Labor Unions in Social Work?

Today is Labor Day in the U.S. - a day set aside to recognize and the American worker. The holiday is indelibly linked with the nation's history with labor unions, organized groups of workers than band together to increase their bargaining power and relative influence compared with "management."

On the whole, labor unions have made a positive contribution to society by successfully combating abusive working conditions, hours and pay. However, there is also a down side to unions. One that has made headlines in the current recession is that unions can make it very difficult for employers (both private companies and the government) to adjust to meet economic demands. If you have to give everyone raises (in spite of shrinking profits), offer the most expensive health insurance, and other fringe benefits (holidays, vacation, retirement matching...whatever), etc., your only option is to lay off workers (even if you need a certain number of staff to continue operating). Suddenly, unions don't seem quite as great, when they directly cause some of their members to lose their jobs.

And when it isn't a factory that can't put out as many widgets as it used to, but instead a service we depend upon - for example, having enough teachers, police, firefighters - it's not just the people who lose their jobs that pay a price, but everyone. Now, don't get me wrong: I'm not anti-union, and I'm not advocating that we abolish them (lest we revert to abusive employment practices). What I am saying is that we should be conscious of both the benefits and the costs.

So what about unions in the Mental Health field? They exist - I know because I am in one. One of my jobs is unionized. That means that everyone who isn't "management" either has to join - pay union dues and get a vote - or decide not to join, still pay for the privilege of "benefiting from collective bargaining" but not get a vote. So, I joined.

Like unions more generally, unions in Mental Health seem to be a mixed bag. The union has done important lobbying and advocacy on behalf of Mental Health services and clients/consumers, working to keep these services in the State budget, and advocate for legal changes such as parity, and safety regulations for staff. This sort of action speaks to the heart of Social Work's mission and values. I also think the union is good to have to ensure fair treatment of nonprofessional staff, who have little training and make low wages overall.

However, when it comes to clinical staff, I think the union is more a hindrance than a help. Because the union is based on the idea that there is a clear division between "workers" and "managers." That means that unions also make it pretty hard to progress up the chain from worker to manager - from clinician to supervisor. Unions don't want to lose members (as they do when someone is promoted), and they don't want to lose a position - they don't want an existing position that is considered "union" to become management. For someone to be promoted, someone else has to be hired for the vacated union position. If the company can't afford to hire additional staff...well, no promotion is likely. I lost an opportunity for promotion because the union would not release my position, and it was very frustrating - especially when I have been paying union dues all along!

Then there is the issue of client care. During the last round of contract negotiations, when the company I work for argued that they could not afford to pay everyone a 3% raise, and continue to pay the % of health insurance premiums the union was demanding, the union voted to strike. When it comes to human services, strikes seem wrong to me. It's basically saying that the monetary dispute between the union and management is more important than client care. Particularly when it comes to therapy, it's not like someone can really substitute for a striking worker. Unions figure that clients who don't get services become another voice to pressure management into agreeing to the unions terms...but at what cost to the clients? What is the impact on high-risk populations, or those who have attachment issues? It doesn't seem responsible to me. Thankfully, a negotiation was worked out prior to the scheduled strike at my company last year...but if the strike had happened, I would have worked regardless. There are more important things than pay and benefits.

Parity

For a long time, insurance companies set a limit on the number of therapy sessions their members could receive each year, and refused to pay for additional sessions, regardless of the client's condition or need. Typically, the maximum was 24 sessions or less a year. That adds up to less than every other week - certainly less than the weekly sessions most therapists and clients prefer.

Insurance policies still specify these session limits, but thankfully, many clients are now exempt, thanks to legislation requiring "parity." Basically, the law now requires that mental health problems with a "biological" basis receive coverage equal to that provided for (physical) medical conditions. In other words, if the insurance company would not put a session limit on the number of times you could see a physician for diabetes, it cannot then limit the number of times you see your therapist for Bipolar Disorder.

This is good news for therapists - we can now see clients as frequently as they need to be seen, rather than disrupting the momentum of treatment with inconsistent session, and/or breaking off treatment when it is still needed...if they have a problem classified as "biologically based."

That, of course, raises all kinds of new issues. For example, while it is usually relatively clear that a medical condition has a biological basis, it can be harder to determine which mental or emotional conditions have a biological cause or component. Postmodern, constructionist theories suggest that diagnosis and etiology are to a large extent an extension of socially agreement rather than objective "fact." Thus, our diagnostic categories may be more about what DSM committees agree upon than about clear biological distinctions.

When we make decisions about which diagnosis to assign and/or bill for, there's often more than one that may be appropriate. Since NOT all diagnosis are covered by parity, it behooves us and our clients to familiarize ourselves with the federal and state parity laws. For example, Major Depressive Disorder is classified as a biologically-based condition, but Dysthymic Disorder and Depressive Disorder NOS are not. Diagnositc decisions therefore carry a lot of weight. Similarly, when it comes to billing, if someone has multiple diagnoses, but only one is classified as "biologically based," you would want to list that one as the primary billing diagnosis (since if you list the other, your claims will be denied after the session limit has been reached).

Overall, parity is a good thing: it allows clients to receive needed services much more consistently than before the law was passed. However, it does raise important questions about the nature of mental and emotion issues, the nature of (mental) healthcare, and the way we define diagnosis and etiology. We have many more questions to answer before we call really say that we have achieved "parity."

Goodness of Fit in Therapy

The Ecological Theory of human behavior in the social environment suggests that how well someone functions in life is the direct result of the "goodness of fit" between the person and their environment. So, for example, how well a student learns is heavily influenced by the degree of fit between the teacher's teaching style and temperament, and the student's learning style and temperament. Similarly, two children with different temperaments may respond very differently to the same parenting; for example, what one experiences as playful roughhousing the other may experience as overwhelming or threatening.

