Category Archives: counseling

Talk doesn’t pay, so psychiatry turns to drug therapy

Via the New York Times

Doylestown, PA – Alone with his psychiatrist, the patient confided that his newborn had serious health problems, his distraught wife was screaming at him and he had started drinking again. With his life and second marriage falling apart, the man said he needed help.

But the psychiatrist, Dr. Donald Levin, stopped him and said: “Hold it. I’m not your therapist. I could adjust your medications, but I don’t think that’s appropriate.”

Like many of the nation’s 48,000 psychiatrists,  Dr. Levin, in large part because of changes in how much insurance will pay, no longer provides talk therapy. Instead, he prescribes medication after a brief consultation with each patient. So Dr. Levin sent the man away with a referral to a less costly therapist.

Dr. Levin, 68, first established a private practice in 1972, when talk therapy was in its heyday. Like many psychiatrists, he treated 50 to 60 patients in once- or twice-weekly talk-therapy sessions of 45 minutes each. Now, like many of his peers, he treats 1,200 people in mostly 15-minute visits for prescription adjustments that are sometimes months apart.

Then, he knew his patients’ inner lives better than he knew his wife’s; now, he often cannot remember their names. Then, his goal was to help his patients become happy and fulfilled; now, it is just to keep them functional.

Dr. Levin has found the transition difficult. He now resists helping patients to manage their lives better. “I had to train myself not to get too interested in their problems,” he said, “and not to get sidetracked trying to be a semi-therapist.”

A 2005 government survey found that just 11 percent of psychiatrists provided talk therapy to all patients. Apex Behavioral Health provides both psychiatry (medication management) and psychologists (counseling) to our clients. Clients are able to see both the psychiatrist and therapist in the same building; often, our psychiatrists will refer their patient to a therapist and vice versa.

Recent studies suggest that talk therapy may be as good as or better than drugs in the treatment of depression, which is why it is really beneficial to see a therapist. Insurance company reimbursement rates and policies that discourage talk therapy are part of the reason. A psychiatrist can earn $150 for three 15-minute medication visits compared with $90 for a 45-minute talk therapy session.

Competition from psychologists and social workers — who unlike psychiatrists do not attend medical school, so they can often afford to charge less — is the reason that talk therapy is priced at a lower rate.

Of course, there are thousands of psychiatrists who still offer talk therapy to all their patients, but they care mostly for the worried wealthy who pay in cash. In New York City, for instance, a select group of psychiatrists charge $600 or more per hour to treat investment bankers, and top child psychiatrists charge $2,000 and more for initial evaluations.

When he started in psychiatry, Dr. Levin kept his own schedule in a spiral notebook and paid college students to spend four hours a month sending out bills. But in 1985, he started a series of jobs in hospitals and did not return to full-time private practice until 2000, when he and more than a dozen other psychiatrists were shocked to learn that insurers would no longer pay what they had planned to charge for talk therapy.

“At first, all of us held steadfast, saying we spent years learning the craft of psychotherapy and weren’t relinquishing it because of parsimonious policies by managed care,” Dr. Levin said. “But one by one, we accepted that that craft was no longer economically viable. Most of us had kids in college. And to have your income reduced that dramatically was a shock to all of us. It took me at least five years to emotionally accept that I was never going back to doing what I did before and what I loved.”

He could have accepted less money and could have provided time to patients even when insurers did not pay, but, he said, “I want to retire with the lifestyle that my wife and I have been living for the last 40 years.”

“Nobody wants to go backwards, moneywise, in their career,” he said. “Would you?”

Dr. Levin would not reveal his income. In 2009, the median annual compensation for psychiatrists was about $191,000, according to surveys by a medical trade group.

Dr. Louisa Lance, a former colleague of Dr. Levin’s, practices the old style of psychiatry from an office next to her house. She sees new patients for 90 minutes and schedules follow-up appointments for 45 minutes. Therapists at Apex Behavioral Health see clients for 45 minutes to an hour. Everyone gets talk therapy. Cutting ties with insurers was frightening since it meant relying solely on word-of-mouth, rather than referrals within insurers’ networks, Dr. Lance said, but she cannot imagine seeing patients for just 15 minutes. She charges $200 for most appointments and treats fewer patients in a week than Dr. Levin treats in a day.

