Transcription for

EXPANDING THE SCOPE OF YOUR PRACTICE TO ADDRESS THE NEEDS OF THE COMMUNITY

DR. JEFFERY ZIMMERMAN

Continuing Education Programs APA

MAY 2017

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May 20, 2017

EXPANDING THE SCOPE OF YOUR PRACTICE TO ADDRESS THE NEEDS OF THE COMMUNITY

DR. JEFFERY ZIMMERMAN

DR. NEIMEYER: Welcome to today's webcast on expanding the scope of your practice to address the needs of the community. I'm Dr. Greg Neimeyer. I direct the office of Continuing Education in Psychology at APA, and also the Center for Learning and Career Development. We're delighted to have you here this morning with Dr. Jeff Zimmerman to talk about expanding the scope of your practice.

Just a couple of words before we get started.

Number one, we very much want to encourage you to participate in today's webcast. If you have questions, want to engage in some discussion, feel free, just take a look in the lower left-and side of your panel on your screen, you'll see a tab marked Questions. Click that and just email us any questions you have, we'll get those to Dr. Zimmerman for him to respond. Just be aware that any questions that you ask will be recorded, and so you will have a contribution to the recording in perpetuity.

In addition to that, I just wanted to take a moment and introduce Dr. Zimmerman. We're thrilled to have him back as part of this ongoing practice series. And today, he is here to talk about addressing the needs of the community and expanding your practice.

Dr. Zimmerman is a PhD in Clinical Psychology, graduate from the University of Mississippi. He also interned at the West Virginia University of Medical Center in the Department of Behavioral Medicine and Psychiatry, and has worked in a mental health center and is Chief Psychologist in the Mount Sinai Hospital in Hartford, Connecticut. He's a fellow and past president of the Connecticut Psychological Association and he has received their award for the Distinguished Contribution to the Practice of Psychology. Dr. Zimmerman is an ABPP board-certified clinical psychologist and also a fellow of the American Psychological Association. In 2015, he received the honor of Distinguished Fellowship in the National Academies of Practice, and was admitted to the Psychology Academy as a Distinguished Practitioner and Fellow.

We're thrilled to have him on board today to talk with us about expanding the scope of your practice to address the needs of your community. Please join me in welcoming Dr. Jeff Zimmerman.

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DR. ZIMMERMAN: Thank you, thank you, Dr. Neimeyer, I appreciate it. Great to be here, thank you to APA and the Office of Continuing Education, and the new Center for Learning and Career Development. And thank you to Dr. Neimeyer and his colleagues and staff for helping put this series together. Thank you too, for those of you who are participating in this webinar and in this series.

We're glad you're here, and as Dr. Neimeyer said, feel free to send in your questions or comments as we go. Don't hold back and don't wait. We'll get to as many of them as we can as they arrive. And certainly,

if you have ideas about specialty practices or niche practices, we will have a little time for discussion towards the end today, so please send those questions and ideas in as well.

This is part of a four-part series. If you've seen or will be seeing the other three parts, you may see some overlap, a little bit of overlap in the certain examples and concepts. Because it all ties together, but at the same time, each of the segments are designed to stand alone. So there are some concepts from one segment that I want to bring into the other segments, so you'll see a little bit of tie-in or overlap if you're participating in all four of them.

So this segment, as we discussed, focuses on building a specialty practice or a niche, both in and out of managed care. One of the concerns that people have is that the niche is something that has to encapsulate their entire practice, and it really doesn't, and you can have more than one niche and we'll be talking about that later.

Many practices are general practices and there's nothing inherently wrong with being a generalist. But there can be a number of advantages to the community for you to offer specialized services, as well as to your staff if you're in a group practice, or your administrative staff, your colleagues. And also having a more sustainable practice if there are areas of expertise and specialty that you have.

But today we'll be focusing on incorporating your vision, using research to build a niche. You don't just do, as we talked about yesterday, or at one of the other segments, you don't just do follow one step at a time, and just kind of fall into something one foot in front of the other. But there are actually ways to build a niche that are thoughtful and based on different types of research that are out there, and we'll be talking about that today.

We'll talk about niches in and out of managed care, and we'll talk about ethics, and especially scope of practice. Building a niche or specialty area is not about attending a workshop and now you're an expert. It doesn't quite work that way, certainly not in this field and not many others.

If your cardiothoracic surgeon, if you happen to need one, says, " I learned everything about what I'm about to do to you at the weekend workshop," I think you might go down the street to see somebody else. Many times the work we do is equally as important, as delicate, and as life-saving, and is not something you become an expert in in a weekend workshop. So we'll be talking about that.

And we'll be talking about the marketing of and building community awareness of your specialty and your niche.

So let's begin by looking at some advantages for having a specialty practice.

One is that, depending on your vision for the practice, why you're in practice, how you're seeing your practice relate to the community, and perhaps the small community, but also a larger community, and how your practice is also related to your own passion for the work. Building a niche can offer you the expertise and the opportunity to create this specialized expertise that's aligned with your passion. As I mentioned, it also brings services to the community that may not be available, or may not be available enough.

So often I get calls from people that are saying, "I went through my panel of providers that my managed care and health insurance company has given me. I'm looking for a specialized clinician and I can't find anybody who does that work." There's 75 or 100 people on my panel in the relevant ZIP codes. I've called many of them and nobody does this work, this kind of work with kids, or this kind of work with the elderly, or this kind of work with LGBT issues, or whatever the issue is. And nobody does this kind of work. Or, "I found one person, and they didn't have any openings," or two people and they didn't have any openings.

So, the idea about creating a niche to offer a specialized service to the community is something that I think is really important. It also sets you apart from the other people who have a more generalized practice.

If you look at one of the referral platforms, or marketing platforms like a Psychology Today platform or one of the others, and you kind of quickly scan through in your ZIP code or other ZIP codes, you'll see that many people have a general practice: "Hi, I'm Dr. Zimmerman. I see adults, I see children, and couples."

And there's not necessarily, if they see children... And there's not necessarily a differentiation across clinicians based on some of these niches or these specialty areas.

It also, though, gives you a chance to create your ideal practice. And, this is something that I think from a self-care perspective, which we'll touch on later also, from the self-care perspective, is really quite important.

One of the advantages of being in private practice, and I guess you could say, it's a disadvantage and an advantage, is you're your own boss. The disadvantage to that is, there's nobody else to complain too [LAUGH]. And there's nobody else to look to for support. Unless you go outside of your practice, which we'll also touch on.

One of the advantages is that you can create the practice that you want to have, that you're not limited into only having the practice that the powers to be want you to have. So if you work in a hospital or a clinic, and they say, this is what we do and we don't believe that from a budget standpoint, or a philosophical standpoint, we want to offer the program that you want to offer, you're done, as long as you work there.

