Multiple Blog Topic Disorder!

I have so many ideas and so many different topics I am thinking about and wanting to blog about my head is spinning! This happens to me in other areas of life, like my art making: Suddenly presented with even 20 minutes (which is a ton of time to have to myself these days) in my studio I have to make a quick decision as to whether to start something new, work on my graphic novel, get back to my big huge project, do another weird mixed media thing that is newish, or pick up a piece and keep working on it, or just chill out and do a collage in my journal. In a case like this, luckily being alone and in my studio, I just go for it and usually just do what feels easiest. If I am at my home and have a very rare opportunity of being alone with a million choices and a few hours time, I am extra challenged. Either I try to do a little of everything, or force myself to just clean some area or do what I did yesterday: I had a book I wanted to read and just sat on the couch reading that book for several hours. That was relaxing for me. No noise whatsoever, no need to look around at the chaotic apartment or be distracted by other things, just focusing on a fascinating riveting book I was learning something every page.

So I could blog about that book or topics related to it. But I have so many topics buzzing in my brain. In no particular order:
1. choose the easy way out and find a cool cultural ritual to discuss and celebrate.
2. pick something to add to the series I’m doing on society’s view of mental illness and separating fact from fiction
3. Mindfulness and how it is used in therapy and everyday life, prescription for any human suffering from anything or avoiding suffering
4. Basic fundamental of the idea of DBT, the dialectic between acceptance and change…
5. Self worth, liking yourself, self esteem, self love, whatever you want to call it and why it is so difficult to deal with in oneself and others and as a therapist as all patients seem to share this issue…
6. Importance of validation for parents
7. Trauma, a million topics emerge from just that word!
8. A holistic view of what “Recovery” means and how it can be empowered and person centered…
9. Borderline Personality Disorder, the hush that still surrounds it, despelling myths
10. many things you might share wtih someone with Borderline Personality Disorder even though you don’t have it, so why does everyone get so angry at even the name of it and why did people argue about it not existing and not being correct to put it in the DSM5 or changing the wording…
11. 9/11 is creeping up on us downtown New Yorkers, what ghosts still lurk down here and in our psyche and collective psyche as humans?
12. All healing boils down to finding balance, following the “Middle Path”. Why is this so incredibly hard to do???
13. Body image again: how can someone say that their low self worth has nothing to do with their body. Liking yourself starts with liking the form that you are in as a person, your shape and size, the inside of your body, things your body does, things you don’t know it does, what you do to it, put in it, stimulate it with, relax it with, soothe it with etc. what is the definition of negative and positive body image? If our own culture is any sign of our relationship with our body, we Americans have a very distorted image about what a body is and a lot of preoccupation with what shape and size it is and what kind of outside appearance we have, and obsession with food, nutrition, good eating, bad eating, dieting, fasting, extremes and middle grounds, feeding our babies and kids, etc. When you think about that, you have to really look at yourself and see how much you unconsciously on a daily basis participate in these fixations…
14. making assumptions about people too quickly. Learning to go back to the child’s curiosity and scientific investigation of everything you encounter through every one of your senses…
15. I can’t end at 14 as I have a crazy preoccupation with odd numbers. For alarms to wake up I have to set the time at an odd number, 8:01, not 8 for example, so I can’t end this post with only 14 topics. I guess the 15th is also about indeciciveness and making choices.
16. Uh oh I just remembered another. Noticing in your relationships with others, do you have some conflicts that could just be reduced to having totally opposing types of coping skills? This is so common in couples as opposites do attract.
17. “Look before you leap” versus “He who hesitates is lost.” The dilemma of the extremes around decision making and reactivity, ie. the person who spends too much time with a pros and cons list versus the person who can’t tolerate being in the “I can’t decide, I don’t know” zone and goes in the direction of acting on impulses and quickly…
18. The use of dollmaking in art therapy.
19. Systems theory explained simply: we all have many parts inside ourselves and we can get to know them better to help them work together. Often extreme crisis, even psychosis happens when all your parts of your psyche are at war or shouting at you at once. Hearing voices could be related to hearing from your parts… (look at “The Beautiful Mind” as example.)

Ok. I am sure I have a hundred more topics but at least I got some of them out there as things I want to investigate. Usually I veer towards making decisions too quickly, but I guess blog writing is helping me slow down, notice my mind’s chaos and speed and curiosity, wanting to connect many ideas and actually having a hard time making a decision!

