Psychotherapy for Work Stress?

May 10, 2008

There are many ways that people can decrease work stress. One can meditate, eat something delicious during breaks, do daily yoga, get counseled (expert feedback on how to do things differently) on how to do their job differently, have a backup plan if they are stressed out about the possibility of being laid off, etc. But that deep process of psychotherapy, which still has some stigma about being just for the mentally ill, how useful can it be? This article answers this question from the perspective of an actual psychotherapist with years of experience treating actual clients for work stress.

Psychotherapy for work stress often starts off with some counseling. The counseling involves providing specific feedback on how to make changes in the job so as to reduce stress. For example, if you work on a salary and end up doing 60+ hours work weeks that wear you out, the counsel may be to find ways to be just as productive at 50 hours as you were at 60+ hours. Another suggestion can be to improve your delegating efficiency, especially if you are one to micromanage.

Sometimes all behavior changing feedback in the world is not enough. Being told to not micromanage, along with specific suggestions on how to improve delegating, would work if we were computers ready for reprogramming. Human beings are thinkers and feelers. It is not easy to break old habits. In such cases, the next step is to get a bit of Cognitive Behavioral Therapy (CBT). This involves learning new ways to think about old situations, which makes it much easier to change behaviors that normally would be very difficult to change.

Let us apply CBT to the manager who micromanages and has trouble efficiently delegating. The therapist can first ask the manager to spend a week writing down how he felt and what he thought whenever he could have placed more authority into her workers. For the first time in her life, the manager identifies her feelings as critical and distrustful. Her thoughts included, “Others are not as effective at the tasks required for the research project as I am, so if I do not give detailed instructions on how to do each task, as well as to do as much of the work myself as possible, the job will not be done well.” Ironically, the more she micromanages, the more dissatisfied her workers become, decreasing the overall productivity. She also loses patience both at work and with her family, due to stress.

The therapist teaches her how to override her thoughts, thus creating new emotions, by coming up with incompatible thoughts. An example would be, “The more trust and ownership of the project I place in my well-trained workers, the more they will come through for me. Also, the better I can delegate, the more patience I will have, therefore I will be better able to assist people with difficulties by listening and troubleshooting.” Overtime, and with enough practice, these new thoughts can trigger the emotion of being trustful. She then becomes patient both at work and at home, as she thinks and feels differently, which then result in new behaviors and lower levels of stress.

For some people, the above is still not enough. We then go to the deepest layer of psychotherapy, utilizing a more psychodynamic approach. One such approach to getting to the root of the difficulty is called Internal Family Systems (IFS). IFS does not involve other family members, but actually helps a person to get in touch with their different parts/subpersonalities. Continuing with the manager example, imagine that the manager relaxes in front of the IFS therapist and thinks about that part of her that is critical. Speaking from the perspective of that part she answers relevant questions about criticism. It is discovered that she had critical parents, as well as critical teachers throughout most of her schooling. She has internalized this criticism, now being her own worst critic. Any time others do something that can reflect poorly on her, she unconsciously criticizes herself. This then comes out as criticism to others.

She and the therapist also learn that that critical part of her does not trust her core self. If she cannot trust her self, then it will always be extremely difficult to trust others. Therefore, the therapy c…. (sorry, didn’t get to finish this yet)

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Couples with Children on the Brink of Divorce: Marriage Therapy

May 10, 2008

Because getting a divorce will end a marriage, but not a family, some divorcing couples with children are opting for couple therapy. Often one spouse is interested in keeping the marriage together, while the other has a sliver of hope for the marriage, but both want to enhance the quality of communication for the sake of the children after the divorce. One of the biggest challenges with such couples comes from the level of anger stemming from months, years, or decades of dissonance. Often one or both spouses come in expecting the therapist to fix or show measurable progress within a matter of several sessions. The reality is that it takes time for trust to develop amongst the three people in the room, and only when trust is there can the most significant progress be made. This leads to the question of what can you request and do to increase the odds that you will either help the marriage or help the communication for the child(ren).

It is important to keep an active dialogue with the therapist around how you are feeling about the process. For example, if you do feel patient and confident in the process, then the therapist can plant seeds of insight that can later sprout as the process goes on. Though not a fast process, it leads toward a level of insight that can result in highly useful intervention. Even on the brink of divorce, and regardless of the level of anger, hurt, disappointment, etc., almost anything can be accomplished with enough time and effort on all sides.

