11 May 2017

Should you use an app to help that client?

Should you use an app to help that client?

As the use of mental health and behavioral apps grows, psychologists must weigh their benefits and limitations

Today there are more than 165,000 health-related apps worldwide, helping users track their diet and exercise, monitor their moods and even manage chronic diseases, according to a 2015 report by the IMS Institute for Healthcare Informatics. Nearly 30 percent of these apps are dedicated to mental health. While the apps present new opportunities for psychologists to boost patient support and supplement the therapeutic relationship, their sheer number and variety can make it difficult for psychologists to determine which are the most effective, safest and most useful.

"There's been an explosion of apps, and clinicians don't have time to keep up with all of them," says Stephen Schueller, PhD, a clinical psychologist at Northwestern University's Center for Behavioral Intervention Technologies. "It's not their job and it's impossible for them to do it."

But since one in five Americans uses these apps, staying informed about broad trends in app use is important for psychologists, says David Luxton, PhD, co-author of "A Practitioner's Guide to Telemental Health" (APA, 2016).

"If you're not familiar with these technologies today as a clinician, it's time to start paying attention because our patients are demanding them," he says.

Why use apps?

Many practitioners find that mental health apps are a valuable adjunct to psychotherapy because they allow therapists to maintain a better connection with their patients and improve their ability to track clients' symptoms and moods. Some of the most widely used of these apps include T2 Mood Tracker, developed by the National Center for Telehealth and Technology (T2), and Optimism Online, a mood charting app that allows clinicians to monitor client entries and receive alerts to help catch problems as they arise.

San Francisco-based clinical psychologist Keely Kolmes, PsyD, says that many of her clients prefer apps to the paper-based tools that she's used in her practice for years, for recording thoughts and tracking moods.

"Apps help prompt my clients to log things like their mood or whether they exercised or drank alcohol or slept well, so that I can have an accurate picture of their week, as opposed to them trying to reconstruct things on paper the day before therapy or during therapy, which is much less reliable," she says.

Apps are also available to patients 24 hours a day, seven days a week, and can be a great source of educational information, particularly at times when a client's clinician is unavailable. These include several apps by T2, such as PTSD Coach and CPT Coach, as well as Day to Day, which delivers a daily stream of advice, support and other information throughout the day to boost a user's mood. Day to Day is one of 14 apps included in IntelliCare, a suite of apps developed by Northwestern University's Center for Behavioral Intervention Technologies that target depression and anxiety arising from various causes.

While more research is needed, several studies indicate that the use of health apps can also improve patient outcomes and satisfaction. A 2015 meta-analysis led by Harvard Medical School psychiatrist John Torous, MD, for example, looked at 10 studies examining the use of apps in the treatment of mood disorders. The analysis found that patients who used these apps reported improved depressive symptoms (Internet Interventions, 2015). And a 2013 study led by University of New South Wales psychologist Tara Donker, PhD, found that participants who used apps reported the apps were a useful way to get self-help for mental health concerns and disorders (Journal of Medical Internet Research, 2013).

Apps can also help clinicians gather data about their practice, says APA's director of legal and regulatory affairs, Stacey Larson, PsyD, JD. For example, several apps provide HIPAA-compliant note-taking (such as Insight Notes and Mobile Therapy) and can generate graphs or tables showing client improvement as well as areas that still needed to be worked on. "A provider can use them to help determine which interventions are working best and which should be changed, and this information can be shown individually or charted for a practitioner's whole practice, to determine how interventions are working more broadly across their patient population," Larson says.

Potential limitations

Despite their popularity, behavioral health apps are not regulated and many are not research-based, says Marlene Maheu, PhD, executive director of the Telemental Health Institute in San Diego.

"We're scientists—we need to have evidence that something works before we use it with our clients," she says.

Schueller agrees, and encourages clinicians to look for apps that come with documentation of the evidence on which they are based, including research on the intervention underlying the app, such as cognitive-behavioral therapy, as well as research specifically associated with the app itself.

