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Tuesday, 31 January 2012

Overpathologization Disorder: A Modest Proposal

At this very moment, clinicians across North America are feverishly at work on the next revision to the Diagnostic and Statistical Manual of Mental Disorders, DSM-V.
Soon to be even bigger.

Each new version of the manual includes many exciting and new mental disorders previously unknown to science, or erroneously thought to be within the normal range of human behaviour and experience.
For DSM-V the committee has taken the step of inviting clinicians around the world to submit their nominations for possible new disease categories. Suggestions are screened and evaluated by the experts for potential inclusion.

To this end: I'd like to offer a modest proposal for the inclusion of a previously undocumented mental disorder plaguing much of the western world and rapidly rising in prevalence.

Overpathologization Disorder: Diagnostic Criteria

Sufferers of OD often exhibit the following characteristics:

A.  A severe and persistent tendency to regard aspects of normal human functioning (e.g., bereavement, burnout, a loss of enthusiasm for uninteresting work) as signs of mental disorder.

B.  Intolerance for anxiety, sadness, anger, grief, or other strong emotions, particularly in others, and believing that such experiences need immediate treatment (pharmacologically or via psychotherapy).

C.  An authoritarian style resistant to questioning about the perceived illnesses, often accompanied by immediate reference to the sufferer’s own expertise and special insight.

D.  Dismissing as na├»ve, underexperienced, or foolish all those who disagree with the perceived illnesses.

E.  The disorder is perceived as a manifestation of personal insight and experience, and is therefore ego-syntonic.

F. The belief is held that diagnosing such illnesses is an altruistic act that does no harm to those so categorized, as it makes diagnosed individuals more likely to seek help.

G.  A tendency to describe grossly exaggerated cases of the pathologized characteristic (cases which would readily meet the criteria for another problem, such as depression or anxiety disorder), then to generalize backward to members of the population who exhibit much milder forms of the characteristic and declare them ill as well (often over-inflating incidence figures by so doing).

Related Conditions

The disorder is a subtype of delusional disorder, and is often accompanied by narcissistic personality disorder.

Epidemiology

Prior to the 20th century, the disorder appears to have been unknown, though a related condition involved defining normal-range human characteristics (e.g., sexuality, falling in love, being from a colonized society) as evidence of moral failing.

The disorder became prominent in the latter half of the 20th century and has increased exponentially since that time.

Individuals in the helping professions appear to be particularly vulnerable to the disorder, apparently due to psychological contagion (mass hysteria is a related form). Such individuals seem drawn to those of like minds, and may be found on committees advocating the formal adoption of new disorders and the broadening of diagnostic criteria for others.

In recent years the problem has “leaked through” to the public at large, where the problem manifests most frequently as a diagnosis of oneself as mentally ill.

Treatment

Treatment of this condition is challenging, as the sufferer seldom sees the problem as damaging, and indeed often overvalues the tendency as evidence of “special insight and expertise.”

Where treatment is possible, education regarding the normality and prevalence of human emotion, distress, and variable self-esteem may be helpful. The sufferer should gently be led to explore the possible problems associated with overdiagnosis.

These problems include the fact that once a normal experience is redefined as a mental illness it loses its “signal value” (or usefulness) to the person experiencing it. For example, a period of poor motivation can be a welcome signal that one’s life has become repetitive and unstimulating and requires adjustment. A child who has difficulty settling and focusing on desk work for extended periods may require a higher level of physical activity. If these “symptoms” are redefined as mental illnesses, their ability to guide action can be lost; the goal of treatment is instead to eliminate them.

Course

The problem seems to be most prevalent in the 20s to late 40s. With age, most practitioners experience sufficient turmoil, stress, and loss in their own lives to recognize the breadth of human experience, and the potential value of intense emotions, including those often labeled “negative emotions.” Direct experience with a broad cross-section of humanity and with a variety of viewpoints regarding the nature of normality is typically helpful in this regard.

 *   *   *

It is my sincere wish that those in charge of creating new diagnoses will see OD as the serious and threatening epidemic it has become. Although there is scant research on it as yet, my experience and special insight are, I feel certain, sufficient reasons to include the diagnosis in DSM-V. Once there, of course, it will become the subject of research and will appear in every subsequent revision.