“Medication is important,” she said, “but it’s the relationship that gets people better.”

Dr. Levin’s initial efforts to get insurers to reimburse him and persuade his clients to make their co-payments were less than successful. His office assistants were so sympathetic to his tearful patients that they often failed to collect. So in 2004, he begged his wife, Laura Levin — a licensed talk therapist herself, as a social worker — to take over the business end of the practice.

Ms. Levin created accounting systems, bought two powerful computers, licensed a computer scheduling program from a nearby hospital and hired independent contractors to haggle with insurers and call patients to remind them of appointments. She imposed a variety of fees on patients: $50 for a missed appointment, $25 for a faxed prescription refill and $10 extra for a missed co-payment.

As soon as a patient arrives, Ms. Levin asks firmly for a co-payment, which can be as much as $50. She schedules follow-up appointments without asking for preferred times or dates because she does not want to spend precious minutes as patients search their calendars. If patients say they cannot make the appointments she scheduled, Ms. Levin changes them.

“This is about volume,” she said, “and if we spend two minutes extra or five minutes extra with every one of 40 patients a day, that means we’re here two hours longer every day. And we just can’t do it.”

She said that she would like to be more giving of herself, particularly to patients who are clearly troubled. But she has disciplined herself to confine her interactions to the business at hand. “The reality is that I’m not the therapist anymore,” she said.

Ms. Levin, 63, maintains a lengthy waiting list, and many of the requests are heartbreaking. On a January day, a pregnant mother of a 3-year-old called to say that her husband was so depressed he could not rouse himself from bed. Could he have an immediate appointment? Dr. Levin’s first opening was a month away.

“I get a call like that every day, and I find it really distressing,” Ms. Levin said. “But do we work 12 hours every day instead of 11? At some point, you have to make a choice.”

Initial consultations are 45 minutes, while second and later visits are 15. At Apex, initial consultations are 30 minutes, while the second visits are also 15 minutes. In those first 45 minutes, Dr. Levin takes extensive medical, psychiatric and family histories. He was trained to allow patients to tell their stories in their own unhurried way with few interruptions, but now he asks a rapid-fire series of questions in something akin to a directed interview.

In 15-minute consultations, Dr. Levin asks for quick updates on sleep, mood, energy, concentration, appetite, irritability and problems like sexual dysfunction that can result from psychotropic medications.

“And people want to tell me about what’s going on in their lives as far as stress,” Dr. Levin said, “and I’m forced to keep saying: ‘I’m not your therapist. I’m not here to help you figure out how to get along with your boss, what you do that’s self-defeating, and what alternative choices you have.’ ”

Dr. Levin said that the quality of treatment he offers was poorer than when he was younger. For instance, he was trained to adopt an unhurried analytic calm during treatment sessions. “But my office is like a bus station now,” he said. “How can I have an analytic calm?”

And years ago, he often saw patients 10 or more times before arriving at a diagnosis. Now, he makes that decision in the first 45-minute visit. “You have to have a diagnosis to get paid,” he said with a shrug. “I play the game.”

In interviews, six of Dr. Levin’s patients — their identities, like those of the other patients, are being withheld to protect their privacy — said they liked him despite the brief visits. “I don’t need a half-hour or an hour to talk,” said a stone mason who has panic attacks and depression and is prescribed an antidepressant. “Just give me some medication, and that’s it. I’m O.K.”

Dr. Levin expressed some astonishment that his patients admire him as much as they do.

“The sad thing is that I’m very important to them, but I barely know them,” he said. “I feel shame about that, but that’s probably because I was trained in a different era.”

Sojourn Chemical Dependency Program

Increasing individuals with alcohol or drug offenses are being required to participate in substance abuse assessment and treatment as an alternative to, or along with, time in jail. The interest is to have individuals with DUI’s, public intoxication, or possession of illegal drugs get evaluated if they have a substance abuse problem, and if so, receive treatment for their alcohol or drug problems.

