Guidelines about Boundaries in THERAPY

This is my post for my Tuesday “words” post.

Finding a therapist that is a good fit is hugely helped by the internet. In addition, if you’re confused at any point about the therapy and your therapist’s boundaries, You can find a lot of top ten lists online about therapist’s boundary violations.

In fact, here is a great list of 30 things to watch out for in your relationship with your therapist. All are very good things to notice; a few things on the list are sometimes ok if you feel your therapist has your best interests in mind (ie. when therapy is free of charge, what are the terms of the contract?)

http://www.therapyabuse.org/p2-wrong-questionable-treatment.htm

Here is another good, slightly humorous view of top ten things you might not know about therapists:

http://www.bustle.com/articles/61462-10-things-therapists-wish-youd-understand-about-what-they-do

I thought I might have something to add to these very good tips and important boundaries to the only thing I think might be missing from these types of lists:

THE INTERNET and SMART PHONE DOS AND DONTS in THERAPY

The internet and other technology make every field completely confusing again and cause us to scratch our heads and reconsider the way we do what we do. From the law to the music business to anything, we need new GUIDELINES:

The Internet (social media, websites, etc.)

DO NOT GOOGLE or LOOK UP former patients:

One interesting mention of the internet in the second link was about how therapists do think about former patients more than you’d imagine but we still don’t/shouldn’t google them to see what is going on with them.

I know that is a good one, as I have been tempted, when thinking about a former patient, to look them up and see how they’re doing/what they’re doing. I have NOT done so with anyone, as I saw a big STOP sign in my head and it was a fleeting “fantasy”.

Social Media makes things extra fun and confusing:

USE SOCIAL MEDIA THERAPEUTICALLY ONLY:

It is great for people to find support and other people going through their experience, whatever media they are using, Youtube, Facebook Groups, Facebook, Pinterest, etc. I often recommend to patients who are interested and use social media, that they look for support groups and other things online, AS WELL AS out in the physical world.

I have watched a few Youtube videos made by patients and listened to Podcasts. The reason is important: The patient wanted me to and asked me to and it was always an important aspect of their therapy work, especially self-esteem and recovery topics. I have even used Youtube videos in session when appropriate.

In addition art therapy gives a patient alternate ways to express him/herself, including through social media. Think of it as similar to brining in some art you made between sessions that is relevant for therapy.

SOME DON’TS OF SOCIAL MEDIA. Some seem obvious:

DOn’t be Facebook “friends” with any patient and with former patients, with some exceptions about former patients. You cannot control patients accidentally seeing posts of yours and finding out you know someone in common. There are proper ways to handle this which would be a post in itself. Start with asking your patient about it  or if you found something, telling them as soon as possible and exploring this.

DON’T connect on  LINKED IN with patients and most former patients. If you’re in the same field, art therapy, you may not be able to avoid some LINKED IN stuff and can have a little more flexible boundaries about it. I never accept Invitations to Connect from current patients; I don’t usually bring it up unless my patient is on LINKED IN a lot or brings it up themselves.

TWITTER: Can I “follow” some patients on Twitter? My answer would be what’s the reason? I have avoided it except in cases where someone had something important related to treatment on Twitter. As a rule, I abstain.

FACEBOOK PAGES: I have public Facebook pages that I cannot avoid patients finding and considering “liking” my page. As they are related to therapy and art, I consider it ok for patients to do that only if they decide on their own for some reason. Also, I do not look a lot at who is “liking” my pages and don’t care much about how many followers or who. IF you’re very into that, be aware of any feelings about patients liking your posts or not…

In some cases you may have liked someone’s Facebook page and then found a patient involved with it. There are cases when you can’t avoid this, especially having patients who are/were art therapists and got a diploma from the same place. Your worlds will be very close and it’s a good boundary test to be aware of this. (IF I am attending an event or workshop etc. and a patient is likely to be there, I process this with the patient before hand.

