Psychological assistant providing low cost treatment for eating disorders

I remain committed to the practice of and dissemination of evidence-based treatments. To that end, I am excited to announce that I have added a registered psychological assistant to my practice in Los Angeles:

Liliana Almeida, M.A, Clinical Psychology Ph.D. Student, PSB-94020579 is no longer with the practice, but we do have a new therapist in training who provides low-cost therapy to patients with eating disorders in Spanish, English, and Portuguese. Learn more about Eliane Spagnoletto, ACSW.

Liliana Almeida, M.A.
Liliana Almeida, M.A.

 

Liliana Almeida, M.A., is a fourth year Clinical Psychology Ph.D. student at the California School of Professional Psychology at Alliant International University in Los Angeles. She received her M.A. from The New School and her B.A. from Rutgers University. During the last 7 years she has researched eating disorders and obesity. Her clinical experience includes working with diverse clients in a community mental health center providing cognitive-behavioral and psychodynamic psychotherapy in English and Spanish.

Liliana will be working under my supervision and is available to work with adult and adolescent clients with eating disorders, anxiety, and depression.  She will provide services in English, Spanish, and Portuguese and will be able to provide some low-cost therapy to those in need.

Portuguese

Eu sou uma assistente de psicologia (PBS-94020579) para Lauren Muhlheim, Psy.D., psicóloga clínica especializada no tratamento cognitivo-comportamental de perturbações alimentares. Como assistente de psicologia, eu forneço psicoterapia cognitivo-compartamental em Português sob a licença da Dra. Muhlheim (PSY 15045) para adolescentes e adultos que sofrem com depressão, ansiedade e pertubações de o comportamento alimentar.

Spanish

Soy una asistente de psicología (PBS-94020579) para Lauren Muhlheim, Psy.D., una psicóloga clínica especializada en el tratamiento cognitivo-conductal de los trastornos alimentarios. Como asistente de psicología yo proveo terapia cognitivo-conductal en Español bajo la supervision y licencia de la Dra. Muhlheim (PSY 15045) para adolescentes y adultos que sufren de la depresión, ansiedad y de los trastornos de la conducta alimentaria.

 

AED Tweetchat on Diabulimia

I have to admit that, when a colleague on the Academy for Eating Disorder Social Media Committee that I was co-chairing proposed “diabulimia” as an idea for a tweetchat, I was not particularly excited.  As an eating disorder specialist in outpatient private practice, I have not professionally encountered clients with diabetes and eating disorders.

Since we could not easily identify any experts on the topic who also tweeted, the idea languished until the International Association of Eating Disorder Professionals scheduled an event on the topic in my area.  John Dolores , JD, PhD, a licensed clinical psychologist and Executive Director of Center for Hope of the Sierras, was the guest speaker.

Prior to attending his talk, I had the luck at the FEAST conference to sit next to Dawn Lee-Akers, CFO at Diabulimia Helpline.  Together Dawn and Dr. Dolores educated me on the severity of ED-DTM1 (popularly referred to as “diabulimia”) and the need to draw more professional and public knowledge about this issue (and both agreed to be involved in the chat).

As a result, I was really excited to be involved in helping prepare for the AED twitter chat on the topic this week and to do my part to bring attention to the issue.  It was a great and informative chat and I hope you’ll read the entire transcript available here.

Some highlights of what I have learned:

  • Diabulimia is a media term; many providers prefer ED-DMT1.  It is most commonly the coexistence of Type I diabetes and an eating disorder with manipulation of insulin to lose weight.  In this case, the insulin manipulation is considered an inappropriate compensatory behavior (hence the use of the term diabulimia).  The individual may meet criteria for Bulimia Nervosa or OSFED.  It is also possible to have Type II diabetes and an eating disorder, which may be included in diabulimia if insulin manipulation is involved.  Additionally, some people can have diabetes and an eating disorder that are totally unrelated.
  • Women with Type I diabetes are 2.4 times more likely to develop an eating disorder than their non-diabetic peers.  Statistics vary quite significantly with a reported 45-80% of Type I diabetics reporting binge eating.  Multiple studies show 30%-35% of women with Type I diabetes report restricting or omitting insulin in order to lose weight.
  • Higher rates of eating disorders among people with diabetes are not surprising due to the way diabetes has traditionally been treated.  The traditional diabetes ‘diet’ focuses on low carbs and high protein, which encourages restriction, which in turn can lead to binge eating.  Diabetes management includes a lot of focus on numbers and on control which may feed perfectionism.  Patients with diabetes often lose weight pre-diagnosis, and gain weight when they start insulin, so come to associate insulin with weight increase.  They quickly learn that they can manipulate their weight by under dosing with insulin.
  • The effects of compensation by insulin are even more devastating than other forms of dietary compensation.  Patients with diabulimia are at risk for serious medical consequences.  The most dangerous short-term consequence is diabetic ketoacidosis, which requires immediate hospitalization.  Longer-term consequences include peripheral and autonomic neuropathy, retinopathy, cardiovascular disease, and even renal failure.  Some of the consequences are irreversible.
  • Diabulimia requires a specific and sensitive treatment approach from a coordinated team of professionals with expertise in diabetes and eating disorders.  The team should include nursing, endocrinologist, dietitian, therapist, and diabetes educator.  It is critical that the team use a consolidated approach and not treat the diabetes and eating disorder separately.
  • Intuitive eating, CBT, DBT, & ACT are successful in the treatment for comorbid diabetes and eating disorders.  The treatment of diabulima requires medical oversight, including regular monitoring of blood glucose, management of certain side effects of insulin re-introduction, and treatment of new or worsening diabetes complications.  Eating disorder patients with comorbid diabetes are more likely to be medically unstable and need inpatient treatment.

With diabetes on the rise and numerous prevention efforts aimed at preventing obesity, I was left wondering:  where are the prevention efforts for the even deadlier combination of diabetes and eating disorders?  For such efforts, eating disorder professionals and organizations must work together with diabetes professionals and organizations.  We invited several diabetes organizations to join our chat, and fortunately, a few did.  We must continue to raise attention to this problem and reach out to others outside the eating disorder field.

Resources:

  • The Diabetes Eating Problem Survey (DEPS-R) can be used by providers to assess whether patients with diabetes may have an eating disorder.
  • Diabulimia Helpline maintains a list of US treatment centers that have specialized programs to treat comorbid Diabetes and Eating Disorders.
  • Diabulimia Helpline recommends this video as the best overview on Diabulimia for patients, family and professionals.

Recognizing and Managing the Subtler Signs of Starvation in Children with EDs

This interaction on twitter caught my eye:

Signs of Anorexia

Watching cooking shows, collecting and reading recipes, and cooking for others (but not eating it oneself) are some of the earliest signs of anorexia that are often missed and misinterpreted by parents. 

In Keys’ landmark study “The Biology of Human Starvation” male volunteers were put on starvation diets.  According to Keys, food became “the principal topic of conversation, reading, and daydreams.”  The volunteers studied cookbooks and collected cooking utensils.  Three of them went on to become cooks even though they’d had no interest in cooking before the experiment.  When starving, people may obtain vicarious satisfaction from cooking and watching others eat.

In my own experience, I contracted severe food poisoning during my second pregnancy.  Unable to eat without severe consequences, my doctors instructed me to forgo solid food for a full week.  I remember clearly that I spent the week lying in bed (entertaining my toddler) and watching cooking shows.  It seemed nonsensical to me at the time, like an unusual form of self-torture.  But, now I know it was an attempt to vicariously soothe my intense hunger.

In her book Brave Girl Eating, Harriet Brown discusses how her daughter went through a “foodie” phase during the onset of her anorexia.  I have seen a similar profile in a number of my young clients.  Parents do not usually think these are signs of trouble and are more often impressed by their child’s sophistication.  Some of the less obvious early signs of starvation parents should watch for include:

  • Reading recipes
  • Blogging about food
  • Cooking food they do not eat
  • Watching cooking shows

Of course, not every child who shows a strong interest in cooking has or will develop anorexia, but it is something that should pique a parents’ interest.

My own daughter went through a phase where she was obsessed with cooking and watching cooking shows.  It so happened that she was not eating enough at this time, which coincided with the start of her adolescent growth spurt.  I did an early FBT-like intervention and she gained and grew; as she did, the obsession with cooking abated.  Was this merely a passing phase or anorexia averted?  I’ll never know, but I’m glad I intervened.  (More about that in future post.)