In your own practice, if you want to offer a specialized program, and you can do that in a way that is sustainable or even just to try it, you don't need to get, you know, the board of trustees or the board of directors to approve it. You can offer that program because that's something you want to do professionally.

My career track has had many chapters, and in those chapters, I've had some specialties that have run a number of chapters. And some specialties that have run a course, and they lasted maybe a season or one chapter instead of a number of seasons throughout my career. And that's fine, and there are some people that specialize in one thing and they do that for 30 or 40 years. I happen to look for more

diversity in the work I do, and those...factors that led to an ideal practice early on in my career have changed, both in terms of what I do, as well as where I do it.

I spent 22 years as a founding and managing partner of an interdisciplinary group practice that had seven offices and 20 clinicians. And, while I started in part-time solo practice and then it was full-time solo practice, I like to say, I have completed the Zen circle, and I'm back in full-time solo practice, as well as doing some other things.

But the ideal practice, which will change, and we'll talk about that in a moment, is something that you can really create if you're your own practice.

I should also mention, it just occurred to me, and my apologies for not mentioning this at the outset, that I should, in the spirit of disclosure, mention that I've written three books on, or co-authored or co-edited three books on practice, and also I'm a founding principal of the Practice Institute. I'm not here representing per se either of those organizations, but I'm doing this work on the request of Dr Neimeyer and the APA. And I should've mentioned that at the outset, so my apologies.

So as I was saying, ideal can change over time. Your interests can change. Your energy can change. Circumstances in your life can change. You can have an infertility issue, you can have an illness, you can have your own family, and what was once a specialty area may no longer be of interest to you.

My wife's also a psychologist, and for a long time she specialized in working, she still sees lots of kids, but she specialized in working with lots of little kids. At that time she had an office in the home, and at one point, she realized, "I'm spending more time taking care of other people's kids than my own." She'd hear her kids in the house while she was in the home office, and she would say, "What am I doing here, spending all this time with all these other people's kids?"

And, she started to change her practice, because what was ideal at one point was not ideal, and she wanted not to be working till 7 o'clock at night, when you see some of the older kids. And from 3 o'clock in the afternoon until 7 o'clock at night, or 8 o'clock, at night, she wanted to have different hours. So she rebalanced her practice like you might rebalance a portfolio of some sort.

Also new technology can create opportunities for you with regard to how you run your practice. There are... You, of course, have to be aware of state regulations and other ethical issues, and where you're practicing, and whether your practicing where you're located or, of course, where the client is located. So you need to be careful if you're doing, if you're practicing out of state, but new technology can offer new opportunities for practice...and for having a specialty area.

So let's look at some of the factors that... Sorry, I didn't switch the slide here... But let's look at some of the factors that relate to an ideal practice.

An ideal practice can enable you to work with some of your favorite kinds of clients. It can be a demographic issue. It can be a diagnostic issue. It can be something that you're passionate about. And you can say, I want some, most, or all of my practice to be in this area.

For example, let's say you are really committed to helping veterans. You can decide, I'm going to have a practice that specializes in that, and that may be all I do.

Or all I do is work with kids under six. There's a psychologist who has a baby practice. And she really does a lot of work, of course, with parents with very, very young kids.

The idea is that you want to align your practice with your interests and align your specialty with your interests, with your goals, with what energizes you, with what's important to you, so that that passion that you feel for the work you do is out there and evident--to you and to the people you come across, you come in contact with. When you do that, you can feel energized by the practice as opposed to drained.

I got into working with families of divorce. Sometimes never married families. And I did that after working with lots of kids of divorce. And it is very difficult work.

I don't go into court but I sit in the environment of the parental conflict a lot. I'm in a very parallel process to that of the children, in that I'm trying to have a positive relationship with two people that have a lot of conflict between them. Although I have an advantage in that, I'm older, I'm not trapped in that family, and I don't love them, I don't love the parents, and I might see them for an hour every couple of weeks. I don't live with them and I'm not six years old.

But I got into that work, my passion was that I didn't want to just be band-aiding the kids and kind of holding them together for 14 years, ten years, six years, or sometimes what I called "hold your breath therapy, " where I took a junior or senior in high school and I said, "Hold your breath till you graduate, then go far away." Whether it be to college, the armed services, trade school, a job, what have you...

I really wanted to help give kids a sense of family, and that was my passion. That divorce shouldn't end a family, it ends a marriage. And that I wanted to teach parents how to give kids a sense of family.

So that fit with creating a niche or specialty in these divorce services that I provide--mediation, collaborative divorce, co-parenting, parenting coordination.

There are days I'm drained [LAUGH], but there are days that I'm energized even when I'm drained or even when I'm tired. And I think that that energy and that passion can't but be realized by your staff, if you have staff around you, by the people that you work with, and by the people who are referring you work.

You want to have a practice that produces enough income that you feel is fair and reasonable.

It's very interesting when I consult to people in practice. Sometimes they'll say to me, "You know, I don't have enough cases," and I'll say, "Well, do you have enough income?" And they'll say, "Yeah, but I don't have enough cases because Friday afternoon I'm like empty."

And I'll say, "Well, do you want to work Friday afternoon?" "Well, no, but I should." Well, why should you? [LAUGH] Because I'm supposed to. Who said that? Where is it written that you're supposed to?

You can decide what income is fair.

And while this isn't a presentation on building your budget for your practice, there are some people that actually build a budget for their practice from the bottom up. And they say, "What do I want to earn? What are my expenses? How much then do I need to bring in, in order to get my earnings, plus the expenses I have? "And then, "How much work do I need to do to make that all happen?" And they build it from the bottom up.

As opposed to, there are six or seven, five, six, seven available days to work during the workweek. And in order to be in practice, I have to fill all available time. We don't have to fill all available time. And if you have enough income that you deem is fair and reasonable, you're good to go. It's not about always more is better.

There are costs, non-financial costs even, but there are costs about working every available hour. Usually those are costs to your own well being, emotionally, and costs to your family.

So the ideal practice has a nice balance between your interests, what energizes you, the income you earn, and also, as I was mentioning in terms of my wife's situation in the past, your lifestyle.

So before we began this session, we were talking a little bit about morning routines and going to yoga, in the morning, before work. If I want to go to yoga in the morning before work, and start today at 11 o'clock or start my day at noon, why can't I in my ideal practice? I don't have an organization that says that you better be here at 8 o'clock or there's a problem.

Likewise, if on that same day, I want to leave at 5 and I worked from 12 to 5 today, five hours, that can also be part of my ideal practice. It may be that another day, I'm working till 9, it may be that I'm not.

I have a colleague who does weekend hours, she sees a lot of kids on Sundays. Not on Saturdays, because where are they on Saturdays? They're at soccer, they're at all the other activities. There it's Sundays.

In families where there's two parents, it's really easy if they don't work on the weekends, it's really easy to get the child into her office, because one parent can do that. And if there's more than one child in the family, the other parent can take care of the other child or children.

