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Friday 30 March 2012

Private Practice: Do You Need a Website?

The Friday Private Practice series continues, based on my book Private Practice Made Simple and the accompanying workshop.

The last post considered how to write a referral form. But of course referral forms are really only useful for the referrals you get from other professionals. In private practice, many people self-refer. At Changeways Clinic we estimate that about 70% of our clients self-refer.
Yes, it helps.

That begs the question: How do self-referrers find out about your service?

In our case, many hear about us from friends and family members who have seen us in the past. Getting psychotherapy doesn't seem to be quite the dark secret it once was - more and more people are seeing it as a perfectly reasonable thing to do. So people often tell others about their experiences, and recommend their therapist to others. This proportion of referrals tends to climb as you get more established and, obviously, as the number of former clients rises.

How else do people find someone? You can answer that question yourself. How do you find a plumber, a hardware store, a nearby sushi bar, a brake specialist? Chances are, you look on the internet. You used to look in the Yellow Pages, but as I discussed several posts back, virtually no one does this anymore.

At our clinic, about 50% of all referrals come via our website. So do you need one? Yes.

A 21st century business without a website is like a 20th century one without a telephone. Whereas in the 1990s a clinic with a website was a novelty, and signalled a certain nerd-like quality in the owner, today it simply signals that you take your work seriously. A practice without a website today seems more like a hobby, a sideline, a temporary lemonade stand.

Some will find your service by doing a web search - more than ever found their therapist using the Yellow Pages. A website gives more information than any directory ad ever did, so people rely on it more.

What about the people referred by their friends or healthcare providers? They'll check you out on the internet before they call - and perhaps they'll look for your number on the net as well. When people recommend therapists, they usually give a few names. Those looking for help will typically google the names. Anyone who doesn't turn up will be ignored: maybe you've retired, or moved, or switched careers, or died.

Website design is not an area of great expertise for me, but in the next few posts I'll provide some basics.

And: Are you in Halifax in mid-June 2012? On June 14 I'll be doing a two-hour presentation as part of the annual convention of the Canadian Psychological Association on cultivating a web presence for psychologists. On June 13 I'll also be offering a full-day preconvention workshop on therapeutic process. For more information, visit the convention website here.

*   *   *

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 29 March 2012

PsychologySalon at VPL: Join Us!

The first of the spring series of PsychologySalon talks took place Monday night at the Central Branch of Vancouver Public Library. We had 195 people attend.
Join us!

The next talk is Tuesday April 24 at 7 pm, and is entitled "Learning to Love our Emotions." The speaker will be Dr Lindsey Thomas, a psychologist at Changeways Clinic.

Here's the summary:

Feelings themselves cannot harm us, but instead provide valuable information that could help us regain control over our lives. However, in a society filled with increasing distractions, it seems we are developing an aversion to our emotions.

Learning to love your emotions involves a willingness to experience, accept, and face negative emotional states.  Specifically, we will look at:

  • The value and purpose of emotions
  • Basic emotion regulation strategies
  • Strategies for approaching rather than avoiding our emotions

Tuesday 27 March 2012

Depression: The Trouble with Walking

Exercise and mood

Surely by now almost everyone has heard about the research identifying exercise as an effective treatment for depression. Years ago the data were a bit flaky, but as research designs have tightened the effect continues to appear solid.
A pleasant day on Vancouver's sewer outflow (!),
Iona Island. Oddly enough, a popular park.

If I met someone who said “I’m depressed, and I’m willing to work on it. But I’m only willing to do one thing,” I would first tell them that depression is best dealt with using a multiple-front approach. The effects seem to be stronger if we begin shifting several aspects of a person’s life at once. (Not that there’s great and well-controlled research examining this point, however.)

But then I’d give in (it’s not my decision, ultimately, it is theirs) and ask if they were really willing to try anything (in addition to, or instead of a pharmaceutical intervention). If they said yes, and if they lived a standard Canadian sedentary lifestyle, then I’d recommend an exercise program. Thirty minutes of exercise, three times a week appears to be about as powerful as medication or psychotherapy, and there is scattered evidence suggesting that six times a week is better still.

Great, but what kind of exercise?

Eventually we want something that gets the heart pumping and that produces a bit of strain – something that will actually increase the person’s fitness. It doesn’t have to be aerobic, but it should make the person puff a bit. “Gain without necessarily having pain” is a reasonable motto.

The problem is that during depression it’s difficult to leap into that much exercise all at once. We often have to ramp up. So walking makes a good start. It enhances fitness somewhat, it gets a person out of the house, it often puts them into contact with other people or with nature, and it can be measured (potentially giving a sense of achievement as the person sets and reaches their own goals).

So what’s the problem?