When a child with a diagnosis of anorexia shows these behaviors, I recommend that they be stopped.  In FBT, parents take charge of their child’s food and food environment.  Food is the child’s medicine and the number one priority.  For this reason, vicarious gratification of hunger should be removed.  Children with anorexia should not be watching cooking shows, reading recipes, or cooking.  I usually recommend that children do not participate in preparing their own food at all in Phase 1.  In Phase 2, children gradually get involved in food preparation again, but the usual rule I recommend is that if they make something, they must eat it.

Presentation on Social Media for Psychologists

Slide1

 

Reprinted from the Rutgers GSAPP website:  
Dr. Lauren Muhlheim
“Use of Social Media by Professional Psychologists”

 

On Wednesday March 27, 2014, faculty and students at the Graduate School of Applied and Professional Psychology (GSAPP) gathered to hear a colloquium presentation by Lauren Muhlheim, Psy.D, CEDS (Clinical, 1995). Dr. Muhlheim is a prominent GSAPP alumna who has a practice in Los Angeles where she provides psychological treatment specializing in evidence-based cognitive behavioral psychotherapy for adults and adolescents with depression, anxiety, stress, and eating disorders. She presented on the topic of “Use of Social Media by Psychologists in a Safe and Ethical Way.”

After earning a B.A. from Princeton University, Dr. Muhlheim attended the doctoral program in Clinical Psychology at GSAPP. She chose GSAPP because she was “impressed by the quality and depth of the clinical training” and knew that she wanted to work in clinical settings. As a graduate student, Dr. Muhlheim trained in the Rutgers Eating Disorder Clinic. In interview, she shared her favorite memory of GSAPP to be working with Terry Wilson, Ph.D., an internationally renowned eating disorders expert. More recently, Dr. Muhlheim trained in the Maudsley Family-Based Treatment (FBT) for adolescent eating disorders and is certified in FBT by the Training Institute for Child and Adolescent Eating Disorders. She is also certified as an eating disorder specialist (CEDS) by the International Association of Eating Disorders Professionals (IAEDP). Dr. Muhlheim has been providing psychological counseling since 1991. She has also supervised and trained psychology interns and other mental health professionals.

Dr. Muhlheim’s work experience has brought her to multiple settings around the globe. For nearly ten years, she was a staff psychologist at Los Angeles County Jail, followed by three years in Shanghai, China, treating clients of varying national, cultural, religious, and ethnic backgrounds. Dr. Muhlheim spearheaded and served as the first president of the Shanghai International Mental Health Association (SIMHA). She has also worked in an Obesity Research Clinic, inpatient hospitals, outpatient clinics, group homes, and private practice.

Dr. Mulheim’s experiences abroad proved to be a portal for her into the world of social media. In her colloquium presentation, she reflected on her years in Shanghai: “That’s where I first became aware of the power of the internet.” She described how she used search engine optimization to attract international patients to their practice website, as well as commented on the challenges she faced when China blocked Facebook.

In 2012, Dr. Muhlheim joined the social media committee of the Academy for Eating Disorders. She served as a co-chair of AED’s Social Media Committee, AED’s Membership Recruitment and Retention Committee, and AED’s FBT Special Interest Group. In her role as a co-chair of the Social Media Committee for the Academy for Eating Disorders, she helped manage the AED’s Facebook, LinkedIn, and Twitter pages, and helped educate professional AED members about social media. More recently, Dr. Muhlheim has stepped up to the position of Director for Outreach with the board of AED.

Over the course of her talk, Dr. Muhlheim educated the audience about social media from a variety of angles. She presented an overview of current technology, reasons why to be on social media, and recommendations for using social media safely and ethically. Loaded with valuable information and insights, her approach was also light and entertaining. She started out her presentation by differentiating among the various social media formats: “Facebook: I like donuts,” “LinkedIn: My skills include donut eating,” and “Twitter: I’m eating a donut.” Although the list of social media sites was lengthy, Dr. Muhlheim chose to highlight Facebook, LinkedIn, and Twitter in particular.

Citing commentary from the APA Monitor, Dr. Muhlheim presented a general outlook on social networking in the world of professional psychology. A rising number of people are turning to the internet for health information, she noted. As the use of social media is growing, psychological professionals are increasingly using media. Graduate students use social media but often lack guidance, because supervising faulty are less experienced with it. She presented the Social Media Ladder as one way to view online participation, showing how people move from being passively involved to being actively involved, actually becoming content creators.

