Instructors nor colleagues ever spoke to me . . . in a classroom, as a supervisor, one on one, or even in a text about therapists’  mishaps and what to do about them.  No one ever spoke about them being opportunities for learning and growth.

Instead, when errors were made, I was taught that they were embarrassments, shameful, and dangerous for any mental health professional. They were things to be talked about behind closed doors with an attorney or forgotten about and not to be discussed with clients and colleagues and under certain circumstances maybe even lied about . . . .

Then, several years back, I attended a workshop at an annual conference for the Association of Women in Psychology. The workshop focused on discussing those very things that I was taught should not be discussed . . . clinical misjudgments, errors in thinking, and client-related mishaps.  It was, for me, a practice-altering experience . . . to be in the presence of counselors, psychologists, and social workers candidly speaking about their professional and sometimes costly gaffs.  It was also a very healing experience . . . to learn that other professionals (many more experienced than me and a few quite well-known) also made mistakes . . . as we grappled together with how to responsibly and ethically admit our mistakes, make amends for our transgressions, and learn from our own misjudgments.

Ours is not the only profession that struggles with how to undo any damage that we may have caused.  Physicians are also taught to play it safe when errors are made and keep their gaffs to themselves.  However, research is increasingly showing that it is often in a client’s  best interest for medical professionals to ‘fess up and admit mistakes made.  Check out When Doctors Admit Their Mistakes and also Risk Management: Extreme Honesty May Be the Best Policy.

Here’s my point . . . . I am a better therapist when I am able and willing to tell the truth . . . the whole truth to myself, to my colleagues and to my clients.  I am a better person when I am able to tell the truth.   And, my clients deserve the best therapist that I can be . . . 100% of the time.  Until the mental health professions are able to create a culture and space in which we can take responsibility for and  learn from our own mistakes, we are not the professionals that our clients deserve.

Surely I’m not a lone voice for shedding the embarrassment over clinical misjudgment and shelving the self-imposed shame of making errors with clients.  When well-trained therapists with good intentions make choices that, in hindsight, are not the most helpful ones to our clients,  I believe it should be the standard of our professions to create a space for owning our mistakes and making amends to our clients with dignity and heartfelt regrets.

It’s time for our professional associations and our graduate institutions of learning to model healthy and appropriate ways to create spaces for dialogue and healing and forgiveness when therapists err.  It’s the right thing to do . . . for our clients, for ourselves, and for our profession. If you, like me, have ever made a mistake and felt the tug to do the right thing and yet have also felt the fear of doing the right thing, today is a good day to start the dialogue.

Tags: Choice, Continuous Learning, Dialogue, Ethics, Self Care, Standard of Care, Truth

“Fat . . . Borderline . . . Retard . . . .”

It is always shocking to me how easy it is for medical and mental health professionals to reduce their clients to less-than-desirable and less-than-accurate one dimensional labels behind closed doors.  I’ve heard excuses that range from minimizing (“oh-he-knows-I-don’t-mean-it”) to intellectualizing (“it’s just a short-hand way to refer efficiently to a particular group of symptoms).

Whatever the reason . . . ignorance, mean-spiritedness, or just plain old laziness . . . if you’ve been tempted to mock a client or speak derisively about a client behind closed doors, you might want to check out Tara Parker-Pope’s post on professionals mocking their clients. It’s one of those things that wasn’t discussed in my ethics classes  but probably should have been.  After all, if we are reducing our clients and all of their complexities to a simple one word label, it’s likely we don’t have our client’s best interest at heart.

Tags: Boundaries, Ethics, Judgment

Dr. Keely Kolmes of San Francisco continues  to be a valuable resource for therapists engaging in social media.  Check out her blog post dated August 5th in which she exposes the privacy concerns  caused by Psychology Today’s newly implemented call tracking.

I just changed the setting on my own listing to decline call tracking and, I’m encouraging you to do the same.

[Thanks, Keely, for continuing to keep us informed on these matters!]

Tags: Privacy, Social Media, Telephone

Although I’m not a fan of  “manualized” treatment of clients, according to professional standards of care and the American Counseling Association’s Code of Ethics (Section C on Professional Responsibility), a professional counselor has a “responsibility to engage in counseling practices that are based on rigorous research methodologies.”

Here are some online resources to help you quickly identify researched based methodologies:

• Society for Clinical Psychology’s Website on Research-Supported Psychological Treatments

• Evidence-Based Behavioral Practices

• National Institute for Health and Clinical Excellence

• SAMHSA’s National Registry of Evidence-based Programs and Practices
  

• Association for Behavioral and Cognitive Therapies
  

And, if you happen to know of other online resources for evidence-based treatment in counseling, I hope you will share them below!