The problem is precisely what makes it a good and achievable early goal: It’s easy. Walking takes no great skill or attention. The mind is left free to wander. We can think about anything we like and not fall down or trip over our own feet.

During depression the mind is pulled toward the negative. Left unoccupied, we will focus on bleak elements of the past (regrets, failures, good times now over), the future (catastrophes that may happen), and the present ("that person over there must think I’m a loser"). A more cognitively demanding form of exercise (such as tennis, skiing, or swimming) gives the mind less room to space out and play depressive scripts. But walking can leave a kind of vacuum in the mind, and both nature and depression abhor a vacuum.

Is there a solution?

There are several.

Mindfulness exercises can help us to return to the sensory present, and to recognize the difference between what’s happening and our (often faulty) interpretations about what’s happening. Mindfulness is a tricky skill to cultivate, particularly during depression, but it can still help if the person has specific exercises to work on.

The sense census is one. When we notice the mind wandering into rumination, we can gently refocus the mind on the input we are getting from our senses. What exactly are we seeing? What colour is that tree? Is the sidewalk cracked or smooth? How many storeys is that building? What are we hearing? Just the traffic on this street, or can we hear the traffic the next street over? Are there any birds singing? Can we hear the wind in the trees? What are we feeling? Can we feel our feet bend as we move through each step? The breeze on our skin? The sensation of our left sleeve?

The sense census incorporates the mindfulness element of returning to the present, and encourages us to relinquish much of our interpretive/evaluative thought. We don’t ask whether we like the birdsong, we just notice whether it is present.

This and other mindfulness approaches can be practiced regularly as a form of walking meditation. But in the depths of depression, mindfulness may be too difficult or insufficiently compelling to practice continuously.

Okay, what else?

If the skill involved in walking doesn’t fully occupy the mind, and if mindfulness proves too challenging to practice for long, we can introduce another cognitive task to attract and occupy the mind.
Internally-produced tasks (“Let’s name all the countries in the EU”) require a certain force of will to keep up. Soon we get distracted and can go back to worrying. An external stimulus can often work better. And here’s where the earbuds come in.

One option is to listen to music. If this works, great. But sometimes during depression music loses its appeal – it gets unplugged from the emotions and seems flat or uninteresting. If this occurs, we need to try something else.

Talk radio is one option. Ideally the depressed person should steer clear of all-news-all-catastrophe-all-the-time stations, or the shock or call-in jocks trying to stir up rage, disgust, bigotry, hopelessness, or fear. During depression the mind is good enough at doing this itself; help is not required. Something like CBC radio or NPR is more likely to be thoughtful, interesting, and educational without feeding the low mood. In this day of iPhones fewer people have portable radios, but major networks (including CBC) have apps that will access the feed live.

Podcasts are another option. The iStore, radio networks like CBC, and other sources have plenty of free material that can be downloaded onto an MP3 player. If you like a certain radio show, chances are you can download as many episodes as you want and listen to them without having to follow the broadcast schedule. As well, many people create material solely for podcast.

Courses. In therapy I invite people to consider what they would be doing if they had an ideal life free of depression – then to start doing precisely those things at least a little bit. Many identify things they would like to learn about. The Teaching Company offers audio courses on dozens of topics, taught by award-winning university lecturers. And many universities have taken to posting their courses online for free download – iTunes University is perhaps the easiest source for these.

Audiobooks. Most popular books have audio versions these days, and most e-readers have the capacity to translate print into (admittedly mechanical) speech. Libraries typically have a good supply of audiobooks, and audio content can be purchased and downloaded easily from iTunes and online booksellers such as Amazon. Even murder mysteries can be an improvement over the horrors the depressed mind can dream up.

Ultimately the goal for people with depression is to be able to walk without having the mind gravitate to misery. And, yes, I’m enthusiastic about the capacity for people to improve their mindfulness skills.

But in the early stages, audio content can make walking more pleasurable, and this can make it easier to keep up. As well, even after recovery many people enjoy adding an entertaining or educational component to their exercise, whatever it may be.

Some special recommendations…

We all have different tastes. Here, though, are some good picks:

  • TED audio. TED is a conference series featuring world leaders in a variety of fields, each given under 20 minutes to make their point.  A useful resource for almost anyone, TED talks are available in audio or video format.
  • Lake Wobegon. Garrison Keillor offers a weekly summary of the events in the fictional Minnesota town of Lake Wobegon.
  • Terry O'Reilly. An adman reviews various issues in advertising in an entertaining format for CBC Radio.
  • Jian Gomeshi and Q. The CBC's weekday morning entertainment magazine, available as podcast.
  • The Teaching Company. Source of audio and video courses taught by some of North America's greatest university teachers.
  • The iStore. The iTunes location for university courses of all types, available for free download. The link is to a description website; for the courses themselves open the store in iTunes and look for iTunes U in the menu bar.

