Finding a Good Therapist

After you have decided to find a therapist, and you meet them and you begin. How do you know you have a good therapist? How do you know that what you need from them is going to be met?

Therapists are human beings, and they make mistakes. They say something too deep too quickly, or make an assumption, or look a little glazed over for a moment… This can happen from time to time. But the experience of being in therapy is much bigger than these little moments between you.

Your therapist should be open to your questions about their practice. What is your therapist’s theoretical framework? What is your therapist’s approach to helping people with your particular concerns? Where did the therapist get their training? If you get a sense that the therapist doesn’t want to answer or is impatient with you, keep looking, especially if it bothers you.

Your therapist should have an idea how long treatment should take, ideally.

Your therapist should check in with you about how treatment is going, on a regular basis.

Your therapist should, at least on the surface, appear to be organized and grounded, as a person. As I said before, they are humans, they’ve had bad experiences, they have problems too, but their problems should not spill into your therapy.

Your therapist should seem like an individual person, rather than a textbook. You should be able to get a sense of their personality in sessions. They use themselves in sessions.

Your therapist is not dominating the conversation with anecdotes about their own lives. They should spend most of their time listening and encouraging you to speak, explore and process.

Your therapist should adhere to ethical rules and guidelines. They don’t invite you to parties, or accept your invitations to barbecues or make uncomfortable suggestions. In Colorado, it is illegal to have a dual relationship with your therapist, including dating and sexual relations. They are in a position of power in your life and it would be exploitative and abusive to engage you in non-therapeutic activities.

Your therapist should inform you prior to the start of treatment of the above, to make sure you are going to be a good fit to work together. Your therapist should be confident enough to say, “we might not be a good fit, I can help you find someone who is.”

If you think I am a good fit for you – give me a call and put me to the test! www.aliceriley.net

Book Report

I have been reading and listening to Healing Developmental Trauma by Drs. Heller and LaPierre that is mostly about the Neuro Affective Relational Model (NARM) of working with people (adults) who have experienced early trauma. What is interesting about it is that it is about more than "shock trauma" which is what most of us think of - child abuse, neglect, a severe accident. They define Developmental Trauma as much more encompassing, even pre-natal insults like a surgery, or a depressed mother. I thought right away, if that is the case then we all have some kind of trauma, and a lot of it makes us different from one another. I used to think that "bad things" happening (and subsequent survival) make us just that more interesting as people. Most of us go on from there, to survive and thrive.

Obviously, my focus in my work is on the adults (and kids) who experience the shock trauma. But as simply as I can explain NARM, here it goes. Our bodies are regulated by our mothers, at first, through gestation, and then through the bonding period. Our parents hold us, feed us, sleep by us and we learn to feel safe and calm and "regulated" neurologically. We become organized and our brain and endocrine systems function optimally. We enjoy good nutrition, health and connected relationships to others assuming that love continues throughout our childhoods.
When that bonding and meeting of needs is disrupted, both early on and throughout our development, our bodies become disorganized and dis-regulated. We learn adaptations to survive the abuse or neglect. Humans (and animals) have three autonomic responses to danger: Fight, Flight, or Freeze. An infant can only do one of these things: Freeze. They will stop crying and disassociate from the body to ignore hunger, a wet diaper, pain. Babies and children will cease to recognize needs and have needs to preserve the minimal bit of relationship with the parent that they can get. As they get older they continue to protect the parent relationship by appearing compliant and good. They are not however, connected to themselves or others, they are not developing their own identity or knowing what they need from the environment. They do not recognize that the failure was in the environment. Instead they just know they "feel bad" and later they simply "are bad."
I wanted to cry listening to and reading this, for the babies out there who are enraged when they even have to "cry it out" as some professionals propose. There are many people who are now adults who experienced this, and just this lack of responding can create lifelong effects. Frequent disassociation, anxiety, panic attacks, health problems, relationship issues. I feel vindicated as I recall my own parenting - I held them, responded to them, bonded to them and I still strive to meet their needs as they grow.
There are five adaptive styles/organizing principles that can become survival mechanisms that go on into adulthood. I can list them but going into all of the traits and treatment here is way beyond my blog scope: Connection, Attunement, Trust, Autonomy and Love/Sexuality. Surviving as a baby or child is one thing, the problem arises as adults because we're not babies anymore. We were abandoned, but no longer. We were harmed, but no longer. Yet people are going through life as if the trauma is still happening and they often can't even put their finger on WHY they still feel bad. NARM does not focus on repeating the past traumas, it focuses on helping people remember without re-experience of it through connecting back to the body and learning to regulate their own biological systems. Developing identity and the ability to deeply connect to another person.
The use of this model in treatment is complex and requires a lot of study, practice and supervision. One of my goals is to do the 12-18 month program. For now I have to say that just having this understanding of the brain's development has made a difference in my practice. I do have a fair number of clients (in person and online) who seem to have one of the Adaptive Survival Styles and trying to do this kind of work online while completely DIS-Connected to them is potentially disastrous. I am ambivalent about continuing as an online therapist for this reason. After all, connection and relationship is what therapy is about, and then sending clients back into the world to try to connect and build relationships with others. It is important to continue learning, be humble, genuine, self aware, regulated and Connected.

