Thursday, December 28, 2006

Pardon the sarcasm...

Here's a touching little scene:

It is Christmas day, and along with boatloads of other folks, the Young One and I are at the cut-rate movie theater, waiting for "The Guardian" to start. A row in front of us, also waiting for the PG-13 rated flick, are an adult man and woman, and two very young children--maybe 20 months and almost 3 years old. The older child is sporting a fuzzy 101 Dalmations coat, and spends a lot of time scratching at her coarsely chopped hair. When she isn't scratching, she's turned in her seat giving the Young One a serious stare. The littlest one, however, isn't so well-behaved. She's squirming, crying, unhappy with the wait, and with the fact that her mom keeps thrusting her angrily at the dad. Dad gets up to go to the lobby, and mom starts yelling. "Get your dirty ass back here!" "Where do you think you're going?" Toddler is now really crying. Dad stomps back, and grabs the kid. She's arching, crying, pulling away from them both. Mom hollers: "You be quiet or I'll call the cops!"

Brilliant. Now both kids are crying.

They didn't make it through the very loud 2 1/2 hour movie, although they lasted longer than I expected. What the heck were these folks thinking when they brought these children to a long, action-filled, loud and NOT age-appropriate movie? Did they leave their common sense at home with their teeth?

There's an old rule of parenting that makes alot of sense to me: Don't make a promise you can't keep, or a threaten something you can't do. I've met several parents who use calling the police, putting kids in jail, or giving them a shot as threats. Does it really need to be explained why these threats do more harm than good? Just ask the nurse that does have to give the child her immunizations. Just ask the police officer who has to come to the home to respond to a domestic violence call.

And yes, there were at least two G/PG rated films showing in the same theater complex, and none were sold out.

Thursday, December 14, 2006

What a mess.

Once again the minds at Missouri Medicaid have issued an edict that makes no real sense whatsoever, unless of course, their goal is to have more and more clinicians decide it is just not worth the hassle to provide mental health services for people living in poverty.

Here's the gist: Until late in 2005, if you were over age 20, Missouri Medicaid would not pay for mental health services beyond medication management. When the Missouri Medicaid wizards finally decided that people over the age of 20 might actually need psychotherapy, they also determined that clinical social workers and counselors would not be paid to provide that therapy--only psychologists are allowed to see adults. That alone makes no sense. So, it is okay for licensed social workers and counselors to work with children--you know, the future of our society and all that--but not adults? Whatever.

All that aside, it was truly good news when they allowed adults to receive any kind of counseling at all.

The good news was short-lived though.

The prior authorization rules that have caused such serious, tragic problems for children and families trying to get help, have now reached their tentacles of fear and confusion to the adult population as well.

This week's "hot tip" from Missouri Medicaid tells the tale:

"All psychology prior authorizations (PA) issued for adults during any calendar year will have an authorized through date of December 31st of that same year. For example, any psychology PA issued during 2006 will close effective December 31, 2006 regardless of any remaining unused units left on the PA.

Should a patient currently in treatment need ongoing services, a new PA period will begin on January 1, 2007. Providers may begin requesting a new authorization immediately under the guidelines established in the December 1, 2005 bulletin.

Reminder: Providers who have been paid for services in excess of four (4) hours for a recipient in the last rolling year will not receive four (4) additional non-prior authorized hours for that recipient."

To paraphrase Rachael Ray: "how stupid is that?"

Monday, December 11, 2006

Bureaucracy at it worst

I tried to do a favor for someone today. I took a young woman to the Springfield Driver's License Testing Office to take her driver's test. No one else would do it--her DFS caseworker's boss said she couldn't use a DFS vehicle, the transitional living program where she stays said their employees couldn't do it because of insurance. The lists of excuses just got longer and longer. She's getting ready to move out of state to go to college, and will be commuting from off-campus, so having a valid license is pretty darned important.

We got to the license bureau, she filled in their form, got her photo taken, and then all wheels of progress came to a complete halt.

We sat.

We sat some more. We listened to another young woman and her dad call the mother to tell her they'd been waiting for almost two hours. There were other people also waiting, and though they were speaking in a different language, it was very obvious they, too, had been waiting for hours.

I finally had to leave, favor or no favor. So, I asked the one employee I could find how long the wait would be. She explained that the examiners were taking their lunch breaks and there were only two examiners available. (Available? Where were they?) She said that we could come back in the afternoon, but it would be packed, and it didn't matter whether we'd been waiting or not, when 4PM came, they'd stop testing. The end.

According to the Missouri Government website, the only Springfield office that does the testing is on Park Central Square. You can go to Republic, on Tuesdays from 9 - 3:30. The wait there is often more than three hours, and even then you might not make it under the time limit to be tested. So, you pretty much need to carve out an entire day just to take a driving test, which they say takes less than a half hour.

This was like something on a bad 1970's comedy,like Airplane or Police Academy, only we'll call this one Driver's License Insanity. Or maybe: How Governor Matt Blunt punishes the masses while giving favors to the people who donate large sums to his campaigns.

Political favors and profit margins pretty much always trump "regular" folks.

