Pre Vacation Blog Post Topic: Vacations!

As a human being, one needs to get away from one’s daily life, no matter how fulfilling and happy it is, or how stressful and difficult it is, and recharge one’s batteries. One of the most important things my supervisor/teacher ever said was, “As a therapist, you need to take vacations, and make them long enough so you don’t burn out.” As actions speak louder than words, he also always took the summer off, granted, part of it involved him teaching in other places and travelling to Europe to work and teach workshops, but a good chunk of it involved going somewhere with his family and making a lot of his own art.

So as a supervisor myself, I am now modeling to my supervisees how important it is to take a good long enough vacation. (And of course modeling the same thing to my patients, but as a supervisee of other therapists, I have the unique opportunity of giving them the same anti-burnout message that my supervisor gives me annually.)

One of the most important facts about taking a vacation is knowing the difference between visiting versus having a real vacation, whether you go somewhere far, near, or right here. A staycation is adequate if you absolutely cannot afford to go anywhere. However, when you take a staycation, it’s a good idea to act like you went away. Check your emails and social media at most once a day at the beginning of the day so the rest of the day is internet free. Try taking a vacation from TV and Netflix. If you want to watch a movie, go to a movie theater, or better yet, if you live in NYC, go to one of those outdoor movie nights they now have here in various neighborhoods or to a drive in movie, or to theater outdoors. Take a picnic to the park. Go on outings without your cellphone or with your cellphone turned off. Catch up on all the cultural events and shows that everyone thinks you go to all the time because you live in NYC, the capital of museums, theater, etc. but of course when you are working, you are too busy or tired to catch up on culture. Take the ferry to Governor’s Island and rent a bicycle for a day or half day. Go to the beach. In short, do vacation-like things that you can actually do right here in NYC. Take yourself out of your comfort zone and go to the far ends of boroughs or areas of NYC you are not familiar with. Never been to Coney Island? Get your towel and an umbrella and spend a day out there on the beach. The water is cold but clean; I just went there this past weekend! There is something very vacation like about taking the subway to the very last subway stop on one of the subway lines, and my favorite last subway stop in New York is the Coney Island stop. So those are some basic rules or tips about having a “Staycation” that feels really good and relaxing.

Another big vacation tip: Going to weddings or family reunions or other similar events outside of the city in which you live absolutely does not constitute a vacation. Ditto visiting any family members, no matter how close you are to them, unless they lives somewhere exotic, and you are primarily going there to have your vacation in that location and stay with them for convenience sake. Sounds cold, but visiting family, at least 80% of the time, just is not the same thing as taking a real vacation. Indeed, many people report that visiting family members helped them realize that they needed a vacation upon their return!

Contrary to what some of our patients think, (ie. It’s August in NYC, doesn’t that mean all the therapists are away for vacation?), therapists often have a great deal of difficulty taking a vacation, even though it is great to model for one’s patients and supervisees that vacations are essential to being a good therapist and avoiding burn out. Often we are in jobs that only give us a few weeks of paid vacation a year. If we are in private practice, it is often a hardship to take an unpaid vacation as one loses that income and still has all the same bills to pay, plus extra vacation expenses.

I admit that for many years, I have avoided vacations and used my dog as an excuse, as it was hard to find anyone with whom to leave an old dog with various medical issues, daily medication and lots of other complicated requirements. Eventually towards the last year of his life, I was able to leave him with trusted relatives with several pages of instructions around how to take care of him, and even take him with me on vacations that involved driving to destinations. By then I had gone many years without taking any real vacation. Last year, over the summer, I took one week of vacation to go to a lovely cabin in the woods upstate. At present, this is the ideal vacation for me: to go somewhere where the auditory stimulation consists of frogs croaking and other nature sounds, and the visual stimulation in the environment involves seeing the sky with only trees in the way, and nightly staring for several hours at a big lovely crackling fire. Basically, as a native New Yorker, my current requirements for a real vacation involve getting away from urban life altogether and being somewhere in nature without much to do besides the basics. That constitutes a real vacation for me, and I confess, it usually takes a few days for me to settle into vacation mode and relax. Last year, I learned that one week away was definitely not enough, so this year we are going away from June 28th until July 16th late afternoon. That is 18 days! A big first for me. I don’t think I have taken such a long vacation since I was in college! It results in about two weeks or so of lost income, but of course it is worth it. And it is very timely, as I notice in little ways that I really need a vacation… I won’t go into details, but about at least a week ago, I started counting down the days until vacation with my young daughter.

