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Friday, 27 April 2012

Private Practice: An Intake Form for your Practice

Our Friday series for the past few months has been on the operation of a private psychotherapy practice.  The past few posts have discussed some of the details involved in designing a website, and I have provided links to the resource forms that accompany my book Private Practice Made Simple (available here on and here on

For more discussion of website design, consult the book or any of hundreds of other resources available out there.

Client Intake

Whether you are in private practice or work for a larger organization, there is always time pressure. Most of us book an hour or so to see a new client, and in that time we try to get as complete a picture as we can of what's been happening in this person's life. Inevitably we manage only to sketch out a brief outline, and try to discern whether we have anything useful to offer the person.

In our training we might often see a person three or four times to complete an assessment, and even then it would seem that we'd barely scratched the surface. A human life is immensely complex and we can't really get the whole picture in a few hours.

Some of our training seemed designed to instil the kind of distorted thinking in us that, in clients, we try to help them exorcize. One odd idea is that we will learn enough from a client during assessment that we can create a complete treatment plan for them, start to finish, then put ourselves on a kind of therapeutic autopilot as we work through the plan.

In fact, this never happens. We will always learn more as the sessions progress. Our understanding of the issues will deepen and suggest new avenues for the work. Clients will develop more trust in us and divulge information that they did not feel comfortable sharing up front.

As well, there are disadvantages to spending three sessions in assessment. If we are billing clients, we will cost them a lot before we ever offer them anything in return. If they have extended health insurance, we may go through most of their paid sessions before treatment begins. And after three sessions, we have set an unhelpful norm for seeing us: the therapist's office is a place you go and answer endless questions, without really getting to work on the process of change.

At best, a treatment plan is a rough outline of the first few steps of therapy, with some idea of where the ultimate destination might be. It's open to revision as we go along.

Even though our intake is necessarily incomplete, we still want to use it to get as complete a picture as we can. But we will never have time to ask all the questions we might like. So we can ask at least some of them on paper, and invite the clients to answer them when we are not billing them for our time.

The Intake Package

Psychometric questionnaires are an obvious source of information that many of us use. There are hundreds of these, and most are specific to the problem at hand. For depression you'd use one, for PTSD another.

Behavioural monitoring is another option. We can ask clients to take home a diary sheet of one sort or another, and keep track of their symptoms, their activities, their panic attacks, or whatever would be useful.

An intake questionnaire is also useful. In the course of assessment we usually want to (or have to) get certain kinds of information: the client's birth date, marital status, person to contact in case of medical emergency, medications being taken, treatment history, and so on.

Most of these questions don't need a lot of explanation by the clinician, and there is little point in spending valuable assessment minutes asking them and writing down the client's answers. We want to make the most of their time with us. So most clinicians use an intake form for clients to fill in before their first appointment.

To help with this, Private Practice Made Simple provides a sample intake form that clinicians can use as a model to develop their own. There's a pdf version you can print out and use as a general guide, and an MSWord version that you can actually edit with the details you want to include in your own form. Here they are:

(The link for the Word version opens our list of available forms. Just scroll down until you see the Client Demographic Form and look for the Word copy.)

As always, of course, I can take no responsibility if you later discover that this template doesn't include crucial information that you need, or if your clients find it difficult or objectionable to fill out. What I can say is that our clients seem very accustomed to filling out intake forms whenever they see a new provider of almost any health-related service, and no one seems to balk at the prospect of completing it.

Toward the end of the form it asks two questions that I believe are very important to good therapeutic outcome.

"In your own words, what is the nature of the concern you wish to address in therapy?"

Life is complicated. In the course of assessment we will inevitably become aware of many issues that a person might work on to their benefit. But why are they actually there? What is the main thing they really want our help with?

"Therapy can be a powerful force for change. In order for it to be most effective it helps to have a clear and specific goal. You may find it difficult to express your hopes for therapy in the form of a goal, but please at least make an initial effort. ... Feel free to list more than one goal if you wish."

