Jul 28

July is National Grilling Month: 5 Ways to Eat Healthy during Barbeque Season!

 

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From July 4th all the way through the month (and the summer!) grilling out is a staple of American life. Backyard barbeques, fire pits on the beach, hibachis at campgrounds all become a place to create delicious meals over a coal bed or wood fire. But too much red meat can be bad for you, and brats and burgers (and even hot dogs) can lose their appeal after too many roasts.

Here are five ways to make your grill-outs healthier and more interesting:

  1. Consider beef and pork alternatives. Grilled chicken is delicious when you make sure to soak it in marinade first and keep basting it so it doesn’t lose moisture. Breast pieces can be sliced horizontally to yield a more even thickness and then cut in strips for fajitas and shredded and doused in BBQ sauce for health sandwiches.
  2. If you haven’t tried grilled fish yet, now is the time. Large steaks can be cooked directly on the grill or planked for delicious smoked flavor, and smaller filets can be grilled in a wire trap to keep them from disintegrating. A little lemon juice, basil, and olive oil can help keep your fish moist and flaky.
  3. Mushrooms are the new burger. A huge Portobello makes a fantastic meat substitute, perfect both for the vegetarians in the family and the health conscious as well. Sprinkle some mozzarella cheese on top during the last few minutes of grilling and don’t forget to season well.
  4. Kabobs let you have a small amount of meat while doubling down on veggies. Cherry tomatoes, bell pepper chunks, button mushrooms, and pearl onions are traditional, but consider adding fresh pineapple or mango, chunks of zucchini, and even sweet potato cubes as a way to brighten the meal and add much needed nutrients.
  5. Pizza night can be healthy and fun on the grill! Throw your crust in a pan and sling it on the back of the grill with a layer of sauce to start cooking while you grill veggies to put on top. Small meat cuts can be quickly cooked then cut up as toppings, then you can cover the entire thing with cheese and close the lid of the grill to finish it off. Try a whole wheat crust brushed with olive oil for a healthier twist.

Your grill outs can be fun and healthy, leaving room for the occasional guilty s’more. Find out what your client’s love to grill and suggest ways to make their own backyard barbeques a little better for their health. Nutrition advice is one of the things trainer insurance is designed to cover, so make sure you have a good policy in place!

Jul 26

3 Amazing Smoothies to Fuel Your Summer Workouts

 

fresh vegetarian smoothie witn oat flakes and blueberry

A smoothie is the go to of any true fitness aficionado – right? But the routine can get boring quickly if you don’t mix it up with different styles and flavors. Here are 3 tried and true smoothies that will get your morning off to a great start.

Delicious Protein Powder Smoothie

Start with a high quality protein powder, Add milk – dairy or non-dairy; almond milk or coconut milk is fantastic. Dump in nut butter of your choice, a banana if you like, or some fruit yogurt. Chocolate is good – go for dark for better antioxidants and less fat. You can mix this kind of shake up in a Bullet blender, food processor, or other mixer and it will be delicious. For best results, keep the milk chilled as cold as possible and use frozen peeled banana chunks for a creamy, smooth taste. You’ll think you are having an ice cream shake. This site has great protein powder smoothie recipes to try.

Yummy Veggie Smoothie

You don’t have to use powder to get protein into a shake, veggies like spinach and kale work wonders, and if you buy these fresh and make sure they are chilled and dry, the texture and taste will be great. Try mixing either green vegetable with a strong tasting fruit like a mango, and add smooth consistency with chilled coconut milk and some frozen banana chunks – or go full mojito with pineapple and mint blended in along with ice cubes for a delicious green drink. Try more green smoothie recipes to find one you can’t live without.

Terrific Fruit Smoothie

Everyone loves a quick fruit smoothie, Washing, peeling (if necessary) and chopping fruits to pop in the freezer can provide a base – or dump your chosen fruits in a blender, puree, and pour into ice cube trays for a jump start. Add yogurt, milk or non-dairy milk, a little cinnamon or vanilla, and garnish with a lemon slice or berries for a boost to your morning that tastes and looks great. Feeling brave? Avocado makes smoothies smooth as silk and the flavor is subtle under the fruit. Try these fruit smoothie recipes and get creative!

Ask your clients about their fave smoothie recipes, and think about holding a smoothie experimentation day with a huge variety of ingredients and BYOB (Bring Your Own Blender). You’ll be amazed at how many variations you can come up with.

