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…

 

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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…

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This week’s post: Celebrities Help With Society’s Progress in Understanding Mental Illness

I am still interested in raising more questions about society’s views, perceptions, misconceptions, stereotypes and prejudices regarding mental illness, as well as asking, “How far have we come in a positive way?” because it is true that we are improving.

Let me make this post more reflective of some positive progress in our society in understanding mental illness. Recent disclosures of celebrities regarding their struggles have been invaluable. Like it or not, celebrities can have a huge influence on citizens’ thoughts and perceptions, regarding everything from attractiveness to mental illness. (Of course, Angelina Jolie’s recent public revelation about her double mastectomy has been instrumental in helping women cope with the possibilities of developping breast cancer, and I even know people who, after hearing about this, decided it’s about time I go get that mammogram I’ve been avoiding. How amazing and wonderful!)

Catherine Zeta Jones comes to mind as the most recent “celebrity confession” regarding serious chronic mental illness. She suffers from Bipolar 2 Disorder, which is less severe than bipolar 1, but her mere talking about her struggles and explaining them even went further to educate people, because the vast majority of people do not even know what Bipolar 2 is or about its existence, so one could argue that though she has a less severe form of Bipolar Disorder, she has been couragesous and invaluable in helping people understand how complicated Bipolar Disorder is and also even more importantly, that many people who have any form of Bipolar Disorder are able to function and contribute greatly to society. The mere fact that many individuals with Bipolar Disorder are “in the closet” about it at work and in other arenas, reveals how easily those people who are taking their medication and other treatments are able to “pass” as not having any type of mental illness.

Wow! How timely. I just googled her and bipolar and she has just the other day, emerged from going to a treatment facility for Bipolar 2. Here is the article in the LA Times:
http://www.latimes.com/entertainment/gossip/la-et-mg-catherine-zeta-jones-bipolar-treament-completed-20130523,0,2772184.story

Actually she first revealed her struggles with bipolar a while ago. In fact, she was “outed” in the fall of 2012 and discussed her struggles in her cover issue interview in InStyle magazine, so actually it should not have come as a shock that she sought out treatment very recently, as most people knew back in fall 2012, as InStyle magazine is pretty mainstream:
http://www.usatoday.com/story/life/people/2012/11/13/catherine-zeta-jones-instyle-cover-helps-defuse-bipolar-stigma/1703053/

Zeta-Jones is not the first to discuss her struggles with mental illness and really help dispel a lot of stigma about it. I don’t usually like to quote from Wikipedia as it is so easy to just go there for info, and I like to cite a variety of websites, but they do have one of the most extensive lists of celebrities who have suffered from some form of schizophrenia:
http://en.wikipedia.org/wiki/List_of_people_with_schizophrenia

There are many celebrities who have talked about their battles with depression, whether as a teenager or adult. Kirsten Dunst was all over the news in August-November 2011 talking about her most recent bout with depression. I learned about it from watching of all things, the E channnel’s coverage of Celebrities with mental illnesses. This supposedly “superficial” channel about celebrities actually did a great show quite a while ago and extensively covered the range of disorders from eating disorders to depression to anxiety, bipolar and also drug/alcohol abuse. I just looked it up and it came out in 2008; I remember watching the show and I really thought it was a great way to help people understand mental illness and related disorders and see that wealth and fame have nothing to do with mental health. This is the summary of that show:

“Celebrity Crises: 10 Most Shocking Mental Disorders is an American television entertainment special produced by E! Networks which documents the mental trials and tribulations of some of Hollywood’s biggest stars.

The special originally aired in the USA on E! Entertainment on 22 August, 2008. It is 50 minutes long.
Synopsis

When Hollywood stars are diagnosed with a mental health ailment it’s big news. From rumours about Britney’s bipolar disorder to Heath Ledger’s bout with depression, phobias and mental illness are getting more attention.

But of course, mental illness can affect anyone. Close to 58-million Americans — about one in four adults — suffer from a mental disorder.

From eating disorders (Mary Kate Olsen) to depression (Heather Locklear, Kirsten Dunst, Mia Tyler, Jim Carrey, Heath Ledger), to cases where stars have harmed themselves (Christina Ricci – cutting) this one hour special will explore ten troubling mental disorders, with interviews from doctors, psychologists and the stars themselves.”

The show may not have been extensive and totally informative about all these disorders. Who could do that in 50 minutes? However, it was great in scope and just introducing these different issues to the public.

