Psychotherapy Perspectives

Thursday, September 14, 2006

YOU are in charge of your Health-Advocating for Your Wellness

Sometimes we forget that we (the consumer of health care services) are in charge of our wellness. This is indicative of the system because often when we receive medical service whether it is psychiatric or for physical ailments it appears that the "experts" have all the power. That is not true, they are our consultants and we need to navigate our own health care by advocating for our wellness. This is true (we are in charge) whether we are in psychotherapy, counseling, or at our physicians office for a check up. The health care regulations make the consumer in charge of our own health. All of us need to take responsibility for advocating for our wellness by doing the following:


1. Recognize that you are in charge of your health.

2. Act in charge of your wellness

3. You are in charge of your health care plan and the health care rules protect you
a. The rules in health care are made to protect the consumer
b. The problem is that health care providers don't always follow the rules and forget that you run your own health care plan
c. Consumers win most appeals with insurance if you challenge them with their own rules

4. Take charge of your health care plan when in a hospital
a. Stay in the hospital for as long as necessary and until you have a safe discharge plan!
b. Make sure that representatives of all the physicians and hospital have a meeting called a care plan , so you understand what your choices are
c. Don't leave the hospital until your care plan meeting takes place and all your questions are answered
d. Make sure that you have a safe discharge plan to home or wherever you are going.

5. Take charge of your health care plan when you are with your physician
a. Formulate your questions before you see your Doctor.
1. Ask your Doctor what the numbers say or the % of this outcome.
a. Don't ask if you are going to get better, ask what the %‘s
2. Don't ask your Physician to play God; he/she is your consultant!
3. Don't ask your Physician about wellness, he/she doesn’t know—

6. When you are really sick, don't be a hero, get an advocate
a. Figure out who that should be before you get real sick
b. If you are having surgery, make sure you have a responsible person on site to sign for you at the surgical center and make decisions if you remain unconscious and something goes wrong.
c. Stop procrastinating and start paying into Long term care insurance before you really get sick and it is too late. It is one of the few insurance programs you will use when you are alive.

7. Most illness is life style related; change your life style to enhance wellness

8. Pay attention to what your parents are going through now and make an effort not to repeat it their mistakes when you get to be a senior.
a. Medicaid planning is for everybody whose estate is worth less then 2 million
b. Be wary of your parents "gifting" when they are sick, see your Medicaid planning attorney even if your parents never plan to be on Medicaid. It makes sense.
c. If your parents want a qualitative life style, make sure that they put enough money into "custodial care" or have a generous long term care insurance program for life.

9. Working with health care insurance
a. Study the small print of the booklet well
b. When you call your health care insurance representative make sure you do the following:
1. Get their name and number to respond to later
2. Most of the representatives do not give accurate information, make sure that they log what you ask into the computer and then log how they answer the question. If they won't log on the computer and print it out for you, then talk to their supervisor
3. Ask for their supervisor (ask nicely)
4. Ask for how to appeal their interpretation (you will probably win if you are persistent!
5. Ask them to fax or call when they logged the response on the computer.



Sunday, September 03, 2006

Boundaries in Psychotherapy Practice

(Excerpts from workshop on “Boundaries” at Children’s Bureau presented by Margy Davis Mintun on August 31, 2006)

By Margy Davis-Mintun, LCSW, ACSW

Boundaries in Psychotherapy practice are established to create safe, reliable and useful platforms for the work to take place, and are the most fundamental responsibility of the Psychotherapist in client relationships in order to establish the ground for therapeutic work.

Boundaries define personal space and can be characterized as physical, behavioral, verbal and emotional. Boundaries can be strong and healthy, rigid and inflexible, distant and fused (lacking definition).

Two aspects of boundaries are going to be discussed,
- Boundaries within the Psychotherapist
- Boundaries between client and Psychotherapist

Boundaries with self include the somatic base of experience, the sensations of our body, and the awareness of our own emotional responses, our belief system, and our interpretation of our history. These define our experience with distance and proximity and reflect how we each navigate levels of connection and distance in our own relationships.