  • Don’t forget to keep your fitness trainer insurance up to date. Nutrition advice counts when you are a personal trainer, so ensure you and your smoothie day are covered!
  •  Discuss how to get protein from fruits and/or veggies for your smoothies – that not all smoothies have to have protein powder. (spinach and kale are high in protein,
  •  Include one smoothie using fruits, one using vegetables and one with a protein powder. Discuss how chia seeds are packed with protein – good to add to fruit smoothies.

Jul 22

Fruit and Hydration go Hand in Hand during the Summer Months

Sliced juicy watermelon on wooden chopping board in kitchen

Fruit and Hydration go Hand in Hand during the Summer Months

It’s summer time and that means heat and sweat which means hydration (always important) is even MORE important. Are you drinking enough water? Getting your electrolytes? Making sure your blood sugar doesn’t tank?

Fruit can be your friend all summer, with high water content, natural sugars for better glucose control, and the ability to be easily grabbed on the go. Summer is the best time for high water content seasonal fruits, so start hitting the produce section whenever you go to the store.

Many fruits have additional benefits beside their hydration properties. For example:

Watermelon

Besides being 92% water, watermelon is packed with nutrients, antioxidants, amino acids, vitamins (including Vitamin A, B6, and C), potassium, magnesium, lycopene, and free radicals.

Cantaloupe

A denser but just as delicious melon, the juicy cantaloupe also has potassium, Vitamin A, choline, and fiber – all important to heart health. In addition, you get a healthy dose of antioxidant and anti-inflammatory phytonutrients.

Honeydew Melon

Another winner from the melon family! Honeydew delivers iron, potassium, fiber, and copper, plus a healthy serving of Vitamin C and 2 different B vitamins. It can aid in collagen production and tissue repair.

Kiwis

Vitamins C, and K as well as potassium, folate, copper and manganese all hide in the green flesh under the kiwi’s furry brown skin.  These gorgeous little serving sized fruits also contain a rare fat-free version of Vitamin E for added power.

Grapefruit, peaches, berries, oranges and pineapple are also great ways to “eat your water” for the day, so plan on plenty of fruit salads and fruit smoothies as well as munching down on whole pieces of fruit at snack times.

A smoothie for breakfast will hydrate you in a way that coffee, tea, or soda simply can’t. A smoothie that also gives you fiber, protein, and a super punch of flavor can be made quickly by following this easy formula:

  • 1 cup fresh fruit (you can also add grated or chopped veggies)
  • 1 cup base: milk, yogurt, kefir, or non-dairy milks like almond, soy, or coconut
  • 1-2 tablespoons of healthy fat (nut butters, flax / chia seeds, or avocado)

You can add protein powder or additional flavoring as desired. Think about sharing this simple breakfast tip with your clients, encourage everyone to eat more fruit this summer, and don’t forget to make sure your fitness trainer insurance is active and covers nutritional advice!

Jul 20

Insurance Company Records Request

It seems that requests by insurance companies or contractors for insurance companies for copies of client records is on the uptick.  More providers of mental health services are receiving letters from these entities requested copies of records for one or more identified clients.  These letters are not accompanied by signed written authorizations from the clients whose records they seek to access.  Providers receiving these letters have uncertainty about how to respond and what information they can or are obligated to provide.

The HIPAA Privacy Rule gave health plans and self-insured employers regulatory permission to obtain information without client consent for billing and health care related matters.  The Amended HIPAA Privacy Rule expanded the uses for which these entities are authorized to obtain, use and disclose protected health information (PHI) without client consent to include the following:

  1. Due diligence in connection with the sale or transfer of assets;
  2. Certain types of marketing;
  3. Business planning and development;
  4. Business management and general administrative activities; and
  5. Underwriting, premium rating and other activities relating to the creation, renewal or replacement of a contract of health insurance. Section 164.501

Treatment of clients for long periods of time or beyond a recognized average time period as experienced by the health plan seems to be a trigger for a review of records.  These requests often seek copies of session notes or progress notes.  I have talked to providers who received requests for copies of a client’s entire file.  The Privacy Rule generally requires covered entities to take reasonable steps to limit the use or disclosure of, and requests for, PHI to the minimum necessary to accomplish the intended purpose. However the minimum necessary standard does not apply to disclosures to or requests by a health care provider for treatment purposes.  