Poetry Therapy and Inner Dialoguing as Therapy

This is a short post on a topic I of course want to explore further.

I have always enjoyed poetry in different ways. During school years I liked to read Shakespearian sonnets and poetry in French as well as English poetry such as Wordsworth and Blake. I also liked writing poems as a high school student. They were pretty typical “dark” teenage poems. In college, I read Russian poetry in the original and got into the “Beat” poets and postmodern poetry. I wrote more poems back then and then stopped writing poetry for a long time, I’m not even sure if I stopped altogether until just recently.

Anyway, I have been doing “poetry therapy” as “art therapy” with a patient and enjoying it quite a lot. It has resulted in me writing more poetry for the first time in years and having fun doing it… It is fun to have a session with a poet and come upon “poems” from the material that arises in the session. There is a sudden invitation to “write a poem about that”. At first I listened to poems by my patient and encouraged poetry writing but did not write any. Then after a few months in April I just naturally started responding to this patient’s poetry with poems of my own and launched myself into writing poetry again. I’ve been writing poems with my patient in sessions ever since and then started sporadically writing my own poetry, which is certainly different from any kind of poetry I’ve ever written. I think when I was much younger I was more conscious of the words I used and the rythm and imagery, metaphor, symbolic language, etc.

The poems I’ve been writing have been very “plain” talk language types of poems, although I wrote one I really liked a while ago called “Invitation to Awaken” that seemed more “elevated” and “poetic”, whatever that means…

I don’t claim to be a poetry therapist, but it is fun to use poetry in the therapy session and have a kind of back and forth call and response that naturally flows from the session and the relationship between me and a patient.

Another thing I’m getting back into that is slightly related is suggesting dialogues for journaling with the object of working on self acceptance and recognizing ambivalence or conflict within the self but not fighting it. For example, if you say, “I want to write poetry but I am blocked and can’t get myself to do it. I fight and push myself but nothing comes…” the dialogue would involve having the Inner Poet talk to the Blocked Poet and have a conversation. Another example, “Part of me wants to have children and part of me is afraid of losing myself and feels selfish…” This invites the Inner Future Mom to have a conversation with the Not Mother self and see what arises.

This dialoguing is also good for people who complain about their impulsivity in any area and desire to control themselves. The “Impulsive” Self may have a lot to teach the “Control/Principal/Judge/Cop” self. If the impulsive out of control self is allowed to have a voice and be recognized, there may be a lot of great creative energy that could be harnessed from this part of oneself and focused into something positive. The Controller could be enlisted to help the Impulsive Self (now Creative Self) to work together and thus the person can recognize that s/he needs and can use both conflicting sides and integrate them so s/he is not feeling pulled from extremes of perfection and self control to total chaos and impulsive acting out…

This is an example of how to transform one’s own energy, the dark and the light and harness it and direct it towards healing and creative purposes as well as “radical self-acceptance”, ie. completely receiving all parts of oneself and embracing them all, not unlike Rumi’s Guest House poem which I have posted on this blog.

Here’s an edited version of a poem started on 6/13/13 and continued the other day and then changed just now, that is related to this issue people struggle with around perfection/control/judgment and chaos/freedom/letting go of control:

Messy

I was walking down the street the other day

and saw an index card on the sidewalk 

that said “Messy”.

That was for me of course!

I picked it up and carried it around in my

messy handbag.

Today I lost my messy card.

Then I found it again but I forgot where.

I glued it into my messy art journal.

Life is messy. The imagination is messy.

The word mess used to mean food.

We need to be fed by our messes

and enjoy them !

Quick Post: Other Opinions on Fighting Insurance Companies

Here are some good points and actual ideas of steps to take to get insurance companies like GHI and I guess even gov’t insurance like Medicaid to change their minds about paying art therapists. In my last post, I had been kind of negative, saying it’s a waste of time contacting them directly, you might as well hit your head against a brick wall.