Goodness of Fit is also a factor in the therapeutic relationship. Different clients respond differently to different therapists' styles, manners of interacting, and intervention approaches. When the fit is good, outcomes may be better than when the fit is less good. It's also likely to be more satisfying for both client and therapist. In contrast, if it's a bad fit, the client is more likely to be guarded, defensive or resistance, and the therapist may be less likely to be empathic and patient. As a result, the process is less likely to be therapeutic, and may even be counter-therapeutic.

Working in agency settings, at least in the settings where I've worked, "fit" is rarely a consideration - or at least, not a deciding factor. The decision tends to be more about numbers - what clinician(s) have room in their schedule or a smaller caseload. Sure, if multiple clinicians are available, the person assigning cases may consider who may be a better fit. However, once the assignment is made (i.e., by the time the clinician and client meet for the first time), it's usually a "done deal" - clients and therapists are typically discouraged from requesting reassignment.

Private practice is a totally different ballgame. Both clients and clinicians have a lot more choices, and the ability to "shop around" for the right "fit." Granted, clinicians don't necessarily want to be too picky, especially starting out, and clients may also find the process of trying out various therapists (and repeating the intake process over and over) becomes onerous if they are too picky. Nevertheless, both have significantly more control over whom they see.

So, what makes for a good "fit" in therapy?

From the perspective of the client, trying to choose the right therapist, you should:

1) Feel comfortable enough to be open about what you're experiencing...without expecting that you'll feel totally comfortable. This is a stranger, after all, with whom you're sharing very personal information. If you expect total comfort from the beginning, you will discount providers who could actually be a really good fit for you. You want someone who challenges you in some way - that's what produces change. It should feel different than talking to a friend.

It's also common to experience whatever relationship issues you may have in life getting played out in relationships with therapists - this is actually good and productive, and helps resolve those issues if you can stick it out. Deciding that it's a sign the therapist isn't a good fit just means that you're putting off an issue that is likely to come up again with the next therapist.

2) Feel like the therapist can help you (i.e., they know something about what you're dealing with), and find their approach acceptable. You don't have to totally understand or believe in all aspects of someone's approach, but if you're operating from totally different worldviews, that can be an obstacle.

3) Consider the logistics - does the therapist's availability work for you? Does the location make sense for you? Is the therapist's financial policy acceptable to you (for example, whether they will go through your insurance, what your copayment or fee is), and do you understand no-show or cancellation policies? If these logistics aren't acceptable to you, they are bound to become barriers in treatment.

From the perspective of the therapist, the consideration of fit has to consider:

1) Our ethical obligation to clients. Specifically:Do you feel you can competently treat this client? Do you have knowledge and expertise with the client's presenting problem? And, although this piece is rarely acknowledged, do you feel able to empathize with the client? If you can't establish empathy, the treatment is not going to work, and while we probably all pride ourselves on our empathy, sometimes there really just is a bad fit, and our own "stuff" gets in the way. Our responsibility, when we don't have the expertise, or empathy for a particular client, is to make a referral to another professional who might be a better fit.

2) Workload balance. Our practice is only likely to feel manageable if we maintain some balance in the work we take on. If we already have several high risk clients, it may not be feasible to take another one. Similarly, there may be a limit to the number of clients with personality disorders we can manage, or the number of cases with a lot of collateral involvement, etc. We have to recognize and listen to our own limits.

3) Logistics: Like the client, we have to consider our schedule and availability (whether we are able to take a client during the time(s) the client is available), and financial agreement (whether we can take the client's insurance, for example).

There may be other considerations on either side. How do you think about finding the right fit between therapist and client?

Busy Work

These days, it seems like everyone is being asked to do more with less...less money, less time, less staff, etc. The only thing that seems to grow is the number of clients and productivity requirements! 

However, even as caseloads continue to climb, along with stress levels, I rarely hear colleagues complain about the time they spend with clients (except to say that they don't always have enough time for each client!). However, I do hear (lots of) complaints about all the other tasks that don't involve direct service - in other words, the busy work.

And there is a lot of busy work. Most of it involves documentation. In fact, just about every social work joke I've heard makes some mention of paperwork. Other kinds of busy work involve meetings, insurance red tape, and phone calls (especially the amount of time on hold, or wading through automated response systems before you get to talk to a real person). 

When it comes to documentation, I'll be the first to say that good records are important. Keeping records is necessary because it helps to ensure a high quality of care (if you have to record it, you're more likely to do it), while protecting professionals from liability (provided they are doing what they're supposed to do). It's also useful to maintain continuity in treatment, remember details, and update other providers regarding treatment that has been provided. 

However, all of these potential benefits of documentation are diminished as the volume and redundancy of paperwork grows. Basically, the more there is, the harder it is to find the useful parts, and the lower the overall quality tends to be (because it is more rushed). 

I had hoped that the trend toward electronic medical records would streamline documentation and minimize the volume and redundancy. However, thus far, I have not experienced that to be the case. Part of the reason may be that I live and practice in Massachusetts. Why, you ask? Because of the Massachusetts Standardized Document Project. Basically, a committee created a full set of mental health documentation (assessments, treatment plans, progress notes, etc.), which agencies have been encouraged to adopt. I believe the goals were twofold: to standardize forms so that, when someone's records are shared with a different agency, the receiving clinicians can make sense of them; and to ensure that documentation meets the standards established by the government and third-party payors. 

While it is hard to object to these goals, the actual product - the standardized documents - leaves much to be desired. The result of committee work is often to make things more involved or complicated, rather than simpler and more concise, for the simple reason that people disagree, and both sides get something included so that everyone will be happy. Of course, in reality, no one tends to be fully "happy" with the result, and that is certainly true of these forms. I don't know anyone who likes them! The psychosocial assessment is a full 12 typed pages, before adding 7 possible addenda (e.g., education, military service, trauma, legal, substance use, etc.). Any useful summary, diagnosis, or risk information is buried somewhere inside the stack, making it time-consuming even if someone else completed it! It has drastically expanded the amount of time I have to spend on paperwork, while making the result less useful for actual treatment.

