Thursday, October 27, 2016

Boy, You've Got to Carry that Weight

It isn’t easy navigating healthcare today, finding the providers you know and love in a new network. You want to continue with your therapist, but when you thumb through the lists of mental health providers, no surprise, she's not there.

It hasn't been easy for those of us on the provider side, either. When the Affordable Care Act passed, we knew that we would be denied claims from these seemingly wonderful, spanking new, mega-cheap health care plans, especially the ones offered by the big companies-- United Health Care, Blue Cross Blue Shield, Aetna, Humana. Some of us didn't want any part them. We told our patients: Before you sign up, do some research . .  if you want to keep this thing we have, going.

We had no idea (still don't) whether or not insurance would pay us for services rendered.

Then it began to happen with regularity, and it continues to this day. An established patient would give us a choice: Do you take this insurance? Or this one? 

Then she would explain: My boss says I have to choose a new one. These are the only plans they've got.

Somewhat shaken, a provider might gently answer:  Likely neither. But call the number on the back of the card and ask for customer service. Mention me by name. See what they say. 

Providers like me felt compelled to add the ugly truth; Oh, and even if they say I'm on that list, the answer might still be, No, they're wrong. They make mistakes, and if that happens, I know it sounds bad, but you have to be prepared to pay out of pocket when my EOB comes up bubkus (Yiddish for Zero paid to provider).

How does it happen, that the customer service rep at the other end of the line deliberately delivers the wrong information? The answer lies in the lists. They are likely using an old provider list. Providers drop out, but companies don't retire our numbers. We're still on the mental health provider panel, although we shouldn't be. Is it intentional? You have to wonder.

The situation puts us in an adversarial position. We're the ones having to explain, post facto: Maybe I'm on the list, but I ended my contract with that company a long, long ago. If they don't pay, or don't pay enough, you'll have to cover the bill. I'm so sorry. It stinks, I know, and but I'm pretty sure that EOB will return with a big fat zero next to Provider Paid.

We sound like the broken records we are.

Suddenly a beloved provider is the enemy, a source of patient stress. We're stressed, too, as providers, because we knows we're stressing the people who count on us, people we would much rather commit to helping through their troubles. But we also know that if we work for less, if we aren't paid what we're worth, we will resent the work and the patient, and likely that will manifest, show itself somehow, in some subtle way. Here come the negative Yelp reviews. Not good.

For those of us who had trimmed third party payers well before the act passed, shaved them down to only "some Blue Cross plans" Obama Care has been less of a challenge. We simply denied new patients with insurance we didn't recognize, might say, I only take a few of the Blue Cross plans, sorry, but there are great people out there. Find one. Because there are.

We could see the writing on the wall years ago, that the only ones making money in this system are the CEO's, executives who are not paying self-employment taxes, as are all of the mental health practitioners in private practice, taxes that slice into our earnings significantly (it is as if we pay social security twice-- once through our wages, like everyone else, but also as our employers, who happen to be ourselves; we pay that other half of the social security net-- we're essentially dinged twice).

So we dropped out of the many provider panels that had never paid us enough, considering our educations and experience. Then we determined a tolerable fee schedule, fees for service that we could live with, not resent, that a middle class client, someone likely to take his family to Disney World for vacation, might be able to afford. We would see patients less often, perhaps, but our time would be be well worth it, quality time. It would be that, or refer those with "bad" insurance" along.

Someone like me, who once would see a couple weekly, would cut that back to every other week, or even monthly when insurance went to the wind. I'd suggest that each partner use the new insurance to see someone in their plan, get individual help for the things we had been working on for some time. Then, when we could, even if it would be once a month, we would catch up. They would pay out of pocket. If you have the volume, you can be creative, do that sort of thing.

But mostly we found a few groups, or a few good insurance plans, and made sure that the patients we would see affiliated with those.

Whatever we put into place, whatever new fee schedule, however we vetted insurance, it can backfire when we're talking about really sick people. Some patients really need that weekly checkup, and they won't be able to make our magic number when the insurance changes, or the job disappears, and it is a matter, truly, of life or death. How do you tell someone who wants to die that he needs to find a new life preserver?

As soon as you get the news from the patient, I've lost my job or I've had to change my insurance and you're not on the plans, it is a very big problem. It shouldn't be, this is hardly a terrorist attack. You might secretly even want the patient to move on, not liking the responsibility of carrying that weight, but it is your weight, and you know how to carry it, and you know, deep inside, that nobody knows it better, or will do it better, than you. Not right away.

So you say, We'll work something out.

And the patient says, I need to know. How much do you charge, anyway?

Because his insurance has covered all of it, until now, except for a co-pay of $10-$50.00.

So you say, My fee is more than you will want to pay, even if you have saved your pennies*, and I still have to see you every week to feel comfortable being your therapist. We have to work something out.
And the patient says, What does that mean, we have to work something out? How much is working something out per week?

Then you do some brief calculations in your brain, might offer: What if I see you for a half an hour a week for $60.00?

And the patient says, I can do that every other week. 

And you say, Done. But we talk for a few minutes on your lunch our on your off weeks.

And the patient says, But what if I don't ever get a new job? What if I run out of money?

You smile and you say, I have confidence in you. I'm sure you'll find a new job.** And whatever happens, we'll work it out. There's always a solution. 

The clincher is the confidence, having confidence in the patient's resilience, and it is much easier to do that with young patients, when we're talking about finding another job, even young patients with bad disease, chronic major affective depression, for example. They get hired faster, even with severe symptoms (no, they don't talk about those in interviews) than patients in their fifties and sixties with less oppressive mental illness.

