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Tuesday 29 May 2012

Resources: TED Talks

This, I recognize, is old news. Ever since Jill Bolte Taylor’s talk went viral several years ago, most people have heard of TED. But few clinicians seem to use TED as a resource for clients. And they should.
A website worth spreading.

What is TED?

TED, for those who missed the bulletin, began as an annual conference in California. The acronym stands for Technology, Entertainment, and Design. The conference invites key speakers in a diverse array of fields to present, limiting their talks in most cases to 18 minutes. In order to squeeze big ideas into a small timespace, the presenters are forced to crystallize their ideas for maximum impact.

In recent years, spinoff TED conferences around the world have adopted a similar format. Top innovators, artists, scientists, and policymakers stand on the stage's red dot and describe their work and ideas.

The only question, of course, is what to do with the resulting videos of the individual presentations. TED organizers decided to post them for free download from their website. All of them.

So you can now go to and watch talks by Bill Clinton, Jane Goodall, Stephen Hawking, Maya Angelou, and hundreds of other brilliant speakers, innovators, and thinkers. You can surf and listen at random, or you can explore themes. Some of the conferences themes are:

  • Architecture
  • Africa
  • Green Issues
  • Food
  • The Mind
  • How We Learn
  • Evolution
  • Storytellers
  • Presentation Skills
  • Oceans
  • Media
  • Business Innovation
  • Cities
  • What Makes Us Happy?
  • ... and more.

How does this relate to mental health and clinical practice?

First, many people who seek psychological help are looking for inspiration. Some aren’t sure what they want to do with their lives, some have become discouraged by the lack of intellectual tone in public discourse, and some simply long to see that somewhere, someone is thinking larger thoughts about the world and the future.

As well, some of the themes are clearly related to clinical issues or social science. "What makes us happy?" is, obviously, concerned with life satisfaction and positive psychology. Other talks discuss prominent social issues, and some speakers describe their survival of fundamental life-changing events.

For therapists looking for informative and inspiring "homework" content for clients, TED can also be tremendously useful.

Jill Bolte Taylor’s viral talk is one that I have recommended to many clients. A neuroanatomist whose career involves the study of mental illness, she describes the experience of awakening one morning in the midst of having a stroke. Her harrowing description of the experience of trying to get help suddenly takes a sharp turn and becomes a meditation on mindfulness and transcendence, bearing a message about the constant availability of inner peace.

And: Let's face it, many of the activities involved in self-care have somewhat limited appeal, particularly when people are in a low mood. Housecleaning seems oppressive and boring, and even a pleasant walk can become an opportunity to engage in negative rumination. It can help to have something else on which to focus one's mind. TED talks generally work well as audio-only content, so people can download audio versions of the talks to iPod (or use the TED app available through iTunes) and play them while doing something that might otherwise be dull. I often play one or two while on a Stairmaster at the gym.

Access points

It's easy to get a taste of TED. Just go to the website at and start browsing. But there are now many hundreds of talks on the site, so it can be a bit overwhelming. Here are a few favourites:

There are many more. I think, though, that if the average mental health clinician watches these six, they will be hooked. The average nonclinician probably will be too.

Whatever your pet interests might be, there are probably talks on the subject from the world’s leaders in the field. TED is perhaps the best and most interesting convention on earth, and with the website you have an open invitation to view every talk that has ever been given. How can you lose?

I recommend TED to many clients who find the site to be engaging, inspiring, and yes, even a little bit antidepressant. Try it.

Friday 25 May 2012

Private Practice: Task Balancing

The Friday series based on my book Private Practice Made Simple (available from and continues. We're in the home stretch of this PsychologySalon series, though the book covers many more topics.

In the chapter on burnout - or, more specifically, avoiding burnout - I recommend that once a year every private practitioner should sit down and think about his or her task balance.

Private practice sounds simple enough: you set up an office and start seeing clients. But in fact private practice can mean any of dozens of activities. And even if we just consider seeing clients, there is the question of which clients, to what purpose, referred by whom, and facing which difficulties.

Over time, a practice can drift based on the people who get referred to you and the opportunities that arise. This is a good thing. It means that the business is responsive to the environment - it is finding its niche, like an animal in an ecosystem.

But you got into private work for a reason, remember? It wasn't just about making money, or seeing the most clients you possibly can. Most people start their practice with some idea of what they want to accomplish, or the populations they wish to serve, or the activities that they actually enjoy doing.

A colleague of mine at the hospital I used to work at had a one-day private practice emphasizing medicolegal evaluations. He was fond of pointing out that he made more in that one day than in the four days he spent at the hospital. His claim has been reinforced by others I know. In a sense, this area of practice sounds like a goldmine.

But I don't want to do it. It doesn't interest me, I dislike the oppositional relationship that often develops in these encounters, and providing data points for the legal system to battle over doesn't seem that interesting or fulfilling to me. So although it might well be a good source of revenue, I've chosen not to pursue it. It isn't a part of my task balance.

You Can Have Too Much of Anything
Mmm, chocolate pie. Daily. Hourly. For months.

Think of your all-time favourite food.