Why is it important to be on social media? According to Dr. Muhlheim, social media helps us stay informed, make connections, meet patients where they are, build a “brand,” learn new information (e.g., “Tweetchats”), disseminate information, advocate for causes, and market products or services. These concepts came alive as Dr. Muhlheim expounded with personal anecdotes and colorful screenshots. “The more online real estate you control, the better,” she explained, “And one way you control your online real estate is through social media.”

Perhaps the crux of her presentation dealt with the safe and ethical use of social media. APA has not yet published guidelines for psychologists’ use of social media, Dr. Muhlheim pointed out. Subsequently, Dr. Muhlheim shared the social media guidelines published in 2010 by American Medical Association, illustrating how these principles apply to her as a professional.

First, she advised, be sure to separate personal and professional content. Keep a personal facebook page for social connections and create a separate practice page for your practice. Create two email address, and do not allow clients to friend you on Facebook. Second, use privacy settings—and don’t rely on even the most restrictive settings as being absolutely secure. Third, routinely monitor your own internet presence, such as by doing a Google search or checking online rating agencies. Fourth, protect patient confidentiality. Per Dr. Muhlheim’s advice, clarify your social media policy for googling, friending, and following; incorporate it into your informed consent for clients. Fifth, maintain appropriate boundaries. Sixth, remember your career and reputation when using social media. In her words, “Think twice, and tweet once.”

Listeners gleaned a variety of handy tips and bits for using social media to advance professional practice. For instance, use LinkedIn as a virtual rolodex to connect with colleagues. Strive for search engine optimization – increase your visibility on other sites and update your site frequently. Utilize twitter as a great way to share articles and stay current, and as an expedient alternative to blogging.

When asked about the challenges of being involved in social media, Dr. Muhlheim stated, “I think the greatest challenge of social media for psychological practitioners today is the fear/resistance many have to using it.” Her advice for current GSAPP students? “Plan to have an online presence” and “be willing to explore and use social media and other new technologies, such as apps.”

Dr. Mulheim’s presentation generated a wave of questions from the audience on the applications of social media to professional practice. In response to concerns over privacy on Facebook, Dr. Mulheim recommended using the most restrictive privacy and security settings, while noting that privacy settings are imperfect. “Assume anything you publish behind a privacy setting will leak.” Further, she recommended that professionals post only that which they can stand behind with integrity. Finally, Dr. Muhlheim responded to questions about the psychological implications of Facebook use on eating disorders. The discussion was thought-provoking and dynamic, as a room of psychology professionals aired concerns over the ramifications of social media use for children and adolescents.

At the end of her presentation, Dr. Muhlheim shared her social media rendition of a bibliography – a link to her Pinterest page. An exuberant round of applause followed, as GSAPP faculty and students acknowledged Dr. Muhlheim’s cutting-edge contributions to the field of professional psychology.

Dr. Muhlheim can be reached by email at drmuhlheim@gmail.com 
or visited at:

Facebook

Twitter

Pinterest

Tumblir

LinkedIN

By: Chana Crystal, GSAPP

Highlights from #ICED2014: The FBT Debate

Drs. Le Grange and Strober
Drs. Le Grange and Strober

ICED 2014 in New York provided a wonderful opportunity to connect with colleagues from around the world who share a commitment to providing treatment to those suffering from eating disorders. Among the highlights for me were the well-attended, first-ever tweetUP and my official appointment as Board Director for Outreach of the Academy for Eating Disorders.

Among the workshops, I was very excited to attend A Comprehensive and Measured Critique and Discussion of Maudsley and Family Based Therapy: The Civilizing Influence of Rigorous and Impartial Debate.   In this workshop, UCLA Eating Disorders Program director Dr. Michael Strober, one of the more vocal critics of Maudsley Family Based Therapy (also known as FBT), went head to head with Dr. Daniel LeGrange, director of the University of Chicago’s Eating Disorder Program and one of the developers of FBT. As the only therapist in Los Angeles certified in FBT, I am highly aware of Dr. Strober’s criticisms of the treatment.

