Psych Central Professional For mental health, psychiatric and psychological professionals. 2016-10-23T12:16:26Z Marie Hartwell-Walker, EdD <![CDATA[Giving Back by Lowering Fees, Part 1: Options for Fee Reduction]]> 2016-10-23T03:16:46Z 2016-10-23T12:16:26Z bigstock--131329163Setting aside some session hours to see people who are uninsured or inadequately insured and who can’t afford your usual fees can help you strike a balance between your social justice beliefs and your own need to make a living. You can fill in some of the service gap in your area by using one or more of these ways to make your practice affordable for more individuals.

Yes, there are downsides. That will be discussed in Part 2. For now, let’s just look at some of the options for providing services to low income and/or uninsured clients. Here are options for providing services to low income and/or uninsured clients:

1. A Sliding Fee Scale

Setting a sliding scale where the fee is adjusted according to income and number of people who are supported by it is one option. Set up a grid. Across the top are income levels. On the left axis is a list of the number of people in the family who are supported by the client’s income. Fill in the grid with your fee per session.

What you set as the fee range depends on the cost of living in your area and what other therapists have found to be a reasonable rate. Many social service agencies use such a scale and would share it with you.

Sliding scales are generally non-negotiable. During the first phone call or first session (before starting a billable hour), share the grid and ask the client to identify his or her fee. If someone can’t afford the fee the grid specifies, it is a courtesy to provide the prospective client with a list of the names of other therapists or community services who will negotiate a lower fee.

 2. Negotiating Fee on Individual Basis:  

Some therapists negotiate fees individually. The sliding scale may seem concrete and easy but it doesn’t take into account the expenses the client is already managing. A young adult who lives with his parents and makes $30,000/year, for example, is in a different situation than a single person who is totally self-supporting on that same income.

There are individuals who are between jobs, who are in crushing debt or who have had a major medical expense. You may have on-going clients who have hit a rough financial spot who need a fee reduction to continue to work with you.

These conversations are difficult. Don’t be shy about asking for specifics. If you later discover they, in fact, could have paid your usual fee but chose instead to go on an expensive vacation, you’ll end up resentful. If, out of shame or lack of assertiveness, the client sets a figure they really can’t reach, they are likely to drop out.

 3. Keep A Set Number of Hours at a Low Rate

Set aside a certain number of hours per week at a set low fee – say $10 or $20. Let referral sources like the local service agencies, clergy and family practice physicians know that those hours are available in your practice. Remind them to screen people’s financial situation appropriately and to call ahead to make sure you have an opening before referring.

4. Offer Group Therapy at a Lower Rate

5.  Extend credit

Another option is to extend credit up to a stated amount. The client pays a portion of the fee each session and the remainder goes on their account. The client contracts to continue making regular payments after termination of treatment.

6.  Do Pro Bono Work

Another way to “give back” without lowering fees is to volunteer your services at a local agency. One therapist I know offers parent consultations at a local parent drop-in center. Another therapist offers family meetings at the senior center for elders and their adult children who are providing care. Still another therapist facilitates a group for Parents Anonymous. None of these women characterizes their work as free therapy. Instead, they see it as providing education and support to people in the community who are already financially stretched. They avoid the potential problems of fee reductions in their practices by contributing to their communities in another way. (For further information, see Pro Bono Work Matters.

 Setting fees is complicated. Setting fees while trying to accommodate those who can’t afford our usual rate is even more so. The solution is to be intentional about it. By thoughtfully choosing one or more ways to give back we give ourselves the satisfaction that comes with doing good in our community while doing good work.





Sharie Stines, Psy.D <![CDATA[Coping with Covert Abuse]]> http://7.824 2016-10-23T06:01:00Z 2016-10-23T06:01:00Z maskCovert abuse is hard to identify because it isn’t as obvious as other types of abuse. It flies “under the radar” and is hard to detect. If your abuse happened in childhood it is even more insidious because your points of reference are limited.

Before proceeding, let’s define what covert abuse is.  Covert abuse includes any type of underhanded and deceitful behavior on the part of the abuser used to manipulate others in order to gain power and control. 

Emotional incest is one type of covert abuse. Emotional incest, also known as covert incest, may or may not involve sexual abuse. This type of exploitation happens when a parent consistently looks to a child for the emotional support normally provided by one’s spouse or another adult.

Covert abuse tends to contain the following dynamics:

  • Abuses occur “casually.”
  • It is subtle, which makes it easy to ignore, deny, and minimize.
  • It rarely occurs only one time.
  • Interactions can include one or all of the following: criticism, boundary violation, sensuality, gas lighting, confabulation, or cognitive dissonance.
  • The abuser tends to be perceived by others as a “good guy or gal,” friendly, or even above reproach.
  • The abuser is very convincing.
  • Victims become desensitized to their own experiences over time.

Ways to identify covert abuse:

Most of the symptoms occur in the target.  The victim of covert abuse often believes that he or she is irrational, questions his or her own reality, feels anxious and depressed, or senses that something is just “not right” in the relationship, but can’t pinpoint what it is.  Victims tend to blame themselves.

How do you heal from covert abuse?

Healing requires self-empowerment. Be prepared to heal alone and learn to trust yourself without much support from others because this type of abuse is very hard to explain to others.  Most people won’t get it and may even think you are ungrateful, crazy, or even abusive yourself. Covert abuse is a much more lonely abuse to heal from than more blatant forms of injuries.

There is one basic method for overcoming covert abuse, and it takes time to develop; it is learning to trust yourself.  You have to get to the point that no matter what the abuser says or does, or what others say to invalidate your experience, you will believe yourself.

In order to trust yourself you begin by looking inside and learning to pay attention to your intuition (gut instincts) and your feelings.  Here’s how:

  1. Mentally state inside your head what your gut is telling you.
  2. Ask yourself what physical feelings you are experiencing in your body.
  3. Ask yourself to label your emotional. Try to identify three feelings words; for example, angry, betrayed, confused.

Realize that common feelings of covert abuse include guilt, fear, confusion, and shame.  These feelings are indications that you are being invalidated by the other person.  Invalidation is a great factor in enabling you to be manipulated and controlled.

Once you have identified what is happening in your inner world, step away from any interaction with the person that is covertly abusing or trying to manipulate you and allow yourself to “detox.”  Take a time out. Debrief. Write, pray, talk to a friend, or do something non-aggressively physical.

Do not re-enter the interaction with the manipulator until you find yourself feeling sufficiently grounded in your own reality.  Your wiser self may even decide that re-engaging with the challenging person may not be something you are even willing to do at all.

It is okay to honor yourself by setting healthy boundaries with people where you intuitively feel that something is just not okay.


To receive a free monthly newsletter on abuse recovery please send your email address to and I will gladly add you to my email list.

Susan Gonsalves <![CDATA[An Open Letter to Psychiatrists and Mental Health Professionals from a Psychiatric Survivor]]> 2016-10-23T03:16:06Z 2016-10-23T03:16:06Z I??m a Survivor words on white buttons or pins to illustrate beiDear Psychiatrists, Psychologists, Clinical Social Workers and therapists,

I am writing to you on behalf of the psychiatric survivors movement. Psychiatry is the only medical specialty to have its own survivor movement – not from the illnesses it hopes to treat, but from the practices of the profession itself.

For me personally, my individual experiences with mental health treatment have harmed me much more than they have helped me. As a survivor of bullying and sexual violence, my mental health treatment served largely to re-traumatize me instead of helping me heal.

When I was bullied during middle school and high school and struggled emotionally as a result, I was encouraged by my parents and my school administration to seek mental health treatment. There, I was diagnosed with half a dozen labels and medicated in high doses.

However, although my treatment team was in frequent contact with my school, not one clinician recommended addressing the root of my struggles: bullying. While I now understand that my anxious, depressed and lonely feelings were a natural response to being bullied, I was told that I was “sick” and “ill” for reacting this way.

This lack of trauma-informed care has followed me all through college and graduate school.

One of the most traumatic experiences I have ever had was being forcibly hospitalized the night of my college graduation.

Let me backtrack a bit to tell you how much my graduation would have meant to me. As I mentioned, I was bullied constantly in high school. I was told that I was ugly and weird by teachers and students alike almost every day. Although I was the valedictorian of my high school, I did not feel safe attending my graduation.

My college graduation was a symbol for me of how much had changed since then. I had a supportive group of friends with whom I was planning to sit. I felt included in all my classmates’ graduation activities, I had a loving boyfriend there to support me and most humbling of all, my professors had chosen to recognize me with an award for my community service and I was going to be a speaker. I remember thinking in the week leading up to my graduation, “Wow, this is what it must be like to be normal!”

The night before my graduation, I told a psychiatrist that I was feeling passively suicidal because of  the stress of graduating college. I said that I did not at all have plans to actively attempt suicide, but I wouldn’t mind if I died soon.

I did not expect that this comment would land me in a psychiatric hospital. When I was told that I was about to be involuntarily hospitalized, I frantically tried to explain myself, saying that I did not have any active plans or possess the means to kill myself, and begging to just be able to attend my graduation. The psychiatrist did not listen. It was done. I had said something I could not undo.

As if missing my own graduation wasn’t punishment enough for saying a passively suicidal comment, I could never have imagined how traumatic and scary the process of involuntary hospitalization, even for just 72 hours, would be.

During my hospitalization, I was invasively strip searched, secluded and restrained, verbally abused by staff members and given medication without being informed of potential side effects and told that I had to take the medication if I wanted to leave the hospital.

When I told hospital staff members what had happened and how sad I was to be missing my own graduation, they responded by telling me that I should’ve kept my mouth shut. My bodily autonomy was completely stripped from me. It was all too familiar and triggering for me as a survivor of sexual assault.

My experience of being re-traumatized by forced treatment is not uncommon. The experience of forced treatment is very often traumatic, and very rarely, if ever, beneficial. Many individuals report their mental health worsening greatly after being subjected to these practices. A recent study found that 63 percent of patients have witnessed traumatic events in psychiatric settings. Thirty one percent have experienced physical assault, and 8 percent have experienced sexual assault (Frueh et al., 2005).

After my first hospitalization, I began experiencing nightmares and flashbacks, both to my sexual assault and to my hospitalization. I had never before experienced these symptoms, even after my assault. My suicidal thoughts became worse, but I did not seek help for fear of re-hospitalization and re-traumatization. Keeping my suicidal thoughts all bottled up eventually turned them from passive to active and led to a suicide attempt.

This is a story with a happy ending. I am alive today. But so many aren’t.

If you are reading this letter, you are taking a very important first step toward providing compassionate, humane, trauma-informed care: listening to mental health clients/consumers/survivors, learning about our experiences and putting yourself in our shoes.

A crucial part of trauma-informed care is approaching mental health treatment with an in-depth understanding of what types of hardships and forms of oppression individuals may have experienced that have led them to seek help. Trauma-informed care means not asking, “What is wrong with you?” but instead “What happened to you?”.

Another important part of trauma-informed care is understanding the ways that forced hospitalization can re-trigger or create trauma. Coercion and force underlie all forms of abuse and oppression and it is essential for mental health professionals to recognize that while they may have good intentions, the use of forced hospitalization or treatment does utilize these mechanisms of control.

I realize that many mental health professionals see forced treatment as a traumatic but necessary tool to use as a last resort to keep people from harming themselves. I of course understand this sentiment; indeed, the desire to preserve life is noble. My personal position is that all forms of forced treatment should be abolished, but in the meantime, while forced treatment does exist, I implore you to use forced treatment truly as a last resort – meaning only after every voluntary, non-coercive form of treatment has been tried.