Thanks for the positivity and good ideas to two therapists:

First, Alan Pottinger wrote on the NYCCAT list serve and the second one is a response from another positive art therapist. These are great ideas and give one hope!:
On Aug 12, 2013
> My dear Colleagues-
>
> the insurance industry is wealthy and powerful because they do everything in their power to deny claims. It is often the first response despite all legal documentation. This will no longer be a fight, when we come out of the woods and simply do not take “NO” for an answer. We all know clinicians especially psychiatrists who can recommend this treatment. Point them to the Title 163 in the NYS Law.
>
> Treatment is between a doctor and the patient. Since we do not have that kind of juice now I recommend using the people we know to push and push and push. They are not going to hand over money because we ask them and its the right thing to do legally, morally or ethically.
>
> Stay on their behinds until we become so irritating they fork over. Ask for a supervisor , ask for the supervisor&# 39;s supervisor anyone you know in the legal world who works with insurance companies can offer advice. Especially if there is an element of danger to self or others because they do not want to be left holding that bag.
>
> By the same token neither do you. So make sure you have at least the minimal insurance to practice in your state or practice within an established health care program. The sort of new ” all under one roof” boutique establishments.
>
> Especially work the children, the elderly, the Trauma sufferers as we usually have great outcomes. Take the patients that are difficult for other disciplines.
>
> REMEMBER-UNITED WE BARGAIN-DIVIDED WE BEG

> Alan Pottinger BFA MA RDT
> Licensed Creative Arts Therapist
> Board Certified Trainer
> 212-562-6891
> 917-563-5602
> Alan.Pottinger@ bellevue. nychhc.org
>
Hear hear! It is so frustrating for me to see people say “don’ t bother, they won’t do it” because if we had that attitude towards licensure – which seemed insurmountable for years (can’t tell you how many people told me it was “useless” when I was NYCCAT chair) we wouldn’t even be able to fight!!!
Have doctors write prescriptions for CAT, letters documenting the medical necessity, have clients write letters to insurance companies, send claims after claims (create a paper trail that’s huge), speak to supervisors etc. I think with the new marketplace for health insurance coming in the next 6 months the time is ripe for change ūüôā

For New York Creative Arts Therapists and the Curious: Insurance Information

Many art, music, drama, poetry, dance and other creative arts therapists in New York State, now that we have Licensing (thanks to the tireless efforts of NYCCAT: the New York Coalition of Creative Arts Therapists) want to know more about how health insurance works in NY, especially those in private practice, so this post is some clarification about what I know in my experience since I got licensed in 2005, when we first got licensing.

Before getting my license, I was operating a private practice without a license and not able to take any insurance from patients, so I was naturally more than excited to be recognized finally as equal to social workers and other psychotherapists. The license was far more meaningful in terms of respect for our work and for the creative arts therapies than about insurance reimbursement, but money is a big part of respect.

Having the license gave art therapists working in hospital and other settings the chance to be paid equal to other clinical practitioners. Those in private practice were able to use the license to get reimbursed by SOME health insurance companies.

At present, Cigna, Aetna, and United Health/Oxford are the health insurance companies which I have had good experience with, in terms of getting any reimbursements and having the ability to take on patients who wanted to use their insurance for therapy.  There is only a small percentage of such patients who would be willing to come to a therapist if their particular insurance would not reimburse, so this is pretty important for those who want to take insurance and want a large bulk of their practice to involve health insurance reimbursement. The reason a therapist chooses this is for building or keeping their caseload to a certain amount, not because it is easier!

Taking on patients with insurance brings many challenges. First of all there is the difference between in network and out of network reimbursement. Many people think it’s good to get on “panels” otherwise known as being an “in network provider”, which means that people who have that particular insurance can pay you a copay for each session, which is usually the part on the member’s insurance card that says “Specialist” and then an amount, which usually ranges from 0-$45, sometimes $50. People with the same insurance can have a range of copays, so if you are in network with Cigna, for example, you may have a patient who has no copay at all and no deductible in network, in which case, you usually have to fill out the 1500 claim form and submit it to Cigna and wait to get paid. You may have other patients with copays. With Cigna, if it isn’t 0, it ranges from 25$-45$. The advantage of a patient having a high copay is simply that you get paid quicker, as the fee you get per session is exactly the same no matter what the copay. A patient got the mistaken idea that when her copay went up, at least I was being paid more, but I explained to her that I get the same $67.93 per session no matter what amount she pays. This brings up a big disadvantage with being an “in network provider” with an insurance company. The fee is set and you have no say about how much it will be per session. For every individual session you get paid the same amount. Most insurance companies don’t seem to raise the fee properly every year to account for adjustment in cost of living. In the many years I have been in network with Cigna, and paid $67.93 per session, this year was the first year Cigna raised the individual therapy session fee to $71!

