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Tuesday, 28 February 2012

Hidden Symptoms of Depression: The "I Have No Life" Oscillation


This is part of a series of posts on some of the less-talked-about symptoms that tend to go along with depressed mood. As I discussed in the first post in this series, the list of diagnostic symptoms for depression is well known, but not exhaustive. During depression people experience many more phenomena as well.

As stated in that earlier post, however, it’s also important to acknowledge that each of these “hidden symptoms” can also occur at other times in our lives. Don’t fret if you see yourself in these experiences.
Alone in a precarious existence...

Do you have a life?

“Get a life!” people sometimes tell us. What they usually mean is that we are occupying ourselves with trivia. If we had an interesting, busy life with a variety of friends and interests, we would not be so focused on and upset about, say, whether they parked their car crookedly.

So: Do you have a life? Do you have a sufficient variety of activities, interests, and friends that you can say that you have a reasonable human existence?

The answer depends on the people to whom you compare yourself. If you are thinking of a jetsetting actor/rockstar who spends every evening at a different gala opening, with a new partner every five minutes, then perhaps you don’t – and perhaps you prefer not to have one. If you compare yourself to more down-to-earth friends and neighbours, then perhaps you do.

“I have no life!”

During depression (and at some other times) it’s common to feel that our lives are not as full as we might like. Partly we are so easily overwhelmed that we restrict ourselves to a smallish existence. Partly, great hunks of our lives may have fallen away unexpectedly (job, relationship, plans), and that’s why we’re depressed.

Sometimes, though, the same life can seem full and satisfying one moment, and empty the next – without anything really changing. It depends on the perspective you adopt.

This is reminiscent of the scene in Woody Allen’s Annie Hall, when Woody’s analyst asks how often he and Diane Keaton’s character have sex. “Practically never! Only three times a week,” he moans.  Keaton’s analyst asks her the same question. “Oh, constantly,” she complains.  “Three times a week!”  Same reality, different interpretation.

The oscillation

During depression, it’s not uncommon to feel constantly that one’s life is not what it should be, regardless of one’s actual circumstances. The negative filter that pervades – and poisons – everything we see can make even quite a nice life seem like hell. This is the usual stance during the depth of depression. The negative evaluation may be objectively true (others would agree that your life truly is awful, even apart from the mood problem), or it may be tainted by the negative feeling of the depression itself.

In milder depression, however, and as a more severe depression lifts a bit, the sense of satisfaction with one’s life can flicker. You go out to dinner with a friend and you feel warm, loved, interested, and content. Yes, you have a life, and it’s a pretty good one. Then you say goodbye to the friend, head home, close the door behind you, and that whole feeling evaporates. Here you are, alone, friendless, and with nothing to do: this now feels like the reality of your life.

Sometimes this phenomenon takes place outside conscious awareness. People know that they feel reasonably well when they are doing things with others, and miserable when they are alone at home, but they don't notice the underlying thoughts.

But some people watch the process happening and are appalled at their apparent lack of a core sense of stability. “I have the same number of friends whether I’m with them at the moment or not,” they say. “How can that knowledge not stay with me and make me feel okay when I’m alone for two minutes?”

That question, asked in frustration, actually has an answer. In fact, it has two of them.

First, this fragile sense of one’s self and one’s life is a fairly standard feature of depressed mood (and of other times when parts of one’s life have fallen apart). It doesn’t mean we have no core, no sustaining personality, no ego strength. It just goes with the territory.

Second, our emotions at times can be very tied to the present moment. If we are engrossed in a project, or sitting in a restaurant with a friend, we feel engaged and loved. If we are alone and disengaged, with nothing to do, then we can feel, yes, lonely and disengaged. Then we can take that feeling and apply it to life as a whole. There are no friends with us in the room at the moment, therefore we have no friends.

How do we stop the oscillation?

We don’t, completely. We will always be affected to some degree by our thoughts and circumstances. But if we are experiencing this wavering of our perception to an uncomfortable degree, then we can do a few things.