The following are some alternatives that I recommend trying before resorting to forced hospitalization:

  • Make a suicide safety plan.

A suicide safety plan is a way that individuals can use their strengths and support systems to keep themselves safe. Suicide safety plans often include warning signs and triggers, internal coping strategies, people and social settings that provide distraction, helpful and supportive friends or family individuals can turn to, professionals to call in a crisis and methods of making their environment safe such as removing all weapons.

For me personally, the act of making a suicide safety plan has felt extremely empowering and reminded me of all the strengths and supports I do have–enough so to keep me motivated to stay alive. Suicide safety plans are often utilized by suicide hotlines and have proven very effective. Please click here for a sample suicide safety plan.

  • Refer the individual to a support group where they can speak openly about suicide.

Something that has helped me greatly with my suicidal thoughts is having a safe place to speak openly about them without fear of re-hospitalization or even any sort of diagnosis, labeling or judgment. There are many self-help support groups that allow members to speak openly about suicidal thoughts, including Alternatives to Suicide, Depressed Anonymous, Emotions Anonymous, The Icarus Project and local support groups for suicide attempt survivors.

I remember the first time I spoke openly about my suicidal thoughts after my hospitalization – it was in a Depression Anonymous meeting. I was shaking, terrified that someone in the meeting would call 9-1-1 or a mental health professional. Instead, I was met with understanding and love. Many members spoke to me at the end of the meeting to give me their phone number and tell me to reach out to them and they checked in with me the next day and afterwards.

The experience of attending self-help support groups has given me so much hope and support that even on my worst days, I know I have a safety net of people to turn to, and that keeps me from hurting myself.

If it will make you feel more comfortable, you could have the individual sign a suicide contract stating that they will not attempt suicide during the time in between your evaluation and their first support group meeting. I understand that some mental health professionals recommend against the use of no suicide contracts. However, I have found that promising myself I will just wait one more day, or just wait until my next support group, has been very effective.

Note: Many fellowships and support groups have online meetings, as well, for people who may live in areas without these kinds of resources.

  • Arrange for the individual to stay in a peer respite.

A peer respite is a center for people in crisis that is entirely staffed and operated by people with lived experience with mental health. Peer respites provide community-based, trauma-informed, and person-centered crisis support in a non-clinical, homelike environment. Mental health peer specialists are on staff 24/7 to counsel and support people going through crisis. Many psychiatric survivors have had very positive, helpful experiences at peer respites. Please click here to find out more information about peer respites in the U.S.

  • Ask the individual to provide evidence of means disposal.

One of my therapists once helped me feel safer being open with him by telling me that if he ever had reason to believe I had a plan or means to attempt suicide, he would first ask me to provide him with evidence that I have disposed of the means. He has asked clients to send videos of themselves flushing pills down the toilet and/or spoken with their family members to confirm that they no longer have the means to attempt suicide.

  • Read through the book “Hello, Cruel World: 101 Alternatives to Suicide for Teens, Freaks and Other Outlaws” by Kate Bornstein with the individual and find an alternative that sounds better than suicide.

This book has saved my life many, many times. The alternatives to suicide range from exercising to exploring your spirituality to “killing off” the parts of yourself that you dislike (personality traits, etc.).

I will admit that some of the alternatives are controversial – self-harm is one and so is trying drugs. The author takes the stance that anything is better than suicide. You as a professional can pick which of these you would like to suggest to your clients/consumers.

Often, just reading the book has given me a laugh and helped me feel less alone in my suicidal thoughts or feelings of being an outcast. Please click here to access the book. There is also an iPhone app with the full version of the book.

  • Help the individual access culturally responsive and linguistically competent care.

Many times, people may be going through a crisis as a natural response to forms of structural oppression, including racism, religious prejudice, xenophobia, queerphobia, misogyny, ableism, poverty and other forms of bias that can lead to severe trauma, so often reflected in state, institutional and interpersonal violence. These forms of oppression are strongly correlated with suicide attempts and a person’s risk for suicide increases when they experience intersecting oppressions.

Very often, mental health systems fail to offer programs that are culturally sensitive to members of minorities and oppressed groups that adequately recognizes the trauma of the oppression they face every day. People of color, people of size, immigrants, refugees and LGBTQIA people are disproportionately subjected to forced treatment.

Additionally, many community-based programs intended to support survivors of violence only re-traumatize people by coercing them into making police reports, cooperating with law enforcement investigations or filing for restraining orders, which can force survivors to relive their experience.

Members of oppressed groups have the right to culturally competent care, including services provided by and for people from racial, ethnic, cultural, and LGBTQIA populations that are historically underserved. Culturally responsive care can also include traditional healing arts such as Ayurvedic and traditional Chinese medicine, Native sweat lodges and talking circles, shamanistic healing, and community garden programs for Hmong refugees. This can also include faith-based counseling or support for religious individuals.

For me personally, LGBTQIA affirming therapy as well as spiritual counseling from a Rabbi have been important parts of my healing and recovery.

  • Help the individual address or make a plan to address whatever external issues are causing them to feel suicidal.

The night before my graduation, I felt depressed and ashamed because some of my family members had told me that they wished I had pursued a more lucrative career. They were disappointed that I was graduating from an Ivy League only to attend social work school instead of becoming a medical doctor or entering a more prestigious profession.

One of my family members actually said exactly those words in front of the psychiatrist and the psychiatrist did nothing to stand up for me or address my feelings of guilt and shame over my career choice. In a lot of ways, my suicidal comment was my way of saying, “I need validation. I need to not feel like a failure right now.” I often wonder what would have happened if that night, the psychiatrist had validated and supported my choice to attend social work school or if we had even acknowledged the difficulty and scariness of sacrificing profit and prestige for one’s passion.

Regardless of your views on the chemical imbalance theory or nature vs. nurture, we can all agree that external factors can be a major cause of suicidality. Bullying, sexual violence, domestic abuse and childhood trauma all increase victims’ risk of suicide. One important way to prevent suicide is to address some of these underlying issues. If a child or teen is being bullied, you can prevent suicide by making a plan involving their family and/or school administrators to make school a safer place for them.

The last time I was triggered and started to experience some passive suicidal thoughts was as a result of a workplace bullying situation. Instead of hospitalizing me, my therapist validated my feelings and helped me make a plan to address the issue in a politely confrontational, constructive way. I immediately felt empowered and hopeful, and my suicidal thoughts quickly dissipated.

I strongly believe that if all of these alternatives were used before resorting to forced hospitalization, forced hospitalization would almost never occur. I was not offered these options as an alternative to either of my two hospitalizations. The times that I have been offered these alternatives, they have been extremely helpful.

Remember: if you do not try these alternatives first, you’re not using forced hospitalization as a last resort.

Thank you very much for listening to my story and considering my perspective. On behalf of the psychiatric survivor community, we thank you for your open-mindedness to these ideas and willingness to provide trauma-informed care.

Best regards,

Emily Sheera

Mental Health Peer Specialist

Psychiatric Survivor

Works Cited

Frueh, B. C., Knapp, R. G., Cusack, K. J., Grubaugh, A. L., Sauvageot, J. L., Cousins, V. C.,…Hiers, T. G.

(2005). Special section on seclusion and restraint: Patients’ reports of traumatic or harmful

experiences within the psychiatric setting. Psychiatric Services, 56(9), 1123-1133.



Christine Hammond, MS, LMHC <![CDATA[Lacking Motivation? Try This]]> http://5.1009 2016-10-22T13:55:56Z 2016-10-22T13:55:56Z lack of motivation“There’s so little time and so much to do,” are lyrics from Grammy award winner jazz singer and composer Louis Armstrong. As a charismatic trumpet player, his career spanned five decades beginning in the 1920’s. While his can-do philosophy probably inspired the lyrics for the song So Little Time, even people who lack motivation feel the pressure of time and work.

Contrary to popular belief, it’s not like a person doesn’t know what needs to be done or lack something to do. Rather it is that they have zero desire to do it.  In fact if a person lined up all the things that need to be done, they could actually spend an entire vacation working and the list still would not be complete.

There are clothes in the washer than need to be moved to the dryer so they won’t get mold on them.  There is a report needing to be complete but nothing put on paper makes sense.  There is a crack in the windshield that has been there for days, weeks, months or dare I say years.  There is a good friend going through a rough time but the conversation is avoided.  Or there is an annual check-up long over do with no desire to make the appointment.

Sound familiar?  Instead of following an old slogan like “Just do it”, try this:

  • Burn-out is real and can only be resolved though adequate rest. Take one day off and do something fun to rejuvenate.
  • Play with a toy, a game, or go to a park.  The distraction can be helpful.
  • Doodling, drawing, or using an adult coloring book can help to spark the creative side of the brain.
  • Call a friend, not the one that is being avoided but another one that makes brings a smile and reassurance.
  • Try encouraging someone else and being helpful in a simple manner.  This serves as a distraction.
  • Watch an old sitcom that brings laughter. It is good for the soul.
  • Make a gratitude list of people and things that have given inspiration and meaning. Take the time to express it to someone.
  • Go for a walk, take a drive, or sit in a different room. This change in the environment can bring a new perspective.
  • When unmotivated, exercise might seem improbable. But it is this precise time to push forward, perhaps experimenting with a new sport or routine.
  • Take time to listen to some music especially non-lyrical music. This stimulates the creative side of the brain.
  • Think small. Attempt one small task of the To-Do list. The success might inspire the completion of larger items.

The bottom line is that doing something, especially something that is restful, is better than doing nothing.  In this way, a lack of motivation might bring a new healthy perspective.


Christine Hammond is a Licensed Mental Health counselor who lives in Orlando and is the award-winning author of The Exhausted Woman’s Handbook.

Tiffany McLain, LMFT <![CDATA[Everything you Ever Wanted to Know about Niching in Private Practice]]> http://8.212 2016-10-21T20:38:10Z 2016-10-21T20:38:10Z “Mar-Ket-ting…?” The veteran therapist says to me, her eyes wide and blinking, brows furrowed. “Why, I’ve never had to do this “Mark Ket” that you speak of.”

One of the primary difficulties for this generation of therapists in private practice is that we are in an entirely new world when it comes to building sustainable and lucrative practices. When our clinical forebears started out, they had the unwitting fortune of stumbling into a wide open mental health market. That fantasy of simply “slapping up your shingle” and having the clients role on in actually used to work. 

Who even says “shingles” any more?! I, for one, do not want shingles.

Which brings us to the larger point: Times have changed for therapists in the U.S. While it’s very difficult to to assess just how many mental health providers there are – and even more difficult to figure out how many of those are in private practice, rough estimates put us between 400,000 – 500,000 mental health practitioners as of 2013, depending on who’s counting.

And we’re on par to grow by 20% by 2024.

Which means that we must take intentional action in order to fill our practices with full-fee clients that we are inspired to work with.

And this is where – gasp – niching comes in.

The anxieties about niching are endless:

  • I don’t want to pigeon-hole myself.
  • I like working with a diverse range of clients.
  • The majesty of my clinical expertise cannot be captured in simplistic niche-based exercises!

You’re not a special snowflake on this front. I’ve heard every argument.

11230511 - stall with sweets at boqueria market in barcelona.Every. Argument.

But you certainly are uniquely suited to rock a client’s world in other ways and this is why niching is so important.

