Violence in our Lives: What to do?

Several ideas have been swirling around in my head for this week’s blog post. The one that emerged today wins, hands down. I am a believer in Carl G. Jung’s concept of synchronicity. When three or four separate but related items come across my desk or inbox at one time, I believe they are connected in some fashion and should be addressed.

This morning I received an email from the Office of Civil Rights listserv on HIPAA Privacy and Security. It contained a link and reference to a letter of clarification written by Leon Rodriguez, Director of OCR.

In light of recent tragic and horrific events in our nation, including the mass shootings in Newtown, CT, and Aurora, CO, I wanted to take this opportunity to ensure that you are aware that the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule does not prevent your ability to disclose necessary information about a patient to law enforcement, family members of the patient, or other persons, when you believe the patient presents a serious danger to himself or other people. 

The HIPAA Privacy Rule protects the privacy of patients’ health information but is balanced to ensure that appropriate uses and disclosures of the information still may be made when necessary to treat a patient, to protect the nation’s public health, and for other critical purposes, such as when a provider seeks to warn or report that persons may be at risk of harm because of a patient. When a health care provider believes in good faith that such a warning is necessary to prevent or lessen a serious and imminent threat to the health or safety of the patient or others, the Privacy Rule allows the provider, consistent with applicable law and standards of ethical conduct, to alert those persons whom the provider believes are reasonably able to prevent or lessen the threat.

Given all the discussion about mental health interventions related to the perpetrators of the recent violence, Director Rodriguez clearly felt it was necessary to remind healthcare providers of all stripes that the law does not prevent them from involving the authorities when they believe an individual is potentially dangerous.

I was educated in the Tarasoff era. It was controversial, but clear, that mental health providers have a clear duty to protect the intended victim of a violent action to be committed by one of their patients. That protection may well include the duty to warn the potential victim. Given the occurrence of mass killings in recent years, it is easy to wonder if we all ought to behave as if we have at least a moral responsibility to notice and to notify the authorities about the potentially dangerous behavior of others.

As a former mental health provider, I worry about the tendency of our country to blame violent behavior on mental illness. As research in the area indicates, the relationships among mental illness, drug abuse and violent behavior are complicated, at best. Social factors such as ‘poverty, family history, personal adversity, and stress’ also feed into this complex equation.

On January 15, 2013, President Obama presented proposals to control the sale of certain kinds of guns and the ammunition they use. He also proposed a whole raft of other actions that will hopefully make our awareness and ability to intervene before violence occurs an easier job.

The knee jerk reaction of the NRA and other defenders of the ‘right to bear arms’ has been loud, and people seem to quickly line up in one camp or the other. That is why I was so struck by the post of a Friend of a Friend on Facebook that I shared his statement on our SOS page. You may not be able to get to it unless you are a registered user of Facebook, but if you are, please take a look. This is a well thought out, rational, and personal reaction to some of the responses to the President’s proposals.

One of those proposals is that teachers and others who interact with young people need to learn more about the mental health issues that might help them identify youngsters who are in need of assistance. Linda Rosenberg, President and CEO of The National Council for Community Behavioral Health shared her take on President Obama’s proposals.

As part of his recommendations to protect our communities from gun violence, President Obama today rightly called for Mental Health First Aid training to help teachers and staff recognize the signs of mental health disorders in young people and find them appropriate care.

The youth version of Mental Health First Aid is an evidence-based training program to help citizens identify mental health problems in young people, connect youth with care, and safely deescalate crisis situations if needed. The program, focusing on youth ages 12 to 25, provides an ideal forum to engage communities in discussing the signs and symptoms of mental illness, the prevalence of mental health disorders, the effectiveness of treatment and how to engage troubled young people in services.

Mental Health First Aid has become a major push for The National Council. Information and resources are readily available.

After all is said and done, we get to the bottom line. What should people do if they find themselves in an active shooting situation? This is not a thought most of us want to entertain, but first-responder agencies have always believed that being prepared for an emergency greatly increases a person’s chances of surviving a dangerous situation. With a grant from the Department of Homeland Security, the Houston Police Department has prepared an excellent video about surviving an active shooter event.  

