Too few psychology training programs offer guidance on the nuts and bolts of opening and running a practice, such as how to find office space, choose an electronic records system and protect against malpractice claims. “Practice Management Insights” seeks to fill those knowledge gaps by giving psychology practitioners the support they need to provide high-quality services in today’s increasingly competitive marketplace.
Even though mental health practitioners often cover a wide variety of difficult subjects in their work, money can be an especially challenging topic to broach. So much so, that sessions can begin and end without even addressing fees or payment schedules with clients. Financial wellness is tied to mental health, and we need to learn to talk about it, according to clinical psychologist Mary Gresham, PhD, who recently addressed a group of psychologists gathered in Atlanta, Ga., for APA’s second local networking event, monitorLIVE. monitorLIVE events connect psychology professionals and thought leaders so they can learn about and discuss issues that impact and elevate the discipline.
Dr. Gresham noted that mental health practitioners have models of good marriages and good communication to teach to clients, but they may lack good models of financial wellness. Most leave money matters to finance professionals, even though mental health practitioners should be the ones applying therapy to the field, she said. While financial planners may take a class in coaching, they haven’t studied behavior, relationships, or any of the other deeper issues related to financial wellness. This, Dr. Gresham believes, is where psychologists can step in and effectively address those issues.
One way to begin addressing financial wellness with clients is through the use of schema—a cognitive framework that can help in the understanding of the concept. Doing so will allow you to interpret implicit and explicit beliefs about money and how they can impact individuals’ lives.
Dr. Gresham explained that money beliefs begin early, at about age three or four. She provided an example—a child thinking money grows in one’s pocket. Practitioners can address these misnomers in the context of behavioral finance, developed by the work of Daniel Kahneman and the late Amos Tversky, which examines how individuals make errors in their thought process around money, like believing money grows on trees or, in Dr. Gresham’s example, in a pocket. Behavioral finance explores how rational or irrational one can be about money matters, such as choosing to take one dollar today to immediately satisfy your desire for money, or taking $1.10 next year, which is actually a 10 percent increase, but might not feel like it.
Dr. Gresham went on to say that schema development depends on cultural beliefs, like thinking rich people are bad and poor people are good (or vice versa), or believing that if you work hard, money will come to you. These beliefs affect us, but they are simplistic, and we need to develop them to make them more sophisticated. This necessary development can happen through research on the cultural differences having to do with money, like the particular rules and customs about money that exist within the families of first-generation immigrants,such as not paying interest on a loan, and how those rules differ from cultural norms here in the United States, where borrowers might not like it, but interest is acceptable.
Another area in behavioral finance Dr. Gresham discussed with the audience is financial trauma. Even though many people suffer from financial trauma, whether they’ve lost everything in bad investments, or because of a spouse’s spending habits, there is not enough research on how to assist people with those experiences. “How do you help people come back from financial trauma and rebuild their lives? We need that research,” she said.
During her conversation, Dr. Gresham also touched on gender issues around money, such as women having lower financial levels of literacy than men and the lack of encouragement of women to enter the financial planning field.
She also noted that practitioners must examine money issues in their own lives, pointing out the costs associated with getting an education in the field and the need to understand what it means to be a self-employed business person by learning to communicate fees and by researching market rates, insurance rates, and retirement plans. Dr. Gresham suggested APA’s Division 42 and the book, “Handbook of Private Practice: Keys to Success for Mental Health Practitioners.”
Keep an eye out for future monitorLIVE events coming to a city near you.
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From the solo practice to the large group practice, whether for profit or not-for-profit, the concepts presented in this series can help strengthen the organization in which services are delivered. *This series is eligible for CE credit. Earn 1 CE credit for each session.
The four 90-minute programs focus on:
How to Create and Implement a Vision for Your Practice
Learn about creating an over-arching vision for your practice and how to use it to guide both clinical and practice/administrative decisions.
Managing Staff and Organizations in Support of Practice Excellence
Learn how to promote excellence in service delivery via employment contracts, policies and procedures, and mentoring to advance staff development.
Expanding the Scope of Your Practice to Address the Needs of the Community
Keep your practice relevant by positioning it to meet the changing needs of the community you serve.
Practice Health Metrics
Keep your practice thriving and growing by tracking your basic metrics (accounts receivables, referral patterns, productivity, etc.), thus assuring the overall health of the practice for the future.
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When Pamela Hays, PhD, began her psychology career, she tried to do it all: clinical work, writing, research and teaching. But she couldn't sustain it. After a decade of going full tilt, she developed neck problems and carpal tunnel syndrome so severe she had to start using a voice-activated computer system.
"I was driven," she says. "But I drove myself into health problems I couldn't ignore anymore."
Hays, now a clinical psychologist practicing in Soldotna, Alaska, might be an extreme case. Or maybe not. Work-life balance is something that many psychologists struggle with.
The unfortunate irony is that psychologists know better than anyone the importance of making time for self-care. "We talk about it a lot with patients, but we don't practice what we preach," says Chelsi Day, PsyD, a behavioral health provider at Windrose Health Network in Indianapolis.
Psychologists might even have a false sense of invulnerability, says John F. Christensen, PhD, a psychologist in Corbett, Oregon, and past co-chair of the APA Advisory Committee on Colleague Assistance (ACCA). "We study burnout and think that applies to the people we're trying to help," he says. "In fact, health is on a continuum, with well-being at one end and burnout at the other. And most of us, during a professional career, slide back and forth on that continuum depending on what's going on in our lives."
Finding balance, however, is easier said than done. "The sin of the early 21st century is being nonproductive," Christensen says. "We're conditioned by our culture to equate value with productivity."
Of course, as psychologists well know, no one is as productive as they can be when they are exhausted and overworked. Burnout is a legitimate phenomenon, marked by feelings of emotional exhaustion, depersonalization and a diminished sense of accomplishment. "When we move into burnout, we get impatient, we treat others as objects, and we start treating ourselves as task-processing machines," Christensen says. "Our empathy tank has run dry."
For psychologists in clinical practice, neglecting well-being can even impair professional competence, making the matter an ethical concern. As Erica H. Wise, PhD, a psychologist at the University of North Carolina at Chapel Hill and current co-chair of the ACCA, argues in a recent article, it's much harder to stay competent when you're burned out. "Competence … is an essential ethical obligation and provides a critical link between ethics and self-care," Wise and her colleagues conclude (Professional Psychology: Research and Practice, 2012).
