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Sunday, September 20, 2015

ICD-10-CM and the Panic that Numbers Ensue

For those of you who do not know the meaning of ICD-10-CM, it is the International Classification of Diseases, a lengthy clinical catalog system conjured up by the World Health Organization (WHO) to designate medical codes. Physicians and clinicians everywhere are bound by them, use theses codes for billing and diagnostic purposes. The ICD-10-CM replaces ICD-9 on October 1, 2015.

To bill, we need to code, and start with procedures. Your primary care doctor perfunctorily codes hundreds of procedures, ranging from removing a dot on your skin, to listening to lungs, heart beats, peeking down throats and wiggling toes. General check-ups might be called wellness visits, now, because things just have to keep changing.

Mental health professionals have only a few procedure codes, a handful, really. Is this an initial evaluation? Group or family therapy? A 15, 30, 45, or maybe a 52 minute-hour? There are a few more.

Then come the codes for diagnoses, naturally. Here's where mental health professionals choose from a considerably wide menu. In the diagram below you'll find some thirty new diagnoses per page, 21 pages in all beginning on page 839 of the appendix in the back of the DSM 5. Therapists tend to keep it simple, stick to basics, anorexia, ADHD, substance abuse and dependency, psychosis, depression, anxiety, autism, and the many variants of common constellations of complaints. But we shouldn't, there is so much more. Go up and down the alphabet, you name it, there is a code for something you never thought that much about before.
ICD-10 DSM-5 codes translated

And there might be a specifier. Is the disorder recurrent? Is it severe? Does it have an organic cause, or a severely anxious component? Are there hallucinations?

Etc. Rock on.

I owe my suite-mate mountains of gratitude, because for years she has provided me time to kvetch between patients. She gives me advice and empathy, and seduces me with candy to keep me awake on the job. But for six months, at least, she's been making meaningful eye contact as her patients slip into her office and I await mine. She'll look serious, and with a raise of both shoulders a slow shake of her head. She inhales deeply, then sighs before booming:
How are we going to prepare for the ICD-10?  It is coming soon!!!! 
I look heavenward, eyebrows frozen in an arch. Nod.

Thinking me not taking this seriously enough, she rants on.
If we don't code properly they will reject our claims. And some codes will be paid at a higher fee schedule, some lower. We have to know!!! I'm getting emails about this from every insurance company under the sun! And I'm making a wedding! I have NO time for this!!!!
Send me the links, all I can offer, mustering an ounce, no more, of compassion.

See friends, it can't be that hard. It really can't, and it isn't. It is far harder for medical providers who have to code that it is the left shoulder, not the right, the right kidney, not the left.

But we will have to  learn all new codes, all of us. The old ones are defunct as of October 1; why, no one knows. And, from what my buddy tells me, procedure codes will pack more meaning.

So because I do have the time, I take twenty minutes and log onto a workshop from Optum, a United Behavioral Health (United Health Care) insurance product that I don't accept, but once did, many years ago when getting on the lists of behavioral and mental health managed care products seemed like a good idea. (Just try to get off. It will take you years, but do it. Don't work twice as hard, twice as long, for even less money.)

Here's what the good people at Optum don't say. They don't tell you what codes to use to get paid more, naturally, because a managed care company is not interested in you making more money. If anything, when you call a managed care Provider Relations Specialist, you might be counseled to code down. That way you, the person seeing the vulnerable patient, will be paid less. The managed care company keeps the money. Hello.
Note: no Aspergers in DSM-5

The mellifluous, compassionate presenter makes the whole experience go down easy, puts the care into managed care. As if you need that. Here's what she does say, notes from the slides.

1.         Coding the diagnoses: Read your DSM 5!

All of the new codes are right there, in a white rectangular box with the old codes. Below the words, Autism Spectrum Disorder, in the picture above, you'll find 299.00, the old ICD-9 diagnosis. And next to that, F84.0, the ICD-10 dx.

For patient visits on or after October 1, 2015, code with the ICD 10, in this case, use F84.0. Not before.  For visits in September, or for back visits in 2015, use ICD-9 codes. 

Never use both codes. 

Oh!  And there are even newer codes, code changes since the publication of the DSM 5. Go to Psychiatry.org/dsm5   and scroll down to Updated Disorders.  

We will still need to code for medical, psychosocial, and functional levels and prognosis.

In case you haven't really read your DSM 5, you can just skip to page 839, the appendix mentioned above, for a quick and dirty translation of codes from ICD 9 to ICD 10. Except for the changes we just mentioned above.

2.         There is something new to be concerned about on claim forms.

Whether you code by paper or online, electronically, you'll have to indicate if it is an ICD 9 or 10 diagnosis/procedure. 

For paper claims, in box 21, at the top of the box, all the way to the right is a space. Your billing program is already filling that with a '9,' probably.  You want to make sure, for visits on or after October 1, 2015, that it changes that '9' to a '0.' White it out and change it if your program fails you.

Electronic billing will offer choices with radio button, a lot more fun.

To add to the fun, there is an industry standard with electronic claims (form 837). For ICD-9 it looked like this: BK= ICD-9.  Now it will look like this: ABK = ICD 10  No one seems to have any idea what this is all about. Before Kugle? After Baking Kugle? No one knows.

3.         Authorizations, eligibility and benefits

The drill is the same. If you're paid as a managed care provider you will be calling for authorizations, etc., when you see new patients. You don't have to call to reauthorize care for patients who have already been authorized. Remember, however, that I sat through an Optum workshop, and other managed care groups may differ. Best, in my humble opinion, is to get out of network and not have to care. But we all start somewhere.