Events like the Sandy Hook School shootings stir up primal reactions for most of us. It is important that we not shut those reactions down. Instead, we need to open ourselves to many possibilities of how we and our communities need to intervene to assure that we and our children are as safe as is reasonably possible.

Please share your comments, experiences, concerns below.



Integrated Medical and Mental Health Care

Almost every time I bring up the topic of behavioral healthcare being integrated with general healthcare delivery, a private mental health practitioner responds questioning how this could possibly work. In response to my June post on this issue, one of our customers shared his thoughts (see comments) about just how this might occur and the obstacles to making it happen in the private setting. I responded like this:

I think many private practitioners are in the same position you are. Unless they do a very health-oriented practice, they see themselves continuing to function quite separately from general healthcare.

The picture is not the same in the public arena. At this time, about 60% of the funding for all mental health and substance abuse services comes from public, not private, sources. Of the people receiving such services, a large percentage have serious physical illnesses as well.

SAMHSA and The National Council for Community Behavioral Healthcare are moving forward with pilot programs and research on the integration of general and behavioral healthcare since this makes lots of sense in the public sector for the seriously mentally ill. But it may also have implications in the private arena. In fact, the move to provide integrated healthcare services in the public sector, and wherever possible in the private sector (like in Accountable Care Organizations – ACOs) has many folks exploring obstacles that may exist to such integration and ways to overcome those obstacles.

Yesterday, I was reading a September SAMHSA-HRSA Center for Integrated Health Solutions newsletter that linked to an interesting article on the use and evaluation of Telephone Administered Cognitive Behavioral Therapy (CBT) for depression. The research started from the current reality that most treatment for depression is provided in primary care physician offices. Of course, this treatment usually consists of medication. While patients prefer psychotherapy to medication for treatment of depression, and both CBT and medication appear to be about equally effective, access to psychotherapy is limited for most people. Cost or convenient access to a psychotherapist covered by their health insurance or some other equally valid reason interferes with provision of psychotherapy.

The research demonstrated that telephone administered CBT was more effective in keeping the client participating in therapy. Both telephone administered CBT and face-to-face CBT were equally effective in diminishing symptoms of depression at time of termination. Face-to-face CBT seemed to maintain the effects better at a six-month measure.

At this point in reading the results, I was reminded of Dr. Suzanne Bennett Johnson’s initiative as President of American Psychological Association (APA) for 2012. She wanted to remind psychologists that they are part of a healthcare profession, and that most of us are well-trained in conducting research. We are ideally suited to design and conduct the studies that will demonstrate just where psychologists and other mental health professionals can best serve in integrated healthcare. I could instantly imagine the re-design of the study reported above to include Skype or other Internet service-based delivery of the CBT so that at least some of the elements of the face-to-face therapy would be present.

There is already lots of opinion about the potential benefits and detriments of remotely-administered behavioral health treatment. Psychologist David C. Mohr, Ph.D., Professor in Preventive Medicine, Medical Social Sciences, and Psychiatry and Behavioral Sciences at Northwestern University lists Internet Intervention and Telemental Health as significant aspects of his interests. Quoted in that 2008 Time Magazine article, Dr. Mohr sees distinct areas where teletherapy or other internet programming might be of use, especially CBT for depression.

Other cutting-edge practitioners have already added internet-based services including videotherapy into their retinue. Given a solid research foundation, video-based therapeutic services might well be a way for the private practitioner of behavioral healthcare to integrate their services with general healthcare.

We can sit back and watch as our healthcare system changes all around us, letting others dictate to us the role we will play. Alternatively, we can be active participants in designing the models for inclusion of behavioral healthcare in primary care. We can design the models, do the research, and market the methods to ACOs, health plans, and medical providers.

We would love to hear from any of you who already work in a setting where mental health services are integrated into primary healthcare. Please let us know your experience and what you think.


Habits, Habits, Habits: How do they affect your life?

In May, I received an email from Charles Duhigg, NY Times reporter and author of The Power of Habit. Or rather, I should say that I received an email from Charles Duhigg’s publisher/publicist who is very good at finding bloggers who have written about psychological topics and who might be interested in his book. Their marketing research was right on target, (see chapter 7, How Target Knows What You Want Before You Do), no pun intended. I am, indeed, interested in certain psychological research, and I did find his book fascinating and very well written. In my former life as a psychotherapist, I would even have recommended it to patients. Instead, I will recommend it to you.

