Dr. Susan Giurleo is a psychologist and private practice consultant–the Biz-Savvy Therapist.  She talked to WTCI via email about what she does and how she does it.

What’s your background? What do you do now?

I am trained as a PhD counseling psychologist and focused my research around education and career development. Over time my interests shifted a bit to helping children with developmental issues such as ADHD, autism spectrum and learning disorders. I was a school psychologist for awhile, worked in a group practice and then got tired of working for others and went out on my own. The whole idea of starting a business was overwhelming and scary to me. I had no business background and neither did anyone in my immediate family. But I was motivated to learn because I wanted to create my ideal practice, utilizing evidence-based approaches to help kids and families in distress.

I spent a lot of time learning how business and health care work. Once I got the business fundamentals down, I started to learn how to market my practice. I quickly realized that marketing involves psychology at its core. The best marketing speaks to people’s needs in a way that allows them to understand products and services and make purchasing decisions.

Learning how to market my practice was fun and rewarding. And led me to where I am today.

Now, in addition to my private practice, I write my blog BizSavvyTherapist.com and provide business coaching and consultation to mental health professionals in private practice. My focus is on the marketing of small practices because I feel that is where people can do the work they love and make a very good living at the same time.

All of the business skills I talk about and teach are ethical and promote good mental health. I teach a strategy called “content marketing” (some call it ‘information marketing’). This approach combines valuable psychoeducation to the public,while at the same time promoting a practice and mental health services. Content marketing allows a practitioner to position herself as an expert or the “go to” person in her community for a specific treatment issue or condition. Based on solid, ethical content clients start to self-identify a fit between their needs and a specific practice or provider. At the same time referral sources such as physicians, lawyers and other professionals come to see the provider as a reliable source of information and quality care for their clients.

The BizSavvyTherapist allows me to combine my passions of promoting mental health, education and entrepreneurship. I feel that the more clinicians I can empower to have strong practices, the more people we can help and serve. It feels like a win-win–more clients, more healing and more income for providers.

How do you go about working with clients using content marketing?

My coaching process has evolved over the past few months.

Initially I ask my coaching clients lots of questions about their reasons for becoming a therapist,why they want to build a practice, what their ideal practice looks like and who they want to help.

To build an authentic practice each one of us needs to know our “why.”  Why do what you do? Who do you help others? What drives your decision to work for yourself?

The truth is, it’s not easy to be a small business owner. Yet, so many therapists start their graduate training with this goal in mind, but graduate with no idea how to go about the process of making money in a helping profession. So, we need to get at the heart of our motivations to be in the business of helping.

Once there is clarity on the why, we then explore how that translates into a profitable business. From my client’s core passions and interests we develop a focus, or a specialty from which they can build an authentic, rewarding business. We generate a business plan that incorporates a balance between their business and the lifestyle they desire. I call this “career/life balance.”

Once this base business plan is in place, I can teach and advise how to do the “nuts and bolts” work of building a website/blog, provide services that clients want and will pay for, and multiple income streams and marketing.

Ultimately, the goal is for therapists to have a solid business that helps people with specific needs and generates a good profit.

In this way, helping professionals can do the work they love and get paid well. It’s not hard to do once people are very clear on their motivations and goals.

What are the basic marketing lessons that apply to therapists?

The cornerstone of any success business requires that we offer something specific that solves a problem or addresses a pain point for people. By default, therapists are trained to help people in pain, but we are rarely specific enough about this.

Human beings naturally categorize things, ideas and people. We are hard wired to sort out “what’s in it for me?” Therefore, we pay close attention to the details of a business or service offering. We are willing to invest our resources (time, money, energy) into something that looks like a good fit for our needs.

This means that therapists need to become more specialized and demonstrate an expertise in one treatment area. People don’t work with generalists. They want providers that can meet their specific needs.

Without a focused specialization, all marketing efforts are wasted. No one can successfully market “therapy.” First of all, how do you define that well enough so people see that they need it? And, let’s face it, no one will trust someone who says “I can help you with any problem you may have.” Would you trust a physician who says they can treat any ailment from cancer to schizophrenia? Of course not. So the first basic marketing lesson is to develop a specialty.

After deciding on a focus for your practice, the next step is to develop a marketing “home” where all of your marketing activity comes together. I always suggest this be a website built on a blog platform (WordPress is my preference). Having a robust web presence allows people to access your information 24/7 and eliminates any need for brochures since the website has all the information people will need.

The website becomes the place where you provide information about your specialty, articles that are informational and helpful to clients (and potential clients). You can list services, products, free newsletters, etc. Once these basics are in place you then branch out into social media using Facebook and Twitter to drive traffic back to your site. It really can be quite elegant and efficient once you get a good basic online structure set up.

And the third marketing tip: show yourself online. Put a picture of yourself on your webpage, get rid of those pictures of sunsets, beaches and drops of water (they don’t mean anything to people). When you engage in social media, always have a picture of yourself associated with the account (whether it be Facebook, Twitter, LinkedIn or another networking site). Therapists are essentially marketing themselves. We don’t have a product. If you won’t show your face online, people will not trust you. Our culture increasingly expects to see faces of others online. The internet is the new community center. I know many therapists are uncomfortable with the concept,but we can’t change cultural shifts. If you want to engage in a marketing plan, be ready to show yourself. Nobody will every visit with an anonymous therapist.

Are there marketing ideas that don’t fit for this profession?

The one things many marketers recommend that therapists can’t use is testimonials.

Ethically, we can’t ask clients to give us feedback that we then share with others.
Sometimes business minded clients will offer a testimonial, but I recommend a policy of not using them because our ethics codes are clear that testimonials can be a place of misused power differential. That really is the only area where we need to adjust our marketing efforts.

However, I also want to say that I hear a lot of talk in professional circles about how therapists should not use social media (such as Facebook and Twitter) but that is incorrect advice. There are many ways we can use these platforms ethically and safely to promote mental health and to market our practices. As long as the information shared is factual and never references real client stories or situations, social media is a powerful tool. There is a lot of debate about this, but many of the people engaged in these discussions don’t seem to really understand the flexibility in these platforms. It is absolutely possible to have an ethical social media presence. I recommend therapists learn how to use Facebook and Twitter with their “professional” hat on, rather than approach it as they would as a private person.

I talk about ways to use social media on my blog.

Any final words of wisdom for people building a private practice…?

Start with one thing. Take one action. That could be meeting with a professional colleague for lunch or coffee, writing an article for a local publication (online or off line), heading over to WordPress.org and starting a blog. The process of building and marketing a practice can seem overwhelming, but when we break it down into steps and stick with it, a lot of progress can be made in a short period of time.

I wish every one the best in their practice building efforts!

Find Susan Giurleo, PhD on the web at BizSavvyTherapist.com, ChildDevelopmentPartners.com, and on twitter: @susangiurleo.

John McDargh is an Associate Professor of Theology at Boston College and author of

What’s your background? What do you do now?

I was raised and educated in the South (Georgia and Florida) – thirteen years of Catholic school and an undergraduate degree in English at Emory University (1970). Upon graduation I was awarded a Danforth Foundation Fellowship, and after four years in the U.S. Coast Guard during the Vietnam War, I used the fellowship to pursue a doctorate at Harvard University. I did an interdisciplinary degree in psychology and religious studies under the Committee for the Study of Religion. It allowed me to range over the entire university and put together a committee with faculty from the Psychology and Social Relations Department, the School of Education, and the Divinity School. My particular area of research was on the application of contemporary psychoanalytic theory, in particular psychoanalytic object relations theory (Fairbairn, Guntrip, Bowlby, Winnicott, Rizzuto) to studying the origin and development of the individual’s conscious and unconscious representations of “God.” I have remained interested in this both for its implications for psychotherapy and pastoral counseling as well as its implications for theology.

The book that was based on that research and subsequent writing was recognized with the William Beers Award for outstanding contributions to the field of the psychology of religion by Division 36 (The Division of the Psychology of Religion) of the American Psychological Association in 1995.