What is the finish line for therapy, at least at the start? What would be a sign that the client got what they came for? Many people have difficulty with this. They come because they are experiencing distress, not because they have a grand vision of the future. But if we don't know where they want to go, we will likely set off in the wrong direction. Let's invite them to begin thinking about the outcomes they would like. We will inevitably return to this issue in the assessment interview, and repeatedly as therapy progresses. Let's signal the importance of the matter early.

Next Friday:  Time to calculate what you actually need to earn in order for your practice to work for you. The form we'll discuss is a long and detailed one, and frankly not all that much fun to work on. But as I stress in the Private Practice Made Simple workshops, it's perhaps the best hour or two you'll spend in practice planning.

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.

Tuesday, 24 April 2012

Is Governmental Gambling Addiction Unethical?

How much governmental revenue from gambling comes from addicts?
BC Gambling ad

In a free society, we might argue that people should be entitled to do what they like: cliff diving, rock climbing without ropes, eating at McDonalds, whatever. It’s our life, after all, we can spend or dispose of it in almost any way we wish.

But in the case of gambling in Canada (and in many other jurisdictions), governments are the primary beneficiaries of gambling revenue. Increasingly, governments are dependent on these revenues and are understandably reluctant to give them up.

It looks like a win-win situation: People line up to give their money away, and the government stands willing to take it for use in public services. Gambling is that most honourable of donations: a voluntary tax.

This sounds fine, and the majority of citizens – including me – have, on occasion, plunked down a dollar or two to purchase a lottery ticket or press a button on a slot machine. If everyone takes some time to donate money this way, the government may be able to avoid a deficit.

The problem is that most of us are not sufficiently dedicated. We lose interest in slot machines within minutes, and grow bored of buying lottery tickets.

And yet, these are enormous sources of revenue for our governments. In British Columbia, for example, gaming revenues (it always sounds more friendly to drop the ‘bl’ to turn gambling into gaming) earned $1.1 billion above expenses in fiscal 2010-11. In the 2009/10 annual report they calculate that revenues after all costs amount to about $435 per capita. This was counted as a “target not achieved,” as the goal of this crown corporation was to have citizens lose slightly more money that year to gambling.

In an interesting use of language, BC Lottery Corp’s annual reports refer to net revenues as the “Net Win”, despite the fact that gambling operations only profit via customer losses.

But the funds go to worthwhile services, don’t they?

At one point, money from gaming in BC was supposed to go to community organizations, cultural groups, and so on. But most of the revenue, 62.9%, now goes into the province’s general budget. Only 12.3% goes to community organizations, and another 13.4% to healthcare services and research.

Still, the province’s general revenues go to provincial programs, and perhaps it’s better to have a voluntary tax than one that is imposed. But where is the money coming from?

It’s hard to say. But a variety of studies in various jurisdictions suggest that a substantial amount of the money comes from people with gambling problems.

  • A report entitled “The Demographic Sources of Ontario Gambling Revenue” indicated that 60% of the income from machines and 35% of the total income was from problem gamblers.
  • The Nova Scotia Video Lottery Players’ Survey suggested that 53% of machine revenues were from problem gamblers.  
  • An Australian report estimated that between 42 and 75% of machine losses were incurred by moderate and high risk problem gamblers.

These reports and others are available from

We all know that some of the purchasers of alcohol (and so payers of alcohol-related taxes) are alcoholics. So what’s the difference between that and casino revenues?

One difference is that most adults drink at least occasionally, and most government revenues from alcohol sales come from users who are not addicted to the substance.

A more important difference is that the government does not itself promote alcohol consumption. There aren’t huge government ad campaigns suggesting that drinking is a great idea, or offering you incentives to start drinking.

