Mental Health Treatment

QUESTION:

If someone sees a therapist through your support groups does it get put into a medical record ?

ANSWER:  

There are number of possible sub-questions in your question, so let’s sort them out.

• LCL runs a number of groups. Our Addiction Recovery Peer Support group meetings are peer-run meetings which are not attended by our clinical staff. These are open to any lawyer or law student and are held at our office on Tuesdays and Thursdays at 1 pm, with other meetings across Massachusetts listed here. These meetings are run in the 12-step tradition, and no records are kept on those in attendance. Staff members facilitate our other support groups listed here, typically keeping attendance records. Feel free to inquire with group leader about the process for any group, and how we can accommodate any concerns you might have.
• If you arrange for an individual clinical evaluation with one of the LCL clinicians, we do keep records, but these are never disclosed to anyone outside of LCL except (1) if you want the records disclosed and provide written consent, or (2) if there were to be an issue of physical danger to you or someone else. (That would include cases of learning of ongoing abuse of a child, elder, or disabled person.) Some lawyers who are especially worried about these things register with us under a pseudonym.
• If, after doing a clinical evaluation, we refer you to an outside licensed mental health provider, they are also required to keep records, but, like us, would be prohibited from disclosing those records without your written permission except in cases of danger.

Both the confidentiality and the record keeping are there with your interests in mind.

I tend to be a private person and I have never gone to therapy. However, I am coming to the realization that I need help. What’s the best first step? I don’t know if I would be comfortable saying anything in a group support group setting.

In general, people are most comfortable beginning with an individual initial session (may be called consultation, evaluation, or assessment).  Once the issues are identified individually, the client/patient and the interviewing clinician can discuss a plan for further help.  Although group settings have much to offer that is different from individual therapy, someone who is new to therapy will often prefer to begin with a referral for individual work.

There are also various and different kinds of groups.  Some, for example, are peer support groups, such as 12-step groups or the recovery-related LCL Support Groups that we offer.  Because those are run by members rather than professionals, they usually follow a distinct structure; they offer a strong sense of “these people understand what I’m going through, and we’re all in it together.”  Among professionally conducted groups, some are didactic, something like classes, providing information or teaching therapeutic skills, while others are more interactive, in which the therapist’s primary role may be to help participants observe patterns in how they interact with others.  There are many other permutations for those who choose to enter a therapy or support group.

If you are a Massachusetts lawyer, judge, or law student (or family member of same), feel free to contact LCL to schedule an initial evaluation to review your needs and the potential kinds of referrals we can make.

I am an attorney who has become aware of circumstances suggesting that another attorney is abusing alcohol and experiencing emotional issues. As a result that attorney is acting in a manner that is unprofessional and he is harassing and threatening others online. If I were to make a referral to LCL how would that help this lawyer? Who would approach him and how? What if he refused services and it just made things worse? Would he ever learn who made the referral? Any insight you can provide would be helpful. Thank you.

Though LCL offers peer-led support group meetings (the core aspect of LCL that accounts for its name and preceded having any funding or staff), other clinically oriented activities are handled by our staff of licensed mental health professionals (2 psychologists and 1 social worker).  As we see it, we cannot ethically intervene on our own in an individual lawyer’s life.

Rather, when we get a call about someone like the attorney you describe, we generally recommend that colleagues, friends, or family who are concerned about his or her behavior and mental/emotional status either come in to meet with us or bring the individual in.  Usually this approach is more effective if it involves more than 1 person besides the lawyer who is the source of concern.  You can call us to discuss the specifics, including who might become involved.  [If there is imminent danger of physical harm to self or others, such as someone drunk and wielding a weapon or making a specific threat, the appropriate resource is an emergency room for psychiatric evaluation, and sometimes police are needed to compel the person to go there.  We are assuming here that the situation is not that dire.]

So, inherently, the lawyer would know who made the referral, because LCL has no way to bring the person in otherwise.  LCL staff would seek to assist concerned others in heightening the individual’s awareness of his (or her) problem, and would also make a clinical assessment and treatment recommendations.  If the person agrees to treatment, LCL staff can also identify treatment options that fit the level of severity and are covered by the particular health insurance plan.  (Many people are surprised to learn that inpatient “rehab” is seldom covered by insurance, but it is sometimes possible to put together a plan that includes a day program and possible a “residential” program, which is different from inpatient.)

As you suggest, some people will refuse help.  (That is less likely if he or she is hearing the same message and the same time from several different people who are important in his/her life, and especially if they have some kind of “leverage”.)  We’re not sure how that would “just make things worse.”  The drinking and otherwise impaired mood/behavior may continue to get more severe, of course, but that can be good in a way if it leads to undeniable recognition of a problem.  Quite often, it is being faced with negative consequences that are hard to deny that finally motivates someone to accept help.

Please feel free to call to discuss the particular case.  You need not give us your real name or that of the person about whom you are concerned.

I am a small practice new attorney struggling with low self-steam, procrastination, and anxiety (especially when I realize how much I should/could have done). I feel like I know in my mind who I can and should be, the projects I would like to carry out but can’t act to make that a reality. I am also suspecting some sort of mental health issue that is affecting my ability to focus and keep up with schedules.   I currently see a therapist, but I haven’t spoken openly about these struggles as they come and go – at least to some degree, and also because I am a new patient and I’m honestly too embarrassed to disclose that and afraid of having that in any sort of record. (Yes, I understand it’s confidential, but there might also be some paranoia issues). My question is whether this “general” therapist should be able to help me with these issues or if it is recommended that I seek a specialized one who will more likely to understand these issues well. Also, it would be great if I could be directed to helpful material about coping with/resolving these issues. Plus any advice is welcome.   Thank you.