Friday, 27 January 2012

Private Practice: The Repulsions

This post is part of a series on private practice issues that will be appearing on Fridays for the next month or two, on the leadup to a series of workshops (based on my book Private Practice Made Simple) taking place in Calgary, Toronto, Ottawa, Vancouver, and Edmonton in March (information here).
Not even an apple to offer us.

Last week I covered some of the hopes for private practice reported by people who have attended my workshops. This week, let's consider some of their fears.

1.  I'll never get clients.

This is hands-down the most frequent fear that people express. They've often been working in large, well-known organizations where the clients are covered by insurers and are referred to the service, not to the person working within it. "If I'm not part of that organization, and if on top of that I'm charging for what I do, how will people ever come to see me?"

This is an entirely valid concern. Most clinicians are, to be frank, lousy at making their services known and have few ideas about how to do it. Fortunately, such things can be learned, and eventually most private practitioners figure at least some of them out. It's a major topic in my book and others in the area.

2. I want a reliable income!

Another dead-on concern. People get used to having a very clear idea about how much money will be in every paycheque. In private practice you never really know how much you're going to make each month. This makes personal budgeting more difficult, especially if you live anywhere close to the edge of your income. Furthermore, there is no way of ensuring that the business takes in a stable amount: it always fluctuates.

Private practitioners have to learn to deal with this uncertainty. One of the best ways is to live with more of a margin than you would if you earned about the same amount in a large organization. You save more, you keep more in savings, you go into debt less. You can also pay yourself a set amount each month from the business, then issue yourself bonuses if the business account begins to build up beyond any reserve that you need.

3.  I know nothing about running a business.

At the workshops I love asking how many people took a small-business management course as a part of their professional training. No one ever puts up their hand. Despite the fact that many of their graduates will be running a business, professional schools almost never devote any time to it. Furthermore, most therapists don't get the experience or training anywhere else - they generally haven't run anything bigger than a lemonade stand.

Fortunately, lots of people have to run businesses, so many of the seemingly-threatening details (How do I do payroll? Book keeping? Tax payments?) aren't actually as difficult as they might seem. Governments actually want people to pay their taxes, so they don't generally make it too difficult to do so. 

4.  I won't have any benefits package.

This is almost certainly valid. As an employee of a large organization, a professional will usually get extended health coverage, sick leave, short-term disability, long-term disability, government pension plan, private pension plan, and vacation pay. The value of these extras amounts to a significant percentage of a person's pay package (it varies, but can be up to 20%). All of this evaporates when you move into full-time private practice. 

Consequently, it's worth contemplating whether one really wants to give up all those benefits. If not, then maybe part-time private practice is an option, or none at all. There are also organizations that offer purchasable benefits packages for private practitioners.

5.  I don't know enough to work on my own!

I applaud the people who say this, because they're right. They don't know enough, and they never will. None of us is an expert on every concern that might appear in a therapist's office. Therefore, if and when they go into private practice they need to have a good consultation network so they can talk over challenges with colleagues. They'll also have to have good boundaries and know when a concern is outside their area of expertise, so they can refer people onward. 

It's the ones who think they know enough to practice independently that I worry about.

*     *     *

So there are a few of the many concerns people have raised about the prospect of private practice. I review more of them in Private Practice Made Simple, and go into more detail about the ones above.

Coming up: More posts on the nuts and bolts of operating a practice.


*   *   *

Want more information on operating a private psychotherapy practice? 

Check out my book Private Practice Made Simple.  It contains information on starting a practice, creating a space, designing a website, getting referrals, managing finances, avoiding burnout, and much more.

The book is available at bookstores, from the Changeways Clinic website, and through Amazon here.


Vancouver Workshop November 29 2013

Click here for information and registration for the one-day workshop Private Practice Made Simple being held in Vancouver Canada Friday November 29. 

Tuesday, 24 January 2012

The Pathologizing of Altruism


Over the past two decades, much has been made in the mental health field of the phenomenon of “people pleasing.” Such folks, it is said, have an extremely fragile sense of self-esteem and make up for it by putting themselves out for others.
We're in this together.