In the case of gambling, however, the BC Lottery Corporation spends millions to promote gaming to the public. The actual figures are never provided in their annual reports, though the Corporation is quite candid about its goals. The top goal in the 2009-10 annual report is to “Build public trust and support for BCLC gaming.” As elaborated in the previous year’s report, “Without the public’s support BCLC’s business and revenue objectives could be placed at risk.”

Incentives are offered, such as go-go dancers on specific nights (presumably for the young male crowd) and (currently) a $100 bonus for signing up to gamble on the corporation’s online website. It’s difficult to imagine the BC Liquor Distribution Branch offering $100 worth of alcohol to nondrinkers to help get them started.

So what should be done? Should we make gambling a private enterprise, in which the profits go to the corporate sector? Should we outlaw it altogether?

Personally, I’m not a great fan of the government-as-parent deciding what citizens can do. But I also question the government’s role as both industry regulator and prime beneficiary of profits – this seems like a conflict of interest. Governments take in more taxes with every new chronic gambler they create. And having seen the results of their “successes” in my office, I’ll confess to experiencing some distaste for the industry.

Luckily, the decision about such things is not up to me. If it were, I would impose a sharp limit on the amount of gambling promotion that can be done, just as we do with cigarette marketing. And I would limit the expansion of casinos. I’d also like the government crown corp to stop making an increase in gambling a business objective. Given that the corp is effectively a branch of government, this makes it government policy to create as many gamblers as possible.

And please, let's stop patting ourselves on the back by talking about gambling profits going to treatment programs. Instead, let's actually publish the percentage of those revenues that are used on antigambling initiatives.

Even better: Let's publish a ratio. The amount of money spent promoting gambling, relative to the amount of money spent treating or preventing it. Then we'll get a sense of where the priorities really lie.

Friday, 20 April 2012

PsychologySalon at VPL: Learning to Love Your Emotions

As we get closer to Tuesday's PsychologySalon talk at VPL, I've opted to repost the description for the benefit of anyone who might like to attend.  We're in the rooms below the concourse level at Central Branch.  Our last talk had 195 people in attendance, so come early!

The talk runs 7 to 8:30 pm Tuesday April 24. Our speaker is Dr Lindsey Thomas, one of the team at Changeways Clinic. I'll be there too, and we'll have a book table available.

Here's the blurb:

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

Dr Thomas and I hope to see you there!

Private Practice: Your website design

A new website is a sapling.

The Friday series on private practice has been focusing lately on the development of practice websites. Last week, I suggested that people wanting to develop a website conduct a survey of existing sites owned by similar professionals, and provided a form for this purpose.

Eventually you will want to work on your own site. You should do this before getting a designer to create your site, because it can take a lot of time and you don't want your designer hanging around, and your designer can't say what you want to communicate. Designers are for creating the medium, not writing your message.

Hopefully you have some idea what you want to put on your site. Two observations are particularly relevant at this point:

First, you don't have to have your site completely designed and written before you get started. Unlike an essay, thesis, or academic paper, which have to be in their final form before you send them off, a website is never complete. You will update and add to it over time. So to get started you mainly need a home page and perhaps a few subsidiary pages. 

Think of your website as a young sapling. It's spindly and has only a few branches. As it gets older you may prune off some of the branches, and others will become thick platforms from which many more limbs protrude. All you are doing at this point is creating the trunk and a few small limbs.

Second, be stingy with your home page. This is the only page that virtually everyone who visits your site will see. You'll want to make it powerful. Don't use a welcome screen ("Here's a pretty picture of my dog that I'll make you look at before I'll let you see what you came here for"). Don't clutter it up (if google can make their welcome screen look tidy and simple, so can you). And don't start with a vague, meandering rendition of your philosophy ("Gosh, life can be difficult for any of us, blah blah blah ...").

Your main agenda for the home page is to help your viewer find what they came to see. Spell out the main branches of content. "Welcome. We offer psychotherapy, professional training services, and consulting for large organizations. Click on each to learn more." Don't muddy it with a lot of preamble.