Therapists know that it takes time for most of their clients/patients to develop enough comfort and trust to be completely open, but when you get to the point of being able to do so, that’s when the therapist can be most helpful.  People who come to see us at LCL are often very open, partly because many of them wait until things have unraveled to a critical extent.  Since that hasn’t happened for you, the sooner you address these concerns the more likely you can prevent bigger problems later.  Procrastination, anxiety, and variable self-esteem are extremely common.  When I’ve given talks on lawyer procrastination, there is almost no one in the audience who does not relate.

As you say, your worries about what is in your record are out of proportion with reality.  With exceptions having to do with danger to self/others, and perhaps a bit less rarely in the context of child custody battles and court orders, your therapist (assuming s/he is a licensed mental health professional) may not release your records.  In addition, who would really care whether you wrestle with the kinds of common difficulties you mention?

Your other concern is valid – not all therapists will feel equipped to discuss matters related to your job functioning as a lawyer, or to dealing with procrastination, productivity, etc.  You are welcome to augment your therapy by coming in for one or a few sessions with an LCL clinician, and we also at times run time-limited groups focusing on issues like productivity/procrastination, since they are so common especially among solo and small firm practices.  Two of the authors whose work we have read in connection with past groups are:  David Allen (getting things done.com) and Julie Morgenstern (juliemorgenstern.com).  In addition, here is a list to top-rated self-help groups in various psychological topics from FindaPsychologist.org.

My anxiety spiked when recently I got my first job (in a small firm) after passing the bar, which meant having to face not only the challenges of “real life” practice — about which there is so much I have yet to learn — but also the need to make loan payments, pay the rent, begin planning a family, etc. I didn’t want to become accustomed to the tranquilizers that my primary care doctor prescribed, so I got into therapy (or counseling, I’m not sure which), and it has helped. I’ve been getting health insurance through my wife’s half-time job, and they just changed to another HMO that doesn’t cover my therapist. Because my income at this point remains quite limited, I may also qualify for Massachusetts’ “Commonwealth Care,” but I don’t see the therapist’s name on that list either. I’d rather not have to start with someone new – is there a way around this?

Efforts at universal health coverage are far from perfected, and you have come across an all-too-familiar obstacle. While most primary care physicians and hospitals are covered by the majority of managed care plans, that is not the case for most behavioral health providers (for a variety of reasons that need not be detailed here). In many cases, the new HMO will allow for a few months of “transitional” coverage for your “out-of-network” therapist. (By the way, for practical purposes you can consider “therapy” and “counseling” to be synonyms.) In addition, if you have the option of switching to a “PPO” or “POS” plan, they will cover providers outside their network, but generally at greater cost to you.

After that transitional period, you will need to wrap up with your current therapist or negotiate a manageable self-pay fee if possible. If your law firm offers a “flexible spending account” (sometimes called a “cafeteria plan”), these costs can be effectively reduced by paying them out of pre-tax income. Otherwise, either your current therapist or an LCL clinician can review the new HMO’s provider list with you with an eye toward choosing a good successor therapist.

Commonwealth Care — though an excellent alternative to no insurance at all — is built upon the existing Mass Health (Medicaid) system and uses that provider list. The great majority of behavioral health providers on that list, you will find, are clinics (either freestanding or hospital) or large incorporated practices. In such systems, you can expect an initial intake evaluation and subsequent referral to the clinician who will see you for further sessions, which may or may not be the same person. LCL would generally not be able to refer you to a particular individual, and we have found that there is often a months-long wait before the initial visit.

The inscrutable world of managed care never ceases to baffle, and we cannot possibly provide a guide through its labyrinthine twists and turns in this column, but if you arrange an appointment with one of our clinicians (at no cost), we can help you navigate. [LCL offers evaluation, consultation, referral, and more, but does not provide ongoing therapy/counseling. To protect you from any conflict of interest, our clinicians also may not refer you to their private practices.]

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Mental Health Services

Ever since I was a kid, I’ve been known to lose my temper, and I’m still prone to losing my composure when irritated. It’s been happening for years with some of my uncooperative criminal clients, but frankly what really got my attention was when I recently found myself behaving that way with my young child (not to mention my wife, who has learned to wait for it to blow over). I should clarify that it never gets physical, but my volume goes up, and some of my words can be quite hurtful. I have no interest in the kind of anger management program that is mandated for guys who have been assaultive; is there another way to deal with this?

It’s true that anger management problems occur on a continuum, and that while some individuals become physically aggressive, may harm others, and may not even be bothered by having done so, many more are subject to reacting to frustration with a milder degree of losing control, raising their voices, adversely affecting relationships (professional, personal, or both), and feeling guilty or ashamed when all is said and done. The roots of these patterns may lie in our personal histories, our neurobiology, or both. As a general rule, when our own self-esteem is solid, we are much less likely to regress into an uncontrolled, infuriated state.

Anger, of course, is a natural human feeling state, built into us to help us survive, and we all have it. We are at our healthiest when we are aware of our emotions, allowing us to respond to a frustration, insult, etc. rather than reacting in a reflexive manner. Quite often, but not always, it is appropriate to express anger— but this is best done assertively (forthrightly expressed in a way that does not harm or threaten anyone) rather than aggressively.

Much like relapses of addictive behaviors, anger tends to follow repetitive patterns. Many people can readily identify those events, interactions, etc. that trigger angry reactions, and may also be able to learn to notice early signs of building up toward an outburst. Working with a therapist (in a dedicated way, over time), it is possible to become very conscious of these patterns, insert more time for thought before automatically reacting, and develop strategies for responding in better ways that may leave you and others feeling fine (or at least OK) afterward. Reviewing the patterns as a sort of “slow-motion replay” can also allow you to notice, examine, and challenge some of the fleeting thoughts and beliefs that elicit angry reactions.

If you come into LCL for a full assessment with one of our clinicians, we should be able to help you zero in on key aspects of your own pattern, and can refer you to an appropriate therapist for the longer-term work that will probably be involved. (In some cases, anger may also reflect a mood disorder or addictive component, in which case those conditions would also warrant treatment.) Changing these behavior patterns will be well worth the effort, allowing you to interact in more rewarding ways both at home and with your clients, and to greatly reduce those painful moments of shame and regret.