It’s never too late to have a more healthy attitude about vacations, as my example proves. (ie. It is not ok to skip a vacation; one must plan at least one vacation per year, ideally at least two weeks long, but at least one week if you absolutley cannot afford more than that.) I am planning to do what we did last summer for one week, but just have so much more time to do it, and more time away from everything else in my life!

Also a small note to all creative arts therapists out there: I think a vacation also involves bringing your art supplies or musical instruments or whatever you need to feed your creative self. As an artist, I try to do some form of art making daily, but life sometimes gets in the way. A vacation for me always means pack a lot of art materials, more than you expect to use, so you have lots of choices of media. It’s the perfect opportunity to do whatever you want and straying from your current series of work or media is a great thing to try to do…

A vacation is a time to recharge one’s batteries, spend time with people one lives with and loves, or if you go alone, a time for enjoyment of solitude and even adventure. Having a family, I know the vacation will be good for me to have time to really appreciate my family and not have the usual daily routine and time away working, etc. What would I rather do right now than, for example, set up a table in the backyard near the pond with lots of fun art supplies and make fun art projects with my four year old? And make fun projects of my own alongside her, as that was also what we did last year, and I definitely believe that there is no substitute for making your own personal art. Making art with other vacation companions is just icing on the cake. Even when she was only three, I modeled for her that we could do art together but she could also have her own canvas to do whatever she wanted on it and so could I.

Or all go together on the paddle boat on the small pond to watch very small frogs. You need to stop the boat and look really hard as the frogs can recede into the green grass, reeds, but once you get adjusted you can see them as well as the odd crayfish. Or watch my daughter tend to the garden she planted last year by the pond and add more flowers and plants to it… And of course, the fire watching and star and moon and sky gazing. A great big dose of nature, quiet, peacefulness, away from all the noise, stimulation and crazy energy of New York City.

It will be interesting to see how it is to stay an extra ten days or so. I’m assuming when I come back, I will not feel that dissatisfaction of having had just too short a vacation, the “I just got used to being there and relaxing and suddenly had to come back,” feeling. And when I come back, I can take with me the vacation feeling and apply it to my life over the summer, so that I go to the beach on Coney Island or somewhere nearby at least once a week and find other fun inexpensive ways to remind myself that the summer is not over just because it is July 16 and I am back in downtown NYC. Another important lesson learned from taking a good and long enough vacation. Year round, it is important to get that same feeling in smaller doses, and contrary to popular belief, New York City, including all boroughs, has a lot of vacation stuff to offer for day trips etc.!!!

So goodbye until I return. I imagine I will not post on this blog during my vacation, as I am not even sure how much internet access I will have, and maybe a vacation from blogging is a good idea. I may still write ideas for this blog and posts that I can work on when I come back. I trust all my old and new readers will still be there mid-July when I return to my life as an art therapist and artist and New Yorker!

Money and Therapy Post #3

A Big Money Topic – Raising one’s fee:

Therapists out there – how often do you raise your fee? Do you raise it by the same amount each time? If you have a sliding scale, do you raise the fee differently depending on what your patient is paying you? Do you sometimes raise the fee with most but not all of your patients, or do you raise it with everyone?

Therapist/Supervisors out there: how often should one raise supervision fees? I have a supervision group that I started four years ago, June, 2008, and it still costs the same per month per person. The economy was worse then. In addition, I pay 30$ more monthly to my own much more experienced and well known supervisor for the supervision group I attend. Should I be charging the same to my supervisees as what I pay? I now have three new people in the group which consists of 6 members, so of course it is my excuse that it is not good to raise the fee when half the people in the group just joined it in part because they figured into their budget that they can afford it.