There are also people in politics who have a lot of power to help the public understand mental illness and decrease the stigma and shame. There are also pioneers in the mental health field, such as Kay Jamison, who is not only an expert on mood disorders but wrote a great memoir of her own struggles with Bipolar 1 Disorder, titled “An Unquiet Mind”. The fact that she is well known for her own “coming out” about her personal struggles, indicates we still have miles to go in decreasing stigma, as we see that in the field of mental health itself, the majority of psychologists, psychiatrists, psychotherapists that suffer from any mental illness do not actually feel safe disclosing about their personal struggles. Another author and therapist who has written some great personal accounts of her own struggles is Lauren Slater. Her work is more on the edge and less well known to the general public, but she has written many interesting books about a variety of struggles.

So, in closing, I do believe that some of the best ways to educate the public about mental illness is through the mainstream media, whether it be a celebrity disclosing their struggles and talking openly about their treatment, or even films that attempt to focus on the topic, whether documentary TV shows like the one mentioned above, or the many biopics and fictions films about mental illness, such as the film “A Beautiful Mind” and the TV shows “Homeland”, “Six Feet Under” and “The Sopranos”, as well as numerous others. Even when such films or tv shows don’t give a totally accurate depiction of a specific mental illness (see my reviews of “Silver Linings Playbook,” they are still contributing to the more healthy dialogue that we need to have about this topic. A little misinformation is worth it if the subject at hand becomes more familiar to the general public and helps people view this topic with more compassion and less judgments…

Violence and Mental Illness: The Stigma and the Truth

This is a huge topic, so I will only touch on one “mental illness”, as there is a trial all about BPD in the press and the jury is deliberating whether to send the woman to be executed or not. So I am not going to write about BPD, as it is extremely complicated and I’d rather wait and see what happens with the jury’s decision and then post on BPD and violence. Just one thing to say, without any statistics, it is my experience that people suffering from BPD do a lot of self harming rather than violence towards others. Everything from extreme binging and purging, self-mutilation, repeated suicide attempts, drug and alcohol abuse, etc. plagues people who suffer from BPD.

As I was posting about the movie “Silver Linings Playbook” and felt that it gave a bad impression that people who are going through mania and manic psychosis are violent, I wanted to write about that and shed some light on it. A colleague shared with me that unlike my experiences, she had seem many males who became violent while manic and in the midst of a manic psychosis, so I wondered, is this movie off the mark or not?

Ok.
I looked around the internet and found a study done in England around Sept. 20101. You can read the whole summary here:

http://www.ncbi.nlm.nih.gov/pubmed/20819987

Here’s the important finding, which is that the comorbidity of substance abuse and bipolar disorder is what increases the incidence of violence in people diagnosed with Bipolar Disorder. In regular English, this means that the subgroup of people who have BIpolar Disorder and are abusing drugs and alcohol on a regular basis, usually knows as “MICA” (Mentally Ill and Chemically Addicted), and requiring treatment of both problems, that those people are more likely to be violent than the general population. However, it seems the risk of violence in individuals suffering from BIpolar Disorder alone is minimally different from the rest of the population. This makes sense as there is probably a lot of evidence that especially polysubstance abuse but also alcoholism and any drug addiction that becomes severe and episodic can result in violent behavior. Which is not to say that every alcoholic or person suffering from drug addiction is dangerous, however, I am sure there are some statistics out there supporting a higher evidence of violence occuring among this population…

“During follow-up, 314 individuals with bipolar disorder (8.4%) committed violent crime compared with 1312 general population controls (3.5%) (adjusted odds ratio, 2.3; 95% confidence interval, 2.0-2.6). The risk was mostly confined to patients with substance abuse comorbidity (adjusted odds ratio, 6.4; 95% confidence interval, 5.1-8.1). The risk increase was minimal in patients without substance abuse comorbidity (adjusted odds ratio, 1.3; 95% confidence interval, 1.0-1.5), which was further attenuated when unaffected full siblings of individuals with bipolar disorder were used as controls (1.1; 0.7-1.6). We found no differences in rates of violent crime by clinical subgroups (manic vs depressive or psychotic vs nonpsychotic). The systematic review identified 8 previous studies (n = 6383), with high heterogeneity between studies. Odds ratio for violence risk ranged from 2 to 9.

CONCLUSION:

Although current guidelines for the management of individuals with bipolar disorder do not recommend routine risk assessment for violence, this assertion may need review in patients with comorbid substance abuse.”