This is a genuine phenomenon. It is close to the concept of the “mirror object” or false self. A mirror object is a person who discards their own interests and opinions, feeling them to be faulty, insignificant, or simply inadequate to the task of attracting the love, interest, and care of others. Instead, they simply mimic the opinions, attitudes, and styles of others. When asked their opinion of a movie, their immediate reply will be “What did you think of it? … Oh yes, I thought so too.”

Similarly, the person who adopts a false self looks to their social milieu to determine what is most valued, and then attempts to embody that. I’m reminded of a young man I saw many years ago who had a pet boa constrictor which he confessed to me he disliked and feared, but which was extremely useful in convincing his friends that he was “cool.” A more conventional example: the adult who adopts all the trappings of success – the country club membership, the boat, the luxury car – despite not really liking golf, sailing, or driving.

Rather than collecting status symbols, the people pleaser occupies his or her time doing favours for others. They may run errands, give unexpected gifts, volunteer for admirable causes, serve on committees, and take up the slack for everyone around them. At the extreme they may do so to their own detriment – leaving themselves with little time to relax, sleep, or care for their own needs. The faulty assumption underlying this idea is “I am only worthwhile as long as I am doing something for someone else.”

The problem with all of this is a common one in mental health: Border creep. What starts out as a label for the far extreme becomes a way of characterizing all related behaviour. So gaining much of one’s self-esteem from doing things for others becomes a sign of a weak character rather than a strong one, an example of unsuccessful development rather than resounding success.

In truth, the creation of a person who gains much of his or her sense of worth from the contributions he or she makes to others is the fundamental goal of childraising. Such a person is a boon to humanity, not a candidate for corrective psychotherapy.

Implicit in the pathologizing of people pleasing is the idea that a truly successful person should feel fully worthwhile despite not doing anything to benefit anyone: A person capable of living as an island, taking much but giving back nothing. This person would be an icon of consumerism, fully worthy of the term: one whose entire life is characterized by consumption rather than production.

Not all of us are suited to the throwing of birthday parties, or the staffing of soup kitchens. We contribute in the ways that match our talents, interests, and abilities. But the idea that a fulfilling life is available to those who reserve all of their potential contributions appears to be false.

The opposite of a people pleaser is not a healthy human being. It is a sociopath. Rather than pathologizing this behaviour, we need to help people celebrate it, and round it out with care for the self as well. To this end, the Christian injunction to “love one’s neighbour as oneself” can be useful. The phrase is an equation, and like every equation, it works both ways. Some of our clients can benefit from treating themselves as well as they treat others.

But it is also the role of therapists to help clients find their inner resources – the talents that they can offer to the world. People with low self-esteem often believe that they have no such abilities, and that any attempt they might make to help others would be scorned. Of the people I have seen with low self-esteem, the problem has not been a surplus of doing things for others, but a deficit. Assisting them to contribute to the surrounding world has been an enormously positive step.

Rather than helping to stamp out people pleasing, then, a more appropriate therapeutic task is often to help people to access and actualize this tendency. We need to find and honour our inner people pleaser, not shame it out of existence.

Friday, 20 January 2012

Private Practice: The Attractions

This is the second post in a series on private practice issues that will be appearing on Fridays for the next month or two, in the leadup to a series of workshops taking place in Calgary, Toronto, Ottawa, Vancouver, and Edmonton in March (information here), based on my book Private Practice Made Simple.

Last week I suggested that anyone contemplating a private practice should sit down and write out their hopes and their fears on the subject - what makes them consider such a move, and what makes them hesitate. I invite participants at my workshops to do this, and I've compiled their responses. This week, let's take a peek at some of the attractions, and the reality behind them.

1.  Freedom from the impediments of large organizations.

When I worked in a hospital setting I once fantasized that an alien observing the actions of management would likely conclude that their primary function was to ensure that no patient was ever seen or treated at the facility. Endless meetings, pointless paperwork (such as recording what I was doing for every 15-minute block of time), and constant "streamlining" and "reorganization" meant that actually doing my job felt like a battle. And sure enough, for me and almost everyone else in private practice, this mostly evaporated when I left the organization and struck out on my own.