So one advantage of being in network is that most people do not have mental health or medical deductibles in network. However, this seems to be changing a lot, and is an important thing to check out when you get a new in network patient. The reason for this is the following: a patient comes and only has one or maybe 5 sessions. They pay you the copay as it says on the card. You submit the claim to the insurance company, only to find out that the person has a deductible of $600 if you’re lucky, or maybe $2000. This is most problematic with someone who comes one to 6 times and then stops, as you get stuck chasing an ex patient for money they now owe you. I have two of these situations going on. In one case the first session which insurance companies pay more for, Cigna pays $150 for the initial session, so I’m stuck texting and leaving messages with this patient that came once. It’s been at least 6 months now and she still owes me $150. In another case, the patient came about 5 times and owes me for those sessions. Through numerous emails and texts, I finally got this patient to start a vague payment plan which is already imploding. I don’t remember how much the patient owes, but it is probably about $300 or more, and I still don’t have it.

Another problem with being an in network provider is that insurance companies have all kinds of strange deals with agencies and schools, which may not be obvious until you have submitted a claim. I have a terrible situation going on because one of my patients had a very confusing plan with Cigna due to the school the patient is affiliated with. I am used to submitting claims to one Cigna fax number and then following up with a phone call to make sure the claim is processing. (Another part of the annoyance of dealing with insurance in network and out of network, paperwork, submitting claims and following up to make sure the claim is processed and paid, a very frustrating and time consuming activity that basically sucks and makes you want to scream at the poor customer service people who have the terrible job of dealing with irate providers all day. So in this weird case, it took a few months to even figure out that I had submitted the claim to the wrong place and faxed it to another place which was incorrect as well, or sent it in the mail. I finally through a few frustrating phone calls and looking again at the patient’s card, found an address to send the claims to. These claims now represent about 18 sessions from January to June 2013, and I have not been paid a cent by Cigna. Through more phone calls to different numbers and getting claim statements in the mail that my claim was being processed, I found out that the institution that handles the claims is waiting for a price quote from Cigna. I won’t go into further detail about this, as it is obviously incredibly frustrating to imagine not being paid for about six months of sessions! The only way to avoid this kind of disaster is to look very carefully at the patient’s insurance card the very first time s/he comes to a session to make sure you have all the info, not just the ID number and the usual stuff but look at the address and contact info and see what kind of Cigna or whatever insurance it is and what it is called, as the companies are huge and have all kinds of subsets of different arrangements.

Also, if you have longterm in network patients, watch out for the new year, which is when their plan could change drastically; the copay could go up or down, and there could suddenly be a large deductible, which, depending on the patient, could drastically change whether or not s/he even is able to continue therapy. Also in July, some employers change things around and have their fiscal year start over, so that is another time when you could suddenly find out your in network patient got their insurance switched to another insurance. It just happened to me with a patient, but luckily I take the other insurance out of network, the deductible was low enough and the patient is invested and ok with these changes…

OK: Out of network, advantages and disadvantages…: As an “out of network” providor, you set your own fee, which is really great, believe me! It means I can finally charge my full fee! The insurance company, if they pay your particular type of license, will pay you a percentage of that fee, and the patient pays a “coinsurance” fee which is the rest, and can range from 50%, not so great, to lower. Of course the more the insurance company pays, the better, and the more likely your patient is to be ok with having you as an out of network provider. Most therapists have these patients pay the fee in full and then they submit the claim to the insurance company, and the insurance reimburses the patient. Of course, being in NYC, and being a “nice” therapist when it comes to these things, as most of these out of network patients tend to be students, often either Aetna or United Healthcare, and as such, they cannot pay up front unless I am lucky enough to get a student whose parent pays me directly, anyway, I usually end up just submitting to the insurance and then either having the patient pay part of it or none of it until the insurance company sends the check to me directly for their portion of the fee. So this can be tricky, as there are many patients who don’t really want to have to pay up front, and given the choice, would just find an in network provider so they could simply pay a low copay. As an LCAT, I am paid out of network by as I mentioned above, Aetna and United Healthcare/Oxford. Blue Cross Blue Shield and GHI do not pay LCATs otu of network, so you cannot bill them. I have some patients who have Blue Cross, for example, who are committed to working with me and just pay me on my sliding scale. This is one of the good cases of not being able to take someone’s insurance. You get paid by your patient and don’t have to submit claims and waste time with insurance companies.