Acceptance. Work at recognizing that this is a normal human experience, not a sign that you have no strength or sense of yourself. It will come and go, like all the other uncomfortable feelings. During depression it may come more intensely. It will tend to fade as the depression lifts.

Desensitization. Some people try to cope by staying frantically busy and never having a moment to stop and “face the void.” This actually perpetuates the problem, subtly reinforcing the idea that being alone is a disaster. Instead, gradually introduce solitude and disengagement voluntarily. If a weekend alone seems too frightening, then start with an hour, or ten minutes.  As your tolerance improves, you can ramp up.

Self-Talk. Remind yourself of the truth. No, you aren’t as social and foolishly busy as your friend Joan. But yes, you do have a life. There are friends and interests. Name them. Expect that this recitation of the elements of your life will feel flat and pointless at first. Keep going.

Welcome the dissatisfaction. Perhaps an objective judge would say that yes, your life really is a bit thin right now. Fine. Use the sense of emptiness as a cue. What would a non-empty life look like? Ensure that you leave room for solitude and reflection in this fantasy, even if they are uncomfortable right now. Take the goals you develop and break them down into achievable steps. You’d like to get another job, so you spend 10 minutes looking for your resume. You want more friends, so you check out the options for volunteering in your neighbourhood.

Follow these steps, and the wild swings in our beliefs about our lives can begin to stabilize.

Next up:  The Collapse of Automaticity.


Online Course

PsychologySalon has developed a cognitive behavioral guide to self-care for depression. Though not a substitute for professional face-to-face care, UnDoing Depression may be a useful adjunct to your efforts.  The preview is below. For 50% off the regular fee of $140 USD, use coupon code “changeways70” when you visit our host site, here.

We also have courses for professionals and for the public entitled What Is Depression, What Causes Depression, Diagnosing Depression, Cognitive Behavioral Group Treatment of Depression, How to Buy Happiness, and Breathing Made Easy. For the full list with previews and substantial discounts, visit us at the Courses page of the Changeways Clinic website.

Friday, 24 February 2012

Private Practice: Preparing Your Office Space

This post is part of a series on private practice issues that appearing on Fridays in 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 2012 (information here).
Not quite ready.

When you first rent an office suite, you just have the bare walls – and even they may not be good enough. You need to do a lot of work to get the suite ready to see clients. Even if you already have an existing space, perhaps there is more you could do to make it an inviting and pleasant space in which to work.

In the form set designed to accompany Private Practice Made Simple (New Harbinger Publications, 2011) there is a two-page worksheet intended to help practitioners plan or upgrade their space.  You can find the form on www.changeways.com; the direct link is here.

The sheet divides the task into categories in an attempt to make it feel more manageable.

Soundproofing

Soundproofing is one of the problems therapists constantly face. We want to do as much as we can to make the office feel safe and secure for our clients. I’ve discussed this issue in two posts on this blog:
Floor to Ceiling

This category includes items such as carpet, paint, curtains, lighting, signage, and more. Each of these is discussed in Private Practice Made Simple. You don’t need to overwhelm clients with your design sense – they will be focused on what brings them to your office, not on your choice of wallpaper. But try to go for something neutral enough that it doesn’t speak louder than the people your office is trying to serve.

Furniture Checklist

This category is more for the practitioner contemplating new office space and how to furnish it. I went through our own space and attempted to list each bit of furniture we have, from desks to chairs to whiteboards.

Keep in mind that a therapy practice has one significant advantage over almost any other health-related profession: You don’t need much equipment. You should be able to start your business without going into significant debt, unlike a dentist.

Additional Furnishings

Some of the bits in this section of the list are less critical to have on opening day, but you will most likely want them eventually. They range from a sound system to a water service to waiting room magazines. Remember to pick everything with the comfort and best interests of your clients in mind.  Keep the Disneyland principle in mind: The line is part of the ride. The therapeutic elements of your space should start the moment the person opens the door to your office suite. So select items carefully.  Will a muckraking gossip magazine mesh with the intent of your service?

Stationery

People often forget the stationery when first setting up their space. And indeed you may not need anything very elaborate at startup. But eventually you will need letterhead and business cards.