Does My Child Need a Therapist?

                 I see a lot of posts, memes, blogs about parenting, about how our kids “drive us crazy” or got into trouble at school for some mischief or even for bullying another child. I have friends ask me often if they should take their child to counseling for sometimes “normal” things related to the child’s particular temperament, and sometimes for what is a good catch on the part of the parent. How would you know if your child is having issues beyond what you, as a parent, can help?

                The critical question I am going to ask is, “does the child’s behavior or mood prevail across two or more environments?” If a child is struggling to concentrate in school, misbehaves, can’t stay in their seat and blurts out in class, but is quiet and pleasant at home, sits and reads, then I would think there is some school anxiety vs ADHD (attention deficit hyperactivity disorder). If a child is moving and off task at home and at school, and in a museum and a grocery store, then we might be looking at ADHD. Confused already? That’s why getting answers from a person and not your Google search is important. There is a lot to consider and asking is perfectly reasonable. Children with ADHD don’t always need a therapist, unless some of their adaptive behaviors have become habits and they need help with social skills and parents may need help adapting their own skills to the child who needs a lot of patience. Kids can usually be easily treated with medication that the pediatrician can prescribe (a simple questionnaire should be given to the teacher and an EKG is usually completed first). Be sure to ask a lot of questions – parents need to know everything they can.

                Similarly, the behavior is not only taking place in multiple environments, but is interfering with normal daily tasks. A child who is developing OCD (obsessive-compulsive disorder) will eventually forego pleasurable activities to complete the compulsive behavior they “need” to complete to resolve the worry in their mind. Most people have a superstition or two, but if a child cannot get dressed before going through several perfect renditions of their task, (flipping the light switch, a chant, touching objects in a certain order) there is a problem.

                If you have answered “yes” to either or both of the above questions (2+ environments, interfering with fun), you may need a professional consultation. It does not mean something is “wrong” with your child, or your parenting. Imagine if your child needed a life-saving medical service, and you decided, “no, it’ll be okay without the intervention?” You wouldn’t likely do that, would you? You’d take your child for the appointments until they were cured. Letting an emerging mental illness go untreated is a threat to the child’s future, so it’s better to get help now while their brains are workable. Yes, many of these illnesses also come out as adults, and we can’t always predict it, but kids can learn valuable coping skills to handle stress throughout their lives. And parents don’t always know the best way to manage childhood anxiety, depression, OCD, ADHD. When you love someone as much as you love your child, your emotions get mixed in all too easily.