In 1979, I was offered a position on theological faculty at Boston College and have taught here ever since. At the undergraduate level I serve the core curriculum with a year-long comparative theology course on Buddhism, Judaism, and Christianity. At the graduate level I teach courses primarily to serve our joint masters in counseling psychology/social work and masters in Pastoral ministry, though a course like “Spirituality and Psychotherapy” typically draws graduate students from schools across the Boston Theological institute – the consortium of nine seminaries and divinity schools in the Greater Boston area. This past year on my sabbatical I was invited to design and teach a pilot course on “Spiritually Oriented Psychotherapies” for the Massachusetts School of Professional Psychology and have just been invited to chair MSPP’s newly forming Center for Psychotherapy and Spirituality.

How do you suggest a non-clerical therapist integrate spirituality into everyday therapy practice?

There are several different ways to approach this very good question, and a great deal hinges on how you understand “spirituality.”   I find that the simplest practical way to define that is the approach offered in my old friend James Griffith’s book, co-authored with his (then) wife Melissa Elliot Griffith: Encountering the Sacred in Psychotherapy: How to Talk with People About Their Spiritual Lives (Guildford, 2002). They propose to define spirituality as a

“commitment to choose, as the primary context for understanding and acting, one’s relatedness with all that is. With this commitment one attempts to stay focused on relationships between oneself, and other people, the physical environment, one’s heritage and traditions, one’s body, one’s ancestors, saints, Higher Power, or God” (p. 16).

This distinguishes yet relates spirituality to religion, since it is from historical religious or spiritual life ways that a great many people have inherited or appropriated the metaphors, narratives, rituals, and confirming communities that organize those vital relationships over a lifetime. It is also the case that a great many persons will self-identify as “spiritual but not religious” — a self-descriptor that Ken Pargament has shown is usually an index of some degree of alienation or disaffection from what person might term “organized” or “institutional religion” (which nevertheless may play a significant if unconscious or even repressed role in their psychic lives).

The Griffiths argue for therapists inquiring quite directly and yet respectfully about whether a religious or spiritual path has been a significant part of a client’s life if it does not emerge spontaneously in the therapy. Even if that proves not to be the case, there are questions which can be asked, if appropriate, that dive for that level of significance that we may term “spiritual.”  Among the questions they suggest are: “What has sustained you?” “From what sources do you draw strength in order to cope?” “To what or to whom are you most devoted? “Why is it important that you are alive?” Finally, there is the question I find myself wondering about, though it is more often picked up obliquely than asked directly, “Who are you with when you are alone?”

How does the skilled therapist “integrate spirituality into every day therapy practice”? The simplest answer is to listen for ways in which it may already be there – or be conspicuously missing — as a resource and source of meaning in the client’s life. It is then addressed as one would any other vital relationship in the client’s life including the relationship they may carry on with deceased relatives and siblings.

By the way, I think that the “clerical” therapist has both some advantages and some handicaps in attending to this dimension of their clients’ lives. The advantage is that if that identity is known to the client it may be accepted as tacit permission to talk about this aspect of the client’s experience if relevant. Many spiritually or religiously committed clients self censor around these matters out of a sense that it will not be respected and may even be pathologized by the therapist. On the other hand, as my colleague Dr. Nancy Kehoe (who is both a nun and a clinical psychologist) has shown, there are complex transferential dynamics that may be set up when the client perceives the therapist as also a religious professional, and these get particularly sticky when it is a shared tradition.

What are your thoughts about displaying religious iconography in psychotherapy offices?

I think that it is important to ask the question, “For whose benefit is the religious iconography displayed?”  For the therapist’s or the client’s? Many years ago,  when I first saw patients for an intake in an office at a community mental health center, I kept on my desk where I could see it (though it would also have been visible to the client), a small icon of the raising and unbinding of Lazarus, because it was meant to remind me of what has always been for me a metaphor for what good therapy aims to do, to help release persons from the “tombs” or dead places in their lives (and it is a messy, stinky affair, as that story attests; it is also a labor of love). The image was in the first instance there for me…but I think now that is inadequate.

I would be much more thoughtful and intentional today if I were seeing the diverse range of folks who are likely to come to community mental health center. My studies of the history of Jewish-Christian relations, for instance, has taught me that one person’s symbol of hope is another person’s emblem of hate (the cross pre-eminently, as the conflict over the cross erected by the Polish government at Auschwitz poignantly illustrated). My work with survivors of clergy sexual abuse has alerted me to ways in which some religious images are triggers of frightening associations. The priest-clinicians that I know would never, for instance, wear a Roman collar when doing therapy, and most especially with survivors.

It seems to me that the more helpful way of thinking about what is displayed in a space putatively about healing is what images are comforting but open enough to be available to the client’s own projective or imaginative construal. Van Gogh’s Starry Night, or Millet’s The Angelus might offer themselves up to rich associations.

I might add that in recent years I have mainly done spiritual direction, and when I do it at my office in the university the surrounding display gives the message that there are multiple ways in which it is permissable to imagine the sacred since Rublev’s Holy Trinity shares space with a Tankha of the enlightenment of the Buddha and a menorah on the shelf is next to a Hopi kuchina!

How psychotherapy’s relationship to spirituality changed over recent years? What direction do you think we are headed?

For eleven years beginning around 1990 I had the great good fortune to be part of the Agosin Group – a team of psychotherapists begun by the late Dr. Tomas Agosin, a psychiatrist on the faculty of Albert Einstein Medical School, who team taught a summer course, “Psychotherapy and Spirituality,” for the Cape Cod Institute. Initially, and for a good many years, the psychotherapists and counselors who flocked to the seminar from around the country spoke of themselves, sometimes cautiously, as “coming out” as clinicians who took seriously the spiritual dimension of therapeutic practice. It was a daring and still politically marginalized interest, and our work was largely laying out the critical theoretical and methodological groundwork to legitimate an integrative approach. Over these twenty years there has been a veritable flood of literature, much of it published by the American Psychological Association (e.g. books by William Miller, Edward Shafranske, Len Sperry, Ken Pargament, Alan Bergin, and James Jones to cite just a few), that has brought that interest and conversation out of the closet and into something approximating the mainstream – though not without resistance, some of it well-considered and worth taking seriously. All this is to the good and to be grateful for.

Now as I see it the problem we face is perhaps rather different. My colleague in the Agosin Group, Mark Finn referred to it as the “commodification of spirituality.” There is, I sometimes fear, a growing tendency for psychotherapists to reify “spirituality” as simply one more pragmatically useful resource to enhance the psychological well-being of individuals in therapy. Spiritual practices like meditation are deracinated from their traditional ethical, ritual, theological,  and social contexts, and offered as value-free (but financially costly) technologies for personal self-improvement. To describe this process in terms of traditional Buddhism (since it is the practices adapted from that spiritual path which have been perhaps most often appropriated in this uncritical fashion): it is like trying to extract Right Mindfulness from the total context of the Eightfold Path and offer it without attention to the ethical practices (right speech, right mindfulness etc.) or the accompanying ontological vision of reality (right view). Or to put it another way, this approach ignores the crucial role of the “sangha” (in other terms, community, synagogue, church, haverot, fellowship) in the process of individual and social transformation. Sociologist Robert Bellah in Habits of the Heart was critical of this long running and very American tendency to a privatized “expressive individualism” that ignored the common good. For all that we may rightly criticize traditional “institutional” religion, it maintained at its best the bracing vision of the human person as ultimately made for and by a common life in relationship to transcendent meanings and values that overcome the isolating centrifugal forces of solitary self-cultivation.

Bibiliography

James Griffith and Melissa Elliott Griffith. Encountering the Sacred in Psychotherapy (Guilford Press, 2001)

Nancy Kehoe, RSCJ, Ph.D. Wrestling With Our Inner Angels: Faith, Mental Illness and the Journey to Wholeness (Jossey-Bass), 2010.

William R. Miller (ed) , Integrating Spirituality into Treatment: Resources for Practitioners (American Psychological Association) 1999.

P. Scott Richards & Allen E. Bergin (eds), Handbook of Psychotherapy and Religious Diversity (American Psychological Association), 2000.

Edward Shafranske, Religion and the Clinical Practice of Psychology (American Psychological Association, 1996)

Len Sperry & Edward Shafranske (eds), Spiritually Oriented Psychotherapies. (American Psychological Association ), 2005.