Electronics

The final category is one of the most daunting for most therapists: items such as printers, phone systems, broadband, point of sale terminals for credit and debit card payments, and so on. Ask colleagues for input on the brands and suppliers they use.

*     *     *

In coming months I may write individual posts on some of the items in this list, as I have done for soundproofing concerns. If I do, I will try to remember to revise this post to link to the posts, but take a look under “Practice” to see what there is. And if you have any particular feedback or ideas, please comment and make your own recommendations.


*   *   *

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, 21 February 2012

Hidden Symptoms of Depression: The Plexiglass Wall


About the series

Last week marked the start of a new series of posts on the less-talked-about symptoms that tend to go along with depressed mood. 
Direct contact can be difficult...

The first post reviewed the standard symptom list used for diagnosis. While useful, these diagnostic criteria run the risk of implying that they describe depression in its entirety. In other words, if you have any additional bits of experience not described by the items in the list, then you must have additional psychological problems – and how depressing is that? In fact, the diagnostic criteria include only a small subset of the symptoms of depression.

But in describing the additional symptoms we run a different risk: that people will recognize that they have experienced them, and will conclude that they must have clinical depression.

Not so. All of the symptoms of depression, diagnostic or otherwise, are elements of normal human experience. We have all had days of feeling low and disinterested, a week of insomnia, a period of inexplicably low energy, an increase or reduction in appetite, a phase of poor concentration.

Whenever I’m speaking to a group of clinicians and run through the list of diagnostic criteria for depression, there are always a few nervous laughs when I mention impairments in concentration and decision-making (often coming from the participants who find themselves in midlife and beyond). 

So if you recognize these so-called “depression symptoms” in yourself, do not conclude that you must be depressed. They are all normal symptoms of being human. They simply tend to become more pronounced when we are depressed.

The Wall

Social withdrawal is a standard symptom of depression – so standard that clinicians often strain to remember whether it is in the diagnostic list. (It isn’t.) It seems to go along with symptoms that are in the list, however. Low energy, disinterest in enjoyable activities, feelings of worthlessness – if you have these, then you will hardly be inclined to race out to parties.

Overcoming depression is, in part, a matter of pushing back against the depressive temptation to withdraw, and so many depressed people find themselves, by choice or circumstance, in social settings. These may be large events (attending movies or parties) or small (going for coffee with an old friend). While in these situations, it is normal (so normal that it is tempting to say predictable) to experience what many describe as The Wall.

The Wall is a powerful sense of separation between oneself and others. It is as though between you and other people there is a barrier made of thick plexiglass – impenetrable and isolating. You can see them, you can hear them. But they are separate in a way that perhaps they have never seemed before. 

This is not just self-consciousness. We all find ourselves regularly imagining what others see when they look back at us, and we are often harsh critics, paralyzing our ability to perform naturally. Depressed people experience this too, and it is often quite pronounced.

But during depression (and in other psychological states as well), there is often a profound feeling of separation from others that goes beyond apathy or low self-worth.

The sensation is something like the feeling one sometimes gets when speaking in a language one has not mastered, or with someone attempting our own language but haltingly. It is awkward and uncertain, and we are profoundly aware of the gulf in perception that separates us. We know the idea we want to express, to push across that gulf, and it is with a sense of detachment that we watch the other person to see if they have grasped what we intended. The awareness is focused very much on the gap between us, rather than on the person we hope to relate to.

When we speak with someone we open a kind of emotional pipeline between our own internal world and theirs. We can sense how they are feeling at an almost instinctive level. When The Wall is in place, we try to install that pipeline, but none of the emotions seem to come through. We understand the content of what they are saying, and perhaps they seem to understand us. But the indescribable feeling of connection is absent.

Who Cares?

The Wall is significant because it seems to have meaning. We naturally ask why it is there. “Why can’t I relate to Joan? What’s different between us?” It’s tempting to conclude that it is something about the other person (“She’s absent”), or about the relationship (“We seem to have grown apart”), or about us (“I can’t relate to people anymore; I don’t get anything from socializing”). 