Unfortunately, there's no one-size-fits-all strategy for achieving personal-professional equilibrium. Stressors and obligations are different for everyone, and they also change over the course of an individual's life. "It is important for psychologists to stay attuned to these issues throughout their professional life span, since personal and work-related stressors tend to shift over time," Wise says. "Work-life balance isn't a once-and-done thing."
Some people start by establishing a career with some balance built in. Day, a sport psychologist, recently decided not to pursue an opportunity that she described as a dream job — building a counseling and sport psychology center at a Big 10 school. Although the opportunity thrilled her, after she factored in the long commute, the fact that she'd be on call 24 hours a day and her desire for personal and family time, the job didn't sound quite so dreamy. "Work-life balance is important to me," she says. "I don't want to burn out in 10 years."
After working herself into physical health problems, Hays left academia and moved back to her home state of Alaska to start a clinical practice. She joined a yoga class and a book group, started spending more time with family, and wrote the 2014 book "Creating Well-Being: Four Steps to a Happier, Healthier Life."
But finding balance doesn't necessarily mean you have to change jobs (or move to Alaska). You can start by taking a critical look at your commitments.
Wise recommends doing either formal or informal self-care assessments, which can remind you of your goals and help you figure out which daily activities energize you — and which feel like a slog. "From that, you have critical information that you can factor into your choices about your personal and professional activities," she says.
Jim Davies, PhD, a faculty member at Carleton University in Ottawa, says that for him and many of his colleagues, a lot of work commitments are self-imposed. "They are projects we are passionate about and take on whether we have the time to commit to them or not," he says. "We're too busy because we're overcommitted, not because our jobs are too onerous."
Davies uses a rigid strategy to balance personal and professional time. Every morning, he fills in a detailed spreadsheet with activities for each half hour of his waking day. "Crucially, I also schedule in my breaks," he says — including lunch, coffee breaks and even daily naps. "For me, prioritizing life means putting it in the schedule like all the other important things."
Still, for many people, time management isn't really the problem, says Sandra Lewis, PsyD, a clinical psychologist at Montclair State University in New Jersey and founder of The Living Source, a company that helps clients improve well-being and achieve their goals. "People focus a lot on time management, but I think in terms of personal energy management. If you have enough energy, you make better use of your time," Lewis says. "In the same way we charge our cellphones, we need to charge ourselves."
Yet when we're overextended, even activities that energize us can feel like one more item on an endless to-do list. So Wise suggests taking advantage of smaller moments. You might not have an hour to go to the gym, but you could take a 10-minute lunchtime walk. If you can't fit in a yoga class, take five minutes between appointments to breathe or stretch or meditate. "Find self-care strategies that you can integrate in rather than add on," she says. "Honor the smaller things."
While such strategies are helpful, more needs to be done to change the culture of workplaces from the top down, says Christensen. Too many organizations value busyness and productivity at the expense of their employees' well-being, he says. "Often in this kind of professional workplace, when you're working with other smart, committed people, the way to excel is to overwork."
Christensen has been collaborating with health-care systems in Oregon to measure well-being among clinicians, including physicians and psychologists. He's optimistic that many such organizations are starting to realize that helping employees avoid burnout is not only good for employees, but also for patients and the financial bottom line. That kind of sea change is crucial for making work-life balance more attainable, he says. "The things we as individuals can do will take us only so far."
Meanwhile, Wise argues that instead of focusing only on reducing stress, the field of psychology should do more to promote and maintain well-being broadly. "We need a more positive vision," she says. "As a profession, whether we practice or do research, whether we're being mentors or treating patients, we need to be aware that keeping ourselves healthy is important."
- Hays, P. H. (2014). Creating well-being: Four steps to a happier, healthier life. Washington, DC: American Psychological Association.
- Walsh, R. (2011). Lifestyle and mental health. American Psychologist, 66(7), 579–592. DOI: 10.1037/a0021769
- Wise, E. H., Hersh, M. A., & Gibson, C. M. (2012). Ethics, self-care and well-being for psychologists: Reenvisioning the stress-distress continuum. Professional Psychology: Research and Practice, 43(5), 487–494. DOI: 10.1037/a0029446
By Kirsten Weir
- This article was originally published in the July/August 2016 Monitor on Psychology
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Whether it's a gathering of health-care providers, faculty, students or a mix, here's how to make your meetings productive
"The next thing you know, the weight of the crappy meeting is higher, and it can spill over into other areas of work," he says.
How can everyone make meetings more effective, even enjoyable? The best gatherings happen when meeting leaders view themselves as stewards of everyone else's valuable time, says Rogelberg. Good stewards plan meetings thoughtfully, manage group dynamics, find out in advance why people want to meet and promote other people's contributions rather than their own.
Here is more wisdom from experts for attendees and leaders on how to meet-up better.
Be on time. Arriving late to meetings undermines productivity from the start—and upper management members are often the worst offenders, says Daniel Post Senning, co-author of "The Etiquette Advantage in Business" and great-great-grandson of manners guru Emily Post. "Often, they believe the rules don't apply to them."
Lateness may cause more than irritation: In a paper under review, Rogelberg and Joseph Allen, PhD, found that when a person showed up less than five minutes late for a meeting, productivity didn't suffer. But when an attendee or leader showed up five to 10 minutes late, "satisfaction, effectiveness and productivity of the meeting dropped dramatically," says Allen, an associate professor of industrial-organizational psychology at the University of Nebraska at Omaha.
Wallace Dixon, PhD, psychology department chair at East Tennessee State University, leads by example by starting and ending his monthly faculty meeting precisely on time. "If you don't, you insult the people who got there on time, reward the people who got there late and convey to everyone their time isn't that important," he says.
Be prepared. Arriving "late, frazzled, with nothing but a leaky coffee cup doesn't leave a good impression," Senning says. Bring something to take notes with and a steady attention span. Complete any assigned reading in advance. "Nothing is worse than showing up to the meeting and finding that no one has read the documents that [you sent, and] you then have to explain to everyone what they should have read," says Allen.
Make your phone (mostly) invisible. Despite the leave-the-device-at-the-door practice made popular by President Obama and Amazon, in most settings it is considered OK to bring your smartphone to meetings if you keep your attention on the speaker, says Senning. He recommends telling people in advance if you plan to use your phone to take notes or images of PowerPoint slides. But if people are gravitating to their devices in meetings, it may be a sign that the meeting needs to be more engaging, says Rogelberg. "Devices are signals," he says. "Psychologically, the person is trying to regain control of the time."