-Mental Health Services

If an attorney develops an addiction to drugs and wants to take time off to enter a rehabilitation facility, does the family medical leave act cover this? Meaning, can that person go to rehab knowing their job is safe when they return?

First, our clinical staff at LCL are mental health professionals and not lawyers, so we cannot answer this question with any certainty.

We have not personally encountered a case where a lawyer was fired for having sought treatment. In many cases, law firm partners, HR professionals, etc. have urged lawyers to get treatment in order to keep them contributing to the firm or company’s mission by regaining their health.

Some more general information about the Family Medical Leave Act may be found here.

Your question implies that the attorney is working for a firm or company. The plight of the solo practitioner who needs rehab is more difficult, since there is no established mechanism to get another lawyer to cover one’s cases during rehab.

Again, we have provided impressions based on clinical practice, and directed you to some articles that may be of assistance, but as clinicians we are in no position to give a legal opinion. We might note that some law firms have written policies about job-related alcohol/drug use and employees who develop alcoholism/addiction; if any partners wish to contact us regarding examples of such policies, please feel free.

Do you know of any private treatment that might address the issue of decades-old PTSD in combination with alcohol addiction and depression? There doesn’t seem to be any information I can find on dealing with all three problems. Please.

This combination of problems – Post-Traumatic Stress Disorder accompanied by alcohol dependence and depression – is not at all uncommon. Any therapist experienced in addressing “dual-diagnosis” (meaning alcohol/drug + other mental health problem) should be able to provide appropriate “private treatment.”

One problem is that there will be many therapists who describe themselves as skilled in these areas but who are not actually sufficiently trained (except with regard to depression, the most common of these diagnoses, which would have been part of the training of any psychologist, social worker, psychiatric nurse, or psychiatrist). If you are a lawyer, law student, or judge (or family member of same) and come for an in-person interview at our Boston office, we can make a specific referral to someone with relevant experience.

You can also contact clinics, which at times offer relevant groups – substance abuse clinics to ask whether they run groups targeting those who also have PTSD (this was the case at McLean’s alcohol/drug clinic last time we checked), or PTSD clinics (such as the Trauma Center in Brookline) to ask whether they offer a group for those who have coexisting alcohol problems.

In your opinion, is it ethical for a QMHP (Qualified Mental Health Professional; Lane County, Oregon) to be “assigned” very disturbed children/families from the Department of Human Services, as well as suicidal clients who are hospitalized? We have a counseling service in our town whose “counselors” with this credential are often automatically assigned these types of high-risk clients. It is my understanding that a QMHP is not a licensed therapist. I don’t think the families of these clients know that their loved ones are not receiving high level mental health care. Should I be concerned?

We should clarify that, while we invited everyone to view our web site, our in-person, telephone, email, and Q&A services are direct to those Massachusetts lawyers whose dues support us (as well as Massachusetts judges and law students and family members). In this case, we actually do not know what kind of education/experience is required to be a Qualified Mental Health Professional, a designation that does not exist in Massachusetts.

In general, community clinics and hospitals do make use of clinicians with lower-level credentials, partly as a way to provide more care within budget. We would think that these clinicians would be operating under the supervision of someone with a higher level of licensure. Sometimes, these individuals become very experienced and savvy over the course of years on the job, and their qualities as sensitive, insightful human beings may outweigh the credentialing issues, just as some people with many degrees have poor interpersonal skills – but, as a consumer, you have no way to ascertain this, so your concern for adequate training is very reasonable. That’s about all we can offer with reference to treatment settings in Oregon.

I read with interest your recent columns detailing ways that our managed care health insurance plans can make it difficult to access treatment for psychological and alcohol/drug disorders. As in-house counsel to a large corporation, I have a choice of various insurance plans. Can you tell me how an HMO differs from a PPO or Point of Service plan, or whatever other kinds of plans?

Choosing the best health plan can be challenging, partly because a given plan’s coverage for medical/physical health services may differ greatly from what they offer for mental health/substance abuse (MH/SA) treatment. In general, an HMO will be your least costly option, though that may be hard to believe when you see the premiums. You will need to choose one primary care physician (PCP) who will handle most of your complaints and will serve as “gatekeeper” to specialists (i.e., the PCP must authorize any services you seek from another doctor or you will have to pay for it yourself). In some plans, any specialists you see must be members of the same physician group (usually meaning that they are affiliated with the same hospital as your PCP). Most HMOs, however, have a separate mechanism for authorizing MH/SA treatment, where you obtain the initial authorization not from your PCP but via a special phone number on your insurance card. In any case, you must obtain authorization and see a clinician who is “in the network.” The authorization will be for a limited number of sessions; your therapist can then apply for more authorized sessions, using a form that involves disclosure of your symptoms, functioning level, and treatment plan. If your treatment is not finished within the approved number of sessions, this process may be repeated a number of times until you have reached the annual maximum (usually 24 sessions unless you have a “biological” diagnosis).

It is very difficult to distinguish any differences between a PPO (Preferred Provider Organization) and a POS (Point of Service) plan, from the consumer’s point of view. In each case, you have a choice – either to stay within the provider network, in a system virtually identical to an HMO, or to choose a provider who does not participate in the plan’s network. This gives you much more freedom in selecting the clinician. However, your cost for each service will generally be higher, and there is often an annual deductible (e.g., the first $100 or more may come directly out of your pocket). Another advantage of going out-of-network is that you may bypass the cumbersome authorization system described above (though the annual maximum still applies). PPO and POS plans have higher premiums than do HMOs. You cannot tell what type of plan you have simply by the “brand name.” That is, Blue Cross, Tufts, Harvard-Pilgrim, etc. all offer both HMOs and more flexible types of coverage.