Niching, however, is not necessary for every clinician who wants to create a lucrative practice. As much as we hear that niching is an absolute essential from every business expert, I’ll concede that not every therapist needs to niche.

You don’t need to focus on a niche if:

  • You’re the lone therapist in a completely unsaturated market, so the number of people desperately seeking a counselor mightily outweigh the availability of clinicians.
  • You have the privilege of an external source of income (partner, family, the lottery), thus you have years, if not decades, to slowly build up a practice without the burden of monetary need.
  • Similarly to the above, you have access to wealth, such that you can slide your fee to the point that anyone and everyone is happy to see you because you compete totally on price.

You do need a niche if:

  • You’re in a saturated therapist market (like California, which contains half of the nation’s MFTs), so clients have their pick of every make, model and type of therapist.
  • You need to earn a very solid income within 6-12 months of starting your practice.
  • You want a great work/life balance, which includes seeing fewer clients, but charging premium prices for your services.

Look – 99% of therapists have the same wishes you do. Those of us who have used niching to expedite our private practice growth had all the same thoughts when starting out. We, too, want to work with a diverse clientele. We, too, want to give back to communities we are passionate about serving. We, too, were terrified that niching would limiting.

But, we also want to be able to financially support ourselves and our families. We want to give back without burning out. We want to be able to take vacations without becoming terrified about the hit to our monthly earnings. By god, man – We want to eat sushi-dinners!

In truth, therapists who niche are a lot like you. 

This is why, over the next few weeks, I’m going to bring you stories of therapists who have utilized niching to excel their private practice growth. We’ll get all gritty into the anxieties they had before niching, the reasons they decided to take the plunge and get real about the impact that niching – and niching well – can have on your business.

While we’re waiting to hear from our first therapist, we’d love to hear your story! Have you niched down? What was the impact? Have you avoided niching? If so, how come? Start the discussion in the comment section below.


photo credits: David Castillo Dominici & fazon 

Jennifer Rollin, MSW, LGSW <![CDATA[Experts Share Tips for Launching a Private Practice, Part 2]]> 2016-10-19T13:12:15Z 2016-10-21T11:11:53Z  

bigstock--131359244I had numerous therapists reach out to me eager to share with others their tips for launching a successful private practice. Starting a private practice is a dream that many psychotherapists have. However, the leap from working for an employer to launching your own business can be a scary idea.

 The following are some tips from psychotherapists who have successfully navigated the transition to private practice.

1. What are some of the biggest challenges in terms of transitioning from working for an employer to private practice?

Jessica D. Kramer, LCPC, NCC says, “I needed to figure out how to run a practice and how to structure my time effectively.  Most people in our industry are practitioners and not business-people, you have to be both.”

Amy L. Hooper, LCSW-C, CEAP director and psychotherapist, Gaithersburg Counseling Center, and Practice Development Coach, says that in her viewpoint, the biggest challenges are, “keeping up on notes when no one is looking!! Just kidding, the hardest transition is probably learning the business end of starting and growing a practice. Most of us have learned the clinical side, but running a business requires a different skill set.”

2.  What are some tips you would share for therapists looking to make the transition to private practice? 

Kramer says, “Make a business plan, if you don’t know how to do that then ask someone.  It is important to set goals and have a plan of attack.  Secondly, learn how to get very comfortable with networking because that is also very important. And thirdly, set personal parameters regarding what type of hours you want to work, what population you want to work with and how much you want to charge and then stick with those parameters.”

“Also, invest your money in an excellent website!  This is critical, do not cut corners. Work with a company that knows therapist websites and understands SEO. Additionally, make sure that you take time for your emotional well-being, self-care is critical at this time and easy to put on the back burner” Kramer explains.

3.  If you could go back and give yourself one piece of advice when you were just starting out in private practice, what would that be?

Kramer says, “Value my time more and don’t feel that I have to do things for free in order to make an inroad.”

Hooper says she would tell herself to, “get really good, trauma informed training, and get a good supervisor. It makes all the difference in the depth of work with clients, and that’s the best way to build a practice, to be a highly skilled clinician.

 Join the Conversation

 While starting a private practice can be scary, many share that it was an incredibly rewarding endeavor in the long-term. Often it is through taking personal and professional risks that we are able to truly grow as people and professionals.

However, private practice is not for everyone. Thus, it’s important to look inward at what you truly desire in regards to your career and then to take steps towards achieving your dreams.

I’d love to hear your tips for making the transition to private practice in the comments below!


Robyn Brickel, MA, LMFT <![CDATA[Intimate Partner Violence: Raising Our Awareness as Clinicians]]> 2016-10-19T13:11:38Z 2016-10-20T13:10:59Z healthcare and social problems concept - womans hands holding puAs clinicians, we want to prevent trauma by raising awareness of dating violence and sexual assault prevention. Most people don’t know how terribly common sexual assault is, or what to do about it.

Intimate partner violence may be even more prevalent than sexual assault. Reports show that one in five women have experienced sexual assault. But nearly one in five women have experienced severe physical violence from an intimate partner, says the National Domestic Violence Hotline. One in three women have experienced some form of intimate partner violence, according to the National Coalition Against Domestic Violence (NCADV).

Stopping intimate partner violence presents its own set of challenges. Domestic violence often involves a co-dependent relationship and two people with histories of trauma.

But it only takes one well-informed, well-prepared adult in the lives of victims to make the difference between someone staying trapped and getting help.

No Typical Profile

Abusers and victims come from all social groups, ethnic groups and professions. Most victims are female between 18-24, but victims also include men.

Domestic violence is about power. Any physical violence in a relationship is harmful and unhealthy. It can happen when one person is having trouble managing their own stress and aims to cope by controlling their partner through force and fear.  The offender uses threats and actual physical or emotional harm to exert control.

Victims often feel responsible for the emotions of their partner. A victim may think that the violence is ‘not his fault’ or ‘he didn’t mean it.’  They endure abuse, hoping that their partner will change. Victims often feel powerless, unable to stand up for themselves, hopeless, worthless and beyond help.  None of this is true.

Many couples who experience intimate partner violence witnessed violent relationships as children. It may be hard for either person to imagine a relationship working another way.

What Needs to Change; Recommended Treatment

average, it takes a victim seven times to leave a relationship that remains abusive, before moving on for good. Why does this happen?
Most people — including the victim — want to believe their partner won’t hurt them again.  They may make statements like:

“Well, he didn’t mean to do that.”

“Well, he apologized.”

“She promised not to do it again.”

An important question must be asked:  What has changed so that it doesn’t happen again? Something more needs to happen than an apology, an excuse or a promise.

Each person needs help. The recommendation from most professionals who deal with domestic violence — including me —  is against therapy as a couple. Rather, we recommend that partners work through individual therapy until there is some growth or change to make it safe enough for therapy to happen together.

Violent behavior is a choice. “It is not caused by drugs or alcohol (although these things can make abuse worse) or by anything the victim did to ‘provoke’ the abuser,” says the Office for the Prevention of Domestic Violence in New York. “Abuse is not caused by a bad day or ‘buttons that got pushed’…. Abuse is always a choice. And it’s never the victim’s fault.”

An important goal of therapy is to help the abuser develop healthy ways to regulate emotions and therefore, make different choices.

The victim of abuse also needs to develop abilities for self-awareness and self-care. Therapy is a vital opportunity to experience what it means to feel safe and fully respected in a relationship. This goal is one of the most important  of the therapeutic relationship between the survivor of abuse and the therapist.

The Importance of Recognizing the Risks to Children

It’s important to talk about what happens children in violent households.  It has a devastating impact on the emotional, physical and neurologic development of children and the consequences are lifelong.

The extent of exposure to violence during childhood in the United States is staggering.  “At least a third of American children have witnessed violence between their parents. Most have witnessed multiple instances,” reports the Child Witness to Violence Project.

This fact isn’t just about kids being in the other room.  They hear it. They see it. It’s somewhat common for children to try to break it up, when they can be physically harmed.   We are still learning about the neurological and emotional damage caused by trauma experienced during childhood.

One landmark study, known as the Adverse Childhood Experiences (ACE) Study by the Centers for Disease Control and Prevention and Kaiser Permanente asked 17,000 adults about their exposure to trauma up to age 18. It included questions about witnessing a mother or stepmother treated violently.

The study also followed health conditions among participants long term.  It revealed the lifelong consequences of trauma.

“Children with toxic stress live much of their lives in fight, flight or fright (freeze) mode,” writes Jane Ellen Stevens, founder of Aces Too High.

They respond to the world as a place of constant danger. With their brains overloaded with stress hormones and unable to function appropriately, they can’t focus on learning. They fall behind in school or fail to develop healthy relationships with peers or create problems with teachers and principals because they are unable to trust adults. Some kids do all three.

With despair, guilt and frustration pecking away at their psyches, they often find solace in food, alcohol, tobacco, methamphetamine, inappropriate sex, high-risk sports, and/or work and over-achievement.

Children of domestic violence live with toxic levels of terror every day, and grow up seeing the world through a lens distorted by trauma. As adults, too many trauma survivors repeat the unhealthy violent relationship model they grew up with. This behavior puts future generations at risk for continuing the cycle of intimate partner violence.

How to Stop the Cycle of Intimate Partner Violence

Some couples get help because they become aware of the impact on their children.  Others get help because someone intervenes.

A child’s stress from violence at home is known to emerge in behavior problems, lower school performance and mistrust of adults.  Often the life-altering change comes through the child because an important caring adult notices something, and becomes appropriately informed.

For example, a school counselor can play a life-changing role for a child or adolescent impacted by intimate partner violence. The counselor may be able to engage with a student who appears exhausted, and can ask “Why are you so tired?” A good counselor will keep asking to understand the situation and guide next steps such as: maintaining a safe place to talk, thinking through a safety plan, knowing where to get help, deciding what to do in an emergency.

What Can Friends and Family Members Do?

The most important thing is to be there and offer support. It does not help to criticize or berate the violent partner. This reaction usually prompts the victim to become more protective of their partner, and more isolated, and you become one less person to turn to.

When you’re with a friend you fear is in an abusive relationship, being supportive means  listening, offering assistance and a compassionate point of view:

  • “I am so sorry this is happening to you. It sounds so incredibly stressful.”
  • “It must be so scary when he loses control. I am so glad you told me.”
  • “I can’t imagine how hard this must be for you. You must be so worried. I’m here any time you want to talk.”

Your friend may not be ready to hear: “I will take you to a therapist.  I will find a therapist for you.”  Family members and close friends cannot usually “rescue” an adult with an abusive partner.

Helping is a matter of being informed so you can point the person to the right resources. Where are the shelters? Who can they go to? What is the hotline number? Where can they safely make the phone call?

In the city of Alexandria, where I work, there is a support network not just for the victim, but for family members and caring friends who want to help.  See More Resources below.

If someone you care about opens up and tells you their awful secret of abuse, the next step is just to be supportive.  “I’m here, you can talk to me.” Building a culture of support for victims of abuse, and their children, is vitally important to reducing rates of domestic violence.

Most victims don’t ask for help, whether they have experienced domestic violence or sexual assault, because they feel ashamed. They believe it’s their fault. The difference we can make comes in the form of support. We can help when we are able to reach out with a message of reassurance and compassion that the abuse is not their fault, and that there are resources to guide and protect them.

It’s important to offer calm reassurance that they are not alone. By listening, acknowledging their experience without judging and being informed and available, you can be the bridge between the despair they know and the support they need.