Diversify the discussion. No one attendee should monopolize the conversation—and no good facilitator should let anyone do it. Dixon says he will pull faculty aside later if they are talking too much in meetings because it bothers other staff and "they will lose faith in you as a leader if you don't handle it," he says. All attendees can share in that responsibility by making an effort to contribute even if public speaking isn't their forte, says Allen. His research has shown that when people make an effort to participate in a meeting—especially when there is a decision-making component—they are happier with the meeting's result and the meeting is more effective.
Move it along. Dixon places a time limit on each discussion item when he plans his faculty meetings and enforces those limits with his smartphone's timer. Another way to prevent run-on discussions and create a sense of urgency, Rogelberg says, is to switch from hourlong weekly or monthly meetings to shorter, more frequent "huddles": 10- to 15-minute meet-ups designed to save time and boost efficiency. If a leader has a difficult time staying on task, any attendee can help move a meeting forward by tactfully redirecting his or her attention to the agenda, says Allen.
Be constructive. Meetings can unravel when attendees cut one another off, dismiss each other, hold side conversations or argue. Avoid such tension, such as by saying, "I agree with some of what you're saying" instead of a short-tempered, "I just don't agree with you," says Brenda Fellows, PhD, of the Haas School of Business, University of California. Along those lines, Dixon advises the department chairs he mentors never to put a contentious issue to a vote in a meeting because it makes people uncomfortable. "Voting only divides, it never unites," he says. "When you resort to a vote, you have stopped talking."
Yoerger, M., Crowe, J., & Allen, J.A. Consulting Psychology Journal: Practice and Research, 2015
Meeting Design Characteristics and Attendee Perceptions of Staff/Team Meeting Quality
Cohen, M.A., Rogelberg, S.G., Allen, J.A., & Luong, A. Group Dynamics: Theory, Research, and Practice, 2011
"Not Another Meeting!" Are Meeting Time Demands Related to Employee Well-Being?
Rogelberg, S.G., Leach, D.J., Warr, P.B., & Burnfield, J.L. Journal of Applied Psychology, 2006
By Jamie Chamberlin
This article was originally published in the December 2016 Monitor on Psychology
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The set of measures is useful for both researchers and clinicians alike—and can save money and time over traditional tools
For years, neurobehavioral researchers often couldn't compare data across studies or even within the same longitudinal study because they lacked a "common currency" for collecting data on various aspects of research participants' functioning.
"People used all sorts of different measures and assessments," says Molly V. Wagster, PhD, a psychologist who heads the behavioral and systems neuroscience branch in the National Institute on Aging's neuroscience division. And because there were different tests for different age groups, she says, "people had to resort to all sorts of different measures to follow someone over a period of time." Plus, she adds, researchers looking for quick-and-easy assessments sometimes resorted to tools designed for diagnosing disorders, not assessing function.
Now all that has changed, thanks to the National Institutes of Health's creation of the NIH Toolbox® for Assessment of Neurological and Behavioral Function. Developed by more than 250 scientists, many of them psychologists, the toolbox offers brief measures—some already existing and some created especially for the project—for assessing cognitive, emotional, sensory and motor functioning in research participants ages 3 to 85.
Introduced in 2012 and adapted for the iPad in 2015, the NIH Toolbox offers researchers a comprehensive set of tools for collecting data that can be compared across existing and future studies, says Wagster, the lead federal project officer for the toolbox.
The NIH Toolbox saves researchers time, says psychologist Richard C. Gershon, PhD, the NIH Toolbox's principal investigator and a professor at Northwestern University's Feinberg School of Medicine. "You can administer the equivalent of a one- or two-day neuropsych battery in two hours," says Gershon. The complete cognition battery can be administered in about 30 minutes.
The toolbox can also save money, says Gershon. Take the test used to assess people's sense of balance, which could be used to gauge older people's risk of falling. "Our test arguably replaces between $10,000 and $100,000 worth of equipment with a $160 iPad," he says.
Clinical psychologists could find the NIH Toolbox useful, too, says Abigail B. Sivan, PhD, an associate professor of clinical psychiatry and behavioral sciences at Northwestern, who helped develop it. In the future, a clinical psychologist might use the toolbox's assessments to help distinguish between attention-deficit/hyperactivity disorder and anxiety, for example, or between Alzheimer's disease and normal age-related changes in memory, she says. Clinicians could also use the NIH Toolbox to track patients' progress over time, she says.
Available as an app at iTunes, the NIH Toolbox can be downloaded on up to 10 iPads for an annual subscription fee of $500. Users can try it out for free for 60 days.
For more information, visit www.nihtoolbox.org.
By Rebecca A. Clay
This article was originally published in the December 2016 Monitor on Psychology
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1. Practice mindfulness. Numerous studies have demonstrated that mindfulness has benefits for body and mind, reducing stress and depression and even boosting immune function. It can also be instrumental in maintaining work-life balance. In a study of working parents, psychologist Tammy D. Allen, PhD, found people with greater mindfulness reported better work-family balance, better sleep quality and greater vitality (Journal of Vocational Behavior, 2012). "Cultivating a habit of self-awareness is vital," says John Christensen, PhD, past co-chair of the APA Advisory Committee on Colleague Assistance. "One of the best things we can do is to develop a reflective habit of checking in with ourselves at least a couple times a day, taking note of the emotional ‘weather' without judgment."
2. Look for silver linings. H. Shellae Versey, PhD, a psychologist at Wesleyan University, found that when working adults looked for benefit in negative situations, they experienced fewer negative psychological effects from work-family conflict. The finding was especially strong for women. During stressful periods, for instance, it can help to think of work-family conflict as a temporary strain, and to focus on the payoffs, such as higher salaries and better opportunities. But lowering expectations and downgrading one's goals did not have that protective effect, she found (Developmental Psychology, 2015). The difference, she believes, is that positive reappraisal is a way of taking control, while downgrading goals can feel like giving up. "Lowering aspirations without having another goal or Plan B in mind could be detrimental," she says.