As usual, the adjunct materials from my book Private Practice Made Simple include a form to help you out. Here it is:

Resource Form:  Your Website Design 

The form is five pages long, but I suggest you print multiple copies of pages three, four, and five.

The first page describes the structure of most websites, which is:
  • Home Page
    • Major Theme 1 (e.g., "Clinical Services")
      • Subtheme 1 (e.g., "About cognitive therapy")
      • Subtheme 2 (e.g., "Difficulties we treat")
        • Subsubtheme 1 (Anorexia nervosa)
        • Subsubtheme 2 (Trichotillomania)
        • Subsubtheme 3 (Pica)
    • Major Theme 2 (e.g.,"Consulting Services")
      • Subtheme 1 (e.g., "Supervision for psychologists"
        • Subsubtheme 1 (Arranging supervision)
        • Subsubtheme 2 (The structure of a typical session)
      • Subtheme 2 (e.g., "Organizational consulting")
        • Subsubtheme 1 (Mental health awareness programs for staff)
        • subsubtheme 2 (Training programs for managers)
    • Major Theme 3 ("Contact Us")

As you can see, for this basic site you'd need three copies of the "Major Theme" page, four copies of "Subtheme", and seven copies of "Subsubtheme". 

Don't skimp on the subthemes. Remember that you don't want a huge amount of content on any one page. If the person has to scroll down more than once, consider splitting the content over two pages. Additional pages do not cost any more money to host, so use them liberally.

Take your list of "bits" that you want to include on your site (my philosophy, my vita, about depression, about PTSD, about CBT, my address, my menu of public talk topics, links to relevant sites, whatever) and start dividing them up across major themes, then decide how to split up the resulting material across subthemes and subsubthemes. You may discover that three topics (about depression, about bulimia, about autism) necessitate four pages: a page for each, plus a larger theme page from which they branch ("About the disorders we treat").

Once you've decided how to lay out your content, it's time to start writing. And for that, I'll leave you on your own.

Want to know more about clinical website design? Consider picking up my book, which is available from here, and from the Canadian site here.

Next Friday:  A client intake form for your 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, 17 April 2012

Sigmund Freud and Psychology 100

Long, long ago in a forgotten corner of the galaxy far, far away –

Okay, it was London Ontario. But it WAS long ago … I taught Psychology 100.

In almost every university, Psych 100, or its equivalent, is one of the most-taken courses. For one thing, it has a reputation as a “bird course” (hard to fail). And every undergraduate is of the not-entirely-unjustified opinion that he or she has a mind, so surely the course will be of interest.

These are setups.

The Department of Psychology at most universities steadfastly wants to defend the field’s seriousness, so the course is typically marked harder than students expect. And the syllabus usually covers the full range of the field, including animal learning, sensation and perception, the inner workings of neurons, and the mechanism of classical conditioning.

In other words: Many of the students who take Psych 100 find it more difficult than anticipated, and dead boring to boot.

Now imagine being the instructor. You have a few students who harbour a deep interest in the subject, and a lot more who compete for the back rows of seats, falling asleep and reading the student newspaper (or, these days, texting), and feeling resentful that for the monumental effort of showing up for lectures they are not being granted an “A”.

You need jokes. In Psych 100 they are few and far between. Rare is the section of this course that doesn’t hear what is perhaps the only joke in all of neurobiology: the “Four F’s of the hypothalamus:  Feeding, Fighting, Fleeing, and Mating.”

That’ll get you through one lecture. But what about the others?

That’s where Sigmund Freud comes in. You’re at the clinical end of the course, which you’ve saved for last. Your students are now thoroughly disillusioned and many of them dislike you for dragging their GPA down. You need to get them through the last few weeks and then you’ll all be free.

And there he is, smoking his pipe, with his Austrian accent, and holding endless psychoanalytic sessions with the matrons of Vienna, frowning at you across a gulf of a hundred years. He’s dead, so he can’t talk back. Why not make fun of him?

