What is psychotherapy?

CA State Law defines psychotherapy performed by a Licensed Clinical Social Worker as:

“The use of psychosocial methods within a professional relationship, to assist the person or persons to achieve a better psychosocial adaptation, to acquire greater human realization of psychosocial potential and adaptation, and to modify internal and external conditions which affect individuals, groups, or communities in respect to behavior, emotions, and thinking, in respect to their intrapersonal and interpersonal processes.”

In plainer language:  Therapy is a non-medical, professional relationship between a clinician and a client.  The goal is to help patients reach their potential, get better at adapting to life’s challenges, and modify the circumstances in their lives–inside and out–that affect how they think, feel, and behave.

What is clinical social work/a Licensed Clinical Social Worker?  How is an LCSW therapist different from a psychiatrist, psychologist, or life coach?

1. You deserve a therapist you can grow to trust.  This may not be the first therapist you meet, or me, or the next one. Trust develops with time, so my hope is that you can find a clinician whom you think you’ll be okay opening up to one day.  Because…
2. You deserve someone you’re comfortable feeling uncomfortable with.  Growth and self-discovery are awkward processes.  When life gets rough or things get tense, no psychotherapeutic intervention can make you “comfortable.”  My wish is that your therapist is someone who will be able to hang in there with you and make the discomfort a little more bearable.  Because…
3. You deserve a therapist who will both support you and challenge you.  Our role is to do both.  (This applies to other relationships in your life, too!)  Acceptance and change work in tandem.  Because…
4. You deserve a therapist who is transparent about your treatment.  While not every client is interested in the rationale behind a treatment intervention or why a therapist is asking the questions they are asking, if you are interested, then it’s totally valid to want to know.  So let’s talk about how a lot of our work is about viewing and thinking with more nuance and balance to reduce your distress.  Let’s ask questions like: Why are we doing what we’re doing?  Is it working?  Where are we getting stuck?  Because…
5. You deserve to feel better.  By “better,” I don’t mean Happy-Happy-All-the-Time or the complete absence of human (and necessary) experiences like sadness, worry, anger, shame, or angst.  You deserve to experience a balanced and complete diversity of the human emotional experience.  Sometimes this may mean being annoyed or even pissed at a therapist.  It can also mean outgrowing a therapist (not all goodbyes have to be bad ones.)  No matter what, I hope that we can support each other in bringing out your full humanity.  

Yes (with some important exceptions.)   Psychotherapy is most effective when you can be open and honest. 

Therapists (including LCSWs) are bound by our professional ethics to maintain your privacy.  We are also bound by health care privacy and confidentiality laws.  For example, the Health Insurance Portability and Accountability Act (HIPAA) contains a privacy rule that creates national standards to protect individuals’ medical records and personal health information, including information about psychotherapy and mental health.

The most common exceptions to confidentiality include:

• To protect the patient or the public from serious harm.  If i have reason to believe that you are likely to cause serious harm to yourself or another individual, I may need to break confidentiality to prevent or lessen such harm.  
• Mandated reporting for child, elder, or dependent abuse.   I am legally required to report ongoing abuse of children, the elderly, or persons with disabilities.  (If you are an adult who was previously abused as a child, I am typically not bound to report unless there are other children continuing to be abused.)
• To obtain payment for treatment.  In order for insurance to pay for your services, they usually ask therapists to submit a diagnosis as well as information on the date and length of sessions.   
• Coordination of care.  I am legally permitted to disclose your Protected Health Information to other licensed health care providers involved in your care.  

Please see the privacy practices handout in your intake packet for a complete description.  Also feel free to ask me about these exceptions, I’m glad to explain how they work and  when I would or would not break confidentiality.