In addition, you don’t have to figure out a diagnosis for the patient, which in some cases is a big relief, as it can be tricky figuring out the right diagnosis for some patients. Not everyone has an obvious depression or anxiety disorder, which is most common for private practice, and some people present with symptoms that do not fit any particular diagnosis very well, so putting down the number for the diagnosis on the claim form is another big important potentially headache making part of taking insurance. Luckily in most cases with insurance the diagnosis is obvious; it is especially helpful when someone comes in who already takes prescribed psychotropic meds, though that is not always an obvious pointer to the diagnosis. There are no particular meds usually for such disorders as the skin picking or hair pulling disorder, which are now included in the chapter on Obsessive Compulsive Disorders; it could take a long time to even find out that your patient has such types of symptoms.

Anyway, I digress. All this is to say that people are wrong when they say to wait until your patient walks in the door to discuss fees. This is an old fashioned out dated point of view. It is actually much easier and usually you have no choice about it, to figure this out in a phone conversation or by email before your patient comes to you. I had someone come in only to find out that I did not take her credit card which she was using for all medical fees with Cigna. I was not sure she would find many therapists who would take her credit card, but maybe some therapists out there have started taking credit cards. Anyway it was a waste of her and my time. Sometimes it is clear that the person will not be using their insurance and in most of these cases I do wait to meet them to discuss fees. However, it is much easier to figure out what’s going on with insurance payment right away, especially with non Cigna patients.

In most cases, the patient does not know much about their mental health benefits and needs to be guided to contact Aetna or United or whatever and ask the following questions and then call you back if they find out they can work with you or figure out what they want to do about the fee:
Do I have out of network benefits for outpatient mental health providers? Is there a deductible? How much is it? What percentage of the providers fee does the insurance pay and how many sessions are covered? The last question is very important, as some companies only cover 20 sessions. The average used to be around 32, but now it can be as low as 20. Supposedly, insurance companies are not allowed to limit sessions if the patient has what is called a “biological disorder”. As far as I have found, that only refers to a few diagnoses, depression and bipolar disorder, schizophrenia and maybe a few others, but no anxiety disorders are included. I’m not sure about PTSD. However, even this “rule” seems to not be followed by all health insurance companies…

 

I

In addition, Medicaid and I think Medicare patients get no reimbursement for LCATs, so you either have to charge Medicaid patients a super low fee and consider them to be your “Pro Bono” patient, which I have done in rare cases. In my experience, it is worth it to do this when you have a very interesting kind of patient and the work is extremely rewarding and different from any other kind of work you have done. One of my most transformed patients is such a person, and it is one of the most rewarding experiences I have had recently in my private practice. As they say, great things come in small packages, ie. low fee!
This sums up most of the important info I have garnered from my experience as an LCAT in private practice dealing with insurance companies. There are also a few patients I’ve had who had only in network benefits but as their copay was $50, I was able to make a deal with them to pay around that much and not use their insurance…

Also, with art therapy groups in private practice, check with the insurance company what the rate is for that, because it is usually much lower than for individual therapy. Cigna pays only $40 per group session, for example.

Note to LCATs out there: as far as I know, Blue Cross, Medicaid and other insurance companies that limit their reimbursement to psychiatrists, psychologists and social workers do not care about the benefits of art therapy or other variants of creative arts therapies and there seems to be nobody to contact who would have any influence whatsoever on whoever decides what professionals to reimburse or not in NY state, so I would not waste time with individual companies trying to convince them to start paying us. Probably the more politically active among you may know which politicians or other organizations to work with to lobby or promote paying LCATs, so that is a great thing to do, but the insurance companies themselves do not care and are such huge beaurocracies, you might as well bang your head against the wall rather than waste any time trying to change their policies…
I hope this proves helpful. Please feel free to comment and post further questions which I will try to answer…

What Makes Certain Posts Suddenly Popular? Mysteries of Blogging…

Just wondering. Why suddenly is my post with a description of the Healing Powers of Art Making from July 2 of this year suddenly getting all this attention? I don’t get it. It seems strange that so many people are looking at it now, about a month later… Any experienced bloggers out there, please let me know what the answer is! I’m grateful for any attention to my blog anyway but just curious. It’s the same with Public Facebook pages. I will suddenly get all these “likes” from random strangers and have no idea how they found my little Tribeca Healing Arts page…

The post is at:
<a href=" https://natashashapiroarttherapy.wordpress.com/2013/07/02/description-of-the-healing-powers-of-art-making/

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