So, to get back to the movie, they did not show the protagonist drinking or doing drugs at all in the movie as far as I remember. Even at the football game, I don’t think he was drunk, but I could be remembering wrong. It seemed like the only hints of drinking under stress were evidenced by the character Tiffany who did not suffer from bipolar disorder, and she was not portrayed as abusing alcohol. So I think this movie could mislead the public into associating manic and other forms of Bipolar Disorder with episodes of violence, when the evidence does not support it…

Here’s another article about the topic, talking about men vs. women but also focusing on the co-occurence of substance abuse and bipolar episodes. The memoir by Marya Hornbacher: Madness: A Bipolar LIfe, is a real roller coaster ride, and great portrayal of someone with a huge drinking problem and bipolar disorder and the self destruction and pain she undergoes after recovering from a very severe eating disorder.

Here are her words about her drinking:

I started drinking when I was ten. There’s a scene in the book where I talk about discovering the booze in the cupboard underneath the stove… It, too, functioned very briefly as a mood stabilizer… It elevated my mood, and just made me feel like I was flying. Instead of feeling like I was going up and down and up and down, there were no more crashes. For a few hours at a time, I wasn’t terrified, I wasn’t anxious — I was just high as a kite. Of course, like any other alcoholic, the reasons you do it at first become irrelevant, because then, you’re just drinking because you’re an alcoholic. When you try to stop drinking, as I did many, many times many years later, you realize it’s not about anything. It’s a function of a kind of desperation and addiction.

So, of course, this topic is extremely complicated, but it is interesting how adding addiction to any other issues magnifies the risks of impulsive behavior, self-harming and suicidal behavior, and sometimes violent behavior towards others… But it makes sense that I have worked with and known of so many cases of people suffering from various forms of Bipolar Disorder who never had any episodes of any violent behavior towards others…

Silver Linings Playbook; From A- to B-/C+ in Less than a Week!

ok. I had a terrible day today, so it feels like the perfect time to have fun writing this post because I saw Silver Linings Playbook for the second time the other day and I was blown away — by how much worse it was on a second viewing! I almost felt scammed or literally “played” that I had such a “manic” experience loving it after a first viewing.

Basically for me, the big test of a movie is, does it stand up to being seen a second and then a third and then maybe even a fourth or fifth time? Doesn’t matter how soon you see it again. As I said in my last post, that is why I love films like “Bringing Up Baby” and more modern ones like “Spotless Mind”; every time I see them, I find something else to love about them and get great enjoyment out of seeing scenes I could practically play over in my head between viewings, such as the dog and dinosaur bone garden digging scene in “Bringing Up Baby.” In fact when I realized how much lower Silver Linings sank on the second viewing I remembered that I talked a lot about Bringing Up Baby in my glowing post; and I realized it was because the elements I liked about Silver Linings reminded me of that classic and maybe reminded me too much of how great that movie was! A really good movie like the “Spotless Mind” one doesn’t remind you so quickly of other movies because there are really great cool things in it to enjoy that seem totally unique to the movie even if it is a familiar “genre”.

So what took the silver linings out of “Silver Linings”? Just about everything except the characters of Tiffany and the father played by DeNiro. The fact that on second viewing the main character Pat did not seem like a real person and those other “supporting” characters were more interesting did not help it. Other complaints that can be quickly listed off: too many montages (I challenge you to watch it again and count how many long montages there are and how much time they take up in between real scenes)– unless you’re watching a cool music video, you do not want to be aware of having a montage much less five or more of them in a movie. OK. I guess my other criticisms do not fit into a short list. Let’s take the most important one, the portrayal of bipolar disorder:
On a second viewing I was shocked I did not notice this important thing the first time: Pat’s big episode was “triggered” by a violent situation which is terrible for many reasons. One, I have worked with many people with serious bipolar disorder and others with family members and close friends with bipolar and never in all the years of hearing all the stories of these people has any of them been described as involving violence, much less two episodes with violence in them (the scene where he almost kills the history teacher and the scene in which he hits his mom and his dad gets violent). This gives the general public a very strange idea about mania and bipolar psychosis and from viewing the film if you did not know about it, you would associate violence with manic episodes. In addition, as I confirmed by talking to a married straight guy about the film, most men in Pat’s situation might have done the same thing upon coming home to their wedding song playing and their wife in the shower having sex with the history teacher, without having any mental illness issue whatsoever, so it confuses the issue to have this event be the major event that results in Pat’s hospitalization. Plus if you watch the movie carefully, you hear that the lawyer obviously used mental illness to get him into the hospital for 8 months instead of put in jail, which puts the reality of him having it in question as it is referred to as “undiagnosed bipolar”. The icing on the cake is the scene where he ends up getting violent with his mom and then realizing he needs to take his medication. None of this fits any of the accounts I have heard of others’ manic episodes. The most common thread is the transition from mania to psychosis involving religious delusions and all kinds of intense meaningful LSD like spiritual experiences as well as grandiose delusions (ie. “I was convinced I had to fly to LA to the big premier of my brilliant movie, or, “I really thought I was god” “I thought I had found the cure to cancer and was about to receive the Nobel Peace Prize,” etc.) Sometimes if a relationship has just ended or some kind of intense love feelings are involved but not receprocated in reality the person while manic is convinced someone or several people are in love with him or her who in reality are not.