If you feel impatient, but willing to do a lot of work between sessions, it can be quite helpful to put a time limit on the therapy. For instance, you can say to the therapist that you would like to accomplish as much as possible within five sessions. Do include a specific goal to be met. This keeps the focus narrow enough to get somewhere in a short period of time so that you can see measurable results. The therapist can use, for example, a brief therapy model involving giving many suggestions, with the idea that at least one may help your situation.

Brief therapy is most effective when people are willing to follow through on suggestions. Examples of what a therapist might suggest include a recommendation to get evaluations or therapy for anxiety, developmental disorders, Post-Traumatic Stress Disorder, etc…. Specific tasks (nuances not included here) can be to go out to dinner and to only talk about positive traits of each other, listening exercises, prayer, mutual meditation, couple relaxation exercises, couple eye gazing with positive self-talk for ten minutes per day, or even complain about each other in a controlled manner. It is also key to avoid self-fulfilling prophecies (being so sure that nothing will change that your actions or inactions make your prophecy come true!), or you can easily sabotage even the most appropriate interventions for you as a couple.

If there has been a history of trouble getting on the same page about parenting, doing a few Behavioral Family Therapy (creating a behavioral plan involving a different way of parenting, based on your family’s unique characteristics) sessions can produce not only effective change for your child(ren). It can also do the same for your marriage, because working together and seeing each other do well can have a profound effect on how you interact with your spouse.

For more information, go to: http://www.SchaperowPsychologyCenter.com

Couple Therapy: The Three Dimensions of Success

May 10, 2008

Sam Schaperow, MSMFT, LMFT, the counselor and Licensed Marriage and Family Therapist, returns for his third column. Previously he wrote about evaluating children who were misdiagnosed with Attention-Deficit Hyperactivity Disorder, then how psychotherapy can help people reach new levels of efficiency and productivity at work while reducing work stress. Now he will help readers to understand how successful couple therapy involves many factors that you will want to understand before choosing to help or enhance your marriage or intimate partnership.

There are many dimensions to good couple therapy. To simplify our understanding, we will focus on three dimensions: “The Assessment”, “The Couple Therapist”, and “The Couple”.

The Assessment: In order for a couple therapist to be helpful early on the couple is assessed. The degree that the assessment is thorough is often up to you. You can request that one session is used to assess the couple, or even multiple sessions so that the couple is best understood. Individual assessments are recommended. Though the couple is a unit with a life of its own, it is composed of two individuals. Understanding each person, how they think and feel, allows for a more thorough understanding of the couple. Beyond these assessments comes psychological testing, such as the MMPI-2 or Rorschach. A trained psychologist, such as Tracy Colsen Schaperow, Psy.D. can administer these tests to enhance the understanding of the personalities of each partner/spouse and how their personalities can lead toward synergy or dissonance.

The Couple Therapist: Finding the right couple therapist for you is important. Specialization is key because couple therapy requires a different approach than individual counseling. Some therapists have years of specialized graduate-level training on family and couple dynamics, while others have no formal training (not even a single class in couples). Some ways to learn about a therapist are to see a résumé (you can ask for one or see if the therapist’s web site has it) or see his or her credentials. For example, the credential “LMFT” means “Licensed Marriage and Family Therapist”, a license that can only be obtained from years of rigorous videotaped (or live supervision) family/couple training and practice. But note that even if a therapist lacks the LMFT, extensive study and numerous trainings can lead to proficiency.

If you go with a therapist without the “LMFT”, you can also ask about experience, certifications, professional memberships, or even ask around to see if the therapist has an excellent reputation specifically in couple therapy. You can also ask about the approach to see if the therapist likes to give out a lot of advice or elicit answers from within your selves. Lastly, it is important that you find a couple therapist who will work with you until your underlying patterns are found and changed, otherwise the couple may revert back to their old ways soon after the therapy ends.

The Couple: The degree to which even the best couple therapist can help a couple correlates with the degree to which the couple is willing to fully participate. Highly motivated couples have a much higher success rate than those who come in with a list of demands involving pricing, time availability or demands, limited willingness to try out suggestions, a partner/spouse persistently laying too much blame on the other spouse, choosing shorter assessments, etc. In summary, there must develop enough trust and motivation; otherwise interventions are ineffective.