I can't blame it all on the MSDP, however. My full-time job does not use it, but still has a ridiculous amount of paperwork, which is frequently redundant...and mostly hand-written, so you can't even cut and paste (the only saving grace when using the MSDP forms). Each client has to have 9 treatment goals, so most of the time we have to spend with each client is focused on updating these, rather than really meeting clients where they are.

I don't have an easy solution to all of this busy work, but I think a priority across agencies needs to be streamlining the paperwork, and other busy work, so that more time and energy can be spent focusing on the people we're meant to be helping. Time is a resource, and in this era of resource scarcity, we need to be better stewards of staff time.

Personal Space

It's been six weeks since we opened the satellite clinic where I work. At that time, we began with a limited staff, and only two programs - adult partial hospitalization and intensive outpatient programs for eating disorders. In the last few weeks, a whole  additional team of staff has joined us in the space, and began their program - adolescent intensive outpatient. We've also added a program director to manage the whole clinic and all three programs. Suddenly, what once felt spacious is feeling pretty crowded. 

Two other clinics the agency opened last year demonstrated how important it was  for morale that staff felt like they had a place to call their own. In limited quarters, communicating and sharing effectively was the key to making sure that no one felt left out, pushed aside, or like their toes had been stepped on. The agency has tried to learn from these earlier experiences, and involve everyone in deciding how best to allocate, arrange, and use the available space. As a result, the multiplication of staff and programs has gone relatively smoothly...but, as with any transition, there have still been hiccups.

We expected to have to be creative about where to meet individually with clients, especially when both staffs are present. This will likely cause some challenges when multiple clinicians assume that a shared room will be available, only to find someone else is using it. It is already challenging because only one of the shared consultation rooms used to have a computer and phone...which have now been moved into the adolescent program staff's office. As a result, the members of our treatment team who are not there every day - namely, the prescriber and dietitian - do not have a readily-accessible phone or computer. The full-time direct-care staff have also recently learned that they're sharing one desk in the chart room, with one computer and one phone. Both shifts have resulted in some sense of displacement, and perhaps even a feeling of being less valued. 

Full-time clinical staff have our own desks, computers and phones in shared offices. This has worked out well so far - I think that just having a designated space allows us to feel secure, settled, and somewhat organized. At least, that has been the case for me. However, when we got new furniture and my desk wasn't facing the way I wanted it, I was perhaps unreasonably unhappy. My office-mate doesn't love the way I have it, but it's important for me to feel comfortable, and she got to choose how her desk would be. Facing a different direction is a small thing, but would be an unnecessary distraction. Amid the chaos of this kind of work, I need at least my desk to be the way I want it!

It's actually remarkable how much our surroundings can affect our mental and emotional state. My old roommate used to say that her messiness would expand proportionally to her stress level; another friend quipped: "my room's a mess = my life's a mess." Having a few personal objects, at summer camp or in your office, provides a feeling of belonging, a tangible anchor that is soothing in a new or chaotic environment. And remember the feeling the first time you got to paint and decorate a room for yourself? While we could theorize how and why we are so influenced by our "personal space," I find it more useful simply to recognize, and hopefully make use of this influence. If satisfaction goes up simply by having a little area to call one's own, we should prioritize this as an easy way to improve - rather than diminish - morale.

How do you connect to your space to feel anchored? How do you arrange clinical and personal space? When has space been an issue for you?

 

Another Ethical Quagmire

Another ethical dilemma has arisen for me this week, in the context of the partial hospital program where I work. Specifically, a current client's cousin may be referred from our inpatient unit to the PHP. My client is understandably reluctant to have a family member present in treatment with her (beyond the standard meetings with immediate family, which don't include the rest of the group, and still leave the majority of treatment separate from family). However, management does not consider that sufficient reason not to accept the cousin.

I have serious misgivings about the idea of attempting to treat clients who are related to each other in the same group program. I've had to stop and think about it more to try to articulate my reasons. My initial reaction was that it should be obvious we can't accept the cousin - an assumption I made because it has been the policy at all the other places I've worked that relatives cannot be in group treatment together, nor can they be seen by the same outpatient providers. Since it is apparently not as obvious as I thought, here are what I consider the relevant issues:

1) Dual Relationships
Obviously, family members have an existing relationship with one another outside of treatment. By accepting them both into the same treatment program, we are putting both in the uncomfortable position of having a dual relationship - family member and group member. Dual relationships are discouraged by professional codes of ethics because they raise the possibility of other ethical issues. Some of those are discussed below, but here I'll focus on boundaries.

Specifically, it can be very hard for clients and clinicians to sort out where one role stops and another begins. What interactions between two related clients are coming out of their relationship as group members, and which coming out of their family relationship? Can there even be group member interactions between them that aren't in some way informed by the family relationship? Nobody can set aside all the things they already know or believe about a person, and limit their interactions to only what they've learned or experienced in the treatment setting. The chances that one will reveal too much about the other, or make judgments and assumptions on the basis of past interactions, is high. On the flip side, it can be hard to leave treatment at treatment, and not have group interactions influence outside interactions. It's hard to compartmentalize, and easy to forget how one knows something.

2) Confidentiality
While both relatives may agree up front to keep things disclosed in treatment confidential...they may not actually do so. There is more temptation to tell other family members what a relative disclosed in treatment, versus what strangers shared. There is also the very real possibility that something from treatment will later be used as ammunition in the heat of an argument. Both are likely aware of this possibility, and may self-censor as a result.

Staff may also (inadvertently) struggle with confidentiality. Just as it may be hard for related clients to separate what they know from outside treatment, and what they know from inside treatment, it can be hard for clinicians to remember what they learned from one client, what they learned from the other client, what the clients said in private, and what they said in group.