Anyway, that is a big problem with the movie on second viewing that makes me change my opinion of the TV show “Homeland”. I was a bit hard on it in my last review of this movie. I still think the ECT was strange and not well explained and that I would like to see the character have a session with a psychiatrist or therapist and also know what meds she takes, however at least her episodes are more realistically portrayed. We see that she is not in reality but we see how subtle it is that her reality is becoming out of wack, which is really well done on that show in that her job is already an inherently stressful and crazy paranoid making job and her obsession with the other character makes sense.

So “Silver LInings” still gets my approval for an ok portrayal of therapy and for the character taking the right medications. Probably the best scene in the movie that reflects the stigma of all kinds of mental illness is when he points out to his family and the others in the scene that maybe he and the other two “crazy” characters in the movie see things and understand things in a way that the others do not; I think that is true. If there is a silver lining to having a serious mental illness, it is that you experience life in a way that others do not and have a unique sensitivity towards others. The way seeing impaired people report that they their sense of hearing is very good…

So, lesson learned: watch out for getting too seduced by a movie that already has a lot of hype. Watch it at least two times before writing a big “I love it” blog post!!! We therapists sometimes get it wrong, that is for sure!

Mental Health Awareness Month Post Number 2!

Ok. I’m interrupting my attempt to get deeper into the issues around money and therapy because I have until the end of May to do my part in raising awareness around mental illnesses and the paths to mental health and stability…

I think this is too great an opportunity to pass up. On my personal Facebook I pledged to post at least once a day a fact or question to do with this subject. Then I decided to do the same on my LinkedIn “share” with connections. I am in too many professional LinkedIn groups to post on all of them! Then I decided to post about it on my public Facebook Artist Page. In fact after I’m done with this post I will announce it on my Artist Page.

I confess as a therapist and human who works closely with people on their very personal paths towards health and real soul fulfillment, feeling myself to be, or at least aspire to be, a sort of modern times Shaman or Doctor of the Psyche, I am really excited about this discovery that May has been Mental Health Awareness Month for over 50 years! How dare they not tell us in grad school or at our jobs and internships! How many therapists know about it??? Check with your therapist and/or psychiatrist to see if s/he knows about it! Spread the word! Thank goodness for the Internet and social media, as they help us raise awareness of such an important topic. There is just too much stigma out there about mental illnesses and so much ignorance. Why do health insurance companies still limit outpatient mental health treatment to 20 or 32 visits a year!?? How dare they set a limit on something so important in such an arbitrary manner! I’ve never had a patient with a mental illness who was invested in his or her therapy, who thought 20 visits or 32 sessions was enough per year. That has to change. What would people with one kidney do if they limited their dialysis visits per year? Unthinkable…

To get back to the point, though I don’t think I’ve strayed that far, in this post I will do what I’m doing daily on Facebook and LinkedIn: I’m going to make a list of ten questions or lesser known facts about various mental health issues. By mental health I include addiction, eating and personality “disorder” issues as well as trauma of various kinds and healthy positive behaviors related to this topic…

1. The relatively new phenomenon of personal blogs about how a person is living day to day with his or her symptoms and feelings about having some type of mental health issue is a wonderful way that people can see up close the courage and strength it takes for people to face their life day in and day out, struggling with staying healthy. It’s also a great testament to how far we’ve come with medications that work for people and with diagnostic criteria that help people come to terms with and manage their daily self care. Of course there is a lot more to improve with medication and treatment, but these very raw personal and honest blogs out there are a great way for people to feel less alone with their particular struggles. For some, the blogosphere is the only community they have and place they feel safe discussing such personal issues and struggles. So I start with a very positive aspect of mental health awareness by saluting all you people out there blogging about your struggles and triumphs. I follow many great blogs of this type and hope to find many more…