"The most reputable apps are generally those affiliated with academic research institutions or government funding agencies, as they are the most likely to detail the app development and validation process," he says. (See list below.)

Patient privacy and security concerns also need to be addressed any time technology is used in clinical practice. Some apps, for example, allow communication between therapists and patients between sessions—a feature some therapists might want and others might not—and it's crucial that this communication be HIPAA compliant, Maheu says. It's also important for providers to understand what, if any, data are being collected when a patient uses an app, and to make sure patients are informed about this, Larson says.

"Mobile mental health apps can be either passive or active," she explains. "Active apps require direct participation from the patient—such as completing mood logs, self-symptom ratings or recording personal experiences, but passive apps are able to access information independently and gather data through smartphone functions such as GPS without the patient or provider even noticing. Though it may be beneficial, some people may not like the potential invasion of privacy associated with this type of data gathering." And Schueller advises clinicians to show patients how to put a screen lock or password on their phones for additional security.

Integrating apps into your practice

With all of these limitations in mind, how can practitioners ensure the best use of apps in practice? Schueller recommends asking colleagues how they may use apps in therapy, and posting questions on listservs to find out what others have found works best. Several organizations provide resources and reviews of mobile health apps, to help clinicians stay abreast of the most effective and safest technologies. (See list below.) APA and the Center for Technology in Behavioral Science also hosted a webinar in May exploring the role of apps in clinical practice. The organizations received an overwhelming response to the one-hour event, with more than 1,700 clinicians registering for the event, says Maheu, CTiBS president and CEO. Two more webinars are being scheduled for the fall. It's also imperative that psychologists take time to test an app themselves before endorsing it with their clients, Luxton says.

"Install it and try out every single possible scenario inside that app so that you know it very well," he says. And always get feedback from patients on how an app is working for them, Schueller says. "As you start to learn more about which apps are really resonating with the population of clients you're working with, it will help get your practice more in line with what your clients want."

And most important, he adds, clinicians must be mindful of how apps fit into the goals of therapy. "Apps are not a panacea," Schueller says. "There's a lot of enthusiasm here and some of it is warranted. But be cautious; they will not completely fix everything."

APA does not endorse any of the apps mentioned in this article.

Mobile health app resources

By Amy Novotney


This article was originally published in the November 2016 Monitor on Psychology

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21 Apr 2017

A Growing Wave of Online Therapy

A Growing Wave of Online Therapy

The flexible nature of these services benefit clients and providers, but the onus is on psychologists to make sure they comply with federal and state laws

It was an ad on Facebook that first prompted Los Alamitos, California, clinical psychologist Nina Barlevy, PsyD, to visit the online therapy website BetterHelp.com. The company promoted affordable online counseling, available anytime and anywhere, and Barlevy thought joining their panel of therapists might be a great way to supplement her income during slow times in her private practice.

"It looked like a good way to expand my practice here and there in my free time, if I was already going to be on my computer in the evenings or on my days off anyway," Barlevy says.

She went through Better Help's rigorous application process, which included verifying that she was licensed, and began communicating with users in her state via the site's secure messaging platform. The site also offers members the option to schedule live video and phone sessions with their therapists, though Barlevy worked mainly with clients via the site's unlimited asynchronous messaging service. They messaged her about many of the same issues her face-to-face therapy clients were dealing with, including stress, anxiety and relationship issues, among other concerns, and she messaged them back with questions, feedback, insights and guidance. They benefited from easier access to therapy, which particularly helps people in rural areas who may not be able to drive an hour each way to see a therapist face-to-face.

"[It is] a whole lot more appealing to be able to sit at your computer and type back and forth with someone," Barlevy says.

Telepsychology, be it by phone, webcam, email or text message, has been around in one form or another for more than 20 years, used most often by members of the military. But the explosion of smartphone users has created new opportunities for app-based companies to offer more accessible and affordable therapy.