In the process of knowing our own boundaries, we become aware of our body sensations in relationship to others. This knowing helps us to gauge the comfortable and uncomfortable.

The distance at which each of us feels comfortable/uncomfortable, often reflects our personal experiences with levels abandonment or control. Our early childhood experience with our primary caregivers, and our notion of safety and danger in relationship, also reflect our history of boundary violations. These factors have shaped the level at which we are comfortable with others, our own boundaries, and the line at which our personal preferences are drawn.

The Psychotherapist who ignores their own needs in the service of the client runs a great risk of becoming vicariously traumatized and/or traumatizing the client. This occurs when we ignore our own experience of distress or boundary discomfort and don’t take action to address our internal or external conflict and it mixes with our perceptions of the needs of the client. Our lack of awareness of our own personal boundaries, and/or self care can lead to resentment and/or unconsciously blaming the client. This can create situations that adversely impact self, the client, and the relationship.

The ability to identify behavioral boundaries begins in childhood in a secure attached relationship where cycles of arousal and relaxation lead to appropriate self regulation. This is as simple as when a child cries and someone picks them up, feeds them, or changes their diapers.

The ability to self regulate emotional states is established as we learn to replicate for ourselves the experience of arousal and relaxation. Learning how to pay attention to internal signals of discomfort and distress in our body sensations and respond to the unmet need by self soothing or taking action.

The ability to have connection to our own personal experience in the context of doing our work allows us to have the means with which to attend to our reactions, so that we can regulate our emotional responses. This means that by attending to the signals from body sensations, emotional responses, and physical comfort, we are addressing our own comfort level and thereby decreasing the possibility of confusing them with client experiences.

Another area of boundaries involves the social context that often informs us of what is acceptable and unacceptable in our social environment. Examples are the secrets we keep, the intimate details we might reveal to specific persons, and the honest ability to say yes or no or to express an opinion. We are influenced by our experience as to what is acceptable, including how much room we have to be honest, authentic, and genuine in our relationships. When we can validate for ourselves what we feel and think, we can more fully sort out our experience. This allows us to be more honest and experience integrity and a sense of connection with others. If we pay attention to the signals in our body and emotions, we can be informed about what is right for us at a specific interaction/time. If we says “yes” and are unaware of the “no” in our body, we may be in contradiction to our true feelings and may be at risk for compassion fatigue. This does not provide healthy modeling for clients.

Boundaries also define the space with our bodies. This space has an intangible but physical energetic quality. Physical boundaries may extend beyond our body varying in size of radius and sometimes may be larger or smaller.

You may notice times when you feel a particular person is too close at a specific time and you feel uncomfortable. Another time, you may experience the person’s proximity differently. Unlike defenses which are rigid, boundaries are flexible and can change depending on the person and or situation.

Another area of boundaries that can arise is around the spiritual beliefs and how these relate to our interactions. For example, if I believe in fate or free will, how does this belief system play out in my decisions and my expectations and interpretations of events, and my relationships? If I believe life is predestined then I may understand my life experiences as part of a greater whole and may have a sense of acceptance about the events and relationships that are in my life. Whereas if I believe in free will, my interpretations about how my life unfolds will have a completely different meaning as will my belief of my ability to influence the events in my life. The awareness of these beliefs will have some effect on how I also interpret the events in the other’s lives.

We as humans tend toward two responses to boundaries with others. Either we tend to hold back and not travel to the edge of our boundary with others by being somewhat cautious and tentative, or we tend to cross over the boundary and notice later down the road in the relationship that the boundary had been passed. In this case we have to back track to a more comfortable place.

What is important in our relationships with clients is that we find a way to be able to either stretch to a more expansive boundary which allows for more full contact with another, or to contract from the spaciousness that creates boundary confusion because we have gone to an unsafe place in our relationship.