Saturday, December 10, 2011

Seeing is Believing

The proof is in the pudding. Don't count your chickens before they're hatched. A bird in the hand beats two in the bush.

There are so many old adages that say virtually the same thing. Yet, there is no shortage of persons who come to my office--usually women--who are angry and puzzled because a man with whom they've been involved didn't do as he said.

The oldest rule of psychology is that past behavior is the best predictor of future behavior. If you want to know what someone's future behavior is likely to be, don't listen to what the person promises. Look at his or her past behavior. Yes, people can change. But they usually don't. Trust me; if everyone who could change their behavior came to psychotherapy in order to change that behavior, I would have a lengthy waiting list and so would every other therapist, and we would all be rich. I fly economy class. Most people with negative behaviors and personality problems never go to therapy and aren't interested. A man who is a chronic cheat or a habitual liar is unlikely to become a different person. In most cases, his cheating and lying works for him and he doesn't care how it affects others.

You (probably) deserve better. This advice is free.

Sunday, October 16, 2011

"Medicare for All" Would Not Be A Panacea

"Medicare for All" is a slogan I've been hearing a lot lately. Unfortunately, those of us who have been Medicare providers know that this would be no panacea for our nation's healthcare woes.

I've stopped accepting Medicare patients. I got tired of re-submitting the same claim form 3 times because an i wasn't dotted or a t wasn't crossed. I also found it impossible to find out in advance how much I would be paid, which is not the same rate for every patient.
I had a patient who had Medicare and Medicaid, and when I tried to bill Medicaid for the co-pay--the usual procedure--I was told I could not, for unclear reasons, but also that I could not bill the patient. I ended up being paid $50 per session for this patient, which is below my lowest fee.
When I signed up for electronic funds transfer, it took Medicare more than 6 months to process my one-page application form.
When I didn't get paid for a patient for unclear reasons, I had to get my Member of Congress to intervene before I was finally paid.

I believe the general public is unaware of how difficult and unprofitable it is for healthcare providers to deal with Medicare. It's naive to think "Medicare for All" would mean guaranteed healthcare, because an increasing number of providers no longer accept Medicare. Health insurance is useless if healthcare providers won't accept it as payment.

Monday, September 26, 2011

Tips for Rekindling Desire

I thought this marriage counselor's blog post had some good tips about sex:

Wednesday, August 24, 2011

Why I Don't Make Appointments Via Third Parties

About once a month, someone contacts me to make an appointment for a friend or relative. I no longer respond to these calls, because I don't have time. The fact is I don't take third party referrals, because I know the person won't show up if someone else makes the appointment.

I've pondered whether the person making the call really believes that their relative, friend or significant other will attend an appointment made by someone else. It's occurred to me these individuals making the calls may just want to be able to tell themselves that they tried to help. A better way to help someone is to tell the person what your limits are. If you find someone's behavior to be intolerable, the best thing for you to do is to stop tolerating it. Doing work for them that they could do themselves, such as making a psychotherapy appointment, does not help. If someone won't make a phone call to set up an appointment for treatment, that person definitely is not going to actually go to such an appointment. Going to therapy is a lot harder than making an appointment for therapy.

Thursday, August 11, 2011

Let Them Smoke

It's an old joke among mental health workers that people with schizophrenia live for three things: Coffee, food and cigarettes. Schizophrenics still have access to food and coffee, but today we live in a country in which smoking is forbidden in most places and the cost of a pack of cigarettes is prohibitive for the poor--and most people with severe mental illness are poor.

These changes were made for the benefit of "society", but the people whom they benefit are primarily middle-class people who can quit smoking if they choose to do so. The laws punish those who have the hardest time quitting smoking (and may have no incentive to do so) and can least afford the financial cost of cigarettes.

People with the worst cases of chronic schizophrenia live in state psychiatric hospitals, where smoking is forbidden. Even if they had the money, they could not choose to smoke.

