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Tuesday 28 August 2012

Practice: On Inequity in the Therapeutic Relationship

Even the presenter can be fired.

The relationship between client and therapist is inherently unequal: The client is more important than the therapist.

The client is the employer. The therapist is hired by the client to perform a task, much as the client might hire a masseur, a bookkeeper, or a cab driver. The client holds the ultimate power in the relationship: the power not to show up, to leave at any point during any session, the power to complain to the therapist’s governing body.

The therapist has a job to do, within a strictly defined role.  The client’s role is much broader and permissive. The client’s needs are more important than those of the therapist, at least for the hour of therapy.

I made this point at a workshop on practice recently and got some raised eyebrows. People were accustomed to seeing the problem the other way around: as one in which the client, experiencing an unmanageable problem, goes to the capable expert and receives a gift of insight or comfort. The therapist is obviously the powerful one, not the client.

But look again: One person is paying (or they are securing the funds to pay, either through insurance or from another third party). The other is paid. Traditionally, the person who pays the salary is the boss. In effect, the therapist is paid to be the less important person in the room.

Therapists sometimes forget this. I see many clients who report that previous clinicians talked about their own issues a great deal of the time. “We spent more time talking about his problems than mine.”

There is sometimes a justification for shifting clients to the helper role. It enables them to see problems from a different perspective, and proves that they have resources to offer rather than just needs to fill. But the agenda should always be to aid the client, not to serve the therapist. If clients pay for a session and we waste part of it talking about our own issues we are essentially stealing from the client. We deserve to be fired.

Some therapists don’t like the idea of being the employee, even though they are. “It’s my job to bring up uncomfortable issues, and to confront the client when necessary.” Yes. Just like a good accountant.

People fear that if they see themselves as employees they will have no power at all. But employees have rights too. They can quit, they can talk back to the boss, they can be assertive about what happens and what duties they are assigned.

The objection reminds me of an observation that often comes up in assertiveness training workshops. When I get to the part about assertiveness with one’s employer, people often object that they can’t impose boundaries with an employer or they will be fired. But of course every employee is assertive at times; it is their job to be. “I can’t stay later tonight; I have to pick the kids up.” “Which of these tasks is higher priority?" “Let me know how this draft looks, then I’ll clean it up.” A completely passive employee is not an asset to an organization. True, the employer can always fire the employee; if they have justification then that is their right. But employees can decide whether an issue is important enough to run that risk.

What if our clients fire us? The question raises the obvious reply. Every therapist will be fired – or laid off – by a great number of their clients. They seldom do this in the operatic rage that the word “Fired” sometimes evokes – though we will all live through these terminations too. More often they will simply not return to our little shop to purchase additional sessions, or they will thank us for what we have provided and indicate that they don’t need us any more.

Put like this it becomes obvious that the whole point of therapy, in most instances, is to be let go by our client.

Rather than resisting reality, we need to embrace it. Yes, we are less important during that hour the client is in the room. Our problems at home, our financial issues, our physical discomforts – they don’t really matter that much while the client is paying us. The masseur does not ask the client to rub his aching shoulder, nor should the therapist impose her issues on the client unnecessarily.

We are the ultimate part-time workers. If we see 25 clients a week, we have 25 part-time jobs. We may be laid off from any of them at any time, and we will replace them by applying for other jobs or hoping new customers call us up. We cannot fear being let go. Being let go is precisely the point of the job. Nor can we deny our status as servants. The task is to be the best servant we can be.

A friend of mine, whose business is helping organizations with their branding, has a card that identifies his profession as “Consultant Storyteller.”  Perhaps ours should read “Life Janitor for Hire”.

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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 21 August 2012

Practice: On Overselling Psychotherapy

Not quite enough, unfortunately.

Like any professional group, psychotherapists have wanted to have their work appreciated and acknowledged within the larger community. Part of this motivation is financial: without public awareness of what we have to offer, we will have no clients and quickly go bankrupt. Part of it is altruistic: we cannot help those who do not come to see us.

But it isn’t enough just to say “I’m here.” We have to say what we can do, what the likely benefits are, and how much it will cost. And suddenly the door opens to a series of cognitive biases and self-serving statements that can distort the message.