Froma Walsh (ed), Spirituality in Families and Family Therapy (Guilford Press), 1998

Find John McDargh on the web at bc.edu. Find the above books along with others on the subject at the Where the Client Is/Amazon Bookstore.

What’s your background? What do you do now?

My background is originally in Family Practice. When I started off, I wanted to be a primary care provider, and so I started down the Family Practice path. Over time, it became increasingly clear that I showed a special talent for Psychiatry, so I chose to specialize in that area. Flash forward ten years, and now I am serving in a bunch of different roles. Clinically, I split my time between my private practice and my clinic practices. Additionally, I teach and supervise Psychiatrists in training, serve on the Executive Council of the APA in New York City, and serve on clinical advisory boards for two top rehabilitation programs. In my private practice, I get to provide high-end patients with psychiatric care that is nonjudgmental and considers their specific needs. In my clinic practices, I get to provide top-quality care to those who will benefit from it the most. The two clinic practices are a HIV/AIDS community program and a community addiction treatment program. In the HIV/AIDS program, I am the sole psychiatrist in a multidisciplinary medical practice, and in the addiction program I am Medical Director. In both clinic programs, patients have not been able to achieve success in their lives for one reason or another. Through closely coordinated care, my colleagues and I assist the patients to lift themselves up to the next level and, hopefully, start to put their lives together. It’s an incredibly rewarding and satisfying experience. My involvement with the APA and the advisory boards is my attempt to help modernize psychiatry. More and more psychiatry is developing a scientific foundation that is helping to destigmatize the various mental health disorders. I am hoping to help increase awareness, acceptance, and support for the various mental health disorders.

How did you first build your psychiatric practice? What worked? What didn’t?

I have to say that I was very surprised by what worked and what didn’t in the process of building my practice. Following advice from peers and friends, I reached out to the psychiatric community and to therapists in my neighborhood with announcement notes. Additionally, I posted a couple of small ads in hobby journals to which I subscribe. From all of this effort, I may have received maybe one referral. What eventually did work was face-to-face contact: I invited colleagues out to lunch or dinner, I attended every professional function I could find, and I made brief visits to neighborhood treatment centers to introduce myself. Within a few weeks of changing my tactics, the phone started ringing with referrals. Once my roster started to grow, I made a point to meet with patients’ psychotherapists. Thereafter, a network for cross-referral began to grow and business started to boom.

As a psychiatrist, what do you most value in psychotherapists with whom you share patients? Which are the therapists you are most likely to refer to?

That’s a question I’m very happy to answer because I am quite fond of the therapists with whom I share patients. They all have three things in common: collegiality, great communication, and a longitudinal approach for each patient. First off, in private practice, our colleagues are the people in our network with whom we interact; therefore, it really pays off to have good working relationships with one another. This is usually reflected by how easily we ask each other questions and tell each other our ideas. I never hesitate to speak with one of my colleagues because I know that the conversation will be easy and I may even learn something! The next thing I look for is great communication regarding my patients. What makes the therapists in my network stand out above the rest is that they give me updates on how my patients are doing — even if I don’t ask. I refer patients for therapy not because I want to deflect that part of the treatment but because I believe my patients will benefit from the additional modality. Therefore, hearing about how my patients are doing enables me to create more comprehensive formulations and thereby provide better care. Finally, and this may be a personal preference, but I like to work with therapists who take a longitudinal approach to formulation. I like to hear what they think in terms of where the patient has been, where the patient is now, and a few projections as to where they think the patient might be headed. Ideally, I’d also like to hear what approaches they would take given the possible outcomes that they suggested. This comprehensive approach to formulation let’s me know that my patients are in the hands of a therapist who has paid attention, has formed an opinion, and is thinking about the repercussions of their various interventions. This is the type of therapist into whose hands I would like to place the care of my patients.

Do you have any additional wisdom you’d like add for therapists starting out in private practice?

Do what’s right for your patients and the universe will do what’s right for you. I know it’s scary to pass a patient on to a colleague when you’re trying to build up your practice and make a living; but refer when appropriate and you will earn a reputation as a practitioner who puts their patients first. When the recession hit and patients decreased their frequency of visits, I felt the familiar pangs of wanting to fill up my practice. An exercise I found helpful in these situations was to imagine my practice full again and the patient in front of me (or on the phone, or being referred to me) as a patient that I would have to go through some machinations to accommodate. In that situation, would I really be the best provider for this patient? If so, then I would take the patient on. If not, then I would discuss referring the patient to a colleague. You’re here to help so do what’s right for the patient and everything else will fall into place for you.

Find Samuel Sharmat, MD on the web at samuelsharmatmd.com.

Tom Corboy is the founder and director of the OCD Center of Los Angeles

What’s your background? What do you do now?

I received my master’s degree from the Department of Counseling Psychology at the University of Southern California (USC) in 1993. My USC graduate thesis was a study comparing various treatments for Obsessive Compulsive Disorder (OCD). In conducting my research, I learned that numerous controlled studies had consistently found a specific type of Cognitive Behavioral Therapy called Exposure and Response Prevention (ERP) to be the most effective treatment for OCD. Much of my post-graduate training was focused on CBT and various exposure therapies like ERP for the treatment of OCD, Panic Disorder, and related Obsessive Compulsive Spectrum Disorders. During my post-graduate training, I also started a weekly, CBT-based, OCD therapy/support group for adults that has been running continuously since 1997.

I am currently the director of the OCD Center of Los Angeles (OCDLA), which I founded in 1999. OCDLA is a private, outpatient treatment center dedicated exclusively to the treatment of OCD and related OC Spectrum Disorders, including Panic Disorder, Social Anxiety, Body Dysmorphic Disorder (BDD), Health Anxiety (Hypochondria), Phobias, Trichotillomania (compulsive hair pulling), and Dermatillomania (compulsive skin picking, or CSP). We have four therapists on staff, all of whom specialize in CBT for these conditions. We treat adults, adolescents, and children, and offer services in both English and Spanish.

Our program primarily focuses on weekly, outpatient, individual CBT sessions, but may also include intensive daily sessions, family sessions, home visits, or couples sessions. Individual sessions often includes “in-vivo” field therapy, during which our staff therapists help clients face their anxiety in real-life situations. We also have ten structured CBT therapy/support groups–six for adults and four for children and adolescents.

How did you go about growing from one person with a specialty into a center with multiple therapists?

Even while doing my post-graduate hours, I knew that I wanted to have a niche practice focused exclusively on OCD and related anxiety-based disorders. After I completed my hours and passed the California state licensing exams, I subleased a small office and opened the center, which was originally just a solo private practice.

Since then, the growth of the center has been very gradual and based on increased client demand for services. After a couple of years of solo private practice, my client base had grown to the point that I hired a post-graduate MFT intern to see additional clients. After another year or so, we both had full schedules, so I hired a second MFT intern, and took over the lease of the entire suite that housed my original subleased office. And a year after that, I hired a post-graduate MSW associate.

For the past five years or so, the center has consistently had 3-4 therapists on staff. Most of the interns and associates have stayed on after receiving their licenses. One staff therapist, Danielle Lieb-Foley, eventually moved to Oregon after getting licensed and opened a similar clinic called the Portland OCD and Anxiety Center.  As I said, the growth of the center has been very gradual – we have only expanded when it has been clear that our client load warranted hiring additional staff and renting more space.

How do you choose staff? How do you recommend people get trained in ERP?

Choosing staff is a critical issue for a niche center like ours. Our treatment program is very structured and extremely specialized. Unfortunately, the vast majority of graduate programs provide only minimal training in CBT, and no training in ERP. When hiring, I look for people who have had some additional education and training in CBT and ERP, and ideally, some experience with using CBT and ERP to treat anxiety disorders.

The OCD Center is fortunate in that we are now established to the point where young therapists with a specific interest in the conditions we treat frequently contact us looking for internships. The first thing that happens upon being hired is that they go through an extensive training in the various CBT modalities we use – specifically ERP, but also Imaginal Exposure, Interoceptive Exposure, Habit Reversal Training, and Cognitive Restructuring. Our training also includes a strong emphasis on mindfulness-based approaches such as Acceptance and Commitment Therapy (ACT), which we have found to be particularly valuable with clients experiencing anxiety.