Finally, some people still have access to the now-heady freedom of an old-fashioned “indemnity” plan, the kind that covered most of us until the mid-1980’s. That type of plan will cover any licensed provider who agrees to accept insurance, and in many cases will reimburse a patient who chooses to pay the provider directly. These companies usually still impose an annual maximum amount of coverage (which does not always seem to comply with Massachusetts’ Mental Health Parity law discussed last issue). If you would like to bring all the brochures into LCL for help in reviewing your options, feel free – no authorization required!

Mental health Services

[RECEIVED 10/15/04] Do you keep all communications confidential including suicide decisions? Suicide is a constitutional right (see COMPASSION IN DYING et al v. STATE OF WASHINGTON et al, 79 F.3d 790 (9th Cir 1996) and STATE OF OREGON, et al v. JOHN ASHCROFT, et al 368 F.3d 1118 (9th Cir 2004), but people treat a person planning this as either a criminal or crazy though they are not and batter them and otherwise harm them. Also not all people discussing plans of things important to them want to be stopped. People discuss things with the request for someone to do something to stop situations they find intolerable, because they don’t want to die alone, or simply because people discuss all sorts of plans that are important to them. I don’t want to be stopped and don’t want to find myself in a situation where anyone does anything to me by force or against my will or without my express consent. I would like to see the situation improved but there is nothing I can do to improve the situation. There are some things some people can do to cease making the situation intolerable. (2) [RECEIVED 10/16/04] I previously asked a question but have not received an answer. Since there is no way to know if you have received the question I am sending it again. My question regards confidentiality of suicide. I did see that you answered a question from someone who is suicidal because they flunked the bar exam. That was not me. I passed the bar exam. At any rate your answer to that question did not respond to the issue of confidentiality. My question is this. What is your policy on confidentiality when you are informed of suicide plans or attempts? Do you keep this confidential or do you tell anyone of this? Since you have not responded to my question I am under the impression that communications to you are not confidential. Your policy is your policy whatever it is, but it is only fair that you disclose what your policy is.

Please note that it sometimes takes several days for our staff to have time to compose responses to your questions and get them posted on this web site.

LCL’s clinical staff are Massachusetts-licensed clinicians, and follow the same practice guidelines as would be typically found in hospital, clinic, and private practice settings. While it is probably true that some suicidal people do not wish to be stopped, and that a philosophical (or possible even a legal) case can be made in the abstract, we think it is clear that our mandate is to support healing and survival. Our policy emphasizes confidentiality in almost all circumstances, but not in cases of imminent harm to self or others. We would be glad to mail you a copy of the confidentiality information sheet that we routinely hand to new clients who come here to meet with a clinician.

-Mental Health Services

I am contacting LCL because I have become exasperated attempting to find either a therapist or psychiatrist for help with my increasingly severe anxiety. The frustrating self-referral process, itself, has made the anxiety worse. My managed care health insurance company gives me names, but when I call the clinicians I find no one who actually has time to see me.

Unfortunately, access to mental health care has continued to worsen (for people using health insurance) since the advent of managed care. At first, the managed care companies (in most cases, “carve-out” companies that handle only mental health and substance abuse treatment) kept their provider lists too small, refusing to sign up providers who wanted to join the “panel,” and some also made it difficult to get more than a couple of provider names at a time. While provider panels in certain areas (like Boston/Brookline/Newton) are often still closed, that problem has decreased, and nowadays most companies offer on-line provider lists. The newer source of frustration is that so many clinicians have opted out of the managed care morass that there seem to be too few with open slots in their schedules. If you are in a position to pay for your treatment out of pocket, or if you are one of the few who has “indemnity” health insurance (will pay any licensed provider, even one who does not have a contract with a managed care organization), the process of finding treatment is much easier. There are other benefits, as well, to not using your managed care plan, including: (1) Your therapy will not be abruptly cut off when the managed care folks think your treatment is not “medically necessary;” (2) You have truer confidentiality, as the provider is not compelled to provide clinical information to the payer; (3) You can select providers based solely on recommendations and expertise rather than on whether they are on a particular list. However, many people cannot afford to self-pay. (50-minute sessions generally range from $90 to $130 or more, depending on factors including the type of clinician.) At LCL, we are accustomed to spending a good deal of time trying to match clients with treatment providers based not only on type of problem and personality “fit,” but also on factors like geography and managed care company. You are much more likely to end up satisfied than by choosing random names from an HMO list. But, we must admit that it now takes significantly longer (especially considering the multiple criteria we use to try to make an excellent match) to complete the referral process.

-Mental Health Services

My husband has, after many years, agreed to get help for his drinking. We were surprised to learn that his health insurance benefits would not cover a Betty Ford-type rehab center, and would only provide weekly outpatient counseling. We were further dismayed (and angered) to find, despite Massachusetts’ “mental health parity” law, that his insurance limits him to something like 8 sessions. That seems like so little for such a big problem, when in the past he’s tried to stop drinking many times on his own and failed. Does it make sense to you?

PART ONE] Concerns about the limits of managed care, particularly related to gaining access to treatment, have been brought to our attention a number of times recently, so we will use this opportunity to piggyback onto last month’s column that addressed the difficulty of finding an available therapist. Prior to managed care (which hit the scene abruptly in the mid-to-late 1980’s), it was common for individuals with alcohol or drug dependence to spend about a month in an inpatient rehab. Most of these, like the Betty Ford Center, were based on the “Minnesota model” of detox followed by weeks of individual and group therapy (along with such ancillary activities as family therapy, exercise, nutritional counseling, meditation, use of AA, etc.) designed to reduce denial, foster acceptance of alcoholism/addiction as an illness and provide an initial grounding in sober living. Almost all of the facilities of that type in New England no longer exist. Individuals who still enter such programs (generally in other parts of the country) usually do so on a self-pay basis, at a cost in the range of a year’s college tuition. The rare health plans that do cover such facilities often apply to members of labor unions.

