Mindful Musings

My Mindful Musings about mental health issues and other therapy-related things. If there is something you’d like me to blog about, send me an email and let me know. And I very much enjoy receiving comments on my posts.

Articles For Clients is a compilation of my posts for consumers of psychotherapy services.

Articles For Clinicians Using Social Media is a compilation of my posts for mental health professions on the Internet.

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LinkedIn Endorsements for Mental Health Professionals


More and more, when I teach to groups on Social Media ethics, people are asking me about LinkedIn endorsements.

  • Should they use them?
  • Should they feel bad if they don’t endorse someone back?
  • Is it okay if they have been endorsed for skills they don’t have?

If you’re not sure what I’m referring to, it’s these graphic pictorials that now lie at the bottom of our LinkedIn profiles:

Screen Shot 2013-07-04 at 1.22.25 PM

It seems like every time I log into LinkedIn, a whole batch of new people have endorsed me for a skill and I’m being given a window with a bunch of tags and plus signs telling me to endorse them back.

The problem is, some people are endorsing me for skills I don’t have (such as neuropsychological assessment). And since I network with many clinicians I haven’t always met personally (some of them have taken a class of mine and wish to connect or some of them I know via email lists), some of the people endorsing me are not really familiar with my skills as a psychologist.

It is certainly nice that people believe I’m good at these things. But I’m not clear they actually have the personal knowledge of me to endorse me for these skills, and I certainly don’t know them well enough to offer a return endorsement for their work.

The challenge with mental health work is that unless you’ve seen me teach (or vice-versa), or unless we’ve consulted on cases together, or unless you’ve received psychotherapy from me (in which case, I am not allowed to ask for a testimonial or endorsement), most of what we actually do that involves our skills is a private endeavor between ourselves and our clients.

We can  be friends with other clinicians and like them very much, but we still do not know what happens behind the closed doors of their office when they see clients, unless we have  supervised their work. And, unless it’s live or taped supervision, it’s still a recounting of the work…not direct observation.

There are just a handful of people whose skills I can comment on, and those are people with whom I’ve met regularly to discuss cases, ethical questions, or whose classes I’ve attended. Other than that, I cannot accurately comment on the skills of colleagues when I have no direct knowledge of how they perform such skills, no matter how great their reputations may be. And while it’s a nice compliment, it’s an empty one if they are commenting upon skills I have if they aren’t intimately involved in my work.

I have spoken to more than one clinician who has said:

“I feel bad because people have endorsed me and I’m embarrassed because I haven’t gone back and returned the favor!”

Others say that they have accidentally clicked on the endorsement boxes and endorsed people they don’t even really know because LinkedIn made it easy to do that without realizing that they had done so.

If you’re someone feeling bad because you have not endorsed your colleagues I say, “Don’t worry about it!”

While LinkedIn endorsements are the current rage, it probably isn’t really ethical to endorse colleagues for skills you think they may have. Or skills that they say they have.

As psychologists we actually have an ethical obligation to take responsibility for the statements others make about our professional practice and activities. In fact, when it comes to advertising and public statements, our Ethics Code for psychologists says under Standard 5.02:

5.02 Statements by Others  (a) Psychologists who engage others to create or place public statements that promote their professional practice, products, or activities retain professional responsibility for such statements.

So if people are endorsing you for skills that you don’t believe you have, by all means, delete them. And if you don’t really know the work of your colleagues, don’t feel bad about ignoring LinkedIn’s suggestion that you endorse them.

Update: July 9, 2013

Thank you to Roy Huggins, MS, NCC, who in his comments below includes the ACA and NASW Ethics Codes. I’d add that AAMFT Code of Ethics (2012), which is one of the few Ethics Codes that has been updated to include the Internet, includes the following relevant statements about advertising:

Principle VIII
Advertising
Marriage and family therapists engage in appropriate informational activities, including those that enable the public, referral sources, or others to choose professional services on an informed basis.

8.1 Accurate Professional Representation. Marriage and family therapists accurately represent their competencies, education, training, and experience relevant to their practice of marriage and family therapy.

8.2 Promotional Materials. Marriage and family therapists ensure that advertisements and publications in any media (such as directories, announcements, business cards, newspapers, radio, television, Internet, and facsimiles) convey information that is necessary for the public to make an appropriate selection of professional services and consistent with applicable law.

8.6 Correction of Misinformation. Marriage and family therapists correct, wherever possible, false, misleading, or inaccurate information and representations made by others concerning the therapist’s qualifications, services, or products.