                Ask your child if they are worried about anything. Tell them you can find someone who can help them feel better. It might not even take very long for relief. A good child therapist can help bring out issues through drawing, through games and help the child identify and verbalize what is worrying them. The therapist can help parents respond more effectively to their child and teach them skills to self-regulate, communicate and listen. Call a therapist, ask the questions, and make the appointment. A wonderful adulthood awaits your child.
ARileyLCSW@live.com. 

The Business of Helping

The past week and a half have been full of learning, mostly about things they just don’t teach us in Graduate school – and how could “they” have? This was 16 years ago, there was barely anything called “the internet” in those days. Things are so different so I have to adapt. I am in a program called Business School Bootcamp – a two week intensive on getting a private practice up and running successfully. Is it all about making gobs of money? No, although it is about value – the value of what I provide and the value a potential client places on getting well. But it’s about finding ways for us to meet – the client who needs my help and the therapist who needs clients, so they can both thrive in the world.

To pat myself on the back, I have done a lot of the things in the lessons already – I did a lot of planning before I went full time. There is more I can do to get my name out there and I am working furiously to do it. So much of it is about technology – just getting search engines to find your website. Researching what people type into a search engine and then matching those words and phrases into the fabric of my website – the part you don’t see, The Code. Dammit, Jim, I’m a therapist not a computer programmer! Ok maybe I am a little now? If you understand that above reference, then you know that I AM a Star Trek fan.  I’m not too old to learn a few things.

So when you, a potential client, looks for someone to pour your soul out to, you type in a search – counselor in Denver area – or something to that effect. A lot of calls and referrals come through Psychology Today and I am grateful for that. This week I actually Googled “PTSD counselor in Commerce City, CO” and my website popped right up. It was a happy moment for me. Once you find your list – how do you know that therapist is going to be right for you? Recently I am getting more Medicaid clients, and I am among very few in my area who accepts it as payment. Right away that puts me on the top of the list of people to call. But I want clients to want to work with me, not just because I take their insurance. I want to have a site that says “I’m your person! I get you, I can really help you, and you’re going to really like working with me because I’m the shiz-net.”

I also chose to be on the Medicaid panels because I see kids in foster care, and all too often families on Medicaid are referred to the county clinics, which are often staffed with new graduates, interns, who are less experienced and over worked. I know because I have been there. I can’t be the best therapist I can be by being overworked, underpaid and having to deal with issues that are harder than I can handle (if I were there ;D). There should be equal access to quality services. Or so I believe. I want these clients to find me so I needed to make it easy to find me. So that’s why you would pick me, or why you would pick someone else. You found a therapist who “speaks” to you through all this media noise. Only I have tried to cut out the noise.

Give me a call and interview me. Then interview someone else. Interview a third person? Why not? This is your healing and your future we are talking about. 

Locker Room "banter"

I was encouraged to say more about this topic after posting online about how to address “locker room banter”. Politics aside, this is what the country has spent a week discussing:

Donald Trump: You know and I moved on her actually. You know she was down on Palm Beach.

Unknown: She used to be great. She’s still very beautiful.

Trump: I moved on her and I failed. I’ll admit it. I did try and f*** her. She was married.

Unknown: That’s huge news.

Trump. No, no, Nancy. This was— And I moved on her very heavily in fact. I took her out furniture shopping. She wanted to get some furniture. I said I’ll show you where they have some nice furniture. I took her out furniture. I moved on her like a bitch, but I couldn’t get there, and she was married. Then all of a sudden I see her, she’s now got the big, phony tits and everything. She’s totally changed her look.

[The men spot Arianne Zucker waiting for them outside the bus]

Bush: Sheesh, your girl’s hot as shit. In the purple.

Trump: Whoa! Yes! Whoa!

Unknown: Yes! The Donald has scored. Whoa, my man!

Trump: Look at you. You are a pussy.

[crosstalk as the bus doors open and close - Trump is still on the bus]

Trump: Maybe it’s a different one.