Years ago, a schizophrenic patient commented to me that he didn't understand how I could drink coffee without smoking cigarettes--"because the coffee brings you up, and then the cigarettes even you out." Some may think that the psychiatric medications our pharmaceutical companies have created are substitutes for cigarettes and coffee, but they aren't. They don't provide pleasure nor do they have a social aspect. And many of them cause weight gain and diabetes. Diabetes is a fatal illness--a fact many people forget. Smoking kills, but so does obesity.

Well-meaning policymakers--as well as grandstanding politicians--often don't think about the consequences of their actions on society's vulnerable members.

Sunday, August 7, 2011

Nanny Diaries

I've had several patients who were nannies, and other patients who hired nannies. I realize some people need nannies to watch their children, but I believe hiring a nanny should be a last resort.

People hire nannies based usually on the nanny's references. These references are from adults who hired the nannies. The only people who can actually report on the nannies' behavior, however, are the children. Parents often have no idea what is really going on between the nanny and the children. A publicized example of this can be seen in the film "The King's Speech," in which Colin Firth's character reveals that he was victimized by his nanny. If the future King of England doesn't get a good nanny, how can anyone know for sure that the nanny they hire is any good? They can't.

Abusive nannies are almost certainly in the minority. A more common, almost inescapable problem occurs when the nanny is good. The children bond with the nanny, seeing her as another parent. Many biological parents are probably in denial about the parent-child bond that can develop between nannies and children. When the children get older and no longer need a nanny, the nanny is typically fired. She may or may not continue some contact with the children. Children who lose a parent before age 11 are at higher risk for depression as adults. Losing a nanny can be just like losing a parent. Could this be the reason why so many children of the wealthy seem to end up on drugs or as suicides?

Daycare, which offers less individualized attention but more peer interaction, is a healthier choice than a nanny.

Wednesday, July 20, 2011

Children Need Risks

I appreciated this story in The New York Times, "Can a Playground Be Too Safe?"

Children need to feel a sense of adventure in play. Too-safe playgrounds, hovering parents and overregulated schedules damage children's self-confidence and creativity. Not to mention contributing to weight gain.

Saturday, June 25, 2011

Mind-Body Connections: Evaluating the Whole Picture

I usually ask patients--particularly when they complain of depression and anxiety--if they have had a recent physical exam. I always ask new patients if they are taking any medications, and I've been pondering the possibility of asking patients to bring in a copy of their most recent physical exam results.

Many medical conditions and medications can cause psychiatric symptoms. Such medical conditions include stomach cancer, diabetes, and certain heart defects, among other conditions. Less serious but more common problems such as anemia and hypothyroidism cause sluggishness that mimics depression.

Hormone drugs such as birth control pills and hormone replacement therapy medications can cause depression. Several of my female patients have told me their depression decreased markedly when they stopped taking birth control pills.

Sleep medications and short-acting anti-anxiety medications can cause rebound anxiety. And let's not forget that caffeine is a drug--although it's "over the counter" at Starbucks--and it can cause anxiety and insomnia.

Most persons who go to a doctor complaining of depression, anxiety or insomnia will be prescribed a pill. Sadly, not all doctors evaluate the possible underlying causes of these symptoms--which sometimes can be a pill the same doctor previously prescribed.

Before you start taking pills for anxiety, insomnia or depression, it's important to evaluate any possible role of a current drug or a medical condition.

Saturday, June 4, 2011

The ADHD Conundrum

Different factions have claimed ADHD is underdiagnosed, overdiagnosed, or misdiagnosed. They are all correct.

ADHD (Attention Deficit Hyperactivity Disorder)is a neurological dysfunction, although for some reason it is classified as a psychiatric disorder. Because it is classified as a psychiatric disorder, it is commonly treated by psychiatrists and psychotherapists. In reality, because ADHD is a disorder of brain functioning (probably in the frontal lobes that control impulses and attention) it does not respond much to psychotherapy. The only purpose of psychotherapy for people with ADHD is to help them understand the illness and cope with the stress it creates.