It is important to remember that if a provider maintains psychotherapy notes as defined by the Privacy Rule those notes are not subject to access by an Insurance company.  It is also important for providers to know if they are covered entities under the Privacy Rule.

So, if the health plan has concerns about the quality of services or the length of time services have been provided it would appear to have a right to access the entire client file.  If the requested use were for a billing question or issue the minimum necessary standard should apply.

Upon receipt of one of these requests I usually advise contacting the client to determine if they will provide written authorization to disclose the information requested.  A provider might consider including a broad consent in their intake forms clients execute on the front end of treatment authorizing the release of any and all information requested by the client’s health plan or payer of benefits.  If the client’s authorization for release of the information sought has not been obtained and the letter received does not make clear the use for which the information is being requested I advise getting clarification of use from the health plan or self insured employer before determining how to respond.  That information will inform whether or not the minimum necessary rule is in effect and how much the provider should release from the client file. Some times the requesting entity will agree to accept a summary of treatment and it is worth pursuing this option.

At end of the day it is the provider’s decision on providing PHI of a client and forced with the choice of being denied payment or future inclusion on a provider panel the decision becomes personal and difficult.  From my perspective more needs to be done to challenge and limit an insurance company’s access to personal and sensitive client information.

Written by Tom Hartsell

Jul 19

Putting the “Fun” in Functional Training: Getting Clients on Board and Enthused

Dumbbell push up group functional training circuit at fitness gym

Have you been trying to introduce functional training to your clients, but they just don’t “get” it? Functional training is one of the most versatile types of exercise, and almost anyone is capable of doing it – even clients who are obese, out of shape, partially disabled, or who have medical issues that preclude high impact or high heart rate exercises. Functional training is also extremely beneficial for clients recovering from injury or illness, who need to work their way back up to a full workout routine.

The core concepts of functional training are:

  • Use all 3 planes of motion.
  • Integrate the entire body.
  • Enrich the mind.
  • Make the workout fun!

The only point of contact with the ground during functional training is the bottoms of the feet, so the goal is to remain stable at all times. Functional training can improve all of the following:

  • Strength, power, and speed
  • Flexibility and range of motion
  • Muscular endurance
  • Cardio vascular fitness
  • Prevention of and rehabilitation for injures
  • Posture and balance

The body itself is the prime workout accessory, but you can make functional training more interesting and fun by introducing props such as kettle balls, dumbbells, medicine balls, core boards, Indian clubs, and more.

Functional training can include one on one and group exercises – and encouraging “play” scenarios isn’t just allowed, it’s encouraged. So are seemingly silly “kid style” moves that you may not have thought of in years, including:

  • Crab walking relay races – you might be surprised when it’s not the leanest, fittest members of the class who win.
  • Time competition – who can cross one foot over the other knee while standing (as if attempting to tie a shoe) and keep it there the longest?
  • Speed competition – set a number of objects on the floor and have class members bend at the knees to reach them and straighten to place them on a high shelf.

You can make functional classes fun, and turn them into gateways for new clients to work up to joining more advanced or complex focused classes. As always, ensure your fitness trainer insurance is up to date, especially when working with those who are out of shape or recovering from an injury.

Jul 11

When Death Threatens Someone Close to the Therapist – What to Expect – Really, not Ideally

We know how to deal with grief in our clients/patients.  We know how to help someone who is very ill go through the various stages and feelings about their own approaching death.  Our professional knowledge helps us to anticipate our own feelings, as well as help our patients/clients deal with their feelings, which naturally can be intense or defended against.

But when it comes to someone close to us, it may not be easy to deal with this final fact of life – its ending.  We can’t be strictly professional about a personal situation.  And we may be surprised by our own reactions, even though we’ve seen them occur in those we have a professional relationship with.    Some of us may discover that we have wonderful, creative responses emerging to deal with this intimate exposure to death. In others, this event may not bring out our best responses.  As usual, there is a wide range of individual differences.

This column is NOT about the unusual death of a child or young person, or a suicide or homicide, but about a mature person’s demise.  Now, when a slowly dying person shifts into hospice, whether at home or in a facility, there is some extent of time to allow all the mixed feelings to emerge gradually into your consciousness, and while some of the feelings may be upsetting, there is no sudden surprise.  Over time, you grow to understand and accept them better.  (If, however, part of your reaction should be deeply troubling, then you may find it useful to have a consultation with a mentor, or a grief counselor who specializes in such feelings.)