3) Conflict of Interest
This may be the most concerning aspect of this dilemma for me. The primary "interest" - priority/responsibility - of the clinician is the client's welfare. Whenever there are multiple clients (e.g., group, couples or family therapy), there is potential for a conflict of interests - something that's good for one might be bad for another. The clinician faces a definite conflict - internally and externally - whenever faced with that kind of choice.

The most often cited example occurs in family therapy when the clinician has to file a report of possible child abuse/neglect. While the clinician notifies the whole family of her legal obligations at the beginning of treatment, it still usually causes problems when a report actually has to be filed. The decision is made easier, however, by clear legal standards (i.e., mandated reporting) and the general ethical guideline to advocate for the most vulnerable/least powerful person's interests.

Assuming no clear power differential between our potential related clients, a conflict of interests between the two would be much harder to resolve. Imagine, for example, they have an argument, and both declare: "If she continues treatment, I'm dropping out!" Assuming neither budges from this position, even after a cooling-off period and talking with staff and peers, the treatment team is faced with quite the dilemma: there are two medically and psychiatrically compromised individuals who want treatment...but not if the other one is present. We might choose the more medically unstable, or the least ready for discharge, but the other one might reasonably claim that we did not fulfill our obligation to her. We might decide to discharge both, to avoid any claim of discrimination against one, but we'd have to find some way to ensure adequate aftercare for both. Yes, it would be quite the quagmire.

There is also the question of whether a conflict of interests already exists if we accept one and not the other. My contention is that our primary responsibility is to the client who has already been admitted to our program. The other is on an inpatient unit within the same agency, so some may say that we have a responsibility to her as well. However, I disagree - the inpatient team is responsible for her treatment, and arranging reasonable aftercare. If she can't come to us, that means they need to find a way for her to go elsewhere, or access a different level of care (IOP vs. partial, perhaps), or have more frequent outpatient appointments and monitoring until her relative discharges and she can start our program. There are solutions. Our responsibility is to ensure the best possible treatment for the client we already have.

It seems clear to me that dual relationships, possible breaches of confidentiality (and self-censorship out of fear of such a breach), and conflicts of interest would interfere with the quality of treatment for both. Instead of providing good treatment to one, we're providing treatment to both that is only ok...at best. That is not ethically sound, damages our reputation in the community, and could influence our reimbursement by insurance...and that's not even considering the cost to the individual clients in unresolved symptoms and ongoing struggle. But, again, this is just my opinion.

Informed Consent

I'm in an uncomfortable position with one of my clients (at the eating disorders partial hospital program) where there is a mismatch between what she wants and what the program requires - specifically, she is already in what can be considered a healthy weight range, but the program "requires" weight gain up to a BMI of 21. Disagreements over this requirement are not an uncommon occurrence, given that individuals with eating disorders are often highly ambivalent, and have highly distorted thinking. However, it does raise some interesting clinical and ethical questions.

I'd like to frame the issue in terms of two ethical concepts. First, all healthcare providers are required to obtain informed consent for all treatment services. That means clients have the right to be fully informed about the suggested treatment, along with its possible risks and benefits; have the right to accept or decline, with possible consequences of both choices outlined; and have the right to withdraw their consent at any time. Informed consent assumes that individuals are legally competent to make decisions for themselves - i.e., adults with sufficient cognitive functioning to fully understand and weigh the risks and benefits, and make treatment decisions accordingly.

Second, informed consent is closely related to another core ethical standard for social work practice (as outlined in the NASW Code of Ethics): self-determination. Self-determination is the freedom to make decisions for oneself, without coercive influences. It means that clients have the right to decide their own goals and values, whether or not we agree with them. This is the basis for a push toward more collaborative treatment planning, with client-identified goals. The only exception recognized by the Code is when a client's choices present a "serious, foreseeable, and imminent risk to themselves or others;" that is usually interpreted to mean suicidal or homicidal intent. According to Miley, O'Melia & DuBois, in all other circumstances, "When social workers impose solutions, give direct advice, assume the role of expert, treat clients as subordinates, or in other ways control decisions, they thwart client self-determination."

So back to my dilemma. When clients are severely malnourished, it causes cognitive impairments, and may prevent someone from providing truly informed consent. In those cases, it is easily justified for the treatment team to require weight restoration as part of responsible treatment. Even so, it is very difficult (though not unheard of) to get a court order to treat a client against her will - they usually have to consent to be admitted to treatment, though as with all psychiatric admissions the legal status is "conditional voluntary," meaning that their ability to make informed treatment decisions may be impaired.

However, when someone is no longer malnourished, but we're still pushing them to gain weight against their will, that seems to violate the principle of self-determination. Yes, a client's unwillingness to weigh more than ___ lbs may be a "symptom," but over a certain point, it's not a risk issue, so they should be free to make their own choice (of course, this begs the question of what that point is). It seems like our role would be to give the information needed for them to make an informed decision - the physical and mental reasons why we recommend weight gain, along with the possible outcomes of gaining or not gaining. If it's more important to someone to feel comfortable with her weight and still somewhat preoccupied with food, vs. less preoccupation but more body image issues, that's a legitimate decision. Hopefully therapy can begin to shift the centrality of weight and body image in self-worth, which may then lead to willingness to gain additional weight.

An additional issue with consent is that we don't talk with clients about weight gain protocols at the beginning of treatment. It would definitely scare a lot more people off, but it would also be more in keeping with informed consent to tell people that they will be put on a weight restoration meal plan until they reach a BMI of 21. Without that information, it seems a little like a bait and switch - people get involved with treatment, connect to the group and team, and delve into underlying issues, and then find out that, in order to keep those positives, they have to do something they aren't willing to do.

I think that forced weight gain beyond clients' level of consent is a significant reason for relapse. If someone isn't on board and willing to be that weight, they're going to try to get back into their comfort zone as soon as they leave treatment, and getting back into the comfort zone is going to trigger the behaviors that rapidly become compulsive. We might better help clients with long-term recovery by taking things more slowly. But that's just my opinion.