Upon completion of this initial training, new staff therapists start with 1-2 clients, and increase their client load only as they become more adept in using these techniques effectively. They receive face-to-face supervision on a weekly basis, which continues in the form of weekly staff meetings even after they have received licensing.

Where do your referrals tend to come from?

Our referrals come from a wide array of sources. After ten years, the center is fairly well-known in the local mental health community. As a result, we get referrals from psychiatrists who want to add CBT to the pharmacotherapy of their patients. We also frequently receive referrals from other local psychologists, MFTs and social workers who want their clients to get into a CBT group to augment their individual therapy. And we get referrals from former clients who recommend us to friends and family.

Another major source of referrals for us is our website. We have made a concerted effort to build a strong web presence, with a lot of time and energy put into ongoing search engine optimization. I think a lot of therapists make the mistake of putting up fairly simple websites which they never update. Our site has grown significantly over the years to include over forty pages of information and online tests. It also includes a blog specifically about OCD and related anxiety conditions.

Find Tom Corboy and the OCD Center of Los Angeles online at OCDLA.com and blogging at OCDLA.com/blog.  For recommended reading about OCD, take a look at the Center’s OCD Readings page or at the WTCI Bookstore’s OCD section.

Keely Kolmes (Photo by Thomas Roche)

What’s your background? What do you do now?

Before becoming a psychologist, I was doing computer consulting and had been fairly immersed in online culture since the early 90′s. I also had interests in sexual health and behavior and had worked previously at the National AIDS Hotline. I went to graduate school for my Psy.D. in 1996 with the dream of working in college mental health and working with students around issues of sexual behavior and identity. I’ve spent eight years working in college mental health, and started my private practice two years ago. Now, I’m doing private practice full-time and I work with a lot of sexual minority clients (LGBT, poly-identified, kink-identified) on a variety of issues including anxiety, depression, relationship concerns, and sometimes sexual issues. I see individuals and couples in my practice. I also offer consultation and trainings to other mental health professionals on managing a professional presence on social media and also in working with sexual minority clients.

What’s been your approach to managing your social media presence?

After starting my private practice in 2008, I wanted to use social media for marketing purposes, but I found it problematic to use my personal accounts to do this since I did not want to lead clients back towards my personal life. In February of 2009, I created my professional Twitter account which felt like a big relief. I was able to take up space online in a completely professional way and keep my personal tweets confined to a locked and private account. Shortly after this, I also created a Facebook Fan page for the purpose of experimenting with Facebook ads. I have opted to keep my LinkedIn profile non-public since I would prefer for people not to be able to browse my contact list. But I do participate in LinkedIn discussions and groups.

Mostly my approach to social media is to participate when I’m moved to do so. I blog when I have a topic I feel passionate about. I tweet when I read things that interest me. And I try to interact a reasonable amount without it pulling me away from other activities. I share things when they excite me and I love finding other people’s resources that are valuable to pass along.

How did you get to 16,000 twitter followers and how does your Twitter/social media presence affect your practice?

Twitter lists categories of suggested users and I found myself listed in their Health category this year. After that, my follower count jumped up a great deal. It’s hard to say how Twitter alone affects my practice. I have never had a new client say they found me through Twitter. Most of my followers on Twitter live in different cities or different countries. I think Twitter expands my reach globally, rather than locally, which is good for helping to establish my reputation and letting other people know about me, but I’m not sure it translates directly into referrals.

However, Twitter has enabled me to connect with other mental health professionals who are passionate about technology and social media. It’s greatly enriched my professional life by leading me to professional collaborations with clinicians in other states and countries who I would not have met before Twitter. Since I love research, writing, and collaboration, this has been of great value to me. I see Twitter as a place for me to engage in professional exchanges with other folks in mental health, although occasionally students and consumers of therapy ask me questions there.

What’s the story behind the Social Media Policy posted on your site?

Last March, I first began to consider therapists encountering client information on the Internet and how that might affect treatment. At that time, it seemed there was a lot of worry from therapists about clients searching for information about them online, but very little being written about what impact it might have on therapy when therapists found client information online. I started developing my research instrument to explore this subject.

In my research proposal I acknowledged that future therapists might need to include items in informed consent such as whether or not they Google their clients and how they respond to interactions with clients online. Through my research and my consultations with other professionals, I began to hear of how many different boundary crossings were occurring via the Internet. This helped me to shape my ideas about what to include in my Social Media Policy.

I saw the Social Media Policy as an opportunity for me to think through my policies and consider why I had adopted them and to articulate this in a language that was understandable to clients. Demystifying the therapy process for consumers has always been of interest to me. I also know that clients might not otherwise know what to expect unless they intentionally or accidentally crossed paths with me online. I believe that in a number of years, all therapists with Internet access are going to have to start including Social Media information in informed consent, and I would not be surprised if the APA addresses this in the near future. I just consider myself an early adopter of the Social Media Policy. But since I think a lot of professionals may not even know where to start, I also wanted to offer this document as a gift to the profession for people to copy, share, or modify to fit their own approaches to clinical care.

Find Keely Kolmes at her website, drkkolmes.com, and on twitter: @drkkolmes.  Her Social Media Policy is here.

Tamarisk Saunders-Davies is a British marketing-professional-turned-psychotherapist. She talked to WCTI via email about her work with female entrepreneurs and the state of therapy in the United Kingdom.

What’s your background? What do you do now?

I did my first degree in Psychology at the University of Newcastle-upon-Tyne, in the north of England. As a teenager I actually dreamed of being a actor but i started to realise what i loved about acting was getting to understand the character and why they did what they did…fairly quickly I realised what I really wanted to do was study human behaviour so I enrolled in the psychology programme.

On leaving university, I pursued a career in marketing and public relations in London, hoping to put my knowledge of human behaviour to good use. I didn’t, but it was great fun if high pressured and very results driven. Eight years into my marketing career, I got to wondering if I still wanted to be doing it 30 years from now and I couldn’t escape the niggling doubt that no, I really couldn’t see myself doing it for my entire working life. So I took a pay cut, carried on working part time and went back to university to get my post graduate in Counselling and Psychotherapy. It was tough juggling the high pressured job, the blinking Blackberry and essay deadlines but I really felt excited about moving towards my new career as a psychotherapist.

Now I’m running a fantastic London based practice working with ambitious, go-getting women who are struggling with issues around work, relationships or both and who are looking to find some clarity in their lives. I also offer consulting services to other therapists looking to get a better handle on their marketing…so maybe I will be doing a marketing job until I retire!

What’s your approach to working with your “go-getting” clients?  How have you marketed yourself to them?

While my training was integrative, I’ve been continuing my development as a psychotherapist by learning more and more about the existential way of working. I’ve been avidly reading works by the likes of Irvin Yalom, Rollo May, Emmy Van Dursen and Freddie Strasser.

It seems to me that a lot of people have the notion, gleaned from movies, television and glossy magazines that life is perfectable. The idea that other people out there somewhere have achieved the perfect life, when in fact no one has, it’s not possible. So they feel dissatisfied with the life they do have or even cheated out of the life they think they deserve. They yearn for for a life of perfect happiness, while failing to take control of the life they do have.

My role as therapist is to help my clients find their own unique meaning for their life, I assist them in recognising that they are free to create themselves and make something worthwhile of themselves, making it more rewarding by taking decisive, realistic action.

The type of clients I work with–career orientated women who are struggling with issues of self-confidence and self-esteem–respond really well to this approach as it’s quite an active and dynamic questioning process. They feel I’m with them, that I’m curious and that I’m not just sitting there saying “hmmmmm” a lot!

How have I marketed myself to them:  What’s really important for me is to get out there, meet people and tell them about who I help and how. I’m very fortunate in that I really enjoy networking and living in London you’re really not short of opportunities to do that! I’ve also got much more comfortable networking online, connecting with people through social networking sites like Twitter. With a little bit of hunting I’ve found loads of people doing exciting things out there and so wonderful opportunities to collaborate with them have cropped up. I’m contributing to newsletters, websites and all sorts.