It’s not that difficult. You can entertain your students with his theory of psychosexual stages: oral, anal, phallic, latent, and genital. Let’s face it: they’re just out of high school. All you have to do is say the word “anal” and they’re entertained for the rest of the hour.

Or you review the Oedipus complex – the desire of the young boy to kill off his father and marry (and sleep with) his mother. Uncomfortable giggles and loud cries of “gross” fill the room, but at least they’re awake.

Freud is routinely treated this way, but if you give instructors a good dose of sodium pentothal and ask them, they’ll admit to feeling a bit unclean and dishonest doing it.

Part of the problem is that Freud is seldom read in any depth, so the bare highlights are about all that many instructors know. It’s a bit like a literature instructor teaching King Lear based on hearing that it’s about an old king who retires.

But part of it is the nature of Freud’s work: The less detail you give, the more ridiculous it sounds. A quick survey of Freud will almost inevitably make him sound like a sex-obsessed lunatic.

And, truthfully, part of it is that Freud’s thinking was grounded in his world and time. His thinking about women was influenced by the thinking of the age. And in a late-eighteenth century culture of largely-absent fathers it was perhaps not so implausible that some boys might think “Just who is this guy who comes by now and then and treats my mother like dirt; I treat her better than he does and I seem to like her more, so why doesn’t he just drop dead?”

Instructors often get a tad more serious when they discuss Freud’s ideas of the unconscious, but even then there’s a temptation to play up the woo-woo aspects of it. “We’re controlled by forces of which we are entirely unaware.” It makes the whole thing sound like a pseudoscientific form of demonic possession.

Some of the worst culprits are people like me, who think of ourselves as proponents of evidence-based methods like cognitive behaviour therapy (CBT): so much clearer, so much more rational, so much more scientific than the armchair musings of cigar-smoking Viennese psychiatrists. “The unconscious,” we are tempted to snort, “What nonsense.”

We’d much rather talk about the ways that we interpret the world around us, how these are learned at an early age when people have the minds of children, and become so automatic that they are used, unwittingly, in new situations where they no longer prove helpful. And why does this happen? Well, because we make use of prior learning without, uh, conscious awareness. Which is totally different than saying there’s an unconscious mind. Somehow.

Make no mistake: The field has come a long way since Freud. Casting the man’s ideas in stone and treating them as dogma turns him from thinker into deity, his books into Bibles. We’ve learned a lot since his day. His therapeutic method still lacks something in the empirical-support department, and has largely been supplanted by strategies that are a lot more focused and that work a lot faster.

But trashing Freud for not getting it all correct is a bit like trashing Captain Cook for drawing maps that turned out to be a little inaccurate, or snorting at Darwin for not understanding DNA. Freud thought and wrote at a time when knowledge about psychological development and disorder was at a minimum. That he got as far as he did is miraculous. We don’t need to make him the head of a religion, but maybe making him the butt of every psychological joke is a little too easy.

So: Sorry Sigmund. I too have fallen prey to temptation, on occasion. Including a few times when trying to corral unruly undergrads. I won’t promise to adopt your methods, or wade through absolutely everything you wrote. But I’ll try not to score cheap points off you in future. Deal?

Friday, 13 April 2012

Private Practice: What should you put in your website?

The Friday series on private practice has been focusing lately on the development of practice websites. One of the main factors that hold people back from creating their site is figuring out the content that they want to include. They fear forgetting something crucial.

Part of this trepidation comes from the experience of writing papers: You only hand it over once it’s complete. A website, though, is completely different. It is never complete. You can add to it any time you like, so it doesn’t matter if what you first put up is imperfect.

Nevertheless, it’s good to have some at least some clue what you want to put on your site. There is a perfectly simple way to do this.


Look over at the desk of the person next to you to see what they’ve been doing. You’ve been inoculated against doing this from the day you entered Grade One. Now that you’re an adult, however, all bets are off.

