A Must Read: “Bitter Pill: Why Medical Bills are Killing Us” by Steven Brill

The cost of medical care has been debated vigorously (and at times viciously) for the past 5 or more years. Many concerns have been raised about the cost of healthcare, as well as issues of access to healthcare. Steven Brill’s recent article* highlights not only the high cost of medical care but the incredible profits and salaries being made by pharmaceutical companies, insurance companies, and hospitals. While filled with examples of the impact of medical care on the uninsured and the under or poorly insured Brill’s article repeatedly illustrates the excessive charges for medical services and medication. He does praise some of the features of Obamacare including the elimination of life time caps on benefits, the prohibitions on the exclusion of pre-existing conditions, and the increased coverage for preventative care. However, Brill reiterates that the cost of healthcare is too high.
Of particular interest to those of us who are providers of health care services is that Brill’s focus on the high cost of medical care is not primarily on outpatient care (particularly not on office visits) but on hospital costs, hospital charges and profits, and insurance and pharmaceutical company profits. Many who provide health care services would argue that we too are being squeezed by these large players who control what we are paid and what services we can provide. Though Brill does raise concerns about the over provision of services, as an issue that is part of the problem.
Brill does not offer a laundry list of solutions. In fact he focuses on how solving these problems will be difficult because of the political influence of hospitals, insurance companies, and pharmaceutical companies. He notes that the pharmaceutical and health-care-product industries, combined with organizations representing doctors, hospitals, nursing homes, and insurance companies spend far more on lobbying than any other groups, including oil and gas companies and defense manufactures. Brill also intimates, on several occasions, that a for-profit/ profit driven health care system may be inherently problematic because while one can defer purchasing many things it is hard for most of us to consider deferring health care, particularly at times of emergency.

*This article can be found in the March 4, 2013 issue of Time Magazine or on-line at: http://www.time.com/time/magazine/article/0,9171,2136864,00.html

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Why I Still Recommend Family Therapy

Why I Still Recommend Family Therapy
February 27, 2013
Over 25 years ago my partners and I founded the Centers for Family Change. One of our motivations, at that time, was to develop a private practice that emphasized family therapy as the primary modality or approach. It was our belief that the most effective way to address many common childhood and adolescent problems was with family therapy. In a series of posts I will discuss why I still believe that family therapy is the best way to address many problems facing children and adolescents. These posts will examine topics such as: the original arguments/rational for family therapy; the elegant simplicity and common sense truths of Structural and Strategic family therapy models; the factors that appear to have stymied the use of family therapy; and a call for more family therapy and examples of how family therapy fits for many problems of childhood and adolescence including ADHD, anxiety disorders, underachievement and defiant and oppositional behavior.
Let me begin this discussion by indicating that I understand why many therapists do not do family therapy, and why many families do not seek it out.
Family therapy is harder than individual therapy:
• the views of more than one person have to be understood, addressed and balanced.
• patterns of interaction need to be identified and tracked; therapists need to think in terms of how systems work in addition to examining feelings and beliefs.
• conflicts can occur quickly and become quite intense.
• the therapist cannot just empathize with and understand the perspective on only one person; there are multiple perspectives and truths to balance.
Families often do not prefer or event want family therapy:
• teenagers may want the privacy and autonomy offered by individual therapy.
• parents may believe the problem lies completely within their child.
• family members may not want to address difficult and painful family issues.
Logistical Challenges exist:
• it is hard to schedule families, more evening or weekend hours are needed.
• insurance may not want to pay for family therapy.
• training programs may not have provided adequate training in family therapy.
Despite these challenges, and in some cases because of them, family therapy is often called for. Unaddressed issues, multiple perspectives on problems, unresolved conflicts, and problematic patterns of interaction all may need to be addressed to effectively resolve problems. Failing to fully consider these problems may hinder or prevent individual therapy from succeeding, where family therapy, despite its challenges, can.

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Are We a Brand? “Reflections on What Brand Is Your Therapist?”* by Lori Gottlieb

In this thought provoking New York Times piece Gottlieb, a relatively new therapist (and former journalist) describes the dilemmas many clinicians face in terms of “how much” and “how to” market themselves.  This challenge is compounded on increased pressures on clinicians: growing number of available therapists, renewed pressure from insurance and managed care to limit services, and competition from coaches.  Gottlieb thoughtfully discusses the pressures she experienced to market her practice and her concerns that adopting an aggressive marketing approach might compromise her clinical work.  In the end, Gottlieb reaches a balance that would likely strike many of us as reasonable: a website but clear limits on the use of social media. What is surprising is that she offers no mention of more traditional marketing approaches (e.g., networking with other professionals) which are widely accepted by most practitioners.