Also, we have all read about, and perhaps participated in, a structured gathering of friends and close family at the bedside of someone who is dying, and who may have even chosen the date.  These  events are typically consoling as well as uplifting; sorrow is mingled with appreciation and love is freely expressed in the room.  Therapists may participate as private persons, but this kind of situation does not generally challenge us, for the simple reason that it is anticipated.

Then there are the other situations. We may watch TV hospital dramas and gain some awareness of what happens in extreme or mortal situations.  But mostly we are inexperienced with death at close hand; we don’t know what to anticipate, emotionally.   Not so, a century or two ago, when many young adults died of “consumption” (TB), when typhoid fever and cholera were common, and most deaths occurred at home.  Today, we may understand intellectually what is happening, but each of us is pretty much on his or her own when it comes to our private emotional reactions. Various religious and ethnic groups have their traditional ways for observing the passage from life to death, but what if your own feelings do not fit into those prescribed formats?  There are the usual feelings of painful sadness and loss, but what about “inappropriate” feelings of anger, relief, helplessness, disgust, or a numbing of all feelings –- reactions which are not so easy or acceptable to express?

Especially when a loved one suddenly has a bad accident or unexpectedly becomes seriously ill, our personal reactions may surprise us.  We hurry to the bedside, our anxiety inevitably elevated.  We hope for the best and fear the worst.  We look for small signs of improvement.  We ask the doctors and nurses for the latest condition of our loved one, and we seek their explanations of many medical details.  We may ask a lot of questions:  what are the medications, what are the procedures, what will this or that do, how long will it take, when will we know the results?????  We try to communicate with the person, and it may feel awkward: what do we say — do we mention death?  Depending on the particular medical personnel involved in the situation, we may feel reassured by the sensitive ones, intellectually satisfied by the impersonally competent, or alarmed and annoyed by what seems like indifferent or incompetent treatment.

Sometimes, good hospital care leads to a recovery, and we can breathe a sigh of relief, literally  – for we have probably been “up tight” in our breathing as well as in our feelings.  Other times, the patient’s body is more seriously challenged and they need the extra supports of an Intensive Care Unit, where blood pressure, pulse, temperature and other bodily indicators are continuously being registered and shown on a monitor.  Intravenous drips of nutrition and enriched fluids are inserted.  Medications may be delivered by IV, or a more efficient central PICC line into the body.  Supplemental oxygen may be supplied.  If lung functioning is more compromised, our loved one may have a ventilator tube put down the throat to enable a machine to assist with breathing.  Bladder and bowel elimination may have to be via tubes.  With entubation of the ventilator (and some other conditions), sedation may be required, and this lessening of full consciousness can to lead to more frustration for all about inadequate communications.  Sometimes dying people follow a steady downward path.  With others, there are false alarms, rallies that don’t last, various uncertainties – all causing more anxieties, more stress.  Some people die quickly, even easily, while with others it is an exhausting marathon for everyone.

We approach the bed and, having first sanitized our hands at the door, we reach out to touch this struggling person so dear to us.  Time passes – time stands still.  All the modern medical technology is doing its job, steadily, quietly, helpfully.  Some of us can ignore these intrusions and focus just on the immediate relationship.  Others may be overwhelmed by the sight of all these tubes and the strange fluctuating lines and numbers on the monitor.  We offer what comfort we can, but we ourselves are often in need of comfort too.  Our emotional reactions may be all over the map, registering desperation and fear at one moment, anger and frustration the next, always some helplessness, with “inappropriate” thoughts about impending death and the changed future afterwards, and the messages of our own bodies about urgent needs to use a bathroom or find some food.  We want to be close to the person, or we want to get away and find relief from the tension, or perhaps a bit of both.

We may be able to rise to the occasion and produce wonderful words of comfort, and bring in meaningful objects to surround our loved one with reminders of special people and pets in his/her life.  On the other hand, we may be so overwhelmed by the enormity of what is happening right before our eyes that our responses may become emotionally numbed and perfunctory, just going through the appropriate motions, while our heart seems locked up and unavailable.  All this is mostly unforeseen and entirely human.