Dr. Strober introduced the packed-room debate by saying, “there will be no flowing of blood at the FBT debate.” Dr. LeGrange presented first and cited the empirical evidence for FBT, admitting “it is no panacea” as there are only 7 published controlled trials. He reported the “most compelling” study of FBT showed that 45% of those who received FBT fully remitted, versus only 20% of those who received Adolescent Focused Therapy. He noted that FBT is particularly helpful in rapid weight restoration and in reduction of the need for hospitalization.

Dr. Strober countered by stating, “there is [only] a sprinkling of evidence in support of FBT.” He argued that the evidence for FBT was actually weak, with only 3 published comparative studies. He pointed out there was no statistically significant end of treatment outcome for FBT. Strober concluded that there is a lack of evidence to suggest FBT is the treatment of choice for all patients. He cautioned that the “glossy language” used by FBT’s proponents needs nuance: “The public discussion is the problem; well-trained clinicians have been accused of acting unethically by not recommending FBT.” Strober stated that his questions regarding FBT’s efficacy have led to hostile, finger-pointing treatment from others. “It’s not that ‪FBT lacks value but that [any critique or questioning of it is dismissed as unethical & unfounded]”. He conceded that FBT should not be dismissed: “I recommend it at times when the rationale is sound.” He joked, “I have been asked why I hate families; as far as I can tell the only family I hate is mine; I quite fancy the others.”

In his rebuttal, Le Grange agreed with Dr. Strober, “It concerns me too that FBT is being touted as the be-all-end-all.” However, he noted that it was still the approach that currently has the best evidence supporting its overall efficacy. LeGrange acknowledged “we are clutching at straws” to find effective treatments for eating disorders. “I agree we need to move forward, with much more rigor, to continue to evaluate the efficacy not just ‪ of FBT but also other ED treatments.”

In summary, there was more agreement than disagreement. Both experts acknowledged that while FBT has value, the research is still young. The audience encouraged them to write a paper together on the strengths and limitations of FBT, with the objective of depolarizing the eating disorder community.

For my part, in the outpatient setting in which I work, I will continue to offer FBT to adolescents with eating disorders and their families when the illness duration is under three years, when the adolescent is medically stable and cleared for outpatient treatment, and when the home environment is stable and the parents are committed to FBT. If early weight gain is not achieved, I always recommend a higher level of care.

FBT Meal Strategies Gleaned from Ziplining

Understanding and Responding to Your Youngster’s Fear: A Metaphor

FBT Meal Strategies Gleaned from Ziplining
The author on the zipline

I often explain to parents that for a youngster suffering from an eating disorder, a meal can feel dangerous – like jumping out of an airplane. A couple of years ago I had the opportunity to (almost) live out this metaphor on a family vacation. This experience led me to reflect on the experience of both the teen and their support team:

Recently our family went zip-lining for the first time. I was terrified. But as I was zip-lining, I paid close attention to how I felt and behaved and what helped me get through the experience.

Despite the excitement I had felt when we initially planned the activity, when I saw the length and height of the zip-lines, I had misgivings. I imagined that this is how many of my patients must feel before many meals. Imagine, though, that they face this fear up to six times daily!

During the zip-lining adventure, I felt most comfortable going after my children and before my husband. Even though once I was on the zip-line I was alone, rushing through the air at speeds of up to 50 miles per hour, so fast my eyelashes were blowing into my eyes – somehow taking the plunge in this order made me feel like I was snugly nestled between them.

The calm and assurance of the line attendants was comforting. They knew what they were doing. At every single end of each of the eight lines, I felt compelled to tell the attendant that secured or unstrapped me exactly how terrified I was. I was relieved when they joked and told me they knew I would be fine. I also felt supported when my kids received me at the end of each line and reminded me that the next one wouldn’t be any harder. Knowing that my kids and husband were there with me and that we were doing it together made this fear something I wasnt facing alone.

So, how does this apply to supporting a young person with an eating disorder?

Physical Placement of Support

During the zip-lining adventure, I felt most comfortable going after my children and before my husband. One of the basic premises of FBT is that the support of the family during mealtimes provides a supportive environment for recovery. Parents often find that sitting at the table on either side of their adolescent during mealtimes provides additional structure and support. It is an act of love to support a child through a meal when they are terrified.

Confidence

If the zip-line attendants had expressed hesitation or anxiety about what they were doing I probably would have refused to go. Calm and confident parents inspire trust in their children, making it easier for them to eat. Sometimes parents have to fake it until they do feel confident.