In my practice, just this past year, it has happened four times (really, four times) what I'm calling sudden treatment-coverage interruptus. Each patient had sought me out, initially, with serious suicidal thoughts or plans, and we had worked for months, sometimes for over a year, grappling with recurring symptoms. When the insurance stopped, or the patient was let go from a job, a crisis loomed. But in each case, following that lag, sudden treatment-coverage interruptus, (not service-interruptus), after some months, the patient either found a new job with decent insurance, or transitioned over to another therapist. We held hands along the way. It felt good, not saying, prematurely, goodbye.

The affordable insurance climate is, in a word, formidable. But therapists have established practices, signed up with people well before the President signed the bill, made the changes, and in those very first meetings, we committed to helping people, or to helping them find help. We can't just close our eyes, run from the insurance crisis, when it presents itself, leave them hanging when the going gets tough. And when we don't do that, what we're seeing in the aftermath of it all, having held on tight, is that not only did our patient grow from the ordeal, toughing out the emotional adversity, but we providers do, too.


*We know if they have saved their pennies or have not, generally recommend that they do when they talk about things they think they want to buy, comfort retail. it is a part of the job, talking about one's relationship to money.

**When the patient is in late middle age, the you'll find something is replaced with, something will change for you. Like they may have to move in with someone, be of service, eat a good deal of pride.

Sunday, October 02, 2016


It was an afterthought. 

I was writing about dysfunctional obsessive behaviors: drinking, drugging, gambling, sex, over-eating, and watching way too many baseball games on television.
Chicago Cubs WIN Flag
he usual coping strategies. And I added, as an afterthought, I considered, just for a moment, prayer. 

But stopped right there. Because, can we really pray too much?

This is the time of year that Jews pray for the welfare of the entire world. Our attention, highly introspective, drilled into us by parents, teachers. God is thought to be closer, He, She's sweating the details, paying attention, trying to see who's been naughty or nice. Santa, sorry, is a total steal.

In the synagogue daily, for the past month, or maybe at home, if you live with a musician, the blow of the ram's horn, the shofar, is a wake up call. Wake up! Think about what you really value, think about the important things. Pray for what matters, strive for better, reach to be a better person, extend yourself. We say that God judges the world, all of it on Rosh HaShana, the Jewish New Year.

It begins tonight, and the Days of Awe last 10 days. Last month, the prequel. This isn’t a party holiday, it is serious. Those of us who observe it don’t drink much in celebration, don’t want to be caught napping. There are loftier things to do, learning in particular, praying, and that's how we want to be seen, as if God, considering us for the coming year, will merely think of us this way.  

There have been extra prayers penitential prayers, beginning before the holiday, continuing until Yom Kippur, the Day of Atonement. People pray early in the morning, late at night, fall into bed exhausted. Why bother with this? Isn't praying three times a day enough?  Either you believe or you don't, is the answer, and if you believe, then you know there is much to pray for, much that neither Donald Trump or Hillary Clinton can or will even try to do a thing about. 

Our lives, the lives of the animals, the fish, the trees, gardens, insects, the atmosphere, the earth's resources, the weather, every income, our stocks, our jobs, you name it, everything is determined, the fates, sealed for a year. It is a one-year contract, designed to keep us on our toes.

Because otherwise, we take everything for granted. This is why therapists try to get you to buy into the idea (with several exceptions) that a little stress is good, a little depression, your problems good too, because these annoyances force our hands, inspire growth, creativity, change. Even learning how to manage emotion, the physiological-psychological baggage that goes with stress, all that painful emotion, is a good thing; managing it, a rite of passage.

When it's not too much.

When it is, when things get really bad, that's when some of us, if we pray at all, start to pray with a vengeance. When things are very bad, people who pray, pray harder. They ask for others to pray with them, for them, for their families. And some of us who never prayed before, begin. Coping in this fashion tends to help us find solace, a little bit of comfort, even if we don't get what we pray for. We will say, You can’t pray too much, you can only pray more. Free will? Sure, but in the end it isn't such a bad idea to ask for help

No atheists in the foxholes.

Once I had an acquaintance who, you could tell, prayed daily, maybe three times a day (since she's Jewish), with intention, meaning attention to the words. People in her synagogue thought this because at weekly Saturday services she spent a long time during the silent recitations of prayers, and she cried, sometimes a lot, sometimes just a bit. So most of us assumed that she had problems, and we guessed at what they were, but we all assumed that she truly believed in the whole idea, the idea of prayer.

Just an aside, in Judaism prayer is important, but actions are more important. During these High Holy Days we're judged on tefilah, tzedukah, tshuvah-- prayer, charity, and a return to doing what we’re supposed to do. (We're assumed to have messed up somewhere). Charity and return are behavioral, not contemplative, and an effort at all three at once holds the keys to life in the coming year.

But back to our story. So one day I noticed this friend wasn’t so intent on her prayers, that she seemed much more relaxed, chatting it up with the other women who sat near her. After services, the women were talking, just idle chatter about books and television, and she joined in. She mentioned that she liked some show that actually bothered me, it had so much gratuitous sex and violence, and I teased her, And here I thought you were so religious. 

She laughed and said, Aren’t you?

Sometimes we are, sometimes we're not. It is the way of all people who appear to be religious. 

Chances are, things picked up for her, something lightened her load. Or, she just burnt out, all that devotion, too much to keep up. She would say, my guess, is that as a coping strategy, prayer can be a masterful, powerful form of meditation, focus. Many of us concur. Still others say, It is more than that. It is life or death.

