Trump Trauma or Trump Overdose?New DSM 5 Disorder

This comes from my own personal experience. Others with this illness, you are not alone! (Stay tuned for post on more severe illness, Trump Psychosis)
New DSM 5 Disorder for OCD or Trauma Chapter, possibly a specific form of PTSD:
Name: Trump Trauma or Trump Overdose, specify whether co occurring with Trump Psychosis
Age: 5 years to 99 years
Symptoms: One or more of the following, occurring at least 3 times/week:
(specify severity: mild, moderate, severe)
1. Trump in any form triggers somatic responses such as nausea, vomiting, digestive issues  
2. Trump in any form triggers responses such as revulsion in form of anxiety, panic, depersonalization, hopelessness and/or depressive outlook.
3.Inability to control obsessive thinking about not wanting to think about Trump and/or experiencing intrusive thoughts/images about Trump.
4. Nightmares about Trump and/or feeling of being in a nightmare while awake. Knowing that you’re not delusional about waking nightmare:
5. Compulsion: Feeling not in control of contact with social media about Trump and spending 20 minutes or more of your day in a Trump Trance writing posts or commenting or reading about Trump while being aware of not wanting to do so. 
6. Paranoia: after other symptoms get triggered, believing there’s something wrong with you or that you’re crazy to have such symptoms/reactions.
7. Frequent Violent fantasies you can’t control about physically assaulting, disfiguring and/or killing Trump or Trump dying sometimes accompanied by brief feeling of euphoria that often triggers subsequent descent into depression.
8.Frequent Violent fantasies regarding sources of info about Trump (usually in form of physically assaulting/destroying TV, Computer or Smartphone, specify whether danger to others)
9. Frequent fantasies about living on another planet, belief and/or realization that you are from another planet if this knowledge further triggers other symptoms. (see treatment)
Treatment/Cure:

1. Cure: Trump somehow disappears. Symptoms should be gone in a few days.

2. Trump gets out of the race. Symptoms will immediately subside, may linger a few weeks.

3. Person with this disorder finds any way to return to their planet and reduce greatly contact with planet earth. Taking a substantial amount of aliens chosen carefully is also a great option. Not a complete cure due to memories of Trump situation and concern for planet Earth.

Treatment for chronic condition:

  1. recognizing you have this disorder and you’re not crazy helps reduce paranoid symptoms while also triggering symptoms if you get reality check through search engine or social media

2. Talking about moving to other countries and picking what country/looking at homes there can help reduce symptoms. Focusing on that country or any other as a safe space may also reduce symptoms.Cure: Trump magically disappears or .gets out of the race.

3. Avoidance of exposure to Trump will reduce symptoms. Tracking time in day that you are symptom free gives hope for recovery. (Trump Disorder tracking App coming soon.)

Medication: Klonopin and similar anti-anxiety medication may help reduce symptoms and other medications of this type may make you so drowsy you forget about him for a while. Any medication proven to reduce nightmare frequency.

Course of illness: whether treated or untreated, will worsen with time. Possible extreme severity can cause another disorder: Trump Psychosis.

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Depression Comix

I saw this when it came out but only just figured out how to reblog these great comic! I was talking about this to a patient. She was scared her therapists (she has me and a psychiatrist) were going to abandon her if she started feels no much better. We talked about the value of therapy when you’re not in crisis and how the goal is healing and growth which can be celebrated and witnessed in therapy. This is a common idea that therapy is just for when you’re no t feeling well…

Depression Comix

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Read at depression comix at http://wp.me/s3zYhM-266

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guest comic by randomdaze

Great blog that captures a lot about mental illness and stigma…

Depression Comix

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A wonderful guest comic by Randomdaze! The characters in the strip are the artist (Maddie; left) and friend (Anna; right). Please visit her page for more awesome work. Thank you very much!

Read at depression comix at http://wp.me/p3zYhM-1yc

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New Book on Depression; Check out this link!

New Book on Depression; Check out this link!

I subscribe to “Brain Pickings Weekly”. Last week they had a great post about this book called: “The Unaddressed Business of Filling Our Souls: Mood Science and the Evolutionary Origins of Depression”
by Maria Popova

She discusses the book by Jonathan Rottenberg “The Depths: The Evolutionary Origins of the Depression Epidemic” and provides really great images of drawings about depression.

Please check out this link for more info!