All three dimensions are critical to the process: beginning properly with a thorough assessment and ending with results elicited by a highly trained professional working with an attentive and motivated couple. For more information on how to approach couple therapy please contact the Schaperow Psychology Center of CT, by visiting www.schaperowpsychologycenter.com.

Not Attention-Deficit Hyperactivity Disorder (ADHD)

May 10, 2008

Family therapy involves meeting with the family to meet a goal. I am Sam Schaperow, MSMFT, LMFT, a counselor and Licensed Marriage and Family Therapist practicing at the Waterford branch of the “Schaperow Psychology Center of CT”. This column will deal with child and adolescent behavior problems that often fall into common categories such as ADHD or Bipolar. But going beyond a one-hour assessment can find something else. Understanding everyone in the family can provide a far more thorough analysis than just seeing meeting with a child in isolation. A thorough assessment, such as one conducted by me and my team, can give an accurate understanding, to be followed by effective treatment. Subsequent columns will deal with the topics of “Psychotherapy for Work Stress”, then “Successful Marriage Therapy”.

I saw children and families at a clinic with a variety of complex problems. Often I could utilize my training and experience to diagnose and successfully treat even the toughest kids. Many mental illness diagnoses from the DSM-IV-TR, an American Medical Association “Diagnostic and Statistical Manual” were not helpful to treat children who went home to the same non-supportive family environment; it was a family-wide problem. Yet at other times accurate diagnoses were helpful in implementing effective treatment. I found that the more hours I spent evaluating, the more accurate my diagnoses were.

Sometimes before seeing me, the child saw the clinic’s psychiatrist (a psychiatrist is typically an M.D. specializing in psychotropic medication). A pattern was formed. While the children who saw me had a wide variety of diagnoses, ~85% who saw the psychiatrist were given ADHD or Bi-Polar. I remember one child who clearly met the criteria in the DSM-IV for Oppositional Defiant Disorder (ODD), such as “often loses temper”, “often argues with adults”, “is often angry and resentful”, and “often actively defies or refuses to comply with adults’ requests or rules”. And yet the psychiatrist gave the diagnosis of ADHD, citing the temper loss as related to an attention deficit. Hours of evaluating did not support ADHD, but the psychiatrist prescribed medication. The family reported a modest increase in focus, but little more. They decided to take their child off the medicine and become fully involved in the treatment process that could potentially remedy the situation once and for all.

Children are often diagnosed with whatever is in vogue. Many insurers/HMOs only reimburse for brief evaluations. This makes a thorough assessment difficult, especially when only certain diagnoses are reimbursable.

Occasionally harm can be done to the child when giving medicine and side effects occur for a time. Hopefully other options will be explored, but all too often another medicine is tried. When the family is finally ready to invest in a thorough evaluation, they can discover what is really going on. Appropriate treatment options can now be offered, particularly when the entire family is involved in the process.

If the diagnosis is ODD, family therapy combined with parental coaching can create a solution within a matter of weeks or months. When the whole family works together toward creating change, that change can happen. For ODD as the sole diagnosis, I find it most important to help the family become more consistent, predictable, and respectful of each other. Appropriate rewards for responsible behavior are also taught, while immediate losses of privileges occur for most ODD behaviors. Losses are all temporary depending on the age and temperament of the child. All of the above should produce fast results that last as long as the parents are willing to follow the plan.

Thorough evaluations typically cost ~$750, which is a relatively small additional cost relative to the benefits that can be seen for years to come. For more information, please visit http://SchaperowPsychologyCenter.com.

AGORAPHOBIA

May 10, 2008

We have found that agoraphobia, including all gradations, is a common enough problem, but the amount of people seeking such treatment isn’t high (so not something we tend to advertise we work with). People suffer from it for years. Many seek out ways to suppress symptoms, such as w/psychotropic medications. None exist that cure a person for this condition, so suppression is the best these can do.

The biggest frustration for therapists who are good at treating it is that it is soooo treatable, yet so few people feel it is worth the time & money to get it truly treated, but instead they spend years or decades dealing with it….

If someone is doing very well in life, except for this, then if they get therapy for it and make full use of the therapy, it should be treated and cured in under ten sessions. On the other hand, if it is but a symptom of a larger issue, then a combination of some treatment for the agoraphobia plus treating the underlying issue should take care of it.