BLOGS:

This is a huge question mark for me. Do any of my patient s or former patients follow or ever read my blog? I actually don’t know. When I post here, I am aware that a patient may come across my blog, so I do have that in mind. As a rule, if it does not come up, I of course do not bring it up, and if it does in the future, I would of course explore the topic with my patient. I have read a patient’s blog only if they give me the link and it is connected to their recovery and they want me to see it.

Therapist bloggers out there: Please share any further guidelines and experiences! You can put it in my comments section.

Blogging Classes: Most therapists out there don’t take these classes, but I do, and I even recommend some of them to patients. If I recommend a particular class, I do not enroll in it, even if I thought I wanted to before. If I found a patient in a class, I would address that and most likely leave the class or at least stay passive (no posts or comments on Blogging U site).

DOs and Donts of SKYPE/Video session: A big topic to address in future…

This is by no means an exhaustive list. Next post could be about the SMARTPHONE and boundaries. It’s a fascinating aspect of therapy and books or at least long chapters could be written about the uses and abuses of the SMARTPHONE technology…

 

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Tuesday Post: Words: One Sentence or More

As a therapist, I sometimes say some useless, some unnecessary things, some not-well-thought out things, and every once in a while I say something quite useful, as I did yesterday with a patient who wrote it down and asked me to print it. Here it is and, not to be showing off too much, I have to follow this “advice” myself often! It’s pretty simple and not anything people haven’t said before…

If you are too busy trying to hold it all together you can’t let it all hang out.

The Call- part 1

This is a really well written description of a really healthy interchange in a therapy “session” on the phone. Also, I myself find that sometimes I feel more useful to my patients on the phone than in person. This is also a great response to a patient in crisis reaching out for help from the only healthy “mothering” figure she has. This blog also reminds me on a separate topic that isn’t connected to the blog post, that therapists sometimes pull away when a patient “needs” them more between sessions. There are no rules that apply except healthy flexible boundaries, neither rigid nor too loose; you can feel the firm boundaries that always help patients as well as caring and being “involved” with the patient’s emotional crisis, so she doesn’t have to suffer alone…

An App for Therapy? First Ever, and I am on It: Everbliss

There’s an app for that… How many times have you heard peoples say it.

An app for therapy and counseling? I actually thought of it and wondered about it before this new first ever Therapy App contacted me. Of course I wanted to be on it. I love finding the new trends in psychotherapy and evaluating them and getting on board right away because I really believe that therapy can be done through many means on the internet, especially Skype and VideoCalls as well as phone. To have an app on your phone and quickly schedule a convenient session — Brilliant.

It’s called Everbliss and it’s easy to use. To find out more about the therapists, I recommend looking them up and finding other profiles and seeing the therapist’s website and/or blog.

So I’m excited to be part of this new app and excited to try it out with new people. Change can be hard at times, but this is one new change of 2015 I am totally embracing!

I will write more about what it’s like to be on the app, without talking about anything confidential of course, just from the therapist’s point of view.

For therapists, it’s easy to put down your availability. And you can just say you are on right now if you are suddenly available. It’s great for when you get last minute cancellations and have some time to work on your schedule.

Also, this app allows for both short term quick therapy and long term relationships. For people who travel a lot this will be great. For now it’s only in NY state and California. Have a free conference room during a break at your job? You can have a session easily without having to wait until you’re home. Don’t like commuting to therapy? this app is for you too…

We will see what the future holds, and where this leads. I think it’s a great idea and will be a fascinating experiment in terms of using the internet and apps for relationships like the therapeutic relationship…

Daily Prompt: The Waiting Room of Life: With Photos

As I am taking the WordPress “Blogging 101” class to improve this blog and my blogging skills, I am trying out their daily prompt. I picked this one from Nov. 16, as it is very timely.

The Daily Prompt is:Waiting Room “Good things come to those who wait.” Do you agree? How long is it reasonable to wait for something you really want?