You know enough not to plagiarize, obviously, but it is completely legitimate to get ideas from what other people have been doing. Call it “market research.”

A downloadable form

At we have a page of downloadable forms to accompany my book Private Practice Made Simple. Although buying the book is a great idea (go do it; here it is on and here it is on, you don’t need to do so to get access to the forms.

For our present purposes, this is the one you want:

Print it out and then set aside an hour or so to get to work.

Conducting your survey

You’re going to look at 10 existing websites for people from your field. If you are a psychologist, for example, just Google “psychologist” and, if you like, your city. It doesn’t really matter which city you pick, because what we’re doing doesn’t vary by region.

Go to the first website you see. Write down the address so you know not to go there a second time.
Look at the home page. On the Survey form, quickly jot down all the types of content you find there, one type per line. “Address & phone number; name of clinician, photo of clinician, type of practice, list of clients seen.”

Then work through the rest of the site, page by page. Add all of the other bits you find. “Vita, definition of bulimia, radio interviews done, slides from past talk on PTSD, google map of location, personal philosophy, etc.”

Now go to another site. Do exactly the same thing. But this time, if a piece of content (“address”) was on the first site, just put a checkmark beside that note rather than writing it down again. If there is anything on this new site that wasn’t on the first one, add it to the bottom of your list.

Then do the same thing for the next eight sites. You’ll need several sheets of the form.

Reviewing your survey

What have you got? A complete listing of every type of content that appears on any one of ten therapist websites. Plus, an indication of how many sites include any particular type of content.

If an item has six checkmarks beside it, that means it appeared on one site, then reappeared on six more. So it’s on 70% of the sites you visited. An item with no checkmarks appeared on only 1, or 10%, of your sites.

So now you know what other people put on their sites. You can look through the list and circle the bits you want to put on yours. The greater the number of checkmarks, the more likely a bit is to be considered standard. That probably means it’s useful at least to consider for your own site.

Some bits (“picture of therapist’s dog”) appear seldom, or you notice that you react negatively to them. Fine, drop it as part of your own site.

Also notice any nagging dissatisfactions that occurred to you as you conducted your survey. Does something seem missing? “Hey, nobody defines what kind of therapy they do.” Lovely. Add this to the things you want on your site.

Remember that your site doesn’t have to have everything on it in order for you to create and launch it. You can always add other bits later.

Next up: Eventually you will want to map out all the bits of your site across different pages. I’ll discuss a strategy for this next Friday.

*   *   *

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, 10 April 2012

Policy: A Snapshot of the Residential Schools

Every Canadian knows at least a little about the bleak history of the residential schools. Children of First Nations families were forcibly removed from their families and made to attend these schools, often in communities far from home. The schools, it turns out, were rife with physical and sexual abuse of the children. Even had they not been, the simple act of forcibly splitting up families was damaging enough.

Non-native people know the story, and most shake their heads at the policy. But without first-hand experience it can be hard to really understand or connect with what happened. Few Canadians have seen even a single artifact from that time.

A friend of mine recently posted the letter reprinted below. No letter can encompass what happened in this country, so inevitably it provides only a tiny snapshot of the attitudes of the period. But I found it telling of the paternalism and condescension of the residential school policy in its casual assumption of authority and generosity of bestowing upon parents the privilege of seeing their own children.

Read it and see if a chill doesn't run up your back.

Friday, 6 April 2012

Private Practice: Naming Your Website

In last Friday's post I emphasized that yes, you need a website if you want clients to find you and if you want to look like you are running a genuine business. Whereas a few years ago a website was an option, it is now no more optional than a telephone.
Good advice for your domain name.

So let's imagine you have decided to create a website for your private practice. What do you call it?

There's a simple form for this at Here's the direct link:
At Private Practice Made Simple workshops last month, several people leapt in at this point to say they'd gone online to try to find a name, ruling out those that were already taken. This is a reasonable approach, but I think it puts the cart before the horse. So let's take the process in order.