Gottlieb touches on challenges therapists face as they consider incorporating social media into her practice and her concerns that an excessive use of social media might disrupt/undermine her clinical work.  The debate about social media is ongoing. Clinicians such as Ofer Zur strongly recommend the extensive use and incorporation of social media into current practice, whereas many others argue for more caution.  Keeley Kolmes, PhD, a San Francisco psychologist offers a very thoughtful discussion of these issues on her website: http://drkkolmes.com/.

I would argue that despite the pressures to market and adopt new technology that we need to proceed cautiously. Going along with current trends may not always turn out for the best (for us, as clinicians, and for our clients).

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The Black Swan: Second Edition; A really worthwhile read!

“A thought provoking book” is a gross understatement when it comes to Nassim Taleb’s The Black Swan. Taleb forcefully argues that the way we think we understand the world is not valid.  Taleb asserts that randomness, unforeseen and unpredictable events, have a far greater influence than we wish to acknowledge. He argues that outlier events (rare, unusual and unexpected )  have a far greater impact on human life than we believe (in fact he argues that these events are the primarily movers and shakers for our lives and our world).  In addition, he notes that we concoct explanations of these events after the fact to try and make them seem predictable, but he asserts, they are not.   Taleb is highly critical of “experts” and their (our?) ability to predict what will occur. He argues that what we “do not know” is more important than “what we know,” i.e., that an awareness or understanding of how little we know is more valuable than focuses on and trying to confirm our theories. Moreover,  Taleb argues  that we are prone to a variety of errors in our attempts to understand and make sense of the world: we often rely on anecdotes and observations (highly unreliable sources of evidence) to draw conclusions and make predictions; and we are prone to retrospectively making sense of things that we had no idea were going to occur, in order to make them (our lives, the world around us) seem predictable. Again, thought provoking, underestimates this book.  Taleb’s arguments force the invested reader to question and re-examine his/her assumptions (which I might venture to argue is a very worthwhile exercise).

For the record:  the complete title of the book is:  The Black Swan: Second Edition: The Impact of the Highly Improbable: With a new section: “On Robustness and Fragility” by Nassim Nicholas Taleb Random House, 2010, USA.
This book is available in hardcover, paper and Kindle editions.

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Freud’s Last Session or is there a God

For those with an opportunity, the play, Freud’s Last Session, by Mark St. Germain, is highly recommended.  This play features an elderly Freud, dying of cancer, engaged in an intense discussion with C.S. Lewis. Freud angrily challenges Lewis’ faith in God. Lewis, in turn, is far more affable, be equally sure of his convictions.  Throughout the play, Lewis and Freud debate the existence of God, and the value (or lack thereof) of a belief in God. Their discussion is humanized as Freud visibly struggles with his failing health.  The conversation occurs just as WWII is beginning, which places the role of beliefs in a historical context. In light of the increased emphasis on the value of spirituality it is unusual to see the importance of spirituality and religion so directly challenged. Regardless of one’s particularly belief system it is intellectually stimulating to watch such a lively discussion of these issues.

This play is currently running through Sept. 2nd, 2012, at the Mercury theater (http://freudslastsession.com/).

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Book Reviews and more: A new blog Feature

In this section of the blog I will periodically discuss books that I have found to be thought provoking.  These will not always be works about therapy, and in fact my hope is to identify a wide range of literature that is both thought provoking and helpful (in terms of understanding and identifying ways to help people change behavior).

The Power of Habit: Why We do What We do in Life and Business,   by Charles Duhigg

In this highly readable work, Duhigg advances the idea that much of behavior is driven or controlled by habits. His deceptively simple thesis is that if we can better understand how habits work, how they can control behavior, that we will be much more able to change behavior.  Duhigg is not referring to only individual behavior but also to behavior on a corporate and community levels, as well. His examples range from an analysis of how habits can explain compulsive gambling to how the famous Montgomery Bus Boycott was successful, in part, because of the power of habits.   The Power of Habit is clearly not a self help book.  Rather, it is an analysis of human behavior, and how something as simple as habits influence and shape behavior. Duhigg’s work calls into question many of our cherished explanations for how and why people behave the way they do. It also suggests that behavior can be changed quite effectively if we understand how habits work.