Art therapist supervisors: I have an art studio supervision format, which means a lot of art making and processing through art takes place in the group. Should I charge a separate materials fee, say every three months an extra 5$ from each group member? So far, I’ve never done that…

Since starting my private practice many years ago, I have raised my “full fee”, the regular amount I charge that very few people can afford and that one insurance company actually pays me, so I’ve raised that fee two times in about ten years! When I write that, I think, it’s time to raise my fee. However, in reality, most of my patients whose insurance does not pay me or who don’t have insurance, are stretching their budgets just to pay what they are paying me now… So I know this is not a good time to raise my fee. Another thing about this topic, it makes sense to raise one’s fee at the beginning of a new year. Somehow people are more able to accept it and it seems less random…

There is the big problem of the economy; I think I raised the fee more regularly before 2007; I don’t even remember exactly when the economy got very bad. However, it is hard these days to raise a fee that hardly anyone can afford on their own. There is also the philosophy I discussed in another post. Basically some people believe there is a fee ceiling to therapy, meaning, therapy should not cost more than about $125-$150 per session hour (50 minutes). I believe that to be true, that there is a limit to how much a session should cost. I even think a reasonable fee is probably a little lower than my “real” fee. Partly I have this “real fee” for people on the sliding scale to recognize to what extent I have “slid” down to meet them where they are at financially. I now won’t accept anyone who can’t pay at least half my regular fee. Most people would think this is too much of a sliding scale, but I remind everyone, this is New York City, meaning that, yes, I have to pay New York City rent on my studio office, but my patients are paying too much of their salaries on their own rent and other New York priced necessities like food, and don’t have much cash left over to pay for therapy.

So this post was meant to focus on fees and fee scales as well as the issues of raising fees and how often to raise them. The questions I’m trying to bring up, besides the ones I already asked are:

Therapists and patients: how do you feel about raising your fees? how do you feel when your therapist announces to you that s/he is raising his/her fee? same question for therapists in supervision with their supervisors raising fees for individual and group supervision.

Therapists and patients: do you believe that there is some kind of fee ceiling for therapy, ie. therapy just should not cost more than somewhere in the neighborhood of $125/session? That there might be a fixed value for the therapy session, especially given the unique aspect of therapy: most people see their therapist once a week, and thus pay about four sessions per month. There are no other doctors you see that often, unless you are going to physical therapy or other forms of therapy, such as yoga therapy, hypnosis, acupuncture, Reiki, etc. When I pose questions about fees I include all these forms of healers in contrast to regular physicians and medical specialists.

Most patients are quite respectful and do realize that most therapists are very dedicated and invested in their work, but they are running a business and have expenses like rent, electricity, insurance, advertising/internet marketing, and for art therapists, a lot of art supplies. In my studio I aim to have a really wide variety of materials, so I do spend quite a bit on supplies as I think it is important for patients and supervisees to see when they come in that they have a lot of creative options. I also have a sandtray and figurines for it, as well as extra sand because a lot of sand ends up on the floor. This is a special kind of sand called moon sand, which costs quite a bit, but it’s totally worth it! The subject of Sand Tray therapy with children and adults is fascinating, and I intend to write a whole post about it soon…

So yes, therapy involves an intimate form of paying money and being payed. There is a conversation at the beginning of therapy that involves fees and cancellation policies. When the sliding scale is discussed, the patient is required to actively think about his/her budget, how much s/he can afford for weekly therapy, and the patient usually takes into account what the therapist’s regular fee is, and usually wants to respect that the fee needs to somehow be reasonable for the patient and respectful of the therapist’s experience, skills and business.

In some ways, a lot of these issues are circumvented by the existence of health insurance. I do have a lot of patients who pay through insurance. However, I have a soft spot for “starving artists”, meaning actors, musicians and performers and visual artists out there who don’t have health insurance. There are also patients who have health insurance, but often the insurance won’t pay out of network or won’t pay a Licensed Creative Arts Therapist. In those cases, I know my new patient is very invested in working with me because s/he chooses to pay out of pocket, when s/he has the option of finding someone else whom the insurance would pay. In those cases, even if the person is paying on the low side, I feel very grateful for their investment in working with me in particular and that we have a strong therapeutic bond, even after just a few sessions. 