Now imagine eating that every day for breakfast, lunch, and dinner.  You can have as much as you want, and you can't eat anything else.

How long will it be before you can't stand it?

If you're in private practice, you probably got into it with a particular idea in mind. You love treating OCD, or helping gay men with the coming out process, or doing CBT for trichotillomania, or doing organizational consulting for nonprofits.

Great. But if all you do is that one thing, your work will soon go stale. You'll become bored, your therapy will become a kind of cookie-cutter factory process, and your clients will suffer. You'll be on the road to burnout.

Like all professionals, you need some kind of balance between the different activities you do. That balance will not remain ideal all by itself, and even if it did, your ideal will shift as you go through your career.

So once a year, it's a good idea to sit down and think about all of the professional activities that you do, and the ones you'd like to do, and decide how to recalibrate your work. Wouldn't it be good to do this on paper, preferably with a structured form in front of you?

A Structured Form

Surprise: Here's the form.

The first category of task is individual psychotherapy. If you don't do this, skip to the next section. If you do, consider breaking this down by population. "Somatoform disorders" for example.

To the right of each item, there are four columns:

  1. Estimate the amount of time you currently spend on this activity in your practice. You can use a percentage of your time, or the number of hours you spend, or any other method that works for you.
  2. Rate the satisfaction that you experience doing this kind of work, using a 0-100 scale.
  3. Estimate the revenue that this activity produces per hour. Although it isn't all about the money, you still have to pay the clinic's lease and you can't spend all of your time on tasks that don't earn any revenue.
  4. Estimate the amount of time you would like to spend on this activity if it was possible to do so. Don't worry too much about the practicality of this. You're investigating your wishes, while fully understanding that not all of them might come true.
  5. If you wish, add another column in the margin that may have significance for you. "Amount this is needed by the community." "How effective I am at this type of work." "Ease of getting more of this work." Anything.
Then do the same ratings for the other main populations you see for individual psychotherapy.

And then continue the process for other private practice activities:
  • Assessment-only. If you see some populations only to come up with an assessment, rate each type you deal with.
  • Group therapy.
  • College or university teaching.
  • Night school / public education. If you offer communication skills classes at the local community centre, write this down - even if you do it for free.
  • Consultation with practicum or internship students.
  • Supervision or consultation with registration candidates in your profession.
  • Consultation for fellow professionals.
  • Organization consulting.
  • Government-related consulting.
  • Committees and boards.
  • Workshop teaching. Break this down by the topic of the workshop, if you have several you teach.
  • Academic writing.
  • Nonacademic writing for the profession. Perhaps your monthly column for the local professional newsletter.
  • Writing for the public.
  • Nonrelated writing. Perhaps you moonlight as a mystery writer.
  • And...all other professional activities, paid or not, satisfying or not.
Once you've finished, you should have a sense of whether or not your practice is currently on track. Maybe you're doing pretty much exactly what you would like. Or perhaps the abundance of depressed clients means that that's all you see any more, and that your passion for writing has been sidelined for too long.

If there are big differences between your current practice and your ideal practice, you can then take the task further and see if there is anything you can do to bring your work closer into line with your vision.

As mentioned above, I suggest doing this once a year. It's a good strategy for reminding yourself why you are in private practice and helping you see where you need to steer the boat.

*   *   *

Want more information on operating a private psychotherapy practice? 

Check out my book Private Practice Made Simple, available at bookstores and through Amazon here.

Tuesday 22 May 2012

Vancouver: The Grouse Grind

At Changeways Clinic, we often encourage people to become more familiar with the resources of their surroundings. And we're convinced that exercise is one of the most potent enhancers of mental health and life satisfaction. Plus, people coming to Vancouver to go to a workshop or conference often want to know what to do. To this end, I'll be posting occasionally about getting around Vancouver and BC.

First up: The Grouse Grind.

The Grind: Up, endlessly up.

Grouse Mountain looms over Vancouver from its vantage point across Burrard Inlet. In the winter it’s home to a smallish ski facility whose main claim to fame is an amazing view of the city on cloudless days.

Like most ski resorts, Grouse has tended to suffer during the summer. Enter the Grouse Grind, a trail that leads up the mountain from the gondola base to the main chalet. The trail is short, only 2.9 km (1.8 miles), but climbs 853 m (2800 feet). That makes an average grade of 29.4%. Along the way there are 2830 stairs, as well as stretches of rock and root to clamber over.

The Grind is notable for being perhaps the least scenic trail in British Columbia, with no views to speak of until you reach the chalet at the top. There are virtually no flat stretches. Not even aficionados claim that the hike is “pretty.”  There’s nothing pretty about it.

Furthermore, the Grind is crowded. Grouse’s own website (located here) reports that over 100,000 people hike the trail annually. Given that it’s only open half the year, that’s over 550 people per day. In practice, the crowd is thicker: on a sunny weekend day there are thousands of people sweating their way up the mountain.

For many years I looked down my nose at the Grind. People had taken an idyllic, peaceful wilderness activity - hiking - and turned it into a competitive gym craze. If you want to go hiking, I thought, go where there aren’t so many people. And get some variety. Routinely scrambling up the same trail seemed stupid given that Vancouver is surrounded by mountains, all of which can be hiked.