Sojourn Chemical Dependency Program is intended to provide a reasonable alternative for chemical dependency services to clients in need of evaluation and treatment. Apex Behavioral Health is experienced in providing services for mandated clients.

Court ordered substance abuse evaluation and treatment is generally not covered by health care insurance. The individual ordered for evaluation has to pay privately for such services. An individuals ability, or lack thereof, to pay adds additional stress to an already stressful situation.

Apex has over 20 years of experience providing court and corrections mandated treatment of substance abuse. With an understanding of individuals’ challenge to afford treatment, Apex has put together an evidence based substance abuse treatment for a reasonable cost.

Courts may wish people go into treatment over serving jail time for substance related issues, and many courts have been accepting of our Sojourn program.

A client would come to a group session to recieve an assessment, which determines how long one continues to come to session for.

The intake and screening fees for Chemical Dependency Issues are only $25.

Clients are referred for a one time screening group. During this session, clients will take a SASSI substance abuse evaluation, along with completing a chemical history and the required legal paperwork.   Following completion of the evaluation session, a brief report is forwarded to the referring source  (which may or may not be a probation officer), including a recommendation for treatment if appropriate.

If the client is required to attend treatment, they then meet with the therapist for an individual treatment planning session. After the treatment planning session is complete, the client attends a minimum of ten one and one half hour group sessions.

Attendance notices and monthly reports are sent to the referral source.

Sojourn is a cash based program.

Initial Screening Group – $25

Individual Treatment Planning appointment – $50

Treatment Group (per group) – $25

If you meet the listed requirements, please contact us.

Sojourn is at the following office locations:

Ann Arbor: (734) 677 -0918

Brownstown:  (734) 479-0949

Detroit: (313) 394-2133

Westland: (734) 729-3133

What Is the African American’s Experience Following Imago Education?

Tanya L. Martin and Dawn M. Bielawski wrote the following article published on November 6, 2009 in the Journal of Humanistic Psychology, and here are excerpts from it:

Abstract

The purpose of this qualitative study is to explore the African American’s experience following Imago education. Six women and six men were interviewed for this study. Qualitative data analysis resulted in the following themes: (a) improved communication between partners, (b) increased understanding of self, (c) increased understanding of partner, (d) increased understanding of one’s own and one’s partner’s childhood, (e) revealed more of one’s authentic self, and (f) expressed need  for more education about Imago therapy within the African American community. Information gained from this study will be of value to the field of psychology, providing culturally pertinent insight about African Americans and how they experience relationships and psychotherapy. The findings are presented and summarized through themes, individual quotes, a composite depiction, and a creative synthesis. Future research in this area would examine the long-term effects of Imago education in this population.

Literature Review

The decline of stable and healthy relationships among African Americans can be traced back to the institution of slavery. Families were often separated and sold to other slave owners in an effort to demean the race and make a financial profit. Unfortunately, the negative effects of separating spouses, family members, and partners were not taken into consideration. For instance, based on a review of slavery documents, when mothers gave birth only their names and their owner’ names were included in the birth record, not the fathers’ or the childs’. As a result, many African Americans may have unconsciously harbored and passed on the negative side effects to other generations. This behavior is so prevalent in the African American society that the discussion of love, happiness, and togetherness is rarely written about, seen on television, or depicted in movies. Therefore, it is necessary to shed light on the many reasons why more information and education is not shared with or offered to this segment of the population:

Since our leaders and scholars agree that one measure of the crisis black people are experiencing is lovelessness, it should be evident that we need a body of literature, both sociological and psychological work, addressing the issue of love among black people, its relevance to political struggle, its meaning in our lives. (Hooks, 2001, p. 5)

Perhaps black people are not experiencing lovelessness; instead, maybe they are being wrongly viewed as loveless. For that reason, it is imperative to change those stereotypes and educate society about African Americans and their ability to be loving individuals. These myths and stereotypes have mistakenly made many African Americans believe that monogamy, marriage, and two-parent homes are characteristics of relationships seen primarily in other cultures.