First, is there a logical name?

Perhaps your clinic is named after you. If so, you have a logical set of possibilities for your website:
Or maybe you've given your clinic a name, so it seems easy:
Alternatively ...

Maybe you're just starting out, and want to come up with your business name and website name at the same time. Or your name doesn't work for some reason. Or you've checked and all the logical versions of your name are already taken. Here are some principles:

If your name is hard to spell, think again. Maybe you are Helena Quattrociocchi. You know from experience that no one can spell it, so they'll never find it on the web. Come up with something else.

Don't make it too long. Perhaps you've settled on the North Battleford Life Change and Anxiety Clinic, for some reason. Rather than squashing all that into one name, consider logical shrinkages such as or

Avoid acronyms. In the above example, it might be tempting to go with Don't. Most acronyms are not memorable in themselves, so this depends on people remembering your clinic name precisely.

Invite your friends over

Consider conducting a brainstorming session with a few friends over coffee or, perhaps better, a disinhibiting glass of wine. Make it genuine brainstorming, though: No criticism allowed, all ideas have to be written down, no self-editing. Let them get a bit silly - that's when the most tangential (and possibly best) ideas are likely to come out.

Don't try to decide between the options the same day. Set the list aside and come back with fresh eyes a few days later. Some foolish ideas might unexpectedly blend to create a single great idea.

What about the suffix?

Make no mistake, your private practice is a business. A prosocial business that benefits others, we hope, but a business nevertheless. So .com is entirely appropriate. A .org suffix is okay, but usually refers to nonprofits. Other suffixes like .net and .info are the also-rans of the internet world; only take these if absolutely everything else is occupied. But do consider: if is taken, then will only cause confusion for the vast majority of your visitors.

If you live in a country with its own suffix, it's a reasonable alternative to use that. is just fine for Canada; and .au for Australia. This still looks professional to your visitors. Avoid further divisions, however: looks a bit too, well, provincial.

Now go to the web

Once you have your list of nominees - and before you set your heart on one of them - do a search on your top options on the net. Cross off the ones that are taken, and look at the ones that are left. Then take your remaining shortlist to friends and family and ask for their honest feedback. They might see something that escaped you. If you are Regan Ngan, then may look fine to you, but the profusion of double letters will be hard for some people to remember or type in.  

Register your name immediately

Once you've settled on your name, register it as soon as you can - preferably that day. You don't have to have your site ready in order to register the name. Buy it and hang onto it before someone gets wind that you want it and snaps it up before you do.

If you are still hankering for a personal site, or wonder if people will instinctively go to another name, buy that one too. Web addresses are cheap, and the price per year goes down the more years you buy. You can always point your second address at the first. 

So go ahead and get both and Then develop one website for and get drjanechoi to forward automatically to it. You can always develop a separate website for later. 

Next Friday:  So fine, you've got a domain name. What should you put in your website?

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Want more information on operating a private psychotherapy practice? 

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Tuesday, 3 April 2012

Is Mental Health Stigma a Useful Concept?

Worldwide, a variety of governments and agencies, including the Mental Health Commission of Canada, have been working to “combat the stigma of mental illness.” On the whole, this seems like a laudable concept. If you go out on the street today and ask people whether they support efforts to reduce stigma, you will have a hard time finding anyone who says “no.”

But ask a second question: “What IS mental illness-related stigma, anyway?” Then you run into the problem.

Lately I’ve been asking this question of mental health professionals and the public. The answers are remarkably vague and wide-ranging. “People think they’re crazy.” “People don’t want to hire those who have mental illness.” “People believe they will take too much time off work.” “People don’t want to have these people as friends.” “They don’t want to rent apartments to them.” "People with mental health problems think badly of themselves." "Actually, I haven't a clue."