And she is very, very busy on Sundays. Very, very busy, and maybe she works a five-day week or a four-day week, or however many days she decides to work.

So your ideal practice can also fit with your lifestyle.

And as I was saying a few minutes ago, it can really keep you vital if you're doing work that matches with who you are, and your passion, and reason or the why for doing the work--as opposed to the what, how, and where you do the work.

So the question often comes up, how do we build a niche? How do I decide on a niche and on having that specialty area? How do I find it? How do I make that decision?

So let's look at that for a little bit. There are three different kinds of research that I think are important in terms of building a successful niche.

The first is the clinical research. What's been done before? You want to do something that works. What works that's been done before? And you can really go to the literature once you have an idea of where you want to go and figure out, Gee whiz... This is what's been working.

You can also go to the community, and say, What currently is available, and what's needed? So, for example, let's say that you have a relationship with a pediatrician. And, you say to the pediatrician, "So tell me about the kids you're seeing and the kids that you refer for mental health services." What kind of services do you refer to a lot? What kind of services do you need? It's kind of like doing a mini-needs assessment. What kind of services do your kids, do your patients need? What kind of services are lacking? What do you find doesn't happen that you need to have happen? Maybe the services are there, but the information flow isn't.

So I've heard many physicians say, "I refer them to a mental health professional and I never know what happens. I refer to any other specialist, and I know definitely what happens with those cases. But I don't know what happens with the cases that are referred to mental health professionals."

So sometimes, you may find it's not a need for a particular service, but it's a need for how that service is not only delivered, but communicated back to the person who refers.

You also can see what hasn't worked. Why have certain programs in that area failed?

There are lot of chronic pain programs out there. Many chronic pain programs open, they're open for five years, seven years, ten years, and they disappear. If you were thinking of starting a chronic pain program, it would make a lot of sense to find out why those programs failed.

You might, for example, be able to find who were the directors of some of those programs in the last five years. You can probably do a search online, and find out some publications, presentations, old websites that are still up, old references to websites and find out who the directors were.

You might be able to contact them and say, "Just was wondering if you're willing to spend 15 or 20 minutes with me on the phone." Many people are happy to do that. I know I am when people call me and they ask me, if I can spend some time on the phone with them.

So you can find out what hasn't worked, as well as what has worked.

You can also call if there's a program that's open. Whether it's chronic pain or something else that you're interested in doing. Hey, tell me about... Especially, if they're not going to be in the same area and won't view you as a competitor. Tell me about what's worked.

There are a lot of people that start a specialty practice, and they never buy consultation from people who are, or never invest in consultation, whether you purchase the consultation, or you have to buy it

through your time and travel expenses, but they don't go some place to sit with the person who is doing the work already.

Our colleagues in medicine often do that. If there's a new surgical procedure, I may go and study with the surgeon, assist the surgeon for a day or two, and watch him or her perform that surgery, and really have a chance to ask a lot of questions. I'm doing that on my nickel, or on the nickel of the hospital that's employed me, to go and really learn and sit by the person who developed this new technique.

We can do the same thing. Somebody has a successful specialty practice. Why not invest, and go and get that information and experience where you can learn about that? I've had people do that with me in my divorce practice, where they'll come in and they'll sit in for a day or two, with permission, of course, of the clients.

The outcomes piece of this is also very important. Once you're up and running, and in the process of getting up and running, how are you going to see if the work you're doing is successful? How are you going to check and make sure that you're actually getting the outcomes that you're looking for?

What changes do you need to make? We don't get the gold ring on the merry-go-round just because. We don't open a practice or open a specialty practices and now, all of a sudden (A) we're experts and (B) we're always successful.

Learning about what's working, what's not working is very, very important.

And having a plan in place, so that you can figure that out as you go, is very important. If you heard our segment about vision, or watched our segment about vision, you'll get a sense of why that's so important to a practice in general. It's also very important in terms of your niche practice, or your specialty practice. And let's look at why that is.

As I was saying a little earlier, keeping your program aligned with your practice vision is very, very important in terms of the people you're reaching, the people that are sending you work, but more importantly in terms of your own energy for the work you're doing.

Imagine sitting there, and some of you may have experienced this, where you're actually doing clinical work that you don't want to be doing. You don't want to be working with the people you're working with. You don't want to be working with these array of symptoms that you're working with, or the array of challenges that you're working with, and you're tired.

Does that come across? Can it not come across, in some way?

Contrast that with you're excited about the work you're doing, you're emotionally invested in the work you're doing, and maybe the work that you're doing in either case requires the same skill set. But can that investment, that emotional investment, that emotional excitement come across?

Of course, it can. And can that make a difference? I think it can make a huge difference.

The training in the niche or the specialty area is crucially important in making it a success and really having it be part of your ideal program. You're making an investment. You're creating, if this was a retail business, you're creating a whole new line of product. Or perhaps a revised line of product. In this case, it's a new line of service or an expanded line of service.

You're going to be investing time and energy, and while you're promoting it, and while you're learning about it, you're not going to be doing other things that might be bringing income into your organization, that helps keep your organization sustainable, so that it can provide services to the community.

That investment needs to be bolstered by your training so that you're going out there providing the highest quality services you can provide. The program development needs to be thoughtful, it should not be, in my opinion, one foot in front of the other. You are creating a program.

Now imagine, if I came to you and I said, I'd like you to write me a large check for creating this program for your practice. I'll create it, I'll staff it. You're going to pay me to staff it, whoever I put in place. You're going to pay me to create it, because there's going to be a loss of revenue coming into your organization.

How important would it be to have a plan for me before you write that check? And that check is not going to be a small check. That check may be tens of thousands of dollars.

How important is it to have that plan? How detailed, how well thought out, and how much are you going to look at that plan and say, gee, it really makes sense, or, it doesn't really make sense to me.

If I said, No, no, no, no, no.... Look I'm just going to put one foot in front of the other. I don't need a plan, you don't need a plan, just hand me over that check and we're good to go. My guess is, most of you wouldn't hand me over that check.

You shouldn't do that for yourself either, because this is your practice. Take the time. Think about the program. Write it down, not just one paragraph. Write down a plan that not only builds the program clinically, but shows how that program is going to be sustainable.

What's it cost to get it off the ground? What's it likely to produce? How are you going to staff it? How are you going to staff it, not only clinically, but how are you going to staff it administratively? How are you going to provide the services? How are you going to make the community aware of it? How are you going to roll it out?

These things don't just happen. In fact, usually if it's not well planned, it falls apart.

Some of the practices that corporations use to roll out new products, new services, new lines of business... The thoughtfulness about that, the product development, the investment in research, is not at all trivial, because they want to make sure that there's a good chance for the product or that service to be successful. Both in terms of design and quality, and sales...