When Did "Religious" Become a Bad Word?

Yesterday, in the context of a conversation about the Republican primaries, a colleague expressed distrust for "religion." I think she (mostly) meant the religious beliefs on the Presidential candidates, and how these beliefs may influence their politics, but it was worded as a blanket statement about religion in general. I wanted to say, "You know I'm religious, right?" but I bit my tongue.

It never ceases to surprise me how negatively mental health professionals seem to view religion. Because I also have a graduate degree in theology, potential employers have asked me questions based on a range of insulting assumptions: that I will proselytize clients, discriminate against LGBTQ individuals, discourage birth control and/or abortion, or otherwise advance the agenda of the so-called "Religious Right." Now, I went to a Boston school noted for its liberal theology, and (in the same conversation with my colleage) have described myself as left of Democrat. I don't ascribe to any of the social principles of the Religious Right, and it makes me angry that they give everyone who's religious a bad name. However, it also makes me angry that open prejudice against religion is demonstrated - and accepted - in a field that is supposedly open-minded and respectful of diversity. When did "religious" become a bad word?

The profession of social work was begun by religious women - women who were committed to social justice because of their religious beliefs. The staunchest advocates for justice - all kinds of justice - that I've ever met have been people of deep faith. The vast majority of religious people are also respectful of other faith traditions, and do not try to impose their beliefs on others. With that combination - respecting a diversity of beliefs, and working for justice - how can religion be a bad thing?

Thinking about the current Republican candidates: much has been written about Mitt Romney's Mormanism, with a generally negative tenor. However, from what I've seen of his campaign, and through his time as governor, he hasn't based his political decisions on his religious beliefs. In contrast, Rick Santorum is unapologetic about basing his political platform on religious beliefs - with little apparent concern that much of the population does not share his ideology. That is a bigger concern for me. I think it's laudable for people, including politicians, to have faith...but not to impose that faith on others.

I think similarly about the relationship between my own faith and work. I am motivated by my religious beliefs, and related values of justice and service, to do this work, and I came to the work through a sense of calling or vocation. But that's about me - what makes it meaningful for me, and gets me out of bed every morning. It's not about my clients, whom I do not expect to share my beliefs, and to whom I rarely reveal anything about my faith background. In my work, I'm much more interested in what matters to them - what gets them out of bed in the morning.

So, please don't make assumptions about my faith based on the "Religious Right," and don't insult me by suggesting my agenda is conversion rather than service. Let's respect faith as an asset, and not fear it, or write it off as a liability.

Electronic Medical Records in Therapy

We all know that electronic medical records are the wave of the future. The very near future. In fact, the wave is washing over me as I write this! The outpatient clinic where I do some fee-for-service transitioned this week from paper progress notes to computerized ones.

The change was accompanied by the usual technological glitches (I didn't have access to the drives when I got there, which was a definite issue!), and special trainings for those unfamiliar with the new format. Some of my colleagues have been resistant to the whole idea, but in general, I'm like the idea of going electronic. For one thing, all that writing takes a toll on my hand! I'm especially looking forward to being able to cut and paste things that are the same each time, but I've had to write out again and again anyway. It's also more convenient to reference past notes, assessments, and treatment plans, and makes it much easier to find out what other providers (e.g., prescribers) are doing with a client (not to mention being able to read what others have written!).

That said, there are also some drawbacks. For one thing, most clients are fairly comfortable with the idea of therapists writing during a session. Typing is another thing altogether. We're slowly getting used to medical doctors using a computer during consultations, but many people still feel like the computer distances patient from provider, or even complain that doctors don't seem to be listening (because they're looking at a screen). Since such a crucial part of therapy is feeling heard, anything that interferes with feeling heard is a problem.

Even if we position the computer strategically and touch-type so that we can maintain eye contact while making notes, we still have to think about the sound typing makes, and what effect that might have on the client. Hand-writing can be pretty unobtrusive - someone who is engaged in affective processing is probably not paying much attention to whether or what I'm writing. However, if I'm typing, it's clear when I am - and am not - writing. My prediction is that more clients would wind up wondering what I was writing as they began to notice the timing of writing - and to engage in projection and possibly transference about it.

From these reflections, it seems clear that typing notes (at least during sessions) would result in some changes in the feel of the session. The obvious solution, of course, is to NOT type notes during sessions, but do it after. That sounds like a great plan - but it assumes the luxury of 50 minute hours, with that ten minutes at the end for mundane things like paperwork. I don't know about you, but I don't live in a world of 50 minute hours. I live in the world of 45 minute back-to-back sessions before I have to run out the door to make it to my other job on time. Everyone I know who isn't in private practice has to think about productivity, and would have to do any paperwork that doesn't get done during the session on their own time.

So what's the solution? I don't really know. Better pay for lower productivity? We can only dream. Clients resigning themselves to typing during their sessions? I fear that's more likely. What do you think about how electronic medical records will or should be integrated into mental health treatment?

Ink

About 25% of people under age 50 have tatoos, and that number goes up when you look at younger segments of the population. It seems like it's almost a rite of passage these days to get "ink." While I don't actually have one, many of my friends and colleagues do. More conservative folks may get tattoos in areas they keep covered, but it's becoming more and more mainstream to have tattoos on places much harder to hide - hands, forearms, neck, ankles, feet (yes, I know feet can be hidden - but I wouldn't want to wear socks all summer!).

However, for better or worse, the corporate world - including healthcare - has not caught up with the times. Every company I've worked for has a policy barring visible tattoos. While enforcement of that policy seems to vary widely based on the agency and position, I can see how many clinicians in my age group might face tattoo-related difficulties at work.

When such difficulties arise, it may be tempting to abandon agency life for the freedom of private practice. However, regardless of the setting, it's important to consider the possible impact of tattoos on the treatment process.