2. Schizoaffective Disorder: how many of you have heard of it? I first learned about it at an internship at a Continuing Day Treatment program long ago, so I have worked with individuals given this diagnosis. The term was first coined in 1933, but I have a feeling most people haven’t heard of it unless they have it, know someone with it, or work in the mental health field. You can find very particular detailed explanations of it on the Internet. I would describe it as bipolar and mood disorders meets and marries schizophrenia types of symptoms. What a challenge to be dealt this card! You have some sort of mood instability, whether primarily depressive, manic or both, as well as possible psychotic episodes, paranoia, hallucinations and delusions. For a really up close and personal account of it, read the memoir “The Quiet Room” by Lori Shiller. There’s still a lot of controversy about this diagnosis, and it comes up in this very moving book. In my experience, I think this diagnosis can be helpful to people suffering from such a confusion of symptoms because usually Bipolar Disorder and Schizophrenia thankfully now are seen and recognized and treated as very different because they are completely distinct. In the past people with either of these illnesses were lumped together , but we know a lot better now. However, there are some people who suffer from symptoms described by this “cross sectional” type of disorder. In my experience it really does exist, and the diagnosis is helpful, as people can be treated with both a mood stabilizer or anti depressant and an antipsychotic type of medication that people dealing with schizophrenia take, and they can have potential relief of their mix of symptoms and also begin to experience themselves as functioning at a much higher “level” in their lives which can be greatly improved and a lot less painful and confusing…

3. So, on the topic of mood stabilizers and “anti psychotic” medication, otherwise referred to as “psychotropic” medications: In contrast to what I said above, it can be confusing for people suffering from Bipolar Disorders, Schizoaffective Disorder, or other schizophrenia related disorders on terms of the wide variety of medications currently used to treat such illnesses. On the one hand, modern medicine has put to rest the confusion of what used to be called “manic depression” and “schizophrenia.” We all know now how different these are, but some of the medications treat both types. The difference is in the dosage. Old fashioned medications like Haldol, as well as the newer “anti psychotics”, such as Geodon, Risperidol, Seroquel, Zyprexa and many others, are prescribed for any form of psychotic episode, as well as being maintenance medication for schizophrenia and related “schizo” type disorders. To make matters more confusing, people with Bipolar Disorders, for whom a typical mood stabilizer like Lithium or Depakote, just to name 2 main ones, does not help enough to stabilize moods, can now take such medications as Zyprexa or Seroquel as mood stabilizers, usually on lower doses than for schizophrenia type symptoms. Some people with a kind of Bipolar Disorder take a typical mood stabilizer, as well as one of these other meds, and as well as an anti-depressant and other medications such as those for anxiety, which are in a totally different classification. So we’ve come all this way in distinguishing Bipolar type symptoms from those of schizophrenia related illnesses, and yet the same medications may be used to treat both. A little confusing. However, it is great that these other medications were discovered to have mood stabilizing properties, as some people need to take them instead if or alongside their regular mood stabilizers. Seroquel is also considered to have anti depressant properties, so probably some of the others like it also do.

4. While in my experience with working with people who suffer from very serious mental illness, mood stabilizers and medications like them can really be miracle workers for those suffering from Bipolar type issues in that, once the right medication or combination is found, people who take their medications daily can experience a great relief of symptoms and a sudden experience of real stability, those suffering from “unipolar” depressive illnesses such as dysthymia and major depression, tend to have more struggles with their medications. There are the lucky people who find the right anti- depressant and get relief; unfortunately of those people there is the group who after 6 months to a year find the medication no longer works, and they are plunged into a depressive episode and have to try some other anti-depressant(s) to see if a different one will work. For others, none of the different types of anti depressants out there seem to work. Some women in the latter group find a doctor who decides to try the more innovative treatment of using hormone medications to treat their depression. I read an interesting article about this a few years ago which really amazed me, as many people I know who suffer from mood disorders tend to complain that they can’t take birth control pills because it sets off depression. Others take hormones for birth control alongside their other meds without any trouble. Thankfully now there is a small group of women who take only hormonal medications to relieve their depressive symptoms! What a great medical breakthrough!

Ok. I have not yet reached number five and this post turned out to be much longer than I expected. So, the above is my food for thought on this topic thus far. I pledge to reach number 10 before Mental Health Awareness Month is up!!!

People Who Live with Mental Illness

I have talked about several memoirs of mental illness that I’ve found to be absorbing and brave. I just in fact read two by Marya Hornbacher, in reverse order of when they were written: “Madness” about her struggles with severe bipolar disorder and alcoholism, and “Wasted”, her first book about her serious long bouts of “bulimarexia” before she found out about the bipolar illness.
Anyway, I think one of the most challenging topics around mental illness, (besides acceptance that you “have” the diagnosis, which in itself is big and can take many years of illness for someone to finally accept it as a biological illness that needs to be treated with medication), is the day in day out living with your mental illness.
Many People are remarkably resilient and can return to their everyday lives quickly after a bout with psychosis, or an episode if some sort or relapse.

