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:

 

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!

Dec 16

10 ways to stay mentally strong during the winter

The winter months tend to bring out the blues in many of us. From it getting darker earlier in the day leading to less vitamin D, to the anxiety of having the perfect holiday with family, to the hustle and bustle of everyone else buzzing around in a hurry and not paying attention. Life as normal is busy and stressful, however the winter months and holiday season tend to be even more stressful than other times of the year.

Even fun activities like going on vacation or taking in a show can seem more stressful during this time of year. Increased stress causes the body to be flooded with cortisol and adrenaline – which leads to an elevated heart rate and high blood pressure. when these side effects are prolonged and repeated, the stress begins to start damaging tissues and organs leading to long term damage.

Becoming aware of the stress and the triggers that lead to higher stress is the first step in combating it. There are other positive choices that can be made to alleviate stressors. Share with friends and family, let’s help to reduce stress among everyone this season.

10 Ways to Stay mentally Strong During the Winter & Holiday Season:

  1. Never criticize someone in public
  2. Breathing – practice breathing exercises that calm your mind and adrenal system, which allows you to stay more in the present moment, focused on positivity
  3. Be open to new ideas, no matter where they come from. Collaboration is a great way to reduce stress and accomplish more
  4. Complimenting others – find a reason to compliment others and truly mean it, you’ll feel great and so will they.
  5. If there is a dispute or argument with a loved one, wait until the situation is calm before addressing it. Be willing to walk away during the heat of the moment.
  6. Address tension when it arises, don’t avoid situations but also don’t be combative during them.
  7. Work to find the solution not the problem. Focus on the positive outcomes and stay solution focused, this will help you be more calm
  8. Smile often. Smiling helps us remember the situation isn’t as big as we may think it is. Smile and share a smile with others, one smile can spread good cheer and happiness to others.
  9. Create loyalty with others by being loyal yourself.
  10. Drop the perfectionist attitude. Nothing and noone is perfect – no outcome has to be perfect. Drop the attitude of perfectionism and expectations of situations and just enjoy being present with who you are in the moment.

 

This season make a conscious effort to eradicate stress by enjoying life and going the extra mile to remain positive in all situations. When you feel tension coming on just breathe and think about whose life you can impact with a smile or a compliment. Showing gratitude is also another great way to reduce stress and tension during this season.

The power lies within you to change the reaction to your situation. Control your thought process and attitude and see how others are positively affected by it too. Share the joy this season and stay mentally strong!

 

CPH and Associates is your leading provider for professional liability insurance.

Dec 09

WHAT IF YOU JUST DON’T LIKE THE PERSON? Professional responsibilities and limitations

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We therapists are generally supposed to be able to provide some form of helpful psychotherapy to any and all who come to us, whether in a private practice, or from a clinic’s assignment, or an insurance company’s referral.  We are similar to medicine’s g.p., the family doctor, now often called a primary care physician (pcp).

In a few cases we therapists may refer certain patients/clients to a specialist, when we judge that some specialized treatment is called for that exceeds our own training.  Most of the time, however, we aspire to be “all things to all people,” with a generalist’s overview of all mental functioning and the repair of all emotional difficulties.  We are also trained to be aware of, and to control — as part of our professional ethics — those private inner feelings that are not therapeutic.

Occasionally all this training doesn’t work.  Into our office comes a person who sets off wave after wave of powerful reactions within us.  Sometimes we can use this “countertransference” to help us understand just how this person manages to mess up his or her life.  Managing our countertransference is part of our job and, while sometimes frustrating, is useful and doable, at least in theory.

But sometimes the person who’s entered our office just rubs us too much the wrong way.  The person may be whiney, mean, crooked, seductive, nasty, condescending, money-grubbing, or whatever — just too off-putting or provocative for us (although perhaps not for another colleague).  We may struggle for a while, with a growing awareness of how very helpless or very angry or very sexual or very (you fill in the blank) we are feeling in relation to this person.

And not only our feelings but our actions may become problematic.  We may find ourselves making errors: forgetting the appointment time, the person’s name, or details of the person’s history; getting sleepy or needed to use the toilet more; speaking abruptly or critically or bristling at questions; gossiping to a colleague about the foibles of this new “case,” thus using distancing language in referring to the person.  Our reaction may be so strong that we can’t control it — or we fear that we can’t.

We therapists know how to deal with a client/patient who is “stuck.”  But if we are the ones who are stuck, even after competent supervision or consultation, and are still not able to feel good enough about ourselves, or therapeutic enough toward this person, then we face a difficult decision.

One choice is to keep plugging along, getting help from videos or books or other professionals, in the hope that we can gradually improve our complicated reactions, create a workable treatment plan, and become more therapeutic.  This option has an ethical time dimension to it: how long can we “fake it until we make it,” while we may also be sending out mixed emotional signals to the person who has come for treatment?  There is no one right answer, but persistent wrestling with it should produce more clarity to us and our advisors.

The other option is to admit defeat and refer the person onward.  Although this happens more frequently with inexperienced therapists, it can be an appropriate decision for any therapist, no matter how highly trained or experienced.  Unfortunately our professional literature provides only a few helpful examples of therapists admitting, reluctantly, that they cannot provide what the new patient/client needs.