It was the very comparison I made that eventually changed my mind: the gym. I was on a Stairmaster in a poorly ventilated gym, pointed at a television tuned to CNN. “Anything woud be better than this,” I thought. Even, perhaps, a hike in the wilderness. Any hike at all.

I realized that I had been contrasting the Grind with something I love: hiking. And it’s a bad comparison. Match the Grind up against almost any trail between the towns of Hope and Whistler and it loses. Badly. But compare it to a Stairmaster at the gym and it wins by a long shot.

The Grouse Grind is not a hike. It’s exactly what Grouse itself calls it: Mother Nature’s Stairmaster. The object of the Grind is not to commune with nature, it is to work out. To this end, most Grinders (as they’re known) time themselves. Go up to some fit-ish people in Vancouver and ask them their “Grind Time.” At least half will know, though they might deduct a few minutes when they tell you.

If you spend an extra $20 you can get a Grind Timer card that you swipe in front of obelisks (straight out of 2001 A Space Odyssey) at the bottom and top of the trail. Your time comes out on television monitors in the chalet, and you can access your history of times on the mountain website. Most people don’t bother with the timer, however.

The all-time best time on the Grind is 23 minutes, 48 seconds. This is essentially an airborne individual that no one should compare themselves against. For most people a time in the 50-90 minute mark is more realistic, with exceptionally fit individuals dipping into the low 40s and, apparently, the upper 30s.

If you go, here are some tips:

  • Know your medical status, and get advice from your physician if you have any reason to think there may be an issue with strenuous hiking. The Grind is no picnic, and it's not the place to start an exercise program after years of inactivity.
  • Don’t overdress or overpack. You will not get lost if you stay on the Grind trail (this is about the only trail in BC that I would say this about). Do bring at least a litre of water, and perhaps a granola bar.
  • Park in the free gravel lot on the right as you arrive rather than in the pay lots to your left.
  • Stretch first; it’s worth it.
  • Consider the alternative. If you can’t stand the thought of a crowded trail, take the BC Mountaineering Club (BCMC) trail, which climbs the same distance, ends at the same place, and is about 100 m east of the Grind for most of the way. The entrance is the same as for the Grind; look for the sign just inside the entry fence.
  • If there is an emergency on the trail, it will be closed by the Fire Department while they bring the person out. Yes, this happens. Rather than standing around waiting for the trail to reopen, take the BCMC trail instead. There is an alternate start to the BCMC trail in the gravel parking lot about 100m beyond the yellow gate at the east end of the first bit of gravel parking. Go with someone who knows the trail so you don’t get lost, however.
  • Take it easy. The first time you go you’ll be familiarizing yourself with the trail. Don't try your hardest. Make your Grind time something that you'll find it easy to beat the next time you go.
  • Don’t overdo it on the first quarter; you’ll be miserable the rest of the way.
  • Gain a small amount of vertical with each step. If you reach upward so that your leg bends at a 90 degree angle and levers you up 15 inches, you will use much more energy than if you took three steps that lifted you 5 inches each. It’s generally more efficient to take many small steps than fewer big ones.
  • When you get tired, see if you can keep going but deliberately slow yourself right down to a snail's pace. You will still make at least some progress toward your goal, and if you are slow enough you will recover without having to stop altogether.
  • If you stop (and most do), make your stops shorter and more frequent.  You will get more relief from the first 15 seconds of a break than from the next 15 seconds. So a five-minute break will not revive you nearly as much as 20 breaks of 15 seconds each.
  • Avoid stopping in the middle of the trail. You'll hold up people behind you. There are wider spots off the trail at the end of most switchbacks. Note: You will get a few eye rolls if you are texting or talking loudly on the phone the whole way.
  • Don’t get discouraged at the ¾ mark. The signs don’t seem to be evenly spaced, and the last quarter appears to be the shortest.
  • Don’t walk down. There’s limited fitness value in walking downhill and the trail isn’t suited to two-way travel anyway. Get a download ticket at the chalet and take the gondola. If you must walk down, take the BC Mountaineering Club trail (provided you have hiked up it at least once so you know where to find it).
  • Keep a record of your times. Improvement is motivating, and you will almost certainly improve your time if you do the Grind regularly.
  • Hike other trails. As I’ve said, the Grind isn’t a scenic trail. Get a few friends (or join a hiking club) and try out some of the other trails on the North Shore. The pace is more relaxed, the views are better, and there are no crowds. Just make sure you are equipped in case the weather moves in, and tell someone where you’ll be and when you expect to be back.
Try it closer to home. Is the Grind a bit daunting or inaccessible? You can still approximate it in any gym. Get on a Stairmaster and do 280 floors. It's close to the same thing.

Coming to Vancouver? Find the Grind by crossing the Lion's Gate Bridge northbound, then follow the signs to North Vancouver and Grouse Mountain. As you approach the gondola base, look for the free gravel lot on the right. Park there, and walk back to the road you came in on. The trailhead is just uphill from the entrance to the gravel lot.