3. Draw from positive psychology. The principles of positive psychology can aid in psychologists' self-care, as Erica Wise, PhD, and colleagues described in an article on psychologist well-being (Professional Psychology: Research and Practice, 2012). Positive emotions can broaden cognitive, attentional and behavioral repertoires, she explains, which boosts resilience and facilitates well-being. One evidence-based way to boost positive emotions is to practice expressing gratitude on a regular basis.
4. Take advantage of social support. Seeking support from other people is critical to well-being. Geertje van Daalen, PhD, at Tilburg University in the Netherlands, and colleagues found that social support from spouses and colleagues can be especially important for reducing conflict from family obligations spilling over into the workday (Journal of Vocational Behavior, 2006). Connecting with professional colleagues can be especially important for psychologists, Christensen adds. "Many psychologists work in their own silos and have little contact with professional peers," he says. "That isolation can be a risk factor for burnout."
5. Seek out good supervisors. Unsurprisingly, sympathetic bosses can also be helpful — something to keep in mind if you're on the hunt for a new job. David Almeida, PhD, at Penn State University, and colleagues found people had more negative emotions and greater stress on days when work obligations interfered with family responsibilities. But those negative effects were buffered by supportive supervisors (Journal of Marriage and Family, 2016).
6. Get moving. A robust body of research has shown that exercise can boost mood in the short term, and in the long term can improve symptoms of depression, anxiety, addictive disorders and cognitive decline.
7. Go outside. Spending time in nature has been linked to improved cognition, attention, mood and subjective well-being. It also appears to reduce symptoms of stress and depression, as Roger Walsh, PhD, a psychologist at the University of California, Irvine, described in a review of lifestyle changes and mental health (American Psychologist, 2011).
8. Make your life meaningful. In his American Psychologist article, Walsh also described the benefits of seeking meaning — whether through religion, spirituality or volunteer service. "We do our best work and live our best lives when we have a sense of meaning — a feeling that what we do extends beyond us and brings good to others," says clinical psychologist Sandra Lewis, PsyD.
- This article was originally published in the July/August 2016 Monitor on Psychology
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Nix the glass table and fill the room with light. These and other research-based design insights for therapists' offices can reap client benefits
Doherty's space is a good example of today's direction in health-care design, which uses research on human behavior and design principles to promote positive interactions between therapists and clients.
"A space should be something that supports you as you try to achieve specific goals," explains Sally Augustin, PhD, an applied environmental and design psychologist and founder of Design with Science, an international consulting firm. For therapy offices, that means creating a calm and refreshing environment to balance the rigorous mental and emotional work of therapy, she says.
Well-designed therapy offices also exude softness, personalization and orderliness, finds research by environmental psychologist Ann S. Devlin, PhD, of Connecticut College, and urban planning researcher Jack L. Nasar, PhD, of The Ohio State University. In their research examining people's reactions to 30 photographs of actual therapy offices, the more a space exhibited those characteristics—cozy elements like comfortable chairs and soft pillows, attractive touches like artwork, and neatness—the better people felt about the offices and the therapists who worked there, they found (Professional Psychology: Research and Practice, 2012).
In addition, good therapy office design should take into account the human instinct to protect ourselves and our territory—a feature that may be particularly important to consider with vulnerable therapy clients, Augustin says. "We are animals, after all," she says. "We do our best mental work when we feel a little bit protected."
So, given such insights how should practitioners design an office from scratch or redo a space that's seen better days? Specifically, therapists should:
Keep it light. The color of the office walls sets a tone. Wall colors in light, soothing colors like sage green or dusty blue promote a sense of calm and relaxation, environmental designers say.
Go with the grain. For reasons that aren't entirely clear, people prefer natural-colored wood with a grain rather than nongrain surfaces, research finds. People also feel more comfortable with wood than with slicker options like glass and chrome, Augustin says.
That said, there's a limit to how much wood you should use: Research shows that when natural wood surfaces like floors and walls exceed 45 percent of a room's surface, they start losing their stress-busting effects.
Let the sun shine in. Natural light is a big mood booster, so when possible, incorporate windows or skylights, says Dawn Gum, director of interior architecture at the national firm EwingCole. If windows are at eye level, the best views look out on calming, natural scenery, not onto bustling sidewalks or roads with distracting sights and sounds.
If your office lacks windows, use floor and table lamps with soft lighting rather than overhead fluorescent lighting to promote a feeling of comfort and coziness, says Gum. Some lightbulbs even simulate natural light, which can boost the positive ambience of windowless offices.
Embrace the natural. Bringing nature into the office—whether with plants, nature embodied in artwork, decorative objects or views of plant-filled courtyards and landscaped areas—can enhance the healing quality of a space. "Just looking at landscaping has been shown to lower blood pressure," Gum says.
The right nature-based artwork can also give clients a way to muse on life situations, these experts add. Images of a pathway through a serene landscape or a bench in the middle of a pleasingly landscaped garden can foster relaxation or allow clients to make mental associations with the imagery. But, Augustin cautions, avoid nature imagery that's confusing, chaotic or complex. "You want to look at a scene that would be comfortable to enter," she says.
Use positive distractions. Fish tanks in medical offices are somewhat cliché, but they may have empirical merit—they're an example of so-called "positive distractions," a phenomenon noted in many research studies (see Resources below). A glance into the tank, or at other inviting sights like art of pastoral landscapes, can provide a respite from talking about weighty issues. "You want views that draw you in and give the part of your brain that has to focus a mini break," Augustin says.
Promote your expertise. Displaying your credentials might seem self-serving, but clients want to see signs of your expertise, research also finds. In a study by Devlin and her students, participants looked briefly at photos of therapy offices with zero, two, four or nine diplomas on the wall. People rated therapists who worked in offices with four and nine credentials most favorably, with little difference between the two (Journal of Environmental Psychology, 2009).
Have your client's back. An evolutionary perspective can help you make intelligent decisions on what is arguably the most important element in your office: the client chair.
To support people's need for control, consider having chairs that can be moved or are large enough to let people shift to one side or the other and adjust the distance between themselves and the therapist. If any of your clients have histories of being physically violent, make sure chairs are heavy enough that they can't be easily picked up and thrown. Likewise, chairs with backs at shoulder height can facilitate a feeling of protection, environmental design researchers add. Other ways to promote a sense of personal safety include placing a plant behind the chair and positioning chairs so clients can see the door.
A related suggestion: Place small tables next to client chairs, which can enhance clients' sense of "territory" by giving them a place to put personal items. Your clients will appreciate that you've attended to their comfort and convenience, says Lynn Bufka, PhD, APA's associate executive director of practice.