I would highly recommend this book. While it may be unsettling to think that something as simple as habits underlie many negative and positive patterns of behavior, it is also a hopeful idea, because it suggests that change is quite possible.

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What makes therapy work?

Recently, I have found myself thinking about this question. I know that my thinking is spurred by the several trends or developments in the mental health field: the push by the American Psychological Association (APA) and other professional groups for Evidenced Based Therapy (therapy that is clearly demonstrated to be effective); ongoing pressure from managed care organizations to demonstrate the effectiveness of therapy in order to obtain authorization for additional covered therapy sessions for clients; and increased requests from clients (and others)  for CBT (cognitive behavioral therapy) or other types of therapy that they have heard are reportedly most effective.

How important is the client-therapist relationship?

At the same time that there has been an increased call for Evidence Based Therapies there has been a growing body of research which has strongly suggested that the “working relationship,”  or “alliance,”  between therapist and client,  is one, if not the most important factors in predicting whether therapy will have a successful outcome. John Norcorss, Michael Lambert, Bruce Wampold and others working in this area has gone on to delineate what factors are key in considering the client-therapist relationship and have stressed that seeking feedback from clients about therapy, is it working for them, is a key factor in improving the working alliance, improving therapy outcomes, and decreasing premature terminations (clients dropping out of therapy).

How does this help us?

These findings suggest that an increased focus on the working relationship can help improve therapists’ effectiveness. Related research has clearly shown that soliciting feedback from clients is particularly important. There is much evidence that consistently asking clients for their perceptions about how therapy is working for them can improve the working relationship, and thus increase therapeutic effectiveness.

For further additional information the reader is directed to the works of John Norcross, Michael Lambert, Bruce Wampold, Scott Miller, to name just a few.

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Effective Strategies for Treating School Anxiety and School Refusal

While it is developmentally normal for younger children to be anxious about school this normal anxiety typically resolves quickly as the child adjusts to school. Moreover, most parents are able to provide the support needed to help their children overcome their initial anxiety. However, when anxiety about school causes a child significant distress intervention is often needed. This is particularly true for adolescents, who, from a developmental perspective, should have resolved normal fears about school.

To effectively intervene with problems of school refusal and school anxiety clinicians need to clearly understand what is underlying these problems. Children may fear and resist school for a variety of reasons. Some children may have undiagnosed anxiety disorders (OCD, a social phobia or panic disorder). Others may have experienced difficulties with peer relations or have been victims of bullying. In some instances, children who struggle academically may feel inadequate and resist school because they experience academics as humiliating. Additionally, significant family problems may leave a child or teen fearful about separating from their family. Finally, more serious psychological or psychiatric problems may be present and school anxiety/refusal may be one manifestation or corollary of these disorders. Thus, when treating children who are excessively anxious about school, professionals need to assess for the following:

  • Presence of Anxiety Disorders
  • Peer problems (particularly bullying)
  • Academic difficulties
  • Family conflicts and problems
  • Presence of significant psychiatric/psychological problems

 

Additional factors that may complicate the assessment and treatment of school anxiety and school refusal are: somatic or medical symptoms, and maladaptive parental responses (these will be discussed later in the section on treatment).  Children with school anxiety often experience stomach aches, headaches, and other somatic complaints that have been found to have no clear cut medical basis. These symptoms often appear in the evening (on nights before school) or on school mornings, but seem to lessen or disappear when there is no school. While some parents, and even some children, are quick to recognize the connection between their anxiety and physical symptoms, others focus on somatic symptoms, and need repeated feedback from medical professionals that there is not a serious physical illness present and that the child needs to attend school.

Treatment strategies vary significant depending on a variety of factors including: the age of the child, the child or teen’s motivation to attend school and engagement in therapy, the presence of other psychological problems and concerns, and the family’s response to the problem.

Treating younger children with school anxiety and school refusal

            With younger children (those not yet in middle school) parental involvement in therapy is critical. First, younger children need support and reassurance to overcome their fears. Second, they often need firm limits to help them contain their anxiety and not give into fears. Third, parents, quite understandably, often react to anxious children in ways that inadvertently exacerbate or reinforce anxious behavior.

            Younger children often benefit from the use of cognitive behavioral strategies that help them find more effective ways to reassure themselves (self-talk strategies) and calm themselves. They are also often receptive to cognitive interventions that help them recognize that their fears are groundless. Parents need to be enlisted to support the use of these strategies and to model adaptive coping. This is particularly important when parents are more anxious and more reactive to their children’s anxiety.