However the constant battle to stay stable and healthy, to keep up all the self-care required to keep illness at bay, that requires a dedication and perseverance of a rare sort. As these memoirs show, it isn’t enough to just be taking your medications as prescribed, although that is a big step forward, but usually, there needs to be some sort of consistent therapy and/or peer support group or group therapy. Along with that, people taking meds need to be aware of mixing them with alcohol and other substances. Part of regular self care involves regular exercise of some kind, engaging in soothing and relaxing activities, and eating healthily. Soothing self talk is key, especially for people hearing mean voices and those who have a running judgmental commentary going on in their brains. Many mindfulness meditation techniques are very useful.
For some, even after severe psychosis and several hospitalizations, life returns to “normal” and taking ones meds becomes like brushing your teeth. These people tend to take good care of themselves and push the mental illness to the side as they go about their day.

For others, it is quite the opposite. For example, for many people with eating disorders “under control”, there is a daily battle with the mind obsessing about body and/or food intake, and it can be frustrating to have mastery over the self destructive behaviors but not over the “sick” thoughts. For these people each day is a battle with their demons.
The same is true for many with bipolar disorder and schizoaffective disorder. Taking morning meds begins the day with the reminder “you have to watch yourself. Be vigilant. This could happen again…”
For these people just having or struggling daily with a mental illness can be exhausting. Self care plans can seem daunting and overwhelming. There is a certain kind of “burn out”, for lack of a better word, that occurs. This person is doing everything s/He is supposed to do. But, “I’m sick of dealing with this. I want it to go away. It’s too painful to try to be stable…” These kinds of thoughts can lead to suicidal ideation. In this case the fantasy of suicide is not directed outwards at wanting to hurt someone else by means of the ultimate form of self destruction, but is really a response to ones situation and being too drained and exhausted by the constant battle of ones own mind. For these people , every day starts with the profound ultimate choice:”Do I still want to live or am I ready to die and thus admit defeat over my illness.” S/hemust recommit to life every morning and choose the hard road of continued extra work, pain and exhaustion. Unfortunayely, once in a while the answer is clearly “no”, and then a well thought out suicide is planned. This is usually not the type of suicide “attempt” cry for help. In this case the person has already shouted and received help and support, but the illness wins over as it is simply too much to bear.

Medication and Therapy

In my last post, I touched on the topic of medications and mental illness. This post will attempt to address some of the issues connected with this vast topic…

Psychotropic medications have always been a controversial topic in many different societies. I have had much experience working with people on all kinds of medications, as well as working with people in the midst of going off their medications, starting to take medications for the first time, and many who tried out medications and then stopped them without finding a medication that was helpful. In addition, I have encountered people suffering from various emotional and mental difficulties and disorders who were vehemently opposed to taking any form of medications but were willing to try alternative forms of healing instead of medications.

I try as a therapist and person to be open to all points of view about this topic. What one chooses to put in one’s body is a very often private and vulnerable personal topic. While psychiatrists that I have talked to about this admit that we know very little about what makes a medication work and why and how, we also know a lot more now than ever before, and there are a lot more choices of meds than ever before…

As I mentioned in my last post, I have found that people struggling with and suffering from such issues/disorders as schizophrenia, schizoaffective disorder and bipolar disorder (both 1 and 2 as they appear in the DSM), really benefit from regular medication for an extended length of time. Often the reason for a re hospitalization or “relapse” with one of these serious disorders is caused directly by the person stopping taking their medications, usually because the person feels a lot better and thus thinks, “Oh, now I can stop taking these medications,” which makes some sense, as very often when our suffering is relieved by medication, it makes sense to stop taking it. But these disorders are more like diabetes. You don’t stop taking your insulin because you feel better. When I worked at a Continuing Day Treatment Center for adults and also at a residence for emotionally disturbed children, I saw how the medications really helped people with these serious types of disorders. Almost all the adults at the CDT were taking some kind of psychotropic medication, and a lot of but not all of the children I worked with at the residence were also on medication. The topic of medication and diagnosis and children is a complicated topic better addressed in a separate post. Suffice it to say that I saw children also helped by medications, especially those with ADHD and other behavioral disorders.

While Bipolar Disorder is a serious and sometimes even deadly illness, it is amazing how much medication taken regularly can really transform someone and their ability to function, such that people who continue to take their medications on a regular basis can function and thrive. Sometimes one or sometimes a combination of medications, and there are now many different mood stabilizers whereas a while ago it was mostly lithium, anyway these meds can really help balance the fluctuation of moods from manic to depressive. Most people have to learn the hard way that they need to accept their biology and that they suffer from Bipolar Disorder, by going off their medications, having a relapse or even two or three, and then accepting it and staying on the medications that work for them. Luckily there are now a variety of mood stabilizers, and these medications don’t all take away a person’s creativity and liveliness; they just help an individual to manage their mood disorder.