Friday 23 March 2012

Private Practice: The Referral Form

On Fridays for the past while, we’ve been talking about setting up a private practice: deciding whether or not to leap into the field, naming the practice, identifying the populations you wish to see, finding office space, preparing the space, identifying your referral sources, and writing a practice announcement.
Private Practice Made Simple
at the Lord Elgin Hotel, Ottawa

But do you want to provide anything along with your practice announcement? Yes! You should include a copy of your referral form. Getting referrals, after all, is the main point of sending such an announcement.

Why a referral form?

Everything about your referral form is based on a single concept:

The point of a referral form is to make sending you a referral easier, not harder.

All else flows from this. At the workshop on private practice several people have, with a slip of the tongue, referred to the form as an Application Form. This is precisely the wrong association. An application form demands that you provide information. Once we receive a bunch of forms, we will screen them and consider who to admit to the inner sanctum of our clinic.

A referral form is precisely the opposite. Its whole purpose is to make sending clients to us simple and straightforward, and to show that it isn't a test that the sender might fail.

But we don't really need one, right?

Right. You'll never require that someone use your referral form in order to refer clients to you. That would be putting a barrier between them and your service. The referral form is simply an option that the person can use if they want to make the process easier.

A referral form helps your sources remember the information they should include - like the client's phone number, gender, and diagnosis. This increases the odds that you will get the information that you like to have. When you receive the form, seeing a chicken scratch beside "Diagnosis" may help you to decipher what your source has written.

What do we do with it?

You'll send the referral form along with your practice announcement, and with occasional practice updates ("Blahblah Clinic announces that Dr Harpo Marx is joining our roster of clinicians..."). You'll also post it on your website in pdf format for free download. And you'll have a bunch of them you can send out or fax to anyone who wants one. For your great referral sources, you might even have pads of them made up by your printshop.

What should a referral form include?

Not very much! Remember, we don't want it to look difficult. Yes, it would be great if you got a complete history on every client you are sent, but this is a faint hope. Here are some bits to include:

  • A header with your complete contact information in all modes (email, phone, fax, and street address).
  • Name of client.
  • The client's gender. It's awkward asking if "Chris Lau" is home if you don't know if Chris is male or female.
  • The client's birthdate. This will signal whether you will be talking to the client or their parent.
  • Client contact information. Usually street address and phone number.
  • Reason for referral. Leave a few lines for this. Your source may just provide a diagnosis, but may want to describe a bit about the problem. The more info you get, the better.
  • Current medications, if any. This will give you hints about the person's condition and concurrent treatment.
  • White space. Many physicians use an address stamp rather than scrawling their address on every referral. Give them space to do this.

Make sure you give lots of space so that referrers don't have to squeeze their handwriting. It will be hard enough to understand as it is. And keep full size margins. If you find it hard to fit everything on a single page, you're asking for too much.

Got a sample?

Yes. In the forms accompanying Private Practice Made Simple there is a sample referral form in pdf format, here. There is also a version in Word that you can edit yourself, posted on this page.

Next Friday:  Naming your website.

*   *   *

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 20 March 2012

Hidden Symptoms of Depression: Anticipatory Flatness

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 stated in earlier posts, however, it’s important to note 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.
Even indoor skydiving can seem foolish. Hard to believe.

Emotions in Three Times

When we think of any event - going to a movie, seeing a friend, working on one's taxes - we can identify the emotions that we might feel in three separate periods:

  1. Anticipatory (or Pre). What do we feel when we consider doing the activity in the future? Is it tempting ("That chocolate cake looks good") or repulsive ("I'll never be able to figure out that financial report")?
  2. Concurrent (or During). How do we feel while we are in the event or performing the activity? Are we enjoying the hike? Is the shopping trip bearable?
  3. Retrospective (or Post). How do we feel afterwards? Are we glad we spent the evening playing that video game? Do we regret getting to the gym?

Why do we do the optional, or supposedly enjoyable, things in our lives? Generally, it is because we look forward to them. We think about doing them, and react with a positive emotion to that fantasy. "Oh yeah, that would be great." In order to get ourselves to take part, all we have to do is give in to the resulting temptation.

Of course, the system doesn't work perfectly. Many of the things we will actually enjoy doing hold limited anticipatory appeal. When you wake up early on a frigid morning, the prospect of going out in the cold and strapping on skis may seem dispiriting. But we generally learn which activities will be rewarding, despite their lack of temptation.