In the period after death, the meaning of “loss” becomes painfully real.  You think of things you would ordinarily discuss with the person, or ask about, or gossip about.  You see a news item or magazine article you would ordinarily clip and save for the person.  You see a movie or TV program but can’t comment on it any more.  Or you enjoy a certain restaurant you both used to go to, or you go to a special spot you used to share together – but not anymore.  You see that your phone has a message waiting for you, and spontaneously you think – but then you remember.

Later, also, following the person’s recovery, or death, we often think of things we should have done or wish we had said.  But our guilt about this, while inevitable, is a misplaced judgment, for we have done the best we could, period.  We showed up, we were present and hence a comfort, we stood at the bedside, we held their hands.  Whatever our feelings happened to be, our actions were the important thing.  We can’t predict or control what our feelings may be in an extreme situation like this, when the life of a loved one is in the balance, but our actions, to show up and offer comfort and closeness, reflect our maturity under duress.

In short, there is no one way of dying, and no one way of reacting to another’s death.  All this is common knowledge for mental health clinicians, but when faced with the stark reality of a loved life threatened with immanent ending, we can often use some reminders.

 

David C. Balderston, Ed.D., LMFT

New York City

May 04

Transparency Without Overexposure, Boundaries without Remoteness

405617This is a Colleague to Colleague Column guest post from David C. Balderston, Ed.D., LMFT.

 

We therapists are paid to be nosey—in a professional way, of course.  We get to ask strangers we’ve just met about their love life, their finances, family problems, job difficulties—whatever is troubling them.  We carefully invade their privacy, probing for dysfunctional connections among their feelings (sometimes unconscious), their beliefs, and their behaviors.   We get to be voyeurs of a sort, peeking into the private details of people’s lives for the most ethical of purposes: to relieve the distress of someone who is suffering or messing up in life.

Because most patients/clients, especially in their first sessions, feel anxious and uncertain about how much to trust us, perhaps embarrassed about what they need to reveal to us, perhaps wary and defensive due to past bad experiences, we try to put them at ease. We explain how therapy works.  We reassure them about confidentiality.  We answer their questions about our credentials and type of approach.

We keep uppermost in our minds the primacy of the relationship.   It is our job to make it work and keep it going, no matter what difficulties may emerge.  One main way to lubricate the relationship is to reduce the emotional distance between our professional image and the purchaser of our services.   We do this both verbally and nonverbally, by what we say and how we act.  Basically, we try to humanize our end of the relationship by being more personal and transparent in many small and subtle ways, depending on our personality and training. We may smile, or comment on the weather.  We may ask if the room is too warm or too cool for them.   We may be deliberately casual in showing them where to put their coat or other belongings.  We may be deliberately informal in asking about their biographical and insurance details, to avoid sounding bureaucratic.  We try to convey to them that we are human, too.

And therein lies a potential problem.  Most therapists agree that it is not helpful to the therapy process if we discuss at length, or even merely disclose, intimate or emotionally loaded details of our private lives.  While hearing such details from us might help our client/patient to relax and talk more freely, it does take the focus away from the person who has come for our help.  This digression may be exactly what the patient/client prefers–an easy defense against having to talk about uncomfortable matters.  It may also be tempting for us to indulge ourselves, by chatting about ourselves in a pleasant way—postponing the real work of therapy.  So it may be our own defense, too, because we know we have ahead of us a process that is complicated and might even fail.

At the other extreme, presenting too formal or impersonal a stance can make the therapist seem remote or forbidding.  If we are too noncommittal or distant, we risk creating such an austere atmosphere that some clients/patients will find it too objective and too lacking in human feeling or concern on our part.

 

Fortunately, we have a built-in safety feature to keep any personal talk from getting too intimate and non-therapeutic.  It is the use of Boundaries.  If the client/patient asks us too many personal questions, as if we were his or her neighbor or cousin, the person is not observing our professional boundary.  Perhaps she/he does not sense that there is a limit in a therapy relationship that is different from the boundaries in more personal relationships.  And the client/patient may crave to know all sorts of things about us. Patients who are socially isolated often want a lot of closeness from us, and can become clinging or demanding, when what they really need is to develop friendships outside of our office.  When we set limits on the amount of our self-disclosures and friendliness, the person may feel rejected, deprived, or annoyed.