Medication also doesn't cure ADHD, but it may be the only treatment that controls the symptoms. ADHD medications are usually stimulants that work to pep up the part of the brain that is malfunctioning. By supporting the part of the brain that controls impulses and increases attention and focus, the stimulant medications--seemingly paradoxically--make people calmer because they are less distracted.

It's my observation that many adults who've had chronic problems with disorganization and underachievement have ADHD that has never been diagnosed or treated. Meanwhile, many children who are diagnosed with ADHD are actually having a reaction to a negative environment, manifested in their behavior because it is primarily through behavior that children communicate (see my last post). In some cases, agitated behavior with no apparent environmental cause is diagnosed as ADHD but is really the onset of Bipolar Disorder. In these cases, the administration of stimulant medications designed to treat ADHD can make the patient worse.

An evaluation for an adult or a child with ADHD symptoms must include a comprehensive assessment of their environment and social, educational and/or vocational functioning. Psychological testing that includes an IQ test may be helpful, because a low IQ can also cause problems with functioning (unfortunately, there is no treatment that can make people smarter, so the best intervention for someone with a low IQ is vocational counseling to help them find something they can do in life).

I believe there are many, many persons with undiagnosed ADHD. At the same time, I believe there are many children who are diagnosed with ADHD who are really victims of parental neglect or abuse. Sadly, many clinicians do not take the time to do complete evaluations.

Thursday, June 2, 2011

Why I No Longer Work With Children

I used to work with children in mental health clinics in Brooklyn and the Bronx, from 1997 to 2003. I also worked with children as 50 percent of my private practice from 2001 to 2005. I no longer work with children, however. I decided that since most of the problems I was seeing in the children were caused or exacerbated by their parents, it didn't make sense to treat the children. Psychotherapy was not what they needed.

Of course, some children do have real disorders, but those disorders, such as Attention Deficit Hyperactivity Disorder, Childhood Onset Bipolar Disorder and Childhood Onset Schizophrenia, are neurologically based illnesses that often require medication and frequently don't respond to psychotherapy. Children do develop anxiety and depression, but in most cases, anxiety and depression in children is just a response to a negative environment. Some of the most commonly diagnosed childhood "disorders" such as "Oppositional Defiant Disorder" are just terms used to describe what children do when they are angry about they way adults around them are behaving.

Here's a case that illustrates the pitfalls of diagnosing and treating children: In 2002, when I was working at clinic in the Bronx, I was assigned to work with a 12-year-old boy, whom I'll call as "Jose." He presented with many symptoms of depression and ADHD, including anger, agitation, restlessness and verbalized unhappiness. He was unable to sit still and seemed distracted. He had a history of being abused by his mother, and had been removed from her care and placed with another relative. We agreed I would see him weekly and also that he would be further evaluated by the clinic psychiatrist.

Jose's relative didn't bring him regularly for his scheduled sessions, and after he didn't attend his appointment with the psychiatrist, I called in a report to ACS (the Administration for Children's Services, New York City's child welfare agency). The ACS worker arrived at Jose's home to discover that he wasn't there and his caretaker had no idea where he was. After Jose was found, he was placed with a different relative.

The following week Jose was brought to his therapy appointment by his new guardian. All of his symptoms had miraculously disappeared. He was no longer restless, distracted, or agitated, nor did he appear to be sad. The clinic's receptionist asked me "is Jose taking some new medication?" All of Jose's symptoms had been a reaction to his environment. Because his new caretaker was empathic and genuinely interested in him and his welfare, he adapted to this new environment by acting like the normal boy that he was. I continued to work with him, because of his history of abuse, and he seemed well on his way to a complete recovery when unbelievably, his former caretaker went to court to try to regain custody of him. She'd felt insulted that someone had decided she was not a fit parent. Jose was dragged into a legal situation that re-traumatized him. The situation was eventually resolved, but only after Jose was subjected to further damage.