The senior managers who establish tattoo policies are probably doing so based on their ideas about "professionalism" - along with other decisions about dress code, and the like. While a professional presentation is certainly important for therapists, I also think it's possible to appear professional with visible tattoos (if they are tasteful and unobtrusive). The bigger concern for me is how clients will interpret the tattoo.

Tattoos are a mode of expression, so we have to assume they will express something to clients - but much of their own individuality shapes their interpretation of the tattoo's "message." It would be a mistake to make assumptions about what that interpretation might be. When in doubt, and it seems that a visible tattoo is drawing a client's attention, I would say the best bet is to make it a manifest, rather than latent, part of the conversation - it's all grist for the mill, after all.

The tattoo may also shape the client's transference to the therapist. After all, a tattoo, as a form of self-expression, is the opposite of the "blank screen. It may influence what other relationships get layered over the therapeutic relationship, what associations are called up, and therefore significantly shape the content and context of therapy.

Whether or not transference becomes a factor, tattoos are inevitably a form of self-disclosure, and should be considered with the same care as other forms of self-disclosure. Will it help, hinder, or be neutral to the therapy? What would it be like for you to have the client interpret (and possibly misinterpret) it? What might it say about who you are, and how might that influence the client?

In all of these considerations, the population matters quite a lot. With some populations, a tattoo may make the therapist feel more accessible, and be a way of joining with clients. In other populations, it might lead to negative judgments of the therapist, or (with kids, for example) be seen as advocating a lifestyle key stakeholders (parents, funding sources, the board) don't support.

The bottom line is that, while you might not even think about your tattoo that often, if it's visible, you need to think about how that might impact your clinical work. If you're thinking about getting a tattoo, you might want to consider one you have the option of hiding if necessary (rather than wearing a band-aid all the time, as one of my colleagues had to do). If you're bent on a spot that you can't hide easily, consider the tattoo and it's message carefully - it will become part of your presentation as a professional!

Things I Didn't Learn in School: Paid Time Off

Today is President's Day, a Federal holiday in the U.S. recognizing the birthdays of Washington and Lincoln. Government offices, schools, and many other workplaces, have the day off.

This is the first year I have to work on President's Day - a fact that has led me to reflect on how agencies determine holidays, and other so-called "fringe benefits."

Let's start with where I'm working now: it's a for-profit company focused on the more acute levels of care (inpatient, residential, partial hospitalization, and intensive outpatient). As a result, 1) at least some of the programs have to run 24/7, and 2) there is concern about lost profits whenever programs are closed for a day. It's no surprise, then, that we're open on lesser National holidays (President's Day, for example, vs. Thanksgiving, when we're closed). We also don't get "holiday pay" - in other words, we don't make more for working a holiday than for working any other day.

I'm actually ok with not having the holiday off, because of another quirk of the for-profit world: "Paid Time Off," or PTO. Companies that use the PTO model don't separate out vacation, sick time, personal time, and holidays. Instead, it's all lumped together into one pool (called PTO). The employee has more flexibility about how this PTO is used. For example, if you have surgery you might use more of it as sick time, but if you never get sick, you have more time available for vacation. That's very different than the non-profits I've worked for, where sick time was treated separately, and was not seen as "earned time." In other words, you weren't entitled to that time, and how you used it was subject to scrutiny. But, back to the holiday: instead of using a PTO day today to get the holiday off, I can use that PTO day as part of my vacation time later in the year. In part as a result, I get more vacation in my first year than many other agencies would offer.

Now, it's definitely NOT true that all for-profit companies are open today. I think there are two other factors that play into it. The first is, will the company be able to get any work done? Any company that relies heavily on shipping, or involves government agencies (e.g., the courts), or schools, or other places that are closed, might as well close because not much will be accomplished anyway (they'd be paying people to come to work but not actually work much). The second factor is, is the agency unionized? Whenever unions get involved, there seem to be a greater number of guaranteed holidays. My second job is unionized and I think they recognize 12 holidays a year, vs. 10 at other non-profits I've worked for, and 6 at the for-profit I work for now (note that this is Massachusetts, and we have some additional holidays that bring the number up to 12).

There may be additional factors that play into an agency's decisions about holidays, sick time and vacations. If you are aware of others (or if my theories are wrong), please leave a comment below. The bottom line, though, is that you should definitely ask questions about the various kinds of paid time off when you're thinking about accepting a job. It would not have occurred to me to ask about holidays, but it's definitely something worth considering. While I prefer having the day available when I want to have time off (rather than a random Monday in February), it would be really inconvenient to have to work holidays if I had a child in school who would have the day off!

Modeling - What Is Normal, Anyway?

One of my jobs is at an eating disorders partial hospitalization and intensive outpatient program. A treatment goal for all of our clients, across the spectrum of eating disorders, is to "normalize" eating behavior. One of the main interventions by which we work on this goal is supervised meals. As staff, we often eat with the clients - to make it less awkward, and to model "appropriate" or "normalized" eating.

Therefore, a perennial question among staff is: What is appropriate to eat with clients? What is normal?

It's comparatively easy to determine whether clients are eating what they should be eating. They are all on meal plans, so we just have to make sure 1) that they're eating the exchanges that are on their meal plan for a given meal, and 2) that they aren't following "abnormal" eating rituals. The latter includes "diet" or "light" foods, unusual food combinations, unusual patterns of cutting/slicing/biting/pacing themselves, and excessive condiments, or foods not considered appropriate to the meal in question (e.g., waffles for grains at lunch).

While there is some variation in what staff consider normal vs. abnormal eating behavior for clients, it becomes even less clear when we stop to think about our own eating - and whether we can eat that way in front of clients. It's complicated by the fact that 1) we aren't on meal plans, 2) we tend to be willing to eat a wider variety of foods, 3) we can eat certain foods (e.g., lean cuisine or diet coke) without it being part of a dangerous cognitive, emotional, and behavioral pattern, 4) there is natural variability in what food combinations people and cultures eat, and 5) many or most women in this culture have some disordered eating habits.