All of these conclusions push us toward more withdrawal and solitude. “What’s the point of doing this if I don’t enjoy it?” This promotes the depression.

What do we do about it?

The solution to The Wall, in most instances, can be summed up as a set of steps:

  1. Reinterpretation. We remind ourselves where the experience comes from. “This is a normal aspect of my mood right now; it’s not a sign that I need to dump Joan or abandon all hope of having a social life.”
  2. Acceptance.  “This will pass, but the more I get alarmed about it and focus on it, the stronger it gets. I need to let it be here, and even give it permission to be here, before it will eventually fade.”
  3. Opposite action.  “This tempts me to withdraw, but what it really shows is that I need to get out with people regularly so that it can fade and I can relearn how to relax and be with people.”

If there are other contributing factors – shame, low self-worth, extreme self-consciousness – then these may take some additional work. But The Wall itself tends to fade with exposure. We may experience it most or all of the times we are with other people, but every encounter can shave a millimeter from its thickness.

We will never notice its final shattering. Only later will we look back and say “Oh, right, THAT feeling. I haven’t had that in a while.”

Next week:  The "I have no life" oscillation.

Friday, 17 February 2012

Private Practice: Viewing New Office Space


This post is part of a series on private practice issues that appearing on Fridays in 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 2012 (information here).

So you want to find your first private practice office, or it’s time to move to a new space. The first time I did this, I wound up with dozens of post-it notes stuffed into my laptop case with details on square footage, costs, what taxes are included, whether there was a gym in the building, and so on. Half the notes didn’t actually spell out which of the available offices they referred to.

Someday I really should get an ADD assessment.

Anyway. Looking for new space is inevitably challenging. You can remember some of the important details (“How much does it cost?”) but others will only occur to you on the fly, or might occur to you once the rental agent has said her goodbyes and vanished ("Wait - did that rental rate include services?").

So it’s a good idea to have a form that you can use to evaluate each of the spaces you look at. The form will remind you what to ask, and you can keep all of the information on a given unit in one place.

Just the fact that you have a form will be useful: Rental agents see that you are organized and that you plan to look at more than one space. If they want to get you for a tenant, they’re going to have to look sharp and offer a competitive deal.

In Private Practice Made Simple (New Harbinger Publications, 2011) I describe some of the important considerations when viewing possible space, and there’s an online form that complements that section.  But you can get the form at our website www.changeways.com with or without the book. The direct link to the form is here.

The form is divided into two sections:  The Building and The Suite.

The section on the building includes considerations such as transit locations, parking, zoning, quality of the public areas, noise levels, disabled access, washrooms, hours of opening, the after-hours entry system, signage, the recycling and refuse system, and the identity of the neighbours.

The section on the suite itself provides space for you to record the square footage (or meters), the number of rooms, and the overall rental rate. Be careful about these - in many buildings the square footage quoted includes a percentage of the common areas (e.g., hallways, lobby), not just the area inside the suite itself. There are also spaces for you to note and comment on the maintenance fee, the waiting room, the reception area, the consulting rooms, the interior doors, the soundproofing, the heating, the windows, the ceiling, the lights, the interior walls, the renovations required, and the neighbours' reviews of the management company.


*   *   *

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.

Thursday, 16 February 2012

The (Hidden) Symptoms of Depression


A new series

Clinical depression presents with a variety of manifestations which, taken together, can be used to make a diagnosis. But in addition to the commonly-cited experiences, there are many more subtle symptoms of depression that can be a part of the picture.

In this series of posts let’s examine some of these less-discussed aspects of depressive experience. But first …

How do we diagnose depression? 

The same way we diagnose any other disorder: with a list of signs and symptoms.

The list appears in the Diagnostic and Statistical Manual, the much (and somewhat justly) maligned guide to psychiatric disorders, soon to be even more reviled with the contentious release of the fifth edition, DSM-5.

Although I’ve been critical of the DSM system in past posts, the diagnostic criteria for major depression are reasonably useful, and (in their current form, at least) set the mark far enough from everyday experience that calling it a disorder isn’t entirely out of line.