Sadly, dysfunctional intimate relationships among adults also gravely affect the children involved. Even in relationships where the parents are married, if they are not happily connected in the marital relationship, the children will most often experience negative repercussions in their own relationships. Hooks (2001, p. 169) asserted “As mass movements for social justice lost momentum so did vigilant affirmative focus on black heterosexual relationships. Divorce rates, which are much higher for black couples than for other groups in this society, are one serious indication of crisis.” Hence, the importance of developing and maintaining happy and healthy relationships has far-reaching effects.

Significant changes have occurred in the patterns of marriage and divorce in the United States during the past few decades, which disproportionately affect African Americans *U.S. Census Bureau, 2005). In comparison with Caucasian Americans, African Americans are less likely to marry, are more likely to marry later when they do marry, and are more likely to be separated, divorced, or widowed than the general population. Some of the factors contributing to this racial disparity in marital status include social movements such as feminism, cohabitation, putting too much emphasis on material things,a nd economic limitations; the misogynistic hip-hop culture view of women as inferior; religious differences; jealousy; and inability to resolved conflict (Dixon, 2009).

Gender issues also contribute to marital instability because of the tendency of African-Americans to protect their sons in ways they do not protect their daughters. The need to compensate for the greater psychological risk to which males are exposed sets up distorted expectations for them which then alienates female children in ways that later contribute to problems in marital intimacy. (Boyd-Franklin & Franklin, 1999, p. 275)

Comparison of African Americans with people from othercultures shows that African Americans are unlikely to seek out relationship therapy; they are more likely to go to their extended family with issues (Ho,1987). African Americans commonly obtain therapy for their children’s problems when referred by a teacher, rather than seeking therapy for their own relationship issues (Penn, Hernandez, & Bermudez, 1997). There is a stark  contrast between the family systems in other cultures compared with that in the African American culture. This is largely because of the fact that African American men were involuntarily separated from their families and used as breeders during the time of slavery – a legacy that in some ways is still apparent today.

Because of the significant decline in marriage rates and escalating divorce rates among African Americans, this study focused on the effectiveness of couples’ therapy, using Imago Relationship Therapy. This form of therapy is derived from an in-depth therapy involving 16 original exercised aimed at improving relationships. The exercise that forms the foundation of Imago Therapy is known as the Couples’ Dialogue, which involves three steps used to deepen, broaden, and improve communication. According to Hendrix (1996), the Couples’ Dialogue is one of the most important tools in the process of improving communication between couples. The three components of the Couples’ Dialogue are mirroring, validation, and empathy. Mirroring is simply listening to and repeating to one’s partner what he/she has said; this is done to bring active listening. Validation is provided after the listener has mirrored/repeated all the information shared by the sender. It is during this exchange that the listener explains to his or ther partner how they “make sense.” empathy is also provided by the listeners as they explain to their partner how they “imagine them to be feeling or to have felt” during the said experience or situation. This dialogue is quite effected because it slows the conversation, allowing both parties to fully participate, but in a structured, heartfelt, and humanistic fashion.

The qualitative model used for this project is the heuristic model which seeks to discover the unique and universal features related to the research question. This model is a deeply personal research tool because it seeks to thoroughly understand and capture subjective experience. This is achieved by interviewing the co-researchers and examining those things directly related to the research question. In the heuristic model, the researcher plays a dual role because he is both a participant and researcher.

In essence, it was important for this researcher (TLM) to be a participant in this study to fully relate to and understand the views of the co-researchers, and heuristic research is the only qualitative model that offers this option. The model offers the elements necessary for completing this study in the most “advantageous” manner possible.

A thorough search of the literature on couples therapy found that studies focusing on African American couples therapy were typically limited to specific areas of research rather than the overall experience of African Americans. For example, drug abuse, interracial relationships, lesbian couples, spousal abuse, and infertility were areas of specialized study. Some articles included only a small percentage of African Americans and were therefore of little use for extrapolation. This search yielded no articles specific to African American couples therapy, demonstrating the novelty and importance of the current study.

Although Imago Therapy has a wealth of positive attributes and techniques, many people have not heard of it, particularly African Americans.