We can't help but hope that when we do pray, when we talk, when we put an invisible concept in the room, as if our words are under consideration, it will make a difference. There's nothing dysfunctional about that, obsessive or not. Perhaps insisting that others do the same, be the same, is.

Have a happy, healthy new year my friends. May God judge us leniently, give us a good one, rich and meaningful, with snapshot memories that move us to good tears, a year that only gently shakes us out of our comfort zones, motivates us to do whatever it is (for I believe it is different for everyone) that our Higher Power wants us to do.

And it wouldn't hurt, honestly, since She is paying attention, if she waved the blue and white WIN flag, and the Cubs win the World Series.


Sunday, September 11, 2016


We were joking around, and at the turn of a word FD remarked, "That might have come out of ________'s mouth." And at the same time we sighed and said. "I miss him." 

It's been a rough summer, still it went by too quickly anyway. A child has surgery, a young man's disease wins the fight. Friends, family, the people we see in our offices all have troubles. We're just here, riding the wave.
Disrupted, Mind Over Mood, SweetBitter

The upside is that I read a few books, almost read others; watched a lot of baseball (Go Cubs Go); lots of lighter side TV, nothing dark or deep, no Thrones. We can talk about books and teev later. Because, you know, it's 9-11.

1.   9-11

The day always gives us pause, or should. We should be taking a moment and reflecting, just a little, on the blue sky that day, the loss, the devastation, the heroes.

The stories are told about heroes, sometimes a fire fighter, sometimes an everyday Joe. We read about these people, or knew them, hear about them on talk radio, young men going up and down stairs, shepherding people to safety, carrying others on their backs, starting over. Not making it outside themselves.

It makes me wonder: Would I have done that? If given the choice, either escape or go back into the flames to help people, what would I have done?

It shames me, even though my rational self fights that feeling, And what makes you think you could lift someone, carry anyone to safety? 

Probably couldn't. Yet is shames me to think that panic would make the choice for me. I'd have stopped breathing, or slowed to a dizzying state. Then recovered just enough, hustled, found my way down, followed the heroes to safety, terrified. Then, finally out of harm's way, the decision to leave would have been regrettable. Totally regrettable.

Fifteen years. It has changed our way of life, probably forever. We take airplanes but stand in long lines, our bags are checked by TSA. This isn't the America some of us loved our whole lives.
Texas Eagle

not clouds
But it is America, and there are choices. FD and I make an annual summer pilgrimage to St. Louis, visit his family and take in a Cubs-Cards game at Busche Stadium.
fields of grain or corn

He's from around there, and I'm from Chicago, so we obviously have very different baseball loyalties. Until last year it's been a slam dunk as to which team had the right to call itself the better team. But now the Cubs are Wonder Boys (I think of them as children, boys), and it is a very good bet that they will win Monday night's game against the Cardinals.

We'll be there. Look for us.

And oh, we took Amtrak. A train.

Two and a half feet of legroom, no crowds. We have two seats each, can spread out. This train has no wifi, but my phone seems to be doing the job and there are electric plugs. (Remember those?)  I can get up and stretch, stand on one foot if I want. The scenery, oh, the fields of gold, the burnt orange baby pumpkins, the tall green corn. Much more here than clouds.

But mainly, no lines, no waiting for the vacation to begin.

2.  Summer Vacation

One of the lessons I learned from my brother's death at a young age:
When you see an opportunity to live, take it. 
On the other hand, it hasn't made me less phobic in certain situations. Like mountain climbing, bungee jumping, or jumping out of airplanes.

So the story goes that we raided the cookie jar and flew south to babysit our southern grandchildren. Their parents deserved a break, needed to get out of town, wanted to attend a wedding and a bar mitzvah in New York. We're in a position to do this, leave the weather Chicagoans wait for all winter, mid-70's, low-80's, to bathe in Atlanta's hot-humid atmospheric conditions, lows-in the- 90's.

And don't forget the rain.

And yet: I'll go back again when it cools off in early November, attend a conference, the Council for Social Work Education's annual meeting. I'd have gone to Costa Rica, Jamaica, the South Pole, anywhere for this conference. But we'll have a do-over to ATL.

What I learned, what made this time so memorable, had to do with one of my fears, acrophobia. 
A fear of heights.

Face Your Fear:
Acrophobia: an extreme and irrational fear of heights, not related to vertigo, an inner ear problem that makes you think you're moving when you are not.
Not the same as aviophobia, by the way, the fear of flying. Don't have that.

But as long as we're talking, the odds of crashing on American, United, Delta, Southwest, etc., are pretty slim:
The phobias tend to generalize, mush together. An elevator takes us to the top of a building and triggers claustrophobia in one person, acrophobia in another, agoraphobia in another, and all three in someone else. We can treat these disorders with medication and CBT, maybe meditation, thought charts, flooding and desensitization.

It stands to reason that if someone is the type to look up the statistics of death-by-airplane, then for sure she would look up the statistics of death-by-ziplining, before agreeing to take a spouse and 3 small grandchildren across the forest in the Southern Appalachian mountains.
Ziplining, not for the feint of heart

On a zipline.

The fellas working at the State Park assured us that the zipline could hold a school bus, and altogether we didn't weigh anywhere near the weight of a school bus, so being rational people, we assumed this to be an excellent way to face the Buddha, conquer my fear of heights. That and be heroes, in this very small way, to our grandchildren. Mainly, by taking them.