Still, such online therapy creates concerns over patient privacy, as well as legal and ethical issues, including interjurisdictional practice issues, for providers who contract to work for these companies, which may not share the same code of conduct and commitment to do no harm, says Deborah Baker, JD, director of legal and regulatory policy in APA's Practice Directorate. Many of these online therapy companies also are not run by psychologists.

"When you're an individual provider, you can't assume that a business is going to be looking out for your best interest, so you really have to dig a little deeper and check in with your professional association and malpractice carrier to make sure you're complying with the law and with the APA Ethics Code."

Benefits for patients and therapists

The growth in online therapy companies—nearly a dozen have launched in the last several years—doesn't surprise Lindsay Henderson, PsyD, assistant director of psychological services at Boston-based telehealth company American Well, which offers therapy through video conferencing. The ease and convenience of scheduling a therapy appointment online and talking with a therapist from the privacy of one's own home—or wherever one may be—is a huge draw for consumers, many of whom are seeking therapy for the first time in their lives, she says.

American Well's online platform helps "normalize mental health care, especially among generations now who are so accustomed to interacting with people using technology," Henderson adds. "It just eliminates so many barriers."

Research studies, many of which are listed in bibliography format by the Telemental Health Institute, also indicate that telemental health is equivalent to face-to-face care in various settings and an acceptable alternative. While much of the research tests only the use of videoconferencing as the telehealth modality, a few studies, including two published in 2013, have also shown that asynchronous messaging therapy can be as effective as in-person therapy (Journal of Affective Disorders and Cyberpsychology, Behavior and Networking).

Even more encouraging is that when digital interventions are positive, effective experiences for patients, they may go on to seek face-to-face therapy, says Megan Jones, PsyD, adjunct clinical assistant professor of psychiatry and behavioral sciences at Stanford University School of Medicine. A study she led found that college students who needed a higher level of care for eating disorders were more likely to seek it out after participating in a digital body-image program and working with a coach online via asynchronous messaging through the online therapy company Lantern (Journal of American College Health, 2014).

"It can really be a nice first step in treatment for someone who needs more intensive therapy," says Jones, who also serves as chief science officer at Lantern.

Mental health professionals can also reap benefits from joining online care teams. In addition to supplementing practitioners' incomes with new patients, providing online therapy can help them maintain a better work-life balance, Henderson says.

"From the provider perspective, the flexibility of practicing telemental health fits so well into my life and allows me to better meet my patients' needs," she says. "I'm not at a point in my life where I want to be going to an office at 8:30 in the evening, but I will happily go to my home office, lock the door and see a patient at that time."

Employment at online therapy companies isn't limited to providing therapy to clients, either. Opportunities abound and will continue to grow in supervisory and training roles as well as full-time research positions at these mental health technology companies, Jones says.

But tread carefully

Of course, online care is not for every patient or practitioner. Clients with more serious mental illnesses or addictions likely need more treatment than digital therapy can provide. And some clinicians may find certain telehealth modalities difficult, says Barlevy.

"I'm such a people person, so it was tough for me to feel a real connection when I was just messaging with people," she says. "Plus a lot of people just stopped responding, and I felt like there wasn't enough time to really build a relationship. It actually turned out to be more difficult than I imagined."

In addition, some online therapy companies don't have clear guidelines for handling risky situations, such as a patient who may seem suicidal in his or her messaging responses, says Lynn Bufka, PhD, associate executive director for practice research and policy at APA.

While some apps do report that they use a member's IP address to determine their exact location and send police if a therapist is concerned about a member's safety, it's often more difficult to determine a patient's level of risk via a messaging app than face-to-face with them in a therapy room.

"If you're using an online therapy platform and you ask someone if they're suicidal and they say no, is that it?" Bufka says. "Those kinds of clinical issues come up, which is why I think most psychologists seem to feel much more comfortable integrating technology into an ongoing face-to-face or video/teleconferencing relationship versus using only messaging."

