, you have to be successful at the other.”

For the entire article in Psychotherapy Networker, go to:

http://www.psychotherapynetworker.org/populartopics/the-business-of-therapy/203-how-to-develop-a-money-mindset

If we don’t make money, we can’t do the work, and the income of therapists is dropping overall.   APA’s 2009 salary survey found that master’s level clinicians in private practice earned a mean of about $40k-$50k, and psychologists in private practice made about $90k, on average, reflecting a drop over the past decade of about 10%.

APA has a chart on their 2009 salary survey: http://www.apa.org/monitor/2010/04/salaries.aspx.

Does it reflect a difficulty making ourselves relevant?  Of course a lot of people are talking about adding “coaching” to our offering, but I see scant evidence that coaches overall are adding a lot to their incomes.  I think EVERYBODY should have a therapist, but it seems they don’t all agree. 

There are a lot of us.  There are 16,586 licensed psychologists in California, and the California BBS lists about 64,000 “active licensees and registrants.”  The state has a population of about 38,000,000, so that’s one therapist for every 471 people.  (Anybody know the national statistics?)

The HIPAA Hippo

Every time I try to read the HIPAA regulations it induces ADHD.  This is a really useful introduction put together by a couple of my Berkeley colleagues, Trevor Graham and Michael Donner.

http://www.alamedapsych.org/HIPAA.htm

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