Validation

At every single end of each of the eight lines, I felt compelled to recount my terror to the attendant that secured or unstrapped me. I didn’t need to hear any response in particular. It just relieved me to express how scared I was and to know that the attendants heard me. When parents hear their child say he or she doesn’t want to eat, it is more helpful to simply hear it and stay calm than it is to get upset and try to argue or reason.

Reassurance

If the zip-line attendants had tried to reassure me by giving me detailed factual information about the strength of the lines and so on, my attempts to parse this information in my state of anxious activation might have only increased my anxiety. Parents can empathize with the fear and express confidence that their adolescent will be okay. “I know you are scared. I know you can do this.” Parents know their youngster and know whether joking will work. It is usually best to avoid getting into the content of the fear, such as how many calories are in the food, why they need fats in their diets, etc.

Togetherness

I also felt supported when my kids received me at the end of each line and reminded me that the next one wouldn’t be any harder. Knowing that my kids and husband were there with me, and that we were doing it together, made this fear something I wasn’t facing alone. The presence and support of parents and siblings and extended family during and after meals is critical.

 

At the end of my zip-lining experience, my nerves were spent and I felt exhausted. But, I was happy and proud I had faced my fear with the support of family. In the far more essential activity of eating, families can provide similar support to make fears bearable and provide an environment that allows teenagers with eating disorders to recover and flourish.

Parents usually get the best results when they are like the zip-line attendants: calm, empathizing with the fear, and never engaging the source of the fear (in this case, the eating disorder). Avoid getting pulled into the content of the eating disorder thoughts. When your adolescent says they are worried about the caloric content of food, think about what they are really expressing: their anxiety about eating. It is much better to empathize with how scared they are than to debate whether food is healthy for them (spoiler alert: it is).

I’m moving my office

On August 1, my office is moving to

4929 Wilshire Boulevard, Suite 245!

(Only one mile east of my old office)

office moving flyer_Aug2013

Since eating disorders are best addressed by a multidisciplinary approach, I am excited to be able to offer expanded services at this new and larger space.  I am pleased to announce my affiliation with Katherine Grubiak, RD, who will be working in my suite part-time.  Ms. Grubiak brings a wealth of experience with eating disorders in both adolescents and adults, and her approach is consistent with the latest evidence-based treatments.

Katherine Grubiak, RD/Biography

Katherine Grubiak is a Registered Dietitian with a focus on blending Western & Eastern philosophies regarding nutritional healing.  She graduated from the University of Texas at Austin and first pursued a career in public health surrounding herself with different cultures and a mission to honor all those seeking healthcare nutritional support. Continue reading “I’m moving my office”

Lobby Day with the Eating Disorder Coalition

Yesterday I participated in a tweetchat with the Academy for Eating Disorders and Eating Disorder Coalition to learn more about Lobby Day.  Here is a summary of the chat:

What is Lobby Day?

The Eating Disorder Coalition sponsors lobby days at the US Congress twice per year.  The next lobby day is in Washington, DC on April 16 and 17.  You do not need to be a member of EDC, but members get a reduced rate to participate.  To get a feel for what lobby day is like, the fall 2010 EDC lobby day hearing is available on youtube here: http://www.youtube.com/playlist?list=PLkWdTgyoj0OZlGp83Sf-49Tb5NyaGzs-C

What issues is the EDC currently addressing?

The EDC is currently working on 2 primary issues:  1) Mental Health Parity (helping make sure people get ED treatment covered at parity) and 2) The FREED Act: http://eatingdisorderscoalition.blogspot.com/2011/07/what-is-freed-act.html.

Previous lobbying by the EDC resulted in Congress directing NIH to release an RFA http://grants.nih.gov/grants/guide/rfa-files/RFA-MH-14-030.html for research studies that use dimensional constructs to integrate biology and behavior in the service of advancing the understanding of biological mechanisms and developmental trajectories of eating disorders.

How can you get involved?

Patients and families can attend lobby day or write letters to their congressman and/or call on Lobby Day to add extra support.

Clinicians can attend lobby day or email mmorris@eatingdisorderscoaliton.

Researchers should apply for the RFA to show NIH that these requests are needed

How does Lobby Day work?