Practitioners also need to do their due diligence when it comes to making sure their decision to contract with an online therapy company doesn't run afoul of complying with the Health Insurance Portability and Accountibility Act (HIPAA), state licensing laws and other legal and ethical practices, Baker says. In addition, platforms that allow patients to connect anonymously with therapists may create legal and ethical issues for psychologists.

"My concern is that some of these models are probably start-ups that are launched by people in technology, who have good intentions but haven't fully investigated all the nuances in what's involved in providing health services," she says. "Do they fully understand HIPAA/HITECH, any related state laws and patient confidentiality policies? Do they fully understand that psychologists cannot simply provide services to patients anywhere in the United States?"

Psychologists interested in joining these companies should investigate those issues, and also find out exactly where patients are located if they are providing them therapy services to ensure that they are authorized to do so. Such issues were part of the reason Columbia, South Carolina, clinical psychologist Shawna Kirby, PhD, decided to part ways with an online therapy company she worked for in 2015. After several months as a contracted therapist, she terminated the agreement, due to a series of ethical concerns she had over how the company dealt with interjurisdictional practice issues, consumer privacy, informed consent and therapy termination. When she brought her concerns to the company's clinical director and owners, none of whom are psychologists, she says they brushed off her concerns, and then eventually blocked her from messaging with her clients. "It all seemed more financially driven, rather than care driven," she says.

That's why it's so important that psychologists play a leadership role at mental health technology companies, Jones says.

"These companies need our knowledge and competency at the heart of their decision-making process because we have a very different framework and we understand the responsibilities that we have to users in a very different way than you do if you come from a technology background," she says. "I want to have a peer at any company like ours."

By Amy Novotney


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21 Apr 2017

Secrets of a Great Group Practice

Secrets of a Great Group Practice

These top practices offer opportunities for research, pro bono work, built-in CE and more

After Anahi Collado, PhD, completed her postdoc at Emory University in Atlanta, the university recruited her for an assistant professor's job there. But she turned it down when an unusual, but appealing, opportunity opened up: The ability to conduct research in-house at Alvord Baker & Associates, a group practice with two locations in Maryland.

Now, Collado spends 80 percent of her time providing therapy and 20 percent conducting outcomes research in the practice and in local public schools where she studies a resilience program. The practice also has a full-time research assistant and director of research to support the clinicians who are part of the research team, which collaborates with Catholic University.

"I have the scientist practitioner model that everyone aspires to have," she says. "Here, it's a reality."

Offering in-house research is also part of the allure at Portland Psychotherapy Clinic, Research and Training Center in Portland, Oregon. Founding partners Jenna LeJeune, PhD, and her husband, Jason Luoma, PhD, were both trained in the scientist-practitioner model and wanted to design a practice that lived up to that ideal. "Even for the clinicians on staff who don't have research time, they see it as a really valuable part about why they are here," says LeJeune, who, with Luoma, detailed their approach in Professional Psychology: Research and Practice in 2015.

Providing research opportunities is just one of the ways these successful group practices appeal to clinicians—others include offering flexible scheduling, community service and mentoring. The Monitor talked with LeJeune and others to find out how they have created group practices where clinicians feel valued and empowered and clients love to visit.

Encourage personal growth. Another popular feature at Alvord Baker is in-house continuing-education programs offered twice a month on such topics as ethics, telehealth and interjurisdictional practice—many of which are presented by clinicians on staff. "We are always learning and always presenting," says founding partner Mary Alvord, PhD, who has a part-time staff member devoted to organizing CE.

Professional development is also a priority at Portland Psychotherapy, which offers lunchtime learning talks. In addition, every six months each clinician meets with Luoma to discuss ways they can grow professionally. "It's really helpful because I don't think I would think as much about the big picture without that meeting," says staff psychologist Melissa Platt, PhD. "There is a lot of attention to professional development here even when we are not outright seeking it."