4.       Specifiers
I indicated above that you will have to specify specifiers, but I'm still not quite sure how. In the DSM-5, however, there are particular codes that you will be adding to your codes, just to keep it all simple. For example, if a patient has been depressed for ten days, not two weeks, check, other specified. If he's been down for two-weeks, then specified.  So clear.

5.      Autism/Aspergers
Aspergers is no longer a diagnosis. It will be considered High functioning autism. All those tee shirts, gone to waste. 

6.      HIPAA 5010

Since 2012, if you're good with HIPAA, you're probably still good. As for me, it is time for another workshop. BCBS, I'm told, has a really good one.

7.  Wrap Up

The Optum workshop kindly provided another link for more information, which we all will surely need, the APA Understanding ICD-10-CM and DSM-5-A Quick Guide.  In straight, easy English, it is a delight, worth a read. 

Remember. . . Time's running out.

But don't panic. You can do this. Even if you are planning a wedding.


Friday, September 04, 2015

Snapshots: Mostly Jewish

We're not likely to get that short
(1)    Looking up  

The other day we were standing in stocking feet and I asked FD, “Am I getting shorter?  And what happens when do you get shorter? Do you lose weight?”

He faced me and said, with certainty, his head inches from mine,
“Yes, you are getting shorter. We all get shorter.” 
He didn’t respond to the weight question.

And I noticed, as he said this, that he had lost some height, and that my chin didn’t point up as high as usual as we spoke, and our eyes weren’t level, but they were almost level.

It was alarmingly intimate.

(2)   Holidays and guilt  
FD waking me up with the shofar

It has happened many times. I’ll be listening to a patient who will suddenly look directly at me, across that perfectly calculated space between us, and declare:
“It’s Catholic guilt. The problem is Catholic guilt.”
There will be a pregnant pause, then a bold continuation:
“You Jews have it too, I think. The guilt.” 
And I confirm this. It is true, for many of us. Guilt is a code that we live by.*(1)

About this time of year I print up a little piece of paper and hand it out at the end of visits.

Here's a list of dates for Jewish holidays coming up. I won't be working or returning calls on these days,*(2) but will get back to you asap. Understand it could be a few days before you get a return call..
Think of this as a yoga retreat for me, out in a desert, far away, but intermittently hopping on a plane, a proverbially late plane, and coming home to work between asanas.
Use the emergency contact if necessary.
Okay, I left out the line about the yoga retreat and the asanas.
Just some of the Jewish holidays

The retreat for Jews, those who sign up, begins in the first Hebrew month of the lunar year, Tishre (rhymes with wish-day). Rosh Hashana. The holiday will be here with the setting of the sun on September 13, a two-day affair, cuz we're Jews.

Then, ten days later, it will be Yom Kippur (the Day of Atonement/Judgement), then Succot (why not build a new home in the backyard) four days after that, culminating with a wild celebration (for the most part alcohol free) Hoshana RabaSimchat Torah, not shown on the calendar above. It goes on and on, or certainly feels that way, and can be quite serious, sobering, which is why many observant Jewish doctors are nowhere to be found on the holidays, except for FD. They seem to find him. 

Even as he's being paged, we're like kids on Christmas, on our best behavior, worried about the King's decisions for our future, no idea how it will all turn out.

What's interesting to me is that there's real anticipatory anxiety going on. Heavenward attention (fear) starts well before Tishre, the month of judgement. Even in the last month of the year, the one we're finishing up just now, Elul, we think that God is listening, a little closer, like at weddings (She attends! Go ahead, ask for it!). The sound of the shofar, the ram's horn, is heard at daily morning services in Elul, loud, insistent, sometimes whiney--plaintive, a plea for mercy. Or a plea for return. Or both.

Some people begin to get nervous mid-July, even before Elul, in the month of Av. As soon as the summer heats up they start examining how they are living their lives and what they should be doing better, differently. It can put a damper on your summer, honestly, examining your deficits.

Emotions are a roller coaster until court is adjourned late in the evening on Yom Kippur, ten days after Rosh Hashana (although the gates remain open, really, until the end of Simchas Torah, and naturally, we're judged every day, in the moment, not for the past so much, as a general rule). But on Yom Kippur the future of every city, tree, insect, person, animal, turtle, lizard, flower, giraffe, and fish is determined. The fast greases a positive verdict.

We'll say, if someone dies just before the new year,
God of mercy, the Old Mighty gave her the whole year
Or when something tragic happens, any time of the year
 It was decided on Yom Kippur
This is an answer, see, to the big question of Jewish guilt, and even the big Why questions. The answer might come down to (1) not praying hard enough, (2) withholding charity, and (3) not making it happen, that promise the year before to very specifically change our behavior, or worse, having no intention to do so. Everybody has to chip in, the stakes for the entire world ride on it.

So you get it, Jewish guilt.  I have no idea what subscribers to other religions have to complain about.*(2)

(3)     Yahrtzeit  

Holidays aren't the only annual interventions. 

When the anniversary of a death is anticipated, families have different ways of handling what can be a healing, if emotional experience.

Some make calls, check out feelings of sadness, empathize and commiserate. There are plans to meet at the cemetery, drop off a flower, or share memories on WhatsApp or a private Facebook group page (others are very public about it). Or there's a picnic. I had a photo shrine pic ready for a previous draft of this post but took it down because FD said Internet stalkers might bother my mother in Heaven. My cousin has pictures of her mom all over her apartment. Sometimes I wonder if our fathers are jealous.

We go to the effort of socializing on or around an anniversary, because we remember, or maybe we forget, but want to connect with other people who remember. Or maybe we just like being with others who care, who still grieve a little, that time of year.*(3)

And it has been said in many a doctor's office, a therapist-type doctor, while tracing emotional cycling, that the anniversaries of deaths are associated with a spike in negative emotion, sadness especially, maybe even depression. The change might begin months before the anniversary. I told one friend who gave me plenty of notice about a dinner invitation that I'd need a rain-check, wouldn't be in the mood. Too close to the yahrtzeit.