This kind of referral, this kind of premature termination, will usually bring positive feelings of relief to the therapist, as well as less positive ones: perhaps shame at admitting one’s limitations, or guilt at having failed to reach one’s professional ideals.  Also, perhaps anger at having one’s best intentions foiled by a person we just don’t, and can’t, like.

Either choice can be hard to accept and work through.  But worst, however, is the prolonged avoidance of making an admittedly difficult decision.  Such therapist dithering is bad for the client/patient and equally bad for the therapist, who will only grow more demoralized and less helpful with the passage of time without a clear direction.

Coming to a clear decision and then taking action on it, whether to work harder or to refer out, will predictably improve the therapist’s bruised sense of self.  The therapist will be doing the right thing about her or his “wrong” feelings, which are really all-too-human ones.

By David C. Balderston, Ed.D., LMFT

Nov 30

Television’s Impact on Emotional Intelligence

Does Netflix Make You a Better Person?

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This Cyber Monday, we’re talking digital: Does Netflix make you a better person?

A recent study linked television dramas to theory on the mind. It’s findings revealed that watching intricate television dramas can in fact raise your emotional IQ, specifically by making your more empathetic.

Two experiments were tested. In the first experiment, a group of 100 people were told to either watch a fictional or nonfictional tv show. Afterwards, they took an emotional intelligence test. The people who watched a fictional tv drama scored higher on this test. They added a control group into the second study, finding similar results still. Researchers also noted that those who watched a nonfictional show scored higher than those who did not watch tv at all.

As a counselor, this indicates that the shows your clients are binge watching could provide more insight than you think. Don’t jump to tell them “no” the next time they mention they’ve spent their weekend binge watching a Netflix series. While TV shouldn’t interrupt your client’s daily routines and obligations, it can be beneficial to maximizing their emotional intelligence during down time. Ask them about the type of shows they watch, and when they typically schedule it in during the day to gain a better understanding of their television habits and how it relates to their emotional intelligence.

For more mental health tips, visit our CPH blog.

Nov 25

Gratitude Journaling

Gratitude Journaling

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Stay Thankful this Holiday Season with Gratitude Journaling.

 

Our lives are so often consumed by stress that we rarely pause to consider all that we are thankful and grateful for. Instead, we often focus on the stresses of work, education, financial, friendships, relationships, and conflicts within the family. We only briefly consider the joyful people and things that also fill our lives.

 

In the spirit of the holidays, bring gratitude to the forefront of your thoughts with Gratitude Journaling. Gratitude journaling is a log kept of all the moments, people, and things in your life that you are grateful for. Ask yourself what you are grateful for each day and write down these thoughts as they come to mind. You may surprise yourself with the large amount of entries you have!

 

Many celebrities and notable philanthropists have incorporated gratitude journaling into their daily routine. Oprah Winfrey is strong advocate for daily gratitude journaling, and notes that there is always time for it in the day. When she had temporarily stopped her daily gratitude journal, she noticed a shift in her mood; she wasn’t as happy anymore. At first she told herself she was just too busy to log daily, but then reflected on how her life was just as busy before when she was journaling daily. Oprah now writes her journal electronically, and writes it down the moment the grateful thought comes to mind. It’s all about prioritizing your journal and making it as accessible as possible, such as writing it down on your phone or a notebook you keep handy.

 
For more articles on mental health, visit our CPH Blog

Nov 17

Update: The Texas Association for Marriage & Family Therapist Case

This blog is an update to our previously posted blog outlining the current case in Texas regarding the Right to Diagnose for Texas MFT’s: 

 

The Texas Association for Marriage and Family Therapists backed legislation during the 2015 Texas

Legislative Session (HCR 84) that read in part:

“RESOLVED, That the 84th Legislature of Texas hereby directs the licensure Board governing the state’s

mental health providers to use the Diagnostic and Statistical Manual of Mental Disorders, the

International Classification of Diseases, and any other appropriately recognized classification systems,

and billing codes therein, for evaluation, classification, treatment, and other activities by their licensees

and in connection with any claim for payment or reimbursement from a health insurance policy issuer or

other payer…”

 

Although this bill had overwhelming bipartisan support in both the State House and Senate, Governor

Glenn Abbott vetoed the bill on May 18, 2015. The intent of this language in the bill was to provide a

work around for the 3rd Court of Appeals decision in the suit filed by the Texas Medical Association

against the Texas State Board of Examiners of Marriage and Family Therapists and the Texas Association

for Marriage and Family Therapists. That decision barred LMFTs in Texas from making client diagnosis

using the DSM or ICD in their practices. The decision is being appealed to the Texas Supreme Court.

The intent of HCR 84 was to instruct the relevant agencies to maximize the tools available to them, to ensure

that licensed, qualified mental health practitioners were eligible for reimbursement by insurance payors. It

deliberately avoided using the term “diagnosis” and instead focusing on currently permissible activities

including evaluation, assessment and treatment in a manner consistent with the classifications and billing

codes contained in the DSM.