Other things to consider regarding confidentiality:

• This means that if we run into each other outside of therapy (whether in public or on social media, etc.) I cannot acknowledge you as a client as that would be breaking your confidentiality.
• Employers don’t receive information about the health services a specific employee receives, even if he or she uses company insurance.  They do get access to some information from health insurance companies, such as premiums and costs incurred by the entire company, as part of administering their health benefits plan.
• If you have a Healthcare Flexible Spending Account, you will likely have to upload the name of your provider and dates of service in order to receive reimbursement.  They would see that I am a mental health professional.
• If you have apps on your smartphone with microphone or GPS location services enabled, information about what you say or where you go (whenever or wherever you have your phone with you) could be transmitted to tech companies.  You may want to consider disabling those features, leaving your phone at home, or turning it off before arriving at the Counseling Center.
• Another way to protect your privacy is to call your insurance company to ask that Explanation of Benefits mailings be sent to you via e-mail.  Although these statements do not disclose specific reasons for service, they may list your therapist as the treating provider which could raise questions should someone read your paper mail.

With formal CBT and DBT-informed therapies, progress is tracked on paper or in an app.  You should also see a gradual reduction in unhelpful coping behaviors and lower scores on objective tests and measures.

I also keep notes on our sessions.  If you’re ever curious, we can look back on what you were struggling then and how things are now.  And if you ever have concerns about our progress, let’s talk about it–this is your therapy and there is a lot we can do to make it work for you.

Progress isn’t linear, though–generally–as therapy progresses you should be feeling better, getting more stuff done, and getting more out of life.  

I believe in utilizing the least invasive intervention possible for addressing suicide.  This means utilizing involuntary emergency interventions only as a last resort.

We’ve gotta talk about this stuff.  I want to reassure you that merely talking about the subject of suicide is not enough to trigger an involuntary hospitalization.  I would hate to have someone avoid discussing suicide with me out of fear that they would lose their freedom.

One thing I talk about in therapy (especially CBT) is how thinking about something is not the same as doing something. (Thought-Action Fusion.)

Many people think about dying by suicide as a way to cope, and the vast majority are able to stay safe while managing those thoughts. 

The fact that you even talk to me is evidence that at least a tiny part of you implicitly believes there is a way out of your situation.  I can work with that.  To do our work, you don’t have to want to live.  You do have to want to work towards wanting a life (worth living.)

So when would you hospitalize someone?

When I absolutely have to. 

People who have suicidal thoughts are usually survivors who have borne a lot of pain for a long time.  They are resilient people.  You have stayed alive this long, which is your track record, so I trust that you have quite a bit of self-preserving capacity.   

I will make the ethical, legal, and personal choice of initiating lifesaving services for suicide attempts in progress or to secure your immediate safety if you are unwilling or unable to take action to prevent your suicide, and if you remain at imminent risk.  I will initiate active rescue if I am convinced that if I do not act, you will be dead.

If you are willing to talk to me, I will always talk to you first to determine whether or not a hospitalization is warranted.  (So please talk to me.) The purpose of the conversation would be to explore alternative ways of coping to prevent the need for hospitalization.  In most cases, clients may be thinking about suicide, with no intention of following through any time soon.   In that case, I want to try and understand your reasons for wanting to die, figure out how that is affecting your coping, and see if we figure out ways to get you some relief that are not self-murder.

To be real with you, the purpose of a 72 hour hospitalization to prevent suicide is not to help the patient “get better” or “feel better.”  It’s to prevent the suicide–for “protection.”  It’s a last ditch chance to keep you alive long enough to make it through.  

I don’t have the power to keep you from dying.  (I’m not Darth Plagueis.)  You don’t even have that power–not entirely.   (A car could sideswipe you, a rhino could escape from the zoo and trample you, etc. TBH I hope not. That sounds messy and unpleasant.) 

If you did hospitalize me, would I automatically get admitted?

Should I deem hospitalization necessary, the most I could do, legally, would be to work with an LPS designee  to write an application for involuntary admission for a 72 hour hold (aka “5150.”)