In Massachusetts today, health insurance will generally cover detoxification only if the individual has true withdrawal symptoms (such as “the shakes”). In those cases, a typical length of stay might be 4 days – just until the acute withdrawal symptoms abate and the patient’s vital signs return normal. Some plans may also cover a period (often two weeks) of “partial hospital” (day) treatment, in which the patient lives at home but spends about 6 hours a day attending group therapy, while receiving individual case management and psychiatric oversight. That’s as close as most patients are going to come to “rehab” when insurance is picking up the tab. Following partial hospital treatment, or instead (if it isn’t covered), insurance usually provides limited coverage of “outpatient” care, which usually means one session per week (individual and/or group therapy). As to the limited number of sessions that your HMO will authorize, that’s a large enough topic to wait for our next column. Meantime, let us remind you that LCL’s staff deal with the insurance morass all the time (though our own services require no payment), and are available to help you navigate.
[PART TWO] Managed care’s raison d’être is to save money, reduce skyrocketing health insurance premiums (though it does not seem to have had this effect), and in most cases maximize profits. Cuts in services have been more dramatic in mental health/substance abuse than most medical services. Though the cost managers have been a bit kinder to outpatient treatment than to inpatient, they have nevertheless erected a number of gateways and obstacles to try to contain costs.

It is true that the Massachusetts Mental Health Parity Law of 2000 mandates that the limits of coverage for mental health conditions cannot differ from that for physical conditions. However, the law contains some very significant restrictions:

§It only applies with full force to so-called “biologically-based” mental health conditions, including major mood and psychotic disorders as well as certain anxiety disorders. ¨

§For less severe mental health disorders, insurers must cover up to 24 sessions per year, and few if any exceed that “minimum maximum.” ¨

§Alcohol and substance abuse disorders, though they would appear to fit within both the “biological” and “mental health” categories, are excluded from both. For these disorders, the mandate is only for $500 worth of services per year (which might come out to around 8 sessions at managed-care-discounted rates). So if one is both alcoholic and depressed, for example, there may be significantly more coverage (via the depression diagnosis) than there would be for alcoholism alone. ¨

§If your employer is “self-insured,” meaning that health claims are paid with the employer’s own funds (i.e., in which the insurance company merely administers the process), the Parity Law does not apply at all, and the plan can impose whatever limits the employer desires.

Regardless of the supposed annual maximum, however, managed care plans need not cover these services beyond the point that they consider “medically necessary.” When the patient sees an “in-network” provider (mandated by HMOs, and encouraged via financial incentives in PPO and POS plans), the managed care company will usually authorize an initial 8 to 12 sessions. If further treatment is desired, the therapist must complete and submit (just before the authorized sessions run out) a detailed request form disclosing much more about the patient’s problems and progress. Typically, a few more sessions will be authorized per request, followed by the need to submit more forms and client information. Obviously, this system builds in incentives for the clinician and/or patient to lean toward a brief course of treatment. It is certainly not designed to minimize relapse potential, and tends to ignore the multiple medical, legal, commercial and family consequences of active addictive behavior. Since LCL’s staff is familiar with “how the game is played,” we may be able, in various ways, to assist when any lawyer, judge, or law student bumps up against these roadblocks to adequate coverage.

I would like to know if this scenario is unethical. My wife and I go into marriage counseling with a clinical therapist (PHD, APA, etc). We divulge all of our dirty laundry. After several weeks we discover that the therapist is our neighbor living on the same street several doors down. My wife and I miss the next appointments out of embarrassment, shame, fear, and paranoia. A few days later we receive bills from her indicating that we are going to be charged for the missed appoinments (clearly an indication that she KNEW we were neighbors)…..It seems that she should have disclosed this to us and to continue treatment was unethical because of the, what I perceive to be, a conflict of interest. We discovered this while sitting on our porch and watching her drive by a few times. Finally I looked in the county’s real estate/tax database and sure enough…..she lived there.

Since we’ve had no response yet to sharing your question with a psychologist ethics resource, we will, for now, provide our own perspective, but we don’t represent ourselves as experts on this score. We have reviewed the American Psychological Association’s ethical code. It prohibits “fraud” or “intentional misrepresentation of fact,” and also cautions against “multiple relationships” (e.g., if your psychologist also had a social or business relationship with you) that “could reasonably be expected to impair the psychologist’s objectivity, competence, or effectiveness” or risk “exploitation or harm” to the patient/client. It also warns that psychologists should refrain from taking on a role in which there is a conflict of interest. None of these seems to precisely apply to the situation you describe.

Nevertheless, if the psychologist realized, before or during her meeting with you, that she was a close neighbor, we think she showed poor clinical judgment by not disclosing that fact to you and giving you an opportunity to switch therapists if you were uncomfortable with her residential proximity. (We say “if,” because, depending on her system for acquiring patient data, she may not have noticed your address until she was sending you the bill for the missed appointments; if she hires a billing service to handle these functions, she may still not be aware of it.) As you probably know, other issues aside, it is standard practice to bill clients/patients for “no-shows” and for sessions cancelled with less than 24-hour notice. It’s not clear why, in your dismay, you didn’t call to cancel further sessions.

Please realize that, in any case, the psychologist is very clearly prohibited from disclosing to others any confidential information that was shared in the course of the therapy, including the fact that you saw her, without your written permission (except as necessary in the billing process, or in the case of imminent potential harm, child/elder abuse, or court order). For example, to tell a neighbor something she knew about you via a therapy session would be a serious ethical/legal breach.

I was dismayed to find that the psychotherapist that I have been seeing for 6 months is no longer covered by my health insurance as of the new year. I felt that she and I were working well together, and that she really understands the stresses that I face as a lawyer. Now I have to decide whether to pay out of pocket. A friend has suggested that self-paying might be just as well, because of issues of privacy, but I thought this was covered by confidentiality. Can you clarify?