The EDC provides training and then takes you to meetings with your representatives. You get to be a lobbyist for a day!  People get to share their personal stories with members of congress.  There is a team leader from EDC there to help you.  Said one participant, “I confess I was nervous the first time – who was I to lobby? Eek! But all you need is comfy shoes and YOUR story: EDC makes it simple.”

Those who participated in the past described lobby day as empowering and uplifting. “The chance to stand with others and speak our own personal story to people in power is transformative.”  It is also a great chance to stand together and make new contacts and friends.

Hold the Date:

If you can’t make it on April 17 hold the date of September 18 for their fall lobby day

Who Killed the 50 minute session?

What Consumers Should Know about Changes to Psychotherapy Sessions in 2013

By Lauren Muhlheim, Psy.D., CEDS and Kantor & Kantor, LLP

Unbeknownst to most mental health consumers, a change went into effect in January, 2013 that may have far-reaching ramifications for those receiving outpatient psychotherapy.  For the first time in 15 years, changes were made to the coding system used to describe and bill for mental health treatment.   This change has resulted in chaos for many mental health professionals who bill their patients’ insurance.  Nationwide, many mental health providers have reported problems with filing and receiving timely reimbursement for claims filed under the new coding system.

Why were the Current Procedural Terminology (CPT) codes changed?  The Centers for Medicare and Medicaid Services (CMS) establishes the Current Procedural Terminology (CPT) codes that providers use to communicate with insurance companies.  The CPT codes are periodically reviewed in partnership with the American Medical Association (AMA).  For the last several years, the AMA and the American Psychiatric Association (APA) advocated for changes in the codes that would treat (and reimburse psychiatrists) like other physicians.  Psychiatrists have traditionally been on the low rung of physician pay scales.  The changes allow (and now require) psychiatrists to bill separately for the different services they frequently provide in the course of a single session (medical examination, psychotherapy, and medication management).  The hope was that the new codes, in providing more flexibility in session length, would highlight the complexity and diversity of what psychiatrists do.  There are additional “add on” codes for “complexity” as well as for crisis management.  Since all mental health providers use the same psychotherapy codes, non-psychiatrists have had to adopt these as well.

For the majority of recent psychological treatment history, the standard 50- minute therapy session was billed to insurance under the CPT code “90806”, and was officially described as “individual therapy 45-50 min.” In practice, most therapists have scheduled patients on the hour and allocated one hour per patient, spending approximately 50 minutes face to face.  This often stretches to 55 minutes by the time one handles payments and schedules the next appointment and allows a few minutes between clients for notes, bathroom breaks, and checking messages.  In 2013, the 90806 code was eliminated and replaced with several alternatives:

  • 90832 – psychotherapy 30 minutes
  • 90834 – psychotherapy 45 minutes
  • 90837 – psychotherapy 60 minutes

Practitioners were informed about the change in October 2012, but given little specific information on how to use them.  The American Psychiatric Association provided the following interpretation:

Note: Since the new psychotherapy codes are not for a range of time, like the old ones, but for a specific time, the CPT “time rule” applies. If the time is more than half the time of the code (i.e., for 90832 this would be 16 minutes) then that code can be used. For up to 37 minutes you would use the 30 minute code; for 38 to 52 minutes, you would use the 45-minute code, 90834; and for 53 minutes and beyond, you would use 90837, the 60-minute code.

By “time,” the APA means face-to-face time with the client.

So what’s the hitch?  The 50-minute session suddenly no longer exists, and that creates a problem. Many practitioners assume the 45-minute session is the intended replacement for the 50-minute session.  However, they fear that reducing time spent with patients will both reduce treatment efficacy, as well as be used as justification by insurance companies to reduce reimbursement rates.  Remember, reimbursement rates haven’t been raised in 18 years and are typically only half of what a patient would pay if they didn’t have insurance.  The other option, the 60-minute session, makes it harder for therapists to complete paperwork and take bathroom breaks unless they space clients further apart, complicating schedules for everyone involved.  And it’s not even clear whether insurers will choose to cover the 60-minute session.   It appears that some insurers are not.