This last example shows how the fee can really express a lot. It can be the patient telling the therapist, “I really like working with you; I don’t even want to choose the economically easier option of just finding someone on my insurance and paying a low copay.” That to me is much more valuable than anyone, insurance company or person, paying me my full fee. It involves someone choosing an option that is worse for them economically because they really value the therapeutic alliance or what their gut is telling them about working with me. A lot of people can tell pretty quickly that they have a good fit or not with their new therapist, and this is one of the most fulfilling votes of confidence one can receive from a patient. Money can communicate a great deal. And money does matter. It means a lot of different things to different people, but money is about value, and how much you value the service you are seeking out and receiving…

Money and Therapy 2

This will be a quick post. I’ll try to stick with one topic. I realized recently that I had been avoiding a growing bill with one of my patients who now owes me a lot of money. I remembered seeing this from the patient’s point of view back when a friend owed her therapist a lot of money. Because he made it ok she kind of resented him for letting her rack up a huge tab, so to speak. Where lies the blame? With him not reminding her of her dept and not processing how it was growing etc. or with her not taking more responsibility?

Well I didn’t want to do that to my patient but I also didn’t want her to quit because of finances. So I told her my idea to freeze the bill at where it was at and put it aside for now. My suggestion was for her to bring cash every session and pay then so as not to get a big monthly bill and freeze the debt where it was, ie. take responsibility to pay every session and thus feel more empowered. I even offered her a further reduced fee by cutting g it down by ten dollars so she could afford to pay each session. I would not do this with a newer patient. As I know her a very long time and have seen her commitment to therapy it was still worth bit for me. Her fee was still the equivalent of more than my regular fee is for someone making more money…

Solution seems to be working thus far and the other day I got a check from someone else who had owed a bit since quitting therapy a long time ago. I’m still chasing after some bills..

Great New LGBT Casebook!

My colleague, Dr. Khakasa Wapenyi co authored this great new book!
Here is the information and a long explanation:
The following was copied from an announcement about the book, so the rest of this post is NOT written by me…

The LGBT Casebook

Edited by Petros Levounis, M.D., M.A., Jack Drescher, M.D., and Mary Barber, M.D.

Even in today’s more enlightened society, it takes courage for many lesbian, gay, bisexual, and transgender (LGBT) individuals to “come out of the closet” and embrace their sexual orientation and identity. Coming out, or facing internal and societal conflicts related to sexuality, involves a great deal of anxiety that can permeate other aspects of an LGBT individual’s life—particularly when seeking psychiatric treatment. The goal of The LGBT Casebook is to help clinicians, trainees, and other mental health professionals address the mental health needs of LGBT people in the context of problems these individuals face in their everyday lives, including homophobia and discrimination.

The LGBT Casebook begins with five chapters devoted to basic concerns that affect LGBT populations, including coming out, heterosexist attitudes, the “don’t ask, don’t tell” mentality, legal issues, gay parenting, and sexual identity in patient-therapist relationships. In the rest of the book, clinician-authors present case studies of 20 patients with different DSM diagnoses, illuminating the impact of LGBT identity and illustrating a way of working with each presented patient. Features and benefits of The LGBT Casebook include:

Insights into the unique problems LGBT people face in their everyday lives when compared with heterosexual individuals.
Problems that are common to all LGBT individuals, such as the anxiety of being in the closet (hiding one’s identity) or coming out (embracing one’s identity).
Practitioners with little experience in working with the LGBT population can gain a better understanding of psychiatric diagnoses within the context of an LGBT individual’s everyday life.
The book can be read cover-to-cover to gain insights into the full diversity of the LGBT population, or by specific chapters of interest to help with the diagnosis of a patient currently in treatment.
A glossary at the back of the book defines both clinical and colloquial terms and phrases that clinicians and patients use to define themselves and their peers.
While The LGBT Casebook is the ideal general overview and roadmap for the clinician new to treating LGBT patients, it also provides new pearls of wisdom and insights for psychiatrists, residents, medical students, nurses, and clinical social workers who are already familiar with working with the LGBT community. By introducing a diverse range of people, diagnoses, and presenting problems, it will serve as a valuable reference book for all mental health professionals when assessing and treating the mental health concerns of lesbian, gay, bisexual, and transgender patients.

Her is a link to the book on

Addendum to Last Post

Scheduling and fees:
The therapist should be clear about scheduling and fees and her cancellation policy. I give out a written description of my cancellation policy in the first session to avoid any misunderstandings. Asking the fee for the first session is fine and a good idea if you’re not sure you can afford it. If you have insurance you should ask about both in network and out of network outpatient mental health coverage before you see anyone. Always ask if there is a deductible, how much it is, is there a limit to how many sessions covered and what is your copay or your part of the fee.