Make a day of it. Grouse is part of the tourist trail in Vancouver, but with some justification. The views at the top on a sunny day are spectacular, there are attractions at the top (a lumberjack show in summer, a zipline area, a pair of orphaned grizzlies, and - if you are fully equipped - some less well-marked trails that lead behind the mountain). The chalet's cafe and informal bistro are good and reasonably priced. Unfortunately the higher-end restaurant has seen better days and is priced more for the view than the quality of the food.

In the neighbourhood. At the base of the Skyride there is a wolf enclosure, and further down the mountain (a drive of a few km) you'll find Cleveland Dam (part of Vancouver's water supply) and walking trails down to a salmon hatchery. If you like suspension bridges, you could visit the startlingly expensive and crowded Capilano Suspension Bridge along with every other visitor to our city, or get in the car and go a bit east to Lynn Canyon Park, where there is a free and markedly less touristy version of the same thing, plus nicer walking trails. 

Friday 18 May 2012

Private Practice: Home / Work Transitions

The Friday series based on my book Private Practice Made Simple (available from and continues.
Noticing the end of the day.

This week we skip ahead in the book to maintaining the therapist's stability and health. There are many elements to this in the book, but on the blog I'll limit myself (for now at least) to the topics for which there is a handout or exercise form.

Keeping work life and home life separate is a problem common to many professions. The classic example  is police work: an officer who brings home the professional role and doesn't learn to turn it off is in deep trouble.

Therapists can be similar. The work we do is often emotionally difficult. Our clients are often going through profound trials, and it is the job of the therapist to join them in that journey and provide what help we can. It is all too easy to take the work home with us, think (or worry) about our clients endlessly, and have a negative impact on our own lives as a result.

To prevent this, it helps to create a boundary between our work and home selves. To this end, many of us develop a set of behavioural rituals to take on the mantle of therapist when we arrive in the morning, and take it off when we leave the clinic for home.

The Home to Work Transition

Many of us lead harried existences, so it is easy to find ourselves racing into the clinic, whipping off our coat, and running out to meet the first client of the day. This is a terrible practice, and will ultimately contribute to a sense of burnout.

Instead, we should punctuate the arrival at work with some specific behaviours that symbolize the transition. These can be purely ritualistic (such as meditating on the names of the people we will be seeing that day) or very practical (such as turning on the sound system in the waiting room).

Here are some of the home to work rituals that participants at past Private Practice Made Simple workshops have reported using:

  • Visiting a coffee shop and reading the newspaper en route to the office.
  • Hanging up the coat.
  • Sitting quietly at one's desk for several minutes doing deep breathing.
  • Checking all voicemails.
  • Tidying the waiting area and/or consulting room.
  • Meditating.
  • Making tea in the office.
  • Perusing non-work-related websites such as facebook.
  • Reading a favourite psychology-themed blog (I'm serious, they say this).

As part of the Private Practice Made Simple adjunct materials at, there is a brainstorming sheet to help you describe or develop your own rituals. Here's the link:

The Work to Home Transition

At the end of a long day it's tempting to just flee home and launch into the rest of life. But this can leave the emotions of our clinical work active in our minds. We can carry the urgency, sadness, or anxiety, or the analytical mindset, into our home life. It's best to punctuate the transition with some consciously-designed practices to set aside the clinical day and move into the non-clinical part of our lives.

Here are some of the work to home rituals that workshop participants have reported:

  • Cleaning one's desk so that everything is ready for the next day.
  • Sitting for a few minutes at the desk before getting up to go home.
  • Drive home, park, and sit in the car for 10 minutes before going into the house and having to talk to anyone.
  • Walk home, consciously looking at trees and plants along the way and allowing the mind to slow.
  • Changing one's clothes completely upon arriving home.
  • Playing with the cat (oddly enough, this is one of the most frequently reported activities).
  • Walking the dog.
  • Creating an image of the work of the day (or the clients seen) being placed inside a glass box for safekeeping.
  • Meditating for 15 minutes upon arrival home.
  • Having an agreement with spouse that for the first 15 minutes that one is home there is no conversation and no requests for decisions of any kind.

Here is the link to the related brainstorming sheet at

To new clinicians these rituals often sound artificial, forced, and of limited usefulness. There is limited intuitive appeal to the idea. But clinicians who make a point of punctuating their transitions tend to report a greater feeling of calm and relaxation, both at work and at home. The therapist and the nontherapist spouse/parent/friend/relaxer are two completely different people. It helps to have some time to make the change.

Even Superman marked the transition by spending time in a phone booth, after all.

*   *   *

Want more information on operating a private psychotherapy practice? 

Check out my book Private Practice Made Simple, available at bookstores 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 15 May 2012

Culture: The Passing of Great Pleasures

(With apologies: The Dismal Science is supposed to be Economics. But we all need the occasional break from psychology too. This is one of mine.)
Goodbye old friend.

Several years ago my favourite bookstore in Vancouver, Duthie’s, went out of business. It had been shrinking for some time, shedding outlets until a single one remained on West Fourth. Then it was gone.