The steps for hospitalization typically go like this:

1. Therapist assesses if hospitalization is absolutely necessary.  Since this decision will impose on the client’s civil rights and freedom,  this is not a decision that should be made lightly or done merely to assuage the therapist’s own anxiety.  If the situation necessitates the initiation of hospitalization, then the therapist brings in an LPS designee (usually a County social worker, or worst case scenario a police officer.)
2. The LPS designee evaluates the client for probable cause to determine a) if they are a danger to themselves and b) if involuntary hospitalization is actually necessary for the person to be properly served.  If no, the LPS must offer alternate, voluntary services and the client can also decide to go home.
3. If yes, then the LPS designee will initiate an application for a 5150 hold.  (It’s an actual paper application form.)  The client (and the written application) are taken to a hospital.
4. At the hospital, a “professional person in charge of the facility or his or her designee” meets with the client face to face to determine whether or not they feel the client is admissible for a 72 hour period of time. If no, the client goes home.  But this is where things get tricky.  Depending on the hospital’s LPS status, they are legally allowed to take up to 1 hour or in some cases 24 hours to find that person to evaluate you (and in Los Angeles County, this does not count as part of the 72 hours.)
5. If the hospital feels the client is admissible and accepts the application, then the search for a inpatient hospital bed begins.  The wait for this is dependent on availability and can take a long time.  The 72 hours does not start until you are formally admitted for treatment when a bed is found.  [Hours spent waiting in the hospital prior to this do not count(!)]
6. The client is admitted and the 72 hour hold begins.  A patient admitted to the facility on a 72-hour hold may be released prior to  the 72 hours if it is deemed that further treatment is not required.  After 72 hours the hold expires and the client must be discharged unless the hospital takes more steps to certify them for 14 days of intensive treatment, including going to court.

This process is in place not just because hospitals are busy to the point of being full, but because everyone deserves to have the chance to prove their case before being made to enter a hospital. That way, no one person has the power to hospitalize another person involuntarily.  It’s not a unilateral decision that I get to make.  The LPS designee gets to decide to write an application, and even if they do, the hospital can choose to refuse the application.

I am sharing this information because I feel patients have the right to be informed about how this process works, as well as to highlight how difficult this decision is for psychotherapists.  This is why most psychotherapists avoid initiating this process until the situation is imminently life threatening.  We would much rather work with you to prevent things from getting to this point.  And a lot of this is really about trust–do the therapist and the client both trust each other to keep the client alive?  If not, then how can we get there?

You have rights and there is an entity called the Patients Rights Office at the Dept. of Mental Health that you can contact if you have any questions about involuntary hospitalization.  They can even come out to the ER to meet with you.

(As you can tell from this wall of text, I’m pretty candid about this subject, so please talk to me if you have any concerns.)

Currently, I work exclusively with individuals.  That’s where the bulk of my training lies and I am happy to leave couples and family work to more experienced therapists.

That being said, I am familiar with both couples and family therapy from my graduate school training.  I frequently bring concepts from Structural Family Therapy (boundaries, enmeshment, subsystems, parentification, etc.) and Emotionally Focused Couples Therapy (adult attachment styles, expression of wants and needs, identifying patterns, building acceptance, etc.) into the therapy room.

I cannot accept appointments made by a third party, especially if the client is over age 18.  Clients are more likely to go to and stay in treatment if they take steps to enroll on their own.  Please encourage your person to reach out to me and make the appointment; if they feel it would help, you can offer to be there for them when they make the call.  

It’s a tough spot to be in; unfortunately there is little you can do to make someone go to therapy if they don’t want to.  You do have some options.  For example, you may choose to arrange a one-time “consultation appointment” for yourself. This is a 50-minute session with a therapist who will attempt to answer your questions about how you might deal more effectively with your loved one.  

Additionally, you may  choose to begin therapy yourself, especially if your life has been adversely affected by the other person and you are looking for ways to change your situation. Sometimes the person in therapy is not the family member who “needs” it most, just the person in the family most willing to seek help.

You, the healthcare consumer, get to make the final call on this. I am not a physician and cannot prescribe medications. 

If your symptoms are significantly interfering with your life, I would always recommend talking to your primary care physician (or get one, if you don’t have one!) and/or a psychiatrist to be fully informed of your treatment options. You have a lot of options and it’s important to rule out any health conditions that might be contributing to how you feel (such as a sleep disorder, thyroid problem, etc.) 

Many doctors are willing–sometimes even very excited–to coordinate treatment with therapists so clients have more resources and ways to approach their mental health.  Before entering private practice I used to work on multidisciplinary treatment teams; I enjoy collaborating with clients and their psychiatrists.