The list of criteria can be found all over the web, so I’ve considered not repeating it here. But how can we talk about the other symptoms without at least mentioning the more widely known ones? To that end, then, let’s recite the list.

The DSM-IV criteria for Major Depressive Episode

The person must have five or more of the following nine symptoms at the same time for at least a two-week period. (Usually depressive episodes last much longer than two weeks, but two weeks is the traditional line in the sand beyond which we call the problem depression.) The person must have at one or both of the first two symptoms in the list (depressed mood or diminished interest). There are some provisos for children, but I’ll ignore these for now.
  1. Depressed mood.  Most of the day, nearly every day.  No significant breaks.
  2. Markedly diminished interest or pleasure in all, or almost all, activities. Again, most of the day, nearly every day. This is what is often called anhedonia.
  3. Significant weight loss (without the attempt to diet) or weight gain. A change of more than 5% body weight in a month is the traditional marker. Alternatively, a marked decrease or increase in appetite nearly every day. Obviously the weight change usually goes along with the change in appetite, but technically you only need one or the other. 
  4. Insomnia or hypersomnia (sleeping much more than usual) nearly every day. 
  5. Psychomotor agitation or retardation to the point that others can observe them, nearly every day. Of the entire list, this is the least commonly observed in milder cases.
  6. Fatigue or loss of energy, nearly every day. This one is so common it is almost a requirement. Not just sleepiness because of the insomnia. People routinely report that it seems to take much more energy to do anything (e.g., walk up a flight of stairs).
  7. Feelings of worthlessness or excessive or inappropriate guilt, nearly every day. Guilt or self-criticism about being depressed doesn’t count; this has to involve other issues as well.
  8. Diminished ability to think or concentrate, or indecisiveness, nearly every day. Also common, this problem can be so pronounced that people suspect they are dementing.
  9. Recurrent thoughts of death, or suicidal thoughts with or without a plan. A fear of death does not count. 

There are some other criteria as well:
  • The symptoms must not meet the criteria for a Mixed Episode, in which the person has some manic characteristics as well.
  • The symptoms must cause clinically significant distress, or must impair social, occupational, or other important areas of functioning. If a person truly has five or more of the above nine symptoms, it is not difficult to clear this hurdle as well.
  • The symptoms must not be due to the direct physiological effects of a substance (such as a prescription medication or a drug of abuse) or to a medical condition (such as hypothyroidism).
  • The symptoms are not better accounted for by bereavement. Oddly enough, experiencing more than two months of symptoms of bereavement is considered sufficient to begin talking about depression again. This causes some eye-rolling amongst clinicians, who argue that depending on the loss, normal bereavement often goes on longer.

So that’s the list …

… and when people write about depression these symptoms are often all that are discussed. But there are others that are just as common, and that also cause problems. One of the challenges is that because people don’t hear about them, they worry that these phenomena might signal some other problem. And because they are often ignored, people don’t know what to do when they have them.

So let’s take some time talking about the additional symptoms of depression that typically get less attention. 

Next up:  The plexiglass wall.

Friday, 10 February 2012

Private Practice: Who Will You See?


This post is part of a series on private practice issues that will be appearing on Fridays for the while, leading up to a series of workshops (based on my book Private Practice Made Simple) taking place in Calgary, Toronto, Ottawa, Vancouver, and Edmonton in March 2012 (information here).

When setting up your practice, or when you are fine-tuning it based on your preferences, your expertise, or the people in your community seeking help, it’s best to abide by a principle that I suggest to clients: Don’t worry without paper.

There’s no point in grinding over an issue in your mind if you’re going to wander off onto another topic or forget what you’ve decided.

So rather than thinking about your practice while driving, or in the middle of a movie, or when avoiding your tax form, devote your full attention to the task. Sit down with a piece of paper and write down whom you want to see, whom you don’t want to see, and what mix of clients would suit you best.

Want some structure to your contemplation? Use the “Practice Populations” exercise sheet adapted from Private Practice Made Simple (New Harbinger Publications, 2011) and posted online at www.changeways.com.  The direct link is here.