How many times have you discovered a pattern of behavior that you would like to change? How many times have you been successful in making the change?

If you struggle as much as I do with habit change, it is not because you are weak-willed. It is likely because you do not have a complete understanding of the behavior you are trying to change, what cues the behavior, and how the reward impacts you. Even if you are clear about those elements, you might have ignored the necessary step of substituting a competing behavior to replace the one you are trying to change.

Not sure you know what I am talking about? No surprise to me. Most of us are not very good at even realizing that we are engaged in habitual behavior until someone else points it out to us.

I recently had a visit from my nephew and his family. Near the end of their stay, his 3-1/2 year old son was using the word “actually” appropriately in many of his comments. “Actually, that’s a tufted titmouse. He takes a seed from the feeder, then goes to the bush to eat it.” It was not until he left that my sister-in-law and I heard me using “actually” often in my comments. It took a 3-1/2 year old to help me see habitual speech behavior that has been with me for who knows how long.

Duhigg’s book is an excellent exploration of habits and their power in our personal lives, in business, and in society. He clearly presents a framework for habit change that most individuals and any therapist can use:


• Identify the routine

• Experiment with rewards

• Isolate the cue

• Have a plan

Duhigg, Charles (2012-02-28). The Power of Habit: Why We Do What We Do in Life and Business (p. 274). Random House, Inc. Kindle Edition.

Part of what appeals to me about this Framework is that it presents a simple system. My personal inclination in life is toward making things systematic and understanding the systems that apply when something is not of my making; so this approach is appealing to my sense of order.

  1. Observe and assess the behavior. Determine what is included in this habit. Get a good picture of the whole thing and how it functions in your life. In Duhigg’s words, identify the routine.
  2. Take a look at just what is rewarding to you in this behavior. Since the reward is a large part of what is keeping the habit in place, understand it well and look at as many aspects of the reward as you can. You may think one part of the reinforcement is what is maintaining your behavior when another part is actually the driver. As Duhigg says, experiment with rewards.
  3. Get a good understanding of just what the trigger is for the habit. What sets it off? For me, sitting down at my desk at work in the morning is my cue to check email. Even if I have decided to do something else first (like write a blog post), the strong pull is for me to check email. According to Duhigg’s framework, isolate the cue.
  4. Finally, in order to change an habitual behavior, you need to determine what you want to do instead, how you will make yourself aware of the cue so you do not go into automatic, what reward you will use to alter the habit, how long you will do the changed behavior to solidify the new habit…as Mr. Duhigg suggests, have a plan.

The simplicity of this framework is part of its power…and part of the power of habits in our lives. If your own habits, the habits of your business or organization, or the habits of our society are important to you, take a look at this book. It is simultaneously a good read and enlightening.

Do you have experiences with habits and habit change that you would be willing to share? WAIT…this is where you would usually STOP READING. Maybe you could change that habit and offer a comment today? Your reward? My profound thanks for reading and commenting. Just enter your comment below.


Caring for the Caregiver: 5 Self-care Tips

When I worked as a psychotherapist, I constantly struggled with the issue of self-care. I was always much better at taking care of others than I was at taking care of myself. I attended workshops and became involved in my professional associations because those activities felt good and were part of my self-nurturing, but they also ate up energy, so they were not as restorative as necessary.

When I had the opportunity to move out of the practice of psychology and into business, I jumped at the chance. Mental health care can be very demanding and eighteen years of other-focus seemed like my limit.

Then Katrina flooded my Mother’s home. Since September of 2005, she has lived with us and is now 92. I have become her primary caregiver. Although she is able to take care of many of her own needs, as she has aged and become more frail, the time and energy required of me has increased.

Last week I attended a webinar offered by my health insurance carrier. United Healthcare seems pretty intent on offering services that might prevent or mitigate illness. When I got their newsletter announcing the workshop, Take Care of the Caregiver, I signed right up. The information and suggestions they offered will undoubtedly prove valuable for me. My guess is that other insurers offer similar resources.