As well, even at the best of times, some things seem tempting but don't lead to a positive payoff. That third beer, the television remote, the game controller, the bag of chips in the cupboard, the internet for yet more aimless surfing - all of these can seem to call to us with their siren song. If we give in, we'll waste yet another evening, suffer yet another hangover, gain yet another pound. The mission is not to eliminate temptation, but to recognize which temptations cause us more trouble than joy.

The Influence of Depression

Depression affects emotions in all three times: Pre, during, and post. Anhedonia blunts the enjoyment of activities (during): things just don't seem as much fun as they usually do, and they take much more effort. 

What about post?  A negative cognitive filter makes savouring past activities difficult: we tend to see the flaws in what we have done more readily, and we have difficulty taking pride in our achievements.

But perhaps the greatest problem lies in the anticipatory period.

Formerly tempting activities (getting out of bed, going outside, calling up a friend to get together) lose all or almost all of their appeal. You can call up an image of riding your bicycle around the local park and it just seems like it would be a flat, stupid, boring waste of time. Indeed, if you got yourself to do get out the bike anyway it probably wouldn't be as much fun as usual. But eventually, with repetition, the enjoyment would return a bit at a time.

The result is that it becomes almost impossible to get oneself to do the things that normally make up a fulfilling life. We get depressed, lose our healthy anticipatory desires, then adopt a lifestyle that makes us even more depressed.

It doesn't stop there. Some of the less helpful temptations that we experience even when we are well ("Hey, let's sleep in, play computer solitaire, turn on the TV, eat that junk food, stay at home") get even stronger than usual. It seems as though there is a magnetic pull toward precisely those activities that will, in the long run, make us more depressed.

These shifts in anticipatory desire (decreased temptation for the positive, increased for the negative) are not just symptoms of depression. They represent some of the main reasons that depression worsens and becomes entrenched. "I'm depressed, I need to take care of myself" becomes, without noticing, a powerful force to make the depression stronger.

In effect, our motivations betray us, abandoning our side and taking the side of the depression.

What do we do about it?

There are several steps:

Recognition. We need to notice the shifts in anticipatory desire, and see them for what they are: normal symptoms of the problem.

Acceptance. We need to accept that these shifts are present, and will continue to be present while the depression is strong. In effect, we need to welcome the symptom rather than trying to kill it.

Relinquishment. We need to give up hope that our anticipatory desires will re-establish themselves on their own. They won't. So we can't wait to feel motivated or excited by things.

Identification. We need to identify the activities associated with feeling better. We can look at our own history for this. "When I feel better, what do I normally want to do?" "When I've been well, what are the things that I've been glad to have done, even if they weren't tempting at the time?" We can also look at the research on depression. "A lot of studies suggest that a regular exercise program is effective, so even though I've never had one, maybe I need to start."

Activation. We need to take those positive activities and reduce them to the point that we can actually achieve them. "Swimming three times a week would be a great idea, but first maybe I'll just buy a bathing suit." We won't revolutionize our behaviour, we'll just change it by increments.

Tolerance. Gradually we will increase the magnitude of goals as we gather successes, while tolerating the fact that concurrent enjoyment is also impaired. We will allow ourselves not to enjoy what we formerly enjoyed, and recognize that our old enjoyment is likely to creep back slowly.

By placing our behaviour in the hands of our knowledge rather than our temptations, we can begin shaping our lifestyle toward one that does not support the depression. As we do this, the depression typically begins to lift. This may not be the only thing we need to do, but it is one of the most powerful antidepressant strategies.

Next Tuesday: Let's take a break from the hidden symptoms of depression and return to other topics.

Friday 16 March 2012

Private Practice: The Practice Announcement

On Fridays for the past while, we’ve been talking about setting up a private practice: deciding whether or not to leap into the field, naming the practice, identifying the populations you wish to see, finding office space, preparing the space, and identifying your referral sources.

This week, it’s time to consider your practice announcement.

Why do I need a Practice Announcement?

Because your referral sources aren’t psychic. They either don’t know you, or if they do, they haven’t remembered that you’re opening a private practice. We’d like them to remember, but they don’t.

So we need to remind them. And we’ll probably do it by sending them something: Our card, our brochure, our referral form. But we need a letter to encase all this and explain ourselves.

Umm, what if I’ve never seen one of these?

As a part of the resource materials to accompany my book Private Practice Made Simple (New Harbinger Publications, 2011), I have developed a sample practice announcement.

Here it is in pdf format:

You can also go the following list and find it in MSWord format that you can edit for yourself:

Practice announcements are deceptively difficult to write, because you have to get a lot of information into a very small space. Expect to spend at least two hours drafting the letter (it’s worth it).

Be concise. It has to fit on one page, without shrinking the margins.

What do I put in it?