Methods

A total of 15 potential participants agreed to take part in the study. Interviews were conducted with 12 African American participants (6 men, 6 women). They ranged in age from the early 30s to mid-60s. Six of the participants were married (3 pairs of married couples), and 6 were unmarried (6 single individuals). One of the coauthors participated in the study as a co-research, as in optional based on the guidelines of the heuristic model. She was interviewed by the dissertation committee chair using the same procedures for other participants. Inclusion criteria for participants were as follows: African American, at least 18 years of age, in an intimate relationship (married or dating for a minimum of 5 years) and completed an Imago therapy workshop for couples and/or couples therapy with an Imago therapist using at least 1 of the 16 Imago educational tools. Participants gave informed consent and agreed to a face-to-face interview, to have the interview tape-recorded, and for the interview to be held in an office setting. They were informed that they could withdraw from the study at any time.

Procedures

Participants were referred fr recruitment into the study by two Imago therapists who used the above-listed inclusion criteria to select them. They were then contacted by the telephone, and an informational letter was mailed to them. Once they reviewed the study information and confirmed they were interested in participating in the study, the prospective participants were contacted by phone to schedule an interview.

The interviewer took notes during the discussion and also recorded the interview on a tape recorder. As the participants began to engage in the interview, their ability and willingness to share their experience of Imago education evolved. The more they talked, the more intimate, detailed, and personal their stories became. Each conversational therapy included the following focusing exercise and 3 guided questions: Think about your experience of Imago therapy. Reflect on whatever becomes present for you surrounding this experience, such as feelings, thoughts, bodily sensations, and so on; (a) What was your experience of going through Imago therapy? (b) How would you describe yourself and your relationship after completing Imago therapy? and (c) What were the things that held the most or least value to you after completing this experience?

Results

One individual co-researcher’s portrait is presented to give an example. The portrait is used here to uncover the true impact of Imago education. Names have been changed for confidentiality.

Will is in his mid-50s. He has been married and divorced twice, is currently single, and has 3 adult children from his first marriage. He has a PhD in finance and is employed as a dean of student services at a community college. He completed an Imago Therapy weekend workshop with his partner to assist her in receiving her certification as an Imago therapist.

Will and his partner have dated “on and off” for almost 4 years, and despite their breakups, they have managed to develop a good friendship. Although they no longer have an intimate relationship, Will remarks that they have immense respect for each other. He approached the workshop with an open heart and mind and observed, “What the Imago experience did, it made me cognizant of my past relationships, it made me present and thinking in terms of what I did in terms of those relationships.” Will began to give his present and past relationships serious thought, as he absorbed the teachings of Imago therapy, “Imago brought increased clarity to our relationship; how we thought about each other, and how we understand where we’re at, and how we understand what makes the relationship work, and what we have to work on in order to make it work. This involved being honest with our past and where we are today.”

Following his experience, Will viewed the relationship/friendship with his partner as a team of sorts, he described a greater sense of responsibility for one’s self, one’s partner, and the relationship. He also articulated a degree of heightened awareness as he described his view of the relationship. Rather than being self-focused and only looking at his needs, wants, and desires, he began to apply that philosophy to hsi partner.

He stands firm on this philosophy: “I thought all of Imago was important. All of the intrinsic value because it talked about moving away from yourself, the individual, and focusing in on the needs of the other, and love means accepting, accepting that person and loving them for who they are. Period. What they don’t have and what they do have. Period.”

Because Will was willing and able to focus on his partner and the institution of “relationshipping,” he was able to have a much broader and well-rounded experience of Imago therapy because he was able to look at his relationship, his partner, and himself, which allowed him to see how each of these entities is connected. After furtherpondering, he found the following: “When I reflected on the Imago experience, it made me think that men have a tendency to not navigate a relationship. They let the woman do the navigation. And man will just be a passenger in the driver’s seat. What it made me more aware of, was not to be a passenger but to help in the navigation and to not take so many things for granted, as men do.”

Once again, Will articulated the need for relationships to work/function as a team. He embraces the team approach and looks at the many aspects of the relationship to bring them together as a whole.