It's not all roses, however. In a big organization you don't have to figure out why the internet is down, where to buy phones, or how to get your landlord to fix the leaky roof. There are people whose job it is to handle such concerns. In private work, it's all up to you.

2.  You see the clients you want to see.

In a large organization you are a peg, the job is a slot, and you don't always fit. You're asked to treat concerns that you are not properly trained to see, and some of your best skills are left unused. You have burning interests in some areas of practice, but your position specifically excludes these. Private practice can allow you to create the service you want to offer, and if there are populations or concerns you don't want to see, you don't have to take those referrals.

But you have to be practical. If your big thing is a relatively rare disorder, it's unlikely you'll be able to fill your practice with that specialty alone. Maybe someday you'll become the go-to person for trichotillomania, but in the meantime you're going to have to branch out a bit.

3.  More money.

People look at the fees that private practitioners charge and have visions of wealth dance through their heads. After all, their hourly rate at an institutional job isn't nearly so high. At my workshops I've taken to having everyone in the room repeat aloud "My fee is NOT my pay!" in hopes of getting rid of this idea. Fees go toward rent, phones, equipment, assistants, and a thousand other expenses, and all the practitioner gets is the leftovers - if any. Plus, we only get paid for some of the hours that we work - in many cases, less than half of them. It's easy to have a private practice and make much less than one would in an institutional job.

That said, it is also possible to make somewhat more - but only if the practitioner is extremely careful with expenses, revenues, and (yikes) practice promotion.

4.  Flextime!

Most organizational jobs set the hours and it is the job of the employee to salute and arrive on time. In private work there are still some constraints, because you have to be reliable for your appointments. But indeed, one can set one's own schedule. If you want to work outside regular office hours, your clients will be thrilled. Want to work late Tuesdays and attend yoga Wednesday morning? No problem. If you want to take Friday afternoons off, you can. You still have to watch your finances, though, because many of your costs (e.g., rent) will be fixed regardless of how many clients you see.

5.  No more medical model.

This is a common hope that people express at my workshops. By going into private practice they will be able to escape a system in which they feel urged to diagnose normal emotional reactions to stressful life circumstances as evidence of mental illness. (Even normal bereavement will shortly become a mental disorder, if predictions about DSM-V are accurate.) If a person doesn't have a formal diagnosis, they can't be seen in many institutional settings.

Well, diagnosis can sometimes be valuable, of course (with some concerns the diagnosis truly does point the way forward in treatment), but private practice does allow a person somewhat more latitude than many institutional settings to focus on the client's life rather than pathologizing their reactions to it. Third party insurers still want to see a medical diagnosis on many forms, however, and so it can still take some resolve to avoid the subject altogether.

*     *     *

So there are a few of the attractions, which are discussed in greater detail in Private Practice Made Simple (along with others I haven't mentioned here). What are the repulsions? Why doesn't everyone take the leap? Next week I'll present some of the reasons that people give for putting on the brakes.


*   *   *

Want more information on operating a private psychotherapy practice? 

Check out my book Private Practice Made Simple.  It contains information on starting a practice, creating a space, designing a website, getting referrals, managing finances, avoiding burnout, and much more.

The book is available at bookstores, from the Changeways Clinic website, and through Amazon here.

Tuesday, 17 January 2012

The Mental Movie Screen Part 3: The External Hard Drive

I've been writing about a metaphor I often use in therapy: The mental movie screen, which is the inevitably faulty internal representation of external reality.
External memory.

In the second post I suggested that when we are anxious or depressed, it often seems that the screen is a bit smaller than usual. We can't keep as many things in our head, and we become absent minded or overwhelmed.

This week, let's follow this tangent a bit further. It's a bit off the subject of introducing CBT, but it is a strategy that I recommend for people who feel scattered, distractible, or overwhelmed.

When I’m working on a project, my mind seems to wander around, bored, thinking of other things that need doing. “Hey, we’re out of milk.” “Shouldn’t I be returning that phone call?” “I need to mail that package later.”