There are various elements to a practice announcement. These include:

Your letterhead. You want to print your announcement on your clinic letterhead. If you have electronic letterhead (something that appears onscreen that you can put at the top of any letter and print out, generally in black and white), you can use that. But it’s better to use your nicer formal letterhead that you can get made up at any print shop.

The date. Print out only as many of these letters as you can send in a day, so that the date doesn’t look old.

Personalized greeting. “Dear Dr ___.” If you can manage it, either do a mailmerge to personalize your letters or alter each copy before you print it (I do the latter, as I’m mailmerge-impaired). A personalized note is much more likely to get the recipient’s attention.

Say what you’re writing about. If 90% of people read the first line of your letter, perhaps 89% will read the second. Less than half will get all the way through it. So make your point early. “Announcing MyClinic.” Then repeat this in longer format in the first paragraph.

A one sentence description. Why are you writing, what do you do, and where are you located? Spend a lot of time perfecting this sentence; it’s the most important one in the body of the letter.

Where are you? People refer partly on the basis of expertise, and partly out of convenience. Yes, your address is on the letterhead, but if this doesn’t make your neighbourhood clear, mention the area.

Your specialties. Who do you see? Don’t list everything you do or you’ll blunt the impact. Limit your list to 3-5 items.

Your modality. Which approach do you use? Increasing numbers of referrers want to know not only who you see, but how you work. They know what they want.

Languages spoken. If it’s English-only, omit this bit.

Your BRIEF bio. Dispassionate, professional clarity is the goal. Avoid vagueness and superlatives. If you go longer than 5 lines you’re not trimming enough.

How are clients referred? Can they self refer? Can any profession refer clients to you?

Payment information. Are services reimbursable? How do you accept payment?

Contact info, all modalities. You can rely on the letterhead for your address, but it doesn’t hurt to repeat your phone number and email.

Enclosures. Have you included anything in the mailing? What?

Signature. Don’t use a stamp or photocopy the signature. If you didn’t spend the time to scrawl your name, why should they spend the time reading the letter?

Who do I send it to?

Anyone who might refer to you. Use the results of your exercise “Identifying Your Referral Sources” from two weeks back.

Next Week: Writing your Referral Form.

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.

*   *   *

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.

YouTube VLog

I have now launched a YouTube VLog on psychological topics called How to be Miserable, with new posts every Tuesday and occasional Thursdays! Come take a visit and see what you think. Consider subscribing (just press the big red SUBSCRIBE button on the page) to ensure that new videos appear in your YouTube feed.  Here's the intro video:

Tuesday 13 March 2012

Hidden Symptoms of Depression: The Inability to Monitor

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 stated in earlier posts, however, it’s important to note 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.
What are they talking about?

Depression’s Social Impact

Depression generally affects people’s social motivations. Rather than wanting to see their friends, they may want to be alone. So the temptation is to isolate. That would be fine, except that isolation makes depression worse. A snowball effect is born: depression makes me want to isolate, isolation makes me more depressed.

As is so often the case in depression, the key is to move in the opposite direction to the temptation. I often work with people on welcoming and permitting the temptation to isolate, but not allowing it to take charge of behaviour; instead, it can be used as the cue to ramp up social contact (yet another example of the principle of opposite action).

But if people can swim against the current and get themselves into social settings, another problem often becomes apparent …

“I can’t hear what they’re saying.”

You go out with friends, and several conversations are going on at once. Normally this isn’t a serious problem. You can screen out most of the talk, and pay attention to the one conversation in which you are engaged. You’ve been doing this all your life: in pubs, at restaurants, at parties, and over the sound of the ads before movies.

It is as though someone in your brain turns up the volume of the conversation you want to hear, and turns down the volume on all the others. In fact, the people who mix sound for movies routinely create precisely this effect when the action takes place in a crowded space. The actor you’re following goes into the party, which sounds loud and confusing, then starts a conversation with someone – and the other sounds fade into the background.

But when you are depressed, you will probably notice that this act of monitoring, or screening out extraneous conversation, is significantly more difficult. You try to pay attention to the person you are speaking with, but the volume on all the other conversations doesn’t change. They continue to intrude on what you’re saying. “I can’t hear myself think!”

When you’re depressed it’s hard enough to carry on a conversation. Your concentration is poor, you’re distracted by powerful emotion, and you secretly believe that no one would be interested in anything you say anyway. Add a bunch of ambient noise that you can’t screen out, and you can lose track of the discussion altogether.

The resulting temptation is to give up. “What’s the point of going out? I can’t carry on a conversation anyway, and I feel like an idiot. I don’t understand what people are saying to me when there are a lot of distractions, and I just lapse into silence.”

So what do you do?