Clinicians at Southeast Psych—with locations in Charlotte, North Carolina, and Nashville, Tennessee—are encouraged to be bold: Recently, one of the practice's licensed professional counselors, Myque Harris, MS, who is also a certified yoga instructor, asked her partners about revamping her office space so she could combine her clinical work with yoga instruction—teaching children, teens and adults yoga poses and breathing strategies that could reduce their anxiety and depression.

"Something I saw as a far stretch, they saw as something great I could offer the community," she says.

Now she has an office with enough open space to instruct up to six clients at a time.

Provide a great space. LeJeune and Luoma renovated an 1889 Victorian home in downtown Portland to house their practice and gave each clinician his or her own room. Platt says the cozy surroundings boost her mood and make the experience of seeing a therapist more enjoyable for her clients.

"I have worked in places where the therapy rooms were sad with no windows," she says. "Clients comment all the time that our environment feels therapeutic."

Likewise, IntraSpectrum Counseling in Chicago, a group practice with psychologists and social workers specializing in serving the LGBTQIA community, creates a welcoming environment by having LGBTQIA magazines in the waiting room, gender neutral bathrooms and even brewing a local coffee brand that has LGBTQIA-affirmative policies for staff and clients. They keep the staff pantry stocked with cheese sticks, granola bars and La Croix sparkling water to keep people's energy levels up.

"Staff only have a few minutes between sessions and you often end up thinking about your growling stomach in the session," says Rena McDaniel, MEd, LCPC, IntraSpectrum's chief operating officer and a staff therapist. "It solves a big problem in a simple way."

Clinicians at Southeast Psych, a general group practice with more than 50 providers, say the fun, positive environment is among the reasons they find their work so rewarding. When clients and their parents come for an appointment, a hostess greets them and offers refreshments and a professional cosplayer wearing superhero or princess costumes entertains younger children before sessions, while older children can play X-box games. The practice also has a theatre in its Charlotte office to host speakers and films for clients or staff. Their philosophy? Break the mold on practice design.

"You don't have to have a water fountain," in your practice, says founding partner Frank Gaskill, PhD. "But if you do, make it really cool."

Make it fun. Several of the practices offer just-for-fun team-building experiences. The team at IntraSpectrum chooses a yearly activity such as bowling or a cooking class to attend together—and all wearing wigs for a festive twist. Staff at Southeast Psych carve out two hours on the last Wednesday of the month for play, such as having pizza and watching a movie or playing arcade games.

LeJeune and Luoma host board games and cocktails at their house once per month as a way for the whole practice to connect. "We try to get to know each other as human beings and meet each other's families and know what is going on in our lives," says LeJeune. "It has made it a totally different place to work."

Offer flexibility. For Harris, who came to Southeast after a stint in a Charlotte private school, getting to set her own hours allows her time to attend school events with her young daughter. "A lot of places talk work-life balance but aren't really living it," says Harris, who doesn't work Fridays and only works half days on Wednesdays. "We are definitely living it here."

Alvord also encourages her staff to set their own hours—and invested in high-quality videoconferencing technology so that staff who can't make it into the office on meeting days can connect from home. "Everyone can see each other even if we can't all physically be in the same office," she says.

Create a supportive environment. At IntraSpectrum, clinicians have weekly "consultation pods" where four or five clinicians with similar schedules meet to talk through difficult cases in depth. More informally, people make it a priority to carve out time during the day to talk through challenges. "People often say that it's a way to be independent in your work, but connected," says McDaniel.

At Portland, clinicians triage cases every other week and "check in on where we need support in our clinical work and our personal life," says LeJeune. Clinicians at Southeast Psych are assigned mentors during their first year with the practice; every new hire attends one lunch and one breakfast each month with his or her mentor to talk about his or her work with clients and how to build their practice.