Foster communication. If you use tables in your office for individual or family sessions, research shows that round tables support better communication and sense of control than square or rectangular ones, says EwingCole's director of research, environmental psychologist Nicholas Watkins, PhD. Also, the presence of computers is shown to impede communication, particularly when the client perceives that the provider is paying more attention to the computer than to him or her. Screen-sharing strategies—technology that enables you to project information onto a table, for example, or simply facing the screen toward clients—can promote clients' sense of trust and inclusion, Watkins notes.
Go with the flow. Anything that promotes flow and efficiency in your immediate and larger office space is worth addressing, according to research compiled by APA's Practice Organization. Keeping a clean, uncluttered desk and placing the items you need closest to you—computer, phones and appointment book, for instance—can help you keep a clear head and feel in charge of your space.
Experts also recommend walking through the functions of your day to identify areas of inefficiency for yourself, your staff and your clients. Fixes can be small and no cost—moving the location of your assistant's desk, for example—or more extensive, like knocking out a wall to create better traffic flow.
Not too fancy, not too shabby. When selecting furniture and finishes for your office, keep client demographics in mind, adds Gum. In general, people feel most comfortable with a middle range of furnishings—those that aren't overly fancy or expensive, but not cheap or shabby, either.
"If you're putting in very expensive materials but your clientele is not at the upper end of the socioeconomic spectrum, you can alienate people," says Gum. Conversely, old or poorly made furnishings can make it look like you're not doing well—the wrong message to send clients.
Put your client first. Remember that you're designing your office more for your client than for yourself, Gum emphasizes. Including some personal elements can be subliminally comforting to clients, but make sure they don't overpower a sense of neatness and calm, she advises.
On a related note, make sure your furniture addresses the specific needs of your clients, says Bufka. If children are among your clientele, make sure you have age-appropriate toys and chairs that are the right size. Be sure that chairs are comfortable for people of all sizes.
Including art that demonstrates your openness to different cultures can also be a plus, particularly if you serve multicultural clients, finds research by Devlin and colleagues (Professional Psychology: Research and Practice, 2013). When the team compared reactions of white college students and mainly ethnic minority adult community members to photos of a therapist's office, the community group rated the therapist more favorably when the art was more ethnic in flavor than Western. "If all of the artwork clients see ... represents a tradition different than their own, it is possible for them to feel unwelcome," the authors write.
Hire a pro. Finally, consider hiring a professional to help you, preferably a qualified architect or interior designer who specializes in health care (see "Tapping design help" below). He or she can help you map out how you actually work and how you want to work, and craft your space accordingly. They also know what's available in furniture and finishes, and about the changing landscape of health care, including new technologies.
Investing in good office design isn't just about creating an attractive space, it's about investing in your business and professional calling, adds Gum.
"If it's designed right," she says, "your office can help you deliver care in ways that really do promote your clients' well-being."
Interested in the link between psychology and design? Check out the work of APA Div. 34 (Society for Environmental, Population and Conservation Psychology), which among its foci explores behavior and the built environment. Learn more about Div. 34 at www.apadivisions.org/division-34/index.aspx.
Center for Health Design
The knowledge repository of research and resources on health-care design topics. www.healthdesign.org/search/articles
Transforming the Doctor's Office
Devlin, A.S. Routledge, 2014. Includes a section on therapists' offices.
Tapping design help
- For architects, seek professionals certified with EDAC, the Evidence-Based Design Accreditation and Certification, the certification for members of the Center for Health Design.
- For interior designers, find someone certified by the NCIDQ, the National Council for Interior Design Qualification. Look for designers who work in commercial spaces with a health-care focus.
By Tori DeAngelis
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These systems streamline practitioners' paperwork—and are no longer as intimidating or expensive as they once were
"In a small practice, there's not a lot of space to store paper records," says Prescott, a member of APA's Committee for the Advancement of Professional Practice. "And it takes time to file those records." Plus, she says, patients expect electronic records, just like they see in medical offices.
But, she says, figuring out how to make the transition has been a time-consuming struggle. Should the practice buy a server—with all the expense and upkeep that entails—or go for a cloud-based product? The cloud offers protection from fires or burglary, but is it secure enough, especially since a breach of confidentiality could be particularly devastating to the reputation of a rural practice? How long would it take the Prescotts and practice manager Ruth Siebert to learn a new system? Answering these and other questions has proven so difficult that Prescott now hopes to make a decision some time during the new year.
Electronic health records are worth the hassle, says Lynn Bufka, PhD, associate executive director of research and policy in APA's Practice Directorate. In addition to offering "less paper, less filing, less cabinet space," she says, electronic records make it possible to access files remotely. It's easier to share records with patients or other providers when you can just click a button to print a copy or save to a flash drive instead of copying page after page of paper records. And thanks to the security measures you can put in place, such as automatic monitoring of who accesses what information and for how long, electronic records may actually be better at safeguarding confidentiality than paper ones, says Stacey Larson, JD, PsyD, a consultant who works with APA on legal and regulatory issues. "You can see if Joe Schmo accessed the record," she says. "You might not know if someone got into the file cabinet."
The federal government is also pushing the use of electronic health records, with the hope that "interoperable" records that can communicate not just within but across practices and health-care systems will reduce redundancies and improve care by ensuring that all providers involved in a patient's care have access to test results and treatment plans. Down the road, says Bufka, referrals from other health-care providers or even payers may even come via electronic records.
Given those advantages, how can you make the process of selecting a system easier? Bufka and others suggest the following steps:
Conduct a needs assessment. Think about the capabilities your practice needs in addition to such basic functions as billing and scheduling, says Bufka. If your office offers testing services, for example, determine whether the record can store the resulting data. If you'll be storing psychotherapy notes on the system, you'll need "data segmentation," which allows those notes to stay hidden when a record is shared. Also consider who will be using the system. If your practice includes a psychiatrist or another professional who can prescribe, you'll want a system that includes electronic prescribing. You might find other features—an internal email system or a web portal for patients, perhaps—attractive.
Set a budget. Many solo or small practices worry that electronic health record systems will be prohibitively expensive, says Larson. The high prices many people have heard about came from early adopters, she says. "There weren't as many options back then, so they adopted big, big systems," she says. Others may have invested in new servers to run their systems or opted for systems with all the bells and whistles small practices may not need, such as prescribing portals in practices where no one can prescribe, she says. Systems—especially cloud-based ones—are now much more affordable, she says, adding that she has seen ones that cost as little as $50 a month to use.