So if you have a cell phone or a computer or a laptop, think about not just what it took to get it actually produced in some factory someplace, but think about the research that went into producing your smartphone. Huge... The research that is still going on to produce more tablets, more smartphones, more laptops, more desktops. And every couple of years or maybe even sooner, we see some of the impact of those developments on the shelf.

The services that you're providing that also represent the quality of your practice to the community are equally important, in my opinion. And deserve the thoughtfulness about how are we going to actually roll out that program? How are we going to improve community awareness? But more importantly even, how we going to build the program from its start? So give that some thought in terms of the niches and the specialty areas that you may be considering.

A question often comes up, though, about what skills do I already have that can help me build a niche? What do I already know? And I would suggest to you that you have many, many skills that are pertinent to niches. You don't, even as a generalist, if you are a generalist, you don't just have skills that are not generalizable to other populations or to other problem areas, or to other diagnostic challenges.

We have, many of us have skills in, of course, psychotherapy, in assessment, in consultation. You may have skills in writing and teaching, in research, in product development.

When I got into the divorce work, I had skills in working with kids and child development. I had skills in working my work with couples, and dealing with conflict that couples have.

You have lots of skills. And one question that's important is where do these skills, how can these skills be expanded so that they relate to areas of need in your community?

And that you can actually apply the skills to areas of need in the community. And it doesn't just have to be about clinical treatment.

So let's say I have skills in assessment. And I also have skills in child and adolescent work. And in doing assessment of kids in adolescence, perhaps kids in adolescence with learning disabilities. I also might be able to take those same skills and look at a population of kids that wouldn't necessarily see me because of a learning disability or psychiatric disorder... But might need help as a high school junior who's thinking about the next chapter of their lives. And maybe applying for college... And might need help in, how do I find the right college, given my learning challenges?

That's probably not in the insurance reimbursable, but might that be an important service that's needed in your community, because what happens if this child gets into the wrong college? That may have a learning center, but the learning center is not sufficient for what this child's needs are.

The child has a failed experience, and after the first or second semester, drops out, fails out, is put on academic probation or what have you, because there was not a good fit in the selection of that college with the child's learning needs.

So you're taking a skill that you already have and positioning that skill to help in a life transition moment for the same population of clients... But to help them in a new way.

We spoke in another segment about Southeast Psych, which is a practice that is very innovative and they see a lot of kids on the spectrum. Their offices are warm, are welcoming to kids. Don't look like a traditional mental health clinician's office. And part of that is that they view their office as a social setting for kids.

What happens when these kids will show up for a group? And that there's a whole experience that they're trying to create for those kids.

Imagine if you have juniors and seniors who are kids on the spectrum, and those kids are about to make a huge transition and go to college. Might they and their parents need some input on how to find the right fit?

So there you take the same issue, and now you may be applying it to a whole 'nother group of kids for that same specialty area.

So we can look at clinical issues like chronic pain, depression, anxiety disorders, those sorts of things. We can also look at issues that are, that may or may not have a clinical diagnosis, that you're actually treating the disorder by providing the service.

Most of your skills or many of your skills can be transferred and generalized to other populations. The idea here is doing that in a way that helps the public. The whole point here is to meet the needs of your community. We're not providing services for the fun of it. We're not providing services simply to earn money. We're providing services in the context of the communities in which we live and work.

So we have a question?

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VOICE FROM AUDIENCE: Yes, we do. Ah yes... "I am an early career psychologist in a rural community. There are very few practicing psychologists in my area, and I am the only psychologist at my clinic. What mentoring resources would you recommend for early career psychologists who may not have psychologist colleagues in close proximity?"

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DR. ZIMMERMAN: That's a real problem in rural communities, because the next nearest psychologist that does what you do may be 500 or 300 miles away. And you can really feel like a fish out of water.

I recall from your question, Dr. Neimeyer mentioned years ago I was chief psychologist at the Department of Rehabilitation Medicine at Mount Sinai Hospital. I was the first psychologist they'd ever hired. I was the only psychologist for a quite a while before we hired other people and I became chief psychologist.

I wasn't even talking to other mental health providers and felt like I was speaking a different language. We were both speaking English, but when I talked to a physical therapist about depression or about symptoms of depression, I'd have one thing in my view and they'd have something else.

As an early career psychologist, you can be especially challenged because you don't have other like professional mentors. Now, you may get some mentoring if there are other mental health providers at your clinic, they may be able to mentor you in some specialized ways. For example, if there are people that do family therapy there and you're doing some family therapy. You might be able to get some great mentoring in family therapy from somebody who's not a psychologist. So that can be one way.

But the other thing that you can also do is, nowadays with technology it becomes a lot easier to connect to other professionals. Even here at APA, you can connect with some of the programs that APA offers and that the Educational Directorate offers.

You can also connect with people that have specialties and niches throughout the country in the work that you do. And perhaps even purchase consultation, so that you can talk about your challenging and difficult cases.

You can come to convention. This is not an ad, maybe it's not intentionally an ad, but you can come to a convention and see if there're people that do the work that you're doing.

Go to their workshops, hand them a business card, take their email address, take their business card. Contact them and say, hey, I'm interested in the work that you're doing, I'm interested in the concepts that you're teaching about. How can I find out more? Can I buy an hour of your time? You don't have to buy that hour of time every week, you could buy it every month, a quarter-hour a week. When you think about the investment, that's an investment in your own skill development.

So, absolutely, don't let the distance and the rural aspects of your...situation keep you from getting the experience and the work you need.

So that's a great question. Don't allow the distance to keep you from getting that consultation and the mentoring.

So feel free if there other questions out there to raise them.

By the way, I'm very interested if you have ideas about niches, about a niche or a specialty area. You can just simply email that niche in or use the platform to communicate that to us.

Yes, we have another question.

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MALE VOICE: I just wanted to mention, you had mentioned about the role of technology in mentoring. And APA this year is going to inaugurate an online mentor match system that's going to start, covary with convention. So people can go on, indicate the kind of mentoring that you want, what you want to connect with a colleague in relation to. And then at convention, you'll be paired together for a face-to-

face meeting. So it will be, you know, an opportunity for people in rural context or any context who want to connect up with colleagues around common interests or mentoring, whatever it may be to connect up. So distance can be collapsed and it no longer needs to sort of separate people who have common interests.

So watch for an email, if you're an APA member, to participate in the mentor match completely free, complimentary... We very much want to meet those kind of mentoring needs.

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DR. ZIMMERMAN: That reminds me that there are divisions that are doing that as well. Division 29, Society for the Advancement of Psychotherapy has done that. I believe Division 42, Independent Practice, has also had mentoring, and there are also not only the one-on-one mentoring or small group mentoring, which was sometimes done online. I was doing that for 29 when they had that program up and going.

But there are also other Q and A activities that you can participate in, where you can call in and listen to perhaps a 20-minute or a half-hour discussion or presentation on a specific area, and then have time for Q and A. And that's not quite the same as developing the safety of a mentoring relationship, which I think is really important at any stage of practice.