The marketplace wants to know that our product works, and that it is worth the price tag. There are two ways to make this balancing act seem to come out in our favour:

  1. Overstate the likely benefits, perhaps by guaranteeing results (which would be great and appropriate if we could actually do this, but we can’t) or inflating expectations.
  2. Underestimate costs, by providing cost estimates based on rapid responders rather than typical cases, and by playing a psychotherapeutic variant of Name That Tune (“I can cure that problem in just X sessions”).

Both of these problems are widespread in the field. We regularly hear about revolutionary new treatments that promise enormous benefits to every client, but that never seem to live up to the hype. The eventual effect is a justified skepticism among referral sources, particularly when the next psychological panacea comes along. The attempt to raise the profile and prestige of the field has the unintended opposite effect.

And we ourselves can collude with hopeful referrers/funders by underestimating the number of sessions that will be necessary for a prospective referral. We want to have a reputation for quick, no-nonsense work (no lolling about on couches for decades with us!), we genuinely hope to be rapidly effective, and prospective cases almost always sound more straightforward than they turn out to be. The referrer wants to minimize costs and speed up the client’s recovery. Both parties are motivated to arrive at an unrealistically brief estimate of the time therapy will take.

The distorting effect can gradually take on ludicrous proportions, and many referrers now reside permanently in Fantasyland. I routinely get phone calls from insurers calling about treatment-resistant claimants who have been off work three years or more, who have complicated and ongoing presentations (with comorbidities ranging from addiction to cancer), and inquiring whether I might take them on for, say, five sessions?

For years I didn’t quite know how to respond to these requests, but in retrospect the answer is simple and obvious, and it is the one I now employ. “No, thank you.” It is inappropriate to establish a therapeutic relationship with a client that will be severed prematurely.

How else can we overcome the hopeful bias in psychotherapy referrals?

  1. Face the fear that referrals will dry up, and base your initial estimate of the number of sessions required on a cold-eyed assessment of the genuine average number of meetings for cases a bit more complex than the one on offer (given that this one will inevitably turn out to be more complex anyway).  
  2. We should refrain from statements about our effectiveness with clients we have never met. Even if we are very enthusiastic about our methods, we should be circumspect about the likelihood of improvement. “Yes, this is found to be effective with some cases, but I will have to learn much more about the client’s situation…”
  3. Hide your enthusiasm under a bushel. Let your results sell your practice, not your promises.
  4. Aim to come in beneath your estimated number of sessions, rather than trying to “make a good start” and then hoping for extensions.

And, of course:

5. Just say no. “I would be delighted to be able to get this person back to work in three weeks, but I’m afraid I’m not willing to take on the case without a commitment for more time.”

What if honesty and humility mean that we don’t get enough referrals? Well: that's life.

*   *   *

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 14 August 2012

Resources: A Depression Program in Farsi

The new Farsi-language edition.

Today I'm announcing an exciting development, long in the making.  The Changeways Core Program is now available in Farsi. And we are making it available free of charge to appropriate healthcare professionals.


Changeways Clinic began its life at UBC Hospital in Vancouver as a post-hospitalization group therapy program for clients suffering from major depression. We developed The Core Program, a cognitive behavioural therapy protocol for running these groups. This includes a manual for clients and another for therapists running the program.

This program was remarkably successful, and we have updated the program repeatedly to incorporate client and clinician feedback and new research. (We call the current version the "3rd Edition" but the first few versions weren't numbered - it's probably actually the 6th Edition.) The program is in use across Canada, and has been implemented in the USA, the United Kingdom, Hong Kong, and Australia as well.

The problem, of course, is that not everyone is able to read the English language manual. Canada is a land of newcomers, and some would benefit more from having the materials in their own language. But  translations are notoriously expensive, and so we have been restricted in our ability to provide multilingual editions.

The Farsi Project

Enter Goli Shifteh, a Cross Cultural Counselor working in the Greater Vancouver area with the Farsi-speaking population. She attended the Changeways Core Program training and began offering the program. She was gratified with the results, and struck by the parallels between cognitive behaviour therapy and the writings of the great 13th century Persian poet Rumi.

She embarked on a difficult and exhaustive project to translate the entire Participant Manual into Farsi, with the considerable aid of her friends and colleagues:

Felora Farahani
Solat Toosi
Mahtab Shariatmadari
Behsheed Darvish

The manual is not simply a word for word translation, but also a cultural translation, expressing the concepts in a way that is designed to be most accessible to Farsi-speaking populations. In addition, the layout and cover design were substantially reworked. The new design is actually considerably more elegant and beautiful than the English version.