The health care system also runs very differently in the UK to how it does in the States, so for me it’s also been key to get on the radar of GP’s. They tend to be the first port of call when people are struggling emotionally. The National Health Service is doing a lot more to create greater access to talking therapies through a programme called IAPT, but demand is still much, much higher than supply.

The clients I work with are used to having a choice of service provider and are prepared to pay to access good therapy quickly rather than wait. In some cases waiting lists to access NHS counselling and therapy runs into years.

Working within the NHS, are you restricted to evidence-based therapy (CBT and the like)?  If so, how do you fit the search for “unique meaning in client’s lives” within that framework?  It seems like the U.S. is slowly heading in a British-ish direction.

The Improving Access to Psychological Therapies (IAPT) has evolved from a paper originally tabled by a very influential health economist called Lord Layard in 2005.

Layard reasoned that funding by the Department of Health (DH) to improve provision of psychological therapies in the treatment of depression and anxiety, would positively impact on the number of people who are ready, willing and able to get back into work. This increase would consequently reduce the cost of Incapacity Benefit (Welfare I think is the US version) for this section of the population, leading to potential savings for the government. By bringing together prevalence statistics for depression and anxiety, costs of training and employing therapists, potential cost savings in reducing the amount of people claiming welfare, and the benefits to individuals and society of improved mental health and wellbeing, Layard was able to make a strong case for investment by central government.

Layard strengthened this economic argument with a moral and clinical one highlighting the inequitable and patchy nature of current psychological therapy provision, long waiting times, and lack of consistency in implementing NICE (National Institute for Clinical Excellence) guidelines for depression and anxiety.

Based on the NICE guidelines (2004), Layard’s proposed solution was for the provision of treatment centres offering evidence based psychological therapies and psychological support. This proposal achieved £3.7million funding to set up demonstration sites in two different areas of the UK, and saw the launch of the Improving Access to Psychological Therapies Programme (IAPT) in England.

The IAPT programme is absolutely about CBT and therapists currently being trained and working within that programme are using that way of working, but there are lots of different types of practitioners who work within the NHS. CBT certainly has a majority share but there are more traditionally trained psychotherapists working within the NHS. The world famous Tavistock Centre for instance, is orientated towards the psychoanalytic tradition.

A full explanation of all the different ways of working within the NHS would take more space than I have here, because provision changes from borough to borough, council to council.

I will say this -  while I believe an increase in access to talking therapies is a good thing, above everything else I believe that a successful therapeutic encounter can only happen if the client has that elusive chemistry with their therapist. I really believe that choosing your therapist, rather being referred to whoever has a free slot for you, is what will lead to that happening. It’s when that happens that good therapy happens.

Find Tamarisk Saunders-Davies on the web at twochairscounselling.co.uk.  For authors mentioned in the interview, go to the Where the Client Is Bookstore.

Will Meek, PhD is a Vancouver, Washington-based therapist who has carved out a niche working with “The Psychology of Men.” He talked to WTCI via email about what that means and what he does.

I am currently employed full time as a psychologist at Washington State University Vancouver, where I run our small counseling center. This essentially means I run the training program, the outreach program, see a full case load of clients, and work on our students of concern committee and am part of the campus Diversity Council. I also teach at Portland State University in the Masters in counseling program. Additionally, I have a private practice in Vancouver, Washington, which I feel quite passionate about. As of this interview the practice is still in its infancy, but I am quite excited about the direction it is going.

Right now I am putting a lot of time into developing my new blog: Vancouver Psychologist. I have written online in some form or another for the past 10 years, and I think this is my best yet. I am also in the process of beginning a research program on psychology of men, which will be centered on another site I have: Psychology of Men. Working with male clients is a specialty of mine, and I think I have some fresh ideas on the subject to share.

What was the biggest surprise in going into private practice?
Insurance! Despite being pretty educated as a consumer of health insurance, being on the provider side was quite a surprise. I heard horror stories from supervisors and mentors during my training, but the reality of dealing with insurance is unbelievable. It takes a very diligent clinician to keep track of all the money he is owed, how the deductibles work for each client, and follow up with session authorizations.

How did you first get interested in the psychology of men?
My first spark of interest came when I realized in my mid-20s that I had never really thought about what it meant to be a “Man.” This was likely the result of some form of privilege, and I soon realized that most of my colleagues, friends, and clients had not considered this aspect of their identities either. So I decided during my post-doc year that I would focus on men’s issues, and I did a lot of reading, personal exploration, and learning about the psychology of men.

The biggest surprise to me was how splintered the literature on this subject was. The were two distinct threads; one from a male empowerment perspective, and another as a compliment to the feminist movement. Not once did I come across something that felt like a balance or integration of both of these perspectives, which is when I decided that I needed to get some of my ideas out there.

You have just started doing research on something you refer to as “Gender Role Advantage”–can you tell us what that is?
Most people studying masculinity have read about Gender Role Conflict (GRC), which is Jim Oneil’s concept about problems that arise when our gender role becomes limiting or harmful to ourselves or others. In working with clients on GRC, I realized that there were major forces keeping men in place with their gender roles and identities, which prevented any change and continued the GRC. These factors amounted to two levels of benefits: (1) acceptance from other men, and success at professions traditionally held by men; (2) increased money/resources, self-esteem, social status, and interest from mates. So gender role advantage is “the benefits from maintaining a particular gender role and identity.” I think that these things must be examined in working with male clients.

Many of my clients feel like they will appear insensitive if they feel good about being a man or explore this aspect of their identity. I think that cautiousness shows some of the awareness of how charged this stuff can be, but once the fear is lifted, it is amazing how powerful and transforming connecting to this part of self can be.

What’s next for you?
I am going to really get some steam behind my research on Gender Role Advantage and hopefully establish that idea in the professional consciousness, since I think that attention to this by clinicians will be very helpful for men going to counseling. I am also going to continue my work in my private practice, writing my blog, working at WSU Vancouver, and teaching at PSU.

Recommended Reading

(All titles available at the WTCI-Amazon Bookstore)

King Warrior Magician Lover
Robert Moore & Douglas Gilette (1991) – HarperOne

The Masculine Self
Christopher Kilmartin (2009) – McGraw Hill

Fire in the Belly: On Being a Man
Sam Keen (1992) – Random House

In the Room With Men
Matt Englar Carlson & Mark Stevens (2006) – APA

Iron John: A Book About Men
Robert Bly (1990) – Da Capo Press

New Psychology of Men
Ron Levant & William Pollack (1995) – Basic Books

Manhood in America: A Cultural History
Michael Kimmel (2005) – Oxford University Press

Under Saturn’s Shadow: The Wounding & Healing of Men
James Hollis (1994) – Inner City Books

Masculinities
RW Connell (2005) – Univ of California Press

Manhood in the Making
David Gilmore (1991) – Yale Univ Press

Castration & Male Rage
Eugene Monick (1991) – Inner City Books

He: Understanding Masculine Psychology
Robert Johnson (1989) – HarperOne

Find Will Meek on the web at willmeekphd.com and psychologyofmen.org.

Dr. Sherman is a psychologist practicing in New York City and author, with Dr. Frances Sommer Anderson, of the upcoming Pathways to Pain Relief.

What is TMS?

For the past thirty-five years, John Sarno, M.D., a physiatrist at The Rusk Institute of Rehabilitation Medicine and Professor of Rehabilitation Medicine at The New York University School of Medicine has pioneered the idea that a wide variety of pain disorders are psychophysiological in origin. A psychophysiological disorder is diagnosed when emotional factors partly or entirely contribute to the development of physical symptoms. Previously, psychophysiological disorders were more commonly referred to as psychosomatic disorders. Such conditions develop out of the physiological reactions which accompany all emotional or psychological experiences. Psychophysiological disorders are just one aspect of the recently energized field of Mind-Body medicine.