Schizophrenia and schizoaffective disorder are much more debilitating than bipolar disorder. However, I witnessed many of my patients healing with a combination of therapy, day treatment which provides structure and socialization, and medication. This combination of approaches really help people with severe symptoms, such that the voices they are plagued by can disappear, or at least subside to the extent that the individual can function on some level and receive some relief. It is very unusual for an individual suffering from these illnesses to be able to not take any medications. There are many good medications out there that work; unfortunately many of these  st cause weight gain, and I saw my patients suffer with the side effects of weight gain as well as worse side effects. Some people manage to be careful with their diet and are able to take these very potent medications without experiencing weight gain. However, I saw many of my patients at the program who were on Medicaid and had poor dietary habits; still for many to be able to socialize with others, even to be able to leave their house or residence and attend the program was a big step towards healing. The medications were only one part of this; therapy, groups, meeting others with similar issues, having a structure to their day — all of this was necessary for some or partial recovery.

Depression, including both major depressive disorders and other less serious depressions, is much trickier in terms of medication management. I have certainly seen people with bipolar disorder take medication for depression along with a mood stabilizer and be helped by the extra medication. I have also seen people get out of a terrible depressive period with the help of anti-depressants. Some of these people were helped by taking some  kind of anti-depressant for several months to a year and then were able to stop their medications and use other means for their daily self care to avoid slipping back into a depression. I have also seen people with depression who continue to take their medication even when they are not depressed, and these people find it helps them to combat the return of depression. Any person taking anti-depressants temporarily or permanently is greatly helped by having  some form of therapy, as well as a support group or yoga or regular exercise or any other number of  “non medications” that help with healing. In fact, sometimes the medication helps the person to be able to be motivated to do these other things that they were too depressed to do for themselves before taking medications.

On the other hand, I have seen some people struggle with taking anti-depressants, even to the point that they are willing to try a few different ones, looking for one that works, only to be defeated. These people sometimes can find no medication that works for them ,and they often make a valiant effort to find one. However, the good news is that there are other ways to shift depressive brain chemistry. Art therapy is especially effective in that the act of making art and being creative in the moment does have a positive effect on the brain. With the support of the art therapist or the group therapy, a person with depression can begin to shift his/her mood towards feeling better. Regular exercise has been proven to help with depression as does yoga. With good support from friends, family, a therapist, a support group or therapy group, some people are able to combat their depression without the help of any psychotropic medication.

Of the people who refuse to try any of this kind of medication for their depression, many do self medicate and even are aware they are doing so. Some use drugs or alcohol, which of course actually physiologically contribute to depression, but the slight lift or high at the beginning of injesting substances can outweigh the crash for many people caught in a cycle of addiction or dependence. Even limiting food intake to an extreme is known to produce a high, so restricting food intake can be another form of self medicating. The challenge for this group of people is to become aware that they are self medicating in an unhealthy way and after that to change these behaviors.

There are people who do not self medicate with unhealthy behaviors who believe alternative medecine is the way to go. These people really work hard to combat their depression with positive self caring behaviors such as regular yoga, massage, reiki, some kind of creative endeavor or creative arts therapy, as well as writing and using some of the cognitive behavioral therapy techniches as well as creative visualization, acupuncture, and even being careful with their diet, as it is true that certain foods contribute to depression.  Often it can become a vicious cycle where depression leads to eating unhealthy foods or bingeing on unhealthy foods, then becoming more depressed and continuing to take bad care of oneself. So changing one’s diet can really help with depression.

Psychological Memoirs Continued

Many of these memoirs have been made into movies. Most notable there are “Girl, Interrupted”, “Prozac Nation”, and “A Beautiful Mind”.

“Girl, Interrupted,” which came out in 1999, was based on writer Susanna Kaysen’s account of her 18-month stay at a mental hospital in the 1960s. I think I saw the movie before reading the book, which is unusual for me. I actually liked the film version and thought that it stayed pretty faithful to the memoir. In the story, Susanna was given the diagnosis of Borderline Personality Disorder, but it isn’t very clear that that was the correct diagnosis. The other characters in the memoir give a nice overview of a variety of issues that these girls got hospitalized for, especially the girl with the eating disorder who ultimately commits suicide when she gets out of the hospital obviously too early. Of course there is the great character played by Angelina Jolie who even won an Oscar for her performance. It is also a good period piece that portrays how different hospitals and society’s treatment of mental illness was in the 60’s as opposed to now.