So ECP absolutely, but certainly for those of you in mid-stage, mid-career, and also advanced career... I think that having those mentoring relationships are really important because there are a lot of situation both ethically and otherwise that come up, that to have a safe place to talk about what's going on, whether it's about your emotions, whether it's about a clinical process and a treatment plan, or whether it's about an ethical issue is really, really crucially important.

And that doesn't end because you've been in practice for 20 years. In fact, I would argue [LAUGH] it kind of increases in some ways.

So as I was saying, by all mean send more questions, send in ideas or questions about a particular specialty area.

One of the things that I do sometimes and we have a lot of people or a larger audience is we play a game called "stump the chump." And stump the chump is where we pick a strange environment or an unusual environment, and we say how could you offer mental health services in this environment. So if you want to play stump the chump and we have time, we certainly can do that.

We do have another question.

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VOICE FROM AUDIENCE: Yes, we do. "What should be more important, your vision or the need of the community?"

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DR. ZIMMERMAN: C, [LAUGH] none of the above. I don't think either should be more important. I think they should be aligned. There should be a way of taking your vision and aligning that with need of the community.

If that can't be done, then that misalignment may mean you're practicing in a wrong place. So it's not that you have the wrong practice--your practice is your practice, your vision is your vision--but it may be that you're in the wrong place.

So, for example, if... I mentioned chronic pain before... If I wanted to do chronic pain work and I worked, since we had the question about the rural community, and I worked in a very rural community of 800. And the nearest hospital was 200 miles away. I might be in the wrong community to do work in chronic pain, because of the lack of healthcare specialists in that community that could help with my being part of a team of professionals who would treat the chronic pain. I might need to move closer to a healthcare center, if that was my vision, or be willing to commute.

And there are people that do that. They, from being bicoastal to not being bicoastal, but perhaps spending two days a week in another community where they can provide that service and have that alignment with the vision and the clinical work they're doing.

I hope that answers your question. I think they're both important, and the challenge, if you will, is to get those aligned, the needs of the community with your vision.

So where do we find these opportunities? And they're all over. They're all over.

Look at what your colleagues are doing nationally. Skim the APA program, look at the clinical presentations. Look at the titles for the research presentations, for the educational presentations, for the workshops. Look at publishers of journals and tables of contents. Look at book catalogs that you get. Get a sense of what other people are doing besides the general descriptions of working with adults, kids, and couples, or families,

Look deeper at the things that interest you. Get one of those books, read one of those journals, or one of those articles. Go to one of those presentations. The opportunities are in some ways limitless.

When I started doing the divorce services, as far as I was aware, there was no organized program around co-parenting in Connecticut at that time. And a colleague of mine and I started one after doing the initial work to get up to speed on it. And we started one.

You can create ideas from where there's a need. What should be done differently where you're practicing? How do you then get the skills to do it?

Does it have to be out of managed care? It doesn't.

You can shift, in terms of having a specialty area in managed care. For example, think about the demographics of our population. We are going to have a greater and greater and greater percent of people over 65 in our population. All those baby boomers, we're growing up. [LAUGH] We're living

longer in general. And we're hopefully more vital. When I was growing up, being 65 was really old. I'm almost there now. It doesn't feel really old [LAUGH] except when my back hurts or I've got some aches and pains. But it doesn't feel really old. I'm hopeful that there's a lots of year ahead.

What services, what mental health services are people who are in their 60s and 70s and 80s and are vital? What services are they going to need?

Somebody in one of the other segments asked a question about practice that specializes in grief work. Well, for every couple that's in their 60s, 70s, and 80s, it's quite likely that one of them is going to die before the other. How important for every couple would it be for there to be grief work? For people who aren't couples? Who else dies? Everybody.

So one of the challenges of being in your 60s, 70s, and 80s is the longer you live, the more people you lose. Heaven forbid you lose your own children. That happens too, unfortunately. One of the biggest fears and scares of a parent and a grandparent is to lose somebody a generation or two below you.

How important, the person who's thinking about having a practice specializes in grief and loss? How important with an aging population to offer those services? By the way, would that be pertinent in rural communities? [LAUGH] And in urban communities, and anywhere in between? Of course, it would be.

So the idea is to say, where can I offer these services, what are these services going to be, and how can I make them pertinent?

You can think about, as you're thinking about whether the niche is in or out of managed care.... How are people going to get access to the services? How are the services going to be paid for? How easy is it going to be for me to get reimbursement?

So in my grief practice that I'm forming, what if it's normal grief and there's not a psychiatric disorder? I would argue that it's real normal to be really sad after somebody you love dies. Is that inherently a psychiatric disorder--I'm not going to get into a discussion about that with our DMS experts out there. But I would question that whether a normal grief reaction is a psychiatric disorder.Is there a pertinent diagnosis that I could submit that would be insurance reimbursable?

So you need to be thinking about that, even in that sort of specialty. What's the fee structure? Can prospective clients afford to come in? Can I do some of that work at a reduced fee? At a pro bono fee even? How do I make sure that the program's accessible financially to my community? And what administrative issues, and I should have said, and costs, are going to be there?

One of the problems with chronic pain programs is that in order to get pre-approval, to provide the program, that's pretty administratively heavy from what I understand in order to make sure that you're going to get reimbursed for the services that you provide.

So you have to have somebody who knows how to interact with that system, be able to do that work, be paid to do that work, and that comes off of the income from the work or the resources that you allocate budgetarily to make sure that that work gets done.

So, if they're trying to get approval for ten people and they only get approval for two of them, they still spent their time on the ten, and you only got reimbursed for the services provided for two, but you still paid salary and benefits for the other eight, which brought in no income.

Can you make the math work? We'll be talking about math in our fourth segment, but can you make the math work to say that, administratively, this program can be viable.

In managed care, the programs have to have a level of medical necessity, the patients have to have a diagnosis that is reimbursable, in order for it to go through managed care.

Medicare has, especially, that special requirements around documentation and they do do audits from what I hear, and you need to make sure that you understand administratively what's needed there. Because you can get an audit where they reclaim not only the payments made on the particular cases that they audited, but then use that to extrapolate, at least they were doing that in the past unless the policy is changed, where they then extrapolate and pull back, or what they call claw back, the payments that they made on many of your cases, and that could be a significant payment that you then owe Medicare.

So it's really important to understand administrative issues, not only just diagnostically, but what you need to be writing in the chart in terms of having a chart that passes audit and how you need to keep the chart. I don't mean to say what you're writing, but how you write, to keep that chart so that it does pass an audit.

There are a lot of people that do great work. They get audited and the work or the payments for the work get clawed back--not because they were doing something fraudulent, but because their record doesn't meet the requirements that the auditor is looking for. So you need to know what that is.