The natural temptation is to hold these errands in my mind while I continue with the task at hand. “I’ll try to remember that for later.”

If we use the metaphor of the mind as a movie screen, we could say that these small tasks will take up a few square inches of space on the screen. Gradually the space available for the task I am working on will get nibbled away until I can’t really focus on it.

This is reminiscent of working at a desk that is piled high with projects, post-it notes, books, and unrelated junk. We can find ourselves trying to work in the tiny clear bit of space in the corner. But the other objects are alive, and calling to us.

Depressed and anxious folk, or people who have rather too much going on in their lives, have a cluttered mental space and a movie screen that is much smaller than usual. When we’re not at our best, we need all the clear space that we can get. So we need to get the details out of our head.

One strategy is to try to block out the rest of the world and focus, so it doesn’t occur to us that we haven’t answered an email or paid a bill.

For most of us, most of the time, this is futile. We never really master the art of slamming the door shut. So the other option is to prop the door open, and welcome the extraneous thoughts that will come anyway. The question is how to prevent them from eating up our attentional field.

A notebook can be a great strategy for clearing the mental space. I keep one to the right of my computer whenever I am working on something that takes focus. If it occurs to me that I need to buy pens, I get this idea out of my mental space as quickly as possible, and down onto the page. Every time an extraneous demand appears, it goes on the list.

This way, I don’t have to remember the errand myself, occupying all-too-scarce mental resources to do so, and I also don’t have to occupy even more resources worrying that I might not remember it. When I finally stop working on the project of the moment, I can simply look at the notebook and decide what to do next.

I’ve suggested this strategy to many of my depressed/stressed/overwhelmed clients, and many have found it helpful. They are not simply distractible; they are self-critical for being distractible – despite distractibility being a perfectly normal aspect of what they are experiencing.

By accepting the problem and using a practical partial solution for it, we can decatastrophize. “I’m not an idiot, and my brain fog isn’t going to stop me from doing things.  It’ll pass eventually, and meanwhile I can use some simple assists to help me cope.”

If you like computer models of the mind, we can think of a notebook as an external hard drive. When your internal processor is a bit wonky, or if you are working on tasks that require every ounce of your processing ability, get everything else out of the way onto the external drive. When you need it, it will still be there.

Friday, 13 January 2012

Private Practice: Why and why not?

This is the first post in a series on private practice issues that will be appearing on Fridays for the next month or two, on the leadup to a series of workshops taking place in Calgary, Toronto, Ottawa, Vancouver, and Edmonton in March (information here) based on the book Private Practice Made Simple.
A bare-bones practice.

Are you thinking of opening a practice?

In the Stages of Change model, people go through a variety of phases before making any major shift in their lives. The model is used most widely when conceptualizing people who are considering giving up an addiction. But it applies equally to those mulling over a career change.

So if you are in the Precontemplation, Contemplation, or Preparation stages, you are weighing the pros and cons of practice. It's best to get these out on the table so that you can investigate each one.

To this end, the adjunct materials for Private Practice Made Simple includes a pair of forms that invite you to brainstorm about the attractions and repulsions of private work. They're available for free from www.changeways.com. Here are the direct links:

Of course, these sheets don't offer much more than a blank page, so you don't really need them.

Take a few minutes with the first form (Why?). What is it you want in your career? Why is private practice appealing? What is your fantasy? Try to overcome any sense of triviality or shame while doing this. In the Robertson Davies novel Murther and Walking Spirits, a wealthy character confesses that his primary motivation in starting his own business was the desire to take a nap every afternoon. Maybe one of your secret desires is a job where you don't have to wake up until 10 am, or one where you take every Friday off. Fine. Write that down.

Then take out the second form (Why not?) and try to tune into the part of yourself that hesitates. Why haven't you done this already? What holds you back? What are your fears? Don't worry about whether your fears or rational at this stage. The whole point is to get them down on paper so that you can take a step back and evaluate them critically. But at this stage you don't want to be evaluative. You just want to give that frightened child inside a chance to speak.