The project is now complete. Now: What to do with it?


The original intent was to create an edition to accompany groups based on the program that were being offered for the large Farsi-speaking community in Vancouver.

Goli and her team pointed out the obvious:  there are many other communities with large Farsi-speaking populations all over the world, and the team wished to make the work more widely available. But how should we do this? If we make up physical copies and ship them from our offices like we do with our other products, we create a financial barrier. If we charge for the electronic version we do likewise.

In light of the generosity of Goli and her team, we have opted to go another route. We are making the Farsi Participant Manual available free of charge to universities, physicians, and mental health professionals in a pdf format.

One option was to simply post the pdf on the Changeways Clinic website, but we wanted to try to get the manual into the hands of responsible trained professionals. Consequently, we've decided to offer the manual upon email request.

To get a copy

Simply email us at products (at) State your profession, country, and a brief reason for wishing a copy of the program, and we will reply with pdf versions of the client manual and related forms for your use and for reproduction for your own clients.

Once you have the manual, you may make as many copies for as many of your own clients as you wish. We do not require that your service be free of charge or covered by a government-funded health program. Many users of the Core Program are in private practice.

What if I don't speak (or read) Farsi?

The translation includes bilingual English/Farsi headings. If you have an English-language copy of the manual, you can easily tell what you are handing to the client. We imagine that many users of the translation will be English-speaking clinicians already familiar with the Core Program, who wish to provide a translated version for their Farsi-speaking clients.

The fine print 

The Clinician Guide for the program has not been translated, because it is considerably longer than the Participant Manual and translating it would have been an enormous job. This English-language guide is available from our offices as well, but regrettably we do have to charge for it. We have created an electronic pdf version available upon request. This allows us to supply it at lower cost than the hard-copy version. If you don't have a copy, simply inquire about this when you write us.

The pdf translation (and any documents purchased or received from Changeways Clinic) is provided specifically to the professional requesting it. It may not be forwarded on to others without the written permission of Changeways Clinic, nor posted in any way on the internet.

Thursday 9 August 2012

Sexual Orientation: A Window on One Family

At Changeways Clinic, we see people from all walks of life with a wide variety of concerns. Among these are individuals dealing with internalized negativity arising from their past treatment as gay, lesbian, bisexual, or transgendered people.

I also offer training programs on "Sexual Orientation Issues in Healthcare" (and "in Education", "in Foster Families", "in the Workplace" and so on). During these, people sometimes wonder if this is really such a big issue anymore. With antidiscrimination legislation, same-sex marriage, and all of the other developments in Canadian society in the past 20 years, does anyone still have a problem with this?

Well, yes. Recently a gay man in the US posted an image of a letter he received after coming out to his father. You can view the online image here.

Do such things happen in Canada? Yes, they do, and I've seen the results in my office. I've also known Canadians to express the idea that if their son or daughter came out as gay, this is precisely what they would do.

My own perspective is that if a person is not prepared to accept differences in their children, then they are not ready to have them. But maybe that's just me.

Tuesday 7 August 2012

Private Practice: Having Separate and Blended Business Identities

Way forward - or dead end?

This week: A reply to an email I recently received about professional identity. Here’s the message:

I am in private practice and I am situated at a clinic with two other practitioners. They/the clinic has a brand and I have my own brand and somehow we are trying to establish a "we." It’s like blending a family.  

We do want to work together, but I'm finding it hard to keep my identity separate without the other therapists feeling shunned. I would appreciate a blog post on working together with separate identities and practices.

This is a tricky issue but one that frequently arises when clinicians join forces. Essentially, this writer had a pre-existing clinical service, with name and website. He then joined up with two other clinicians and together they formed a new business with a new name and website. The question is whether he really wants to form a new family, or whether he just wants to rent a room from someone else’s family.

His hesitation:  If he stops doing business under the old name and cancels the website, he loses all of the positive regard and name recognition that took him several years to develop.

But if he keeps doing business under his old name, he fears that his colleagues may feel excluded and question his commitment to the new venture. Also, it may be confusing for referral sources.