Retreating back into solitude is a lousy idea, but going to your usual haunts may seem futile. The best thing to do is to push social contact, but to pick your settings. Here are some tips:

Control your environment. Maybe you’re used to chatting with people while the television or radio are on. When you’re depressed, make a point of reducing these distractions so that you can pay closer attention to the conversation. Choose instrumental music rather than songs with lyrics, because the words will pull at your attention.

Meet outdoors. The main problem is extraneous conversation. The noise of traffic, wind, or waves isn’t nearly as distracting. Walking outdoors gives you some exercise, allows you to communicate without staring into the other person’s face (which can be distracting or difficult), and takes you away from other people’s conversations.

Go to quieter restaurants. Your usual favourite restaurants or other meeting places have a certain noise level – a level that may not normally be a problem. When you’re depressed, however, those places may be too loud or distracting. Try to socialize about as much as you formerly did, but choose places where you can think. Go for restaurants with a lot of fabric, with narrower tables (so you can hear the other person more clearly), or with separate booths.

Steer out of the crowd. If you are at an event like a party, look for the quieter spaces where there are fewer people. Gently and casually lead the people you talk to away from the crowd, and face the periphery rather than the centre of the group.

Lighten up in silence. If you go to loud places, recognize that you may have some difficulty. Let yourself be quiet and don’t pressure yourself to leap into the discussion as much as you might ordinarily do. Avoid criticizing yourself for not being more social.

Will I ever get it back?

Yes. As depression lifts, the ability to selectively attend to conversations returns. Often this ability seems to lag behind a bit, but it comes back eventually.

Next up: Anticipatory Flatness.

Friday 9 March 2012

Private Practice: Farewell, Yellow Pages

Our Friday series on setting up and operating a private practice continues. The series is based on my book Private Practice Made Simple (New Harbinger Publications, 2011) and the workshop of the same name appearing in 5 Canadian cities this month.
Not a simulation.

Past posts have considered the decision whether or not to leap into the field, naming your practiceidentifying the populations you wish to see, finding office space, preparing the space, and brainstorming about your possible referral sources.

That last post included a link to an exercise sheet that I said would take quite a while to complete. So this week you get a break from the forms, and hopefully I’ll save you some funds while I’m at it.

I Need a New Edition Already

When you write a book, you hope that your content stays current for at least a few years. You also hope that you don’t go back and change your mind about some of the things you’ve said. For the most part, I’m happy with Private Practice Made Simple. But, yes, I’ve already started my file for an eventual revision. There’s only one thing in it thus far.

Yes, it’s time to dump the Yellow Pages.

In the book I said that usage of the venerable Yellow Pages has been declining in recent years, but that it’s probably still a good idea to have your practice listed for the next few editions.

Okay, but the curve is a bit steeper than I thought. Time to pull the plug.

What makes me think this?

First, I enquired around our clinic, and it appears that it has been upwards of two years since our print copy of the Yellow Pages has been opened, let alone used productively. In fact, it took a bit of doing to find it when I took the photo for this post.

Second, no client in the past five years has so much as mentioned the Yellow Pages, despite our practice of asking how they heard about us.

Third, we recently received the new copy of the Yellow Pages, which seems to be about a third the thickness of the one from just a few years back. As businesses drop their listings, the directory becomes less of a default reference for people. “Well, if all else fails, it’ll be in the Yellow Pages” is no longer true.

Fourth, the online version of the Yellow Pages doesn’t seem all that useful. I’ve conducted Google searches for a number of businesses that have print listings in the Yellow Pages. In no case was the Yellow Pages listing the top appearance of the contact information in the search results. In most cases, the Yellow Pages listing didn’t even appear in the first few pages of results.

So yes, if you have a Yellow Pages listing, it’ll also appear online. But if you have any other online presence whatsoever, this will be completely redundant and will add virtually nothing to your visibility. Remember WordPerfect? At one point it was the dominant word processing program. Now almost no one uses it. Word and Pages are the new WordPerfect.

Well, Google is the new Yellow Pages. And it’s free. Save your money.

This point may itself be redundant surprisingly soon.  A year and a half ago, the value of the stock of the publisher of the Canadian Yellow Pages was over $6. As I write this, it is worth 11 cents. Even if you want to keep your listing, there may soon be no Yellow Pages to list in.

And as for those rival general business directories (I’m talking about you, CanPages), my advice goes double. Save your money.

Welcome to the twenty-first century.

Next Friday: The Practice Announcement.

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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.

Tuesday 6 March 2012

Hidden Symptoms of Depression: The Collapse of Automaticity

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 stated in earlier posts, it’s important to note 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.
"I can drive this in my sleep ..."

Quick now: Did you brush your teeth this morning?

If you took the question seriously, you probably did one of two things:

1. You thought “Yes” because you brush your teeth every morning, so you must have done so today.
2. You ran your tongue over your teeth to see how they feel.