Tags: Ethics, Website

Now that you know that you need to engage in clinical consultation on a regular basis and you know how to put your own peer consultation group together, do you know what is supposed to happen during your meeting with your consultation group? You actually have lots of options but my point is that you need to plan ahead of time how you want your meetings to proceed.  Otherwise, it can end up looking more like a clinical coffee klatch than clinical consultation.

Start with the end in mind. Consider what you want to accomplish at your meetings.  Do you want feedback from your peers?  Do you want to learn about a  particular theory or methodology?  Do you want to formally staff cases?  Are you looking for resources for a particular client?  All of these are possible but you’ll need to structure your meetings accordingly.

It’s about you and your performance. Clinical consultation is an opportunity for you to seek and receive feedback about your performance from other professionals that you respect.  Give some thought to how you (and the others in your group) want to receive that feedback.  Is the culture of your consultation group such that unsolicited feedback is acceptable?  Do you need to be invited to provide difficult feedback before you actually do so?  Some might say that by virtue of simply being in a consultation group, that all feedback is welcome.  However, unless stated up front (and again as new professionals join you), you will need to state it if that is the case.  This is especially important for those who are not familiar with the use of consultation groups.

Present clinical cases professionally. If you are going to focus on formally staffing cases (and even if you are not), you may find it helpful to agree upon a structure for presenting your cases to your group.  There is no one “right” way but agreeing ahead of time will make sure everyone is covering the basics.

Share the time. One of the decisions to be made is how will you share the time you have allotted for your consultation group. Does everyone get a chance to share?  Or, are a select few participants assigned to present cases?  You don’t want to simply “wing it” only to discover that no one or everyone wants to talk.

Decide on the structure of your meetings. Do you want to allow time for a “check in?”  Do you want to jump right in to clinical discussion?  Do you want time to to share resources and events?  By deciding and agreeing on this ahead of time, you will avoid your meeting turning into a social hour.

These are some of the considerations we took into account while creating our consultation group.    Can you think of other things that might be helpful?

Tags: Consultation, Ethics

I’ve told you that every mental health professional needs regular consultation and I’ve told you about the benefits of peer consultation groups.  Today I’m going to tell you how to put together a peer consultation group that ROCKS! Here are some things for you to consider as you put your own peer consultation group together.

• Mix it up.  Diversity in the composition of your consultation group matters.  It keep things interesting and increases the likelihood that biases are not overlooked. Those differences can help you stretch beyond your usual thinking and outside of your typical comfort zone.
• Consider safety.  You are going to be talking about your strengths and your weaknesses in a consultation group.  Although the discussion will most often be structured around your clients, the purpose of your consultation group is to expand and support your choices and your behaviors in therapy.  As such, you are going to have your own blind spots and vulnerabilities pointed out and talked about.  It’s important to choose colleagues that you can learn to trust.
• Similarity matters.  If the individuals in your group are too different from you in their disciplines, ethics, or processes, you may find that there is no sense of safety in which to discuss your own vulnerabilities.
• Expertise matters, too.  Look for colleagues that know more than you in at least one or two areas so that you can trust their feedback when you need it.
• Plan on mentoring. Including colleagues who know less than you in a particular area allows you an opportunity to mentor others in the field.  Take advantage the mentoring that you can provide and take advantage of the mentoring that you can receive!
• Size of group. Just like in group therapy, I think 7-9 is optimal.  This affords for someone to miss a group and you still have a group.  And, it’s not so many that you get overlooked in the group.
• Stable composition. A consultation group functions best when the composition remains stable.  In my current group, we must unanimously vote someone in  before they can join us.
• Frequency of meetings. I prefer peer consultation groups that meet on a regular schedule.  Mine meets monthly.  Of course, we are free to consult by phone in between our regularly scheduled meetings.
• Attendance. Sketchy attendance at peer consultation groups can sabotage your group.  When forming your consultation group, set the expectation for a commitment to attend each month.  Obviously exceptions will crop up in anyone’s schedule.  However, consistent attendance and full participation will go a long way toward building trust and confidence in your group.

So now that you know what I consider to be important when putting your consultation group together, drop me a note below and tell me about yours.  Did I miss any important elements?  Is yours decidedly different?

Tags: Consultation, Diversity, Ethics, Expertise, Mentor

Every mental health professional needs consultation on a regular basis.  I wrote about that in my last post.  If you work in an agency or organization, it’s likely that consultation is built into the system.  However, if you have ventured out into private practice, you have to work a little harder to get your consultation needs met.