What is already well documented is that conventional treatments for back pain fail abysmally. If mainstream medicine effectively treated back pain, for example, desperate patients would seldom seek the help of Dr. Sarno and other Mindbody medicine experts. In his writing, Dr. Sarno identifies Tension Myoneural Syndrome (TMS) as a benign, psychophysiologic process in which mild ischemia or reduced blood flow to postural muscles, nerves, and a variety of tendons is initiated by dynamic psychological factors. What does that mean? Myoneural refers both to the functional and structural relationships between muscles (myo) and nerves (neural). Nerves transmit electrical signals to muscles, commanding them to contract or relax. Ischemia describes a condition of reduced blood flow or circulation to a particular area. Dynamic psychological factors are psychological forces that operate outside of an individual’s awareness yet still affect that individual’s behavior, just like an odorless and colorless gas causing baffling physical reactions. Therefore, TMS is a psychophysiological pain disorder where emotional experiences, which may be partially or completely out of a person’s awareness, produce ischemia or reduced blood flow to the postural muscles, resulting in mild oxygen deprivation and pain.

The overlapping relationships between blood flow, emotional experiences, and physiological reactions are immediately recognizable in the everyday phenomena of erections and blushing. Embarrassment is accompanied by increased circulation to the face and neck, and when a person is frightened, the blood drains from his face and he acquires a ghostly pallor. Sexual arousal redirects blood flow to the penis, which is actually a muscle, and an erection ensues. If that same person experiences fear or self-consciousness, blood flow to the penis is reduced and the man cannot sustain his erection. The interaction between emotional experiences, blood flow, and myoneural activity is the same psychophysiological process involved in TMS.

Dr. Sarno describes TMS as a physical disorder characterized by pain and/or other neural signs and symptoms affecting a variety of musculoskeletal locations. We use the term pathophysiology to refer to how a disease or malfunction arises from abnormalities in the structure or functioning of bodily systems. The pathophysiology of TMS involves the circulatory system.

Dr. Sarno emphasizes that the pain is real; it is not imaginary or “in the patient’s head” as sometimes misconstrued by physicians and mental health professionals. For example, few would misunderstand diarrhea as “fake,” imaginary, or “just in the patient’s head,” simply because it resulted from a “nervous stomach.” Because TMS is a physical disorder, the subjective experience of the pain is indistinguishable from pain originating from organic conditions such as injuries, tumors, and infections, even though the pathophysiology responsible for the syndrome is psychologically induced.

Dr. Sarno conceptualizes the pain symptomatology as a self-protective reaction or a defense against recognizing and experiencing intolerable affects, not the result of structural damage or disease. So when a herniated disc is diagnosed as the cause of the patient’s pain and disability, a psychophysiological disorder is misdiagnosed and physical treatments not only fail but serve to intensify the symptomatology. Appropriate treatment is delayed or denied, and iatrogenic, or physician-induced, debility develops.

If someone thinks they might have TMS, what should they do?

Often, individuals suspect accurately that they are suffering from TMS. However, it is essential that the diagnosis of TMS be confirmed by a physician, preferably one familiar with Mindbody disorders. Unfortunately, medical training promotes a collective professional blindness to Mindbody disorders. Conditions are inaccurately understood to be either physical in origin, or psychiatric in nature, ignoring the fact that in some instances the two may be related and that the whole can indeed be greater than the sum of the parts. Consequently, treatments based on a faulty diagnosis are doomed from the outset.

If an individual has access to a physician specializing in the diagnosis and treatment of Mindbody disorders, consulting with that physician is the logical first step to recovery. In the New York City area, individuals can consult with John Sarno, MD who first developed the concept of TMS and its first effective treatment. Ira Rashbaum, MD is another physician in the New York area who treats Mindbody disorders. In Detroit, individuals may consult with Howard Schubiner, MD, and in Chicago, John Stracks, MD. David Schechter, MD is a specialist in Mindbody medicine practicing in Los Angeles. David Clarke, MD writes and lectures extensively on Mindbody medicine. In New Hampshire, individuals can be evaluated by Marc Sopher, MD.

The preceding list of Mindbody practitioners is by no means definitive. If these physicians are geographically inaccessible, an individual should contact the nearest physician. Often these practitioners can refer prospective patients to someone closer to them.

If none of these resources represent viable options, then the patient should consult with a trusted physician, if for no other reason to rule out serious conditions such as fractures, tumors, infections, etc. If these diagnoses are excluded from the differential, the patient should certainly engage the physician in a discussion about whether symptoms could be explained on the basis of a Mindbody disorder.

Once a diagnosis of TMS is established, treatment may take several different forms. Of great interest is that large numbers of people have been permanently “cured” after reading one of Dr. Sarno’s books. This is important in theorizing on the nature of the psychophysiologic process and what is required to reverse it. Clearly, the acquisition of information about the process must be therapeutic. Therefore, merely explaining the diagnosis often results in symptomatic relief.

In addition to providing basic information about TMS, as part of the psychoeducational treatment model developed initially by Dr. Sarno, the physician may recommend any number of therapeutic modalities which help patients observe and monitor the relationship between their physical symptoms, and their emotional state. Physical symptoms are now enlisted as signals to guide introspection, rather than evaluate structural pathology.

Many patients do require individual and/or group psychotherapy. To avoid the same pitfalls patients face when they seek evaluation of their symptoms from physicians unfamiliar with mind body disorders, it is imperative that a prospective patient be referred to a psychotherapist experienced in treating TMS. The previously cited physicians can help with the referral process, as well as collaborate with the therapist and work together as a team to treat TMS and other Mindbody disorders.

Does treatment actually work?

Unfortunately, drug companies and medical device manufacturers have little incentive to fund research on Mindbody disorders. Furthermore, if mainstream medicine has a blind spot for Mindbody disorders, then it’s impossible to be curious about them and systematically investigate them. Although almost all of the evidence demonstrating the efficacy of treatment for TMS is anecdotal, it must be remembered that this body of anecdotal evidence has been collected by Dr. Sarno over nearly forty years from tens of thousands of patients. I have received photos from former patients in which they are break dancing, sky diving, or performing yoga contortions worthy of Cirque du Soleil. All of them had been advised to undergo surgery to correct disc herniations, the presumptive cause of their incapacitating pain. At the time of these photos, all of their scans would be unchanged, yet they are engaged in activities that are impossible for anyone who suffers from back pain. Psychotherapy cannot correct a herniated disc, however it can effectively treat TMS pain.

Dr. Arlene Feinblatt, formerly the Director of the Psychophysiological Pain Service at The Rusk Institute of New York University Langone Medical Center published data obtained from Dr. Sarno’s patients who participated in a time-limited, group psychotherapy treatment module. Her study demonstrated that patients who experienced the greatest relief in their pain symptomatology also significantly improved their tolerance for negative affect. Recently, Howard Schubiner, MD and his associates conducted a small scale, randomized controlled trial evaluating the effect of psychoeducational treatment on pain reduction in patients diagnosed with fibromyalgia (which is regarded by many as a TMS equivalent). The statistically significant results demonstrated sustained pain reduction in the patient group receiving an innovative psychoeducational treatment, compared to a wait-list control group. Obviously, similar studies need to be conducted, expanded, and replicated.

Find Dr. Eric Sherman on the web at PathwaysToPainRelief.com. For more about TMS treatment, try the TMS Wiki.

Frances Sommer Anderson, PhD is a New York-based psychoanalyst and expert on treating chronic pain.  She talked to WTCI via email about what she does and how she does it.  Hear Dr. Anderson speak and learn more about treating chronic pain at the

What’s your background? What do you do now?

The body–disabled, disfigured, and in pain–has been the focus of my work as a clinical psychologist and psychoanalyst, beginning in 1974 with my clinical psychology internship at Rusk Institute-New York University Langone Medical Center. Learning to help children and adults cope with and surmount congenital, traumatic, and progressive loss of bodily functioning was a daunting challenge in the beginning: I had to confront my own vulnerability to the vicissitudes of life and the fear that we all have when we experience a loss of the capacity to function physically. I soon found this work compelling and was fortunate to become a member of the psychology staff for 12 more years.