But you may not have a clear memory of brushing your teeth this morning. You do it automatically, and no memory of it gets stored.

Much of our behaviour is automatic. For example, most of us have a morning routine of some kind, in all likelihood including brushing our teeth.

We don’t haul ourselves out of bed and say “Right. I guess I should brush my teeth today. When shall I do that? Before I shower? After? I’ll need toothpaste. How much will I put on the brush this time?” We just do it. The process is so automatic that we don’t consciously think about it.

Some of us even catch ourselves and wonder “Did I do it?” We might feel our toothbrush to see if it’s wet. It is.

Other behaviours have at least some automaticity involved: getting the kids up and out the door, returning emails at work, chatting at social events, cooking, driving to familiar locations, shopping, and so on. They don’t require a lot of thought or planning, we just do them. If we add them up, they make up a substantial part of our lives.

Of course, we also have a few things with very little automaticity involved: giving a verbal report at a meeting, finding an unfamiliar address, raising a difficult issue with a family member, cooking a completely new dish, and so on. These tasks involve not only the effort of completing them, but also the effort of consciously initiating and guiding them. We have to think about what we are doing.

And during depression?

When people are depressed, they are often easily overwhelmed. Years ago a client of mine said, with some disgust, “I’ve brushed my teeth all my life, but it was only when I got depressed that I realized I have 28 teeth! And every single one of them needs to be brushed, on one side, then the other, then the top. It seems like too much work, and it’s hard to get myself to do it!”

Others have similar experiences. There’s a dish they’ve made hundreds of times, but now it seems too complicated and difficult to manage. They’ve paid the phone bill religiously every month without thinking, but now it seems like a herculean task to open the envelope. They’ve always done the laundry while chatting on the phone, but now it seems to take their full attention.

Part of the problem, of course, is the standard loss of energy that people experience in depression.

But partly, it appears that automatic behaviour patterns (chains of behaviour that are so well-learned that they do not require conscious guidance) fall apart. Suddenly every task needs planning and effort, as though it’s the first time you’ve done it. “Hmm, shaving. I guess I need lather first, right? Where is it? Here. Is that enough? Now, which side first?”

The actual behaviour required is the same, automatic or not. But non-automatic behaviours always feel more onerous to us. It’s harder to get ourselves to do them, and they seem to demand more effort. They are tempting to avoid.

The result is twofold. First, people with depression tend to do less, because of the increased effort that seems required to do even trivial tasks. Second, they become self-critical for having the symptom. “I’m lazy, I’m unmotivated, I can’t take care of myself, people must despise me.” Needless to say, this only magnifies the problem.

So what should be done?

As usual, part of the goal is to recognize that the symptom is just that: a symptom of something happening in one’s life, not a personality trait. To that extent, it can be accepted. If we have the flu, we expect a fever, and we don’t criticize ourselves for running a temperature. Rejection of a symptom doesn’t make it go away, it just makes us feel worse.

Waiting for the problem to go away doesn’t seem to work, however. We need to push ourselves a bit at a time to get back into something of a routine. We do this by deliberately giving up on being our nondepressed self for the time being. “Yes, if I felt better I’d be doing a hundred things a day. But I’m depressed, and if I try the unachievable I’ll only feel like a failure. So I’ll just focus on doing a few things. Right now, I’m brushing my teeth. When I’m done, I’ll decide what to do next.”

It’s also worthwhile to stop multitasking. At your best, perhaps you can get the dishes started, toss something in the oven, and go shower while planning your workday. When your automaticity collapses, you’ll feel overwhelmed doing this and you’ll get lost and forget things. A certain amount of multitasking is useful for most of us, but during depression it can be counterproductive. Relinquish the desire for efficiency, and focus on one thing at a time.

While doing things that used to be automatic, remind and reassure yourself. “You can do this. You’ve done it before. And you don’t have to do anything else right now. It’s okay that it’s more difficult than usual. It will get easier.”

Reducing the self-criticism, initiating small tasks, and shrinking the snowdrift of chores can all help give a sense that life is becoming more manageable, and thereby helps with depressed mood. And as the mood lifts, by this and other means, it becomes easier to do things, and repetitive tasks begin to need less and less conscious guidance. We can still be mindful of what we are doing in the here-and-now, but we don’t have to force ourselves into action.

Next up:  The inability to monitor.

Friday 2 March 2012

Private Practice: Identifying Your Referral Sources

On Fridays for the past while, we’ve been talking about setting up a private practice: deciding whether or not to leap into the field, naming the practice, identifying the populations you wish to see, finding office space, and preparing the space.
Hmm, who might refer to you?

