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

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

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

If you’ve missed my posts concerning the risks of mental health professionals’ use of social media here and here, you may want to go back and take a look. 

More privacy concerns related to Facebook are addressed in Jenna Wortham’s article this week in the New York Times. That’s why I was happy to also stumble across Will Baum’s interview with Keely Kolmes, Psy.D. about her thoughts on mental health professionals’ use of social media.  (Don’t forget to check out Keely’s Social Media Policy here.)

If you have your own policy on social media (or any aspect of it), I hope you’ll email a copy of it to me so that I, in turn,  can share it with others here at Private Practice from the Inside Out.

Tags: Ethics, Social Media

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

I have made the choice not to contract
with managed care companies
for my professional services.
Here’s the  8 reasons why . . . .

Conflicts of Interest

As a Licensed Professional Counselor, I am required to avoid potential conflicts of interest.  My primary concern is for my client’s well-being.  Therapists working under the constraints of managed care companies are sometimes put in the position of having to choose between what is in their own best interest and what is in their client’s best interest.  I do not want to be put in that position.

Managed care companies were created to “manage” and contain escalating health care costs.  Their bottom line is to reduce costs and raise profits; it is not to increase the quality of care or quality of life for my client.  In many cases, therapists who contract with MCC are actually paid to NOT see clients.

Restricted Choice

Often managed care companies restrict the client’s choice of therapist by offering only short term / brief therapy that I refer to as “drive-by” therapy.  Such therapy meets the financial criteria of managed care companies but may fail to afford my client the opportunity to get the information / therapy that s/he wants / needs.  It is my belief that this often results in my client’s quality of care being compromised. And, this, of course, can result in the possibility of my client’s needs going unmet.

Managed care companies often choose to limit what  therapies are offered, can restrict what is discussed in therapy, and decide which clients can be seen and for how long. Some managed care companies have even included “gag clauses” in their contracts to prevent therapists from suggesting more effective treatments.

Professional Expertise

I believe that my client should be able to access the full range of mental health professionals according to client needs.  Often managed care companies restrict the professionals that clients are allowed to work with – preferring to refer clients to therapists who have a record of providing short term therapy rather than to other therapists who may provide better results or offer a different packaging of services.

Contractual Limitations

I believe that a client has the right to full disclosure of any arrangements, agreements, contracts, or restrictions between any third party and me that could interfere with or impact your treatment.  Managed care companies may label counselors’ choices to advocate for clients in this manner as “Managed Care Unfriendly Behaviors” and take such actions as they deem fit.  Typically “violations” such as these result in therapists being removed from provider panels or censured in other ways.

Privacy / Confidentiality

By contracting with managed care companies, it is likely that I would be required to share my client’s deeply personal information with gatekeepers and utilization review professionals; it would mean potentially allowing literally hundreds of other to have access to my client’s personal information.

Medication

Research has consistently shown that medication for problems with mood is most effective when combined with psychotherapy.  Nevertheless, managed care companies frequently approve medication only for their members rather than permitting them to also work with a mental health counselor.  Again, the appearance is that of being more concerned about money rather than my client’s needs.

Time

Managed care companies usually require therapists to justify and convince Utilization Review professionals before treatment is approved / continued.  This is time consuming for the therapist and for the client who is required to continue his / her therapy in “fits and starts.”

Diagnosis and Stigma

Managed care companies typically cover only those services deemed medically necessary which is defined as being literally about life and death and the treatment of illness. This means that they require a diagnosis of mental illness for my clients.

My practice is solution- focused on quality of life and personal goals. My work with clients focuses on prevention, exploration, and personal growth rather than simply survival. We typically talk in terms of possibility and resourcefulness, gratitude and integrity, commitment and personal responsibility.  Working with managed care companies is not a choice that I can ethically make.