The yahrtzeit, for Jews, marks the day a parent, child, or sibling died. We might keep a yahrtzeit for grandparents or aunts and uncles, or other special people, too, but it isn't technically ours. Again, the date of the anniversary is as it lands on the lunar calendar, which varies year to year on the Gregorian calendar (the one most of us keep, January, Feb, etc.) It can be confusing because even Jewish types don't use the lunar calendar much, except to check on the proper time to light the Sabbath and holiday candles.

So we're never really sure when the yahrtzeit will be unless we check that or use a phone app. Or we can wait for a postcard from the synagogue,
Remember so and so, whose yahrtzeit is on such and such a day 
 Most are not so crass to ask for the check, but it might be implied. It is also an invitation, really, to stop by to say kaddish, the special remembrance prayer.

But for many of us, knowing when it will be is too important to wait for the shul's notice. When one of us figures out the date we'll inform the rest of the family.
September 3 is Mom's yahrtzeit; let's do dinner that week.
Or maybe we'll get more specific,
This year, mom's yahrtzeit, the 19th of Elul, will be on Thursday, September 3
Figuring out when will it be can trigger strong emotion, that's the beginning of the anticipatory anxiety I'm talking about. Maybe our brains are reenacting the stressful times attached to the death itself, or the anticipation of the death itself. I randomly remembered, two days after a yahrtzeit, when someone mentioned going to the ER at St. Francis, how I threw myself on my mother, as the paramedics hauled her in on a gurney at the beginning of what was to be the end and said, in answer to her question, "You're not going to die."

So the yahrtzeit is grief work, reliving a trauma, and the experience feels a little like acute stress disorder.

It all makes sense when we're in the moment, when someone is dying, when a death is imminent, inevitable, and comes to pass. Elisabeth Kubler Ross famously noted five stages of grieving: denial, anger, bargaining, depression, and acceptance. For that emotional resolution to continue annually, however, years after someone's passing, tells us everything about how we're made. *(4)
We might forget where we put our keys, may have no idea what we're looking for when we walk into a room, cannot remember who we saw yesterday, but we're wired to remember the important things.*(5)

*(1) If you are too young to know the Crosby Stills and Nash song, Teach Your Children Well, here's a link.

*(2)  Probably all religious codes are the same, capitalize on fear, assuming that within that code is tucked the concept of divine retribution. That tickles our most primal fear, the fear of annihilation.

Which Darwinists believe is burned into our DNA, and mental health professionals insist is a product of parental behavior (the rod), instruction (talks at night before bed, rewarded with hot milk and cookies), and institutional hypnosis (Hebrew school).

Jung's concept of a collective memory explains why all of us, at certain times of the year, are programmed to feel certain ways. Americans just feel like lighting up the barbecue on July 4th to make fireworks with that lighter fluid, consciously or subconsciously looking skyward for the rockets red glare, ala 1776. Groups remember even ancient history, like the Jews remember God holding a mountain over our heads, making us an offer (the Torah) that we can't refuse. Memories are passed on in some still inexplicable way. Gotta love Jung for this one.

Therapists might say that the emotional programming of the Jewish high holidays is necessary because most of the year we're sleepwalking.

And there's this comforting feeling, too, when the season fades away,when everyone anticipates getting back to work without interruption the second week in October this year. We turn, not only to friends and family, but to our Maker, and say,
Same time next year 
 We hope in Jerusalem, if at all possible.

*(3) The crazy thing, should you do this, pass along the memories with one another, discuss feelings about the relationship you had with a person long gone, is that it affords an opportunity to work out some guilt, or neurotic misgivings, legitimate regrets, too, even anger. My brother, at dinner on Sunday, told me that he felt guilty for one thing only, not taking Mom out to dinner more often. And I told him, that after two years, I'm working through some of mine for not confiding more, not telling her the things that might have made us closer, and not listening to her often enough, because I knew she always craved more intimacy with me. If you don't do this, don't have the dinner, don't do anything that brings a loved one to life once again, it is your own loss, imho, and experience.

*(4) I'm told it improves as the years roll on, the intensity of grief work. That's what I tell people.

*(5) The important things, unfortunately, would include traumas, and for that, everyone needs therapy. For the things parents teach us, the things that stick, no matter how many days pass, we might need therapy, too.

Friday, August 21, 2015

Headspace and Mindfulness Revisited

The other day FD sighed, "You never blog about me anymore."

Mindful fishing

So I asked him (for a good offense is always the best defense), "Why do you bother wasting time fishing? You bring home nothing and the salmon at the store are bigger and better, and no worms are wasted."

I don't mention that the recent pic of a three-inch blue gill made me sad.

"It is relaxing," he says. "and allows me to spend some quality time with my grandsons and clear out my head."

So I wonder,
Might everything that holds our attention, that helps take our minds away from the stress and anxiety of every day life, be considered a mindfulness technique
I've heard people who downloaded the phone ap Headspace say that even five minutes a day, the minimum recommended dose of mindfulness meditation, is too hard to fit into their daily schedule. The process of mindful meditating is very easy if its essence is attending to one's breathing, becoming attentive to the five senses, and "watchful" of thoughts. Yet it feels like it should require some kind of warm up, maybe yoga clothes or something. A mat.