It is an unfortunate fact of managed care that HMOs maintain restricted provider lists. This is one of many measures taken to contain costs. The mental health/substance abuse portion of a health care plan is often subcontracted for management by a separate company. Because these companies are constantly undergoing mergers, acquisitions, and restructuring, and because a job change may require an HMO change, many people may find themselves in your predicament. It is worth appealing to the HMO for a single-case exception that would allow you to continue with your current therapist. They may decline, of course, especially if your therapist appears to be oriented toward long-term (i.e., more costly) treatment. When a choice is available, it is often wise to select a now-rare “indemnity” health policy — the old-fashioned type that does not have a restricted provider panel. Next best would be a PPO (preferred provider organization) or POS (point of service) plan, both of which allow subscribers to go “out-of-network” in exchange for a lower rate of reimbursement. The premiums are generally higher for these plans, but it may be worth it. Privacy is another issue. Whenever you utilize health insurance to pay for psychotherapy/counseling services (like any medical service), a diagnosis must be included on claims submitted by the provider. It is impossible to be 100% certain that such information will never leak out, e.g., to an employer, to a national medical database, etc. In many HMO plans, a diagnosis alone will suffice for the first 8 sessions per year. More extensive disclosure — at least on items such as symptoms, suicide potential, substance use, environmental stresses — is required to extend treatment. While it is reasonable to be concerned about privacy, especially for those in high-profile positions, this concern has to be weighed against the cost of treatment. Harmful outcomes seem to be rare. For example, in this writer’s 20+ years of clinical experience, the only known case where disclosure to health insurance had adverse impact was one that resulted in an increased premium. If money is not an issue, the self-pay route is certainly safer. Therapy costs are tax deductible as medical expenses, of course, but one might have to produce documentation (and thus sacrifice privacy) if audited. Services that we provide at LCL, by the way, are free of cost and do not make use of health insurance. As part of our assessment, we discuss insurance related concerns with our clients when referring them to other professionals.

-Mental Health Services

I was wondering if it’s okay or allowed if my therapist and I did things outside of the office, like as friends?

In general, the ethical codes of mental health disciplines (including psychology, social work, and psychiatry) strongly discourage “dual relationships” with clients/patients. Most firmly prohibited are sexual relationships, which have been damaging to many individuals (as well as the careers of many therapists). But other kinds of dual relationships can also have an adverse impact. Because of the parent-like aspects of the therapist’s role as well as the client’s openness with private information, a therapy relationship contains the potential for exploitation of various kinds, e.g., if there were also a business relationship (say, the client invests in a project in which the therapist has an interest). While friendships are equal, two-way connections, therapeutic alliances focus on the client’s concerns; socializing can blur this boundary and interfere with the clinical work. (This is only a partial review of potential adverse consequences.) There are exceptions, of course, such as chance encounters and treatments that require exposure to real-life stimuli.

Because therapists and clients share intimate material and commonly develop positive feelings toward one another, it is easy for both to wish to expand into the realm of friendship. But since there is a potential for harm, those lawyers and ethicists who advise mental health clinicians almost always warn them to avoid personal relationships with clients/patients not only during the treatment, but indefinitely afterward.

I’ve been seeing a psychotherapist for six months now after coming to recognize recurrent problems in how I relate to the partners in a series of law firms for which I have worked. Now I have questions about my relationship with my therapist. At times I wonder whose therapy it is, since I’ve learned more than I need to know about his life and problems. I find myself trying to solve his problems, and, later on, feel angry.

This is a tough one. Your observations about your interactions with your therapist may mirror, to some extent anyway, patterns of relating to others in general. Your feelings of anger in this case, however, may also indicate a problem with your therapist.
Years ago, the traditional therapist was silent and non-directive, disclosing as little as possible about himself (using masculine gender here since your therapist is a man). Many therapists still work that way, and we occasionally hear complaints about that. Approaches that have gained prominence more recently involve increased therapist activity, and often more openness. This more active style may help set a more collaborative tone and permit a therapeutic relationship that is recognized for what it is – a relationship. It should always be clear, however, who is the client and who is the therapist. For example, a therapist statement like, “Yes, I, too, have sometimes felt competitive with coworkers,” may validate a client’s feelings. Some therapists also purposefully use their reactions in the session as a tool to help clients understand their impact on others. Clinicians differ as to what kinds of disclosure are appropriate. But in almost any case, a clinician’s need to elaborate on his problems (irrelevant to the client) should be reserved for his therapist.

You might initially address your discomfort with the therapist himself; generally a trained clinician will not take offense, but will explore the problem with you. Since the situation is so complicated, it is also often worthwhile to get a second opinion, or consultation. Generally, the consultant will talk with and give feedback to both therapist and client. At LCL, we sometimes provide this kind of consultation and in other instances make referrals to other professionals for that purpose. In some cases, a change of therapist may be indicated. In others, the process of working through the impasse may itself become the most beneficial part of the therapy.

I am concerned about my law partner, who practices criminal law and formerly worked as a police officer. He has confided in me that aspects of a recent assault case have triggered an eruption of feelings related to an incident on the (police) job some years ago. He seems much more nervous and moody, having nightmares and sudden vivid recollections of that incident. I’m glad that he did seek help, but he apparently found some form of therapy that involves watching the therapist move her finger back and forth for a few sessions. To me, this sounds kind of “out there.”

It sounded that way to us, too, when we first learned about this approach, and it remains controversial within the field. But many therapists have now been trained in “EMDR” (Eye Movement Desensitization and Reprocessing) and swear by it. As we understand it, the alternating right/left eye movements are supposed to create a state in which traumatic events, encoded differently in the brain from normal memories (and packed with emotion), can quickly be re-experienced in a more detached way, without overwhelming the patient. That can be advantageous in accelerating “desensitization,” a technique that has been around for many years, in which anxiety around a particular stimulus is gradually diminished. Another familiar therapeutic strategy, known as “cognitive restructuring,” is also a component of EMDR. Cognitive restructuring, a part of many therapies, involves learning to change how we look at or think about ourselves, others, and our experiences. In the case of past trauma, the ultimate goal (in any form of treatment) would be to transform the emotion-laden memory (in many cases experienced as a “flashback,” as if happening in the present) into a “regular” memory (with emotional intensity fading over time). Most forms of trauma treatment are not brief, though the intervention can be relatively short-term when the trauma itself was time-limited and especially when the individual does not wait months or years before talking about it. Although drawing upon existing techniques, EMDR purports to provide powerful and faster results. Whether it will ultimately be seen as making a unique contribution remains to be seen (research findings are mixed), but our impression thus far is that, in the right hands, it is a safe approach. We strongly recommend that your partner, if interested in EMDR, see someone with credentials in both that technique and also more traditional forms of treatment. We can assist in making a referral.