In 1979, while still at Rusk Institute, I began working in John E. Sarno, MD’s pain program, under the supervision of Arlene Feinblatt, PhD, the psychologist who collaborated with him in developing treatment of the pain syndrome initially termed, “Tension Myositis Syndrome, (TMS)” which he now refers to as “Tension Myoneural Syndrome.” Treating people in chronic, severely debilitating pain, as a psychosomatic manifestation according to Dr. Sarno, was an exciting opportunity to learn about the mindbody connection, which had fascinated me since my first undergraduate psychology course. After I left Rusk Institute in 1987 for full-time private practice and psychoanalytic training, I continued to collaborate with Dr. Sarno in treating TMS. In 1998, I published “Psychic Elaboration of Musculoskeletal Pain: Ellen’s Story,” a detailed presentation about my work with one of his patients (Relational Perspectives on the Body, The Analytic Press, Lewis Aron & Frances Sommer Anderson, Editors). In this chapter, I illustrated how overwhelming emotions were related to the development of Ellen’s TMS pain and discussed how we worked with these emotions in the psychotherapy process, thereby relieving her pain.

While treating Dr. Sarno’s patients, I developed a TMS symptom-tension headaches. As I delved into the early childhood origins of my own TMS, I refined my skills at identifying sources of TMS and its equivalents. I wrote about my personal journey, “At a Loss for Words and Feelings,” in my edited book, Bodies in Treatment: The Unspoken Dimension (The Analytic Press/Taylor & Francis Group, 2007). I have learned that accessing and experiencing “hidden,” “forbidden,” “repressed/dissociated” emotions is the crucial entry point in recovering from TMS. My colleague, Eric Sherman, PsyD, and I are publishing a book of case studies (late 2010), Pathways to Pain Relief, in which we illustrate how we treat people diagnosed with TMS by Dr. Sarno.

How do you distinguish TMS pain from other pain?

As a psychologist, I am not qualified to make a medical diagnosis, even a psychosomatic diagnosis such as TMS. A physician distinguishes the TMS pain through an interview and examination initially, thereby linking mind and body with a diagnosis of TMS. Teamwork with that physician is a requisite. Let me elaborate by illustrating why the teamwork is necessary. When I’m treating a patient who has been given a TMS pain diagnosis by a physician, I obtain written consent to collaborate with the physician, explaining the “rehabilitation team” approach, learned at Rusk Institute, which I have used effectively with Dr. John E. Sarno for more than 30 years.

As the treatment evolves, I learn about the person’s pain pattern. If the pattern changes for the worse, e.g., the pain intensifies and/or moves to a different location, I refer them to the physician to report these changes. While I may surmise that the intensification and/or change in location are related to emotions that are being evoked and/or warded off as a result of the therapy process, the physician needs to make an assessment before we explore the hypothesized emotional “triggers” further.

When I am working with a patient who was not referred for TMS treatment, I am, nevertheless, attuned to the mindbody connection and alert to “signals” of discord that may come in the form of unpleasant/painful sensations or other medical conditions. I first recommend that the patient consult with their established physician for an evaluation. If there are “no significant findings” or the results sound ambiguous, I raise the possibility of TMS by discussing the mindbody connection and suggesting that they read material about TMS written by physicians [see Recommended Reading, below]. If they “recognize” themselves in what they read, I refer them to a physician qualified to make a TMS diagnosis.

How do you go about treating someone with TMS?

First, I will oversimplify by saying that the treatment is implied in the diagnosis: If hidden/repressed emotions create somatic pain as a distraction or avoidance mechanism to protect the psychological self from intolerable emotional pain, then treatment must aim to identify and help the patient experience and explore those emotions. Now this appears to be very easy for many people–the ones who become pain free after reading a book on TMS. I hear stories about these people from patients and have witnessed this kind of cure among friends and family members. These people didn’t need my help! How they are cured so quickly is a very interesting and important matter that I can’t address further here except to say that I’ve learned a good deal from treating a few of these people over the years after they’ve experienced a recurrence of pain that won’t go away.

The people I treat have usually tried very hard to eliminate the pain and are quite discouraged and critical of themselves because they haven’t been “successful” on their own. They often feel that they’ve “failed” the program, citing statistics in Dr. Sarno’s books about how few people need psychotherapy. As he has described, often TMS sufferers have internalized the value “Americans” place on being independent, self-sufficient, and invulnerable and have been rewarded professionally and financially for these traits. Many of the founders of our country were people in desperate straits who had to work hard to survive. Acknowledging vulnerability and fear could have been more perilous than toughing it out. Thus, it seems to be a part of our national “character.” Another large group of people with TMS have been rewarded for being nice, considerate, peace-makers, for pouring oil on troubled waters, indeed for making sure that there are no troubled waters.

These admirable qualities contribute to building a robust economy and to the smooth working of our social structure. When relied on at the expense of acknowledging one’s own feelings and needs, however, a consequence may be emotional and/or mindbody disorders such as TMS and its equivalents. The disavowal of dependency, vulnerability, and anger/rage contributes to overflowing emotional reservoirs of shame, fear, grief, longing, rage, and even love. The reservoir of rage that Dr. Sarno has brought to our attention, is problematic for many of us in our civilized western culture. Within the last few years, he has increased our awareness of the young child within who needed, and stills needs, unconditional love and acceptance. He has encouraged his patients to get to know that child through journaling and in therapy. In addition, quite a few of my patients have discovered the frustrated, insecure, adolescent who has also been unconsciously disavowed.

So, the treatment begins by exploring the context in which the symptom developed. Often, people do not have an awareness of the emotional impact of the physical/work/family/relationship environment in which they live because they have learned to survive and thrive by disavowing the emotions I described above. I ask for minute details, like a journalist, sometimes annoying with my “picky” questions about “who, what, when, where, and why.” We learn a lot from what they can and cannot answer. My aim is to help them identify “stressors” that can lead to the overflow of an emotional reservoir into a pain symptom. For example, a 36 year-old patient recently told me that, within the past year, his father had died suddenly, he had lost his job, and separated from his life partner. While these life events would cause many of us to have overwhelming feelings, he had scant appreciation of just how stressful these events had been. Thus his therapy began.

While identifying the life events preceding the onset of the pain, I am listening intently to how the person is speaking about the event. How is my patient reacting emotionally to what they are telling me. For example, are they laughing when telling me about what sounds like an enraging/embarrassing/shaming/humiliating situation? Do they seem sad when speaking about sad matters? Can I detect any emotion at all as they speak about a highly volatile interaction or a devastating loss? I often refer to this function of the therapist as the “emotion detector.” In the initial consultation I begin to bring the patient’s attention to this dimension of their participation, carefully probing to assess the extent of their awareness and how they react to my inquiring. We often identify this as an area where they will need to do work both inside and outside of the session.

For people who have great difficulty being aware of what they are feeling about what they are saying, I work intensively on this in each session. I recommend that they take a “feeling inventory” several times during the day and evening: Ask yourself, “What am I feeling about the events that happened during the past hour? How did I feel when my supervisee didn’t meet the deadline and casually brought the work into my office without acknowledging that it was late? How did I feel when our nanny called to say that she had an emergency and had to leave immediately, possibly indefinitely? How did I feel when our 16 year-old son showed up two hours past his curfew, undeniably drunk?” At the beginning of therapy, some people need to take this inventory once every hour.

As we are doing this “emotion detection” work inside and outside the sessions, we are also tracking pain levels as well as presence and absence of pain. This strategy is aimed at making links between emotions and pain symptoms. I offer a few examples to illustrate:

1) A patient had been pain-free all day but noticed that his pain started on the way to the session.  I asked what he was thinking and feeling along the way.  He realized that he had mixed feelings about being in the session.  As we examine these feelings, his pain lessens but is not completely alleviated.

2) A patient is pain-free in the session until she starts to describe an interaction with her husband the previous night.  In our discussion, we discover that she was furious with him and afraid of feeling her anger.  We spend some time helping her tolerate that feeling right there in the session.  As she becomes more comfortable with feeling angry, we talk about some constructive ways to express it to him.  Her pain gradually subsides.

3) A patient is in excruciating pain as he enters the session and has no idea what brought on the pain the day before. We begin our search for the emotional triggers and discover that he had been dreading an upcoming phone call to his mother in which he planned to confront her in a way he had never done.  As we discussed his strategy and what he was afraid would happen, his pain started to subside.