One could argue that if it hadn't been for my intervention, Jose would have continued to have been neglected and his mental health would have been in serious jeopardy. I would agree, but it doesn't change the fact that most of what I did for him was work that I wasn't paid to do. I worked as a "fee-for-service" therapist at the clinic and was paid only for therapy sessions. This model is extremely common in New York. All the work I did advocating for Jose--calling ACS, attending his court case and making follow-up phone calls--was unpaid.

Our mental health system simply isn't designed for children. In later posts, I'll describe more pitfalls of the system. For my personal well-being, I had to remove myself from working with children. Most children's problems need to be addressed by professional child welfare workers and advocates, not by psychotherapists. But because the system continues to describe children's natural reactions to negative environments as disorders, therapists and other mental health workers are often the persons who end up advocating for children's basic needs.

Sunday, May 29, 2011

Five Things Your Therapist Wants You To Know

This is my first post for this blog. I'm a licensed psychotherapist in New York City. You can learn more about my practice at

As a sole practitioner, I am the receptionist, office manager, billing clerk and quality assurance director for my practice. Most patients don't think about the complexities of running a professional practice, nor should they. But for my first post for this blog, I've decided to be upfront and tell any prospective psychotherapy patients a few things that the therapist they are going to see (me or anyone else) wants them to know BEFORE they call to make the first appointment:

1. We need to know what time you are available to attend a WEEKLY appointment. Psychotherapy isn't a one-shot deal, or an annual visit like a physical exam or dental cleaning. Even if you are "interviewing" several therapists to find the one that's right for you, it doesn't make any sense to schedule even one appointment with a therapist if that person doesn't have a slot that fits your schedule. Instead of saying "Are you taking new patients?" when you call or email, state the times/days that you would be available to attend weekly. "Are you taking new patients?" is a superfluous question, because if we aren't taking new patients, we will let you know.

2. We need to know how you're going to pay. I know this is an unpleasant subject. But if you're going to be attending weekly sessions, you need to know (and we need to know) if you can afford the treatment. Recently I turned away a prospective patient (whom I referred to a clinic) because he had no health insurance and an annual income of $18,000. Putting people into debt only increases their mental health problems. Sadly, our society limits healthcare for people with low incomes. This is a problem that I as an individual cannot solve.

3. We don't know the details of your health insurance plan. This is something every plan member should find out for themselves. Aside from scheduling psychotherapy, you need to know the details of your plan in case you need surgery or hospitalization. (If you want to see some dramatic stories of what happened to people who didn't know how bad their health insurance was, see Michael Moore's documentary film "Sicko.") Every major insurance company sells many different plans. If you have health insurance through your job, your plan may have a custom design.

4. The 6 p.m. slot is usually taken. Most people work 9-5 or 9-6, so many therapists are always booked between 6 and 7 p.m. If you can arrange with your employer to take a long lunch once a week, or you're willing to find something else to do between 6 and 7 p.m. and come to an appointment around 8 p.m., you're more likely to find a therapist who can give you an appointment. Long-term patients sometimes ask if they can be moved to a more convenient time once that timeslot opens up. This is how many therapists fill their 6 p.m. slots.

5. Your problems didn't develop last week. I will see people on an urgent basis (1-2 days) if they have had a recent crisis such as being the victim of a violent crime, or if they are mandated by their job for an assessment. For emergencies such as suicidal intent, I send people to the emergency room of the closest hospital. Most people, however, have problems such as chronic depression or relationship issues. Since these problems developed over months, years or decades, the first appointment for therapy does not need to be this week. If you can't wait one week to start your therapy your difficulty in tolerating a wait may be a pervasive issue in your life and this might be one of the issues you need to address in therapy.