It is, in a word, terrifying. They kept saying, Don't look down, but what is the point of this, being up in the treetops, swinging like Tarzan and Jane, if you don't look down and enjoy the view? And so, we engaged in a desensitization therapy, the kind you don't generally read about in the books.

The only problem with this intervention is that there is really no turning back. Once you're strapped to the line, you don't have anyplace else to go. (Or so they said). It is a do or die thing. And honestly, I loved it.

Turns out that it is good not to have Googled the odds of death, or even injury, by zip-lining before saying yes to the kids. A 2015 study found fatalities on the rise. But these are primarily due to backyard kit set-ups  drinking beer, probably, while doing the installation.

Six deaths in 2015.
The annual injury rate for all zip lines climbed from almost 8 per 1 million U.S. residents in 2009 to nearly 12 per 1 million in 2012. Causes included falls, collisions and slamming into objects at the end of the course. Injuries were most common in children and teens.
So I don't know. I guess I wouldn't encourage this as the best way to get over acrophobia, although it certainly works.

But those glass elevators at the nicer hotels do, too.

3.  TV, Books, the Movies 

New to me, Crazy Ex-Girlfriend, and Rachel Bloom had me at West CovinaCrazy Ex is longer than most sitcoms, might even be a full hour, which made it even better, and actors break into song, ala the musicals of old. Does she suffer mental illness, our new favorite lawyer who leaves partnership at a top firm to move across the country (West Covina, California) to stalk her ex-boyfriend?  I don't know, have only watched a few shows so far. But she's very, very funny.

I caught up with old seasons of Mom, am now ready for Allison Janney to hit bottom again this coming season. Right, have to blog about those 12-Step meetings. Will get to it.

Saw only one movie, Finding Dory, which nobody spoiled for me, so I'll not write about it, will return the favor.
Finding Dory--topical

I don't know where to begin with books, considered writing about Mind Over Mood in this post, but it will take too long. It's going to have to be a whole post. The authors have found a way to put all cognitive behavioral therapy tenets into one little feel-better flow chart and shared it in this work book. So wait for me on that. Or just buy the book.

Meanwhile, we have Disrupted, which for the life of me, when I mention it, always comes out Disturbed.

Disrupted, by Dan Lyons.

At the age of fifty, Dan Lyon lost his job writing for Newsweek, a print magazine. Newsweek is in jeopardy, online news has cripple sales, and the magazine wants to replace older, more expensive writers with younger, cheaper staff. Esteemed in the industry, Dan is hired by a funded tech company, HubSpot, perhaps as a PR stunt.

He is a fish out of water, the oldest employee in the shop, and can't relate to the jargon, the values, and the cult atmosphere. Millennials pledge robotic loyalty to the founders and the company which is not turning an actual profit, and never may.

But here at HubSpot, kids are hired right out of college with the lure of stock options. They drink the Kool Aid that they will become rich one day, and that they are amazing, that the company is amazing, that the industry is amazing, a word used as often as a pronoun in a normal conversation. The minions are herded onto the sales floor as telemarketers. Their product is software, quite probably, second-rate software, if that. It is the type of software that businesses buy to spam the rest of us, garbage email. Open it, there will be follow up spam. Click on the company link, be hounded for life to buy amazing products you don't and never will need, products that aren't even very good.

The incentive for this tedious, demanding sales job? The company is flush with perks, those exercise and yoga classes, a plethora of food and candy, not from vending machines, but in dedicated rooms, walls of candy. Parties that begin early on weeknights, last until the next day, the kinds of parties that overflow with alcohol, employees sneaking off with one another to empty rooms. Make work fun so people love to come to work in the morning, gladly working their you-know-whats off, remaining loyal, until they are fired on a whim, lose their coveted stock options. Bye bye.

Millions, billions of dollars are to be made, we learn, but the money goes into the hands of the very, very few.

Do we hear about it in therapy? You bet we do.

Dan, by the way, is now a writer for the television show Silicon Valley. The disruption probably turned out to be a good thing for him.


Friday, August 05, 2016

Expletives, Suicidal Thoughts, and the F-That Video

Note: The following comments have nothing to do with any particular religious code or belief system, are not officially endorsed by a minister, priest, shaman, rabbi, witch, or any other clergy person (so far as the author is aware).

On occasion, a therapist will let an expletive slip, immediately regretting it. After hearing her apology, the patient will say, No problem, don't be silly. The therapist might ask, What would be a better word?

There's always a laugh and a consensus: There is no better word.

We're taught that the emotion should come from the patient, although people like to see signs of life from their therapist. It feels intuitively correct, this protocol, that if anyone should emote strongly, abandon control over words, it should be the patient. The therapist should control it; it is not his therapy.

Therapy is an empathetic process, however, and in that process of validating the patient's right to strong feeling and expressing it, a therapist might fall under the spell, emote too, communicate with too much empathy, use those expletives feeling the pain. Because expletives have the power to convey felt pain. Extreme pain inspires exaggerated language. Ever stub your toe?

We must take a more scientific look at this, and in the scientific process, define terms, clarify:
expletive (def): An additional word in a sentence that lacks intrinsic meaning; a word often interjected into a sentence as an exclamation, implies obscenity.  
Exclamations, we learn in school, deserve exclamation points. The example of the stubbed toe plays out this way:
 "Oh, s___!"
But we don't want our children to use that word, so convention has it to teach them other words, substitutes, like fiddlesticks (!).

And when writing, to use exclamation points.
"Jack returned to find his bicycle gone!"
Jack was really upset.

The exclamation point eliminated the need for expletives.