Lately, in sessions with patients, this topic comes up a lot, during transitions such as moving to a new neighborhood, job searches, a long paper, thesis or dissertation, other career issues and relationship issues, even waiting for a psychiatrist appointment.

WhenI usually bring up Dr. Seuss’s book “Oh, The Places You’ll Go!”, because my favorite page is his interpretation of the “Waiting Room” of Life, and you see the people waiting and his text includes “waiting for their hair to grow”.

I found a link to the exact page spread from the book!:

Everyone is just waiting for serious stuff like a Better Break, or for material things. My favorite is about the hair, as I have experienced that in the past few years. I like changing my hair a lot, and I decided to grow it long. As I have no interest in extensions, I felt like I was in that waiting room, waiting for my hair to grow. At several points in that process, I felt urges to cut all my hair into a short hair cut, and it was hard not to run to a barber and do it, very tempting, every time I saw some actress with a “Pixie” Haircut I missed having that hair cut from for me the late nineties into 2000. But I stayed put in that waiting room and my hair eventually grew to the point where I needed to trim it. then there was the urge to change it up, but I haven’t acted on it.

the other funny thing is I have never had a “waiting room” in my private practice which most therapists of all kinds tend to have. Even now in my relatively new studio, I have two rooms and could have made the first one a waiting room, but I chose instead to use both rooms for art making and art therapy and therapy. So the waiting room in my practice where patients may bump into each other is the hallway, elevator or bathroom…

Right now, I am waiting for a bunch of things alongside several patients waiting for their particular things. I started a graphic novel in the year 2000 and it is waiting patiently for me to get back to it and eventually finish it. At this point, the new pages I did last year are in some box in my apartment but I have no idea which one, so I hid the project from myself! Now I”m waiting for those pages to show up somewhere. I find that misplacing things at my house or studio involves waiting for them to suddenly appear. Whenever I am looking for something, I usually find something else I forgot…

In sessions with people who are in that waiting room, they are acompanied by me as their therapist, waiting with them, and we explore what it is like to sit with the not knowing, non clarity, no answers, no doing aspect of the waiting, which usually is what is most uncomfortable for people. Meditation in action or sitting meditation or yoga are good for this too as you notice what is going on with your breathing. Are you waiting for your next breath? Are you waiting to end the meditation if you set an amount of time?

The sentence “Wait and See” has been difficult for me throughout my life, as I am the impulsive type; I make decisions quickly and don’t like prolonging the pros and cons list or even making this list, which has gotten me into trouble, so I am working on sitting with things more and not reacting so much. “Act, don’t react” the Yogi teabag told me just this morning.

The altered book project is an interesting aspect of this waiting as I have 16 projects in various states and stages, and I’ve been fine with working on different ones and not having an urge to finish any…
These are photos of the two rooms in my studio office. (I didn’t clean up to take the photos.)

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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

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…

The Altered Book: A Great Project for In Session Art Therapy

When I was in graduate school for art therapy, I had never heard of an altered book or seen one, and certainly it did not come up in my “Materials” class. We did not get assigned any kind of Altered Book in any class, whereas now I am hearing from grad students that in some class or other, one of their assignments involves an altered book, which is usually assigned to do outside of class.

I think my first experience of an altered book may have been at the Outsider Art Fair. I distinctly remember going to this Fair years ago when it was always in the lovely Puck Building, which is still there, located on Lafayette near Houston St. in Soho, downtown NYC. In fact years before that, I had some of my graduate art therapy classes in the Puck Building and we organized the student art show on one of the floors of this building. It is certainly a beautiful building. The last time I was there for an art event was the comic book graphic novel fair a few years ago when I met one of my favorite graphic novel authors/artists, Lynda Barry. It must have been back in 2008 when she had just published this beautiful book about her art making process, called “What It Is”. Anyway I think I saw an altered book years before that encounter in the same building. It was made by a female outsider artist and I remember the book being very thick and beautiful and having a lot of glue on all the pages. It was very inspiring and I wish I could remember the artist and find a photo of it.