If you call a new therapist and don’t hear from her after a day, call someone else. Therapists need to respond quickly to set up your first session. It’s better to call do you can have a short conversation and hear her voice. Don’t take up too much time on the phone. Most therapists prefer to meet in person and have you ask questions then. If someone responds by phone but doesn’t take much time talking on the phone, this is NOT a bad sign for the reason I just mentioned.

If a new therapist keeps canceling without rescheduling or doesn’t see you consistently at least once a week from the beginning, that is a bad sign. You need to start out with regularly scheduled session and get your own time slot at the beginning of treatment…

Quick Post: Finding a Good Therapist

As usual, this is not a quick post. All references to therapists i use the she pronoun just to make it simple, so assume “she or he” when you see it.

People get very confused about whether they like their therapist, if they are supposed to talk about things they don’t like, and especially how long to put up with a therapist they don’t like.

Here are a few quick tips:

Scenario 1, the perennially dissatisfied patient: you think you don’t like your new therapist, but you have never liked any of the therapists you’ve tried out. There was something wrong with each one. In this case, just not liking her is not of a sign you need to find a new therapist. Be aware that you probably are looking for some kind of perfect therapist that doesn’t exist, so hang in there with her, and make sure to keep talking in your sessions about what specifically you don’t like about her. Is it her approach, what she says or doesn’t say, something really specific or something vague that probably means you don’t trust her and have to be patient, as you are not used to trusting any therapist. This is one of the few scenarios where the therapist may be right to challenge you to stay with her and tolerate your discomfort.

Scenario 2: the therapist with bad boundaries: believe it or not, I’ve actually heard awful stories about people’s former therapists. If you feel ignored, not listened to and frustrated, trust those reactions and look at the evidence. Here are some things you should never put up with: your therapist always answers her phone during sessions and talks with other people during the time you are paying her for. If you complain and she keeps doing this, leave and get another therapist. Your therapist talks a lot about herself, and it usually has nothing to do with what you’re talking about. Bad boundaries. The only time your therapist should say anything about her own experience is when it relates to your issue and you feel comforted, seen or relieved after she shares with you. Otherwise you do not need to put up with a therapist with such poor boundaries. Or, she talks too much about her other patients for no apparent reason. If it feels like she’s acting like your friend, look into what she’s doing. If she’s just giving you some harmless advice about dating or ways to cope with your anxiety or asks you to call her if you’re about to engage in some kind of destructive behavior, these are actually normal ways to work with someone and do not indicate a boundary problem.

Scenario 3: tricky one. You know you want an active therapist and do not tolerate the anxiety of sitting saying nothing. You explain at the beginnng that you have too much anxiety or trauma and can’t bring things up and need to work on it but you do eant her to ask you questions to help get you talking. Your therapist waits for you to talk, even if you sit quietly for the whole session. Especially if you let her know you need help from her to talk. If she won’t break the ice with some kind of “I’m wondering what’s on your mind?” after a few minutes of silence, her orthodox approach is no good for you. Find someone who can meet your needs.

These are the most common complaints about therapists and the most easy problems to recognize. More complicated problems include, the paradoxical therapist. Complaints sound like, “She asks me how I feel about something and then seems to judge my feeling”, “she asks me something and then interrupts me or disagrees and tells me what I should be thinking.” These are red flags that things aren’t great and you need to speak up quickly and complain, and then see how you feel in the next few sessions. Another one involves “she seemed to be purposely acting like my dad to make me react and told me she was doing that to help me but I didn’t like it.” Sounds crazy but I’ve heard stories like this. Another one is the overly infantalizing and warning therapist. “I told her about my self-destructive behavior, and she made predictions that I’m heading for another suicide attempt” or something like that. It would be better for her to ask you more questions about your current behavior and how you feel about it.