Otherwise, a declarative sentence, one that simply declares, conveys information, ends with a period.
"Class is dismissed at 3:30."
Now, of course, an emoticon would be expected, a variation of a smiley face, most likely, after Class is dismissed at 3:30. But assuming this a classic grammar class, only the period is necessary, in this way the words, and the period after them, must do the work. Ditto, the question mark.
"Did you ask permission?" 
Question marks, however, oddly, get in the way, sometimes, and are forgettable. And commas become a way of life, one that needs to change, become forgettable. Break up that sentence or use a semi-colon for G-ds sake.

Exclamation points win the prize as most highly valued punctuation marks, taught to be used sparingly in college writing classes; otherwise they lose their effect. The exclamation mark is privy to its own renaissance, however, in the past fifteen years, as THE preferred means of written emotional expression. Second only to CAPS and EMOTICONS.

WE CAN THANK THE MILLENNIALS, whose social networks far exceed those of the average baby boomer's, who felt the need for an effective emotionally loaded repertoire, and disseminated, however that is done, caps and contemporary hieroglyphics, those symbols that say so much more than a few words can express, worth a thousand words.

Emoticons are easy on the eyes, whereas letters are not, useful to convey what we are doing, feeling, (at all times), with symbols of food, drink, recreation, holidays, sadness, disappointment, anger and love, each color heart a different meaning, if only one learns the code.

All good, too, because online communication has had a positive effect on most of us, enables more and better communication. If we do it anonymously we can let down our guards, our defenses, unmask in a chatroom or with a blog, even a comment. Even with friends, in a text, we'll express feelings with emoticons and it feels perfectly safe. Even smart.

Therapy has always been a safe place to express the ugly, share when sharing with others is just too uncomfortable, too embarrassing, or has been unsuccessful in the past, accomplished nothing. And therapists have light-sabers with different settings that zap negative emotions, unexpectedly. They do it with just one look, sometimes, saber set to the look setting. If all anyone has to do, to feel better, is talk to just anybody, or shout out online, or on the phone, there would be no need for therapists.

Therapists would not need training in those Jedi schools. The economy would tank.

But should the expletive be a light-saber?

Four-letter words, the ones we're talking about, by definition imply obscenity, either as an action or a blasphemy. As such, these words successfully express negative feelings by temporarily externalizing them, like pregnancy, the feelings better out than in. Swearing tamps down the affect, displaces it, like slamming the door.

So for the therapist feeling badly for the patient, expletives work, too. But if they are not in the service of the therapy, if the therapist isn't using them intentionally, then it isn't right, might even upset the patient more.

Which is why Yiddish is better. For centuries, the old Jews, sweeping the floor of a hut or tiny apartment that never looked clean enough, rather than beat their wives or smack their husbands, kids, the dog, although they did some of that, too, used words that sounded funny but strong, externalized their pain. We should use them. They upset no one and make everyone laugh. There must be a list online somewhere.

Take the word, drek, rhymes with wreck, evocative of the "s" word. Typically, when one drops a pickle jar in the street or on a hard kitchen floor, what comes out of the mouth is:

"Oh, s___!"

But one could say, "Oh, drek!"

Except that this is not how the expletive is supposed to be used. It is more of an adjective: "The house smells like drek (if  a pet has not been able to wait).  Or better, "I feel like drek."

In fact, most yiddish words don't quite make it as substitutes for the "f" word, or the "d" word, or even the "b" word.  Chaval. So forget that online search.

(Chaval means too bad, or what a shame, rhymes with la-doll. That you can use.0

So we are back to therapists controlling their use of strong language, remaining professional, letting the patient do the swearing.

And yet, (as Jonathan Safran Foer would say in that survivor book Everything is Illuminated):

A Story

I'm with a friend and we're talking about meditation, that tried and true intervention, a distraction from obsessive, recurring thoughts, stinking thinking in Alcoholics Anonymous-speak. Thoughts are self or other-blaming, self or other-punitive, cohabit with hopelessness and self-pity, fear and loathing, and maintain depression and anxiety, tempt substance abuse and suicide to alleviate the pain.

She was really down, rock bottom sad, and I felt powerless, had to ask, "Hey! Have you seen the F-that meditation video?"

No, afraid not.

"Oh, you should. It is really, really funny."

Will do, she says, still very sad.

A laptop in my purse, I pull it out, find the link, hope not to be hacked in a coffee shop. She laughs so hard, tears come to her eyes.

I determine to recommend this paradoxically conceived video to patients, one punctuated with expletives delivered in a soothing, therapeutic, relaxing cadence.

And never again to swear in therapy.


TOTAL NONSEQUITOR-- Best treatment I've ever seen on perfectionism, WHY I QUIT  PERFECT, really good read.

Monday, July 18, 2016

Snapshots: Baton Rouge, Nice

First, Baton Rouge.

Three police officers, shot down. One, just vacuuming his car. I saw the video, the reenactment. The shooter, an ex-Marine, hides behind the corner of a convenience store at a gas station, peeks out, eyes his target, an expert marksman, takes them down.

What is this?

At first you think, Oh, another reverse racism thing, Race in America, the unsolved puzzle, the ultimate in displacement, the psychological defense, placing one's negativity, anger, on someone, something else. If I come home angry and slam a door, or kick the dog, my anger is now in the door, it is the dog's problem. I feel better, momentarily

An immature defense, and too simple an explanation for recent murders in Dallas, five policemen were killed, nine injured, and now . . . more dead in Baton Rouge.