Once you've spent some time sitting with each possibility (Yes! No!), keep the forms with you for a few days. Additional attractions and repulsions will occur to you at unexpected moments. Write them down.

Then return to the forms and wake up your inner adult. Time to set your instincts aside for a bit and evaluate in cold blood what you have written. You might rate each of your fears and hopes on a numerical scale, perhaps from 0 (not important, not relevant, not true at all) to 10 (essential, valid, certain). 

You'll realize you don't have enough information to assess all of your considerations, and this will point the way forward. Information-gathering is half the job of opening any business, and you'll begin to see at least some of the information that you need to have in order to make the decision.

One of my favourite outcomes at a Private Practice Made Simple workshop was an upper-year graduate student who came up to me and declared her gratitude for the day. "As a result of coming here I've realized that I don't want to have a private practice after all!" It might have been possible to see this as a failure, but my job was to provoke careful thought, not to do a sales job on the idea of private practice. By coming to the workshop she had had some issues raised that for her tipped the balance toward "no," at least for the time being. If the new decision was the right one, then the registration fee was probably the best money she'd spent in ages. "No" is the right decision for many - likely most - therapists.

Next week I'll reveal some of the attractions people have reported. These are discussed more fully in Private Practice Made Simple, but I'll do a precis of some of the important ones.


*   *   *

Want more information on operating a private psychotherapy practice? 

Check out my book Private Practice Made Simple.  It contains information on starting a practice, creating a space, designing a website, getting referrals, managing finances, avoiding burnout, and much more.

The book is available at bookstores, from the Changeways Clinic website, and through Amazon here.


Vancouver Workshop November 29 2013

Click here for information and registration for the one-day workshop Private Practice Made Simple being held in Vancouver Canada Friday November 29. 

Tuesday, 10 January 2012

The Mental Movie Screen, Part 2: Panavision or Pinhole?


Last week I talked about a metaphor I sometimes use in therapy: The internal movie screen. We feel like we're reacting to the outside world, but really we only see a selective bit of reality limited by our perspective, our senses, and our attention. Once we've got the movie screen in mind, we can add a few more ideas.

Have you ever been in a movie theatre and, just before the movie starts, the black frames around the screen slide in or out to accommodate the shape of the movie image? The sides slide back for a widescreen film. Sometimes the top and bottom move in a bit.

In the Tuesday post last week we considered how mental experience is not based on reality, but on a perceptual representation of reality that is never really complete. The metaphor for this internal representation was a movie screen.

This week's point: The screen isn’t always the same size.

Sometimes it shrinks. When you’re stressed out, it gets smaller. You can’t pay attention to as many things at once. Perhaps you’ve noticed yourself losing or forgetting things. Or you’ve been trying to work out a mental problem that you can normally solve, and it somehow feels like your mind isn’t big enough to hold the concepts. This is like making a familiar recipe and finding that the pot is overflowing. Someone shrank your pot.

In times of stress, the screen's frame moves in, shrinking what we might call your attentional field. What could normally fit, doesn’t. That’s okay, if you have a pretty simple task. Running, say. Or sorting nails.

But if you have a complicated task, like performing mental arithmetic, or writing a story, or resolving a dispute with your partner, you just can’t do it.

Depression shrinks the screen too.

What widens it? Relaxation helps. Meditation can be a good strategy, helping to pull the frame back. Being in a natural setting seems to do it for many people, strangely enough. There’s something about sitting comfortably overlooking a large expanse that seems to allow the mind to calm itself and spread out.

So if we’re depressed or anxious or burnt out, what should we do?

Well, obviously, we can do those things which have usually worked for us in the past. Head to the lookout, sit on the meditation cushion, practice yoga, breathe using the diaphragm.

But when we are distressed these strategies, though they may help, will seldom work as well as they usually do. They’re still worthwhile, even though we may feel dissatisfied with the results.

The other task is acceptance. We need to acknowledge that our minds have shrunk before, and they will do so again, over and over throughout our lives. And this has not harmed us directly in the past, and is unlikely to do so this time either.