Many therapists choose to pay an individual counselor for their clinical consultation on a regular basis.  If that is what you prefer, then you can expect to pay whatever that therapist’s usual and customary hourly fee is for his / her consulting and therapeutic services.

However, here are nine benefits to creating a peer consultation group to meet your consultation needs:

1. As a solo practitioner, you remain isolated most of the day except for seeing your clients.  A peer consultation group allows you to meet some of your basic social needs.
2. It also exposes you to new / different ideas, perspectives, and energies.
3. It allows you to learn about other therapists’ business and clinical practices.
4. It may give you a broader range of professionals to refer to.
5. It exposes you to more professionals who may refer to you.
6. It exposes you indirectly to more resources in your community.
7. It can serve as a knowledge bank for clinical issues that you are not familiar with.
8. It can serve as a check point for potential ethical issues.
9. It’s free!

Have I convinced you yet of the huge benefits to participating in a peer consultation group?  In my next post, I’ll tell you How to Create a Peer Consultation Group that ROCKS!

Tags: Consultation, Ethics, Network

Back in the Day . . . .

When I was in graduate school, no one talked about the need for a professional counselor to participate in ongoing consultation post-graduation.  Instead, as I remember, we were taught that ethical therapists seek consultation when they do not know how to proceed with a particular client.  Nothing was said about seeking ongoing regular consultation at all!

The New Standard of Practice

However, times have changed and these days regular clinical consultation is increasingly considered the minimum standard of practice. Unless you are under clinical supervision (which is different than clinical consultation), every practicing mental health professional should either pay for regular i.e. ongoing individual clinical consultation or be involved in a peer consultation group.

What Consultation Can Look Like

Thankfully, I had access to clinical consultation for most of the two decades that I have been in mental health.  However, what that has looked like has varied considerably. . .

• One on one clinical consultation . . . .
• Agency-required “staffings” . . . .
• Treatment team meetings in a psychiatric hospital . . . .
• Small-group consultations that were spontaneous in format and content . . . .
• Thematically-focused peer consultation groups (where I learned how to apply solution-focused brief therapies and, in another one, clinical hypnosis) . . . .
• And, for the last two years, I have been attending a monthly peer consultation group with 6  other therapists. You can check them out here: 
  • Valerie Varan, MS, LPC,
  • Amy Maddox, MAEd., LPC,
  • Leslie Vogt, MA,
  • John Harder, LCSW, ACSW,
  • Julie Uhernik, RN, LPC, and
  • Donna Schwartz, MA, CACIII.

Peer Consultation for Tamara

A peer consultation group can look and function in a lot of different ways. My current group is a really interesting mix of backgrounds.  In addition to the varied disciplines that you can deduce from the credentials above, one of us is child-focused, one is addiction-focused, three are heavily trained in energy medicine (and the rest of us are interested and learning as we can), one works with equine therapy, one is heavily trained in Western medicine, and I practice with a dual emphasis on systemic and depth psychology.

Still not sure that you need regular, professional consultation?  In my next post, I’ll talk to you about the benefits of peer consultation groups.

Tags: Consultation, Ethics

If you are a mental health professional (or an allied health professiona) with an online presence, then you know how critical it is that you control your online identity.  It’s not a matter of simply slapping up a website or blog.  You need to stay on top of how you name is being used and who else might be using it.

Sree Sreenivasan has written an informative post at DNAinfo entitled Identity in the Age of Facebook.  In her post, she identifies at least four things you need to do to maximize your control over your online identity.  Take a look and let me know what you did with the suggestions she provided.

Tags: Professional Image, Security

Every responsible adult needs a personal will and every responsible psychotherapist in private practice also needs a professional will.  Ken Pope, Ph.D. has posted on his website a chapter (from a book he has co-authored with Melba Vasquez, Ph.D.) entitled Therapist’s Guide to Preparing a Professional Will.

You may not like to think about the many ways that you can  end up unable to take care of your professional responsibilities but ethically, you are still required to do just that.  Take a look at Ken and Melba’s suggestions for how to get your professional will in order.

Do you already have a professional will?  Is there something that you can add to these suggestions?

Tags: Ethics, Professional Will

The CBS Evening News posted an article by Armen Keteyian that states . . .

Nearly every digital copier built since 2002 contains a hard drive – like the one on your personal computer – storing an image of every document copied, scanned, or emailed by the machine.”