But this massacre is different; one of the policemen, one of the victims is not white, his skin tone is closer to black, so there must be some mistake.

The perpetrator, Gavin Eugene Long, reached 29 short years of age yesterday, the day of the shooting, a birthday, death-day celebration. He self-identifies as Cosmo Setepenra on YouTube, an author of three self-published books, a life coach, and the leader of an extremist group, the Sovereign Citizens.

Protests are not enough, preached Cosmo. Violence is what is called for in the struggle against the government of these United States, a war against the police. He thought the violence in Dallas a good first step.

To me, first glance, this is a man in a florid manic episode, full-blown, psychotic and narcissistic, a person whose reality testing has likely been compromised by mental illness. His words:

If anything happens to me is a reference to his suicide-homicide. Youtube took down his videos, but they're nested in the link above.

An ex-Marine, he had military training. This would be an asset, should one become paranoid, want to take a society, even one with democratic ideals, down.

A therapist would maybe say, "They are only ideals, the government is the means to realize them. It may another two hundred twenty years to create a perfect society. Let's strive for better. How can you make it better? Let's talk about your ideals."

But most probably Cosmo needed another kind of doctor, too, one to give him something that would help him sleep a little, take off that trigger-happy edge.

Nice, France     
Fire Works, Evanston, IL

But first, a story.

Always a fireworks fan, the Fourth of July has become a bit much the past few years. Alley displays are out of control, fire crackers and rockets explode throughout the night, usually a lovely summer night in Chicago.

You want to keep the windows open. The dog covers his ears with his paws and moans.

But watching the faces of the children at an authorized beachfront festival is irresistible, and the music, so,patriotic, upbeat. This year my grandson invited us to join him and his parents to see fireworks. FD suggested we skip the crowd, watch from the top level of the hospital garage near the lake. Perfect for me.

We hadn't counted on security chasing us away.

As an alternative, FD drove us as close as he could to the beachfront, dropped us off a few blocks from the action. We would be in the thick of things (the child among us wanted to do this, anyway, hadn't particularly liked the garage rooftop).

Every street to the Evanston, Illinois beach cordoned off, saw-horses blocking traffic, blinking red, pink beams flashing from flashlights. No vehicle entry to the lake.

You don't think, Well, a truck could plow through that.

But now you do.

When I told a friend that it hadn't been my first choice, going to see fireworks where hundreds of people would be gathering, a jihadist's dream location, and a symbolic gesture, too, this being a national holiday, she told me,
"You can't stop living. That means they won!"
I thought that ironic. They stop others from living.
He had a history of mental illness, according to his father, two nervous breakdowns in Tunisia. Neighbors said he often acted nervous and angry.

Mohammed Lahouaiej Bouhlel murdered people enjoying their holiday, punished others for being happy, for having something he didn't have, maybe. Happiness.
Oddly enough, he flaunted the Koran, scoffing Islamic law, beat his wife, took drugs, drank alcohol and ate pork, according to his cousin. He did not, as far as anyone knows, act as an ISIS puppet.

What could have been done to stop this? He told police that he was delivering ice cream to the beach, so they let him park the refrigerated vehicle over night. They didn't bother to ask for a sample, we suppose. That might have changed everything.

Authorities had him days before that. French police intervened as he threw a heavy board at a motorist during a traffic altercation. He had priors for theft and violence.

Mental health professionals had him, too, the ones treating those nervous breakdowns, and his family knew he could be violent, the potential was there.

Nobody reeled him in, however, when it mattered, when that divorce went through.

Sometimes these things aren't as complicated as they seem.

Great, but what's a professional to do? And law enforcement can't deprive citizens of their rights. We've all watched Law and Order. 

It becomes what might each contact have done, each person who comes into contact with a Mohammed Bouhliel, or a Gavin Long.

What would I have done, had the Bastille Day terrorist in Nice come to see me?  We'd have talked about that marriage, and his anger.

Gavin Eugene Long wouldn't see a mental health professional. He would be the problem of his commanding officer, and likely a military wildcard. But he had a commander, once, who might have picked up on that mania, had he a bit more training.

And we haven't even talked about Bowe Bergdahl, a very different story, an American soldier who walked off his post in Afghanistan, only to be captured by the Taliban and released in exchange for five Taliban leaders in Guantanamo Bay.

(Spoiler alert, if you haven't listened to the podcast, Serial).

What possessed Bowe to walk off, we want to know, ultimately costing the world, not only the US, perhaps hundreds of lives in the future? Do Taliban leaders return home and take up knitting?

Bowe had schizotypal disorder, we learn on that second season of Serial, and should never have been in combat. He had been diagnosed, then sent off to war, couldn't take camp, and the hypocrisy of command. Took off.

O're the rockets red glare, the bombs bursting in air, gave proof, through the night, that our flag was still there.

I don't care what anyone says. Next year, I'm staying home.


Friday, July 08, 2016

Taking Notes

When I told one of my friends that there's no way I would remember the most important, the most salient details of a therapy visit if I didn't take notes right then and there, she said, "Well, you wouldn't be my therapist. I need someone totally looking me in the eye."

I didn't tell her that I could type ninety words a minute and never have to look at the screen.

I'm not exactly sure how they teach note-taking in graduate schools anymore, hopefully the importance of a good genogram (family tree diagram that indicates alliances), among other things. In some Masters programs, surely, the old process recording is still taught.

A process recording is what is done in the courtroom. You write down, verbatim, word for word, what the client said, although he's not on the stand. It is useful in many ways, not the least of which is that when there's a need for clarification, nothing's more powerful than telling the patient, "Let me see what we talked about last time. Oh. Here it says, in your words. . . ."