At the same time, we are being professionally curious about many aspects of their lives.  So there is inevitably an imbalance:  you are supposed to tell me a lot about yourself, while I stay more reserved (preserving my professional boundary).  We know from our training to limit our personal disclosures to only what we believe is needed to maintain or improve this special relationship.  This can lead to some conflict in us when we decline to gratify a client/patient’s wish for a yearned-for closer connection.  Thinking ahead, when you realize that you may well be asked about something that is personal, it is helpful to rehearse your answer, so that you can articulate an appropriate boundary, and still convey respect (and not frustration) toward your client/patient, without seeming flustered or caught off guard.

It takes sensitivity to say No (I won’t tell you everything you want to know about me.) without offending our patient/client.  We may disclose a small amount of information that should not be upsetting: “Yes, I had the flu for a few days, but I’m feeling much better now.”  (You refrain from revealing that you were in the hospital.)   “Yes, I have raised children, so I know what you’re talking about.”  (You refrain from revealing that a daughter struggled with dyslexia, or a son had a drug problem, or was very ill with cancer for over a year.)  Furthermore, our refusal to respond to some personal approaches from our clients/patients actually is a reassurance to them — they can trust us not to get too familiar or forget our professional responsibility, which is to work for the betterment of their lives, lived mostly beyond our office.

Both persons in the therapy room have boundaries, which deserve our careful study.  The boundaries of both parties are important to keep intact and functioning appropriately for the sake of this special relationship.  Each person in this charged situation can go too far, and each person needs boundaries to prevent that.  Likewise, if boundaries are too formidable, they can also hinder progress.  We therapists respect our patients’/clients’ boundaries and do not insist on discussing what feels too personal and defended.  And we maintain our own boundaries and keep most of our personal lives outside the conversation.

Ideally, the boundaries are for the sake of both parties in the relationship, and serve to keep the sessions focused on the client/patient. Good training, supervision, and reading about what other therapists do, will help us in finding some middle ground of carefully personalized responses designed to prevent premature terminations due to the therapist being too personal or too impersonal.   There are plenty of good ways to reply, respectfully setting limits, when we are asked to reveal details of our private lives.  In the end, each therapist will establish his or her unique set of limits, being flexible and moderately disclosing when it is helpful to the therapy, and otherwise being clear about boundaries while maintaining mutual respect.  We get asked all sorts of things in therapy, but we are not obliged to answer all queries.  We can just accept them as indications of the dependency, annoyance, anxiety, or human interest of the person we are trying to help.

Psychotherapy can seem paradoxical: delivering highly professional help through a relationship that can feel very personal, even though it is not a friendship.  We need to have both a transparent humanity and professional boundaries, and the exact balance is up to us, using our best intuition and clinical knowledge, our caring and our self-discipline.

David C. Balderston, Ed.D., LMFT

Feb 09

MINDFULNESS: self-awareness vs. self-criticism

The beginning of a new year traditionally is a time of fresh starts and planned improvements in one’s life.  While we psychotherapists know sell the fragility of good intentions, nevertheless these heartfelt hopes are at the start of any initiative for change.  For us, change has a dual focus: how we improve clinically, and how we develop “the person of the therapist.”  Articles on “the person (or the self) of the therapist” have existed in the professional literature for years.  They stress the individuality of each therapist, and that our development is a never-ending dynamic process.

The “self” needs to be self-co0nscious, aware of its own workings.  We know that self-awareness is a necessary part of a therapist’s skill set.  But by itself, self-awareness is not sufficient to make us into better therapists.  “Mindfulness” is also required.  Mindfulness combines self-awareness with how we use it, for ill or good, for growth or condemnation.  The term is much in the media these days, but the concept has been around for a long time.  “Mindfulness” is our English word for a basic recommendation found in ancient Buddhism.   It has also been the title of numerous recent books, for example the 1989 book by Harvard psychologist Ellen J. Langer.  It is also an emphasis in several newer therapies, such as DBT, ACT, IFS, and others.

Mindfulness begins with a question: “All right, what’s happening in this brain box of mine?  When I unpack it, what do I find?”  An answer to the question might be: “I find the most amazing stuff, which I never suspected was there when I was 21 and didn’t really know myself very well.  And when I become mindful, I am aware of all sorts of raw feelings, and fantasies and impulses,  that serve to remind me of my common humanity.  In addition, my mindfulness invites me to accept without condemnation all those inner reactions.  They may feel good or bad to me, but they are simply artifacts of my existence as a human being.”