For psychiatrists, the new codes are extremely complicated. The 2013 Medicare fee schedule reveals that reimbursement for psychiatric evaluations with medical services – those done by psychiatrists – will be lower than reimbursements for psychiatric evaluations done by social workers and psychologists.  “This makes no sense, and seems to run counter to the premise that creating a comprehensive system of coding services would create an appreciation for the complexity of the medical aspects of treating mental disorders, address parity, and decrease the stigma to seeing a psychiatrist.”[1]

The CPT changes have thus far resulted in confusion and delays in processing mental health claims because insurance companies were not prepared, equipped, or organized for this change.   Insurance companies had not yet set rates for the new codes, nor had they decided which codes they would accept.  As a result, claim processing since the first of the year has been slow, impacting patients, therapists, and insurance companies.   Helen Stojic, a spokeswoman for Blue Cross Blue Shield of Michigan told NBC News, “The amount of changes and the work involved was much bigger than … the folks involved anticipated.”[2]

Around the country, mental health providers have reported problems with insurance reimbursement.  Some are reporting financial difficulty due to the delay in cash flow.  The biggest worry, however, is that this coding chaos will affect care for millions of vulnerable patients.

What does this mean for providers? In simple terms, less pay, delayed payment, and financial hardship.  “We are ethically bound not to leave patients hanging,” Steven Perlow, president of the Georgia Psychological Association and a psychologist in private practice said. “I will personally see people for a sliding scale … there have been situations where I’ve seen people for free.”[3] Additionally, providers may experience disincentives to stay on insurance panels.  Lastly, these factors may affect providers’ ability to deliver quality care.

What does this mean for patients? To start with, session lengths could be reduced by 10%, meaning less treatment.  Furthermore, patients may have increased difficulty finding practitioners who are willing to accept insurance. Therapists may very well be waiting to see what is happening with reimbursement rates before accepting more insurance patients, or may leave panels altogether.

These outright denials of payment and system wide delays have caused chaos among providers and their patients, and could last for months.  This disorder and confusion has the potential to jeopardize access to care for millions of mentally ill Americans, who depend upon the stability of treatment from their mental health providers.

Action Plan

If you feel that the 2013 psychotherapy CPT codes have negatively affected how you are able to deliver or receive patient care, let your voice be heard:

http://www.realpsychpractice.com/2013-cpt-codes/

Lauren Muhlheim, Psy.D., CEDS

Lauren Muhlheim, Psy.D., CEDS is a psychologist and certified eating disorder specialist practicing in Los Angeles.  She specializes in providing evidence-based psychotherapy for adults and adolescents.  www.laurenmuhlheim.com

About Kantor and Kantor                                                                                                                             

Kantor & Kantor is one of the most experienced and highly respected law firms dealing with the prosecution of claims against insurance companies. If your insurance company has unfairly denied payment for benefits, we can help. Call (800) 446-7529 or log on to www.kantorlaw.net.


[2] JoNel Aleccia, NBC News, Glitch in medical code threatens mental health care, therapists warn, http://vitals.nbcnews.com/_news/2013/02/07/16842490-therapists-change-in-medical-coding-threatens-mental-health-care#.URPN_3hBLqc.twitter (February 7, 2013).

3 JoNel Aleccia, NBC News, Glitch in medical code threatens mental health care, therapists warn, http://vitals.nbcnews.com/_news/2013/02/07/16842490-therapists-change-in-medical-coding-threatens-mental-health-care#.URPN_3hBLqc.twitter (February 7, 2013).

 

Recovery Record App

Since my first foray into using Recovery Record app several months ago, I was pleased to discover that it is now improved with an interface for clinicians to access their clients’ records which are linked through a  code that patients enter.   Self-monitoring by clients has never been easier.

Self-monitoring of food intake is a helpful eating disorder recovery tool and a central element of treatment in cognitive behavioral therapy.  Research shows that self-monitoring is associated with a positive treatment outcome.  Many of my clients complain about having to carry unwieldy and obtrusive papers to record their intake.  A few have searched for iPhone apps and unfortunately chosen calorie-counter apps that only increase their preoccupation and eating disordered symptoms.  Now there is a better solution, an app called Recovery Record.  Available through the app store, Recovery Record was developed by an Australian student along with Stanford University.  It offers places to record food intake as well as thoughts, feelings, binges, purges, and urges.  There are supportive messages and reminders are sent if a meal is not logged when expected.  There is no affiliated calorie database.

To read more:  visit Recovery Record