People forget.

I've been deposed a few times, and in that process the lawyers on both sides of a case review your notes before the interview. They always joke about mind, tell me my notes are illegible, ask me to read back what I wrote. My response would be, Why do you think they're illegible? No one is supposed to read them but me. The writing would be difficult to discern, even for me, reinforcing the myth (maybe) about doctors and penmanship.

But that was back then, in the day, pre-electronic everything.

Shredding charts every seven years, over time, became quite the chore, and being more ecologically green, the whole thought of paper, paper, everywhere, just felt wrong. So, for a few years now, the typing began, and it is more elegant, and easier on the eyes, having the luxury of seeing words on paper and not having to wonder, What does that say?

Oh, but how to keep them safe from hacking.

Here's my system, feel free to try it. Each patient has a flash drive, their very own, that lives in the paper chart with a full name and account number, housed in a locked file drawer. Each visit, the record is typed, signed with my initials, encrypted with a password, and saved on two master flashdrives that are inserted into a USB hub that can hold several flash drives. Then, every month or so, the patient's own flash drive is inserted into that and the notes are copied to it.

This may seem tedious, but it avoids wear and tear on the flashdrives. They aren't inserted in and out so often that they lose their integrity.

Word 365 allows password encryption by going to "Review" on the menu and following instructions. Using a Mac, with "Pages," it is even easier. Go to File, set a password.

Once that note is complete, saved to the master flash drives, it is never changed, so the date never changes.

No names on any notes, no birthdays, nothing but a variation of the patient's true account number that I take off my billing program, also password encrypted on a old PC that is disconnected from the web.

Like paper charts, the master drives are locked in a file cabinet, still attached to the hub that I attach to my laptop the next time I return to the office to take notes. I turn off the Internet on my laptop while the hub with the masters is attached. Macs are supposed to be more secure, but still.

Nothing's saved on my computer. After the visit is copied to the flash drive, it is deleted.
But it is also saved on a cloud, later in the day, with visit information added to one long file, also password protected. That's done at the end of each day, when the Internet is turned on, briefly. Not that my service provider isn't safe, but it makes me uncomfortable working with patient charts.
Once the visit has been uploaded to the cloud to become a part of the patient's chart, when I need to review it, there's no waiting, no wear and tear on a flash drive. These won't last forever if they're swiped in and out regularly.

So when I need to refer to what was said last week, that's where I go, the cloud, where the entire chart is there for me to access, typed, not handwritten.

Lots and lots of passwords, but they are easy to remember because of an algorithm I made up with patient initials and two of the numbers in the account.

Here's a sample patient visit.

Pt Code and Date of Visit
Current Primary DX:
Process recording
Current Symptoms:
Plan for the week:
Long term Goals:   same  ___  new____
New Goals:
So let's say the patient's name is Jennifer McGooglestein Romiretsky. One could conceivably code her as JMR289703 if 289703. The 289703 would be the account number provided by the billing program. Or you could cut it back to JMR03-1. The 03 is the end of her account number, and the -1 means she's the first JMR03.  You might, for example, also be seeing John Miguel Robertsonsteinenvasser, who has the chart number 297403. He would be JMR03-2.

See how easy this is? And you thought therapists mostly think about despair, panic and suicide. Not so.

Now let's make up the rest of the visit note. Anything in parentheses wouldn't be in the note)
Visit Specs: Pt Code, Date of Visit, and Procedure Code : JMR03-1   6-30-16   90837
Current Primary DX:  F33.1  (Major affective disorder, depression, severe)
Process recording: OMG! I hate my life! Yesterday I slept too late, walked into the elevator with my boss. He said, "You look like ___. Why do you even bother coming to work?" And truthfully, I couldn't make it through the day, not sure how I did, and on the train home I fell asleep, realized I'd left my phone at work. I don't even know if I can stay awake for this visit.
(etc. only write what feels important)
Current Symptoms: fatigue, hopelessness, hypersomnia, 
Plan for the week: See Dr. Promtigyoplicweiner for medication re-evaluation, use imagination exercises discussed last week
Long term Goals:   same  _x__  new____
New Goals: none
           TD   (your initials)

How easy is all of that? Feel free to ask questions.


Monday, June 27, 2016

Snapshots: NASW16 and Transformations

When I told FD that I wanted to go to Washington DC for the annual National Association of Social Workers (NASW) conference, he surprised me and said, "I haven't been to DC."

So let's go.
NASW annual conference 2016 in DC

(1)  Going it Alone 

Many of us don't like attending conferences by ourselves, and being one of this population, I dreaded walking into the enormous conference auditorium (the Marriott Wardman Park ballroom) alone. FD, a medical doctor, not a social worker, would be roaming the Holocaust Museum by now, fearless, yet shaken. 

Considering the space between workshop participants in the auditorium, three to four seats apart, it seemed that hundreds attended alone, like me. 

And we have to do what we have to do, most of us armed with a truckload of CBT exercises to power through that test.  

A few deep breaths, a critical eye at faces for signs of friendliness, and one can and will survive.

(2) Opening Remarks

Darrell Wheeler, the president of NASW, tall, relaxed and polished, opened the keynote session with questions to a few seasoned academics about the future of social work . He's younger than me (not by so much), but has done a whole lot more. 

Here's the best answer to what social work academics would hope to see by 2020.