 

State studies documented that 173 out of 254 Texas counties are designated as Health Profession Shortage

Areas (HPSAs) for mental health. If LMFTs and other licensed mental health professionals are unable to

practice given the uncertainty of reimbursement, these shortages of access to mental health care will

worsen.

 

All mental health professionals without medical licenses need to get involved and support the efforts by

the SBEMFT and TMFT to assist in this battle against TMA. Ways to help include reaching out to

legislators, contributing to the TAMFT Political Action Committee (PAC) or the Practice Protection Fund

set up by AAMFT.

 

An interesting side note: According to Governor Abbot’s campaign finance reports the TMA PAC

contributed $43,485.41 to the Governor in 2013 and 2014.

Nov 12

Coloring Books: Not Just for Kids

Coloring Books: Not Just for Kids

Meditate through Coloring Books

Screen Shot 2015-11-12 at 12.40.38 AMRemember the childhood days of spending hours carefully coloring in the pages of a color book with crayons and markers? According to recent studies showing the benefits of meditation through art therapy, it may be time to pick up the coloring book again.

Everybody experiences stress, whether it be physical stress, mental stress, financial stress or emotional stresses. We encounter these magnitude of stressors throughout any given day, all of which can take a toll on our physical health, vitality, and happiness. Meditation, in addition to regular exercise and a healthy diet, can decrease this stress to promote longevity and a positive mental state. According to Psychology Today, meditation is the practice of turning your attention – or bringing awareness – to a single point of Screen Shot 2015-11-12 at 12.40.47 AMreference. This point of reference can be your breath or body, but must be in the present moment. The purpose of meditation is to clear the mind of existing external thoughts. Unsettling thoughts, such as relationship and life issues, melt away while meditating. Meditation provides people with a deeper sense of self-connection and mental clarity.

Meditation can be practiced in a multitude of forms. Art therapy has become a widely acknowledged, contemporary form of meditation. The American Art Therapy Association describes art therapy as a “life-affirming” expression that can aid in melting away stress, and enables people to focus on the singular task at hand: the art that is being created in the present moment. Drawing in a coloring book is a simple, but highly effective, way of practicing art therapy. The next time you feel overwhelmed with stress, pick up a colored pencil or marker, and let your focus and stress melt into the pages.

Stressed at the workplace? Check out more of our latest tips on stress management with 5 Easy Ways to Beat Stress at the Workplace.

Oct 20

The Right to Diagnose for Texas MFTs

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On November 21, 2014 the Texas Court of Appeals, Third District, At Austin in Cause No. 03-13-00077-CV issued its decision in a case brought by the Texas Medical Association (TMA) against the Texas State Board of Examiners of Marriage and Family Therapists (TSBEMFT) and the Texas Association of Marriage and Family Therapists (TAMFT). The court invalided a TSBEMFT board rule (22 Tex. Admin. Code §801.42(13)), which stated that a marriage and family therapist may provide “diagnostic assessment which utilizes the knowledge organized in the Diagnostic and Statistical Manual of Mental Disorders(DSM) as well as the International Classification of Diseases (ICD).”  The case had been assigned to a three judge panel and resulted in a 3-2 decision in favor of TMA on this issue.

The deciding two justices, Justice Scott K. Field and Justice Bob Pemberton reasoned that TSBEMFT exceeded its authority granted by its enabling statute, the Licensed Marriage and Family Therapists Act (Texas Occupations Code, Chapter 502) in implementing the rule cited above. Texas Occupations Code  §502.002(6) allows marriage and family therapists to provide “professional therapy services “ including “evaluation of …cognitive, effective, behavioral, or relational dysfunction.”

The majority found that “evaluation” did not mean “diagnosis” which they opined is reserved to medical doctors under the Texas Medical Practice Act (Texas Occupations Code, Chapter 152).  Under the Texas Medical Practice Act “practicing medicine” is defined as “the diagnosis, treatment, or offer to treat a mental or physical disease or disorder or a physical deformity or injury by any system or method, or the attempt to effect cures of those conditions.”

The dissenting justice J. Woodfin Jones, the Chief Justice, wrote a dissenting opinion in which he accused the majority of playing a semantics game and for not adopting a more general definition of “diagnosis”. He wrote that “no therapist could hope to successfully remediate ‘cognitive, affective, behavioral or relational dysfunction’ without performing a ‘diagnostic assessment’ (in the general sense) of the individuals involved, and any therapist who attempted to evaluate an existing dysfunction in a marriage or family without considering clear mental and emotional issues of the individuals involved would likely be committing malpractice.”

TSBEMFT and TAMFT are appealing this decision to the Texas Supreme Court and the decision has been stayed pending the appeal.  If the decision is allowed to stand Texas LMFTs will be unable to make a DSM diagnosis. This has serious implications for client care and billing and for other mental health professionals in Texas who do not have a license to practice medicine and who may be targeted next by TMA.

An interesting side note:  The two justices in the majority deciding the case both listed TMA as supporters of their election campaigns in 2012.

 

Provided by trusted attorney Tom Hartsell and CPH and Associates, your leading provider for professional liability insurance for mental health practitioners.

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