Tuesday, April 23, 2019

But what does all this paperwork mean?

By now, most of us are used to having to fill out a bunch of paperwork every time we see a new provider. Doctors, therapists, and other professionals have all sorts of forms and information we ask for before providing help, and for all sorts of different reasons. We've become so desensitized to it, that many comedians and shows have joked about not reading the terms of service, instruction manual, or even assembly guide for a service or product. Others get nervous when asked for so much information... what does it all even mean?

The first form that most therapists will hand you is the informed consent form. You might already be familiar with the idea of informed consent for medical procedures, research, or law. The basic idea of this is that the participant, patient, or client has been taught about whatever they will be undergoing, and agrees to it, with full knowledge of risks and benefits. This is fairly easy to understand when it comes to something like surgery; we know that the procedure may not work, or things may otherwise not go as planned. Similarly, therapy may not go as you expect. You may have skills to practice or work to do outside of therapy, and you may begin to notice thoughts and feelings you didn't notice before, whether due to increased awareness or to things changing. This can be quite scary. Fortunately, unlike with a surgery, you're not under anesthesia; you can talk with your therapist about how things are going for you, and adjust the plan accordingly.

The informed consent form will also tell you more about your therapist and their policies. This should include things like your therapist's licensure information, fees and insurance, scheduling and cancellation policies, and terminating treatment. Most therapists also have rules around contact outside of sessions, and this can vary a lot from person to person. Some therapists are available for emergency calls 24/7, while others can't promise to pick up, but will be able to call back. Therapists also have different policies about sending texts or emails, particularly if you want to talk about things typically discussed in session.

Therapist forms will also include a section on confidentiality. Typically, whatever is discussed in session stays confidential. There are, of course, some exceptions, which your therapist should explain to you in person. Therapists are mandated reporters, meaning that if they have reason to believe there is active suicidality, homicidality, or child/elder/dependent adult abuse, there is a requirement to intervene and report this to the proper authorities. There are also other specific cases that may override confidentiality. For example, if you are involved in a legal dispute and your mental health is relevant to the case, a judge could subpoena your therapist's records for use in trial. If you are seeing a therapist through insurance, than your insurance company will need access to information like your diagnosis. If you are seeing someone through a clinic or group, the confidentiality rules may extend to other clinicians within the same group, particularly if your therapist is in training. This information should be in the informed consent, though you can always ask your therapist if you're unsure.

Different therapists also have different confidentiality policies around child, couples, and family therapy. Many therapists utilize a no secrets policy with couples or families. This is particularly the case for couples, and meant to prevent one half of the couple from trying to get the therapist to ally with them by keeping something like an affair secret. When it comes to minors, the age and specific case matter a lot in determining how much the therapist communicates to the parents. In California, a minor over the age of 12 can consent to therapy without their parents present, if the therapist deems them mature enough. Thus, some therapists may choose to limit information they give to the parents when it comes to what is discussed in session, leaving it up to the minor themselves to decide. However, in some cases, parents are more involved in therapy. A therapist may give the parents a general sense of how therapy is going or what's being worked on without mentioning details into the kid's life, or may work concurrently with the parents to ensure the home environment is suited to the kid's needs, and help the parent better advocate for their child. For younger kids, the parents may sometimes be in the room during treatment. For older kids, the therapist may ask the kid themselves what they would prefer. It all depends on the therapist's view.

Among your starting paperwork, you may have received a packet talking about privacy practices. This is likely to be similar to something you've signed at a doctor's or dentist's office before. This is due to something called the Health Insurance Portability and Accountability Act (HIPAA), which is the standard for security for protected health information. This covers a lot of how therapists and doctors handle confidentiality and make sure client records are secure. Doctors and therapists will often discuss if certain services are "HIPAA-compliant", particularly online platforms used for messaging or video chatting; some therapists have access to secure means of remote contact that can be used to communicate between sessions, or even for remote sessions. HIPAA also requires us to inform our clients on how we keep their records secure by giving them a Notice of Privacy Practices and having them sign a page saying they received it.

There are a number of other kinds of consent forms that are also relatively common, depending on the case or therapist. If you have a doctor, psychiatrist, or previous therapist you'd like your therapist to talk with, you'll need to sign an authorization form. If you switch therapists or start seeing a therapist after having seen a psychiatrist for a while, this can help a lot. This can also help with issues that are partly medical and partly psychological, since therapists aren't trained in the medical side of client issues. For kid clients, it can also help to have their therapist in touch with their teacher or other school staff, particularly if academics or school behavior is affected by their symptoms. Some therapists will also have a separate Consent to Treat a Minor form for kid clients. There are also separate forms to consent to therapy over phone or video (often called Telemedicine) and forms to consent to audio or video recording (usually for training or treatment planning purposes).

The bulk of the information required from a client is in the intake form, also called the Biopsychosocial. Along with standard client details, it will ask about current symptoms, family history, substance use, medical history, work history, and much more. One of the most common areas of confusion here is the psychiatric history. This area asks if the client or family members have ever had prior outpatient or inpatient treatment. The difference between these two is that outpatient treatment is any kind of therapy where you remain at home and show up once or more per week, while inpatient is a program where you stay at the clinic, whether a residential treatment facility or a hospitalization program. Another area of confusion is the developmental history. A lot of people don't know or remember much about their childhood development. However, issues like early childhood illness, premature birth, or developmental delays can point at undiagnosed issues, cause problems that affect social and emotional growth (ie bullying), or otherwise correlate one's mental health.

Depending on your therapist or your case, you may also be handed additional forms to fill out. If you are looking for a particular diagnosis, or your therapist specializes in one, you may be given some paperwork meant to assess related symptoms or diagnose. Some therapists have policies around checking all clients for things like trauma or dissociative tendencies, as these symptoms aren't always mentioned or recognized initially, but their presence can change how treatment is handled.