When you're looking at prices, make sure you're looking at all the costs involved, not just the initial start-up costs. Other costs may include training and monthly subscription fees either for the practice as a whole or per provider.
Ensure patient privacy. "Be knowledgeable about how data are stored," says Bufka. "There's not necessarily a right or wrong answer when it comes to cloud versus localized storage, but you'll want to know the pros and cons."
Privacy is the main issue Prescott is struggling with as she searches for the right system for her practice. Cloud-based products seem very secure, she says, and the vendors would assume much of the responsibility for complying with the Health Insurance Portability and Accountability Act (HIPAA). (With a server-based system, she explains, responsibility for HIPAA compliance rests on the practice.) "Even though there are a lot of arguments that records are more secure on the cloud, many people are uncomfortable with private information being placed in the cloud," she says. "You read in the paper all the time about things being hacked." While keeping records on a server within the building would probably be best for her, she adds, it's a much more expensive option.
Review your options. If you're already using practice management software, ask the vendor about electronic health record software that's compatible so you can stick with what you're already comfortable with, suggests Larson.
If that's not possible, ask colleagues whose practices have needs that are comparable to yours what system they like, says Prescott. A colleague who touted one brand turned out to like it because of its billing feature—a nonissue for Prescott's practice, which requires patients to pay up front.
You can also view options online through an aggregator site, such as www.capterra.com, which brings together information on hundreds of electronic health record systems, including about 150 systems specifically designed for mental health professionals. "You can type in what you want, and it spits back options," Larson says.
Test the system and the vendor's technical support. Be sure to try out an electronic health record system before you commit, Larson emphasizes. Once you've got your choices narrowed down to two or three, contact each vendor and ask them to walk you through their systems. Many will even let you test demos online. "If your practice isn't tech-savvy, choose a system that's more intuitive and has good customer support," says Bufka. Also ask what kind of support you'll have as you learn the system. And remember that you can always call APA and the APA Practice Organization staff for advice. "It has been super-helpful to talk with different staff members about the research they've done," says Prescott.
Visit APA's Practice Central and search for "electronic health records" to watch a video on using electronic health records.
Learn more about contracts for electronic health records at the federal government website.
By Rebecca A. Clay
This article was originally published in the January 2017 Monitor on Psychology
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This article looks at the new threats to client data, discusses the ethical considerations psychologists face, and advocates for the foundation of best practices to prevent breaches of client data.
The NSA has built an infrastructure that allows it to intercept almost everything . . . . I can get your emails, passwords, phone records, credit cards.”
— Edward Snowden
Protecting clients' privacy is clearly one of psychologists' top ethical priorities. To help prevent disclosures of patient information, APA offers specific guidance in its Ethics Code (APA, 2010) and its "Record Keeping Guidelines" (APA, 2007).
Unfortunately, with today's ever-evolving technology, such guidance may not be enough. As Edward Snowden showed the world in 2013, information on cloud storage centers is not secure (Gellman & Soltani, 2013; Greenwald, 2013).
This article gives an overview of the current record-keeping and communication regulations and guidelines, looks at new threats to client data, discusses the ethical considerations psychologists face, and advocates for the foundation of best practices to prevent breaches of client data.
From pen to keyboard
In 1965, Intel Corporation co-founder Gordon Moore successfully predicted that circuit technology would double every two years and lead to exponential growth while reducing the size of everything. This became known as Moore's law.
Since then, personal computers and smartphones have become ubiquitous and nearly 3 billion people have Internet access. This pervasive accessibility affects both practitioners and clients. Today, communication with a client can occur via text and/or email. Metal file cabinets have evolved into encrypted digital containers. Record keeping can be entirely digital.
In response to this revolution, over the years U.S. agencies have sought to provide legislative frameworks for the proper handling of private information. Among them is the Health Insurance Portability and Accountability Act (1996; HIPAA), which sought to increase the accessibility of medical records while maintaining confidentiality. The law calls for health providers to "maintain reasonable and appropriate administrative, technical and physical safeguards" when using electronic health information (HIPAA, 1996).
In 2003, the Department of Health and Human Service (HHS) provided security standards for health-care providers, including psychologists, who transmit private health information. The standards mandate that providers must take precautions to prevent a breach of data and that they conduct risk analyses. These regulations also apply to providers' business associates — practicing psychologists who operate with insurers must follow HIPAA's privacy and security rules and ensure that their business associates do so as well.
In 2009, The Health Information Technology for Economic and Clinical Health Act (HITECH) formalized business associate liability and offered stricter regulations for using client records. This law placed the burden of security on a business associate to meet security and privacy requirements. In addition, business associates are expected to provide notifications of any breaches to the entities they cover and are subject to civil and criminal penalties for the misuse and/or loss of data. For practitioners, this means if they sign a business agreement with a business associate to store client records or materials in a cloud environment, the associate must meet HITECH requirements.
APA's record-keeping guidelines
While APA's Ethics Code provides ethical principles and standards for psychologists, it does not provide specific record-keeping guidelines. That guidance comes from APA's "Record Keeping Guidelines" (2007), which highlight the many interactions that practitioners have with the health-care system and federal regulations, such as HIPAA. For this article, we are particularly interested in guidelines 3, 6 and 9 (of 13), which focus on the topics of security, privacy and confidentiality:
Guideline 3 deals with confidentiality of client records. This recommendation states that practitioners should be aware of the regulatory and legal requirements that involve records.
Guideline 6 outlines the security measures that psychologists should engage in to protect those records. If practitioners create physical records, they should protect them with key and cabinet. If they use digital records, practitioners should properly secure them.
Guideline 9 informs practitioners on the use of electronic records. APA analogizes electronic to physical records and states that practitioners should be concerned with the use of e-mail and other communication tools because of the possibility that they can been seen by others.
These guidelines are not enforceable; they only offer guidance to practitioners.
Unfortunately, neither the federal government nor APA has proffered specific steps that should be taken to increase privacy and confidentiality to meet the challenges created by today's technology. The current guidelines only state that practitioners should use "passwords, firewalls, data encryption and authentication" (APA, 2007, p. 998). Although these recommendations would better secure systems, they do not establish directions and specific methods for creating secure passwords, activating firewalls or using data-encryption techniques, and they do not explain what authentication protocols are.