Philip Seymour Hoffman’s Death and Legos

On Feb.2, 2014, (James Joyce’s Birthday), Philip Seymour Hoffman died of an overdose. On that same day in the United States, about 99 other people also died of drug overdose.

This week in my practice, I had quite a few intense sessions with people, the kind of sessions that feel like they are of an existential matter, or an existential crisis. Talking people from the ledge, not necessarily people about to end their life immediately or go overdose, but people questioning their own life and its possible meaninglessness, feeling a lot of self loathing and worthlessness, or destroying their creative spirit with judgments, comparisons and criticisms. In about 9 sessions yesterday, I think Philip Hoffman’s death came up somehow in about 8 out of them and the morning before also in another session. What does his death represent besides a reminder of the deadliness of drug addiction and polysubstance and heroin abuse? It’s about recovery and finding yourself at a crossroads in your life, your shadow is beckoning you to eternal emotional pain and despair and a small shred of hope, a light in the distance, is still also there calling you away from the darkness. It’s about the work in most therapy, the goal being for the person to come to like him or herself more and hate him or herself less…

Some of these sessions went to a very blunt place where I pointed out, we all have what I see as 3 choices when faced with existential angst and self destructive thoughts about life being meaningless or ourselves being failures, worthless, whatever we make is not good, and being told positive things about ourselves makes us feel worse instead of better. So your choice is to end it now and be done with the endless suffering — what the BUddhists refer to as suffering due to addiction, attachment and delusion. The other is to kill yourself off symbolically and destroy your creative spirit and continue living the life of a deadened person; this choice involves giving up on yourself but continuing to appear to be alive but to be dead inside. Many have made this choice, a kind of circle of hell on earth, an acceptance of depression as part of everyday life. The other choice is the hardest for people who have been to the darkest part of their psyche and lived through it: the choice to awaken and emerge from the traps of addiction, delusion and attachment. All humans are at times addicted, deluded or attached. People wake up everyday and live through the day in such a state of mind. Addiction is not just to substances or gambling, sex, love, shopping, food or work, money, success, approval, anger, etc.

Delusion is not limited to humans wandering around in psychotic states. We are in delusion quite often in everyday life, when we do not observe what is really going on and enter a kind of state of ignorance.
“In the Mahayana tradition, two levels of ignorance (avidya) are identified. Dzigar Kongtrul explains:
There are two levels of ignorance: ignorance of the absolute, or the essential nature of phenomena, and the ignorance that prevents us from taking an accurate reading of the relative world. These two kinds of ignorance are like two kinds of thread: When they are tightly woven together, they are not easy to identify, yet they make up the fabric of delusion.
As a result of the first type of ignorance, we lack wisdom. Lacking an understanding of our true nature, we perceive that which is illusory and spacious to be solid and real. The second type of ignorance is the inability to clearly understand the laws of karma and interdependence, which then results in an inaccurate relationship to the world.” From Wikipedia

Carl Jung referred to this type of ignorance in terms of “attitudes”. When a person does not see clearly what is real, they take on an attitude or attach a kind of power to something that then renders it not real and the person continues to see it that way. We see this all the time with various kinds of simple realities. Your “boss” at work becomes more than a “boss”. A boss is someone who has the role of directing people who work for him or her and defining the tasks and roles of the people who work for him or her, but for many they attach more power to their boss and their boss becomes too powerful or their parent instead of simply their boss. We do this with all kinds of things. As an artist I have done this with a gallery or exhibition. My work gets rejected and for a while I live in a delusional state of mind in which this particular gallery and the “juror” who picked the work to go in the show and the work that was not admitted to the show become more than what they really are. I give them some kind of power to decide that I am a “bad artist”, “not good enough”, a “failure”. The gallery is one of probably millions and it is simply a place that payed someone to look through images of work submitted by artists and decide which to put in a particular show that would take place for about 30 days. When I let go of my delusions and attachments to this delusional idea of the gallery and juror of the show, I see the reality, and go back to doing what an artist does whether s/he gets in a show or not, creates art on a daily basis.