The form has three sections:

Ages and genders. Think about the various stages of life, the genders, and whether you will see couples and/or families. Perhaps you will want to indicate your preferred mix (“mostly senior women but partly a wider age range and some men for balance”). Or perhaps you would like to see certain groups only for certain issues. For example, perhaps you will see adults for a wide range of concerns, but you only want to see teens if they present with eating disorders.

Population groups. In addition to the broad cross-section of people that most therapists see, perhaps you would like to focus your recruitment efforts on a few particular types of people, either because they are ill-served in your community or because you have special expertise. Perhaps you speak Portuguese and could offer services in that language. Perhaps you have a special interest in multiple sclerosis, or transgendered people, or skiers, or Buddhists, or people recovering from stroke, or police officers, or students, or people going through in vitro fertilization. Make a note of the populations you would like to see, as this will guide some of your promotional work.

Concerns. This section of the form overlaps somewhat with the previous one, but here you will emphasize the focus of attention during your meetings with the client, regardless of whether they are gay or straight, Muslim or atheist. Perhaps there are specific DSM or ICD categories you like to treat. Consider taking down your diagnostic manual and flipping through it to spark your ideas. Also consider writing down groups that you really want to avoid, either out of preference or expertise (“I have no success with eating disorders”). Then consider issues that don’t involve specific diagnoses: custody and access disputes, return to work after disability leave, forensic issues, bereavement, and so on.

Keep the form with you for a few days. Additional thoughts will pop into your head.

Run your results past a colleague in private practice and ask for feedback. Does it sound reasonable? Have you been too broad or too narrow? Are there enough potential clients in your community, and are there too many or too few practitioners serving those groups?


*   *   *

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, 7 February 2012

Choosing Therapy Goals: Broad Swath or Narrow Slice?

Sometimes a person will come to therapy with multiple issues, or with a single type of problem (obsessive compulsive disorder, say) that manifests in dozens of areas. Almost anyone suffering from depression, for example, will have many symptoms (possibly including sleep disorder, lack of exercise, social isolation, lack of enjoyable activity, work conflict, and more), each of which may be contributing to the problem.
Trying to do too much can be discouraging.

In such situations, clinician and client alike are faced with a choice. Do we try to get started on everything at once, or do we pick and choose?

It’s tempting to adopt a broad focus. All of the issues are problematic and likely affect the person’s mood. It would be great to change them all. And indeed, change can feed back and make other changes possible. Improvements in sleep may improve energy, which may help work performance, which may enhance rewards, and so on.

The problem is that therapy has limited potency. When therapist and client work together, they have a certain amount of “push.” If we spread this across too many targets, progress on any one of them may be glacial or absent.

I sometimes discuss this idea with clients using a metaphor. “You’ve got twenty heavy boxes on one side of a big room, like a gymnasium. You need to get them to the other side. You can spread your arms the width of the pile, put your shoulder to it, and push. But they may not budge. What would you suggest?”

People immediately see that a more effective strategy is to tackle the boxes one or two at a time.  Though (granted) a bit obvious, I’ve found that creating a visual image like this seems helpful. And indeed, clinically it’s helpful to identify a lot of the problems the client is experiencing (we’ll never hear the complete list in the assessment phase), then to pick two or three on which to get started.

Why two or three? Why not one?

It would make logical sense to start with one issue, and indeed, we will discuss issues one at a time. But if we spend the first five sessions of therapy on just that one topic (repeatedly checking that doors are locked, for example), the person will soon experience an overwhelming sense of anxiety that only a tiny portion of the problem is being addressed.

Instead, we can make try to make deep inroads in two or three areas. This tends to chop up the problem, making the remaining issues less solidly entrenched. The progress made with our “sample issues” undermines the idea that nothing can change. “I didn’t think my diet would ever get better either, but it did – so maybe I can start clearing the backlog of unopened mail too.”


Where should we start?