Susan Gonsalves <![CDATA[Shhh! Let’s Talk About Moderation for Mild Substance Use Disorders]]> 2016-10-19T13:10:41Z 2016-10-19T13:10:41Z Low, Moderate and High gauges. Vector.Are you worried about your patient’s drinking?  Do he say he is not an alcoholic and AA is not for him?

Approximately six percent of the Unites States’ population struggles with a severe alcohol use disorder.  This group and their loved ones will experience devastating consequences.  On the plus side, most traditional treatments and self-help groups are geared for their recovery.  However, there is a larger number of the population—over 90 million people— that have a gap in services.

Moderation Management found that they will avoid getting help for fear of being labeled an alcoholic, forced into treatment, made to attend 12-step meetings and have to stop drinking completely.  As health care providers, we need find ways to assist this large number of alcohol users who are not experiencing addiction, but may be dealing with a mild or moderate alcohol use disorder.

There is a controversial, emerging treatment option: moderation.   Moderation is described as a return from out of control or harmful drinking to consuming within safer drinking guidelines. Moderation has also been called moderate drinking, asymptomatic drinking, controlled drinking or reduced risk drinking.

The Dietary Guidelines for Americans defines moderate alcohol consumption as having up to one drink per day for women and up to two drinks per day for men while the National Institute on Alcohol Abuse & Alcoholism (NIAAA) offers another definition: up to four alcoholic drinks for men and three for women in any single day, according to and a maximum of 14 drinks for men and 7 drinks for women per week.

I have found NIAAA’s guideline to be more risky.  Many people start to feel an effect of the alcohol after two drinks and may be intoxicated by four drinks, thus having a harder time sticking within his or her predetermined number of drinks.

A standard drink= 12ounces of beer=5ounces of wine=1.5ounces 80-proof liquor

The Quiz

 Based on my 20 years experience of working with people experiencing problems from alcohol use, I developed the “How Do I Know If I Can Keep Drinking Quiz.” The quiz offers predictions for whether someone is a candidate for moderate drinking.  It is personalized to the patient’s specific experiences and goals.  Certain questions have positive predictions for success while others offer lower chances of success in being able to moderately drink.

The more positive predictors the better, and vice versa.  If there are too many negative predictors continuing to drink may be very risky for your client.

Negative predictors for being able to moderate include:

  1. Daily drinking
  2. Consuming to deal with emotions
  3. Drinking alone
  4. Experiencing mental or physical health problems
  5. Having legal, probationary or employment conditions

The worst predictor for being able to continue drinking is having withdrawals potentially life threatening withdrawals such as delirium tremens “the shakes,” sweating, increased pulse, hallucinations and seizures.  This result almost always means that the body has a physical dependence on alcohol and that the person likely meets Diagnosis and Statistical Manual 5 criteria for a severe alcohol use disorder, placing them into the six percent of the population who is physiologically unable to moderate.

Several predictors that lead to a better chance of being able to drink moderately include:

  1. Experiencing a period of abstinence to develop and implement coping skills
  2.  Monitoring amount and frequency of drinking and staying within the guidelines listed above
  3. Consuming when alcohol is part of a celebration and not the main focus
  4. Delaying first drink until after age 15. One study of over 40,000 adults found that nearly half of the people who began drinking under age 15 met criteria for a severe alcohol use disorder while that percentage dropped to less than 10% if they waited until age 21.
  5. Having family support.  Research shows that the number one predictor for being able to moderately drink is having a support system that can offer perspective, accountability, and motivation.

It is important for clients to have tools to learn how to moderate. They need to understand why they were drinking, why they want to continue and ways to make it safer for them.

We also need to prepare them for how to drink again—something that is very unusual for an addictions specialist to do!  Some of my clients have been surprised at how they feel when they begin drinking again.  For months, they faithfully tracked their clean days.  It was a way to earn back trust from family members and increase their damaged self esteem from the past choices they made in relation to their drinking.

As clients resume alcohol use, clinicians should help watch out for any emerging mental health symptoms, an increase in amount and frequency, the impact of consumption and the intent of drinking.  If someone is trying to change their mood, this situation may be a slippery slope back to risky patterns.

Some tools for successful moderation include:

  1. Learning new ways to relax and have fun without alcohol
  2. Sipping slowly and enjoy the flavor.  If you don’t’ enjoy it- don’t drink it.
  3. Alternating between an alcoholic and nonalcoholic drinking
  4. Avoiding “shots”
  5. Putting money that would have been spent on drinks towards a fun event

A Sample Moderate Drinking Plan is below:

Moderate Drinking Plan


I am choosing to keep drinking because: _____________________________________________________________


I will not drink in these situations: _____________________________________________________________


I will not drink until: ____________________________________________


I will not drink after: ____________________________________________


I will alternate an alcoholic beverage and: _____________________________________________________________


I will have no more than: __________drinks per: _______________________


I will not drink under these conditions: _____________________________________________________________


I will review my plan with: _______________________________________


If I/we notice: _____________________________________________________________


I/we will: ____________________________________________________________


Revise the plan as goals change and lifestyle demands.  For example, as someone becomes a parent, his or her consumption patterns are likely to decrease.  Parents of pre-teens and adolescents will want to be aware of the messages they are sending regarding alcohol.  Obviously if a medical issue arises, the plan will need to be adapted.

A Moderate Drinking Plan is not written in stone.  We need to watch out for denial and involve a friend or family member in the moderation process.  Once clients have successfully implemented their plan, I often move them into a maintenance phase of therapy.  I will see them periodically to monitor progress and watch for relapses in risky patterns.

Moderation Management found that there are four times as many drinkers experiencing problems than people who drink at levels that meet criteria for a severe alcohol use disorder.  They also note that nine out of 10 drinkers will not seek help—that’s 90%.  There are varying degrees of alcohol use and consequences. Behavioral health care providers need to offer alternatives to the traditional models of alcohol treatment.

While it may seem counterintuitive, by engaging your client in a discussion about moderation as a treatment option, you might actually reduce their risk of becoming an alcoholic.

Cyndi Turner, LCSW, LSATP is the co-founder and clinical director of Insight Into Action Therapy and has been in the addictions field for more than 20 years. She co-developed and facilitates the Dual Diagnosis Recovery Program©, is an expert witness, a clinical supervisor for licensure and provides therapy for players involved in the National Football League Program for Substances of Abuse.  Her book “Can I Keep Drinking? How You Can Decide When Enough is Enough” challenges the traditional belief that all drinkers experiencing problems must be alcoholics who need to quit drinking forever. or











Christine Hammond, MS, LMHC <![CDATA[Can a Narcissist’s Deception be Harmful to Millions of People?]]> http://5.993 2016-10-18T16:42:57Z 2016-10-18T14:13:57Z denial movieNarcissists have the ability to charmingly convince people of anything they want to convey. Their manner of speech, intertwined with shallow flattery and a flashy smile, is woven with truths, half-truths, and fiction. While this might gain media attention for the pure entertainment value and seem innocent, it does have the potential to cause harm on a large scale.

This concept is clearly demonstrated in the movie Denial which was released in September 2016. This true-life docudrama portrays the struggles of an American professor, Deborah E. Lipstadt, as she defends herself in a British court case. Her book on Holocaust deniers portrays people such as historian David Irving, who made false historical accusations that Hitler did not order the persecution and execution of millions of Jewish people during World War II. David Irving filed a law suit against Deborah Lipstadt and her publisher Penguin Books for defamation of character.

The movie portrayed David Irving as a narcissist (this is not an official diagnosis of the real person; rather it is an analysis of the character in the movie). For those who are unclear as to just how a narcissist manipulates and deceives, this movie describes it perfectly. The list of symptoms depicted includes:

  • Need to be the center of attention: One of the opening scenes of the movie is David Irving interrupting Deborah Lipstadt while she is giving a lecture at a university about her new book. This grandstanding was then recorded by David Irving to be used on his website as a demonstration of her unwillingness to debate the facts of the Holocaust.
  • Desire to be recognized as superior: The attorneys for Deborah Lipstadt suspected that David Irving had this desire and used it against him. In a pretrial discussion before the judge about whether to use a jury, the attorneys suggested that twelve common people would not be able to understand the intricacies of the case as clearly as the judge. David Irving agreed not to have a jury trial.
  • Lack of empathy: In this case, the movie demonstrated all of the other characters as capable of empathy except for David Irving. This was especially true when several members of Deborah Lipstadt’s legal team visited the remains of the concentration camp in Auschwitz.
  • Need for excessive admiration: Throughout the movie, David Irving dominated the media with his propaganda. At the advice of counsel, much to the dismay of Deborah Lipstadt, she remained silent until after the case was decided. The stark contrast only highlighted his showboating.
  • Automatic compliance with expectations: (Movie spoiler alert!) In the end, David Irving loses his case, but that would not be apparent from his media interviews immediately following the ruling. Instead he claims a victory and expects everyone around him to agree with his stance and perspective.
  • Arrogance: Even the physical appearance of David Irving in the movie portrays an arrogant attitude through his puffed-up chest, raised chin, and downward gaze at others. When he speaks, it is clear he will only talk to those he believes are worthy of his attention, not anyone else.
  • Takes advantage of others: This is the most disgusting aspect of the movie as it is evident that David Irving is blatantly taking advantage of the Jewish people’s suffering to gain self-promoting notoriety as a denier. This shameful display underscores the worst aspect of narcissism in the worst possible manner.

So to answer the question posed in the title, yes, a narcissist’s deception can be harmful to millions of people. It was for the family, friends, and survivors of the Holocaust. The portrait of David Irving in the movie Denial is such an example of lying and maliciously deceptive behavior characterized by the narcissist.


Christine Hammond is a Licensed Mental Health counselor who lives in Orlando and is the award-winning author of The Exhausted Woman’s Handbook.

The Carlat Psychiatry Report <![CDATA[Research Updates in Psychiatry: Depression and Suicide]]> 2016-10-14T17:07:24Z 2016-10-16T11:06:56Z Depression and Suicide Research UpdatesDEPRESSION

Physicians May Overprescribe Antidepressants Based on Brief Depression Questionnaires

Brief depression screening questionnaires are popular, especially with primary care providers (PCPs). However, a new study suggests that PCPs who use these questionnaires might be prescribing antidepressants to patients who don’t need them.

This was a prospective study of patients at six primary care office locations in California. Each patient was administered the Patient Health Questionnaire-9 (PHQ-9) by the researchers immediately prior to a primary-care office visit. The PHQ-9 assesses how often respondents have experienced various symptoms (such as feeling down, sleep problems, thoughts of harming oneself) in the previous two weeks. Scores can range from 0 to 27. PHQ-9 results were not shared with the physicians.

For this study, the researchers focused on a specific population of 595 patients, those with a PHQ-9 score less than 10, since this group is considered to be at low risk for depression and poor candidates for taking antidepressants. In this group, most (545) did not complete a separate measure of depressive symptoms during their office visit. Very few of these patients were diagnosed with depression (10.5%), were recommended an antidepressant (1.6%), or were prescribed an antidepressant (3.8%). However, for those patients who were administered a brief depression symptom measure by their primary care provider, 20% were given a diagnosis of depression, 12% were recommended an antidepressant, and another 12% were prescribed an antidepressant.