The most cautious response is to have staff follow the program's standard meal plan when eating with clients. However, while safe, this strategy isn't necessarily "normalized." For example, the standard meal plan only includes 1 grain with lunch, but I like to have a sandwich, with 2 pieces of bread. Trying to develop a less rigid policy becomes tricky, however. We definitely don't want to eat diet foods in front of clients - we don't want to portray "normal" eating as having to choose diet or low-fat options! But, if we don't let them have soda, should I avoid drinking my regular coke in front of them? Can I drink water for a meal, if they're drinking milk? I'm not going to measure out my foods like they do (that's not normal), but will it therefore look like I'm eating less? The possible pitfalls are numerous, both because of the ranger of staff's personal preferences, and because we have no way of knowing exactly how clients are perceiving our behavior.

Another dilemma that comes up is how to "normalize" social interactions during meals. We want to model "normal" mealtime conversation, while also guarding against dysfunctional group dynamics (i.e., competition among clients). As a result of the latter consideration, we don't let them talk about food, meal plans, or what anyone is (or isn't) eating. However, it's very "normal" to talk about food during a meal! It's sometimes hard for me to remember not to comment on something smelling good, or to mention a favorite food, or whatever. Because eating is anxiety-provoking for clients, it's common for staff to offer some form of distraction, for example trivia or other group games. This habit is also not particularly "normal" - most people engage in small talk or conversation during meals. Therefore, I prefer to try to model mealtime conversational patterns by facilitating conversation.

However, that puts me square in the middle of another therapeutic quagmire: small talk involves some amount of self-disclosure. It's considered "small" talk because it steers away from areas that may be vulnerable...but, we know as therapists that any bit of self-disclosure may have some greater significance to clients, or impinge in some way on the clinical work (via clients' assumptions, judgments, assumptions about our judgments, sense of themselves as similar to or different from us...etc.). In modeling "normal" mealtime interactions, I'm sharing things I would most likely not share in the course of typical treatment - where I'm from, where I went to college, what sports team I root for, etc. Nothing huge, but still, little details about myself that might color a client's later interactions with me. What is safe to share, and what isn't? In a group setting, with high client turnover, it's hard to know for sure.

As you can see, the simple question of "what is normal" is incredibly complex when asked about meals in a treatment context. What we eat, do, and say - about anything - has clinical significance. I therefore have no simple answers to guide a policy for myself and colleagues. Do you face similar dilemmas in your work? What do they center around? How do you navigate these kinds of challenges?

Recharging Your Batteries (Are You an Introvert or an Extrovert?)

Therapy can be draining. It's draining for clients to do the emotional work necessary for change, to "wrestle with their inner demons." However, it may be even more draining for clinicians. Because the therapeutic relationship is unidirectional - for the benefit of the client, not the clinician - energy flows from us to our clients...but not vice versa. We accompany our clients into their emotional struggles while keeping both our clients and ourselves anchored, but do not receive emotional support in the process. Don't get me wrong - there are plenty of rewards to doing this work - but recharging our emotional batteries is not one of them.

Therefore, if we're going to continue lending strength and energy to our clients, we have to find ways to recharge our own batteries. Taking care of our physical needs helps - in other words, getting enough sleep, food, exercise, etc. Getting support also helps; we may get it from colleagues, supervision, friends and family, or our own therapist. However, the degree to which support is helpful, or the degree of support that is helpful, seems to depend quite heavily on whether we are extroverts or introverts.

Pop culture sometimes misconstrues these personality traits, describing extroverts as outgoing, and introverts as shy. In reality, extroversion and introversion have little to do with whether one is willing or able to socialize. Instead, these traits relate to whether socializing feeds or depletes our energy. Extroverts are energized by social gatherings, and leave feeling like their batteries have been recharged. Introverts are the opposite: social gatherings sap their energy, and they leave feeling more drained.

While it might seem logical that extroverts are more likely to become therapists than introverts, I have not found that to be true. I know many people who work in various human services who are introverts - myself included. It does present a challenge, however: work that is already draining may be rendered more draining by its social nature.

We may compensate by spending more of our free time alone or with close others...but introverts, like all people, also need social support, and so we need to spend at least some of our free time nurturing real-life relationships. It can be hard to strike the right balance to support our work, our need for support, and our need to recharge our batteries. Extroverts may face a similar challenge in trying to balance their need to recharge through social contact with the need for self-reflection and centering that therapeutic work also requires. In both cases, it is crucial to pay attention to our own inner state, energy levels, and needs.

Are you an introvert or an extrovert? Do you experience any difficulty striking the right balance between competing needs? How do you recharge your batteries?

The Medical Necessity Catch-22

Last month, I expressed frustration with insurance companies' reluctance to cover medically necessary treatment just because the client was experiencing (normal) ambivalence about behavior change. This week, I am (yet again) frustrated with an insurance company's initial refusal to cover treatment, this time for the opposite reason.

To be fair, they did pay for 7 weeks of inpatient and residential treatment thus far - due to the severity of the client's anorexia and the risk of death or medical complications as a result of very low weight. She was one of several patients discharged from residential last week because of contagious illnesses, with the understanding that she would re-admit once she was feeling better. Still at a dangerously low weight, with abnormal labs - but miraculously not having lost weight since discharge, in spite of illness - the insurance initially declined to authorize her readmission. Their rationale? She IS motivated for recovery, didn't lose weight and her electrolytes were within normal limits. 

Wait, didn't they just tell me they only wanted to pay for treatment for motivated clients? 

This client had gone to some pains to prevent weight loss and normalize labs because she was afraid she'd wide up inpatient instead of residential. Had her hard work basically undermined her ability to qualify for treatment at the appropriate level of care (i.e., residential)? What message does that send to clients, and at what risk?