Not having gone farther than open Headspace, which calls for an email address immediately to continue, it might be presumptuous to recommend it. But my thinking is why not try it, at least until you have to plunk down the monthly fee, soon after the first ten days, pretty sure. I recommend it to those who like aps and have memory leftover on their phones, because a mindfulness ap has great potential as cognitive behavioral therapy. Of course you can  do it without a mat; almost anything can be thought of as mindful meditation with the right intent: walking, running, babysitting (maybe not when the baby is awake), shopping, gardening, whistling, even driving, although maybe driving isn't the best idea, unless you are being mindful of traffic. This is all about leaving judgments behind, losing the good/bad, sick/healthy, beautiful/ugly ways we look at almost everything.

Lose the labels, lose language if at all possible, and just live and experience life. No, that is not easy, but it has to be healing. That said, it probably won't make you rich, like they say on the radio in the Headspace interviews.

We can look at other behavioral applications that work, too, that also enable us to experience the moment to the fullest, do a comparative analysis. (They likely won't make you rich, either). Fishing, for example, is  a mindful sport. Because FD is relaxed merely reeling in a tangled bunch of string hanging from a pole, he can handle his thoughts, judge them less, because they don't upset him so much. He'll judge himself less, too.

There are other ways to get to this benign place. Once my nephew bought me a ticket to a new and trendy sensory experience, a pool, probably the size of a mikvah, encased in a soundproof, totally darkened room, designed to recall the womb, bring a soul back in time. He didn't know that I'm afraid of the dark, so he wasted $25.00, but I can see why he would think me a good candidate. Anything for nothingness. I think I still have the coupon somewhere.

So fishing works like that, and so does a sensory deprivation pool, probably, as does tennis and other sports, too!  How can anyone think about problems or anything else, when there is even a remote possibility of returning a ball well, perhaps even finding the racquet's sweet spot. It is all any tennis amateur cares about, really. Golfing is the same way, focus to connect well. (If only our focus to connect with people compared). And what is smacking a baseball, getting a hit or a home run, if not concentration upon the present, the speed of the ball, the arc of the pitch. Maybe all sports are mindfulness techniques, and maybe they are all recommended in the Headspace ap.

Therapists have always liked CBT because you don't need to change clothes, certainly, to work it. To counter a negative thought with rational thinking, for example, one might be in tuxedo. It is the same with mindfulness, which is probably best in comfortable clothes even in nothing at all, assuming we can lose our judgements, reservations. Who doesn't focus on the pounding of water on skin while in the shower?  Or the smell of soap, the steam? We can counter a negative thought in the shower, too, think how irrational it is to think we aren't as good as other people.

So why not put mindfulness into the CBT bucket, or shower, and put the CBT into mindfulness, even suggest the two can be one, if performed well, like most twos.

Wait, before we combine them (consider that done) a few more thoughts about meditation:

Mindfulness is marvelously adaptable, a flexible approach to feeling good, and it probably lowers blood pressure, but not cholesterol, because feeling good, a person who likes to eat is likely to just go for it, abandon a diet.

Also, we probably should mention at least one other meditative school, the Maharishi's meditation of the sixties, repeating a mantra, or even dharma, returning everything into white, as the Carly Simon song goes, to experiencing everything that is both inside and outside our selves. These are less flexible, compared to standing on the train on your way home from work and becoming mindful of your weight on your feet, or how fascinating it is that the brain does this job, balances you, not without help from a germy pole held tightly in your fist so you don't fall, a mindfulness exercise. Actually, the Maharishi wasn't a fool.

Long-time readers recall my reservations about mindfulness not so long ago. Someone suffering from severe anxiety had panic attacks at a mindfulness workshop. He asked me to give it the nod. Should he try it? Sure, go to the workshop. What have you got to lose? He suffered panic attacks at the first meeting and the instructor blamed him for doing it wrong.

Rethinking it now, of course anxious and depressed people (and who isn't) might likely to be even more anxious or sad in a group workshop, so many eyes in the room, so much new information to digest, instruction to execute. So we talk about that and much, much more at length in therapy, before shooing anyone off to a retreat, and suggest people are mindful of mindfulness training. Think of it as a weekend at a mental gym. Really want that?

But now, at least once a week, finding myself at that inevitable therapeutic impasse, because therapy is full of these, I'll bring up behaviors that define mindfulness as alternatives to whatever is holding us up, either negative thinking, ego-dystonic behavior, or emotional pain. These are the ABCs of CBT, cognitive behavioral therapy, fyi, affect, behavior and thought.

Because Aaron and Judith Beck got here first.

But they didn't say it quite this way.

A quick look at the basics (according to TherapyDoc who has read many books on the subject, if not opened the ap):

(1) attend to things inside, turn your attention to the rumbling of the stomach or heartburn, the feel of your socks on your feet (take 'em off if no one is around), whether or not you are hot or cold, how your breath feels inside your nose, the tiredness of your eyes, etc.

(2) attend to things outside of you, the ticking of a clock, the gurgling of an aquarium, the noise of the dishwasher or fan, the smells of cooking, the shadow of a lamp on the floor, the glow of the bulb inside the lamp, the different pieces of furniture in the room. Touch a person. Or if you are outside, watch the clouds in the sky for longer than a moment. Cloud-gazing is the original Rorschach test, so you can analyze what you see, what it says about you. It tells me that I really don't like giant ants.

(3) Keep on attending, watching, everywhere, all of the time. Be in the moment. If thoughts interrupt your discovery, watch them, too, even see them as words on a piece of paper, don't judge them or be upset about them, they are only thoughts, not real events, not happening right now. Sure, they may have happened, or might happen, but stay with what is outside of your brain, right now.

(4) Emulate others in the animal kingdom. Check out this bird, for example. No intention of letting anything bother him.
Nothing but mindful

(5) Emulate children. When they go to a rocky beach, they don't complain that it is too hot or too cold or there are too many people. They skip rocks on water, throw sand, consider what they can do with it, because there is so much! They search the earth and the sea just to see what they can find, right there in the moment, and this makes them happy.
Cloud-gazing mindful

Skipping stones-behavioral mindfulness
And they watch clouds, too.