Serve the community. Giving psychology away is an important common goal among the clinicians at Alvord Baker—many give free talks at local social service agencies and schools on such topics as cognitive-behavioral therapy and managing anxiety. They take turns facilitating monthly support group meetings of the local chapter of CHADD (Children and Adults with Attention-Deficit/Hyperactivity Disorder). In Charlotte, the clinicians at Southeast Psych do the same. Harris has given seven talks this year on such topics as how meditation can help children with ADHD and talking to children about sex. Southeast Psych also created "Psychology for All," a nonprofit arm of the practice that offers discounted services to local residents who can't afford psychological care.

As rewarding as these practices are, though, Gaskill says there is a downside to having a popular group practice: You often have to turn away great ­clinicians who want to work there. Southeast Psych gets at least two new resumes every week from prospective therapists.

At least one of those psychologists was inspired enough to create his own version. "He wrote to me eventually and said, ‘You guys rejected me, but I read your book, took it to heart, quit what I was doing and now I have my own group practice,'" says Gaskill. "Fifteen people now work for him; it is really cool to see that."

By Jamie Chamberlin


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17 Nov 2016

Are You Really Ready for Private Practice?

Are You Really Ready for Private Practice?

As a new psychologist, starting your own business is no easy feat. Here's advice to smooth the way.

By Tori DeAngelis
Print version: page 40

So you want to be a private practitioner? You're not alone. More than half of psychologists who deliver health services are primarily independent practitioners, according to the latest data from APA's Center for Workforce Studies.

But starting a practice fresh out of grad school isn't always feasible. Besides entering a difficult economy and lacking community connections, chances are you haven't yet acquired crucial financial and marketing acumen, says Steven Walfish, PhD, an Atlanta-based practitioner and president-elect of APA's Div. 42 (Psychologists in Independent Practice).

"Grad school teaches you how to be a good clinician, but no one teaches you how to run the business side of a practice," says Walfish, author with Jeff Barnett, PsyD, of the 2009 APA book "Financial Success in Mental Health Practice: Essential Tools and Strategies for Practitioners."

To prepare for the private practice path, experts advise you to:

Gain experience first

When you first leave grad school, think about working for an established group rather than trying to set up your own shop right away. By joining a group practice or taking a job in a community agency or medical setting, you can gain experience, connect with colleagues and have a guaranteed paycheck with benefits. It can also give you an inside look at how to run a business, says Dave Verhaagen, PhD, a managing partner at Southeast Psych, a large group practice in Charlotte, N.C.

"Like a lot of people out of grad school, I had no training at all in business," Verhaagen says. He opted to work for a few community agencies and then a group practice before launching his own. The experience gave him a good sense of the realities of the work world and "ideas about how I'd run my own business differently from what I saw out there," he says.

Develop a niche

While at the beginning of your practice you will probably need to take any and all clients, specialty niches tend to provide the best income and make the best use of your time and energy, psychologists say.

Think about populations you most enjoy and are best at treating, as well as what the market needs, experts advise. In Denver, private practitioner Susan Heitler, PhD, discovered a lucrative niche in marriage counseling when she noticed there were many people who wanted help creating better marriages — not just those in the throes of divorce. But there weren't many practitioners who could do that well. "You need to find something that's unique and in demand and that people are willing to pay for," Walfish says. "It will help you stand out from other practitioners."

Watch market trends

Be aware of social, geographic, economic and political trends that may square with your interests, says Walfish. If you live in a city but your specialty is children and families, consider practicing in the suburbs. If you notice one market trend evaporating (the need for psychological testing to assess personality structure, for example) and another one gaining steam (say, psychological testing for adult attention deficit disorder) determine how to get on the new track in a way that suits your abilities.

Walfish speaks from personal experience: When he began practicing in the 1980s, he conducted psychological evaluations for people in residential substance abuse treatment programs. Then, managed care came along and eliminated payment for those assessments, so he began specializing in short-term therapy. Today, Walfish sees patients considering weight-loss surgery, a high-demand area that fits his skill set well. He fully anticipates changing again if the market calls for it.