-Mental health Services

I am a senior attorney and have been thinking about contacting your office for a while now. I don’t want to discuss my problem here but suffice it to say that I am uneasy about certain things relating to my practice (I practice general law). I haven’t done anything criminal but I am at risk for my actions being misconstrued by an outsider. I had planned to call your office but happened to learn about the new “snitch” rule the same day. Now I don’t want to call. Care to comment?

Rule 8.3 Reporting Professional Conduct went into effect on March 1, 1998. In essence, the rule now requires lawyers to report serious violations of ethical duty by lawyers and judges.

However, the staff at LCL are not attorneys, they are licensed clinical social workers, so the rule does not apply to them. Second, a lawyer being assisted by another lawyer under the auspices of LCL enjoys precisely the same confidentiality protection as exists between a lawyer and client (see Rule 1.6(c)).

We hope that your concern is laid to rest but if not, feel free to call LCL, even anonymously if you like, to talk further about Rule 8.3 or the limitations of mental health-related confidentiality. If you after doing that you are still unsettled, we could refer you to an attorney with whom you could speak. Given that you are feeling vulnerable about your practice, please do seek out assistance here or elsewhere.

-Mental Health Services

After reading your June 1997 column, I realized that I probably had Attention Deficit Disorder, and started getting treatment for it (psychotherapy and medicine). This has made a real difference as I am less restless and better able to stay focused. Unfortunately, though, I still forget crucial details, work in a very unorganized way, tend to focus on less important tasks before important ones, and in general, still get into some pretty big messes. If someone could just follow me around all day and keep me organized, I would do just fine. Obviously that can’t happen but do you have any other ideas?

While there is no simple or completely effective fix for Attention Deficit Disorder (ADD) — including the use of medicine and therapy — a new field has evolved of organizational and career “coaches.” Coaches work with all kinds of people who feel the need for assistance in organizing their lives and pursuing goals in a more directed manner. Additionally, some coaches specialize in helping those with ADD.

Although coaches cannot “follow you around” all day, many do their work by phone as needed, so that you can get closer to “real time” input than you can from a therapist. Along with strategies to better organize your work and home life, you might also be assisted and supported in identifying strengths and limitations, obtaining and reviewing relevant testing, and making longer range plans.

Career coaching is a still emerging field but LCL has assembled a working list of career/ADD coaches. We recommend first meeting with a staff clinician for an evaluation to confirm the nature of the problem and formulate a more comprehensive set of recommendations. You can also get information from a referral service provided by the International Coach Federation of New England, whose president can be reached at 978/692-4454.

Mental Health Services

In the course of my probate practice, I have frequently recommended mental health assistance for clients, but it was not until I sought some help for a problem of my own that I really learned how difficult it can be to access suitable care and have it covered by my health insurance. Do others run into the same roadblocks?

Before “managed care,” I might have recommended that you get a referral from a trusted friend and then interview two or three potential therapists if you could. However, things have changed dramatically since then. If you are like most Massachusetts residents, your health coverage is through an HMO. In this case, the first step is to contact your primary care physician, who will determine whether mental health treatment is “medically necessary,” and a referral warranted. (Some plans offer a central mental health phone number as an alternative to the primary care physician.)

When a referral is made, it must be to a clinician who is on your HMO’s “panel,” a restricted list of providers who are employed by or have a contract with your HMO. Once you begin therapy, the HMO will probably pre-authorize something like eight sessions, based on (a) your own description of the problem and (b) psychiatric diagnosis (always required) from the professional. For additional sessions, the therapist would then provide the managed care company with more detailed information about your problem, symptoms, functioning, treatment plan, etc. In a sense, the managed care company becomes the co-treater. These companies are prohibited from sharing your personal information with others, such as life insurance companies.

You may also run across Preferred Provider Organizations (PPOs) and Point of Service (POS) health plans. These plans also have restricted provider lists, but usually will cover “out-of-network” providers, albeit at a rate that costs you proportionately more out of pocket. A third type of health insurance is “indemnity” coverage, which covers all independently licensed providers and requires no pre-authorization. This type of insurance used to be the most common but is now rare.

A public defense lawyer with some life difficulties, I have been seeing a therapist for about six months. I had thought we were doing pretty well together until he recently recommended group therapy. I don’t understand why he made this recommendation. Not only that, why would I want to disclose personal issues to a group of strangers with problems of their own?

The short answer to the concerns you raise is for you to talk with your therapist about why he recommended group therapy for you. Generally speaking, though, there are many excellent reasons to consider group therapy, either as an alternative or adjunct to individual therapy.

Groups come in many varieties. Some are time-limited while others are long-term or ongoing (participation ends when one’s group goals have been reached). Often, the latter are “process” or “interactive” groups, meaning they primarily focus on how members interact with one another. These groups enable individuals to access various aspects of their personalities in a way that individual therapy does not. By contrast, short-term groups usually focus on a particular theme, offer a didactic or other structured agenda, or are skill-building in nature.
Despite their differences, both short- and long-term groups share common characteristics, or what Irvin Yalom calls “therapeutic factors” (The Theory and Practice of Group Psychotherapy). Group therapy is particularly powerful in its ability to give members the sense that they are not alone or unique. Groups also instill a sense of support and hope, with members learning from each other. In a way, the group provides a room full of “therapists” (i.e., people in a position to pay close attention and give honest feedback) who are empowered to help one another. The “strangers” to whom you refer quickly become a close network of supporters. The fact that they have and disclose problems of their own helps them to understand and assist you. Their lack of connection with the rest of your life further lifts the concern about confidentiality.