Use of the screening measures, which was more common during office visits in HMO and Veterans Affairs settings, increased the likelihood that patients who were not likely to be depressed would receive depression treatment (odds ratio 3.2; 95% confidence interval 1.1-9.2). The study highlights the need for more research to determine the best way to use brief depression questionnaires in primary care practices, and to balance benefits and risks of treatment, including overdiagnosis of depression and the use of antidepressants (Jerant A et al, J Am Board FamMed 20l4;27(5);6ll-620).

TCPR’s Take: Most psychiatrists are aware that brief symptom measures are meant to be screening tools, not diagnostic instruments. Nevertheless, this study shows that in the primary care setting these questionnaires may provide the justification for a diagnosis of depression and the prescription of antidepressants to patients who are not clinically depressed. Without more evidence to support the use of screening instruments in primary care settings, this practice should be reconsidered.


Sunshine Linked to Suicide Rates

This article originally appeared in The Carlat Psychiatry Report -- an unbiased monthly covering all things psychiatry.
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Sunshine and other forms of bright light are considered to be helpful for depressed patients. Patients with seasonal affective disorder (SAD) feel better as the days lengthen, and bright light therapy is effective for the depression in patients with and without SAD. However, seasonal studies of suicide have found that the prevalence is highest in the spring, which is counterintuitive if we consider light to be an antidepressant. A new study out of Austria clarifies this seasonal finding by separating out the effects of sunshine per se versus seasonality. The results are a bit perplexing.

Researchers analyzed retrospective data on all officially confirmed suicides in Austria for a 40-year period (nearly 70,000 deaths from 1970 to 2010). They then looked at data derived from meteorological stations on the average duration of sunshine per day in hours. Finally, they used mathematical techniques to separate the effect of sunshine exposure from the season.

On each day studied, independent of season, researchers found that the hours of sunshine and the number of suicides were highly correlated. They found a positive correlation between sunshine and suicide that held not only on the day of the suicide but also 10 days prior to the event. Conversely, they found a negative correlation between the number of suicides and the daily hours of sunshine for the 14 to 60 days prior to the suicide, suggesting more daily sunshine over a prolonged period may protect against suicide. This protective effect was more pronounced in men than women.

The implications are that brief exposure to sunshine may increase the risk of suicide, especially in female patients. Why this might happen is unclear. The authors hypothesize that brief sunlight might energize depressed patients before significantly improving mood, and that this could increase their motivation to do something about their condition, no matter how drastic.

Researchers said more study is needed to determine which patients with depression are most susceptible to the effects of sunshine (Vyssoki B et al, JAMA Psychiatry 2014; Epub ahead of print).

TCPR’s Take: There were some limitations to this study—for example, it did not account for other climatic factors (such as temperature, humidity, and air pressure) that vary along with the amount of sunshine to a certain degree. While the findings may represent a statistical anomaly and need to be replicated, you might consider more closely monitoring your suicidal patients, especially women, when the weather takes a sudden turn toward sunny days.

Jennifer Rollin, MSW, LGSW <![CDATA[Experts Share Tips for Launching a Private Practice]]> 2016-10-14T17:05:18Z 2016-10-15T10:04:42Z PsychotherapyMany psychotherapists dream of launching their own therapy practice. For some individuals, the idea of setting your own schedule, fees and “being your own boss,” sounds highly appealing. However, the leap from working for an agency to launching your own business can be a scary prospect.

The following are some tips from psychotherapists who have successfully navigated the transition to private practice.

1. What are some of the biggest challenges in terms of transitioning from working for an employer to private practice?

 April McDowell, Ph.D., LMFT of Decision Point Therapy, LLC, says that the biggest challenges from her perspective when starting a private practice are, “Balancing one’s schedule to adjust to the new responsibilities involved in becoming `the boss’  More time has to be devoted to non-clinical activities, particularly in the first few months of starting your own practice and it can be challenging to find the new normal for your schedule.”

McDowell explains that another challenge is, “trusting oneself to effectively run your private practice. Pushing through the initial doubts and fears and building that self-trust in your new role can be very challenging, but will come with experience and a strong support network!”

Alison McGrath Howard, Psy.D., M.Ed., CGP says, “Self-confidence is one of the biggest challenges that clinicians face when they transition from a structured work environment to one of their own making. Private practice can leave people feeling a bit lost and unsure of themselves if they are coming from an agency or other fully staffed office. Lack of confidence can lead to turning away clients who you are able to help because you don’t think you have enough experience. It can also influence how you handle the financial piece of the practice.”

 2. What are a few tips you would share for therapists looking to make the transition to private practice?

 Amy L. Hooper, LCSW-C, CEAP, Director and Psychotherapist, Gaithersburg Counseling Center, Practice Development Coach, says, “Choose a specialty that you LOVE! It will make marketing much easier and help you stand out. The best part is, then you’ll love the clients you’re working with and it will make working so much more rewarding.”

 McDowell says that it’s important to, “gain experience in private practice as an employee or contractor before starting your own practice.  In my opinion, the trend of therapists starting practices straight out of school (with no previous experience in private practice) is not one to follow.  The learning curve is just too steep for those therapists! Learning how to be an effective business owner takes a lot of time and focus and if you’re completely new to private practice while starting your own, the required time and focus will most likely interfere with being your best clinical self (not to mention, with your personal life).”

McDowell says, “I worked for several years in two different private practices before opening my own and I’m extremely grateful I had that foundation.  Even just one to two years of experience in another private practice can be extremely valuable in preparing you to launch your own. Also, begin marketing and advertising activities for your practice before launching it.  Building a bit of buzz about your practice launch before it opens can help you hit the ground running. Additionally, it can give you a head start on developing relationships that will help your practice thrive in the long run.”

McGrath Howard’s advice is: “Get a supervisor or into a peer supervision group or both. Figuring out the financial pieces, scheduling, paperwork, and working on a changing professional identity is hard work and clinicians need the support of people who have been in the field a long time and peers who have similar private practice experience. Also, don’t try to be all things to all people! Know your limits, schedule time for yourself to rejuvenate.”

3. If you could go back and give yourself one piece of advice when you were just starting out in private practice, what would that be?

McDowell says, “Build up a trusted group of mentors, consultants, advisers, and professional peers before the practice opens and make a commitment to serve those people in exchange for their knowledge. Take every opportunity you can to learn from this group.  Build up your knowledge bank with their help and view that as the end goal, not necessarily getting clients from them. Focus on building deep relationships with a small, intimate group of such people as you move through the beginning stages of your new practice.”

 McGrath Howard states, “I was fortunate to have been able to grow my practice slowly, and didn’t feel stressed by financial concerns, so I have no regrets about how I started out. I will say that one of the best decisions I made was to get into advanced training right away, which created an environment of peer support and helped me to feel like I was staying in clinical shape.”

The Bottom Line

 The experts agree that building a strong support network, working on your sense of self-confidence, developing marketing strategy and doing your research, are all critical components of launching a thriving private practice.

Tiffany McLain, LMFT <![CDATA[Setting Your Private Practice Up For Success: Intention]]> http://8.186 2016-10-18T23:00:29Z 2016-10-15T00:50:26Z Over the past three weeks, we have taken a deep dive into the #1 Factor that leads to private practice success by breaking it down into its components.

Thus far, we’ve covered time and money. Now, in this last installment, we cover what is undoubtedly the most important component – intention.

But before we dive in, let’s take a look at an image from Tim Urban over at Wait But Why that will break your heart.


You sure?


Source: Tim Urban / Wait But Why

Source: Tim Urban / Wait But Why


“Why, my heart isn’t broken,” you say. “That’s just a picture of some snowflakes with some other snowflakes that are crossed out.”

Sure, at its face, it’s just a few snow flakes, 90 to be exact. In fact, these snowflakes are a representation of how many winters the 34 year old illustrator, Tim, has experienced in his lifetime, along with how many more he has yet to experience if he lives to be 90.

And, if he lives to 90 years old, here’s how many more presidents he will see in the White House:

Source: Tim Urban / Wait But Why

Source: Tim Urban / Wait But Why


If you haven’t already read Tim’s original article – The Tail End – I suggest you stop everything you’re doing and read it. Now.

Have you read it?


Okay, then let us proceed.

You’ve, no doubt, gotten an inkling about where I’m going with this.

You likely went private practice with vague notions of what it was all about – the desire to work for yourself, the ability to make more money, the opportunity to work in a style that felt more connected to who you are.

Yet, so quickly things become frenzied, overwhelming – work bleeds into life, bleeds into work. Another Halloween passes, a Christmas or two, another birthday and another. All the while, you are consumed with anxiety about gaining clients, building your practice, creating a decent income, networking with colleagues, catching up on notes.

Meanwhile, another election cycle comes and goes. A school year ends and begins again. Leaves turn green, then yellow and then orange before falling off the trees. And then it all starts over.

When we stop to ponder the passage of time, the beauty of each moment becomes clear.

Which brings us back to Tim Urban’s poignant reflections.

Like 60 more swims in the ocean.

Source: Tim Urban / Wait But Why

When you imagine having only 60 more times to step foot in the Atlantic, setting up an intentional practice becomes not a luxury, but a necessity.

Setting Your Practice Up For Success: Intention.

All of which brings us to the point of this, the most fundamental aspect of creating a foundation for private practice success – the art of being intentional in your actions.

You now know it’s important to be intentional about how you set up your schedule.

You now know it is also important to be clear about your financial expectations when determining your fees.

But at the base of it all is the importance of being intentional about how you set up your practice, because it is vital that you make conscious decisions about how you spend your time.

62089733 - dad and her daughter playing together.

What is your purpose at the end of the day?

In a remarkable article that has now gone viral, Bonnie Ware – a palliative nurse – wrote about the regrets of the dying. Among the things people regretted the most were working too hard and losing contact with important relationships.

While creating an intentional private practice can actually give you a lifestyle that you prioritize, too many of us become slaves to the demands of our private practice anxieties.

So here, in the last article of this series, I implore you to take the time to be intentional about creating your private practice in a way that let’s you live with purpose.

Here are six questions to ask yourself when deciding what you truly want out of for yourself when setting the stage for your private practice. Grab a pen and write these down. The more specific you can be when writing, the more likely it is that this exercise will create a shift in your daily activities.

  1. Are there things I could be automating in my practice right now that would allow me to have more time to spend on the activities that bring me joy?

  2. What are the day to day frustrations that come up over and over again?

  3. How could I shift my my daily habits in a way that would solve this problem?

  4. If I had 10 more years to live, would my practice be set up differently?

  5. How?

  6. When you consider your current caseload, are you choosing to spend your time with clients that allow you to be your best self, that – at the end of the day – fill you with jouissance?

Now take a moment to reflect on one of your joys – be that hugging your mother, hearing your first born giggle uncontrollably, or making lasagna for your partner. If you live to be 90, and that is a big “if,” what would that graphic look like? Do you have 20 more opportunities to do this thing you love? 10? 5?

While it can be sad to learn how short your time here really is, to quantify the number of times you have left to experience that which you love – this is exactly what you need to do.

And then, use this as a foundation to create a practice that allows you to truly live, while you still have the chance.



Photo Credits: Bernard Bodo

Bret Moore, Psy.D. <![CDATA[Non-Traditional Therapies are a Good Alternative to Medications, Psychotherapy]]> 2016-10-14T17:05:46Z 2016-10-14T17:05:46Z Group TherapyIdentifying effective treatments for veterans with posttraumatic stress disorder (PTSD) has been one of the top priorities for the military and veteran  mental health communities.  Currently, there are only two medications (paroxetine and sertraline) approved for PTSD and just a few talk therapies that are considered bona fide treatments (e.g., exposure, cognitive therapy).