"The people who have long-term success are those who can adapt to these changes," Walfish says. "Without adapting, I think practitioners can get angry, depressed, burned out and fall into learned helplessness."

Create a strong plan

That includes developing a mission or value statement for your practice, a list of whom you'd want to work with if you decide to create a group practice and a business plan. To develop your plan, tap experts in accounting, taxes and mental health law, and talk with practitioners who are already out there, Walfish says. "Don't just go on the experience of one person who is terribly successful or one person who is all gloom and doom," he says. "The more private practitioners you can talk to in the beginning, the more accurate your knowledge base will be."

Develop new talents

To run a successful practice, you need to learn business skills, as well as skills related to new content areas you'd like to practice in. Heitler did extensive reading to get up to speed in her area and ended up writing two well-known books incorporating what she learned, "From Conflict to Resolution: Skills and Strategies for Individual, Couple and Family Therapy" (1993) and "The Power of Two: Secrets to a Strong & Loving Marriage" (1997).

Sell yourself

It's not enough to be a good practitioner: You must market yourself, too, says Vancouver, B.C.-based practitioner Randy J. Paterson, PhD, author of the 2011 book "Private Practice Made Simple." That means giving free talks in venues such as schools and community centers. Also consider meeting with people who could refer clients to you, such as physicians, allied health professionals, educators and leaders in faith communities. Finally, be sure to use technology to your advantage — for example, building a strong website that defines your practice and draws clients to it.

In general, "you need to get over the idea that your clinical competence alone will sell your practice," says Paterson. "Ultimately it will, but not at the start."

Be bold

As you develop your practice plan, envision the kind of practice you'd really like to have and how to implement it, Verhaagen says. "We realized early on that we wanted the tone to feel fun and positive, not heavy," says Verhaagen, who specializes in treating young adult males. That's why when clients walk into his practice they encounter a bookstore with free coffee and Wi-Fi. In the treatment area, he's hung movie posters on the walls and placed mannequins of superheroes including Batman, Superman and Wonder Woman — a playful way of conveying themes of strength, resiliency and a positive focus.

"Also, be sure to vet potential hires to make sure they're a good fit with your values and culture," he says. Encouraging your team to spend time socializing so that they forge good personal bonds can likewise foster a healthy practice, says Verhaagen.

Respect your worth

Some graduate psychology students may feel that dealing with money is morally wrong or even beneath them. But to be successful, you have to know and appreciate your value in dollar terms, say practitioners. Learn to be comfortable charging a fee that reflects your worth and your area's market, Paterson advises. Remember that your hourly rate encompasses business costs including your phone system, computer, test materials, assistants and time you spend outside therapy working on a client's case. Be sure to compare your rates with those charged by other professions, he adds. "People [often] pay more to take their cat to the vet than they do to see a therapist," he says.

Charging a healthy rate for your services can actually promote good therapy, Verhaagen adds. It prompts practitioners to do their best work and provides clients the incentive to work hard, he says. "We can help a lot of people and do really good work and still think very much like a business," he says.

Diversify

Your skills can be used in a variety of interesting ways besides seeing clients. For example, in addition to providing therapy, psychologist Tish Taylor, PhD, conducts workshops for teachers and educators on dealing with children who have emotional and behavioral problems. Genie Skypek, PhD, writes software that helps social service agencies track patients. Walfish and colleagues Pauline Wallin, PhD, and Lauren Dehrman, PhD, are using their consulting skills to develop an online business called The Practice Institute, which will help psychologists gain the tools to build successful private practices. Others author self-help books, create educational CDs and DVDs, conduct forensic evaluations and run corporate retreats. Aim for a practice that is varied, balanced and in sync with your interests, Walfish says.

"We have a tremendous skill set that gives us an advantage over other mental health professions," he says. "Extending that skill set helps to create opportunities."


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