The following themes were derived from analyzing the transcripts and notes from the 12 interviews: improved communication between partners, increased understanding of self, increased understanding of partner, increased understanding of one’s own and one’s partner’s childhood, revealed more of one’s authentic self, and expressed need for more education about Imago therapy within the African American community. For example, the experience of improved communication between partners was reported by 67% of participants. The majority of participants (92%) reported experiencing an increased understanding of self as a result of Imago therapy. With regard to the third theme -namely, increased understanding of partner- some of the participants (58%) d0escribed having felt “selfish” prior to understanding how their partners truly felt.

The majority of participants (67%) reported an increased capacity to understand their own as well as their partner’s childhood. “Childhood wounds” represented an aspect of the understanding of childhood that was particularly relevant for the participants. The identification of those wounds led to a personal and relational healing process.  In terms of how Imago helped participants understand their partner’s childhoods, one participant said, “Well, by understanding Barb’s childhood, I can understand where Barb is coming from.” Although the theme of revealing more of one’s authentic self is closely related to the theme of increased understanding of one’s self, it was necessary to count them as separate themes because the participants experienced and shared with their partners a more “real and true” sense of themselves. This authenticity, reflected by 42% of the participants, was often expressed as a “revelation” and/or a “letting down of one’s guard.”

All of the participants identified the need for more relationship education within the African American community.  One participant stated, “..So here’s a tool that maybe can help to address some of that issue. So the first thing I started looking at, coming out of Imago and my session and the exposure that I had is, HEY! Why aren’t we pushing this thing in the Black community?”

Discussion

This study sought to answer the question, “What is the African American’s experience following Imago education?” Here, we elaborate on the overall findings in relation to the themes described in the Results section. In an effort to foster more effective communication, the Couple’s Dialogue was used. All the participants in the present study had learned this exercise as part of their Imago workshop or therapy sessions, which led to improved communication between partners being reported by a majority of participants.  Although the dialogue was sometimes initially approached with resistance, the participants remained cooperative and open-minded, as they used the dialogue and experienced positive changes in their communication.  The improved communication was directly related to each person allowing his or her partner to “speak their voice” while the other intently listened.

For many of the participants, once they observed an improvement in their communication, they also recognized an increased understanding of self. The improved communication may have inadvertently facilitated this process, as the participants were able to “view” themselves from their own perspective as well as their partner’s perspective. Increased understanding of self also encouraged the participants to look outside of themselves in a greater attempt to experience an increased understanding of their partner. The participants reported that various Imago exercises facilitated this process, such as: the Couple’s Dialogue, the Parent-Child Dialogue, and the Behavior Change Request.

The Imago education further provided the participants with tremendous insight and increased understanding of their own and their partner’s  childhood. This process offered many “aha” moments. The participantsbegan to understand that their current behavior and the behavior of their partner usually originated in childhood. As a result, understanding the past helped thembetter understand the present. Once the participants began to relax, let down their defenses, and trust the process, they revealed more of their authentic selves.

Despite the many positive findings, the study is not without limitations. Because of the limited scope of the project, the sample did not completely represent a full socioeconomic and cultural range of the population. Also, although a standard set of questions were used in the interview, it became difficult to keep the participants in the role of interviewee because they kept going off on tangents and asking questions about Imago therapy. This limitation of the heuristic approach is offset by the advantage of having a free-flowing conversation, which allows collection of more data and the determination of themes. A quantitative approach may be used in future studies to more definitively assess these themes.

The majority of participants expressed growth in terms of the above themes, but they unanimously stressed the critical need for more education about Imago therapy within the African American community. They identified the high rate of divorce, single-parent homes, and dysfunctional relationships as the top three reasons for education this segment of the population. Overall, the participants reported positive experiences following their Imago education experience because they considered it to be “very valuable and personally beneficial.” The results of this study are in agreement with other research that has examined the satisfaction and effectiveness of Imago therapy.

Future research should be designed to include a follow-up interview to be given at the conclusion of the co-researcher’s 1-year anniversary of the completion of his or her Imago education. The study could be replicated with other races, cultures, and ethnicities with a larger sample size. This duplicated study could be used to compare and contrast what the participants learned about themselves, their partner, and their relationship. Furthermore, a comparison study of African American who receive couples therapy versus those that do could not be conducted.