After attending their seminar, I got to thinking a bit about their ideas and others I have heard. These are a few I have gleaned over time.

  1. Practice mindfulness. Being really ‘present’ in whatever you are doing diminishes the frittering away of time and energy. This can be quite difficult to do when you feel great pressure and the demands of caring for others, but it is very much worth the effort to practice some activity that will assist you in focusing on the things and people for which you are responsible. For some of us, meditation can be helpful. For others, exercise does the job. Whatever method you prefer for increasing your ability to attend well to the persons in your care, use it. Get rid of the excuses and move forward.
  2. Set limits on what you can and will do.You cannot possibly be responsible for everything. Most psychotherapists know this, but it is often difficult not to feel responsible for the entire well-being of clients. Once you have learned to set boundaries as a therapist, it is easier to maintain your energy.The same is true when doing other sorts of caregiving. Know what you are able and willing to do and only do that. This will mean that you may need to find others to provide what you cannot, but that is OK. Just make sure that you know where your abilities and willingness end, that it is perfectly OK to have those end points, and that and your charges will be happier and better off for that clarity.
  3. Let others help you. It is much easier to set limits on what you will do if you let others help you. If you are taking care of children, that means letting their grandparents, aunts and uncles pitch in. If you are taking care of an elder, it may mean involving your siblings or finding programs and assistance in your community. If you are taking care of clients with behavioral health disorders, it may mean delegating tasks to others i1 your organization as well as finding a network of resources in your community that your clients can use.
  4. Take some time for yourself. Give yourself a moment whenever you can. Even brief times can have major impact. Just sit still and breathe for a minute or two. Go for a walk alone. Sit and watch the sun set. Schedule a manicure or a facial or a mini-spa day…or give yourself one. Indulge in a massage. If possible, schedule regular time away from those to whom your provide care. Utilize some of the others in your life so you can schedule an afternoon, a weekend, or a week away. You need vacation time. Take it.
  5. Schedule rest. Do your best to get enough sleep. If adequate continuous sleep is not a possibility, schedule mini-rest breaks into your day. If you always feel exhausted, you are less likely to be the kind of caregiver you would prefer to be. If you are permanently tired, you are more likely to experience suppression of your immune system and susceptibility to illness. Letting others help you may give you the time you need to rest.

I wish I could say I am good at these five things. I am working to be better at them. I’ll let you know when I get there.

I am sure many of you have found ways to take care of yourselves so you can do a better job of taking care of others. Please share some of your secrets. Inquiring minds want to know!

Favorite Technology Tools

I know that most of you work in behavioral health organizations. You probably use the technology that is provided to you even if you know of better tools that would make your work life smoother and easier. After all, the goal is to serve consumers of substance abuse and mental health services, not to the be the coolest technology shop around.

But maybe that is not totally the case. . . . Do you have a favorite technology tool that you love to use in your practice or workplace or at home? Is there something that has become so indispensable that you cannot imagine getting along without it?

I am not a big searcher for new software programs or apps for my Android cell phone or Amazon Fire. I tend to try things that are offered by family or friends, choose the ones that work for me, and then leave well enough alone. If I have chosen well, the updates offered by the company from whom I have purchased the product almost always keep up with and even anticipate my needs. But that is not always the case.

A few years ago, I was considering creating a training video for our electronic claims module. I saw some information about a program named Camtasia Studio, by TechSmith. I liked the description so much that I tried the free demo.

I was in love! This program does everything I need a video-creation tool to do, and it does it simply. I started with Camtasia 4 and am now at version 7.1. Like I said, when I find a tool that works for me, I tend to stick with it.

This is the sort of video you can create with Camtasia.

When I first started doing these movies, I let our web server handle them and just gave the direct link to the file to the customers we wanted to see them. This got the training module into the right hands, but did not make the video available at large.

Now I want to go farther. I want to be able to create videos and to embed them here on my blog or on our web site. Even though I am not an expert video maker, I want to create more of them and get them out there. The more I do, the better I will get at them.

What cool tools do you have that you rely on every day? Is there some program or app that you cannot do without?

Please tell me what you think. Your feedback and comments are always appreciated.