I Know Better

I have mental health professionals declare on a regular basis that you “can’t survive in private practice without participating in managed care.”  But, I know better. What I know is that you can’t thrive – both personally and professionally – while participating in managed care.

Once I realized the ethical implications of working with managed care companies, I terminated all of my contracts with managed care.  It’s not a decision that is right or necessary for all therapists but it was the best decision that I’ve made to date.

I am now celebrating 10 years of being an insurance-and- managed-care-free  private practice. I’m thriving and you can, too!  All it requires is courage.

If you, too, run a practice without managed-care, I hope you’ll drop in here to chat about your experiences.  And, if you have yet to make the choice to opt out of managed care, I would be happy to help you find your courage and to help you create a path to a fee-for-service only practice.

Tags: Choice, Contract, Courage, Ethics, Packaging

Earlier this month, I was asked to speak to a group of new professionals interning at Aurora Mental Health Center.  The topic was on why it’s important to join your state and national professional associations.  Just in case you are hesitating, here are 23 reasons that I believe you should join your professional associations today.

1. This is your number one career development tool.
2. This is how mental health professionals get things done.
3. Often there are special resources available to you.
4. This is where you go to learn how to be a professional.
5. This is how you stay informed about your profession’s standards of practice.
6. This is where you learn about professional trends and mandated changes in practice.
7. This is where you can build relationships and expand your network.
8. This is where you get continuing education at affordable prices via conferences, workshops, and forums.
9. Often those continuing education opportunities include a free breakfast, lunch or dinner.
10. This is how you protect and promote your own profession.
11. This is where you increase others awareness of your practice or your employer’s visibility in the community.
12. Student memberships are often reduced or no fee.
13. There are always opportunities here to give back to / build up your profession by your volunteer efforts within the organization.
14. There are often opportunities for community service.
15. This is where you go to stretch your own thinking and stay creative in your work.
16. This is where you learn what others in your profession are doing.
17. This is where you can easily establish yourself as a leader.
18. This organization may choose to sponsor your work, research, or workshop.
19. Many organizations offer members free listings and links on their websites.
20. This is who negotiates for the best and most affordable liability insurance.
21. This is where you get free advice on ethics issues.
22. Many organizations offer job placement services.
23. This will allow you to know other professionals to consult with and refer to (and vice versa) as your needs dictate.

I’m sure there are more benefits / reasons to join.  Can you tell me why you’ve joined your professional associations?

Tags: Ethics, Relationships, Workshop

When you get ready to close your private practice, for whatever reason, you can’t just shut the door and walk away. Did you know that?  Attorney Richard S. Leslie has written a thoughtful article in the January 2010 issue of the Avoiding Liability Bulletin.  In it he details some of the following for your consideration when you decide to close up shop:

• Ask yourself who needs to be notified – clients, former clients, insurance panels, landlords, supervisees, colleagues and business associates, referral sources, and your licensing boards;
  

  "You Couldn't Have Planned This if You Tried" by Ken Douglas / Today is a Good Day

• Consider the possible circumstances that might result in you closing your door – retirement, geographical relocation, health emergencies, financial circumstances, your own death, your spouse’ or partner’s death,and other unforeseen circumstances;
• Your state may dictate certain actions that you must take when you close your practice;
• Your professional code of ethics and HIPPA will certainly have standards that you must adhere to when closing your practice;
• How to notify existing clients;
• Subsequent maintenance, storage, and access to records;
• How to provide public notice of the closing;
• When and how to notify former clients;
• Why you may not want to terminate liability insurance policies when you close your practice;
• And, in the event of your death or incapacity to handle these things, who does it for you?

Every mental health professional and every professional coach is required to responsibly close their private practice  – regardless of whether their closing is planned or unforeseen.  Whether you’ve been in business for years or you are just now getting started, now is the time to take the steps necessary to prepare for the eventual closure of your practice.

Tags: Closing Your Practice, Ethics, HIPAA, Records & Documentation, Relocation, The Unexpected