In reality, the gallery’s juror did not want any of ten images I emailed them to be in some show of theirs. I know these are ten of countless pieces I will continue to make. When I am not attached to my work being seen or to this gallery’s show, or even to a particular art work being good or bad or craving attention for my work or addicted to approval from the outside, I can be a relatively happy being who engages in the creative process for the sake of the process and my happiness is derived from the engagement with the materials and the process not with any product or result of a product. Because I have survived many of these rejections, each time I am quicker to be able to return to reality. Reality is always much simpler than the delusional or attached or addicted version of reality. In reality a glass of wine or a new dress is a material thing to enjoy but it does not have more power than that. Having a book published or a painting in a show or an award for a movie is a part of reality but cannot define a person. Exhibit A: Philip Seymour Hoffman, human who, given 46 years on earth, achieved a level of success, reknown, acclaim and material riches, as well as a family, and promise of more opportunities to hone his craft, gain more reknown and more enjoyment from his creativity as well as further fame and money, perhaps the joy of watching his children grow, that few ever come close to, he, who with all of thi,s was not able to escape the suffering that addiction brings to all who succomb.

Bringing us back to the choices and the therapeutic session sometimes taking on the conversation of existential dilemmas nobody escapes. Challenge is: can you wake up tomorrow and show up for life whatever it brings and be awake, not living in the past or some fantasy of the future moment? If you can do that, you will escape your own attachments to some definition of who you are, who you are supposed to be, who you expect yourself to be, your addictions to anything that seems like it will fill an empty hole, your delusions about your own reality and the people and other beings you encounter throughout your day. It’s an invitation to let go of your beliefs, your assumptions, your cravings, your attachments to outcomes and goals. As Marsha Linehan wrote: “The fundamental nature of reality is change and process rather than content or structure.” I found this quote, wrote it in my journal and shared it with about 4 patients in the course of my day, as I need to constantly remind myself of this truth; armed with this one small bit of wisdom about reality, you may save yourself from the terrible fate of Philip Seymour Hoffman and the 99 other unknowns who died on Feb.2, 2014 in the USA of the same cause… as well as the countless people walking the earth, who have no awareness of their own suffering in the form of addiction, delusion or attachment…

The philosophy of playing legos, contributed by a five year old, to be explored in another post.

The Birthday Self-Portrait: My Birthday Post, 2/1/2014

A long time ago, I was looking through a book of some artist’s work that I admired, it might have been Adolf Gottlieb, but I’m not sure, I’ve tried to figure out for sure which artist this was, but I never succeeded. Anyway, I read that he whoever he was, had an annual habit of making a birthday self-portrait every year for his birthday. I thought this was a really great and fun idea. I started doing it, but now I can’t remember how many years ago it was. I’m pretty sure I did a “Shoe Portrait” self-portrait the year I was making my series of Shoe Portraits. I can’t remember what shoes I picked to paint but I remember making a weird doll and sticking it in the painting. I think I cut the canvas and somehow put the doll in. Must have been about ten years ago in 2004 maybe. Anyway, every year after that I’ve done a birthday self-portrait, usually inspired by whatever kind of art I happened to be making at the time. I know last year I did a doll with a small tiny “clock” in her, from a watch ring I had. I made the doll from scratch. I will find a photo to post of it. The year before, 2012, I’m not sure what I did. I have two of them in my house from recent years, but I’m kind of annoyed at myself that I didn’t pay attention to what I did and document it better, since it was a fun kind of annual ritual and a fun creative gift for myself on my birthday. Usually I start them about a week before. This year for the first time, I made something I didn’t like and then changed the project completely. I started with a collage with a lot of cut out and ripped images, beads, an old drawing and other stuff and put it up on my studio wall. The next day or two after, I decided I didn’t want to finish it and that I didn’t think it was a real self-portrait, so I decided it would make sense to make an altered book, as I have been making them all year and very obsessed with them, as anyone who reads this blog regularly knows. I ended up cutting up that first collage and putting some of it in the book.

So I chose a book I had already worked on, a little children’s book with each page split in to two halves, originally the book was for matching the top image with the bottom, so it was fun to play with the format. I had already done a lot in the book and decided it had enough in it to build on and that it already had the feeling of a self-portrait, so I started altering it more, ripping out stuff and adding in stuff over the last week. I put s a few photos of myself in it and ended up using one on the cover as today I decided the cover didn’t seem right, so I ripped off an image of a person with a mask and put a photo of myself on it with the other images. I continued working on it today, which sometimes happens, that I end up finishing the self-portrait on my birthday, but I usually get it done by the day before. Of course as this is an altered book, I still don’t feel satisfied that it is finished, but it definitely feels right as my self-portrait for 2014 and reflects some of the past year’s experiences, both losses and rebirths.
I will post a few photos of the project…