            Firm limits are also important. Allowing anxious children to stay home from school does not help them be less anxious, as avoiding the source of anxiety only results in increasing avoidant behavior. Thus, parents often need support and encouragement to insist that their anxious child attend school. While accommodations can be made to help a child cope with their anxiety about attending school, not going to school is not a good option. Children who miss school often become increasingly resistant to attending as the avoidance lowers their anxiety and the idea of returning to school seems more daunting.

            Parents often find it difficult to effectively respond to their child’s anxiety. Some may provide excessive amounts of reassurance (rather than pushing a child to learn how to reassure him or herself). Others may become impatient and frustrated (yelling at an anxious person has not been shown to lessen anxiety). Finally, those parents who struggle with problems with anxiety themselves may find their child’s anxiety particularly unnerving. Parents often need direction on how to firmly, but calmly respond to their anxious child. In addition, when parents disagree on how to respond, intervention is needed to help them find ways to take a more unified stance.

            An example of a case recently seen in our practice involved a 9 year old boy was very anxious about going to school, particularly about taking the school bus. This boy frequently claimed to not feel well and not want to go to school, on school day mornings. His mother typically would walk him to the bus stop, wait with him, but if he balked about getting on the bus, the mother would often end up yelling at him. Not surprisingly this only resulted in the child becoming more upset (e.g., temper outbursts and running off). These bus stop scenes were happening at least twice a week when the family started therapy. The therapist was able to assist this child and his family by setting up a plan where the mother stayed calm, accepted that she could not make the child get on the bus, and would need to drive the child to school if he refused to get on the bus. The parent’s main objective was to remain calm, in order to help the child stay calm.  Positive reinforcement (being picked up from school) was used to motivate the child to take the bus. Ideally, the therapist would have worked with the child on finding strategies to help reassure himself and calm himself. However, this boy was reactive to therapy, refusing to participate. Thus, the work with the parents was the key to helping this child significantly decrease his school anxiety and school refusal.

Treating older children and Adolescents

            Working with older children (preteens) and teenagers is easier in some ways (teenagers can more effectively use CBT strategies) and harder in others (patterns of school avoidance, anxiety and refusal may be longstanding). A thorough assessment of what is contributing to the school anxiety is essential with these age groups.  In our practice we have had cases where: undiagnosed learning problems accounted for much of the anxiety and resistance to attend school because this teenage boy felt very stressed about not being able to manage academically;  bullying and threats from peers were to such a degree that one teenage girl literally did not feel safe in school; the presence of a major depressive episode resulted in a boy feeling unable to cope with school (focus on his work, respond to questions) and thus seek to avoid attending. Thus, careful assessment of the source or sources of school anxiety and refusal are critical. 

            In working with teenagers we have found that a combination of individual and family therapy is typically most effective. In individual sessions the therapist can work with the adolescent: educate the adolescent about anxiety, identify more effective coping strategies to manage and alleviate anxiety, and motivate the adolescent to work to overcome anxiety and attend school. In family sessions, the focus is often on helping parents provide more consistent and effective support and structure. In one case, involving a significantly depressed girl who was very anxious about being in school, her parents were able to arrange that she could visit the school social worker if needed and also would not be called on in class, by teachers. These interventions helped reduce the teenager’s resistance to going to school, reduced her anxiety in class so she was more able to focus on academics, and helped her feel more supported by her parents.

Coordinating with school personnel

            Regardless of the age of the child, coordination with school personnel is critical so that all parties are “on the same page.” Not surprisingly children and adolescents not only will play parents against each other, but will do the same with parents and school staff. Thus, by working to improve communication between parents and school staff this type of problem can be eliminated. Often contact with school personnel can reassure anxious parents that school staff can and will be helpful to their child.

Conclusions

            Working with school anxiety and refusal can be very challenging. Children and teenagers can, in more extreme instances, be very resistant to going to school. It may difficult, even impossible (initially), to engage some children and adolescents in therapy and establish that the goal of therapy is to return to school.  In these instances more family focused treatment may be necessary, with the emphasis on how parents can more effectively respond to their defiant and anxious child.

            Family work is essential, from our perspective.  Even the best intentioned parents can inadvertently respond (out of their own frustration or anxiety) in ways that intensify and exacerbate problems, e.g., the frustrated parent who yells at the anxious child, or the anxious parent who does too much reassuring rather than pushing their child to work to reassure themselves. Moreover, most children and adolescents need parental support to help them overcome their anxiety. Finally, if there are significant family concerns, or if the child is struggling with more significant emotional involvement, family involvement is critical. When significant parental conflicts are present, it is incumbent on the therapist to identify and attempt to address these issues. When a child or teenager is struggling with major depression or other serious psychological problems, parents need to understand their child’s needs and how to best respond to them.