Read this article before you dispose of your old photocopier.  Your clients’ privacy, your privacy, and your license depend on it.

Tags: Ethics, Security

Miles Halvorson of Fargo, North Dakota  asks,

Is it possible for a psychotherapist to start a private practice out of one’s home, rather than rent office space? What are the drawbacks and limitations?”

Hi, Miles!  Thanks for writing.  You ask a really good question.  The short answer is “Yes, it’s possible” but the longer answer is “. . . but I highly advise against it until you have considerable and varied experience behind you.”  Here’s some questions for you to consider when deciding whether or not to work from home:

Do you have a separate entrance to a professional and private home office and bathroom? You, your family, and your clients deserve a professional and private space in which to do your clinical work.

Where will clients wait to see you? Do you have a waiting room?  In their car?  On your front porch?  Will they have privacy from your neighbors while they wait?

How will you deal with door-to-door salesmen, postal workers and other deliveries that show up while you are in session? Those interruptions actually happen all too often unless you take steps to prevent them.

What plans do you have for dealing with threats or violence? Your unhappy clients, their unhappy spouses, and their unhappy friends can show up.  You need to be prepared with a way to keep everybody safe.

How will you handle clients who have lousy boundaries? Clients will call at 2 AM and they will show up without appointments and they may wander through your home or refuse to leave when they are upset.

How will you handle clients (or wanna-be clients) who decide to stalk you? And, how do you explain to your family and neighbors without violating confidentiality.  (Yes, this really does happen.)

How do you protect your non-work time when you are at home 24-7? Boundaries tend to come with experience  – lots of experience.

How do you protect your client records and your workspace from prying eyes? Will your office be off-limits to guests and other family members?  Even when there are sleepovers and you are needing the extra space?

Are you willing to put in phone lines and designate a computer solely to your work? You can’t expect to appear professional if your phone is answered by a 10 year old or by your partner.  And, neither can you share your computer with others if it has confidential information on it.

What are the tax implications? Yes, there are some financial benefits but there are also some financial costs to officing at home.

Here’s the bottom line . . . . Most clients that seek psychotherapy have a trauma history and most clients with trauma histories struggle with boundaries.  Until you have impeccable personal and professional boundaries of your own and are experienced enough to effectively manage your client’s boundary issues, I would advise you against hanging out your shingle on your own front door.

Related Post:  7 More Considerations for Working Out of Your Home

Tags: Boundaries, Location, Office, Safety

Are you a psychotherapist who uses Facebook and Twitter?  Do you blog or engage in other forms of social media?  If so, you need to consider the sticky situations that you may stumble into without any ill intent.  Here is one article by Dana Scarton in the Washington Post that highlights examples of what I’m talking about.

I’ve begun to look for mental health attorneys to join us here on occasion at Private Practice from the Inside Out to help us tackle some of these choice points in private practice.

Let me know if you think this would be helpful to you and if you have a favorite mental health attorney to recommend.

Tags: Boundaries, Ethics, Social Media

I told you what you might need to know about working with managed care and I told you why I choose not to work with managed care.  Today I ran across another post written by Rand Partridge, Ph.D. about the conflicts of interest inherent in contracting to work with managed care.

Suicide seems like a strong metaphor to use, I know, but the implication of choosing to contract with managed care can be life threatening to both your client and your business. Take time to read and ask questions so that you can make an informed choice.

You can thrive without compromising your values, your clients, and your business.

Tags: Choice, Contract, Ethics, Values

One of the choices every practitioner in private practice has to make is how to set your fees.

Karlaye from Arizona writes . . .

. . . I set my base fee at $ 125 per hour . . . but the insurance companies that I work for set it at $85-95. If I have a private patient, its fine, but when I have a client that wants to use their insurance, I can only set it at that price. Is that correct?”

And, Jason from Colorado asks . . .

Is it OK to charge my cash-paying clients $85 / hour and charge my insurance- paying clients $100 / hour?  It’s the only way I can see surviving in this economy.”

When setting your fees, you need to be careful.  Health care providers are the most common perpetrators of insurance fraud.  Sometimes such fraud occurs out of greed; however, it is much more likely that you may be engaging in fee-related practices that are illegal and not even know it.

If you have chosen to work with insurance companies, make sure that you are not charging you cash-paying clients a different rate than those who are filing on their insurance. Regardless of your intent, charging different clients different fees for the same service  (based only on whether or not your client pays cash / uses insurance) is not OK.

Look for a future post when I discuss reduced fees and sliding scale fees.

Tags: Fee, Fraud