Historically, LCL has always been a supporter of groups as a legitimate modality, and has sponsored at least one support group since its inception in 1978 — long before we offered assessment and referral services. In fact, we believe so much in the efficacy and healing powers of the group process that we are now offering a number of groups, led by mental health professionals on LCL staff in our Boston office. The groups are confidential, free and mostly time-limited (generally 12 weeks). We also make referrals to alternative or longer term groups.

Frequently my clients find themselves in crisis situations without knowledge of where to go for help. The need for this type of knowledge was made alarmingly clear recently after reading about a local publisher who committed suicide apparently after having trouble finding help. Please advise on the steps my clients or I can take to gain access to quick help for emotional or family problems.

In the case of this tragic episode, it was reported that one of the calls was made to a psychologist referral service that unbeknownst to the caller had been temporarily suspended. However, in general a referral service is not a crisis line. It can be a good way to get referred to an appropriate clinical provider, but usually not on an immediate basis. It is also preferable to seek help before a problem reaches crisis proportions.

In a non-crisis situation, you can seek a referral through an acquaintance who has had a good past experience (although the therapist may not be affiliated with your HMO), through your primary care physician, or through an assistance program like LCL. At LCL, a match will be made based on type of problem, geographic and other logistics, and insurance type.

In a crisis situation, however, particularly outside of business hours or if you are unable to reach your primary care physician, you should call the mental health phone number shown on your insurance card or go directly to a hospital emergency room, preferably one that is covered by your health insurance. If the professional at the ER believes that your immediate safety is at risk, you may be referred to an inpatient facility. Psychiatric stays in hospitals are generally between three and ten days.

If you are safe and want only to speak with a caring volunteer, you may call a crisis line like the Samaritans at 617/247-0220, or CONTACT at 617/244-4350. Regardless of what measure you take to get through a crisis, the most lasting help will most likely come from sustained outpatient treatment, meaning counseling/psychotherapy, and medication when needed. However, as a safeguard it’s not a bad idea to keep emergency service information within easy reach.

I wanted to ask your opinion about the therapy I’m in. I became the senior partner of my father’s environmental law firm a little over a year ago after he died. I was very close to my father and was grief stricken — the reason I started therapy. My therapist really helped me come to terms with my father’s death. In fact, that’s how I was even able to take over the practice. However, I dont know if therapy is working anymore. I used to really look forward to going and found that the time flew by. Now I almost dread the sessions, and once I am there I really don’t know what to talke about. We discuss family issues but nothing we talk about really feels that important. I don’t know if I should say something to her, quit, or do something else.

If you haven’t raised this in your therapy, do. Although being honest with a therapist can be difficult — especially when it concerns the therapist or the therapy itself — it can be exactly what is needed to get things back on track. Therapy in general, even therapy that is very good, can get stuck or derailed, either because the identified piece of work is done (for example, the acute grief is now resolved) or for other reasons. The best way to sort it out is through dialogue with your therapist, who can help you understand why your experience is so one-dimensional right now, or if the therapy needs to stop or change in some way.

If after talking with your therapist the therapy still feels “off,” consider getting an outside consultation. The consulting therapist will meet with you and possibly your therapist as well, and will make recommendations. Don’t let your kind feelings about your therapist get in your way; a well trained therapist is one who would welcome this idea (or propose it) and truly wants what is best for you. There’s a good chance your therapist can steer you in the direction of an outside consultant, but LCL staff also is equipped to provide or refer you for consultation. There is no charge for an LCL consultation.

I have found your column informative, although I’ve never considered myself someone who needs mental health assistance. Something has come up, however, and although I would rather not write about it here, I notice that you often recommend seeing a “therapist” or “psychotherapist” or “counselor.” Before I put myself in someone’s hands, what is the training or licensing for these people?

This is a good question, because these terms are actually quite vague. The unfortunate fact is that anyone can hang out a shingle with the title of therapist, psychotherapist, or counselor. (For all intents and purposes, there may be little or no difference among these terms, although some would consider “counseling” to have less clinical and more advice-giving connotations.) When we speak of a therapist in this column, we are referring to someone trained and licensed in any of a variety of specific disciplines.

A clinical social worker (LICSW means licensed to practice independently) has a masters degree in social work, a field with a rich history of addressing social needs and providing assistance by taking into account individual and systems factors. A clinical psychologist has a doctorate (Ph.D., Psy.D., or Ed.D.) including training in psychological theory, clinical techniques, research, and psychological assessment. A psychiatrist is an M.D. who, after medical school, chooses to specialize in mental health treatment in residency, generally gains much hospital experience, and is able to prescribe medications. (In recent years, psychiatry has moved increasingly toward expertise in the biological/medical aspect of mental health treatment, leaving the “talking therapy” to the other disciplines, although there are still many psychiatrists who do both.) A clinical nurse specialist also comes from a medical background, has an RN and a masters degree, and may be able to prescribe medications under the supervision of a psychiatrist. There are a number of other kinds of masters-level therapists, with titles such as “mental health counselor” and “marriage and family therapist.” Some, but not all, are licensed. Finally, there are certified alcohol/drug counselors, who have perhaps a year’s formal training, often augmented by relevant life experience. To complicate matters, many psychologists and social workers also gain certification in alcohol/drug/addiction treatment over and above their other training and licensing.

In many cases, the particular personality, clinical orientation, and experience of the practitioner may be more important than academic/professional discipline. Although a license is no guarantee of quality, we believe it vastly improves the chances of receiving quality care. A major part of our work at LCL is to match people with “therapists,” which is shorthand for any of the kinds of licensed professionals described above.