Thankfully, when I appealed the decision, they did ultimately approve her readmission to residential. However, I'm still frustrated. Refusing to pay for treatment because clients are too motivated (in this case, claiming she could recover with less intensive treatment because she was motivated), or because clients aren't motivated enough, puts clients and clinicians in an uncomfortable catch-22. Whatever the client does, s/he gets the short end of the stick. 

For clinicians, we're faced with the daunting task of walking the tightrope in advocating for our clients: we need to frame the clinical information we provide to insurers to highlight just the right degree of motivation and progress. Too far in either direction, and our clients could be refused treatment. For clients, the danger is that those who are denied treatment for being too motivated or working too hard on recovery will learn that they need to be more symptomatic to get the treatment they want and need. When the symptom could be deadly, that's a serious concern. 

Yet another reason why healthcare reform should be a significant priority!

Medical Necessity, Revisited

Several months ago, I wrote about the intricacies of "medical necessity" - the criteria insurance companies use to determine whether to pay for treatment. Most basically, treatment is deemed "medically necessary" if:
1) there is a diagnosable (i.e., DSM or ICD classified) mental disorder, with evidence of specific symptoms supporting the diagnosis.
2) the mental disorder causes significant impairment in functioning, in areas such as social, occupational, educational, self-care, and judgment
3) the proposed treatment is consistent with accepted standards based on disorder and level of impairment

Ideally, it boils down to this: the client has a mental health problem that is getting in the way of functioning; treatment is offered that is appropriate for the client and problem; treatment follows a plan and results in improvement. The treatment continues to be deemed medically necessary as long as there is some improvement in response to treatment, but symptoms and impairments continue.

Unfortunately, even this isn't always enough for insurance companies. I have been dismayed to have several conversations with insurance reviewers lately in which they were reluctant or unwilling to cover "medically necessary" treatment (i.e., diagnosis, impairment, clinically appropriate intervention, improvement in response to intervention, and continued impairment) - just because the client was ambivalent about recovery.

I've also written in the past about ambivalence...and so have people far wiser than I. An extensive body of literature has been developed around the centrality of ambivalence in all kinds of behavior change. Much of this literature hinges upon the Stages of Change model, which suggests that people go through five stages during the change process (though not necessarily in a linear fashion, and often several times before lasting change occurs):

1) Precontemplation - the person is not aware of, or at least not acknowledging, the existence of a problem or need for change 

2) Contemplation - the person is aware of the problem, but is torn between staying the same and changing (i.e., ambivalent) 

3) Preparation - the person has decided to make changes and is getting ready to act 

4) Action - the person is actually working on change 

5) Maintenance - the person is working on maintaining changes

Relapse - a return to an earlier stage (e.g., a resurgence of ambivalence) and/or reverting to pre-change behavior - can happen at any point, and the process of change resumes. The ultimate goal is to transcend the maintenance stage - to get to the point where the person no longer has to work on maintaining the change because it has become ingrained. Motivational Interviewing is largely designed to help people work through their ambivalence and progress through the stages of change.

The bottom line of all this is that ambivalence is absolutely normal and to be expected in the course of changing longstanding behaviors. Good treatment - treatment that adheres to acceptable standards in the mental health professions - works with this ambivalence and helps people to resolve it in a way that affirms life. I consider this early part of treatment absolutely necessary, because actual changes can't happen (or at least can't last) until ambivalence is addressed.

I find it deeply disturbing that insurance companies do not want to pay for treatment when the client is ambivalent. I find it even more disturbing when we consider that many behaviors that are a focus of treatment can cost people their lives - drugs, alcohol, eating disorders, self-injury.... If my client has a life-threatening problem and is on the fence about changing, I see treatment as beyond medically necessary - treatment is often the thing that tips the balance in favor of change, and therefore moves the client toward life-preserving change.

If an insurance company sends my client away until they're "ready" and 100% committed to change, what will the cost be? What will the literal cost be to the insurance company when that client keeps needing a higher level of care, and more importantly, what will the cost be to the client in lost relationships, opportunities, or even life itself?

I think it's time to redefine what we as a society consider medically necessary.

Breaking Up is Hard to Do!

A lesson learned early in life - breaking up is hard. It hurts to be broken-up with...but it also hurts to be the one doing the breaking. It's still a loss, even if it's your choice, and you think it will be better for you overall. It's also hard to know you're hurting, and/or letting down someone you've cared about.

Leaving a job is a lot like breaking up - whether you quit, or get fired, one party in the employment relationship is choosing to end it. Feelings stirred up may include sadness, anger, disappointment, rejection, abandonment...maybe even feeling betrayed by the "infidelity" when someone went looking for another employer/employee without letting the other party know their intent.

I'm reflecting on this because I resigned this week. After accepting a full-time job (I'll be at a new eating disorder partial hospitalization program opening in December), I had to tell one job I'm leaving completely, and tell the other I'm cutting way back on my hours and clients. It was nerve-wracking for me, and awkward, and I continue to feel like I'm letting people down.

And then there are the clients. Leaving a job as a therapist (usually) means ending relationships with each of your clients. This is the part of my job transition that is hardest for me. I'm painfully aware that I'm terminating not because it's clinically indicated, but because I'm choosing to leave. I do this work because I want to help people, but now I'm doing something that hurts. Of course, they will all still be able to get treatment...but one relationship doesn't replace or erase a previous one. It's still a loss.

It's a loss for me, too. These are people I've come to know and care about, and for whom I've worked hard. What's harder than the loss, though, is accepting their expressions of hurt, disappointment, betrayal, and abandonment. All while still finding a way to say a meaningful goodbye that solidifies the progress they've made and lays a foundation for the work they have left to do.

Yes, breaking up is hard to do!

I'm spending the next ten days or so making referrals, summarizing treatment, and speaking and writing my goodbyes. I'd love to hear how others thing about, and go about, this challenging part of therapeutic work.