8.8 Specialization. Marriage and family therapists do not represent themselves as providing specialized services unless they have the appropriate education, training, or supervised experience.

In Bed with our Clients: Should Psychotherapists Play Matchmaker or is this Plain Old Erotic Countertransference?


This piece was originally published, in slightly different form, at Psyched in San Francisco

Last January, there was an opinion piece in the New York Times, written by Richard Friedman on whether therapists should play Cupid for our clients, basically performing as a matchmaker and setting them up on dates. The article focused primarily on the fantasies that some clinicians have had about wanting to do this and the potential issues that could come up regarding transference. It did not speak directly to erotic countertransference, but I think this is a key component of such a question.

Following the article, HuffPost Live did a segment on which I was one of four guest clinicians interviewed about our points of view on the issue. As expected, the show included diverse opinions and even had one clinician, Terah Harrison, who has expanded her practice to include matchmaking services. Another clinician, Dr. Lazarus, argued passionately that we are ”uniquely well positioned,” to make such matchmaking recommendations to our clients.

Jeff Sumber believed it was unethical but he admitted to having such strong fantasies about fixing up his clients that he’d deliberately scheduled people back-to-back, in hopes they might meet. (I imagine his clients are now wondering as they arrive for therapy if the person leaving is someone he has selected for them?)

Guess which role I played on this segment? Yes, I was the conservative fuddy-duddy talking about ethics, dual relationships, and risk management.

One of the problems with acting upon these fantasies and meddling with our clients’ love lives is that our clients can come to believe that we know better than they do what is good for them. And we can fall prey to such beliefs ourselves. We can think we know our clients very well, and we do come to know them deeply. But we are not psychics or mind readers. We are simply psychotherapists. We were trained to improve people’s mental health and recognize relationship patterns so that we can help our clients identify these patterns, understand their origins, figure out if the patterns work, and shift them when needed. We were not trained to assess chemistry and dating potential between two people who haven’t met, so this is beyond the boundaries of our competence.

In some ways, we already play matchmaker to our patients in appropriate ways. For example, we may refer an individual patient to a couples therapist or to a psychiatrist, which is one type of matchmaking which actually serves the treatment. But for as many times as I’ve heard that my referral was a good fit, I’ve had clients return and say, “I couldn’t stand that doctor, I hated the other one’s website, and the third never returned my calls. Can you give me some other names?”

This kind of frank feedback might be more difficult to give if the person whose name and number I’m sharing is a potential romantic partner or someone from my personal life who they know I care about. They might feel pressure to please me or think I know better than they do who they should be dating.

One of the truths we all must learn as we become experienced clinicians is that our impressions of our clients (and our colleagues as well as others in our lives) are not objective. We are forming subjective impressions of people all of the time. If we mistake these impressions for “the truth,” then we’ve fallen prey to the fantasy of our own omnipotence.

One person in Friedman’s article recalled a boss who tried to set her up with one of his patients. Later, the female subordinate realized it was the boss who had a crush on her. For me, this was the very core element to this question of whether we should be doing this. I would guess that psychotherapists who become invested in trying to introduce their patients to potential romantic partners are passively expressing erotic countertransference. This may be a way to “get into bed” with one’s clients figuratively—since it’s very clear that to actually bed a client would be completely unethical.

After all, if you are successful in romantically hooking two of your clients up, you will ultimately find yourself in two therapies listening to two different people telling slightly different stories about one another. Will the stories match up? Is one person expressing more commitment than the other? Are you pulled to protect one of them? Unless it’s pure magic between them, you have placed yourself in the middle of quite complex terrain.

If the potential dating partner is not another client of yours, but, rather, someone you know in your personal life, you may then be getting extraneous information about your client from that person, unless you draw a firm boundary and refuse to hear such stories. Either way, you still have a commitment to maintain confidentiality and objectivity in that relationship. Is that even possible?

Regardless of which scenario unfolds, this is my idea of a psychotherapy nightmare in which I would be forced to try to stay objective and keep silent about two people to whom I have different allegiances. To maintain balance here would require extremely good boundaries (likely beyond my capabilities) or it would likely warrant a referral out of treatment in the more forseeable event that I lost my ability to remain objective.