"I would hope," a professor smiles, "that by the year 2020, when I tell people I'm a social worker, that I don't get that blank look, the one that says, Say what? That No, you're not, impossible, look."
Darrell Wheeler, PhD, president of NASW

Kudos to her on that one. 

Another professor suggested an answer to What are the big questions that contemporary research professionals needs to answer? Dr. Richard Hart said we should investigate the efficacy of how well cognitive behavioral interventions work with various populations. The people we see in our practices are so diverse. 

So true. But I would hypothesize, based upon (a) the National Institute of Mental Health's strong insistence that CBT has already been empirically validated; and (b) most trained clinicians are well-trained in it, if not in graduate school, then in continuing education; and (c) that we use it already without regard to race, color, nationality, etc., that all of these techniques work just fine (they do in my practice, which is diverse, and surely for my tribe), and if we try something and it doesn't work, we'll look into the war chest to try something else. 

Meanwhile, it took me three tries to find someone who smiled when I raised my eyebrows as if to say, Anyone sitting here? Three's a charm.

This young man followed Dr. Wheeler's beginning. I sensed he was a musician when the notes wafted into the room, no violin in sight. 

Young Kai, an innovative, original, yet classical artist walked gently into the room, his violin crooked under his neck, sawing away with the bow. He stopped right in front of my row to finish the piece but naturally, I couldn't get my phone out quickly enough to get a picture. But he punctuated his narrative with his music and many of us recorded him. Not sure it is kosher to post my video, so if it interests you, look for a YouTube video. I think there are recordings on his website. His CD's must be wonderful.
Kai Kight

Kai reminded me of Giacometti bronze, something I'd see later in the sculpture gardens at the Smithsonian, studied many years ago in an art history class.. 

He performed his many notes and what he calls air violin, and spoke about his life, told us that about training in Beethoven and Mozart, the expectation, when you train as a classical musician, that you will execute each note to perfection. 

This changed, the need to do it their way, the classical way, when one afternoon Kai's mother told him that she had cancer, would be undergoing chemo. 

He speaks in metaphors, and seemed to be saying that his emotion changed how he played, that he evolved into this extremely powerful, angry (that's what at least one of us detected) performer who did whatever the hell he wanted to do, when he took a bow into his hand.

Then, at a contest, he froze, could see nothing, hear nothing, couldn't play, certainly could't play what was expected. But what came out was pure, and real, and good, and from here a new talent and message evolved. 

The lesson, according to Kai, is that There's beauty in beginnings, for he had to start over, become a new type of musician to fit into his new emotional world.  

Therapists know the lesson well, that rationally, change, transformation, shouldn't be scary, it is what we want, as therapists, what we are reaching for. New beginnings, the start of transformations, can be beautiful indeed. And they feel good, as soon as we lose the fear. 

And yes, his mom is fine. When we heard that, the applause, the foot stomping made another kind of music.

(5) Soledad O'brien and Uncovering

If you're unfamiliar with the work of Soledad O'brien, that should change. As much social worker as journalist, Soledad is the voice behind Black in America and Latino in America, CNN award winning productions, now under the wing of Starfish Media. 

All mental health professionals, including clinical social workers, uncover stories, encourage personal narratives. That is half the incentive for joining the club. But we don't produce them, and we can't tell them over, not the way journalists do. No amount of release of information takes away that element of potential coercion. We can't encourage patients to let us tell their story. We can't evoke a Yes, you can tell my story. It is their story to tell, first of all. And for sure, most will say yes to please the therapist. That is the nature of therapeutic relationships. Gratitude- authority. Despite every attempt at egalitarianism.

So it is good that Ms. O'brien is doing the job.

And she established a scholarship fund for disadvantaged young women who want to go to college. 

Worth the price of my ticket to DC is her own story, alone. Soledad tells of being the child of a Black Cuban mom and a White Australian dad, and how her mother, launching her into 99.6666666% white populated schools, merely suggests that she and her siblings, blend in. How hard could that be? 

Soledad O'Brien #NASW16
One of the journalist's more interesting spins on what we do:
Social workers trade in hope. 
Yes, we do. It is one of our defining attributes. There's something ridiculously positive about social workers. 

4. The War Memorial and The Smithsonian
DC war memorials

It was impossible to stay in and attend CEU workshops on a beautiful day, considering I had never been inside the Smithsonian, and hadn't seen the Viet Nam War Memorial. The only time I'd visited DC was on a stop to Baltimore for a wedding. I snuck away from the conference. FD had been in the Holocaust Museum while I attended the conference. Admission is free for the Holocaust Museum, as it is for all of them, but you need to get tickets in advance between March and August.

We rented bikes the first day and cried at the memorials. Both our fathers served in the Pacific. It is by the grace of the Old Mighty that we are even here.

The sheer emotion. . .

WWII, only one front

Viet Nam War Memorial, even more astounding
Inside, the paintings at the Smithsonian overpowered me, the Paul Mellon collection at the National Gallery of Art, in particular, and the Robert Irwin at the Hirshhorn, All the Rules Will Change. Of course I liked that.
All the Rules Will Change-Robert Irwin

 So that's the kind of stuff you're treated to, if you pop for the conference fee and airfare to a place like Washington DC. Our nation's capital. The workshops will inspire, too, in different ways.

I saw Dr. Wheeler at the hotel that first night of the conference, complimented him on an entertaining, emotional first day. I also told him it was nice that he was footing the bill, since he was signing a credit card receipt. He laughed, but he got it, my reference to his remarks about being president of NASW, a job that can be hours of work on a given day or three for no pay.

He's got an expense account, FD assured me. 

Well, I'm deducting every penny, too.