In part, these answers can be taken as indicators of the scope of the problem. Stigma isn’t just one thing, it’s a cluster of things. The result, however, is that when two people talk about stigma, there’s a good chance that they are thinking about entirely different phenomena. One person is talking about the problem of housing the homeless, the other is talking about the difficulty in describing one's depression to the relatives.

The wrapping and the contents

Words are often used to bundle phenomena. We notice that our chair doesn’t float into mid-air, that a released pen falls to the floor, and that rain hits the pavement. We group these events under the label "gravity" – a concept that unites various experiences.

A friend gives us a birthday card, they volunteer at the annual fun run, they sponsor a child in another country, and they help out with the dishes after dinner. We begin to think of the word “generous.”

Words like “generous” and “stigma” are like boxes that contain a wide variety of ideas. Over time the boxes themselves begin to seem real, as though they are identifiable things of their own. It becomes easy to assume that we know what they are.

But when I talk about stigma, I am likely thinking about certain items inside that box. When you hear me use the word, you might well be thinking about a different set of items. We can talk about completely different ideas, both thinking that we understand one another and never really communicating. What began as a useful unifying concept becomes a barrier rather than a facilitator to communication.

Why focus on stigma?

Obviously this problem can occur whenever we talk about any concept: intelligence, integrity, criminality, health. Why bother with stigma?

The bundling problem becomes particularly pronounced when the box’s contents are very diverse and relate to one another only loosely, when the contents are never clearly defined, and when people use the box’s label without specifying which contents they are referring to. In these circumstances, the odds of having a discussion that no one really understands go up significantly.

Mental illness stigma fits all three criteria. The term covers a broad array of phenomena.  It is seldom well-defined, even in lengthy discussions of its effects.  And when people discuss any of the phenomena packed within the box, they usually use the term itself rather than spelling out which bit they are referring to.

As an example, the Mental Health Commission of Canada recently launched an anti-stigma campaign called “Opening Minds.” Read their News Release to see if you could figure out what stigma means if you did not already think you know.

To be fair, the news release is quite a brief document. The Commission provides a slightly deeper treatment of the subject here, and includes a definition of stigma:

"Stigma is made up of two parts: negative and unfavorable attitudes, and negative behaviours that result from those attitudes. People living with a mental illness often experience stigma through:

  • Inequality in employment, housing, educational and other opportunities which the rest of us take for granted.
  • Loss of friends and family members (the social and support network).
  • Self-stigma created when someone with a mental illness believes the negative messages."

Stigma, then, is the practice of discrimination, the loss of valued others, and a self-perception problem. Well, yes, all of these can be effects. But then when we talk about stigma and don't define which bit we mean, how do people know what we are talking about?

Who cares?

If we take the problem of stigma seriously, we'll want to target our efforts carefully and define our goals. But when we use a mushy catch-all term we run the risk of racing off to solve the problem without clearly defining the outcome we seek. Our very thinking can become mushy.

In a "Fact Sheet" about stigma, the commission uses remarkably imprecise language and some questionable epidemiology. One of its key messages is "Mental illness is an illness like any other." Meaningless on the surface, it lumps an enormous variety of difficulties under one label, then equates it to physical illness. Is this helpful, or does it simply encourage precisely the kind of overgeneralized reductionism that we are trying to overcome? Some research suggests that stigma actually increases the more that people equate mental illness with physical illness.

Chopping Up Stigma

Am I saying that mental illness stigma doesn't exist? Of course not. It does, and it can be a significant problem.

What I am arguing is that lumping all attitudes, behaviours, and reactions to all mental health problems under one catch-all term is unhelpful, creates more confusion than it is worth, and makes it very unlikely that our efforts will pay off.

Rather than brushing the whole idea under the carpet, then, or treating it as a "motherhood and apple pie" kind of issue, perhaps we need to unpack the term and do away with the wrapping. We need to distinguish between various types of stigma and see different solutions - ranging from depathologizing unpleasant emotion to building affordable housing. Blunting the impact with a vague term is likely only to result in large expenditures with few results. This would be a shame.