Indeed, there is a deficiency when it comes to  treatment choices for veterans.  Then there is the issue of tolerability. Many Veterans Quit Treatment

Many veterans who are prescribed medication quit because of the side effects.  Some of the more common ones are stomach upset, agitation, sweating, insomnia and emotional numbing.  And then there are the sexual side effects.  As you might expect, reduced sex drive and the inability to achieve an orgasm-common side effects of PTSD medications-can be quite troubling for a soldier in the prime of his life.  And it is not just men that experience these side effects.  It is not uncommon to hear females complain of low libido while taking these medications.

There are problems with the most popular talk therapies as well.  Treatments like Prolonged Exposure and Eye Movement Desensitization and Reprocessing are challenging for many veterans.  These treatments require the veteran to relive the trauma, and in some cases, emotionally and physically re-experience the trauma in session.

Recent research has shown that a substantial number of veterans drop out of these treatments prematurely; up to half in some cases. And for those who are able to complete treatment, questions about long-term effectiveness have been raised.  Even when outcome scores on PTSD measures drop during treatment, most veterans continue to experience enough severe symptoms to retain the PTSD diagnosis.  Unlike previous claims about talk therapies “curing” PTSD, it appears the results were overstated.

Reasonable Alternatives To Traditional Treatments

As a result of growing concerns about availability, tolerabilit, and effectiveness of traditional PTSD treatments, interest in alternative therapies has grown at a breakneck pace.  In previous columns, I have written about the popularity of techniques like yoga, transcendental meditation, mixed martial arts, and equine therapy.

I have even written about entire organizations like Boulder Crest Retreat,  a civilian, non-profit group dedicated to these types of therapies.  Boulder Crest Retreat is the first rural, non-profit wellness center for veterans.  Based in Bluemont, Virginia, Boulder Crest is currently collecting program evaluation data in hopes of identifying the scope of impact it is having on program attendees.

What Is The Hold-Up?

So why are these alternative and non-traditional treatments still considered alternative and non-traditional?  It is pretty simple.  There is a lack of evidence.

Regardless of how innovative and cutting-edge they are, new therapies must be backed by sound science before they are accepted into mainstream healthcare.  This hesitation is for good reason.  Before introducing a new treatment to the public, we need to be sure that it is safe and effective.  And the only way to do this is through clinical research.

The Unintended Consequence

There is an unintended consequence, however.  Although the need for therapies and programs to be backed by science is important, it prevents effective treatments from reaching those most in need in a timely manner.

Scientifically assessing the merits of a new therapy or program can take many years and a substantial financial investment.  For example, a randomized clinical trial is considered the “gold standard” when it comes to clinical research.  However, this type of study can cost hundreds of thousands, if not millions of dollars to complete.

And depending on the type of study and research question being asked, it could take years before enough data is obtained to make a definitive claim about the results.  The reality is that few organizations outside of universities, corporations or the government have the finances, staff and time to oversee such a tremendous undertaking.

It Can Be Fixed

There is a solution.  Private and public sector collaboration is the key to bringing safe and effective therapies and programs to the market in a timely manner. We need a marriage between the innovative and entrepreneurial spirit of our private citizens and the funding and accountability of our government.   This collaboration is our best chance to meet the needs of those who have sacrificed so much for our country.

It’s not an easy fix, however.  Because of regulatory and bureaucratic challenges, private and public partnerships are difficult to construct.  It takes an unwavering commitment on both sides and much flexibility.  Unfortunately, this is not the current state of affairs in our country.

*This article is based on a previous column written by Dr. Moore and published in Military Times.

Christine Hammond, MS, LMHC <![CDATA[The Huge Frustration of Personality Tests]]> http://5.987 2016-10-18T16:39:38Z 2016-10-14T15:03:19Z personalityOk, I admit it. I have a love/hate relationship with personality tests. And sadly, the tests that are most loved are the silly ones like: which Star Wars, Disney princess, or Harry Potter character are you? As a cross between Darth Vader, Tiana (Princess and the Frog), and Dumbledore, I’m not sure if I should be wearing all black, dressy white fur, or a colorful robe. What these characters have in common is unclear, but it is amusing to take the test and imagine.

Then there are the more involved assessments utilized by coaches, career counselors, and employers to discover strengths and weaknesses at the most basic level. Some of these are available online for free or minimal cost. These tests can help avoid poor career choices, offer insight as to strengths, suggest suitable mates, discover ideal environments and identify leadership potential. Some examples include:

  • MAPP (Motivational Appraisal of Personal Potential) assessment identifies a person’s ideal career path, aptitude, temperament, and ability to relate to others.
  • Myers-Briggs Type Indicator is widely used by employers to determine if a candidate is a good fit for a particular position, categorizing a person within 16 different personality types.
  • StrengthsFinder classifies key personality strengths in order to encourage a person to work from their strengths instead of boosting up their weaknesses.
  • Enneagram labels nine major types of personality, the worldview, basic desire and basic fear.
  • DISC (Dominant, Influential, Steadfast, and Conscience) places a person in one or more of the four main types of personality pinpointing ideal mates, motivations, and vocations.

The obvious downside of these exams is that they are self-administered, which means the test is only as good as the honesty level of the person taking it. If a person lacks self-awareness, these exams can be frustrating, adding to confusion instead of clarity. Even worse is when a person relies on information from a friend or spouse to complete the test, because the nature of their personality is likely to color the responses.

Significantly lacking in all of the above mentioned personality tests are personality disorders. A personality disorder by definition means a person lacks objectivity, has no clear perception of themselves and others, lack of affectivity of mood (either too intense or too flat for the circumstances), poor interpersonal functioning (inability to relate to others well), and significant impulse control in all areas of their life. Of all the things an employer or potential spouse might want to know about another person, this would seem to be high on the list.

Yet there is no good online, easy assessment for personality disorders. Rather there is a lengthy (500+ questions) and expensive version called the MMPI (Minnesota Multiphasic Personality Inventory) which is only administered and assessed by a trained psychologist. Once a personality disorder is discovered, all of the above tests can become invalidated because the person taking the exam lacks a clear understanding of how they relate within their world.

This is the part I hate about personality tests. They offer a limited and sometimes inaccurate perspective, especially when a person has a personality disorder. The very thing a test should be utilized for – Is there a personality disorder or not – is the very issue that is not addressed.

So I’ll return to the fun assessments that liken a person to a color, person, flower, or spaceship. At least here, you truly get what you pay for.


Christine Hammond is a Licensed Mental Health counselor who lives in Orlando and is the award-winning author of The Exhausted Woman’s Handbook.

Jessica Dore <![CDATA[An Interview with the Author of “The Heart of Couple Therapy”]]> 2016-10-12T23:06:28Z 2016-10-13T13:05:59Z The Reception At The PsychologistEllen F. Wachtel, Ph.D, JD, is the author of  “The Heart of Couple Therapy : Knowing What to Do and How to Do It”  and a clinical psychologist in private practice in New York City. Dr. Wachtel is an adjunct faculty member at the Ackerman Institute for the Family.

 Your book, “The Heart of Couple Therapy: Knowing What To Do And How To Do It,” presents an integrative approach to couple therapy. Which therapeutic traditions have you incorporated and who in the field has influenced your approach?

I first started integrating various approaches when doing family therapy with parents and young

children (see my 1994 book, “Treating Troubled Children and Their Families”). At that time, the integration consisted largely of introducing psychodynamic and cognitive-behavioral understanding and interventions into a family systems foundation.

Initially, in my work with couples, I integrated an understanding of each individual’s psychodynamic issues into what was primarily a solution-focused approach. I used the genogram not only to understand the transmission of family patterns across generations but also as a window into each person’s psyche, world-view, and both conscious and pre-conscious schemas and wishes.

 Over time, my work with couples expanded to include the emotion-focused work of Les Greenberg and Sue Johnson; the focus on vulnerability cycles as described by Michele Scheinkman and Mona Fishbane; and the more direct work on sexuality described by Ester Perel and Suzanne Iasenza.

 What are some of the most difficult things that clinicians who do couple therapy tend to struggle with, and how did you aim to address these things with your book?

 Working with couples can be highly gratifying but not infrequently, good sessions, in which the couple seems to “get” the unproductive cycles in which they engage, do not lead to enduring change. Both the couple and the therapist can feel stuck and demoralized by how entrenched these patterns can be, despite the couple’s good will, insight and desire to change.

 My book describes numerous methods designed to help motivate each individual to expand his or her sense of self and to combat the all too common feeling that “this is just the way I am.”

 The book demonstrates how consistent attention to the couples’ strengths, the noticing of steps in the right direction (for example, being more emotionally open in a session) and the generous use of positive feedback helps combat despair and brings out the best in each partner.

 Another common difficulty in couple therapy is that the sessions devolve into mutual complaints and counter accusations, leaving the couple feeling as bad or even worse than when they first arrived at the meeting. Therapists must learn how to change the focus from complaints to longings.

Rather than blaming one’s partner, each person is encouraged to search inside himself and change his or her role in problematic interactions. Right from the beginning of the work, I encourage self-examination and humility by asking each person, “what do you know about yourself that makes you not the easiest person in the world to live with?”

 In the introduction to your book, you talk about the ever-evolving method of integrative couple therapy that you’ve developed through years of practice. What advice would you give about developing an integrative approach to a newer clinician who is interested in incorporating a range of methods and techniques into their practice?

 Therapists need to have a large repertoire of methods since each couple is unique and the particular form of integration will vary from couple to couple. So for instance, one couple may need to work on connecting at a deeper level emotionally, while another’s difficulties may be primarily based on a lack of know-how in regard to resolving conflicts.

 Both beginning and experienced therapists should take workshops and read books on a variety of approaches so they have the tools to innovate and design a form of integration that not only works for the couple, but feels natural and organic to the therapist.

One particularly useful place to learn a variety of ways of working and how to integrate them is at the annual meetings of The Society for Psychotherapy Integration. Although the particular integration will vary both from couple to couple and therapist to therapist, the aim with all couples is to help them relate to one another in a “brainstorming,” non-adversarial manner so that they can not only resolve conflicts but also try to gratify each other’s longings.

 The therapeutic relationship is an interesting aspect of couple therapy; it is an equally important factor in achieving positive outcomes, but it must be approached differently with a couple. What are some of the key points for establishing this alliance in couple therapy that are different from how it’s approached in individual therapy?

 Often, in individual therapy we initially form a therapeutic alliance by empathizing with what the patient is feeling. In couple therapy, we must be careful not to appear to be siding with one person. Too much expression of empathy for one person can feel like a rebuke to the other.

Rather, we can express empathy and understanding for what they, as a couple are going through. The doubts, the anguish of feeling disconnected, the stress of horrible fights, the fear of the future are but a few of the many emotions that couples share and that can be empathized with and perhaps even normalized.

 But even more important than that is helping the couple feel valued for how they are as a couple despite the difficulties that have brought them to your office. Giving feedback about some of the positives about the couple so that the couple feels that you like them and see their strengths as well as their problems is a crucial aspect of forming a therapeutic alliance.

 So, for instance, perhaps despite their difficulties they respect each other as parents, or they have warm relationships with family and friends or they have a shared sense of humor which peeks through even when discussing their difficulties or they work well together on projects.