Book Warehouse stepped into the pole position. And now it too is selling off its stock and will shortly be gone. This leaves a few small struggling independents and the book megastore chain Chapters/Indigo, which is slowly but steadily morphing into what appears to be a candle-and-knickknack store. Given that its US equivalent Borders is now gone, one wonders how long Chapters has.

As the tide has receded, the once also-ran outlets at airports have become some of the best bookshops – not because they have improved, but because they still exist.

Everyone has their own passions. Some, inexplicably, can spend years of their lives watching major league sports on television. For me, wandering through bookstores has been a mainstay. A lazy urban walk seems incomplete without a side trip into the stacks.

The feeling of loss would be more pure if I wasn’t complicit in the execution of my old friends. I too have succumbed to Amazon, and have felt the illicit joy of receiving one of their shipments. I try to buy at real bookshops when I can, but it’s a losing battle. As the stores shrink, it gets harder and harder to find anything that I want, and Amazon has it all.

I imagine that many of us secretly view shopping on Amazon as second- or third-best. What we really want is to be set loose in one of their cavernous book distribution centres with a bag of sandwiches. Or a sleeping bag.

I mentioned the passing of bookstores to a client a few weeks ago and he said “It’s the record stores I miss.” He’s right. They provided another great thing to do on an afternoon. The Canadian Mint apparently offers tours, but why bother? Every dollar is like every other. In a book or record store you have real wealth – every cover encloses a different world, and you can have any of them if you want it.

The other day I was shopping for a birthday present and thought I’d buy a recently-released CD. I wondered if this was a good idea – who buys CDs any more? But I thought it would be likely a farewell experience; perhaps the last CD I would ever buy.

Then I discovered the problem. Where would I find it? The main record store downtown just closed. I checked the website of the mall a few subway stops away. It no longer has a record store. Then I remembered the Best Buy a few blocks away. Sometime when I wasn’t paying attention they stopped selling CDs. I stopped into London Drugs, our local pharmacy-and-everything-else chain. The guy in electronics had his red-sticker gun out discounting the last of their stock.

If London Drugs doesn’t sell CDs, they effectively no longer exist.

A few years ago The Economist wrote about a focus group that EMI in Britain had run, asking youth about their listening habits. As thanks for participating, the company had laid out a table with CDs; people were welcome to take as many as they wanted. No one took any. That taught the company more than anything else: the clock was definitely ticking on that end of the business.

So no more bookstores. No more record shops. What next? A friend reports that he buys his clothes online, which is just fine with me; I’ve never liked clothing stores. With the advent of Kobos, Kindles, and iPads, books themselves may be endangered – the look, the feel, the smell. They would be deeply missed.

The trees are still there, mostly. The oceans, and a few of the fish. The mountains that never contained coal or copper. But in an age of wealth and supposed advance, it seems ironic that many of the greatest pleasures are being phased out. Or is that a sign of codger-hood approaching? “Why son, I remember when passenger trains …”

I like passenger trains. And books. And record stores. And the outdoors. As I write this it is sunny outside. Time to get out in it.

Friday 11 May 2012

Private Practice: Can you afford an assistant?

The Friday series based on my book Private Practice Made Simple (available from and continues, and we are in the midst of financial planning.
Spring in Vancouver.

When people first start a private practice they have plenty of time on their hands. The phone isn't exactly ringing off the hook, and the clients are few and far between.

This is fine. There's plenty to do at this stage anyway. Systems need to be set up. Forms need to be written. The website needs developing. A reputable printer needs to be found.

If all of these tasks get done, sooner or later the practice will begin to fill up. And sooner or later you will find yourself racing from client to photocopier to printer to office supply store, wondering why you ever thought private practice might be an enjoyable way to make a living.

But hey, can you really afford an assistant?

If you're thinking of a full-timer, no: you probably don't. But a part-time assistant can be an enormous boon, and although it will cost money, a good assistant will make you money in the long run.

This week's form is designed to show how. Here it is:

Let's lead you through the exercise, and work out an example as we go:

Step 1

How many hours of admin work does your practice generate in an average week? If you don't know, consider keeping a diary for a week - but be prepared for a shock when you discover just how much time you are spending on tasks for which you aren't paid. Example: let's guess 15 hours.

Step 2

Let's face it: You will never get rid of all the nonclinical work. Some things, like doing a final check before sending the taxes to your accountant, or the new pamphlet to the printer, you will have to do yourself. And sometimes a bit of admin work can make a nice break from the emotionally involved work of seeing clients. So estimate how many of the hours in Step 1 you will keep for yourself. Example: Let's say you keep 5 of the 15 hours.

Step 3

Subtract the hours in Step 2 from those in Step 1, and you have the number of hours of work you could cede to an assistant.  Example: 15 - 5 = 10 hours.

Step 4

Your assistant probably won't work as quickly as you. You understand the business a bit better (at least for now), and you are motivated to be efficient. As well, your assistant will get stuck and need to consult with you about some tasks. So take the hours in Step 3 and multiply them by 1.25 to get a rock-bottom estimate of the number of hours your admin work will take them, and by 1.75 to get a more generous (and realistic) estimate. Note that I'm not saying assistants are slow - I am routinely surprised at the efficiency with which our clinic assistants work. But I have a bias to underestimate things in the planning process, and when you first start hiring assistants your workplace will not be organized to maximize the gains from their talents. Example: 10 x 1.25 = 12.5, and 10 x 1.75 = 17.5 hours. 