They also play games.  Consider an adult version of freeze tag. Catch yourself thinking, doing or feeling something you don't like to feel, think, or do. Then freeze. In the game someone shouts freeze. So do that, shout freeze. 

Then take in all that sensory information we discussed in #2.

(6) Work your imagination. If you catch yourself thinking thoughts that feel mentally destructive, get creative, go to what you're going to make for dinner, what you might do in the evening or the next day, even think about what it would be like to take a vacation. Change your life story and make it into someone else's life story, more interesting, how you would see it in a movie, a romantic comedy. This can be hard, so let your mind wander to the places you know about, like what's in the fridge, what should be in the fridge, what music would be nice to hear, what you can do for someone else. Let these thoughts ascend, and the ones that upset you, deflate like lead balloons. See thoughts inside balloons that are losing their helium, coming down, down, down, until they are nothing but scrunched up pieces of blue, red, yellow and white rubber that might or might not have to be recycled.

Too much to ask? I hear that mats are only ten bucks.


There are many good books on mindfulness, try Buddha's Brain, by Hanson, and the mindfulness solution for pain, by Gardner-Nix,  (not that the book will necessarily take away your pain, but the idea is distracting).

the mindfulness solution for pain, by Gardner-Nix

Buddha's Brain, by Hanson

Friday, July 17, 2015

How to Save a Life (Part Three): Arguing with Suicide Intent

It is summer, and you wouldn't think people are too down, but maybe it hasn't been the best summer for everyone. Hopelessness doesn't always flip with the seasons.

A patient described panic symptoms, not knowing that she had suffered a panic attack. 
"But I told myself," she went on, "that everything will be all right. And it was!"
multiple meanings of spiraling BALANCE  

Therapists, friends-- we all say it with confidence: Everything will be all right.

The reply, "How, exactly, do you know?" is the tricky part. How do we know?

Emotions are temporary states, for one. We cannot stay in the same exact emotional headspace forever, wired as we are with homeostatic neurological and hormonal systems. Without therapy, we are changing all the time.

And therapy has improved exponentially in recent years.  Interventions are tested and have proven empirically effective. Change is so likely that when hopelessness spirals out of control and patients talk of suicide, therapists apply an adage,
Suicide is a permanent solution to a temporary problem.
There's so much else to do. But a body has to get there, has to get help.

There's a post on this blog (February 16, 2009) about a popular song, How to Save a Life by The Fray. The essay is long and winding, refers to the ballad, a lay-person's failed suicide intervention. The gist of the post (and one that follows, How to Save a Life, Part Two) is that when in doubt, when a friend talks about suicide, get him in for an evaluation, somehow, even a hospitalization, a visit to an ER with you. After that a primary therapist, and likely a psychiatrist, too, will shoulder the responsibility. As a friend you are a first responder, but not the last.

Fray has the right idea.
Step One
You say, 'We need to talk.'
He walks away, you say, 'Sit down, it's just a talk.'
The purpose of the talk, even between friends, is to evaluate the situation. How bad is it? Poke around the topic especially, as the song suggests, at the end of the evening, when everyone else has gone home, but just one person is still awake, prowling around grumpily after the party. Sleepless.

It's just a talk.

See if you can get to something really important, suicidal intent. The plans actually follow the decision. So sniff out intent, that's how you know the answer to the question, How bad is it? Add to the list items about thoughts and plans. Invade the privacy, pass through social stop signs to check out sad friends. The refrain . . .
Where did I go wrong, I lost a friend. 
is simply too sad.

It isn't easy, prying like this. Mental health awareness advocates spend their days organizing suicide awareness walks,  prevention months, weeks and days, to teach us how to pry. These are opportunities to bring up the subject, good times for the talk, perfect segues into a difficult subject.

As are podcasts. There's one by Cheryl Hamilton, totally worth a listen.. Teaching a wilderness search and rescue class in New Haven Connecticut, with no training in it, she accidentally stumbles upon a young man intent upon jumping off a ledge to his death.  She tries to talk him down, and the results, the effect upon her, and perhaps upon him, too, startle them both.

The difference between where I'm at now and where I was in 2009 is that I'm a lot more confident in having the talk. You see, even being a therapist, this is a difficult discussion. You can't be too confident when you are dealing with hopelessness, can't be too smart, and should never get too lofty or too glib. So having more confidence could be bad, and can come back to bite you. But when you learn more about suicide, you do get more confident, and if you can keep it in check, will be more effective at this whole saving lives endeavor.

At some point after writing the How to Save a Life posts, I had a very sick patient who had been suicidal all her life, and it was one of those things where you want to punt to someone smarter, but the patient already likes you, so you can't. And you like her, too, and can never be too sure, when you suggest someone sees someone theoretically more qualified, that that person, the one to take over for you, really is.

So I dig in, embrace the therapy, and one day happen to be checking out the University of Illinois Bookstore online. I'm there to see what the professors are teaching in clinical social work methods these days. I find gold, a reading requirement for a class in treatment, a text by Shawn Christopher Shea. Dr. Shea is a pioneer in a new methodology, the CASE approach, Chronological Assessment of Suicide Events for mental health professionals.

Shea's text, The Practical Art of Suicide Assessment is technical, and for therapists, but could be for anyone. Rock star Kurt Cobain's story, for example, and his suicide note, make up almost an entire chapter.

Just a few take-aways for now on the reasons, or triggers for suicide, and a bit on intervention. It isn't like we can stop here, but if we know what really causes people to make the decision, we might be more able, if not so confident, in having the talk, and yes, punting for help if desired.