Bush: It better not be the publicist. No, it’s her. It’s —

Trump: Yeah, that’s her. With the gold. I better use some Tic Tacs just in case I start kissing her. You know I’m automatically attracted to beautiful - I just start kissing them. It’s like a magnet. Just kiss. I don’t even wait. And when you’re a star they let you do it. You can do anything.

Bush: Whatever you want.

Trump: Grab them by the pu**y. You can do anything.

This exchange was recorded in 2005. People have been horrified for the most part, but some people don’t think it’s a big deal. Mr. Trump disregards it as “locker room banter” meaning this is how guys talk when they’re alone.  They brag about grabbing women, they move on women “like a bitch, and try to fuck them.”  Perhaps some men do talk this way… hopefully only a few compared to the majority of the population. It is not the norm, it is by definition, deviant behavior.

Athletes in locker rooms are expressing horror. Women with sons are expressing horror, young sons are expressing horror. Women, girls, are sharing stories of daily sexual assaults, the kind that is considered “minor” and “not reportable.” In passing, on the crowded street, or bus, elevator, party. Since age 9, 12, 15… and continuing until they became “too old” or “fat” to be bothered with. But for the most part, they want to know how to make this stop.

One of the things I do in my profession is train on the topic of “Primary Perpetration Prevention.” There is also secondary and Tertiary prevention but my focus right now is primary – preventing abuse, mainly sexual, from ever taking place. And yes, we start when humans are small and impressionable. Why? Because research tells us that adults who sexually abuse began doing it as children and/or teens. And they start by doing it to other children because there is a difference in power, strength, age or ability. However, no-one did any research on the sexual abuse of children by children earlier than the mid 1980s – adults were convinced that children just did not have sexuality let alone a proclivity to abuse, given the right circumstances. A team of psychologists at the Kempe Center in Denver developed a program in the mid 1990s to work with adolescent offenders with largely positive results. Young minds can learn three important skills: Communication, Empathy and Accountability. I was trained to be a trainer on these topics by one of the authors, Gail Ryan, MA, in 2009 who is now retired. I want to carry on her legacy.

Very basically – communication is the ability to send and receive messages. Ideally they learn to do this is a healthy family setting. Not all kids grow up in nurturing and safe homes. They learn to keep secrets.

Empathy is the ability to read and understand the emotions of other people (or even animals). Children without empathy will not understand when they have hurt someone’s feelings, or identify someone’s feelings.

Accountability is the accurate attribution of wrongdoing. If you make a mistake, own it and make amends. There is a consequence to a behavior vs getting away with it.

This morning I posted this on Facebook, my private personal page:

If you are ever in a locker room, and you hear somebody talking about grabbing women (etc) and another person laughing along here's what you could say to make a difference:
"I heard you say that you grabbed a woman etc. and I feel very uncomfortable and/or angry and I'm sure that woman was uncomfortable and/or angry; What you were describing is abusive and illegal and it needs to stop."
#notokay

The structure of the response is what I teach adults to use. First – communicate that you HEARD it and or SAW it with your own ears and eyes. Often someone who is offending and keeping secrets will “gaslight” you with, “I didn’t do that/say that, you saw wrong, it wasn’t me.” No, stand firm. You know what you heard and saw.

Then you talk about your feelings and or the feelings of the person who is being harmed – uncomfortable, hurt, mad, in pain, point out tears and sadness if it is present. They need to be helped to identify emotions and hopefully feel them. This is obviously much easier with young people.

Accountability can simply be a prohibition. Research also tells us that young people do not know which behaviors are illegal. Telling someone their behavior is illegal can make it end right there. Many of us grew up in a family where getting a pinch on the bottom is cute and funny. But most of us who don’t like it were able to say, “I don’t like that,” and it stops. Because when you respect the body and wishes of another, that’s what you do. So the final part of the above intervention tells the people to stop.