As a blog post on my art therapy blog, this is a more personal post than usual, but I will end the verbal part by saying I recommend it as an art therapy project for doing with an adolescent or adult patient for their birthday. You can invite them to bring in a recent or old photo or several and then ask them what kind of medium they want to use. Anything can constitute a birthday self-portrait. A box with the photos incorporated into it, an altered book of course, a drawing or painting or collage on paper or canvas. Other interpretations of the self-portrait for those who only think of a painting of their own face and might feel discouraged and not interested in that, there are so many ways to make a self-portrait and it doesn’t have to have a picture or drawing of your face in it at all. Make a doll or a birthday pillow. A clay bowl to put flower petals in. A box that you can add small notes about what you want for yourself for the coming year into. Knit a birthday scarf. Buy a journal/sketchbook and decorate the cover and start your journal on your birthday. Have your patient make him or herself a birthday card. I have done this often and made a card for my patient while s/he made a card for him/herself. Making a card for yourself whether for your own birthday or for any other day is always a good art therapy activity. I usually give my patient a list of affirmations to choose to copy on the inside of the card or that could inspire you to make your own affirmations and write them inside your card to yourself. Collages with tiny mirrors are a fun twist on the self-portrait. I have one in my altered book. I encourage my patients to get themselves a special birthday present, whether an object or something like a massage, so doing a self-portrait can be an added way to feel special about marking for yourself your own arrival on this planet. It is helpful especially for depressed patients and people who claim to not like their birthday. I don’t always feel super excited for my birthday lately, so I understand when people want to forget about it or make it a day they don’t do anything special, but in art therapy this can be an opportunity to take better care of yourself and reclaim your birthday as a special day, which it is after all. Doing something special for yourself to mark the day you arrived here and that you are still here, no matter how you are feeling, can be very healing and self affirming. It’s kind of like the concept of “The Artist’s Date” from the book, “The Artist’s Way”. As a young 4 year old child once told me, “You have to love yourself of course.” and “You are your own best friend.”

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Photos: from top
First Photo: page from book showing the split page format
Second Photo: page from book top matching bottom
Third Photo:Inside front cover. QUote says: “How many are silenced because in order to get to their art they would have to scream.” -Ann Clarke
Fourth Photo: Current cover of book with photo and plastic doll in model magic
Fifth Photo: older version of front cover
Sixth Photo: Inside page of back cover
Seventh Photo: Image of doll, last year’s self-portrait

End of Year Reflections on Life, Brushing Your Teeth and Sisyphus

When I was a child, I was very messy, and it seemed like I was not related to the rest of my family. I remember thinking, Why do the adults tell me to clean up my room? I will just mess it up again. And why do people make their beds every day? they just mess them up at night and have to make them up all over again. At least there is a reason to brush your teeth at regular intervals.

At that time I did not know the myth of Sisyphus, the poor man who is in hell pushing a large boulder up a mountain, only to reach the top and see it go fast down the mountain to the bottom, then to have to go back down and push it back up again, knowing it will just fall down the mountain.

I’ve remembered this myth a lot, especially as a therapist dealing with people suffering from all kinds of things from depression to eating disorders to addiction. This metaphor is so apt for such suffering; the sufferer has the knowledge that life does not seem like that, it actually is exactly like that.

Read the full story: http://www.mythweb.com/encyc/entries/sisyphus.html
we, I included, only seem to remember him as that sufferer doomed to this repetitive task in Hades, however, in life, he wielded the ultimate power of stopping people from dying for a time.

Anyway, for better or worse, most of us just remember this man, seemingly helpless and powerless over his fate, doomed to this repetitive, exhausting task. I’m not sure what changes in knowing the whole story, but still, life seems to be the same as this image. We labor and sweat over pushing a huge boulder up a mountain, only to see it speedily fall to the bottom, and then, without question, we hurry down the mountain, and push it up again. And not just once, but over and over, much like we make our bed over and over, eat and digest our food and get rid of it and then eat again. Most of daily tasks of living involve repeating such things, with full knowledge that we will be doing it again. Same with even things that give people a “high”, like yoga or exercise. You leave the gym, feeling good, but knowing you will have to go back on the treadmill again soon, or back to the yoga class to repeat it all over again. Basically any activity will involve this, some that are pleasant, and some not.