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What makes us better?: A new study calls into question our understanding of change.

A recent study about a so called “honest placebo” has received a good deal of attention. This study is particularly intriguing because unlike other studies of placebo interventions the participants clearly knew they were being given a placebo, yet still benefited from receiving the placebo. This reseach makes us stop and question our understanding of what make us better, gives us relief from symptoms, and helps us change.

The study, led by Ted Kaptchuk at Harvard Medical School’s Osher Research Center and colleagues from Beth Israel Deaconess Medical Center (BIDMC) appeared on December 22 in PLoS ONE, an on-line journal, found that placebos worked nearly twice as well as no intervention in relieving irritable bowel syndrome (IBS) symptoms, despite the fact that patients in the control group receiving the placebo were clearly told they were receiving a placebo. The investigators stated that they went out of their way to be clear with patients that they were receiving sugar pills. The authors stated that, “Not only did we make it absolutely clear that these pills had no active ingredient and were made from inert substances, but we actually had ‘placebo’ printed on the bottle,” and further notied, “We told the patients that they didn’t have to even believe in the placebo effect. Just take the pills.” What is particularly startling about this study is that the placebo effect was quite powerful. The authors noted that those in the placebo group did as well as those who typically receive the most effective medications for IBS.

The investigators were cautious in interpreting their results, stressing that they only conducted one study, and that it was time limited, lasted for 3 weeks. Clearly their cautions are important: this is only one brief study, looking at one disorder. However, the study does raise intriguing questions about how and why people benefit from treatment. The authors hypothesized that possibly the ritual of taking medication may have accounted for the benefits of the placebo.

It is a short leap from this study to thinking about how and why mental health treatment, psychotherapy in particular, helps patients. There is a consistent body of research supporting the benefits of therapy, but there is no definitive answer or answers to how and why therapy works. In fact, there is an increasingly strident debate about what accounts for change: the specific strategies and methods associated with a given model, (Evidence Based Therapy) or the non-specific ingredients of therapy (empathy, hope, the client-therapist reliance). Advocates of Evidence Based Therapy assert that there is evidence that certain models and techniques are more effective, often Cognitive Behavioral Therapy. The American Psychological Association is a major proponent of evidenced based therapy and recently developed a website highlighting evidence based treatments http://www.div12.org/PsychologicalTreatments/disorders.html). On the other side, are a group of research (mostly psychologists as well) who argue that the claims of evidenced based therapy are greatly overblown and that the non-specific ingredients (primarily the therapeutic relationship) are what account for change (see for example the work of John Norcoss, Scott Miller and others; Miller’s website offers an accessible understanding of this view: http://www.scottdmiller.com/).

While one limited study clearly cannot resolve this debate it does force us to think more about how and why change/symptom relief occurs, and how/why different interventions work. In fact, the researchers note that previously it was assumed that placebos worked because people thought they were getting something that would help them. Their work clearly challenges our assumptions about how and why placebos work, further calling into question what accounts for change/symptom relief.

It is possible that rituals, in this study medical rituals (doing things that are associated with making one better), may be an ingredient in accounting for change/symptom relief. While there is far from definitive evidence to support this idea, this study reinforces the notion that we need to be more modest in our claims that we understand why and how change occurs. It also clearly suggests that we need to work to better understand what brings about change/symptom relief.

Posted in Treatment and Assessment of Problems of Childhood and Adolescence, What's in the News: Comments on news items | 125 Comments

Educational Consultation Group

This spring the Centers for Family Change will offer an ongoing educationally based consultation group for mental health professionals. This program is available to all independently licensed mental health professionals (psychologists, social workers, LCPCs and LMFTs).  This group will discuss current clinical issues and problems, as well as  treatment strategies and approaches.  Topics will include issues such  as working with resistant adolescents, managing family conflict, adolescent substance abuse, the divorced/divorcing family, and infidelity.  The discussion will be led by one Center for Family Change’s senior therapists.

The group will be offered free of charge.

One hour of CEUs will be available for LCSWs and LCPCs.

Please contact Peter Perrotta, PhD, at cffcfamily@sbcglobal.net for more information.

Exact dates and times, as well as topic areas will be posted in February.

Posted in Treatment and Assessment of Problems of Childhood and Adolescence | 101 Comments