“Prozac Nation: Young and Depressed in America: A Memoir”, written by Elizabeth Wurtzel about her struggles with depression while she was at Harvard was published in 1994. I do not remember if I have read the book or not, but the movie was ultimately disappointing despite some good acting on the part of Christina Ricci. The movie was released in 2001 and did not receive much critical acclaim, much less any Oscar nominations. I personally much prefer the psychologist and author Lauren Slater’s accounts of her own bouts with depression, which were covered in “Welcome to My Country” and “Prozac Diary” which came out 1998. Slater has always been a controversial figure in the community of psychology and psychiatry. The story of the controversy is well covered in the Wikipedia article about her many books and their reception. The fact that she stopped working as a therapist for the most part in order to focus full-time on her writing helps me deal with her unorthodox methods of discussing her own mental illness and her work with her patients. I get the sense that she is a much better writer than clinician. This is partly due to her strange boundaries. I remember reading an article of hers in Vogue magazine called “Divided Lives” which turns out to have come out in the January 1995 issue. If I remember correctly this is the article of her deciding to try an experiment and become friends with one of her patients who terminated the psychotherapy with her. As far as I remember, this experiment was a disaster, as one would have predicted. Anyhow, her depictions of her bouts with mental illness, including writings on her difficulties with pregnancy and medication issues are very interesting and well written. I think her metaphorical memoir of lying that I mentioned in my last post would actually make a great film. Christina Ricci might do well portraying Slater!

So “A Beautiful Mind”, which came out in 2001, technically does not go with these other films, as the book it is loosely based on is a biography (1998), not a memoir. However the movie’s portrayal of a man’s descent into schizophrenia seems to put it in the category of these other films as a biopic and portrayal of mental illness based on a real story. Many were disappointed in this film’s avoidance of John Forbes Nash’s homosexuality, and I would agree that it was a shame that the film steered clear of this part of his life. However, the film was very moving, and the acting by Russell Crowe was really stunningly great, from my point of view. While the film did not follow Nash’s real life closely enough, as a story of a young man’s descent into madness and semi recovery from schizophrenia, the film was excellent. The portrayal of the loss he felt when he on his own decided to reject his own hallucinations of, most notably, a young friend from college and a little girl, which seemed to be parts of himself that he could not internalize and integrate, this portrayal of the loss he felt while at the same time deciding to “ignore” them for his own health and sanity was a great commentary on an interesting issue about all kinds of psychosis. The truth is, people often do become attached to aspects of their psychosis, and then it can be a wrenching life or death decision to choose sanity and lose one’s very close companions, who have seemed very real to the person. There is a loneliness that follows, and even sometimes, people report feeling empty and flat without their invisible unreal companions, while at the same time they recognize that they have returned to sanity from a very dangerous inner world. This is a complicated and difficult crossroad which was very well and quite movingly portrayed towards the end of the film. In fact I found it to be the most important moment in the film. I found it a little hard to believe that genius Nash stopped taking any form of medication and used mind over crazy mind, so to speak, in order to remain sane. This seems highly unusual. I have worked with many people suffering from schizophrenia and schizoaffective illness as well as bipolar disorder, and these very biological illnesses almost without exception require quite a bit of medication to keep a person stable.it would be as though a person with diabetes decides to use her mind to control it instead of insulin…

In my last post on memoirs of mental illness, I failed to mention Styron’s brilliant memoir, “Darkness Visible”, a story of alcoholism and suicidal depression that interestingly comes late in the author’s life while he is in his 60’s, quite a contrast to the majority of these types of accounts which begin with the author having some kind of episode in their late teens or early twenties. Styron is a great writer of fiction, and this very personal non-fictional account of his struggles is really a great book for anyone to read and get a good glimpse into the world of depression.

“My Depression: A Picture Book”, written and illustrated by poet, children’s story writer and playwright Elizabeth Swados is also brilliant, as well as being quite funny, despite the serious topic and the writer’s very serious family history; both her mother and brother suffered from schizophrenia and both of them committed suicide. So this is a brave story of survival and a courageous battle with terrible depression. The illustrations are whimsical and delightful. She does decide to take medication and her treatment of this topic is great. I have worked with many adults suffering from depression, some of whom have taken medication for it as well as many who stopped their Ned’s or never decided to take them. This is a very controversial topic- medication for depression, as opposed to medication for the other mental illnesses mentioned above. Good topic for next week’s post…