Start by forgetting the myth that suicide is always an act of a disturbed, depressed individual. (That myth is in one of these posts somewhere). Suicide is a decision, a way to solve a problem. It is about feeling cornered, or trapped in a painful dilemma. Note the language, painful dilemma, not depression. Sometimes people perk up and feel just fine after making the decision.

Step One, therefore, is the same, the talk, talking about the triggers, the dilemma. Then when that is fully fleshed out, when no more words from our sad friend are forthcoming, we might begin to wind the conversation around the rationale for it, for that decision, the pros and cons of suicide as an intervention. It isn't the most rational solution, although it might work. But it might not. Even in our death, our problems continue to affect others. And maybe people don't want to do that, hurt others, saddle other people, people they love, with their problems.

The triggers according to Dr. Shea:
Every therapist should have them memorized before stepping into their first job, but again, everyone else should know them, too.

1. External stressors: deaths, rejection, public humiliation (a big one), and serious illness;
2. Internal conflict: psychological impasses, unconscious conflicts, cognitive distortions and binds;
3. Neurobiological dysfunction: exogenous toxins such as alcohol and cocaine, endogenous (already there before situational stress), and pathophysiology, the biology of depression, for example, or other illnesses.

Once we have the triggers on the table, the words are, Build on that.

Again, just for today, let's just look at the first trigger, external stress, a loss, perhaps a death.

Ask about the impact of that loss, how did it really feel? How did it affect the present, life today, practically speaking? What will be missing now that things have changed, now that there is no job, or now that someone has passed away? Can the loss be replaced. Is that even possible? Is there a satisfactory substitution, if not a replacement? And finally, can the patient see that the pain will lessen eventually, even end?

The answers to these questions clarify the direction of a friend's (or patient's) strategies for coping. Because at the end of the day, suicide is just one way to cope. There are others.

Once I asked a patient who had lost someone a similar barrage of questions, including her belief in an afterlife. She did believe in it, and contrary to that helping her feel better (her friend being in a better place), the belief had solidified her desire to hand out together in Heaven. She didn't believe God punished those who put themselves out of pain by suicide. So we had to discuss that, see if there were other ways to be together, like rereading emails, attending to surviving family members.

This is cognitive behavioral therapy, or CBT. with its focus upon thoughts, triggers, the dilemma with the potential to culminate in a deadly decision. The goal is to find alternative solutions and to debunk the rationale for suicide.

We ask a few good questions of the patient: Will suicide actually work? Will it end the pain? Really, who knows? Will it solve the problem? It might create new ones, worse problems for other people. Debts might be someone else's debts, insurance likely won't pay out.

Is suicide ethical? If it causes pain for others, maybe not.

Besides suicide, what's a person to do? Here I'm talking to that person who has suicidal thoughts, intent, even plans. Stay alive, for one, to keep the discussion, the conversation going. Be open to being talked out of it. You might be bored with the topic, your problems, your reasons to end it all, saturate your interest. Strangely enough, you might get bored, but not everyone else is. Talk about the dilemma when you have that gift, the opportunity.

There really are people who are interested. Find them. These are your people. One of them will find a way for it to be all right.


Monday, July 06, 2015


The Kotel, Western Wall
It was a fast day yesterday, meaning no food or water from sunrise to sunset (we have 25-hour fasts, but this one, the 17th of Tammuz is considered a "minor" fast, less intense). FD and I woke up at 3:45 am to get in some breakfast before sunrise.

This helps tremendously, a pancake or two, a cup of coffee, a couple of preventive Advil. But when you're fasting until 9:15 pm on a summer day, you get more than a little thirsty.  I traditionally tease my children with a text, a reminder of the joke about the old Jewish guy on a train in Europe. He continuously bemoans aloud, "I'm so toisty," until someone finally listens to him. (There are variations, all with the same punchline.). It is my final text of the long day.

Anyway by 9:00 that day I'm at work, where people are often talking about food, and their diets, how cutting out certain foods, white flour or sugar especially, helps them lose a couple of pounds and improves their state of mind. Abstaining from anything is empowerment, imho, in moderation.

A Jewish fast is an empowerment opportunity of a different sort, however. It is thought that the Old Mighty (my grandfather's nickname for Her) is more accessible, a little closer on these set days, that She's really listening, hoping we'll connect sincerely, and more often. And when we fast, we're more likely to tune into that side of ourselves, the side that communes with a higher power, people say. I like to call this part of us our religious life. We have many lives, all tucked inside, and this can be one of them, or not.

When we're depressed it can go missing.

As it is also the Muslim month of Ramadan; Jews are not the only ones fasting this day. This has to be an interesting month, psychologically, for the cousins, and the world over their effort is both baffling and admired.

There are two summer fasts for Jews, one the 17th of Tammuz, then another, more compulsory, on the 9th of Av, three weeks apart. The fasts remind us not only of the destruction of the Holy Temples of Jerusalem by the Babylonians (586 BCE) and the Romans (59 CE), but also the many bloody initiatives of other nations intent upon destroying the Jewish people.
mass grave in Belson

Since the experience with Germany in World War II is so close to us, and because there are still survivors of the war, some of whom are still around to speak about it, and cinematic footage of them in dirty striped prisoner pajamas, blank-eyed living skeletons, and footage of the dead, too, ominous mountains of real skeletons, mass graves, thousands of confused, terrified men, women, and children shoved onto trains for days, no food, no water, no toilets, on their way to the ovens, and death marches, miles in the snow in those thin pajamas, sub-zero weather, those who stumble and fall, if they aren't already dead, shot on sight. The Holocaust reduced the population of Jews in Europe dramatically from almost 17 million to less than 11 million. But what is 6 million Jewish people, after all. What do Jews even contribute to society?