Mindfulness also promotes a focus on the present moment.  Therapists for years have encouraged “living in the here and now,” a phrase that emerged from Gestalt psychology.  Instead of dwelling on guilts about the past or anxieties about the future, one learns to concentrate on the immediate moment.  So often, people do not pay attention to what they are experiencing and doing right now.  Their minds are jumping ahead or revisiting the past, instead of being aware of and paying attention to what they are actually feeling, thinking, and doing in the present.  People admit this when they say, “My mind wandered,” or “I wasn’t thinking about what I was doing.”  At the same time, we are also trained to

consider a client/patient’s past experiences and future dreams or anxieties as other important factors in treatment.  So we can encourage mindfulness to help a patient/client from dwelling excessively on past bad experiences or fears of a bad future.

This focus on immediacy prompts its own questions to the self of the therapist: “What am I thinking or feeling right now?  What fantasies or images are popping up into my consciousness right now?  What was my mind doing just now, right before I paused to ask myself these questions?  What scenario was I rehearsing, what memory was I replaying, what pleasure or trouble was I anticipating, what conclusions was I repeating to myself?  Or was I somehow distracting myself, going vague or changing the subject, to avoid facing something unpleasant?  What re the predictable patterns of my mind at work?  Can I study the workings of my mind and not end up discouraged, overwhelmed, or craving some quick fix?”

As clinicians, we swing between being in the moment, and considering the claims of past and future, in all our sessions.  We also learn to pause and take seriously those moments of fleeting uneasiness that flicker on the edges of our consciousness.  A problem may arise only when we become aware of inner thoughts or feelings that are unwelcome or upsetting to our sense of self, and then our private distress can interfere with our professional concentration on being present with our client/patient. This is when the mindfulness of the therapist can neutralize the seeming “badness” of any inner events, and free us simply to observe them without judgment, and activate our inner scientist to analyze them as sources of useful data about ourselves and those we work with. 

Mindfulness is an important utensil in the therapist’s professional tool kit, but it is not always easy to do. As trained therapists, we are not supposed to be judgmental or moralistic about anything we hear in a session, or about the person who’s telling us. (We do consider the consequences of behavior, however.) Yet when it comes to monitoring our own honest private reactions to patients/clients who may be difficult or pathetic or sexy or threatening, our own self-evaluations may become a problem for us.  We may become aware that we feel like scolding, or showing direct affection, or becoming teacherly, or getting rid of a particular patient/client.  We may also become aware of feeling sexually attracted to, or disgusted by, or helpless concerning, or furious toward, the person we’re working with.  If our mind slides too easily into a self-critical mode, making punitive remarks to ourselves, our consciousness becomes split between doing therapy and tending to our own distress.

The good news is that mindfulness does not pass judgments.  It is not the same as our conscience (“super-ego”  for psychodynamic therapists).  Our self-awareness is our inner scientist, observing and ever-curious about new emerging data.  “Oh, now I’m feeling warmly and sexually attracted to this particular patient/client.  That’s so interesting.  I wonder what it means.  Am I sexually frustrated in my personal life? [This would be a subjective counter-transference reaction.]  Or is this person exuding a strong sexuality toward me, which would suggest something else (neediness-?) about his/her personality?  [This would be an objective counter-transference, induced by the client/patient.]  I am pleased to know that my emotional reactions are good clues to certain realities, within me or my patient/client, that deserve  my attention.”  Mindfulness is the cultivation of this inner curiosity-without-condemnation.

On a mindfulness continuum, most therapists operate somewhere between the extremes of a punitive self-criticism and a denial of any faults or weaknesses or blind spots. For most therapists, there is a  fluctuation of self-awareness that sometimes is praising and other times is self-correcting.  We are trained to see our own reactions as “grist for the mill” therapeutically, and not to be surprised or self-condemning if we experience feelings of sexual arousal, anger, disgust, envy, anxiety, or affection in relation to those we work with.  Yet we may still be uncomfortable with experiencing such feelings, even though our professional training and ethics prevent us from ever acting out such feelings (and their fantasies).  “I know it’s OK to feel this way, but I wish I didn’t,” or sometimes “If I react this way, does it mean that I’m not a good therapist?” This is where our “observing ego” (a term from psychoanalysis), being  self-aware without moral judgment, can help us.