There are definitely other problems that you might encounter, so try to trust your gut feelings. If you don’t feel comfortable enough, you may just have a bad fit and need to try someone else. If she’s a woman, try seeing a man to notice if gender makes a difference. As I said before, in cases where you get very picky and don’t like anyone you try, then you need to look at your trust issues. In most of these other bad scenarios, the patient tends to stay too long because they are afraid to confront the therapist. The best thing to do is be honest. State what behaviors you don’t like, and that you are going to try someone new for those reasons. If you can’t say it to her face then at least email her…

There are also many complaints I hear about psychiatrists, actually more about them than about therapists. Basically you are paying a high fee and the session should last at least 45 minutes long. The psychiatrist should ask you lots of questions at the beginning, and any time you are trying a medication for the first time, she should have you return in one week. She should answer any questions you have clearly. There are no stupid questions about medications, and you have a right to know about them. After you are stabilized on medication, your psychiatrist should see you about once monthly unless you’ve been working with her for years and don’t change medications frequently. She should be asking you about your job or lack of job, your relationships, areas of stress for you, any trauma history, your sleep and eating, how therapy with your therapist is going…Basically, the session should include her checking in and finding out about how you’ve been doing since the prior session. If you feel like she just throws prescriptions at you, that’s not good enough. At the end of each session, you need to make the appointment for the next session. Don’t let her say, “Just call me in a few weeks, and we will set something up.” A lot of medications mess up short term memory, plus most psychiatrists have a very busy schedule, plus many people will put off future appointments for various reasons , so you need to know when you leave the session, when you will see your psychiatrist again. Make sure she tells you about vacations and covering doctors in case you have a crisis or run out of medications. Remember you are paying a lot and deserve to feel like a satisfied customer…

Mental Health Awareness Last Post

It’s June 1, and Mental Health Awareness Month is over officially, but I have 3 more topics to add to my list before I go back to the promised second part of my posts on Money and Therapy…In a year it will be Mental Health Awareness Month again, and the DSM V will be just coming out at the same time.

8. Gender Dysphoria: It seems that the DSM V is getting rid if the category “gender identity disorder” and substituting Gender Dysphoria, which they describe as:
A. A marked incongruence between one’s experienced/expressed gender and assigned gender, of at least 6 months duration, as manifested by 2* or more of the following indicators: [2, 3, 4]**
1. a marked incongruence between one’s experienced/expressed gender and primary and/or secondary sex characteristics (or, in young adolescents, the anticipated secondary sex characteristics) [13, 16]
2. a strong desire to be rid of one’s primary and/or secondary sex characteristics because of a marked incongruence with one’s experienced/expressed gender (or, in young adolescents, a desire to prevent the development of the anticipated secondary sex characteristics) [17]
3. a strong desire for the primary and/or secondary sex characteristics of the other gender
4. a strong desire to be of the other gender (or some alternative gender different from one’s assigned gender)
5. a strong desire to be treated as the other gender (or some alternative gender different from one’s assigned gender)
6. a strong conviction that one has the typical feelings and reactions of the other gender (or some alternative gender different from one’s assigned gender)

B. The condition is associated with clinically significant distress or impairment in social, occupational, or other important areas of functioning, or with a significantly increased risk of suffering, such as distress or disability**

There is more, but if you’re interested you can check it out on their website. The interesting part is that the B category about impairment in functioning was added, and I think it’s a big deal because you could have all 6 of Category A, but if it’s not causing distress or impairment in functioning, then you are simply a healthy transgendered individual, and do not have some sort of mental illness…

9. I think PTSD and depression are still very separate categories in this new DSM, and I think from my observations and experience as a therapist that many people who suffer from depressive episodes have a significant traumatic event that sets off the onset of depression and related symptoms, so perhaps there could be a form of depression that is described as a PTSD
induced depression… Under the PTSD diagnosis there is reference to depressive types of symptoms:
“3. persistent, distorted blame of self or others about the cause or consequences of the traumatic event(s)
4. persistent negative emotional state (e.g., fear, horror, anger, guilt, or shame)
5. markedly diminished interest or participation in significant activities
6. feelings of detachment or estrangement from others
7. persistent inability to experience positive emotions (e.g., unable to have loving feelings, psychic numbing)”

However it still seems important for there to be a specific subtype of depression as induced by trauma, which I don’t think is clearly outlined yet…

10. Why are mental health and mental illness still viewed as so separate from “physical illness”? Is it really different? Is the mind so separate from the body? What difference would it make to our society if the two were not so separate? Would it change anything about health insurance coverage? More importantly would it change how we view illness and health?

So I end on a basic question we can’t really answer fully, but it seems important to pose these types of questions…