The most important consideration is the client’s choice. Where do they want to start? What feels both manageable and significant to them? If we start with issues that seem trivial or beside the point, motivation will flag and we will have little effect on the other problems. If we start wherever the client has the most motivation, we will maximize our likelihood of success, and that success will seem more significant and inspiring than progress on side issues would be.

Sometimes a client will choose the most difficult problem. People trying to learn better assertiveness skills, for example, often choose “battles with my wife” or “supervision sessions with my hostile boss” as their prime targets. It’s best to start with something that’s a bit simpler, but that relates in some meaningful way to the prime target. Perhaps there is an elder brother who is vaguely like the boss, and early practice could focus on interactions with her. Whatever is chosen can be framed as a step toward dealing with the main issue. “If we start by practicing giving your opinion with a good friend, we can work our way up to doing it with your father.”


Then what?

Hopefully we will make a fair bit of progress on the issue at hand – cleaning out the basement, starting an exercise program, resisting the compulsion to unplug appliances before leaving home. If we have chosen well, a sense of confidence will develop, and the person will feel more capable of dealing with the remaining issues.

Sometimes these other issues will have begun to dissolve on their own, without attention. “Yeah once I began eating properly I started walking to work instead of driving. Didn’t I tell you that?” Progress in one area somehow reverberates through the system to impact on other problems. The person’s sleep improved, so they felt more energetic during the day, so they could concentrate better at school, so the procrastination has already started to diminish.

Is this relevant outside therapy?

Therapy is just a microcosm of life. Any of us, faced with a multitude of tasks, will benefit from abandoning any attempt to complete them all at once. Instead, if we pick a small number of critical tasks and push them to completion, our sense of momentum will increase our confidence, and we will find it easier to get the next things done.

In my own life I have often taken on more projects than I can realistically complete, then felt my interest and enthusiasm flagging. This is my cue to set some of them aside and concentrate on two or three. If I have just one project on the go, I get bored and burn out on it too easily. If I have a few, I can switch from one to another and maintain my interest. If I have ten, I’d rather sit on the couch and do nothing.

Friday, 3 February 2012

Private Practice: Coming Up with a Name


Perhaps not the best name for a real estate firm.

This post is part of a series on private practice issues that will be appearing on Fridays for the while, 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).

In Private Practice Made Simple (New Harbinger Publications, June 2011) there are a few guidelines about naming your practice. Here’s a summary:

  • If you plan to operate a multiple-provider practice, think about it before you name it after yourself. Will your colleagues want to be known as “Anna Johanson (And Other Less Important Clinicians)”?
  • Avoid naming your practice after a specific location. Someday you may want to move, or you might open a branch office somewhere else. The North Calgary Clinic will be a bad name for your new place in South Edmonton.
  • Your name should be easy to spell.  Consider the spell-ability of your own name here. If people routinely get it wrong, consider naming your clinic after something else.
  • Make it memorable but simple and short. A bland name (Therapy Services Inc) will be easy to forget. And no one will even try to remember a complicated one (like The Rothstein Centre for Metatheoretical Modeling).
  • Don’t name it after just one difficulty, or that’s all you will get referred to you. If a person with OCD is sent to the Halifax Panic Centre, they will guess (perhaps wrongly) that you aren’t much of an expert on their problem.  
  • Pick a name for which the web address will be intuitively obvious.

As I’ve mentioned before, as part of the publication of Private Practice Made Simple, I’ve posted a series of exercise sheets online that are based on concepts from the book.

For naming your practice, the sheet is a brainstorming exercise that invites you to sit back, space out, and dream up as many options as you can. Then you’ll set the list aside for a day or two before coming back to it. At that point you’ll be able to view your list with fresh eyes. You’ll cross off some options immediately, and a few new ones will most likely come to mind – possibly even the one you will eventually use.

The sheet on naming your practice isn’t mentioned in the book itself, so it’s just on our own website at www.changeways.com. The actual page can be found here.

A BONUS: Does your practice will involve diagnosing clinical depression? Maybe my online course "Diagnosing Depression Using DSM-5" can help. Click here to access this $25 course for 80% off, or just $5.

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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.