The thought of wanting to intentionally create such a complication for my practice is improbable. Yes, I want the best for my patients. This, of course, includes their romantic happiness. But part of what I hope to do is to help them feel empowered to go out and find a partner on their own. I want to help them improve and trust their own judgment and intuition in finding good partners for themselves — not to believe they should depend upon my judgement or elevate my perceptions above what they believe to be true about themselves. This is one more reason that I think that matchmaking should not be on the psychotherapy menu.

Polyamory Presentation at the Multicultural Summit | Guest Post by Ryan Witherspoon, MA


This is a guest post by Ryan Witherspoon, MA. Ryan is a psychology graduate student, completing his MA at Pepperdine University and preparing to enter a doctoral program this Fall.  He is training to become a clinical psychologist and will eventually work in private practice, teach and conduct research. He intends to specialize in working with sexual minority (LGBTQA, kink, poly) clients as well as their relationships and families.

Last month I was fortunate to present a poster titled “Polyamory as a Cultural Identity: Implications for Clinical Practice” at the National Multicultural Conference and Summit in Houston Texas.  The poster presented a literature review on polyamory geared towards clinicians, woven together with my ethnographic impressions, sample case vignettes and comments from clinicians both with and without experience serving this population.

The notion of positive and successful consensual non-monogamy continues to be a controversial topic in the psychological community.  This is especially true for polyamory, which so far seems to retain the fringe attribution that other forms of consensual non-monogamy, such as open relationships or swinging, have gradually sloughed off via growing public awareness (and tacit acceptance) of these practices.  However as I discussed in my poster, it is becoming increasingly evident that polyamory may be far more common than many realize.

Given my premise that polyamory can constitute a distinct and evolving culture, it seemed fitting to present at a conference dedicated to multiculturalism.  However I must admit to feeling anxious about how my poster would be received.  Waking nightmares of distinguished psychologists angrily and loudly contesting, or worse – cursorily dismissing my work haunted me in the days leading up to the presentation.

Fortunately, as with my symposium presentation on LGBT polyamory at last year’s APA convention, the response could not have been more positive and encouraging.  Every single person I spoke with was incredibly enthusiastic about the topic and my work.

My poster received an enormous amount of interest and traffic; I spent the entire 90 minute session talking to people individually or in groups.  It seemed like nearly everyone who saw the title stopped to stay a while.  The important take-away for me however was not just the positivity of psychologists’ reactions, but the particular flavor of them.

Beyond appreciating the poster, numerous people personally thanked me for sharing work on this topic.  Their reactions were as much emotional as intellectual, expressing relief and gratitude.  Psychologists and students alike spoke with me about the dire need for greater awareness of these issues among the clinical community.  Numerous times throughout the session clinicians told me stories of polyamorous clients at their practice, clinic or school that nobody knew how to work with.  I heard reports of biased supervisors, ignorant trainees, and clientele whose needs were going unmet due to the paucity of clinically-relevant knowledge on alternative sexualities.

My experiences presenting on polyamory at APA and the National Multicultural Conference and Summit have reinforced my belief that alternative sexualities are rapidly growing in participation and visibility.  I sincerely hope that expanding education and training among clinicians about these populations will ameliorate widespread biases and gaps in knowledge.

Diversity and multiculturalism are by definition expansive and inclusive concepts.  Therefore I believe that – as with LGBT populations decades ago – we must embrace the fact that these communities exist, they are more common than many realize, and psychologists must rise to the occasion by establishing standards of culturally competent care for them.

View the poster.

Yelp-Proof Your Clinical Practice – Alpha Launch!


The most common consultation question I’m asked is “What can I do about the negative Yelp review I just received?”

Until now, there hasn’t been much that we can do other than do good work, listen to our clients’ feedback, and hope that we don’t upset someone enough for them to want to publicly complain about our work on the Internet. My typical first response to someone who just got a bad online review is to recommend that they take a deep breath, try to shake it off, and seek support from their colleagues and people who know them and their work.

But for two years, I have been working on a solution. In my trainings, I’ve recommended that the best way for clinicians to manage this is to take steps to put client feedback back into their own hands by developing post-treatment feedback forms and getting client consent to post aggregate data on their sites.

Sample Referral Graph

Nine months ago, I developed a questionnaire asking psychotherapy clients what they would most like to find in online reviews of therapists. One hundred and thirty-six participants responded and I used that data to develop a follow-up survey. I’ve been using my own follow-up form in my practice for almost two months, as well as implementing an ongoing feedback form. I’ve also had a couple of other clinicians alpha test this in their own practice.