Oh, never mind. It wasn't my intention to go here. It is too sad. For a look at photos of the Holocaust, mountains of Jewish shoes and eye-glasses, maps of concentration camps, emaciated bodies, look at Shamash.org or better, visit a Holocaust memorial museum, like the Simon Wiesenthal Center's Museum of Tolerance  in person. Any Holocaust museum will do. Anytime.

Fasting, if you do it six times a year, for many years, is still likely to be dreaded each and every time. But it isn't really that bad, and those of us who wouldn't, couldn't, miss a fast, know it. The less spiritual can point to the benefits, purging the body of all the garbage we've eaten the week before. When the fast is over, if we don't eat too much in breaking it, if we keep dinner moderate and healthy, we feel great, assuming we haven't a "caffeine headache." (Hence the early wake up before dawn for coffee).

And even the next day, today, at the pool at 6:30 in the morning, when the body has adjusted to the cool water, the jump in serotonin in this therapydoc's brain is measurable, words for this post swimming in the brain with every stroke.

It is paradoxical that the anorexia of depression functions to increase depression, makes it worse, denies a good state of mind. The treatment is to increase appetite, and certainly, make sure the patient sleeps a solid six, at least, which is one of the benefits of medication. Sleep and food are healing.

So unless fasting is one of those things your doctor tells you to do before a procedure, or your clergyperson really recommends as a traditional way to connect to certain events and your Higher Power (assuming the pri-care has signed off on it), take all this talk of fasting from food and water for many hours at a time with a grain of salt.

Preferably on a no-yoke omelet, half a bagel on the side. With butter, thank you, and at least a quarter of a cantaloupe. They're in season it just so happens.


Tuesday, June 30, 2015

The Supreme Court, the Opposition, and the Gay Marriage Law

We have to talk about the Supreme Court decision making it a Constitutional right for gays and lesbians to marry in the United States of America. Less than 50 years ago the psychiatric community pathologized same-sex attraction, deemed it a disorder with a real DSM II code. That didn't last long.

Reporting the news, in the same breath, journalists quoted various self-identified groups of conservatives opposed to the decision. Googling "opposition to gay marriage," I found page after page after page of groups and individuals dead set against the right of same-sexed couples to marry. Many, if not most, because of a Bible prohibition.

Being one of a bible thumping tribe, the bible being the Torah, thank you, Orthodox the persuasion,
this booming opposition is a concern. There are so many commandments, and it is ridiculously difficult to keep the entire Torah, although that is the goal. (No idea what it means, by the way, to be Ultra-orthodox. Orthodox implies strict observance of Jewish law, or halach. All stripes of orthodox believe that Moses, a servant of the Old Mighty, passed the law along to the Jewish people. They were the only people who would take it, and they had to because God held a mountain over their heads, made them an offer they could not refuse.)

We could talk about all that for hours, but since it was 3500 years ago, and Moses isn't around to verify, we can only assume that he wouldn't lie to that crowd of three million who heard the Ten Commandments, ala Cecil B DeMille, as hail, fire, thunder, and lightning pounded them senseless, along with trumpet blasts, let's not forget, until they cried, "Stop! Tell it all to Moshe (Moses). We trust him. This fireworks display is too much!"

So God did just that, told it all to Moshe, and Moshe told it to those three million, who told it over to their children, who told it over to their children, who told their children, ad sterpes, until this very day.

And yes, we are still telling our children. And it is easy, because it is all written down, and sure enough, in one of the chapters there is a passage forbidding men from lying with other men. And that is why so many Judeo-Christian folks are still confused and intolerant of homosexuality. That is why there are so many opposition groups.

So, the strangest thing happened on my way to getting a PhD. I had asked for and been granted a year's leave of absence following the dreaded first-year comps. My family had a five-year plan to live and study holy things in Israel well before my decision to go back to school. Permission granted, the dean reneged about it being a year off. He wanted me to hook up with a social science professor as a research associate. That wasn't easy, but it happened, and I studied with one of the very best in Israel.

At the end of the year, packing to return home, stacks of academic articles about homosexuality made their way into my suitcases. All that literature, no matter what else might have been in the cards for me, determined my dissertation topic.  I just had to figure out how to make it something that would keep my interest in the coming years.

Being a family therapist, exploring variables in the parental acceptance of gays and lesbians did the trick. Now all I had to do was round up about 60 parents, interview and test them, and I'd be on my way to a PhD.

In 1998 most universities had not made the leap to allow researchers to look to the Internet to find subjects for study. It took some explaining at the time. At the end of the red tape (at a major mid-west state university), the Internet sample of parents most desirous to participate happened to be religious. Christians, many of them, had joined a movement called PFOX, Parents and Friends of Ex-gays, an arm of Project Exodus. Meeting together and talking about their issues, they came to the realization that hitting their kids over the head with theology wasn't working. Better to quit fighting, love them as is, and maybe someday they would give up on the lifestyle. Return to God.

PFOX is no longer around, except perhaps as a fringe group, but the entire Exodus movement, leave the lifestyle, come back to God, petered out, probably because the therapists who supported them had promised parents they could convert their children to heterosexuals (when they were ready) and couldn't. The practice of conversion therapies is and was at the time, unethical. Indeed, the major mental health organizations have all issued statements to that effect. Subjects endured shaming and humiliation from such therapies, treatments that undermined self-esteem and mental health in too many ways to count.

Meanwhile, before that hit the fan, I had managed to interview thirty-five parents who had participated in Exodus support groups. They described their own personal horrific emotional travels beginning when their child came out, or with the realization that their son or daughter would not be bringing home an opposite sex partner, this a traumatic experience for most. All dreams of grandchildren (this was fifteen years ago) dashed. Parents talked about their grief process and how they ultimately came around to accepting partners and friends, having barbeques and picnics in the kill them with love, or hate the sin, love the sinner world view. They stopped fighting, started loving, all the while hoping that their acceptance and love might change their child's predilection.