So here you are: in your pristine new clinic. Painted, furnished, soundproofed. You lean back in your new chair, and it occurs to you. Something’s missing. Oh, right.

The clients.

You can be as competent as you like, and it doesn’t matter. Telepathy doesn’t work as a practice advertising tool. Sit in there for days, and the only person who knocks will be from the successful dental practice down the hall who can’t find the washrooms.

If you play your cards right, many of your clients will self-refer. They’ll find you through your website, through word of mouth, they’ll see you quoted in newspaper articles, and they’ll call you up.

But you will always rely to some extent on referrals from other professionals. At Changeways Clinic, about 35% of our referrals are made by other professionals. The number of these referrals has been rising year over year, but not as fast as the number of self-referrals, so the overall percentage has been gradually declining. Still, it’s a significant source for us and will continue to be. And when you are first starting out, no one in the public will know about you. Almost all of your clients will be referred.

So it makes sense to take some time and think about who is going to do this. Obviously, only people who know about your service can refer someone to it, so you’re going to have to contact them and let them know what you offer.

In the form set designed to accompany Private Practice Made Simple (New Harbinger Publications, 2011) there is a four-page worksheet intended to help practitioners identify their current or potential referral sources. Here it is:

Potential Referral Sources (pdf)

I suggest spending a few hours (yes, hours) working on this form. You may hate it, but I can almost guarantee that you will look back on it as time well spent. It’s divided into three sections (which can be done at different times). Let’s review them.

Part 1:  Your Existing Referral Sources

Obviously this is only going to be useful if you have already seen some clients in your practice. If you are completely new to the field, move on to Part 2. If you have an existing practice, though, this is likely to be the most important section.

Take out 50 to 100 of your most recent files (see? I told you that you’d hate this). For each case, try to identify how they found out about you. (Hint: if you’ve never asked this, START NOW.)

If they self-referred, how did they pick you? Put a check mark beside the appropriate option on the form (website, previous client, family/friends, directory, etc).

If they were referred by someone else, figure out who that was. Write down the name on the form. If you find a second client referred by the same person, place a tick by the name.

When you’re done, you’ll see about how many clients came from each source. If they are evenly and thinly scattered across sources, consider taking out another batch of files to continue the process. Eventually your biggest referral sources will emerge from the pile.

Part 2:  Potential Referral Sources

Now it’s time to identify people who may or may not ever have referred to you, but could in future. This section is divided into two parts.

First, professionals who already know you or your work. Include people you’ve worked with in the past, colleagues in related departments, people you chat with at local association meetings, and so on. You may blank on these at first, but if you keep at it some names (or faces) will come to you.

Second, other professionals who know your target client populations. In your region, who tends to come into contact with the clients you want to see? If you treat dental phobia, then dentists may be a good source. If you work with diabetics on lifestyle management, the local diabetes association and physicians who work with metabolic disorders may be worthwhile possibilities. If you can’t come up with specific names, list the categories of people. You can research who and where they are later.

Part 3: Additional Referral Sources

In this section you are invited to consider a variety of different categories of potential sources. Each one is something of a brainstorming exercise. You may want to use the internet as an assist. The categories include:

Professional directories and online referral services. Most health professions have some kind of listing of people who are accepting clients. A declining number of these are print editions. Increasingly, they are online searchable databases designed to help people (clients or referrers) find clinicians within a specific region who practice in various areas. Search on your own profession or service and you will find them.

Clinical research groups. Universities and clinics that carry out clinical research (such as drug trials) typically screen a large number of people to get the few who fit their intake criteria. They will often provide those who are screened out with a list of clinicians who might be able to help them. Find out who does research on the populations you most want to see.

Nearby medical practices or social service agencies. One of the main criteria that people use when referring is “Are they close by?” Once you have settled on a neighbourhood for your office, start looking for nearby agencies and clinics that might turn out to be a source of clients. You can use the net for this, or you can simply wander the neighbourhood and look at building lobby directories.

Insurers. Health, disability, and auto insurers typically have lists of private practitioners to whom they send clients who need help. Depending on your training, profession, and specialty, this could be a major source of clients.

Others. This is the obligatory catch-all category. Once you know the people you want to work with, additional ideas may come to you. The form gives a few examples. If you know Polish, perhaps the local Polish Cultural Centre would be an excellent place for your work to become known. If you are gay or see a lot of gay clients, then the local gay community centre or business association are obvious choices.

*   *   *

Once you’ve made up a list of potential referral sources, of course, you’ll want to do something with it. In future posts we’ll talk about some strategies for making your service known to them. There are many more ideas on this topic in my book, Private Practice Made Simple.

Next Friday: A more specific post about a longstanding source of calls and referrals that has fallen by the wayside.

*   *   *

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.