Step 5

Estimate how much you will pay your assistant per hour. Example: Let's say $15.

Step 6

Now multiply the hourly rate in Step 5 by each of the two hours-of-work estimates that you came up with in Step 4. This is how much it will cost you to get an assistant to work those hours.  Note that this is a rough estimate, and doesn't include benefits that you might pay (unless you include them in the hourly rate when you do your estimates). Example: $15 x 12.5 hours = $187.50; $15 x 17.5 hours = $262.50.  

Step 7

Now divide the amounts in Step 6 by the hourly fee you charge clients. This gives you the number of extra hours that you would have to see clients in order to pay for your assistant.  Example: Let's say your hourly rate is $100. This means that if you saw about 2 extra clients a week, you could get an assistant to work for you for 12.5 hours; and that if you saw about 3 extra clients you could get 17.5 hours of assistant time.

In effect, seeing just one extra client per week would allow you to purchase several hours of an assistant's time. For most therapists, it translates to between 4 and 18 hours of assistant time for every hour of billable client time. You can see that if the administrative burden of your clinic is preventing you from seeing more clients, hiring an assistant may be a very good idea. On the other hand, if you are barely scraping by and the extra clients don't seem to be available, then hiring an assistant may not be such a good idea.

For more on the nuts and bolts of working with assistants, I will refer you to the Chapter 8 of Private Practice Made Simple. 

Next week:  We jump ahead to the forms from the chapter of Private Practice Made Simple on burnout - and how to prevent it.

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 8 May 2012

Less Conditional Positive Regard

Last week I pointed out that unconditional positive regard is a myth. Time to follow up.
Not sour grapes but sour cherries:
 Spring has arrived.

Unconditional positive regard was proposed as a therapeutic stance in which the role of the therapist is to create as broad and open a setting as possible so that clients can have the space to contemplate the unthinkable and truly explore themselves. If we think that the therapist will frown or pass out if we reveal our hidden urges, hostilities, or wishes, then we will be less eager to discuss them. But it is often within the parts of ourselves that we regard as unacceptable that we will find the capacity to change.

Somehow, like Atlantic salmon escaping from Pacific fish farms, unconditional positive regard got out of the therapeutic net and began contaminating the world beyond the clinic. As a result, thousands of people have embarked on a quest to receive unconditional positive regard from those around them, unaware that they are searching for a gryphon – a mythical beast.

Our emotional reactions are created as much by expectancy as by events. If we do not expect to lift off when we flap our arms, we will be unperturbed by our inability to fly unaided. If we believe that the light should change the moment we press the button, however, we will be frustrated by even a minor delay.

So believing that unconditional positive regard is out there wandering around, that other people get it all the time, and, further, that it is one’s right as a human being to receive from family, friends, and spouse, is a kind of poison. The fact that we never seem to get it feels less like the natural state of the world, and more like a judgment against us. We are inherently faulty, we are misfortunate in our choice of companions, and the world has treated us poorly.

If we can release this mistaken expectation and acknowledge the reality that we will never truly receive it, we can rest more easily. And we can notice and feel grateful for the positive regard that we do receive, particularly when it comes despite our faultiness, our lateness, our untidiness, or our hundreds of other quirks. Rather than not quite being good enough, we can see the acceptance of others as being a bonus, an unexpected but welcome boon, rather than as a pale reflection of the indulgence we wish we could get instead.

Where to from here?

It’s a constant disappointment to notice how often the spotlight comes back to ourselves, and our own responsibility for our lives. We cannot change others, and exhorting them to make their love for us more unconditional (so that we can stop worrying about their needs or feelings) tends to bring on precisely the rejection we hope to eradicate.

Instead it’s up to us to examine the path we build for the fellow travelers in our own lives. What do we expect of them? Do we carefully define all the acts, words, and emotions that they must exhibit in order to be worthy of us? Do we reduce their range to a narrow tightrope that we expect them to walk? Or do we strive to broaden the path for them? Do we widen the rope to a trail, the trail to a road, the road to an open field in which they can be whoever they are?

We may need to provide feedback now and then. The daughter who loves drawing at the breakfast table may need to be told to get ready for school. The new romantic partner may have to be informed of one’s expectations regarding fidelity. We will strive to hang onto our affection for the person beyond the behaviour, even when their actions are not particularly lovable. But we will also forgive ourselves for letting it go now and then, recognizing that if we fail to cultivate the extreme equanimity of a Buddha, this is no great surprise.

The feared result, of course, is chaos. If we have few expectations, much less demands, of others, won’t they take full advantage of us in every way possible? Will we not become their enabler, their “yes man”, their patsy?

No. Knowing their propensity for lateness, we will happily decline the suggestion to meet them on a rainy street corner after work. We will still point out the fact that the school bell rings at 9, or that we hope they can be present for our birthday party. But we will focus our affection on the person, not the behaviour, and attempt to create the widest highway for their actions that we can manage. It won’t be unconditional. Every highway has a shoulder, after all, and beyond that a ditch. But it will be the widest we can make it.