But we still have our taxes to do. So we can adopt strategies to work with a smaller screen:

Stop multitasking. When we switch from one task to another, we shuffle what we were working on to a corner of the screen, and use the remainder of our attention for the task at hand. But having a smaller screen means we need to devote as much of it as we can to the task. Normally we might be able to process two things at once, or alternate between tasks, but while our attention is impaired we are best advised to simplify.

Clear the space. Normally we can filter out the demands of the environment, or tolerate their pleas for our attention. But when we are stressed or depressed, this becomes more difficult. So we can cope by tidying everything away except for the task of the moment.

Reduce interruptions. Find a way to get blocks of time free from distraction. The phone and television are turned off, the family knows to leave us alone for an hour, and for a specific time our privacy is sacrosanct.

Stop rushing. We can let go of our usual expectations about how long things will take. Normally we can calculate the month’s receipts in an hour. With our reduced attentional field we will allow and expect ourselves to be slower, relinquishing the temptation to hurry. We will use the calculator for sums we could ordinarily do in our head. We will write down our reasoning. We will double check.

Ritualize. Normally you can toss your keys anywhere and remember where you put them. Now we need simplicity, and we don’t want to spend hours hunting for things. So we can put a bowl by the door for the keys and cell phone. We underschedule a bit so we aren’t rushed. We push ourselves just a little bit more to put things away rather than leaving them out, occupying a fragment of the movie screen, calling to us.

And we stop criticizing ourselves, which only shrinks the screen more. We begin to see the mental movie screen as less solid and more fluid, subject to expansion and contraction over time. When it contracts we avoid attributing this to a permanent characteristic of ourselves (“I’m so stupid”). We strive to welcome the opportunity to practice simplicity and clarity.

Friday, 6 January 2012

Training: Private Practice Made Simple


In March 2012 I will be offering a five city workshop series based on my book, Private Practice Made Simple (New Harbinger Publications, 2011). Here's the schedule:


  • March 3 - Calgary, Olympic Volunteer Centre
  • March 15 - Toronto, Best Western Primrose Hotel
  • March 17 - Ottawa, Lord Elgin Hotel
  • March 22 - Vancouver, Holiday Inn Vancouver Centre
  • March 24 - Edmonton, Lister Conference Centre, University of Alberta


The program is a full day. The flyer, and links for online registration, are available here.

What about the blog?

Over the coming weeks my Friday posts will focus on the mechanics of operating a private practice in psychology or mental health. The Tuesday posts will emphasize issues of (hopefully!) broader appeal to practitioners and the general public alike.

The private practice posts will cover a variety of practical issues. The book contains references to online forms, and these are available free from www.changeways.com. Many of the posts will include links to specific forms that readers can use to help design or fine-tune their practices.

What's the focus of the workshop?

Here's the text from the flyer:

Therapists routinely say it. “I was never trained how to run a business.” We were taught assessment strategy, how to conduct therapy, and when to refer - but not how to perform many of the central activities involved in running a private practice. So we stumble through, gradually picking up ideas and skills as we go along, and about the time we’re planning our retirement we begin to think we understand.

But running a practice doesn’t have to be difficult. Many of the skills can be communicated and learned relatively easily. This program covers a wide variety of strategies to make your practice more successful, more effective, and more fun.

Here are some of the topics covered ...

Getting started

  • Selecting a location and practice name
  • Defining your scope of practice
  • Furnishing and organizing your space

Creating a website

  • The importance of a web presence
  • How to organize the site
  • Working with a developer
  • Monitoring site visitors and usage

Getting referrals

  • Using directory services
  • Identifying your best sources
  • How NOT to waste time and effort
  • The practice announcement
  • Corresponding with sources

Practice finances

  • Setting fees and calculating income
  • Facing financial realities
  • Working with an accountant
  • Accounts, salaries, and expenses
  • Should you incorporate?