 It is almost always possible to find something that goes well in their relationship, and by making note of that the therapist not only builds a therapeutic alliance, but helps them feel a bit less despairing about their relationship.

Your book emphasizes a strengths-based approach to couple therapy. For therapists who have been trained in psychodynamic approaches, how might this challenge them to do things differently to what they are accustomed? 

One of the challenges for psychodynamically-oriented individual therapists when they do couple therapy is that therapists originally trained in psychodynamic approaches are often prone to notice emotional damage, impairment and unconscious issues that play a role in the couple’s difficulties.

Frequently these perceptions are accurate and important. But just how they are taken into account in the work and how they are balanced with perceptions of the equally crucial strengths on which change must be grounded, is often the critical difference between successful and unsuccessful couple therapy.

 At the heart of this book is a detailed examination of the myriad of choice points therapists encounter in every session and the consequences of pursuing—or not pursuing—any particular line of inquiry. My hope is that this book will help therapists learn to notice and work with strengths, rather than responding first to deficits.


Margaret Altman, LCSW, MSW <![CDATA[Distressing Facts About Distressed Therapists, Part 2]]> 2016-10-11T13:26:55Z 2016-10-12T13:26:19Z bigstock--125504153One out of every four psychologists has suicidal feelings at times, according to one survey, and as many as one in 16 may have attempted suicide.
  • In a survey of female psychologists, 76% of the sample experienced some form of depression, with the most frequent diagnosis being dysthymia
  • A study of female mental health professionals revealed respondents to have experienced significant distress within the past three years.
  • Research has shown that female therapists commit suicide at higher rates than the general population.

( The above data is from an article by Doug Girard, Psy.DHow many clinical psychologists suffer from mental illness?  Updated Aug 7, 2014 · Updated by  Anita Sanz, clinical psychologist

The Why

The reality of the numbers seems surprising given the large number of women with this degree  (approximately 71 percent as of 2010) and their enthusiasm and investment in the work and in the profession.

It is also  fairly widespread belief that a psychology degree is an optimal choice for a woman because of the possibility of being in independent practice with creative potential, earning a good amount of money and structuring one’s own hours to  meet the needs of family and other responsibilities. Even Forbes steps in to assert thatThe 25 Best-Paying Jobs For Women Right Now  include psychologists.”

Some of the reasons for the depression and suicidal thoughts are neatly summarized in several articles and they range from treating individuals with negative and sometimes dangerous behaviors, isolation in private practice and dealing with managed care and paperwork requirements. But there is much more that pertains to women. 

The Wounded Healer

There is the opinion that psychologists and therapists make use of their own mental health as a foundation for their work. Commonly known as the ‘wounded healer,’ this notion states, “therapists are both motivated to become healers and strengthened in their capacity to empathize with others by painful life experiences.”

“I think people who are drawn towards professions such as psychology, usually their interest comes from something very personal,” says Russell Federman, Ph.D., the director of counseling and psychological services at the University of Virginia in Charlottesville. “It’s not because they’ve had a simple, gilded, wonderfully supported life.”

This underlying motivation, if it is a search for meaning and for answers, is often a difficult and emotionally turbulent one for any individual. It is possible that some people who enter the psychology field are searchers but there are more challenges that face the female psychology student and professional.

More traditional and destructive reasons are barriers for women from the onset of their journey through their attempts to climb the professional ladder. These are our social values as they relate to gender roles and sexism/discrimination.

In our paternalistic society and others, value is placed on women who fill roles as wives, housekeepers, bearers of children and caretakers. The professional fields that are often deemed to be suitable for females are teaching, nursing and caretaking. Many young women have internalized these values and experience very negative feelings and feedback when they opt out of traditional roles.

This dilemma is an on going struggle as they age into their late 30’s given the science that informs us that the ovum age along with the woman and she becomes less fertile as she grows older. Women do combine full-time work with child rearing and marriage again having to cope with divided responsibilities, divided priorities and negative feedback.

The other, mostly hidden reason is reported by professional women who seek funding for research, who seek academic positions in universities or who work in the private sector. Women professionals state that there is sexism in these domains that restricts their upward mobility in favor of male practitioners. This factor is daunting and depressing but is part of the reality for professional women in our society.


The obstacles are clearly presented in an article by two female psychologists. They state that female early career psychologists face unique challenges during the course of their occupational development. Even though women earn the majority of psychology Ph.D.s, (approximately 71 percent as of 2006), women are continually underrepresented in academia and face a distinctive set of issues.

There is no question that representation of women with psychology Ph.D.s in academia and other occupations have vastly improved, however as of 2006, women still only held 46.2 percent of tenured or tenure-track faculty spots, and 33.4 percent of full professorships.  Approximately only 25 percent of women decide to go into academic based careers, down from the 40 percent who state they wish to do so at the beginning of graduate school.

One of the biggest factors in this decision is the desire to start a family.

Women with families have significantly lower odds of gaining tenure and married women with young children have about a 35 percent less chance of getting tenure than a married man with young children and 33 percent lower odds of becoming tenured than a single woman. Unfortunately, academia may be unknowingly perpetuating a system where talented women leave early in their career because of feeling that career must come before family.

Family leave benefits vary widely from university to university; some universities can provide six weeks or more of leave, while others provide leave dependent on the amount of full-time hours an individual has recorded, often leaving graduate students, postdoctoral researchers and beginning faculty with few leave options when having children and coping with parenting responsibilities.

No doubt, these early experiences color a woman’s expectations of the field and how she will continue to be treated, as well as her expectations for continued success. It is particularly ironic as many women are choosing to have families in graduate school and during postdoctoral training because of heightened flexibility and biological and social time points.

In another article, the point is made that women psychologists have effectively been engaged in challenging the sexist attitude in their field. Notable early contributions have been made by Naomi Weisstein in her 1968 article, “Psychology constructs the female, or the fantasy life of the male psychologis” and Carolyn Wood Sherif in 1975 with “Bias in psychology.” Both were reprinted in Janis Bohan’s (1992) book, “Seldom Seen, Rarely Heard: Women’s Place in Psychology.”

The Path Forward

The question remains: How can this information be of use to women who are entering or plan to enter the profession of psychology?

Being aware of the burdens and challenges that lie ahead on the pathway to the Ph.D. and beyond is one of the important uses of this data. Establishing and joining support groups and advocacy groups is a dynamic way to empower oneself and others. Another recommendation would be for those who seek tenure to evaluate each university’s tenured positions to find the ratio of women to men on the faculty.  In a “female friendly” university environment, the barriers to advancing one’s career may be identified early in the process.

Finally taking care of oneself emotionally and physically is the foundation for any kind of success in a career. Having compassionate, supportive friends and family who listen and who encourage is fundamental in this process.

Being marginalized is a damaging process and the stain of stigma is especially difficult when one self-stigmatizes. With the high expectations and admirable goals that women (and men) have when they pursue a professional career, the shock of being discounted at any point is frightening to anticipate. And yet we must move ahead with the will and the enthusiasm that will enable us to surmount many obstacles and have satisfying careers.

Christine Hammond, MS, LMHC <![CDATA[How to Win over an Angry Narcissist]]> http://5.982 2016-10-18T16:36:48Z 2016-10-11T16:00:55Z angry narcissistThe other day I received a phone call from a narcissist raging over something that just occurred. Within 30 minutes, the narcissist had completely calmed down, the situation had radically deescalated, and there was a clear path forward. Even I, as someone who works with narcissists regularly, was shocked by the dramatic turnaround.

Did I just get lucky or was there some method that could be duplicated? After much analysis and a quick refresher course from the book Thank You for Arguing (by Jay Heinrichs) on the persuasion tactics that were utilized, I stumbled on an effective formula.

Sidebar: Before discussing the formula, it is important to note that this narcissist is someone with whom I already have established a relationship of trust. Meaning, this is not a new relationship where the narcissist would most likely begin the conversation by persuading me with their skills of charm. Rather, they felt comfortable enough to get right to the point in an aggressive manner. While this can be intimidating at first, I choose to see this approach as an indication of mutual respect, even if the narcissist is not respectful in their choice of words or manner of speech.

Step 1: Change the mood. The narcissist opened the discussion with a personal attack directed at me about something that happened in the past. This blaming tactic is done to divert attention from the real frustration, fear, or insecurity. Ignoring it is likely to bring on more confrontation, so I chose to find some small part of responsibility that I could take. I did not however, take it personally or accept full blame; rather, I changed the mood by being empathetic. This immediately took the wind out of the narcissist’s sails and allowed me a small window to ask a question.

Step 2: Focus on the present. “What brought all of this up?” I asked in an effort to bring the conversation into the present instead of continuing to discuss the past. This was perhaps the bulk of our discussion as the narcissist explained the current circumstances followed by their intense frustration. Again there were several accusations towards me and others but instead of focusing on that, I chose to acknowledge the validity of their anger. “I would be angry about that too,” and “You are right about that,” allowed me to be on their side rather than against them.

Step 3: Listen for the insecurity. Behind every narcissistic rant is a deep-rooted insecurity such as fear of abandonment, not being good enough, or being out of the know. Think of it as a hidden gem that once discovered should be hidden away and not put on display. Displaying a narcissist’s insecurity is tantamount to mutiny and likely will be met with a severe backlash. Instead, recognize the current insecurity and speak to it without identifying it. “I can see how not knowing this information would make you upset,” is an example of how to acknowledge the insecurity without stating the narcissist’s vulnerability.

Step 4: Move to the future. This is the trickiest part of the steps. If done poorly or prematurely, the discussion will wind up at step one all over again. Timing is everything. Wait for a pause of realization before suggesting some future mutual action. By sharing responsibility in the plan going forward, I speak to the unspoken fear of abandonment. The narcissist wants to know that they will not be alone in taking action and instead have a team of people assisting them. This also speaks to their need to be in the center of attention. The use of the word “we” is very powerful. “Now that I understand your position, we can work on this by …” This statement should be followed with a couple of suggestions for proceeding forward but with limited choices. Too many options can increase rather than decrease frustration. Having no option doesn’t allow the narcissist to be in charge going forward.

Step 5: Quit while ahead. Once an agreement has been reached, end the conversation immediately. Don’t bring up another issue or try to explain how the opening attack was unfair. This will backfire and undo any accomplishment made thus far. It is better to let some time pass before addressing any additional issues.

Try these five steps the next time a narcissist makes a personal attack. You might find, as I did, just how to win over an angry narcissist.


Christine Hammond is a Licensed Mental Health counselor who lives in Orlando and is the award-winning author of The Exhausted Woman’s Handbook.

Margaret Altman, LCSW, MSW <![CDATA[Distressing Facts About Distressed Therapists, Part 1]]> 2016-10-11T13:25:49Z 2016-10-11T14:25:26Z The Silent Killer

Distressing Facts About Distressed Therapists, Part 1Psychologists and therapists in general are an interesting population. Many of them are committed to the difficult task of helping people achieve healthy emotional goals. They seem to be a satisfied bunch; a significant number of these professionals make their own hours, become fairly independent of systems and make adequate money.

And yet, what little data has been produced in research shows that a surprisingly large number of these professionals are depressed and become suicidal.  In fact, the reports that do come out indicate that women psychologists and therapists are in a higher risk category than male psychologists for depression, suicidal ideation and suicide.

One would think that the organizations and associations that psychologists belong to in a professional capacity would be alarmed about this situation and taking notes? This question was posed to the psychologist Dr. Nathan.