Providing specific guidelines that are constructed and updated regularly might alleviate part of the burden on practitioners to prepare for and understand growing threats to client privacy.
Threats to client privacy
Many psychologists are embracing email and text messaging to communicate outside of therapy sessions. Some, too, are writing notes in electronic medical records that rely on local, network and/or cloud storage. Others are interested in using smartphone applications and social networking interventions. And numerous practitioners see telehealth as a potential intervention and therapeutic delivery method (Colbow, 2013).
All of these uses of technology increase the risk to client privacy. These risks include:
Risks from individuals and collective actors: On Sept. 1, 2014, The Guardian reported that an individual or small group of hackers "exploited" celebrity Apple iCloud accounts, which stored phone data including emails, address books and photos (Arthur, 2014). Although celebrity data were the main targets, hackers could have compromised other individuals' accounts using similar methods. If a practitioner had chosen to communicate or store any records on Apple's iCloud platform, the information could have been compromised.
Information that is stolen via digital storage services is regularly sold on the "dark Web" — hidden websites that are inaccessible to most Internet users. Some medical records can be purchased for about $50. Similarly, if psychologists communicate with clients via smartphones and similar devices, those communications could be compromised with mobile malware that costs around $150.
Risks from corporations: Companies that provide cloud storage, email and communications services generally make money from mining personal data. Their privacy policies and terms of services can be complex, which can place a significant burden on psychology practitioners. For example, Facebook, like Google, uses social profiles for marketing and to provide users with related information. Facebook has expansive privacy policies to enable it to provide "relevant" advertising and learn about user habits. If a psychologist is communicating protected health information on these platforms, the corporate entity would have knowledge of client contact. Certain companies provide stronger privacy policies for communication. For instance, Apple's iCloud service does not mine emails for content. Most providers do not encrypt emails at rest (on cloud servers), allowing companies to more easily hand over message contents to third parties (Apple Inc., 2014a).
Another concern is data retention. Most cloud storage and communication providers say little about how long they keep their data. This amorphous data-retention policy stands in contrast to APA's record-keeping guidelines, which suggest that client records and data may be destroyed after seven years in the absence of superseding legal requirements. This policy also calls into question a practitioner's ability to maintain and provide confidentiality and proper informed consent when using certain corporate providers. And it is questionable whether practitioners could ever believe that records had been deleted if the cloud provider did not clearly and publicly state its data-retention standards.
Risks from the government: A variety of governmental entities interact with client data. As Edward Snowden and journalist Glenn Greenwald revealed in 2013, NSA analysts were able to access private cloud data centers from Google and Yahoo (Gellman & Soltani, 2013), which could have compromised protected health information and other client data.
Email at public universities is also at risk. Anyone can request the emails of public university staff members through a Freedom of Information Act (1966) request. Although some universities and colleges defend against open access to communication, email-based consultations between providers (that do not contain protected health information) might not be as protected as messages conveyed through patient files and electronic medical records would be.
Client information may also be inadvertently compromised as a result of the Stored Communications Act (1986), which was created before the Internet, email and personal computers became the tools of everyday life. The law states that email left on Web servers for over 180 days is considered abandoned. That "abandoned" data can be requested without formal judicial review. In addition, beyond surveillance by the NSA, the Federal Bureau of Investigation is permitted to access email in certain situations without first notifying the person under investigation (Counterintelligence Access to Telephone Toll and Transactional Records, 2012).
Various principles and standards in APA's Ethics Code are imperiled by the use of electronic storage and communications. In particular, psychologists should be aware of Principle E and Sections 2, 4, 6, and 10 of the Ethics Code.
Principle E (Respect for People's Rights and Dignity) provides a foundation for privacy and confidentiality. This principle recognizes the need to protect these rights and to safeguard clients' trust. Because of emerging threats to privacy, client data may be underprotected, regardless of current policies.
Section 2 of the Ethics Code focuses on ethical questions regarding competence. Of specific interest are Standards 2.01 (Boundaries of Competence) and 2.03 (Maintaining Competence). Standard 2.01 posits that psychologists must practice and provide services within their area of competence and that psychologists have an obligation to obtain training and/or support in areas that they are not familiar with, including technology. Shapiro and Schulman (1996) warned that accepting new technologies without critical, expert analysis might test practitioners' boundaries of competence. Similarly, Standard 2.03 outlines an expectation that psychologists will continue their education.
Taken together, Section 2 suggests that practitioners are expected to gain competence or support if they use privacy and security tools. Ethically, it may also be expected that practitioners continue to be informed about the various threats to client data.
Standard 4 may be the most relevant to the issue at hand because it explicitly outlines privacy and confidentiality expectations. As noted earlier, digitizing records and communications may lead to them being accessed by outside entities. This threat primarily affects two standards: 4.01 (Maintaining Confidentiality) and 4.02 (Discussing the Limits of Confidentiality). Section 4.02 establishes an ethical obligation to explain how certain record-keeping and communication practices may limit confidentiality. As a result, if psychologists use text messaging and email with a client, it might be ethically appropriate to talk about how these technologies may result in intrusions on privacy. In discussing the limits, it is important to consider how a client's information could be used against him or her. Psychologist-led discussions should facilitate evaluation of the appropriateness of certain disclosures on the basis of foreseeable client risk.
Section 6 specifies ethical obligations for record-keeping and fees. The standard of interest is 6.02 (Maintenance, Dissemination, and Disposal of Confidential Records of Professional and Scientific Work). The Ethics Code explains that within any medium, record storage and creation must be kept confidential. Moreover, if a practitioner needs to use shared records (such as in hospital settings), he or she should minimize the use of protected health information whenever possible to improve client privacy. Today's therapeutic interventions are performed in a variety of settings, and as technology becomes an important part of these, maintenance of confidentiality in record keeping comes into question.
Section 10 deals with concerns regarding therapy. According to Standard 10.01 (Informed Consent to Therapy), clients are to be informed of the limits of confidentiality and about communication methods available during treatment. If practitioners are interested in communicating via email and text, clients should be informed about these methods. Without a thorough informed consent process that covers these factors, client confidentiality cannot be properly founded (Everstine et al., 1980).