God can do anything. Let go, let God. So many of us believe this. They defaulted to love is the answer.

But nobody talked about marriage.

I heard their stories, fascinated. The rest of my sample came from the other camp, PFLAG, Parents and Friends of Gays and Lesbians, and random people who saw fliers or had heard about the study. They, too, had difficulty initially, but never thought things would change with a loving, accepting relationship. They accepted with more of a grin and bear it, This is my kid, I love my kid. Often one parent accepted. Another did not.

And now? Now that it is a right to marry? Which parents will be going to the weddings? My guess is that most parents will go, but it will depend upon so many variables, like social support and willingness to differentiate as a marital team. One parent might go, the other stay home. People will do whatever works.

And those who object, but don't want to lose their child, might be telling like-minded friends that it takes a lot to make a marriage work. The divorce rate is above fifty percent. The odds are against them. Getting married and staying married are entirely different matters.

Maybe some will even add, "But if these kids can make it work, more power to them."


Monday, June 08, 2015

The Therapist Takes a Vacation and Blurting: Six ways therapists can recover from mistakes

We all do it once in awhile, say something we wish we could take back.
You may not even notice when your therapist does it, might not even get it, but she does.
Mount Kilimanjaro

You likely will notice! And when you do, might be tempted to confront, and you might just do that. But this is a hierarchical relationship, despite all our talk about Empowerment Therapy and Call me by my first name. We come to rely upon our therapists, don't get excited at the notion of arguing or challenging them. Well, some do.

Which is fine!

But we therapists know when it's a blurt, a wish I could'a taken that one back moment, either by the look on your face, or through the words that play later on in our heads. (Many of us do this, think about you when you're gone, try to capture answers by reviewing what happened in the room.)

If we think we've erred, and shouldn't have said what we've said, we have options, some more mature than others, some more therapeutic than others. Let's start with five of them.

(1) We can wait to see what happens. If the patient hasn't questioned us and didn't look confused or upset, we might totally get let it die.

(2) Alternatively, we might call the patient a few days after, ask if she's okay, suggest that some of what was discussed last visit might have been disturbing. If we're confronted here, we have the option of explaining ourselves. Best to have the explanation ready.

(3) We might do an honest assessment to determine what possessed us to say whatever it is we said. This might take a few days, but the explanation will likely be better, and more true, with a few days hindsight. At some point the data will come in handy.

(4) We can call a consultant and discuss what happened to get another spin on it, get it off our chests.

Whether we think it through ourselves or with a colleague, it is safe to say that we don't just blurt things. There are reasons for what comes out of our mouths, and these are systemic, not all about us. The patient is driving what happens, the therapist is the passenger, occasionally sharing directions.

(5) We can decide not to decide, to wait and see where the patient is next visit. We might bring it up then, at the right moment, explanation in hand.

Let's take a quick example.

A patient of means travels often, talks about his vacations as they affect his family dynamics, mostly. But there is always a reference to the beach, and to the food. The therapist is not of means and does not travel much, but one day has an opportunity to do so, go someplace exotic.

When she cancels for the week she'll be gone, the patient gingerly asks, "So where are you going?"

The therapist tells him, straight out. The patient seems uncomfortable.

This is not a good sign. It means that the tell is a blurt, a blooper; the discussion of the therapist's vacation not the best move.

Why? He could have grimaced because he realized he had to drive car pool the next day, or something else. We can't assume, that, however because of these four unspoken laws.

(a) There is an unspoken (covert) rule that it is okay for the patient to leave the therapist, naturally, whenever he wants. But it is not okay for us to leave them. This feels like abandonment, especially if the therapist is going far away. (When I took two weeks to go to Israel a few years ago, a patient did land in a hospital. Nothing to do with me being gone, she said. Of course.)

(b) Does anyone really need to be thinking of their therapist in any other context other than in that chair, facing someone else's chair, listening intently with concern? Probably not.

(c) The less we talk about ourselves, the more the person who is paying for the visit talks about themselves, which is how it should be. Yes, even as they are walking out the door, it is about them.

(d) If an absence must be discussed, and sometimes it should be, then it is the patient's feelings that matter, not the details of the therapist's time off. When the patient asks, "So, where are you going?" the more relevant response is, "What kind of stuff do you think is going to be coming up for you while I'm gone?" Then, "And how will you be coping with that."

So a blurt, any error in judgement, probably shouldn't be ignored. The patient will be talking about it with everyone else anyway, so direct communication is more than called for. But did the patient contribute to the blurt? Only in having presented a certain amount of information that triggered something, some off observation or comment, and that needs to be discussed, too, the patient's input.

Which brings us to number (6), if we're counting Six ways therapists can recover from mistakes .

A little speech can go a long way toward rekindling the therapeutic alliance. Make it relevant to what was said, and be sure to assess what it is about the patient that contributed to your impulse to share:

(6) Last week, after you left, I thought I detected a little discomfort on your end.

I thought about what I said, that I'm going to climb Mount Kilimanjaro, thought about it a good deal. I tried to figure out why the impulsive share. So much information about my travel!. You might think it natural, after all, you travel a lot, and surely that contributed. But it didn't feel right to me, and I'm sorry. We should have just talked about how you'll be handling things while I'm gone.

Fact is, I hardly tell anyone about trips, certainly not patients. You share quite a bit about your travels, so maybe that had something to do with it, but I think there's more.

It is this wonderful quality you have that makes people want to share with you. It's true, you know, that a lot of people probably want to talk to you about all kinds of things.* So don't change.

But from here on in, I probably will.


Only say this if it is probably true. It does happen to be true about many, many people, and most of them don't even know it.