-Sam Schaperow, MSMFT, LMFT

Mental Health Parity Law has more holes in it than Swiss Cheese

May 10, 2008

From SchaperowPsychologyCenter.com director:

In treating people after the Mental Health Parity Law took effect, I’ve learned that this law has more holes in it than Swiss Cheese. I have listed some of the examples:

1. Only some insurance plans contain Mental Health Parity (it excludes private plans, some non-state plans, etc.).

Those with parity:
1. Exclude provider parity, meaning:
a. Providers who haven’t needed the business enough to join the panels will either not be covered, or will be covered with out of network benefits only (instead of major medical full coverage).
b. Providers without the credentials of the medical directors of many plans will be less covered than those with (typically an M.D. or D.O.):
i. For example, MHN (Healthnet) requires paperwork every 10 sessions by non-M.D. providers of mental health, which is time consuming and arduous, disallowing the provider from giving full attention to the actual case and instead focusing on redundant paperwork.
ii. Non M.D./D.O. providers will be reimbursed less in-network, meaning they must see many more patients to make up for this substantial pay reduction (imagine if suddenly your accountant/lawyer/physician got a 50% pay-cut!). And out-of-network, you’ll get less reimbursement, by as much as 50%, making it less affordable to see the more experienced people who typically charge what their M.D./D.O. counterparts charge.

2. Anthem Blue Cross Blue Shield, even Century Preferred, requires even more frequent paperwork, which often can’t be honestly done w/o patient participation, wasting sessions as often as every 4th.

3. I have a Bipolar client whom I saw twice per week, but then her Anthem Century Preferred plan cut it back to once per week. I sought a peer review through the appeals process, but they actually sent it off to non-peers (people w/o my credentials in family therapy) who held up the denial. This goes against my interpretation of the state statute, but the state/insurer was of no help when I alone tried to fight it.

4. I went so far as to go in person, unreimbursed, to the Anthem Medical Director to try and get my services covered better for my client’s Mom, but he denied me parity with people w/his credentials, even though I had much more therapy training (though clearly not medicine training) than most of the psychiatrists. I ultimately decided to give a deal to the clients by conditionally waiving part of their balance, but that then makes it harder on me to give them my all.

5. Quite some time after this incident with Blue Cross, for another client I was seeing under Blue Cross’s contracted out mental health HMO, Value Options, I was audited. I was never told why, but I had to then spend ~50 hours dealing w/the audit process. In the end it was determined that not only did I bill accurately for the mostpart, but where I made errors, I actually underbilled, so in the end Value Options had to send me a check for about $24. So, I earned $.48/hr. from the whole process. Do you have any idea how much good I could have done w/that time for my existing clients if I didn’t go through that audit?

6. Aetna used to cover all providers the same out of network, but in the fall of ‘06 they changed their policy and reimbursed their clients 40% less for the majority of mental health practitioners, w/o regard to the quality and training of those who got the reduction. Even if that saves Aetna $ in the short-run, if people don’t use the best providers as often due to finances, there can be much bigger and more costly problems that can cost Aetna more in the long-term.

7. Utilization management is not or hardly affected by the laws, since insurers can still place policies and do what they want for the mostpart, such as with a Bipolar Disordered person needing hospitalization, the insurer can say if someone isn’t actively trying to kill themselves or others, then they can’t get hospitalization. Sure the patient may attempt suicide and succeed at it a few days later when home at night, but still this is just how it works. Similarly, the insurer can say twice per week therapy only when in a crisis, *as they define it*, which means that the therapist has little to no say in what is defined as a crisis.

8. If you apply for an insurance plan individually, and you’ve had mental health history, most of the plans will deny you.

9. Solutions: I think the two solutions are:
a. Returning to pre-HMO/PPO days to when plans basically covered the coverable services without a a strong discrimination between types of providers. They also allowed more time in hospitals, etc.
b. Change insurance plans to what they were conceived of, at one time, catastrophic coverage. This can reduce premiums paid by individuals/employers, thus allowing more ability of individuals to seek out the healthcare they want. The closest we have are high deductible plans that can combine with a Health Savings Account. This combination gives people the ability to see who they want for how long they want, but the cost is shifted to the patients directly while they save indirectly through lowered priced premiums.

Sam Schaperow, MSMFT, LMFT