A friend from perhaps twenty years ago and far away characterized himself as an “extremely sensitive individual.” Not a bad thing, and there are several in my life today who would similarly describe themselves. Unlike these others, in his case it meant “prone to grossly overinterpret anything anyone does.” A moment’s lateness meant that others did not respect him; a failure to anticipate his dissatisfaction signaled unforgivable carelessness; a poorly worded phone message clearly spelled out a deeply hurtful insult. For others he not only demanded they walk a tightrope, he turned out the lights to see if they could find the rope in the dark.

Predictably, he was often angry at former friends, and doubly so given that they could seldom divine what he was upset about. Friendship with him was like walking in a minefield – you never knew when you might say a laden word and become the enemy. Recognizing that this self-protective behaviour no doubt came from a difficult history was helpful, in that it enabled friends to focus on the person behind the demands. And it was important to stop trying to walk the tightrope, as this only led to exhaustion.

Instead, you had to accept that at any moment you might be in the doghouse, and carry on with your life until he forgot, forgave, or explained what was bothering him. Had he been able to relax his expectations, he might have had more friends, and their pool of affection for him might have been deeper. Instead he was a peripheral figure to most – someone whose friendship you could lose without being crushed.

His regard for others was highly conditional. It was not my job to demand he be less so; instead it was up to me to broaden the highway I let him walk. Ultimately my own life changed and I moved several provinces away. But I still think of him, engaged in the search for unconditional positive regard, angry at not getting it, and imposing tight conditions on all others. It was the road to unhappiness. He was poisoned by a bad fish, a toxic idea.

Maybe all psychology should be done in closed containment pens. When that stuff gets out it can cause a lot of damage.

Friday 4 May 2012

Private Practice: Comparing Salary and Private Practice Income

The Friday series based on my book Private Practice Made Simple (available from Amazon USA here, and from Amazon Canada here) continues, and finally we’ve arrived at financial issues.

When I conduct workshops on this subject I usually start with a brainstorming session about the attractions and repulsions of private practice. People list a lot of attractions, but as the list lengthens we can all feel an elephant growing in the centre of the room.

And then eventually someone says it:  “Umm, it’s not the main thing, but, umm, make money?”

Of course. Businesses make money. Most clinicians are not independently wealthy, and they have families, homes, a mortgage, and other expenses. They cannot afford to run the practice for nothing or at a loss. Presumably they didn’t go into the therapy field in order to become millionaires – or if they did, they were harshly misguided. But yes, they want to earn a good income with their practice.

And just look at that hourly rate. In my home province of British Columbia, the recommended rate for private practice psychologists is $175 per hour. Compare that to the hourly rate for psychologists in instititutional settings, where it runs between $40 and $55 per hour.

My gosh, by opening a private practice you might be quadrupling your salary!

A lovely fantasy. But this is like saying “Buying a house would cost me $600,000 but the rent for one is just $1800.” The numbers are not comparable because they refer to completely different things.

What do you get paid for?

First, let’s consider when you might actually receive your hourly rate in institutional and private practice settings.

When I worked for the hospital, I was paid for 7.5 hours a day, regardless of what I did. I would be paid for seeing clients, just like in private practice. But I was also paid for sitting in committee meetings, consulting with the department secretary, preparing for sessions, writing notes, conducting research, designing information sheets, calling referral sources, and even wandering the hallway. To be sure, like most professionals I put in a lot of unpaid overtime. But I would be paid for 7.5 hours, even if I didn’t see a single client that day.

In private practice you do many of the same things, but you only get paid for the time you actually spend with clients (and, occasionally, writing a note on the client’s behalf to an insurer or lawyer). You still have to consult with colleagues, keep up to date on the research, design forms, write notes, prepare for sessions, call referral sources, and so on, but you don’t get paid anything for doing these things. Plus, there are many more things to do: interact with your landlord, arrange and troubleshoot computer and phone systems, manage the finances, plan the promotion of your clinic, and so on. All of these take time, and none of them pays a nickel.

So in private practice you actually get paid for many fewer activities than you would in a salaried position.

But it doesn’t stop there.

What does your fee go toward?

In an institutional setting, your pay is your pay. Some of it goes to income tax, some goes into your pension plan or other benefits, and most of it goes into your pocket.

In private practice, your pocket is the last place it goes. Before you pay yourself you must pay every expense the clinic incurs: the assistant’s pay, the lease, the furnishings, the phone, the computers, the test materials, the photocopying, the accountant, the stationery, the pamphlets, the ads, the insurance, the business license, and more. Once all of these are paid, you (and the income tax department) get the leftovers. If any.

Furthermore, most of your expenses are fixed: they are the same, regardless of the number of clients you see. If no one comes one week, you still have the same list of bills, but you have much less revenue with which to pay them.

What about benefits?