To view a preview of the data I’m getting, peek at my Client Feedback page.

Now you can get your hands on this survey because I’m releasing it in a public alpha launch.

Here’s how it works.

You pay a very reasonable set-up fee, I will host your form, then you send the link to your feedback survey to clients who have completed treatment with you and wait for your results to come in. Once you have 15 completed surveys, you will be sent an aggregate view of your data. If you’re itching to know how many responses you’ve gotten before you reach your 15, go ahead and check in with me and I’m happy to let you know.

Sample therapy goals graph

Why the wait? We wait for 15 clients to complete the surveys to help protect the privacy of your clients. The goal is to see how you are doing generally, not person-by-person. And the potential end-user of this site is clients who are looking at your ratings online. If you like what you see and want to continue using the form, you can pay for a monthly (or yearly subscription, at a lower rate).

Also, some research indicates that it takes 6-10 local reviews for a business to gain trust from consumers. We want to make your results a bit more robust for you and your potential clients.

Every time you get 5 more responses, you’ll get an updated graph with a time and date stamp.

If you want to get a better idea of how your current clients feel about how their therapy is going, signing up also gets you a PDF of a Checking In form you can give to your current clients to see how they feel about how therapy is progressing.

How is this ethical? For one thing, it is sent only to clients you have completed therapy with, and with their consent. No testimonials or text-based responses are shared with anyone but you. Aggregate data is revealed which does not compromise the identity of participants to you, or to the public (or to their friend lists or Facebook. Bleh!).

How is this good for me? If you wait out the initial period as you build your feedback data, and send this to all clients you complete treatment with, you will have an alternative data point that you can post online to show people “Hey, I sent this to all of my clients, and here is what they are saying about my services.” This can take the sting out of the unfortunate experience of getting a negative online review from one disgruntled client.

You’ll also get a very good idea where your growth edge is and how you may be already excelling in your care and where you may need to pay a bit more attention. And if you choose to keep your feedback private, you can simply use it as a tool to improve your services.

How is this good for clients? It helps them to find out the information they want to know about you and your practice: the issues you treat, what you’re especially good at, and whether people who work with you would be comfortable referring others to you. It also protects their privacy without exposing their personal issues to their friend networks or the public. And it gives them a chance to honestly give you feedback, without any negative consequence. I believe that in our changing culture of Internet transparency, it also lets clients know that you are willing to stand behind your services and receive feedback about how you’re doing.

Do you want to take control of client feedback and make sure you know how your clients feel about your services? If the answer is yes, join me in my alpha launch.

Get started now by adding “Yelp-Proof Your Practice” to your cart in my online store.

I’ll follow up with an email with the FAQ, and giving you all you need to get started. If you have questions and concerns, we’ll chat on the phone and I can tell you more about my experiences with this product.

As an alpha launch partner, I’ll also be asking you for some feedback of your own, sharing what you like and don’t like about the product, and you can have a hand in fine-tuning it and shaping it.

I hope you’ll join me in this new venture and adventure!

If you’re looking for other resources about managing Yelp, I highly recommend the articles below:

Ofer Zur’s brand new post on Modern Day Digital Revenge offers many tips and resources for dealing with online reviews.

Matt Lundquist of TriBeCa Therapy in New York had a creative and human approach to dealing with his own negative review on Yelp.

Pysychotherapy Finances did a review of what you can do about Yelp, interviewing me and Dr. David Ballard, last year.

A recent blog post of mine had a number of experts weighing in on what you can and can’t do and whether those posting reviews of our services still have a right to confidentiality.

My New York Times Op-Ed, The Wrong Type of Talk Therapy, was when I first began wishing for an alternative to online review sites which might better protect consumers.

Lastly, some people have taken to adopting my language from my own Yelp page and using it on theirs. I allow any and all clinicians to use this on your page, if you wish.

Posting a review of my services is your right as a client and it is entirely up to you to decide whether you wish to write a review. But I gently discourage clients from posting reviews of my practice for the reasons below.

1. The American Psychological Association’s Ethics Code states that it is unethical for psychologists to solicit testimonials: Principle 5.05 “Psychologists do not solicit testimonials from current therapy clients/patients or other persons who because of their particular circumstances are vulnerable to undue influence.”

Since you may decide to return to therapy with me at a later date, I do not request testimonials from people who have ended therapy with me.

2. Unlike other business owners who may respond to their Yelp reviews, as a psychologist, I must provide confidentiality to my clients. This means I am restricted from responding in any way that acknowledges whether someone has been in my care.