I am not going to tell you that this is easy to do. What if you are at a party and you witness someone being harmed? You are in a dangerous situation, no doubt. However, a room full of bystanders is just as culpable as the perpetrator. You must intervene or get help. Someone I know said saying these things could cost them in their individual sub-cultures (work?). I suggested these were people they were better off without. Humans can be held to a higher standard and should be. Women are your mothers, sisters, daughters, friends, wives. We deserve to be safe, to walk down the street feeling no leery eyes on us, no rude comments (even if they try to convince us they are compliments), no hands grabbing us, from a friend or a stranger. Men can help to make this kind of world a reality by speaking up routinely, until it doesn’t feel scary. Practice makes perfect.

My next training is through Foster Source – a foster parent support organization. The training is in Greeley, CO on November 19 from 9-11:30. There is a lot more than the above but even if just the above can make a difference, please use it. 

Online Therapy Part II

So it has been 4 weeks or so since I became active with the online therapy company.

Here’s the breakdown: The first two asked to be transferred within 2 weeks. One transferred and I think the other ended up cancelling. Not a good fit. The first one gave me a “bad” review however, when I talked to the quality assurance therapist, she saw how engaging this client would have been difficult no matter what (and she was demanding that I respond 7 days a week) and gave me some good hints about her process. The second one, I think got offended because I didn’t receive her message after a week and I was sending her notes about getting her engaged in treatment. She didn’t respond to asking about working with me despite my error. This month, one client decided she really didn’t like texting, and because it’s a slower process than traditional therapy. So... a rough start.

But even in traditional therapy, a therapist has to take time to get to know people otherwise how can we really be helpful? One of the hints is that after 2 more weeks, you ask about how the client likes the platform? Then you ask about your work together. You propose this structure during the introductory 10 minute free video chat. Seems to help set a pace for clients. Will do.

So now I have about 5-6 clients, most of whom are new but engaged in the process. I can pick up a max of 4 new clients per week. I have done some brief video chats with them, which I offer in the second week. Some like that, some don’t. But they all say they like seeing my face so they know who they’re texting – they see my photo on the profile page but I don’t see theirs. I more easily match stories to faces so it helps me keep track a lot. I have a client in the UK, which is really interesting, and the others are in Colorado, near and far. Picking up clients is a bit like bidding on a cow at the State Fair – you have to be scanning the “online office” when they post new clients to be matched. You have to check for your state and then reply quickly if it’s someone you want to work with. I have found that Fridays are good days but it means connecting over the weekend a bit so they don’t get discouraged. For just one person here and there I can manage that. It feels a little trollish to be doing that, vs going out with the kids or friends…

I tell people I respond at noon(ish) and 8:30(ish). We have to check twice a day. Some people write more than others, obviously. One person asked me to write even if she didn’t, just to let her know I was there and thinking of her. Sometimes I find myself still out running errands or at lunch at noon so there’s a little issue with time management here and there. And my younger daughter is staying up a little later so I switched from 9 to 8:30 to get a jump on tucking in time. She’s ten but she still likes me to stay with her until she falls asleep. I both love and loathe it… On Fridays I respond around 5PM while I am at Taekwondo with my aforementioned child. That way everyone’s weekend can begin…

So this has been a private practice supplement and also a JOB as a practitioner. Very interesting as an experiment in a new treatment modality and a social movement. I honestly wish I had heard of it 2-3 years ago, I could have used the side income, the experience. But here I am… Jumping in with both feet. In October I begin a “Business School Bootcamp for Therapists” program to help me revv up my practice and give me some skills to be successful. I can’t afford not to be, and I really like being my own boss. I will likely write about my upcoming experience and new insights into this whole thing. 

To Join or not to join?

If you are a therapist, you are providing a medical service. Mental Health care is a part of being healthy and having someone to guide you is just as important as having a doctor to give you a check up – check your vitals, run some blood work, treat an illness. So therapists are professionals who have the ability to be paid by health insurance. Now… there are hundreds if not thousands of companies – more so now than ever – that offer insurance and pay providers in their networks.