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Feb 03

Federal Regulations and Guidelines for Client Access to Records*

 

Accessing client records

Guest Blog written by Tom Hartsell:

*An earlier version of the article did not include a statement that the definition of a “covered entity” was applicable to Texas Mental Health Professional guidelines. Texas has expanded the definition of covered entity to include any provider who receives, transmits or stores PHI in electronic format for any reason or purpose.  Any email or text messaging that a Texas MHP participates in will cause a Texas MHP to be a covered entity for Privacy Rule purposes.

I have spoken with literally thousands of mental health professionals (mhps) during my career as a lawyer that have been faced with a request for records.  I wish I had five dollars for the number of times I was told by a mhp, “I never give out copies of my records, I only provide summaries.”  I have had a difficult time convincing many of them that their clients were entitled to obtain copies of their records.

The US Department Of Health and Human Services has published guidelines for individuals’ right under HIPAA to access their health information (45 CFR §164.24).  The thinking behind the Department’s regulations and guidelines is to provide individuals with easy access to their health information to empower them to be more in control of decisions regarding their health and well-being.  This will allow individuals to better monitor their conditions, adhere to treatment plans, find and fix errors in their health records, track progress in wellness or disease management programs, and directly contribute their information to research.  The goal is to put individuals in the driver’s seat with respect to their health as we move toward a more patient-centered health care system.

The bottom line is that individuals have a right to review and obtain copies of their records.  Summaries can only be provided if the client requests one or agrees to accept the summary in lieu of the copies. “Records” means any item, collection or grouping of information that includes protected health information (PHI) and is maintained, collected, used, or disseminated by or for a covered entity.  I have had many mhps tell me that they are not a covered entity because they keep paper records so they do not have to worry about HIPAA.  I then ask them if they have you ever communicated with a client by email or text messaging.  I have never had any one tell me they have not.  Those electronic communications with your clients make you a covered entity.

A mhp is allowed to withhold psychotherapy notes from review by a client.  These are defined as notes a mhp records in a separate file from the client’s clinical file about the communications shared between the client and the provider that are for the provider’s use only.  Many mhps tell me that they will not turn over their notes thinking the psychotherapy note exception applies.  When I ask them if they keep these notes in a separate file I am often told that they do not.  If not, then they are not psychotherapy notes as defined by the regulations.   In some states, such as California and Minnesota, clients are allowed under state law to access psychotherapy notes and they cannot be withheld from a client.  Generally, where a state law provides better privacy protection or greater access to records” state law will supersede federal law.

The regulations allow a mhp to also withhold information under the following circumstances:

  • If any portion of the requested record is reasonably likely to endanger the life or physical safety of the individual or another person.  This ground for denial does not extend to concerns about psychological or emotional harm (e.g., concerns that the individual will not be able to understand the information or may be upset by it).
  • If any portion of the requested record is reasonably likely to cause substantial harm to a person (other than a health care provider) referenced in the PHI.
  • If a personal representative (i.e. parent) has requested access and any portion of the requested record is reasonably likely to cause substantial harm to the individual (i.e. child) or another person (i.e. the other parent).

These rules are game changers for mhps in states like Texas that that allow for denial of information based on professional judgment that disclosure would be harmful to the patient’s physical, mental, or emotional health.  Under the Federal regulations and guidelines concern for emotional health would not constitute a basis unless the mhp could tie it to some risk to life or physical safety like an increased risk of suicide.  It would be important for that risk to be evident from the face of the records themselves in the event a complaint were filed with a state licensing board or the Office of Civil Rights.

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Jan 13

6 Steps to Getting Paid: Billing for the Modern Clinician

By Alison Cooper with SimplePractice

SP Billing guide coverAt SimplePractice, we spend a lot of time coming up with ways to make the lives of clinicians better. And one thing we hear frequently is how billing can create anxiety and uncertainty for our customers. Figuring out when and how to bill, choosing what tools to use and tracking your payments all require careful consideration.

Many of our customers say they want to do billing more efficiently but don’t know where to start. For too many it’s a process to dread—but it is a necessity if you want to get paid.

In response, we’ve created a comprehensive and easy-to-understand guide to help clinicians who may not like the billing process — or those who don’t mind billing but feel they could do it more efficiently.

Our guide only takes about 15 minutes to read, and shows you the steps to develop your own personalized and easy-to-maintain billing system. You’ll learn how to create a frictionless routine to help you get paid more quickly, improve financial transparency, easily view your income stream, and most importantly, give you peace of mind — and who doesn’t need more of that in their lives?

Download our guide now!

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