From P. Nathan. Ph.D., University of Iowa:

The American Psychological Association APA), hasn’t released any relevant data (on distressed  psychologists who commit suicide) since about 1970. Why? The APA doesn’t want anyone to know that there are distressed psychologists. (Peter Nathan, Ph.D., is a former member of an APA committee on “troubled” psychologists).

What is the APA hiding and why should female professionals in the mental health field  be very concerned?

The only published data—now nearly several decades old—on actual suicides among psychologists showed a rate of suicide for female psychologists that’s three times that of the general population, although the rate among male psychologists was not higher than expected by chance.1

The Broad Lens

In general terms and through a broad lens, the suicide rate women across the country for ages 45 to 64 jumped by 63 percent. For men in that age group, suicides rose by 43 percent, states Katherine Hempstead, senior adviser for health care at the Robert Wood Johnson Foundation, in an article in The New York Times.

In England, the following statistics are cause for alarm: women are the highest risk group for mental health problems, according to new data ; one in five women reported a common mental disorder such as anxiety and depression in 2014 compared to one in eight men, according to the survey of Mental Health and Wellbeing.

Young women also have high rates of self-harm, post traumatic stress disorder and bipolar. Mental health charities said the figures showed nothing had improved. Post-traumatic stress disorder was seen in 12.6% for women of that age compared with 3.6% of men.  Rates have steadily increased in women and remained largely stable in mensince the last survey in 2007.

Looking at physicians (psychiatrists), mental health professionals kill themselves at an abnormally high rate, according to psychologist David Lester, Ph.D., director of the Center for the Study of Suicide,

Indeed, highly publicized reports about the suicide rate of psychiatrists led the American Psychiatric Association to create a Task Force on Suicide Prevention in the late 1970s. A study initiated by that task force, published in 1980, concluded that “psychiatrists commit suicide at rates about twice those expected [of physicians]” and that “the occurrence of suicides by psychiatrists is quite constant year-to-year, indicating a relatively stable over-supply of depressed psychiatrists.” No other medical specialty yielded such a high suicide rate.

A number of surveys, conducted by Guy and others, reveal some worrisome-some statistics about therapists’ lives and well-being. At least three out of four therapists have experienced major distress within the past three years, the principal cause being relationship problems. (Guy & Liaboe, 1985).

More than 60 percent may have suffered a clinically significant depression at some point in their lives, and nearly half admitted that in the weeks following a personal crisis they’re unable to deliver quality care. As for psychiatrists, a 1997 study by Michael Klag, M.D., found that the divorce rate for psychiatrists who graduated from Johns Hopkins University School of Medicine between 1948 and 1964 was 51 percent—higher than that of the general population of that era and substantially higher than the rate in any other branch of medicine.2

The Narrow Lens

The literature on psychologist suicide is not new but is consistently cited. One of the earliest studies and one still highly recommended, conducted on this topic was by Steppacher and Mausner (1973); they found that from 1960 to 1969 suicide rates amongst male psychologists were slightly below that of the general population, but that female psychologists had suicide rates nearly three times that of the general population.3

Studies are rare that have explored the prevalence of mental health problems among psychology graduate students. There have been studies of symptoms, however: A 2009 APA survey found that 87 percent of psychology graduate students reported experiencing anxiety and 68 percent reported symptoms of depression. Even suicidal thoughts — with a prevalence of 19 percent — were relatively common.

“The numbers suggest we’re certainly not immune [to mental health problems],” says Phil Kleespies, Ph.D., a psychologist with the Department of Veterans Affairs Boston Healthcare System in West Roxbury, Mass., who co-led an inquiry on suicide risk among psychologists…. “Having a doctorate in psychology doesn’t necessarily mean that you’re going to be able to deal with your own personal depression.”

  1. Steppacher and  Mauser. SUICIDE IN PROFESSIONALS: A STUDY OF MALE AND FEMALE ……/436.full.pdf
  2. Suicide Compared to Other Causes of Mortality in Physicians. Authors Michael J. Klag MD, MPH, First published: April 2005 Full publication history  DOI: 10.1521/suli.
Joseph R. Sanok, MA, LLP, LPC, NCC <![CDATA[Slow Down to Spark Creativity]]> 2016-10-10T21:22:21Z 2016-10-10T09:30:00Z

Creative Human Brain in the Work. Conceptual Background for BusiWhen I was a kid, I remember the story of “The Tortoise and the Hare.” They’re having a race. The tortoise starts out really slow. The hare almost gets to to the finish line, but decides to sit next to a tree. The hare falls asleep and the slow and steady tortoise passes the hare to win the race. Slow and steady wins the race.

The point of this story is to teach perseverance and to stop the urge to sprint and expend too much energy at once. Also, the hare is arrogant and thinks he has the race and takes a break early. Obviously terrible qualities! 

Does Slow and Steady Win? 

But sometimes it’s best to have chapters of sprinting and chapters of pausing. Sometimes it’s working 60+ hours per week to launch a dream business. You keep a full time job, but you’re building your dream. Sometimes it’s phases of parenting. Or when you’re a sandwich parent that is taking care of parents and kids. The reality is, life isn’t really a marathon where we never stop. Instead, it’s a bunch of sprints and rests. 

When I think about slowing down, I think about stopping and sitting on a hill. The sun is rising (I’m like how the heck did I get up this early, obviously this IS a dream!) and crisp air hits my meditative yoga pose. 

The reality is, I’m probably never going to meditate on a mountain at sunrise. Even when I was hiking through Nepal, the crisp air never called me as strong as the warm sleeping bag. 

In our heads, we equate slowing down with stopping. Yes, it can be that. It can be that we just need to unplug and go on vacation. But a vacation is hard to sustain. When I talk about slowing down, I’m talking about reducing, eliminating and stopping. 

Reduce, Eliminate and Stop

We may need to reduce what we we do and how we do it. This might be that we intentionally check email less. Also, we might eliminate tasks that are just filling space and taking away from a healthier and happier life. This change could be that we outsource our laundry or stop doing the tasks in our businesses that we dread. 

But there is a time for stopping. It’s not usually three weeks in Nepal, but the principle is the same. Throughout history, every major religion and social movement has encouraged fasting, sabbath or boundaries. 

Growth Over Reaction

When we don’t have a specific focus in our life, it’s easy to live in a responsive and reactive manner, instead of a planned growth approach. 

We have to get to that email, that soccer practice, that homemade meal or that family obligation. 

But we don’s ask ourselves, “Why did we commit to soccer ever single Saturday? Is that good for our family and relationships?” 

Slow Down, Spark, Creation 

Ever notice how your best ideas come when you’re in the shower, working out or about to fall asleep? When our brains aren’t focused on work, they tend to sort through all the ideas. Then, when we least expect it, they pop up. 

There’s a natural cycle of slowing down, sparks and creation. The problem is, most of our entrepreneur minds have trouble slowing down. Our “slow down” is to watch Netflix, read a marketing book or listen to a podcast. 

Genuine slowing down allows our brains to decompress, dream, and check out. When this happens, sparks of creativity start to fly. Then comes planning and focus to create something innovative. 

Conferences like the Slow Down Conference help spark this process to create habits and see outcomes. 

Intentionally slowing down is about deciding what we can do to take clear steps toward a healthier life, one that intentionally starts with betterment of self, those around us, and our communities. Maybe the hare actually was onto something! 






Christine Hammond, MS, LMHC <![CDATA[How Narcissists and Hurricanes are Alike]]> http://5.970 2016-10-09T19:38:34Z 2016-10-08T13:07:31Z Hurricane_Fran_sept_1996As a 25-year resident of Florida, this latest hurricane is the fifth one I’ve lived through. While there have been countless tropical storms and tornadoes, nothing compares to hurricane-force winds, except, of course, narcissists.

Their reputation precedes them. If there is ever an ideal time to release a self-deprecating scandal to the news media, it is during the preparations for a hurricane. With reminders of previous hurricanes and their subsequent damage, predictions of the current path and its continual changes, and countless photos of empty shelves, boarded-up windows, and abandoned streets, there is an absence of any other news information. Not only does the reputation of a hurricane precede itself, it dominates. The same is true for narcissists. Anyone who has endured the path of a narcissist knows the best strategy is to prepare ahead of time and listen to the advice of those who have already survived.

The calm before the storm. Just prior to a hurricane hitting, the weather is beautiful. There are clear skies, an absence of humidity, the temperature is just right, and it is inviting to be outdoors. But behind the façade is a powerful force that only the animals seem to sense. Birds fly in the opposite direction, smaller creatures take cover, and even the crickets and frogs become silent. The calm before the storm is eerie. It is an indication that the dangerous hurricane is near. This is very similar to the initial feel a person has while dating a narcissist. There seems to be nothing wrong and everything looks perfect. Only those with a keen animal-like instinct know to avoid the narcissist.

Front side of the storm. The initial bands of wind and rain are shocking yet manageable. First-time hurricane survivors tend to let their guard down because they wrongly believe that this is the worst part of the storm. They might venture outside, posting pictures of bending trees, arrogantly assuming that others are overreacting. This is like a sucker punch. As the eye of the storm approaches, everything rapidly escalates as the winds intensify and the rain blows sideways in heavy sheets. Narcissists use the same tactic. The idea is to set their opponent off balance by allowing them to think the narcissist has thrown an initial powerful punch but they have not. It is the next punch that is the most dangerous.

Eye of the storm. Once again there is an eerie calm amidst blackness. Even if it is daytime, the sky is dark and low as the winds become silent and the rains cease (some hurricanes even have clear skies in the eye). Depending on the size and speed of the storm this can last for a few minutes to almost a half-hour. Make no mistake: it is the eye in the center of a storm that determines the strength. The more controlled an eye, the more powerful the storm. At the heart of every narcissist is a deep insecurity. Just like a hurricane, the deeper the insecurity the more controlling the narcissist. Just because a narcissist reveals that insecurity, it does not mean a person is safe from attack. Rather, the reverse is true especially as the back of the storm approaches.

Back side of the storm. The violent nature of the storm following the eye now seems to have been minimized in comparison to the front. Literally out of nowhere, things rapidly escalate to a level well beyond what was expected. This is when trees fall, loose objects become projectiles, roofs collapse, windows shatter, screened-in rooms cave, and flooding begins. As the bands of wind and rain sweep around the eye, their direction changes, causing even more damage. It isn’t over until the last band dissipates and the skies clear once again. Once a narcissist feels exposed or vulnerable (appearance of the eye), they attack with such force that it leaves a permanent emotional scar. This is the knockout punch.

Cleaning up from the damage. The light of the day brings clarity as to the extent of the damage. Some have more damage than others and worse yet some are completely devastated. Stories of survival are recounted, curfews are lifted, neighbors band together to help each other, electrical companies work overtime, once-blocked roads are cleared, trash is picked up off the ground, and a new normal ensues. But the memory of the storm lives forever so much so that even the mention of a pending storm clears grocery store shelves days in advance. This PTSD (post-traumatic stress disorder) reaction is common for anyone living in the area. So it is true also for anyone who has lived through a narcissistic relationship. The PTSD responses to new narcissists are normal as a person prepares for the worst.

Not all storms are like nor are all narcissists alike. Some are more powerful than others, some have greater influence, or some weaken just before impact. Nonetheless, it is good to be prepared and aware by planning for the worst and hoping for the best.


Christine Hammond is a Licensed Mental Health counselor who lives in Orlando and is the award-winning author of The Exhausted Woman’s Handbook.