When I was budgeting for my program at a hospital, I couldn’t just write down the salary a new staff member would be paid. I had to add 17% to reflect the value of the additional benefits the person would receive: pension plan, extended health, short- and long-term disability insurance, and so on. Plus, the employee would be entitled to 10 statutory holidays per year plus several weeks of holidays – all of which would be paid the same amount as a regular workday.

In private practice all of these benefits disappear. You can buy extended health and disability insurance if you want it, but that will come out of your take-home pay. And although you will likely take most statutory holidays and some vacation time as well, you will get paid nothing for them.

So …

So the rates of pay for institutional work and private practice cannot be compared directly. In private practice you are paid for far fewer activities than in a salaried position, and that pay goes to many more things than in an institutional setting. Plus the invisible 17% over and above your salary vanishes.

The result is that some months, private practitioners may have no take-home pay whatsoever. Rather than being a “license to print money,” a private practice has to be carefully managed in order to preserve a fair proportion of the revenue for take home pay. This can be done, but not without careful planning and a stingy nature.

Next week: I’ll introduce perhaps the least appealing of the forms that accompany Private Practice Made Simple: The Private Practice Income Calculation form. Completing it may take two of the dullest hours of your life – but if you do, you will be ahead of the vast majority of private practitioners. You’ll have a sober assessment of the amount of money you need to make and the expenses your clinic will incur.

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

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Want more information on operating a private psychotherapy practice? 

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

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

Tuesday 1 May 2012

Unconditional Positive Regard: Therapy's Poison Pill for the Culture

Okay, so maybe there's one exception.

Carl Rogers was a great man and a brilliant therapist. Among all the talk of cognitive behaviour therapy and all the other “evidence based treatments” is an acknowledgement that most of the improvement typically seen in therapy can be readily attributed to the so-called “nonspecific factors”, of which the quality of the relationship between client and therapist is the greatest part. And Rogers was the king of process, to the exclusion of almost all technique. Rogers’ ideas influence what almost all clinicians regard as the foundation of all of their other work.

Then there is unconditional positive regard.

This is a therapeutic stance that the clinician is enjoined to adopt during the therapy session. Whatever the client says or does, it is the clinician’s job to maintain his or her seat as a clinician, to see that the client’s emotions and actions make some kind of sense if only we understand them well enough, and to sweep our own fragile egos out of the way as best we can.

So far so good. But unconditional positive regard somehow leaked out into the public consciousness and became an expectation of parents, spouses, friends, family members, and all who work with the public. Whatever a person does, they should be met with the warm solidity of a relationship that is supportive without any conditions whatsoever. Those who fail to provide this nurturing blanket are simply not living up to their responsibilities as humans in relationship.

There’s just one problem.

Unconditional positive regard is a myth.

It doesn’t exist, not even in therapists. It is a stance. A role. Not a reality.

The truth is, none of us are able to manage truly unconditional positive regard for anyone – not a customer, not a stressed-out spouse, not an innocent infant relentlessly throwing food on the floor, not a faultlessly dementing parent asking the same question again and again. Certainly not for a rebellious teenager in a rage about being insufficiently “validated.”

We might strive to maintain our equanimity, to remind ourselves that the infant is learning about cause and effect, the parent honestly does not recall asking the question four times in a row, the adolescent exists within a toxic hormonal soup of confusion and fear. But we do not entirely succeed and we never will.

Like emulating the Buddha, or Christ, or the religious leader of your choice, unconditional positive regard is an admirable goal. But if we actually expect it of ourselves, or believe that others have easily mastered what seems so impossible for us, then it becomes a tool for guilt.

And because the term has been bandied about so much in the public discourse, people have naturally come to expect unconditional positive regard from others. From their parents. From their siblings. From their friends. From their (God help us) spouses. And it has come full circle. Clients now arrive in therapists’ offices describing the trauma of not having been loved unconditionally by others.

Perhaps it is up to therapists, who carelessly unleashed this beast upon the world, to speak up and slay it. We need to remind the world of the truth.

There is no unconditional positive regard. You will never fully succeed in providing this, and you will never receive it. From anyone. And you shouldn’t. Feedback from others is part of what helps us to modulate our own behaviour. Positive regard from others, without any conditions whatsoever, is the desire of our own narcissism, not of our inner adult. If we snap at our spouses, put them down when they speak, ignore their achievements, rant at will, and generally misbehave, we cannot expect that their fondness for us will remain undiminished and unflickering.

Even new parents do not feel unconditional positive regard for their offspring. They are usually able to tolerate much more than they would of another adult, or perhaps of someone else’s child, but they will, inevitably, have moments of wishing they could just be alone for ten minutes, of thinking that perhaps they would have been better childless.

If we, or our clients, are searching for that all-forgiving breast, that provider of unwavering support no matter what we do, the mission of adulthood is to accept that we will not find it, not to carry out the search with an air of firm entitlement. Because we are not entitled to unconditional positive regard. And if you don’t believe that, then believe this: Even if you are entitled to it, you will never find it. If you think you have: You’re kidding yourself.

Tolerance, kindness, understanding, and, yes, unconditional positive regard are admirable aspirations.  But that last is just that: An aspiration. Not a reality. It takes time, but we can eventually get used to it.

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