But the programs in managed care do need to meet medical necessity.

Programs outside of managed care can, but don't have to. So the program for college students don't have to. The program for consulting with parents of little ones doesn't have to. Those parents might not have a psychiatric disorder.

Think about the weight of saying that somebody has a psychiatric disorder. There's not a stigma to that I would hope, but I know in certain circles there still is. But nevertheless, we're saying that, that person has a psychiatric disorder, versus maybe they're a new mom or a new dad, and they have reasonable questions about the development of their child, or maybe they have a child that has some developmental issues and they're looking for some consultation based on your expertise.

Is that a psychiatric disorder? I'm not sure if that qualifies, and you might not have met the child yet to actually diagnose the child and say that child, at four months old, has a psychiatric disorder. You might not be able to know that yet, but still can provide some help with the parent who has some concerns about their baby.

Does that meet medical necessity? I would say probably not. But you might have a very important program that you're offering to the community.

And also, by the way, to the baby doctors, to the pediatricians out there, who are trying to provide some support for these parents and for their patients, but who may need a little bit of help in terms of the time that you can provide, as well as your expertise in developmental issues, if that's one of your expertise.

So let's look at where to get more ideas about programs.

So my dear friend, and colleague Steve Walfish has done quite a bit of research on this. If you look for the Lee, the center one, if you look for the Lee and Walfish article, you'll see 158 strategies in nine different content areas where people are building specialties or have built specialties outside of managed care.

There's no shortage of areas. Some are more assessment based, some are more clinically based. Many of our social worker colleagues, have been very creative in this way. Many of us have been trained in the delivery of service that is related to the medical model, and we don't see ourselves as necessarily having the skills to be able to go outside of that medical model. That's kind of our own frames that we put around our skills to say that we've got to stay in there, as I was talking about earlier.

The niche that we have, as we were talking about, can bring us a lot of satisfaction. It can help make a practice more diverse, it can help make a practice more sustainable. It can align with your passion so that the work you're doing is something that is meaningful to you.

But there's one challenge that we just barely touched on, that I'd like to drill down... Drill down into more in this presentation.

And I'm going to spend a moment to read to you from our ethical, APA ethical guidelines. And by the way, if some of you are not psychologists, look at your own ethical guidelines in your respective professions. I've done so and many of the ethical guidelines have a lot of overlap. They may have different words, but there's a lot of overlap to them.

So in our ethical guidelines, "Boundaries of Competence: Psychologists provide services with populations and in areas only within the boundaries of their competence based on their education, training, supervised experience, consultation, study, or professional experience."

If the niche you are looking to start is not specifically related to your education, training, supervised experience, consultation, study, or professional experience, if it's something kind of new for you, you need to be very careful that you really have the competency to provide those services in the niche.

That was subsection A.

"Subsection C: Psychologists planning to provide services involving populations, areas, techniques or technologies new to them, undertake relevant education, training, supervised experience, consultation or study." So if you don't have that true area of expertise, then you've got to go get it.

So I received an email recently from somebody who may be interested in writing a manuscript on providing psychotherapy with African American women, and what did I think of that concept for a manuscript for a journal that I'm editing, on practice...

And I said, wow. I thought back to the African-American women that I had worked with over the years, and I thought, to my awareness of what happened from the moment we first began work together and the importance of being sensitive to not only my position as a male but as a white male, and now as an older white male... And what that conveyed and what assumptions were being made, not only perhaps by me, but also by the client--about who I was, what I stood for, what would happen if they said A versus B versus C... And were we dealing with that, or were we not dealing with that, or how are we dealing with that?

And I encouraged that potential author to write a manuscript, because...to submit a manuscript, because the idea being that how many people in practice really are up to date on what happens, not only with if they're a white male with an African American woman, but what if you're an African American woman with a white male client or a Hispanic client, or an Iranian client? And how culturally sensitive are we in spite of how culturally sensitive we might think we are or want to be?

So the idea about not assuming our excellence... We spoke at one of the prior segments about, there's research out there and there's a lot of experience, I have some experience of asking this question to large audiences of: How many of you are above average? And way more than 50% of the audience that come to hear my presentations are above average. And that's either because I have a selection issue and I just get all those above average, or we're really not as above average as we like to think we are. And some of us may downright be below that mean [LAUGH], but we don't self-assess that way.

My guess is also we don't self-assess in terms of our being below average on some of the skills in areas that we really need to, to make sure that when we build a niche or specialty area, we really have the skills and we're really functioning within the boundaries of competence that we should have.

So how do we assure that our ethics and scope of practice are at the highest level we possibly can have them that?

By the way we have about 20 minutes left. So if you have questions again or ideas about specialty practices, please send them in because we will quickly run out of time.

So many people go and take a workshop. I want to learn to do custody evaluations... So I don't. [LAUGH] But if I did, I'm going to go take a workshop. And, I find that there's a workshop, it's a two-day workshop or a three-day workshop about doing custody evaluations.

There are workshops on probably as many things as you could consider having a niche practice in. It may not all be provided by APA, they may be provided by other organizations, but you probably can find them out there.

So if you wanted to take a workshop on working with babies or parents of babies, you can find that. Working with infertility, you can find that. Sports psychology, you can find that. Many, many niches... The learning disability workshops, you can find those.

Do those make you an expert? They make you informed. But they don't make you an expert. Taking a two- or three-day workshop, or four-day workshop on doing--I mentioned custody evaluations--on doing custody evaluations, may teach you the ins and outs of how do you actually set that up, what do you need to know about writing the reports, about picking the instruments, about doing the assessments... What's the standard of care?

But do you know what to do when you get in trouble or challenged in some way? Do you know how to handle difficult cross-examination when you're on the stand in the midst of the trial or the hearing? Have you had the experience about that? And when the opposing attorney is asking you really tough and perhaps trick questions, do you really have the experience of doing that? So what happens on the first case, where you're going on the stand?

So the idea is really that, in that example, and so many more, the workshop that you took is really just the beginning. I think the workshop is the bottom rung of a ladder of training and experience, but it's the very bottom rung, it's not the whole ladder.

I mentioned earlier that you can go observe, and actually get some mentoring from people who are doing the work already. In the slide that had the picture of the United States on it, whatever work you're probably thinking of doing, there's probably somebody who had the same thought. They might have had the same thought five or ten years ago. Maybe you're very innovative. If you are, and it's a completely new thought...

Or it's a new way of doing something, you may be the first, but you may also need the foundation that somebody else has done to be the first.

I'll give you a personal example. My wife, Lauren Behrman, is also a psychologist and she does divorce work, and she's been a parenting coordinator for many years. And a few years ago, she had the idea--she also doess collaborative divorce, for those of you who that are aware of collaborative divorce... And she had the idea grafting the two together.