I made my first “altered book” years before that without knowing it was an “altered book”. It was not quite what we tend to think of these days when thinking of Altered Books. I took all the pages out of this strange pretty bad dramatic novel I did not read and altered the cover completely to the point where it was not recognizable as having been a book. I put a lot of plaster of paris on it and then mod podged tissue paper collage. Then I somehow found part of a cardboard box and attached the book to it so the top opened up as the cover. I think I used the pages to rip up and glue inside the box. I will take a photo of it. Strangely it was a gift for a close friend, but she was a close enough friend that she told me she found the box to be too disturbing to use or look at, so I took it to my studio, where it has been more appreciated! It inspired one person to make something like it with me, and she ended up taking a dislike to the project and left it with me when she left town after we went through her art that she had done in art therapy with me. I still have that rejeccted box in my studio as well. (It inspires me to write a whole post about “ugly” and “rejected” art work and how it is therapeutic in art therapy!)

More recently, a few years ago I stumbled on an online class about altered books, and in fact I have now taken 3 online classes about it, each class covering different aspects of the art making process involved in altering books. I have been making them with patients for a while now, and by making, I really mean inviting patients to try it out and see if they like it. The first part of the process involves the explanation of what it involves, which is, basically, you choose a book and then you can start anywhere in the book or with the cover or back cover and start picking art materials to use on the book. The first steps also often involve ripping out pages from the book, either to use in the book or to throw out. It is usually good to do this at the beginning as a way to give yourself permission to “alter” the book. We all have pretty fixed notions about the sacredness of books, which I think still exists despite the internet, reading on tablets and other devices, or perhaps, the tablets have made books seem even more precious. Jumping in to starting an altered book project requires a certain amount of adventurousness, ability to tolerate anxiety about the unkonwn and anxiety about trespassing a boundary and destroying something in some way in order to create something completely new. It also involves changing ones mind in framing the idea of that book, from something to be read and kept intact, to an object just like any other “found object” to transform and make your own through your own creative expression.

There are many different aspects to altered books as part of the art therapy session that are quite fascinating, so this post will only touch on the first part, the beginning. Once invited the interested patient will next be introduced to the random assortment of books I have to choose from and pick something that speaks to them to alter. Usually Hardback books are more inviting as it is easier to treat the cover like a canvas, but lately I have seen a few people pick soft cover books, becasue I have a few that are an interesting size, kind of square and with a lot of photos, and a cover that is more sturdy than the usual paperback. So far, nobody has decided to go home and pick out one of their own books. Part of this I think is the therapeutic value of taking a book that’s in my studio already taking up space as a book waiting to be chosen, so the process of accepting this odd art project is made easier as you are not “ruining” one of your own books. And I really have a strange random assortment of everything from dictionaries/thesauruses to cookbooks to spiritual meditation type books. Included is a thick hard back Italian novel and some other random novels as well as several books with pictures about fashion or the styles of certain decades. I have a travel guide. I had a guide for artists about materials and how to use them.

This aspect of rejection of the project that began when I made my own rejected “too intense” book box and then an “ugly” book box with a patient is a part of the altered book project. I have had a few people pick out a book and start altering it and then by the next session ask to shelve the project until “I’m in the mood for it. It’s too daunting right now.” The Altered Book will either be seen as a great container that is continually inviting or sometimes it represents being overwhelmed and unable to make any decisions about what to do, resulting in the project getting “shelved”. One of my patients started a first session very excited about all the varied materials I had, wanting to jump right into art therapy and got going very creatively with some book that she even worked on for the first few sessions. At some point I think she started cutting pieces out of the book to create a kind of box within the book, maybe even using an exacto knife. Then in the next session she declared she no longer wanted to work on it, was not in that “headspace” anymore and went to other forms of art making. She made great use of art therapy but never went back to the book until we were terminating and she fondly remembered it as her introduction to me and our work and I think decided to take it with her. The book project just functioned as a jumping in point.

