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.

Wednesday, January 16, 2019

Why Your New Year's Resolution Isn't Working

So, it's mid January. Just a few weeks ago, you were determined to start off the new year right, so you decided to make a resolution. Maybe it's one of the common ones, like exercising more, losing weight, or getting organized. Maybe it's more specific to your life, like visiting your parents more, actually using the vacation days you've saved up, or learning a language so you can travel or communicate with loved ones. You might have started out strong, like by starting a new diet, but maybe things are starting to get difficult, and you're noticing more slip-ups as time goes on. Or maybe you haven't really started on much yet, and although you got the gym membership, you haven't been once, thinking that you have the whole year to work on this. By February, actually achieving your goal may seem impossible. By March, you may have given up, or forgotten your goal entirely.

Over half of people who set resolutions in the new year fail. It can be so tempting to say that this year will be the year everything changes, but much harder to actually follow through on that. Change is a gradual process, and the more of your life you need to change to make the resolution happen, the harder it can be. Learning a language from a book is going to be difficult if you rarely read books. Further, if your resolution doesn't excite you, the motivation to change is small. No matter how excited your best friend or partner is about their workout regimen, you're not going to be motivated to try it if the pressure is entirely external. Maybe you'll go once or twice, but it's less likely to turn into a lifetime habit or hobby if it doesn't align with your priorities.

The resolutions I mentioned in the first paragraph reflect the most common ones. "Exercise more" is the most common new years resolution, with "lose weight" coming in second. You'll notice that many of the most common goals include the word more... "save more", "travel more", "read more", etc. But "more" is not specific enough! The vagueness of resolutions are part of why they are so often doomed to fail. A goal like "call mom more" doesn't tell you when or how often to do it. Setting goals should be almost as specific as coming up with plans.

The idea of setting a SMART goal is one that came first in the business and management world, but people quickly found it useful in their personal lives. The idea is that goals should be Specific, Measurable, Achievable, Relevant, and Time-bound. This is the difference between "exercise more" and "go to the gym twice a week" or between "learn Spanish" and "gain one level in Spanish on Duolingo each month".

To make your goal more specific, look at how you want it to be achieved. Are you losing weight by dieting, exercising, or both? What part of your life do you want to be more organized? Is there a reason for the goal, like fitting into a particular item of clothing, or getting a promotion? Saying you want to be healthy is a good theme, but saying you want to quit smoking is a more specific goal.

As you specify your goal, it becomes easier to make it measurable. If you've already decided you want to go to the gym, think about how often you want to go. Do you want to start strong, and go three times a week, or do you want to start once a week and work your way up? If the latter, make sure to plan out how you're working your way up. Starting at once a week and deciding you'll go every day "someday" isn't going to get you there. Saying you'll go once a week for two months, then twice a week for two months, and continuing on from there, is being specific about being measurable (and time-bound, but we're getting ahead of ourselves).

Making sure your goals are achievable can be difficult if you're the kind of person who will drop one goal in favor of something else, or if your goals are so big that you don't know where to start. Sometimes, making your goals more specific and measurable can help make them more achievable. But if you're not a morning person, waking up at 6 to go for a run every morning may not be the best way to get more exercise. Further, look at the skills and tools you currently have. If you want to eat healthier but don't know how to cook, buying a bunch of fresh veggies won't help much if you don't know what to do with them. However, starting with a frozen veggie mix for a stir fry might be closer to your skill level.

As you make your goal more achievable, make sure you're keeping it relevant to your overall goals. This lines up with making sure it's something you're motivated to do, as I said earlier. Setting a goal to call your mom every week is great, but if you're only doing it because you feel guilty for not talking to her enough, it's going to be harder to make that happen. Further, it can be easy to get sidetracked in working towards goals. If you decide you want to read more to learn about the world, make sure the books you're reading are relevant to the overall goal of learning about the world.

Lastly, giving your goals a time bound provides a sense of urgency. Many of us operate better with deadlines; it's what we're taught in school, and what keeps us going at work. Others are more interested in forming habits. Consider if you're looking to achieve something and then be finished with it, or if you want to work something into your routine. Do you just want to go on one vacation this year, or do you want to make travel a bigger part of your lifestyle? This can also depend on whether deadlines or routine work better for you. Some people are more likely to learn a new instrument if they practice every day. Others are more likely if they have a concrete end goal of "play my brother's favorite song at his birthday in June". If you have an end goal, go back and make sure it's achievable based on your starting point. If you've never played the piano, you may not be able to learn a concerto in three months, but you may be able to learn your favorite pop song by the end of the year.

Once you have a SMART goal, it can be broken down into smaller goals. What's the next step? It could be committing to a tool or method (i.e. learning yoga at a particular yoga studio), planning out your progress over the year, or even just doing more research. What can you do to make progress on your goal today? In the next week? This month? Keeping track of these smaller goals can help a lot, so your first step might just be deciding how to track your progress. This might involve using a journal or planner, an app with automated reminders, scheduling time to work on your goal, or regular check-ins with an accountability buddy.

As the year goes on, it can be easy to get discouraged. Skipping a smaller goal, missing a deadline, or slipping up once does not make you a complete failure. Focusing on your mistakes can be easy; part of why tracking progress is so helpful is that it can remind you of how far you've come. People who diet often talk about the concept of cheat days, and I think this can be applied to any goal. If you got home too tired to meditate before bed, that can be a cheat day. This concept helps in letting the mistake be an outlier, rather than feeling like making mistakes is part of the pattern. It can fight against the thought "I screwed up once, so why even try". If your goal was to finish reading a book every month but take a month and a week to finish one, you still finished the book. If you lose 15 pounds but your goal was 20, you still lost weight.

Remember also that life can be unpredictable and get in the way. You might not have the energy to cook a large meal if you're feeling sick, and that's okay. If your career gets more hectic, you may have less time to spend on hobbies. Sometimes, life gets so hectic that it's unrealistic to keep holding the same standards for yourself. It's okay to say you can only practice guitar on weekends, or that you can no longer afford to go to Europe next year. It's also okay to say rock climbing is no longer interesting to you, and you want to drop that goal entirely. Your goals should be serving you, not the other way around. It's all about getting what you want out of life, and part of that is knowing when to lean in and when to let go.