Because as a parenting coordinator, you are there, as I said earlier, kind of in parallel process to that of the child. And you're supposed to be a neutral, and yet you're dealing with the warring parents, both of who are advocating for their position. And she had the idea, taken from collaborative divorce, of what if you had two parenting coordinators? And each served as a coach for the respective parent, and then together, they addressed the issues that would come up with one like recommendation?

She wrote the first article on that. But she couldn't have done that without having the foundation in the parenting coordination in the first place. And she couldn't have done that without having the foundation in working with families and couples, and in working with kids.

So it's not one foot in front of the other, but it's building skills that rest on the skills that come beforehand. And then, the creativity of saying, gee, maybe there's a new way to do this. Maybe there's a way to take the skills I have and tune them in a way that can make them more helpful perhaps to a smaller group of people, but to make them more helpful.

So as you can tell from my comments, I very much value mentorship. I happen to think that you should look at mentorship as a necessary business expense. [LAUGH] Keeping the heat and lights on in your offices is a necessary business expense. Perhaps having an accountant for your practice is a necessary business expense. Your malpractice insurance is. I hope you view your dues for APA and other professional organizations as basic, necessary business expenses. Your mentorship should also be, in my opinion, a necessary basic, business expense.

How do I assure that I don't slip below the mean, and become below average and not even realize it?

I've been in practice 35 years, you can't tell me that I'm not as good as the person that has been in practice five years. You probably can't tell me [LAUGH], but that doesn't mean it's true, it just means you can't tell me. I don't want to hear if it's true. Because we can't all be above the mean.

So how do I ensure that I don't slip? And maybe I don't slip in general, but maybe I slip in specific. Maybe I slip with regard to this niche. Maybe I'm a little burnt out. Maybe I'm a little sloppy.

Do you want to be seeing me from the community, if I'm a little burnt out and I'm a little sloppy? Or do you want to see this other person over here who's not burnt out and who's not sloppy?

Do you want to be my malpractice carrier if I'm burnt out? [LAUGH] Or not burnt out?

We have another question.

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FEMALE VOICE (READING): There are many online coaches that appear to have minimal training and few limitations regarding interstate Internet work. What advice and caveats do you have for psychologists who would like to add a coaching niche to their work?

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DR. ZIMMERMAN: I'll tell you the first thing that comes to my mind is be very, very careful. You are still functioning as a psychologist. It's very difficult to say, I'm a psychologist at 9 o'clock when Mary or Mark Jones came into my office, but at 10 o'clock, I'm not a psychologist anymore, I'm a coach. And the work I'm doing, it's nothing to do with psychology, it's not under my license, it's under this other umbrella, excuse me, of being a coach. I think it's very hard to make that distinction, and it's very hard in terms of your risk management and your liability to have that distinction.

And if you're then having an online presence and going across states, as we talked about earlier, I think it would be very easy for somebody to make the argument that you were still functioning under your license. And therefore, you may have been practicing in that other state without being licensed to do so.

Now let's take the worst case scenario. So at 10 o'clock, the client that you coached, at 11:15 the same day they suicided. You didn't do a mental status eval as a coach. You provided the services, you thought. The client didn't give any indication that they were suicidal.

But now the family knows that they were talking to you, Dr. Zimmerman, shortly before they suicided. And they say that since you're a psychologist and were communicating across state lines, that now you have to defend from the claim that this was a patient of yours that you didn't provide an adequate standard of care for.

And when they ask for your file, there's no mental status exam, there's no mental psychiatric history in your file. There's no indication that you did anything that you would typically do as a psychologist, but yet you're deemed to be a psychologist.

So I'd be very careful, and I know there are people that hold both of those together. And they continue to hold their psychology license as well as they do coaching, or have a dating service, or some other perhaps marginally related business... But I'd be very careful about doing that, certainly without consulting your risk management company to know where you stand. And then if you complicate that by going across state lines, [LAUGH] you're adding another level of risk.

Another one, okay...

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FEMALE VOICE (READING): I'm currently on several managed care panels and am considering leaving the panels to only accept out-of-network clients. The reimbursement for out-of-network is around three times higher than what I'm currently getting from managed care. However, I'm nervous that there aren't enough people in my community who have out-of-network benefits and can afford my fees. How can I make that determination? Currently, there's a huge demand for in-network providers.

>>

DR. ZIMMERMAN: So, often in many communities there's a huge demand for in-network providers. If the fees are triple out-of-network, you only need a third of the caseload. You also don't have to have that happen all at once.

You don't on January 1st, let's say, go from being fully in-network to fully out-of-network. In fact, you don't have to have it be fully ever. You can, for example, resign from panels one at a time. You can resign from panels and have what's called a single case agreement, in which the people that are still, that you're already treating can continue with you. Which helps you transition until you have the natural, till they leave your practice naturally. Attrition was the word I was searching for...until you have natural attrition.

You can also have a specialty area, and that specialty area, if it is outside of managed care because it's not related to a psychiatric diagnosis that's reimbursable... If your specialty area is outside of managed care, you can have a specialty area, build that up. And then slowly drop the managed care panels, so that you've got some comfort level over here that this work can support the cash flow that you're looking for and that your practice in general can still be sustainable.

So there are a lot of strategies. It doesn't have to be all or nothing. It doesn't have to be all at once. And you don't have to abandon the community need, either.

Sometimes people say, Which managed care company should I drop? Should I drop the lowest paying one? And that's not necessarily the right answer. Sometimes the lowest paying one is the one that's most dense in your practice. Sometimes the lowest paying one may be the easiest one to deal with, and the higher paying one may take a great deal more of administrative time. And you might have more write-offs, actually from the higher paying one because of unpaid claims.

So it's important to, as we'll talk about in our next segment, to do the math so that you know that. But to take us full circle, my first answer would be, it doesn't have to be all at once and you have plenty of time to make that transition.

We have another question. Great!

>>

FEMALE VOICE (READING): I am a psychologist and I am investigating beginning a practice serving physicians. I have over 18 years experience working with coaching and leading physicians in corporate environments. I see a lot of burnout, depression, marital discord, etc. But docs do not want to have any record of a diagnosis or mental healthcare or issues. So I'm thinking of marketing a professional societies... Excuse me, so I am thinking of marketing to professional societies and having a cash-only practice to avoid the need for diagnosis to any third party. Thoughts?

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DR. ZIMMERMAN: So my first thought is, it depends. If you're going to be providing individual psychotherapy, then you're going to have a diagnosis in your record. And the physician needs to understand that there's a diagnosis. It may not go to a third party.But you can't guarantee that it won't go to a third party.

Because, for example, your file might be brought into court and then that diagnosis becomes public.So you can't guarantee that the diagnosis will not go to a third party.