Why do some people get excited to do an altered book in the first one or two sessions of trying it out and then run away from it, shelve it, reject it? Maybe when this happens it is because I, the art therapist, am actually more excited about it than the patient and have high expectations for it being a great kind of project for long term therapy. Perhaps for some people, there is too much commitment too early and they are not really ready for it.

The other interesting thing about doing Altered Books is when people do get invested in them and go back to them every session. Lately that has been happening, probably because a few people in my supervision group randomly chose to work on altered books without my prompting them. Two people have left the group with unfinished books they have taken with them. One person brought her own book to the group to alter with materials from the studio. So that energy of the altered book I really believe was “percolating” for a while in the studio. I had another rejected altered book started about a year ago in one session and then put aside. For a while I was not really focusing on altered books in the studio, just taking these classes and thinking once in a while about it, and learning more ways to approach the Altered Book.

At this moment, my studio feels filled with Altered Books! Like anything that grows in a garden on its own, it feels like this altered book contagion has just sprung up naturally. Just this week I introduced the altered book as an option to 2 patients who got excited about it, chose their books and jumped right in using different media. Last week I had started my own altered book project in the supervision group I facilitate, thinking that now that I have so many patients working on them, I want to do one at the same time. So I chose a book that is a guide to artist’s materials for artists. It was very exciting to imagine taking this book that divides up all the materials and methods and painstakingly describes how to achieve certain effects, and how to “properly” use the different materials and media and rip up the pages and paint on it and collage ripped pieces on to the pages to start the process of making it into a book I hope will be hard to guess exactly what it was even called or to have a vague sense when looking through my book that there are a lot of pictures of how to make art and art materials terms but nothing much else kept from the original book. Synchronicity abounds in doing altered books. For me it came when I opened the book and realized it had belonged to the friend who rejected my first book box project and returned the gift to me. Of course I ripped her name out of the book first.

Anyway, at this moment there are at least 8 altered book projects that have been just begun or are in the mid stages of alteration. If I actually count how many patients have started altered books recently, excluding the person from last year who has not expressed interest in going back to the project, it would be 7, so my guess was not far from wrong, as I am the 8th and then there are one or two people in supervision doing them.

The next post would raise the question: What helps a person stay with an altered book project and continue working on it regularly? and What is it about Altered Books that some people become “blocked” or lose interest after jumping in excitedly.

The one thing true of everyone is that the beginning, that first session of being invited to make one, choosing the book and jumping into it or onto the cover and starting right away to alter it is universally exciting and stimulating. I have only seen people be intrigued and excited when they begin this process. Some express having a weird feeling about “destroying” a book but when encouraged get past that feeling. The fascinating part of the Altered Book is after the initial excitement and embarking on this without a doubt long-term project, there is a moment of remaining with it and committing to it further through getting inside the book and getting going with paint, collage, mixed media, ripping out pages and getting one’s hands dirty. It seems to require about 3-4 sessions at least to determine if one is going to get “turned off” of the project and too overwhelmed, or further jumping in and committing more and more to it. Those who find it to be a kind of safe container stay with it. Leaving it with me in the studio is a big part of that process. I will hold on to their book until they come back to it, so they don’t have to see it for a week. It is very different to work on a long term art project whether it is because the work is very large and will take a long time to finish no matter what or the project by its very nature requires time invested. It is hard to work on a lot of pages at once, especially if you are using any kind of paint or ink. Anyway, leaving the book with me allows the creator to take a break from it and not have to look at it in between sessions. This seems to help the project to become a safe container and holding environment. Even with my own altered book, I decided to try out at first just working on it during the supervision group and leaving it alone, so I also take a week off from it, in order to further get into the experience of my patients and supervisees doing this kind of project…

To be continued…

Here are some photos from my own altered book which I have worked on in different situations, first started it in the supervision group I facilitate, then worked on it alongside several patients who are doing altered books as well as in my studio the other day when I added a kind if nest into the book…

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