I started off working a full time job while seeing clients through 2 EAP providers - that’s Employee Assistance Programs. They don’t pay well but the client work is interesting. The credentialing was pretty easy as well. Clients usually self refer and have a limited number of sessions that the company pays for. Beyond that I offer a reduced rate for them to continue for the same number of sessions they got through their benefits.

How can any one therapist get credentialed with all of these companies? Recently, I joined Cigna, and it was a fairly painless experience. They were efficient about sending documents back and forth, my recruiter communicated with me often, when everything was done they credentialed me in 3 weeks, when they had up to 90 days. I have been told by another Cigna provider that they pay timely and have been good to work with. Their rates are similar to what I have seen, mostly Medicaid rates but clients usually have a co-pay. Medicaid credentialing, here in Colorado anyway, has been a completely different sort of animal.

One therapist in a cohort group I’m in on Facebook said she contracted out her credentialing to someone who does it for a living – a medical biller or something. I had no idea people did that although it makes sense because doctors who open a practice have to accept a lot of insurances and they have even more documents to provide. Do they have time for that? I don’t think so. My mother has offered to help me do billing and what not and I could add her to my profiles as an office person, but I would prefer to pay her and I can’t right now and I don’t think I really want to join more insurance panels. I can take any client with PPO benefits – meaning they can see someone out of network. They pay me then submit the bill to their insurance to be reimbursed. The last person who asked me about that discovered she had to meet a huge deductible before she would be reimbursed anything. I tried to sign up with her insurance but they are not accepting new providers in my county unless I can prescribe and/or speak a language not usual for the area, like Farsi or Somali.

Getting back to Medicaid. In Colorado, the State was divided into regions a few years ago and companies bid on regions. I live in Adams County – which is covered by BHI. I want to work with kids from Denver (foster care) and Morgan Counties, these are covered by ABC. A friend of mine said to apply at Colorado Access. They had no application – they said send us an email. They emailed back: we don’t need anyone right now. I thought, that can’t be true! I went on the State Medicaid site, was able to apply and be approved as of June 1. However, if you’re not part of one of the managed care entities, you will bill and not get paid. Sadly, I am not going to get paid for a few clients, but I am okay with that now. They needed the help, they got better and I am not going to take any more until I can get paid.

I finally reached someone about my questions with BHI and she was great at explaining all of this to me.  I sent in my documents, waited, and then was told that I passed round one and in a months she and the team would start round 2. I had to send her more documents, that I really could have sent her with the first round had she asked. I am very close to being done, I have clients in a rural county Human Service Agency waiting for me to start. That was the reason I got ABC coverage in the first place, otherwise I would have been declined (there is a need for therapists in the rural areas). There has been so much outrageous duplication and waste in these processes. Being a Black Belt in LEAN/Continuous Process Improvement, I have truly struggled to be patient with the inefficiencies.

CAQH is a national clearinghouse for billing. Cigna required me to join so they can pay me and credential me through this company, however Medicaid wanted my number as well. There are a few more similar companies, depending on which insurance panel you are on. Again, duplication. Now Colorado has a ballot initiative this fall for a single payer system. I can really see the benefit to this but man if I have to scrap everything I have done to date just to join that one I might lose my ever loving mind.

In the meantime, I do a few other things – I do paintingparties, I sell my art as much as I can, I have done a training on Primary Perpetration Prevention for foster parents through Foster Source, a new support agency a neighbor of mine started this year. I saved up before I quit so I could have flexibility and a nice summer with my kids. I signed up (aka invested) for a Business School Bootcamp for therapists because I need to know MORE of how to make this work. Marketing, networking, getting referrals, it’s all part of this thing we do and it is an entrepreneurial business. It is not a passive activity. While I want to help people of lower income and who have struggled more to get ahead, I deserve to make a decent living doing it. So do you!