On the other hand, if you were to provide specialized workshops in burnout and preserving families for hospitalists, the doctors that are employed by healthcare corporations, or medical directors who are employed by insurance companies, and you wanted to offer workshops... Those workshops, you would not be having individual files on each clinician, each participant, and therefore you wouldn't have diagnoses in a file. You might have a record of names that these ten people came to your weekend

workshop on physician burnout, but there wouldn't be diagnoses. So from the standpoint of trying to preserve that confidentiality, I think that kind of structure for the service delivery would probably meet that need of the confidentiality.

But you don't have to submit to the insurance company to wind up having your record public. So that physician is getting divorced, and the divorce is going to trial. And somehow the spouse or the physician wants you to testify, and there your record is public and so is the diagnosis.

Yes, we have another question.

>>

FEMALE AUDIENCE MEMBER: I have a question to piggy-back off of that. So what if the psychologist is not reporting to that job? So say, if this is for a physician, she has to practice outside of the job. So she doesn't have to report to the doctors, or, say if it's someone that deals with the veterans, they don't have to report to Veterans Affairs or, you know, their colleagues.

Would that be the other side of not having to report the diagnosis, to like a commanding officer or to their directors, however?

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DR. ZIMMERMAN: Well, the issue often is if they are providing treatment to the community and they have a malpractice claim, my understanding is they don't want that diagnosis to appear in terms of the risk management for their own liability or potential liability for the care of that patient. The reason the procedure that the physician performed went poorly, the reason that the diagnosis was missed was because they were depressed, or they had an anxiety disorder. So if they're providing clinical care, they're often wanting to, in my experience, they're often wanting to make sure that nowhere does it show that they have a diagnosis.

But if you're providing the clinical care to them, and you're providing that with assessment and treatment in psychotherapy, then your standard of care is to have a complete record. And that complete record should show, in my view, should show that you assessed whether or not there is a psychiatric disorder, and that that assessment had integrity to it. You didn't just write down, there's no psychiatric disorder, and likewise, for other cases, you didn't just write down, there was, so that you can get insurance reimbursement.

I hope that helps.

Do we have one more?

We're just about out of time, and I'll show you the marketing slide after we do this question, if we can just run a little bit over if that's okay.

>>

FEMALE AUDIENCE MEMBER: Can you renegotiate with a managed care company, regarding fees if you have a niche?

>>

DR. ZIMMERMAN: Yes. [LAUGH] Do your homework. If you have a niche that is underserved by their panel and you can prove that, and you can prove that by doing your homework.

Look at the panel.Look who's in what ZIP codes. Look at the prevalence of the disorder that your niche treats. Look at how the provider network is balanced, and whether or not the provider network is sufficient for the prevalence compared to the general provider network.

So, if you find that truly--you know, you're the only one as our ECP colleague earlier, I'm the only one from miles and miles around--if you're the only one for miles and miles around, that does that niche, you have a contract with the managed care company, but that contract has provisions for how you can terminate the contract, almost all of them do. I would say they all should. They have provisions for how you can terminate.

So you can go back to the managed care company and you can say, you know, while this contract kind of automatically renews, I'd like to renegotiate the terms of the contract, specifically the fee payment for when I'm working with patients with this diagnosis, or these diagnoses.

And you may go back and forth. You probably aren't going to be successful with the first person you speak to. You probably do need to go up the chain, and not just talk to the first person in provider relations. You might need to speak to the director of provider relations, the vice president in charge of provider relations, you may have to go high up the chain, you might have to meet in person.

And you do need your data, because what you're doing with your data is you're giving the person you're talking to the data to persuade the person or people they have to talk with.

And they can't just say, well, Dr. Zimmerman thinks he deserves more money, because after they stop laughing [LAUGH], you're going to get a call that says no, or an email that says no.

You really have to go with data. What's the need? What's the prevailing rate, as best as you can tell?And how do you justify that?

So I know we're out of time. I want you to just, the last slide, I'd like you to think about in terms of marketing.

Being aware, who do you target? Who touches the people that you're looking to see?

So I mentioned to you the LD for kids that are going to college, doing the assessments and the fit for kids who are going to college. Would I go to pediatricians on that? Probably not.

But there's a whole industry out there of tutors who, let's call them tutors or education specialists, who help prepare kids for college. Might they touch those kids? Do they want success in their placement of those kids?

And might I be able to offer them something that could help give them that success, by being able to help them really get a good understanding of the learning needs and how that fits with what the institution offers or not?

So, wherever you find them, who are the people that touch the people that you want to work with? How do you approach them? What attracts them to you and to your program?

What will deter you getting referrals? Look at the other side, don't just look at what do I need to do. Look at what do I need not to do.

So for many years, I did a lot of organizational consulting. Dr. Zimmerman was not an advantage in most settings. In fact, in some settings, a jack and a tie was a disadvantage. And I learned quickly that one of the first questions I would ask when I had the potential to go into a company even to offer my services, was, "Tell me about the culture..." And one question I would ask would be, "Tell me about how people dress, and what you're thinking of." And being a suit was a definite no-no in certain companies. And showing up in a sports coat or open collar as a man would be a no-no in other companies. Because there be all kinds of presumptions about that.

So, you do need to find out what's going to deter the referrals, even down to dress, perhaps office location, perhaps what you have in your office, what you don't have in your office.

If you work, for example, with law enforcement and first responders, and you don't know that safety is the most important thing in their vocabulary, most of their vocabulary, and you go in talking about the services that you provide and how you're going to help take care of them doing this difficult work and the trauma from the difficult work--and you don't use the word "safety," you're probably not getting asked back, because that's going to deter, it's going to block you being asked back because you're not aware of what their needs are.

You have to do your homework and do your research. And marketing your niche practice is not just about doing it at the start, but it's doing it throughout. So that you actually know what works, you have assessed what works, and you're really clear about what fine-tuning you need to do.

So I'm going to wrap up here, I'm sorry we've gone over few minutes, but I really appreciate the questions, and thank you.

Just to conclude, the advantages of a niche practice is it can give you diversity in the professional services that you provide. Some of us really like that diversity, I know I do. It can help with cash flow, like the question about getting out of some of the managed care panels. I think, very importantly, it offers unique services to the community and services that may be in special need in that community, and may be underserved in that community.

It can change the standard of care for what happens with people who, or for how people are treated, who have that kind of issue that they're contending with, whether it be a psychiatric disorder or otherwise.

In the divorce work, there was a time when the word "co-parenting" was unheard of, and now the word co-parenting is becoming more of the norm, and something that many people in divorce will say to each other, "You know, we've got to co-parent better." And it's becoming more of the community standard in a lot of communities, even with high conflict.

So there are a lot of advantages to creating a specialty and having a niche. But I think the most important one is that it allows you to make a difference, it allows you to make a positive difference. And I can't think of what can help us sleep at night, help us deal with the burnout from this work that we're all susceptible to, help us deal with the stress of this work, the vicarious trauma of doing this work, than knowing that we're making a positive difference.

So thank you for joining us today.

And we hope you join us for other segments and other programs going forward.

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