This image is the image of the human suffering, or doomed to repeat over and over. However, there is something to be said for looking at this story from a very different point of view, and reframing it completely, mainly with the basic tenets of mindfulness.

What if you are doing that, but you are supremely focused on what it feels like in the moment to touch this boulder, to push it and see it get larger and heavier as you push it? What if you are looking at the mountain and the ground and observing the weather, the feel of the boulder on your hands, how your hands look as you push the boulder. and what if you are indeed, pushing it up the mountain with the knowledge that it will fall back down and you will start it over again, but it does not seem fruitless and you do not feel you are in a prison of your own making, but actually liberated in the doing of it, because you have realized that you do not care what happens to the boulder, you do not care how heavy or light it is, and you do not notice that it is a repetition, or you do not care, as you are excited to see it fall down the mountain, like a snowball you built up that has melted, but does not prevent you from anticipating the next snow fall with the excitement of a little child?

Do we imprison ourselves in our own suffering? Is the key to liberation simply our own mind setting us free?

I see this with dishes. If you simply notice the feel of the water on your hands, the sight of the leftover food sliding off the dish and watching the drain, feeling the air on your skin, does it matter if you will do the dishes again tomorrow and forever? If we live for the moment with full belief in the moment, and do not look back to the past, thinking of what could have been or what we could have done, and do not project into the future what we must be or need to be or have to be happy, have we not freed ourselves of the worst kind of suffering and pain, the emotional kind?

This is what the artist does. I take a piece of paper and rip it up and glue it on another piece of paper, or take paint on a brush and stroke it over the paper, and then repeat the motion endlessly. There is no final painting or work, there is no complete boulder. I start again every day, if I am open to the process I do not really care what the “product” looks like. In fact, it is indeed ephemeral, even if I see it in my studio the next day. I am on to the next piece of paper, doomed to repeat myself in some new way. Why are the most repetitive things in life, both considered like torture or to be soothing ways to heal from trauma? Emotional pain and suffering and relief from suffering are both in this image of pushing the boulder up the hill. How you feel about yourself, the boulder, the mountain and the environment inside and outside yourself is what makes the difference between doom and complete freedom. Yes, we either live and keep being disappointed, or we can die, or choose to be dead while living, or we can laugh in the face of life and death. There is a choice, the choice itself may be the only thing we have that will not disappear or disappoint. In the moment of the here and now, we have that small choice, and that may be all. Even if it is meaningless, the matter of choosing is of extreme and absurd importance…

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…

Altered Book Workshop Proposal Accepted!

The good news is that my altered book workshop proposal for the 2013 Creative Arts Therapy Summit this fall was accepted! The whole event will be taking place in NYC in various locations, from November 7-13, 2013. Link to the site is:

http://www.cvent.com/events/expressive-therapies-summit-2012-registration-site/event-summary-a631d616cdd6499c92f749761a4d1d3a.aspx

The other part of my news is that instead of a 3 hour experiential workshop, I will be doing the workshop in 80 minutes, basically and hour and 20 minutes, which basically cuts out a little over half the time, so I tried to re focus the workshop.

Here is my description of it: (Let me know what you think; it’s a lot to pack into 80 minutes!!!)

Title: Altered Books with Adults in Art Therapy; Conquering Creative Blocks and Depression

Description:

In this workshop, we will discuss how the medium of altering books in art therapy uniquely treats adults with any kind of creative block and/or depression, connected with past or present trauma and feelings of creative deadness or loss of the creative “spirit.” Through the experiential, participants will choose a book and begin to alter it, thereby experiencing the uniqueness of this format that allows for the creative spirit to reawaken. The transformative experience of “destroying” a book to create something new can jump start the creative process through the variety of options, length of the project and the holding environment of therapy. I will also provide actual examples of Altered Books in process by some of the adults I am working with to demonstrate the scope of options in this particular medium and the essential role of the art therapist and therapeutic relationship in this long- term process.

3 Measurable Objectives:

  1. Participants will learn about ways that creative blocks and/or loss of creative spirit in adults is best treated through the creative process itself combined with the relationship with the art therapist.
  2. Through art making and viewing real examples of patient and therapist artwork, participants will learn about the different options provided by altering a children’s board book versus an “adult” hardcover book, and the messages the choice of book can convey to the patient and therapist.
  3. Through the experiential, participants will start the process of altering books and use at least 3 different media and techniques involved in the process of making an altered book.