Clinic staff

  • When do you need an assistant?
  • The clinic manual
  • Setting up payroll
  • Staff retention issues
  • Bringing colleagues into the practice

Professional presentation

  • Office layout 
  • Why you should sit in your client’s chair
  • Handling payments and bookings

Information management

  • Client number systems: Why bother?
  • Demographic information forms
  • File organization
  • Data security

Fifteen ways to avoid burnout, including:

  • The annual redefining process
  • Imposing your own boundaries
  • Why not to work to capacity
  • Identifying an avocation
  • Defending the work/home boundary
  • The price of not taking vacations
I won't cover all of these topics in the blog. But let's see where it goes.

Tuesday, 3 January 2012

The Mental Movie Screen Part 1: Introducing Cognitive Therapy Experientially


The world inside

Cognitive work can seem a bit esoteric if you launch into it from the perspective of theory. I find that its simplicity and practicality come down to Earth a bit if we come at it from the realm of personal experience, preferably right there in the therapy room.

As is so often the case, the therapist isn't essential. I'll paraphrase what I sometimes do when introducing the idea to clients. This may take a bit of indulgence from blog readers, but it won't be the first time I've asked for this.

Take a moment and notice where you are. Look. Listen. Smell. Feel.

Did you notice the bit of clutter nearby? The sensation of your right foot in your sock? That faint intermittent sound from outside the room?

Probably not. Or if you did, you missed thousands of other details. If you moved to another room, you couldn’t draw the room you had left with any great accuracy.

We think we see the world, but in fact we see only a tiny proportion of it. The whole thing seems to be in colour, but our peripheral vision receptors are mostly black and white. Not only do we not see what is there, we fill in the blanks with things we did not actually see. We take vibrations in the air and turn them into sound. We hear sounds and interpret them as language.

And that’s just the present instant. This moment, this room. If you close your eyes you can see visions from the past. Your third-grade teacher’s face. The friend you fought with and never saw again. A birthday party. Your first workplace. Your first kiss.

Much of this, it turns out, is constructed. If you draw the layout of your elementary school and then go back to visit you will discover that you missed significant details. Your memory of that traffic accident isn’t exactly the way it happened.

But you can create images from the past, and they are something like the past reality.

Not only can you make up the past; you can also make up the future. Imagine future successes, possibilities, dreams, hopes. You can terrify yourself with images of future catastrophes. If you are a worrier, you may be quite accomplished at this.

Now: Did you notice that when you considered something from the future, you lost your third grade teacher’s face? Now it’s back again.

Put your teacher’s face into that future image somehow. Now add your first workplace. Feel your right foot while you do this.

You can do it, but it gradually begins to feel like juggling. Bits flicker in and out. There seems to be a limit to the number of things you can hold at one time.

Where are all these images, sounds, awarenesses, playing out? Think of it, if you like, as an internal movie screen - or a set of three screens: past, present, and future, all playing out in front of you. What you see seems like reality, but it isn’t. Even if you are fully present to the moment, undistracted by future or past, you can’t hold the entirety of the experience in your mind.

Why does this matter?

Our emotions and our behaviour seem to be based on reality. They’re not. They’re based on what appears on the movie screens, and much of what appears is distorted or fictional.

Wait: There’s someone behind you with an icepick. Until you learned that, you couldn't react, didn’t feel fear, didn’t run from the room. You can only react if you perceive the icepick. If it appears on the movie screen.

This seems to be two things at once:

1. Too obvious to bother commenting on.
2. Philosophical hairsplitting nonsense.

But, obvious though it might be, it’s important. This idea is at the foundation of cognitive therapy.  Selective perception, and the misperception of reality, lies at the core of much of our distress – and some of our misplaced happiness.

Like a movie, we only see what sits within the frame. We react to Tom Hanks, or to Susan Sarandon, or to Brad Pitt, and to what seems to be happening to them. But if we pulled the frame back, we’d see the boom microphone, the equipment, the limits of the set, and we’d have a completely different experience. Suddenly it’s not a story about a bank robbery. It’s a story about some people making a film.

When we’re investigating our minds, it’s worthwhile to stretch our attention a bit to become aware of two things at once:

1. What’s going on out there.
2. The fact that we are viewing only a part of the movie.

We can hold both awarenesses in our minds at once, just like thinking of our third grade teacher’s face at the same time as we notice our right foot. We can get just a little less caught up in the story, at least for a moment.