APA's Ethics Code and "Record Keeping Guidelines" inform counseling and record-keeping, but there are additional practices that psychologists can consider to further prevent breaches of confidentiality. To proactively help prevent privacy breaches and maintain client confidentiality, psychologists can:
Develop a threat model: Practitioners should create a threat model to assess each client and his or her practice's associated risk (Barrows & Clayton, 1996; Lee, 2013). The Electronic Frontier Foundation (2014) has suggested that such threat models contain five questions:
- What do you want to protect?
- Who do you want to protect it from?
- How likely is it that you will need to protect it?
- How bad are the consequences if you fail?
- How much trouble are you willing to go through to try to prevent those?
Practitioners could, for instance, answer those questions with the following responses:
"I want to protect client records and communications."
"I want to protect it from unauthorized government access and individual hackers."
"I am currently working with a public, political figure, who has expressed concerns regarding unauthorized disclosures and leaks of data."
"Considering the public nature of this client, my practice could be threatened and culpable for damages."
"I am willing to spend an additional hour per week to secure this individual's client records on an external, air-gapped computer."
In general, APA's Ethics Code and the "Record Keeping Guidelines" emphasize stronger protections. By asking these five questions, practitioners can reduce accidental and/or targeted attacks on client information.
Encrypt everything: If possible, every client record and communication should be encrypted. When mobile devices are used for client contact, it is important to consider the phone's encryption capabilities. Currently, iPhones, with a good password, can be encrypted and protected from password attacks for about 5.5 years (Apple Inc., 2014b). It is also possible for iPhones to encrypt iMessages (text messages between iPhones), which would only be accessible between sender and recipient. Older phones cannot generally encrypt messages.
The APA Practice Organization (2014) separated computer encryption into three parts: (a) full-disk encryption, (b) virtual-disk encryption and (c) file/folder encryption. Full-disk encryption provides protection for an entire system, but once a password is used, the entire file system is accessible. Virtual-disk encryption is an encrypted container that acts like a digital flash drive and is protected from access through encryption. These containers require a password after logging into the computer. The file/folder encryption option regards individual files. For instance, a Microsoft Office Word file can be password protected.
By using all three of these methods, a stolen computer would be protected at multiple levels and virtually inaccessible.
The chief technology officer of the Freedom of the Press Foundation and technologist for The Intercept suggests disk encryption, firewalls, strong passwords (never renew or use the same) and cryptology to communicate when possible. For example, Apple computers come with built-in full-disk encryption via FileVault. In addition, by using a strong, 8- to 10-character password with special symbols, varied capitalization and avoidance of dictionary words, practitioners can have an encrypted and well-protected computer.
For instance, Google Apps uses various standardized security certificates to ensure data safety and retention. Even if practitioners choose to be responsible and HIPAA compliant, files should still be encrypted. Devereaux and Gottlieb (2012) recommend that if cloud providers encrypt data, this process should meet the need for "reasonable conduct" and protection of records.
This argument is predicated on trust. A cloud provider that encrypts data but still has access to encryption keys would be forced to decrypt this information if compelled by the federal government. Likewise, if a private employee or contractor was given the key, they could potentially decrypt data unlawfully. Any cloud storage used should be backed up locally and completely encrypted prior to upload. There are a variety of encryption software packages available; one example, a cross-platform option, is TrueCrypt.
Use two-factor authentication: This authentication method requires psychologists to first enter a password and then a six- to eight-digit "token" to log onto a site. If a password were lost or stolen, an attacker would still need access to the token to log in. Without the token, a stolen password would be of no use. Mobile devices can often receive two-factor tokens via text message. Google, Dropbox and Twitter are all examples of companies that offer such two-factor authentication.
Work with air-gapped computers: Psychologists who are working with the most sensitive cases and clients may need greater data protection. Similar to locked and local file cabinets, an air-gapped computer is separated from networked data and Internet access — Ethernet cables and Wi-Fi antennas are disabled or removed. This would likely necessitate a practitioner to purchase a separate computer that would stay permanently disconnected from the Internet and only provide access to files. To share files with another computer, the psychologist would need to manually move them via USB-based external drives, thus lessening the risk of data leaks. Using an air-gapped computer, however, does present a different risk: If the computer's hard drive fails, the data is not backed up on a network, so data loss is more likely.
Modify informed consent: APA's Ethics Code states that informed consent should incorporate a method for securing, protecting and handling data. As Devereaux and Gottlieb (2012) suggest, it is important that an informed consent document properly explain, justify and present accurate risks of data storage and communication. If psychologists agree with their clients that they may use phone, text and/or email communication, the psychologist should inform the client about the increased risk of confidentiality breaches and about ways to reduce such leaks. In the interest of client privacy and autonomy, it may be appropriate to suggest pen and paper if worries about privacy concerns are present.
More than ever, practitioners are considering digital means for client records and communication. But with technological advances, there are greater threats to client confidentiality. Individual hackers have more power than ever to buy and sell private information. Corporate entities are scanning data by default for advertising and marketing purposes. In addition, governmental actors are collecting massive amounts of data (even when protected) for further analysis. With each step, important ethical obligations have been threatened.
As a result, it is vital to approach all cloud-based client work with caution. By following best practices, practitioners can significantly reduce the chance of breaches. At a time when even data stored in "secured" locations is at risk, psychologists should consider the appropriateness of current informed consent practices within the United States. Moreover, practitioners should question whether electronic-transmission surveillance laws are compatible with this field's support for privacy.
While individual practitioners should and do bear the ultimate responsibility for confidentiality and privacy, a unified message from APA might help prevent data storage and communication concerns resulting from poor and/or naïve risk management. Although APA's Ethics Code and "Record Keeping Guidelines" place the responsibility for client confidentiality — in any medium — with practitioners, it is important that an organization provide constant, up-to-date guidance for members.
Future record-keeping guidance would likely benefit greatly from the inclusion of best practices.
Psychologists should not fear technological changes, but they should prepare for the unexpected. By synthesizing the various individual, corporate and governmental actors that threaten client privacy, practitioners should have a newfound understanding and appreciation for security concerns.
Written by: Samuel D. Lustgarten, a graduate student in the counseling psychology PhD program at the University of Iowa, Iowa City. His research centers on the intersection of technology, psychology and client privacy.
This is a condensed version of "Emerging ethical threats to client privacy in cloud communication and data storage," which appeared in the June 2015 issue of the APA journal Professional Psychology: Research and Practice, Vol. 46(3). To read the full article, which includes all references, go to http://dx.doi.org/10.1037/pro0000018.