The first issue is to figure out whether there really are two different businesses here. Does the author work fully in the space with the other two? Or does he work with them part-time and maintain another office for the rest of his work?

If he has two separate businesses, there is no real issue. He should maintain “John Smith Counseling” (not the real name) with an address at 123 Oak Street. He should also appear on the joint service website, which we’ll call “Sunrise Therapy.” His description on John Smith’s website should mention “I also contribute to the work of Sunrise Therapy (webaddress).” And his personal bio on the Sunrise site could say (if his colleagues agree – and they are entitled to veto this) “I also provide services on the west side of the city through my own practice (see johnsmithwebaddress).”

Let’s imagine, however, that “John” has moved in with “Ann” and “Rob” full time and does not maintain separate office space. In this case, he needs to decide whether he will maintain two streams of clients – those referred to “Sunrise” and those referred to “John Smith.” Doing this, in my view, leads to unnecessary confusion. He really is functioning as part of a joint practice, and I would recommend that all clients be considered clients of “Sunrise”.

What about finances? This group has decided on a fee sharing arrangement. Clients make payments to the clinic, then a percentage of these is retained by the clinic to pay for rent, assistant, phones, and so on. All clients seen at “Sunrise” use the space, say hello to the assistant, and so on, and so all billing should be the same, regardless of whether the client arrived there via a referral to “someone at Sunrise” or to “John Smith”.

On another note, this questioner mentions that part of the point of getting together with the others was to get more referrals – but it turns out that the majority of his referrals come directly to him, and that he has had very few referrals through the joint venture. My query here would be: What does your percentage pay for? It may seem as though John is getting nothing, but the majority of the Sunrise “cut” is likely to be paying for rent, assistant, stationery, phones, and so on. Only a small proportion of that percentage will be going to promotions, and it will take time for the new venture to build up a name and clientele.

Should John retain his personal website? Yes. Here he can add whatever content he likes, without having to get it vetted by his colleagues and without running the risk of outshining them with his volume of contributions. But now that he is part of “Sunrise” he should tone down his own business identity. His header should now say “John Smith, (degree)” rather than “John Smith Counseling,” which sounds like a company name. His company is now Sunrise, so he should avoid confusing the issue. Should he eventually leave Sunrise, he can always change his own header back.

In his website content, he should now clearly state that he offers clinical services through “Sunrise Therapy,” and he should provide numerous links throughout his site with the Sunrise site. On the Sunrise site he will presumably have a personal bio, and this should include something like “For more information about me, see my personal website here (link).”

What if John and Sunrise have both incorporated? I would suggest that he consult with an accountant about this. If there are no objections from the accountant, however, I would suggest that all clients seen on Sunrise’s premises should be billed through the Sunrise corporation. At the end of the month, Sunrise should issue a cheque to John. The accountant can comment on whether it would be better for the cheque to be made out to John Smith or to John Smith Counseling Inc. It may be best to let John Smith Counseling Inc. become inactive, and just use Sunrise Inc as the business.

All this sounds fine, but what if John is really a bit iffy about Ann and Rob, and isn’t completely sure he wants to be tied to them? In this case, he could redefine the relationship as one in which John Smith Counseling Inc simply rents space from Sunrise, and keeps going as an independent entity.

In this case, however, John would not be entitled to be listed on the Sunrise website. He is only a tenant renting the space that Sunrise cannot use; he is not a part of Sunrise itself. On his own website he would list his street address but would not include the Sunrise name. He would be entitled to request that the door plate and building directory include both businesses for the suite that they occupy.  He would also request that clients make out cheques to “John Smith Counseling” and would provide them upon intake with a notice that he is not affiliated with Sunrise except for sharing office space.

And what if the three participants have wildly different areas of expertise? In this case, it will be difficult for Sunrise to develop any kind of cohesive identity. It would be better to have different businesses with different identities – like conglomerates do when they retain different brand names for their pasta and automotive divisions.

Also, what if one or more of the trio also has a side business in something else? Perhaps John does clinical work, which is the main Sunrise business, but also has a sideline in professional training workshops. He could choose to keep this aspect of his work separate from Sunrise and bill it through his own business – particularly if he does not use any of the Sunrise facilities or resources for that part of his work.

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Got a question about psychology, therapy, or practice that you’d like to see addressed on this blog?  Drop me a line at: paterson (at)

*   *   *

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.