3. I hope that if we work together, we can discuss your feelings about our work directly and in person. This may not always feel comfortable, but the discussion of positive and negative reactions to our process can be an important part of your therapy. If we are not a good match, I’m always happy to help you find a therapist who better suits you.

4. If you still choose to write something about my practice on Yelp, remember that this is a public forum and you may be sharing personally revealing information with a wide range of readers. To preserve your privacy, consider using a pseudonym that is not linked to your regular email address or friend networks.

5. If you believe that I (or any licensed mental health professional) have done something harmful, consider contacting your state licensing board to make a formal complaint. This may protect other consumers of therapy services. Be aware that details of your therapy may come up if there is a formal investigation.

 Add “Yelp-Proof Your Practice” to your cart in my online store.

50 Shades of Stigma: Are we as kinky as we think we are?


Originally published at Psyched in San Francisco

The popularity of the 50 Shades of Grey books has been staggering. They have become the 9 1/2 Weeks of a new generation; glorifying the excitement of power, bondage, and…well, mind games. In fact, those who know what consensual BDSM participants actually do together have criticized the trilogy for portraying kinky sex as unhealthy and non-consensual. Others note that some of the activities in the book convey a lack of knowledge about keeping BDSM physically and psychologically safe.

However, it is clear that the public is fascinated by kinky sex. In fact, 14% of American males and 11% of American females have engaged in some form of BDSM sexual behavior (Janus & Janus, 1993). But BDSM remains a taboo topic in the field of mental health where sexual diversity training focuses primarily on the experiences of gay, lesbian, and bisexual individuals. Despite removing homosexuality in 1986, the Diagnostic and Statistical Manual of Mental Disorders continues to list Sexual Sadism and Sexual Masochism as Paraphilias, or sexual disorders.

The tension between public interest in BDSM and outdated training of clinicians has created opportunities for psychotherapists who identify as “kink-aware” or “altsex friendly,” to identify themselves to savvy psychotherapy clients. These clients want to avoid wasting their time and money spending hours in therapy only to have their proclivities pathologized by clinicians who know nothing about their lifestyles. In fact, Kink-Aware Directories and Poly-friendly Directories exist to help consumers find a wide range of services from informed professionals. The Bay Area even has its own group: Bay Area Open Minds, to help clinicians network and to help clients find us.

Just as it’s not easy for all people to “come out” to their friends, family, or co-workers as kinky or polyamorous, it’s also not always easy to come out as an altsex-friendly mental health professional. Those of us who advertise these services – whether we identify as altsex clinicians or just allies — face the same challenges BDSM and poly clients face. Many health professionals believe that alternative sexuality is a sign of illness. If you truly want to see power dynamics in action, try coming out as an altsex friendly trainee in a psychology graduate program. It takes strength, courage, and support to do so surrounded by ill-informed colleagues. It is even more challenging to do this if you are a student, very much in need of affirmation from professors and supervisors.

Sexuality remains such a forbidden frontier that if one speaks up
 about the experiences of sexually marginalized people, it is assumed that they must be a member of the group. This circumstance keeps some altsex clinicians and their altsex positive allies silent. By contrast, few clinicians would worry that by specializing in treating substance abuse, eating disorders, anxiety, or depression, people might think they are in recovery, bulimic, depressed, or anxious. But most cannot imagine why a person would willingly speak up about kink in our field unless one were kinky herself.

I am a kink and poly-friendly professional who works with altsex clients. I discuss my altsex research, teaching, writing, advocacy, and clinical work in many professional settings. There are many reasons to be an altsex positive clinician. You may
 have known and loved someone who is kinky or poly, as a friend, partner, or family member. Maybe you have had your eyes opened to your own biases and judgment and want to make a difference. Maybe you believe in everyone’s right to fantasize or engage in consensual sexual acts, regardless of whether you experience the same desires. I believe that all clients deserve a safe, non-judgmental place to talk about their fantasies, behaviors and identities.

It is my hope that the public’s interest in exploring these fantasies and ideas in stories and media may begin to expand our notions of what is normal and will help change outdated ideas about sexual pathology. If every other person on BART and MUNI is reading 50 Shades of Gray, a book about sex and power, then shouldn’t it also be safe to go to your psychotherapist’s office and explore these issues there?

Janus, S., and Janus, C. (1993). The Janus Report on Sexual Behavior. New York: John Wiley & Sons.