Recommended Reading

For patients and therapists:

John E. Sarno, MD

Healing Back Pain: The Mind-Body Connection

The Mindbody Prescription

The Divided Mind

Howard Schubiner, MD

Unlearn Your Pain

David Clark, MD

They Can’t Find Anything Wrong

David Schechter, MD

The Mindbody Workbook

For therapists:

Lewis Aron and Frances Sommer Anderson (Editors)

Relational Perspectives on the Body

Frances Sommer Anderson (Editor)

Bodies in Treatment:  The Unspoken Dimension

All titles are available at the WTCI-Amazon Bookstore.

For more about Frances Sommer Anderson and TMS, try FrancesSommerAnderson.com and the TMS Wiki.

What’s your background?

I graduated from Boston College with a degree in psychology and received my masters degree in counseling from the George Washington University. I became a licensed professional counselor shortly thereafter. I knew early on that I was going to pursue some kind of career in mental health, but I just didn’t know how or what it would look like.

I remember, quite clearly, that I struggled mightily once I received my masters degree. I had all these grandiose ideas about starting my own private practice but had absolutely no idea what that truly entailed. When I think back to that time I wish someone would have given me a good shake or dumped some cold water over my head…anything to wake me up to reality!

I spent a few years trying to build my career as a clinician and it was quite disheartening. I took jobs hoping to move one step closer to my career goals only to find myself feeling boxed in and stuck in a series of dead end jobs.

But here’s the honest truth about my circumstances at that time. Most of it was my fault. It took me years to realize that the mental health profession, like any other industry, will gladly define you if you let it. And that’s what I did. I didn’t make an honest effort. I spent my days hoping the field would find a place for me. It did, but it was never what I had hoped.

I can look back on things now and laugh, but at the time it was truly a painful process.

The “light bulb”, for me, did not go off until 1999 when a friend of mine shared an amazing story about how he landed his dream job within the profession. I gained a significant amount of insight from his story, and began to move away from the blame game. I took note of all the wonderful marketing and sales concepts he used to find success – ideas like permission marketing, the true definition of value, sales progressions, and the importance of building relevance and credibility. I’ll explain these concepts a bit later. I mention some of them here simply to illustrate that there were a lot of unique approaches to business development I had never thought of at the time. All of them provided motivation for me to change.

Rather than expecting things to come to me, rather than passing up on opportunities or going through the motions, I decided I’d be the initiator. Rather than being average at a lot of things, I chose to become very good at a few things. I set new goals in this direction and have spent the past several years learning, growing, and taking advantage of new opportunities that come my way. It has made all the difference in terms of my personal enjoyment and the general satisfaction I get from doing my work.

What do you do now?

At present, I am a writer, consultant and the Director of Business Development for a large behavioral health care organization. Essentially, I am responsible for ensuring my organization’s treatment facilities are growing. It’s a fun job because I have a say in the services we offer and I am able to partner with people in the community who are doing some incredible things with regards to mental health services.

After 1999, I realized I had interests and passions within the field that could be nurtured elsewhere. So I began getting involved in business consulting. I worked with Industrial/Organizational Psychologists on work culture and social dynamics to help improve business performance. As the years passed I starting learning skills I felt could be successfully integrated into a mental health paradigm. It seemed to me that a lot of valuable business development innovations and techniques were underutilized in our industry.

What excites me about utilizing sales and marketing concepts in the mental health field is the fact that they can be applied to all settings within the profession. They certainly apply to private practice, but also have relevance in organizations, schools and even as part of the job search process.
When I realized this and started using these concepts within my company I saw our outcomes improve considerably. And when others began using them they saw similar results.

How do you apply some of the principles/approaches (e.g., the true definition of value, sales progressions, the importance of building relevance and credibility) when working with clinicians on private practice building?

There are numerous ways to apply these principles within a mental health model. I tend to take a different approach when people ask me how best to grow a private practice. Here are a few ideas I use as a way to begin applying some of these concepts.

Break Away from a Traditional 1-to-1 Financial Model

When I was working as a private practitioner I was stuck in a “this for that” model. I would provide a 50-minute session in exchange for an hourly fee. The problem with this approach is that I tended to reach the limits of my earning potential quickly. There are only so many hours in the day and there is just so much that the market will bear for my services. I see a lot of private practitioners struggle as they try and grow their practices under this framework.

Where do you turn once you reach the boundaries of your service delivery model? I suggest looking for ways to diversify. Expand your service offerings and/or partner with others in an effort to create multiple streams of income. When you hear stories of people who move from slow and steady growth to immeasurable success what you find, more often than not, are people who leverage the power of passive income. They have found a way to generate income with less effort not through smoke and mirrors but by setting up systems to where they can add value in numerous ways.

I understand that the phrase “passive income” elicits all kinds of negative responses. Many people associate it with pyramid like schemes. But passive income has value if used with purpose and principle. Consider this example.

When I lived in Washington, DC I knew a psychologist who had a thriving practice with offices in Washington DC, Maryland and Virginia. She understood the power of systems and built a practice around up and coming therapists in the DC metro region by offering a win-win opportunity. Talented but inexperienced clinicians received mentoring, supervision, counseling experience and a percentage of earnings while my friend received her own percentage from each practitioner.

This is not a new model for any of you I am sure. However, what struck me about this approach was the fact that it had a snowball effect that seemed unstoppable. My friend’s reach within the marketplace was astounding. She had income coming in simultaneously from numerous clinical groups, individual sessions, trainings and workshops without her having to be present for each and every activity.

As a result, she had more time to focus on other business matters such as networking functions, clinical research, strategic development and writing. It made her smarter and more marketable within the field.

Understand that “Markets are Conversations”

A lot of ambitious practitioners choose traditional models of advertising to get the word out that they are open for business. I’m a big believer in marketing one’s services aggressively, however, if you’re not careful you’ll spend a significant amount of money with very little results. I often tell people to be careful not to create marketing materials or to place advertisements that exist in a vacuum. A brochure that you mass mail, business cards you drop off and print ads you place without any kind of follow up will have very limited impact. You need to have a step-by-step process put in place that will take people from point A to Z. I often refer to this practice as a “sales progression”. When creating a marketing plan you should identify strategies that build upon one another. For example, if you give a free talk be sure to have a system in place where you are able to follow up with your audience. Have them sign up to receive a newsletter from you or offer them a free tele-seminar that will take place weeks after the training. You want to put systems in place so people have an opportunity to experience what you have to offer and then they are given an additional opportunity to progress to the next level (e.g., seeking individual counseling, signing up for an intensive paid workshop, joining a new group you are facilitating).

There is a considerable shift taking place across all markets that has implications for how you choose to advertise and market your services. Standard marketing messages often have very little emotional appeal and are easily ignored. In addition, today’s markets offer a plethora of choices. People can easily ignore your message if they perceive no value. So how do they pay attention to your message? People are looking for substance and value. They are finding it more and more online by asking questions and participating in conversations. You need to find ways to be a valued contributor to those conversations. The great news about this shift is that you do not need large amounts of money to market yourself effectively. You don’t need to be on TV or in a magazine to reach your audience.

Your effectiveness as a marketer is not about how slick your brochures are or whether or not you have a compelling name for your practice. It is about your ability to identify communities and to be a valued contributor to the conversations that are taking place. This image should help clarify my point further.

Change Your Definition of “Value”

“Value” is often defined as what one receives in return for some sort of payment. A much better definition of “value” is: the act of offering something beneficial to others without any expectation of receiving something in return.

This is where true growth and opportunity takes place. My friend, who I mentioned earlier, used this model to find his dream job in the field. Initially, he turned down two jobs from one of the largest mental health employers in his area effectively ending any chance of working for them in the future. This would have been true had he not decided to make the decision to help the company find better candidates for the two positions he turned down. And once he filled the two positions for the company his value and credibility went through the roof! He made himself indispensible by thinking of others and helping them achieve their goals. The result: they asked him what he was looking for in a new job and then they created it for him!

A great way to build your network and to increase your relevance in your market is to find unique ways to offer unexpected value for your potential referral sources and clients. They will be impressed by your generosity and you will be nurturing a consumer base that will have powerful long-term effects.

Find David Diana online and order a copy of his free e-book, “Change Therapy,” at www.davidpdiana.com.