Friday, December 08, 2006

Oddness abounds

Ice and snow seem to bring a contagious sort of insanity to folks who aren't used to it on a regular basis. So, for "Ozark-Americans" a long-lasting dose of ice and snow can cause some way-crazy behavior to seem almost acceptable.

The past week or so brought some Al Gore-worthy weather extremes to Missouri. A week ago last Wednesday night, forecasters promised some pretty heinous weather. The grocery store was packed. Like sardines. Folks grabbing hot dogs and ice cream, sodas and soup. The lines were ten deep. And of course I was queued up with the best of 'em. The man in front of me was missing a lens from his glasses, and his three-day stubble made him look old and tired. From a distance you'd probably wonder if he had place to sleep that night. But close up, the twinkle in his faded blue eyes let you know he had life under control. Surrounded by carts full of quick-fix junk food, his hand-held basket seemed out of place with its bounty of fresh strawberries, oranges and grapes. A small loaf of whole wheat bread and a pack of gum rounded out his purchases. The Young One says its "weird" how people just start talking to me, and this was no exception. In a clear voice, he told me about how he'd lowered his cholesteral level drastically, talked about his doctor's advice, what he used to eat, how much better he felt since he started eating healthy stuff. Later, when we finally got out of the store into the pouring freezing rain, we watched him hop on an old Schwinn three-speed bike and pedal off into the night. He didn't look the least bit perturbed to be stuck on a bike in the weather. And the grin he sported under a jauntily-cocked safari hat made the idea of even starting to feel sorry for the guy totally ridiculous.

Driving Highway 60, west of Springfield to Butterfield provided lots of oddness to add to the list. I'll leave our fellow blogger over at the Holy Grail Press (click the link to the left over there) to describe the church marquees and signs that basically provide the definition to the word kitschy, but the latest example of "your tax dollars at work" is the new highway sign just west of the main Aurora highway intersection which proudly proclaims that "Marrionville" is only a few miles ahead. That's groovy, except Marionville (home to the often celebrated Comets high school football team) would probably appreciate the highway department running their spell check before approving new signage.

Then there was the trash. I drove behind several pick-up trucks on my jaunt to chicken factory hell in Butterfield, five of which were spewing trash with each pothole. Papers, cans, rope, plastic bags, all came flying and bouncing out of the truck beds. One driver looked behind when a large tarp flew out. Didn't stop though, I guess it was just too darn cold to worry about litter, but hey, the dude at least noticed.

The Springfield School system superintendent learned a good lesson last Thursday. A recent transplant from Colorado, he decided that, in spite of forecasts of up to 12 inches of snow to add to the already accumulating 4 inches of ice, school should stay in session. Add to this the fact that every other school in the area was shut tight. Even Nixa, which notoriously stays open, was closed. Look, I'm all in favor of educating kids, but as a former teacher I know that the three main reasons to teach (June, July and August) are rivaled only by the addition of spring break and snow days, so when the Young One said his teachers were grumpy about being stuck in class watching the roads get slicker and the ice get deeper, that may truly have been the understatement of the month. Later, Superintendent Ritter decided to admit his goof, but just couldn't resist telling us unprepared Springfieldians how lame we are to actually think we should not be out driving in this mess. I think the real lesson here is that he may want to learn how to consult with his co-workers and colleagues when he makes decisions. They might be able to give him a little insight into his new environment.

The crowning example of abounding oddness through this spell of weather? The Young One actually wore a coat without the usual Parental Unit nagging. Maybe it really is the end of the world as we know it.

Tuesday, December 05, 2006

How much therapy is enough?

One of the reasons the minds at Missouri Medicaid have created such a huge mess with their prior authorization system, is because of a few therapists who are unable or unwilling to terminate therapy, and who don't know how to empower parents and kids to handle problems without calling the counselor every whipstitch (an okie word that means something like "really often"). Their clients may stay in counseling literally for years. Obviously this costs the state a lot of money, and it calls into question the efficacy of counseling as well as the ethics of the counselor.

So when is enough enough? Sometimes it doesn't even matter what the therapist says. I can think of one client I worked with who after a while simply didn't need to be seeing me anymore. She needed to just be a teenager and have a life where everyone wasn't rehashing the abuse she suffered at the hands of her biological, foster and adoptive parents. But each time I told her DFS worker this, the worker insisted that the kid stay in counseling. And each time this girl did something particularly teenager-ish the worker was on the phone to me. I guess I was supposed to fix it. But if being a teenager was a diagnosis, we'd all have a psych record in our medical history files, right?

Just because someone has been mistreated, or has depression or even schizophrenia, doesn't mean they are incapable of handling life without calling the therapist. Therapists don't do clients any favors if we're not helping them come up with their own solutions to life's problems. What is the point of psychotherapy if the only real outcome is that the client has our phone number on speed dial?

I've known parents who feel so incapable of dealing with their child that they ask me to attend school meetings, talk with teachers, handle family arguments, pass on bad news and the like. Do you think if I did that, I'd really be helping them? I don't. It is like that old phrase about giving a man a fish or teaching him to catch his own fish--I think it is much more important to help parents be able to deal with problems on their own, than it is to do a quick intervention that may solve a short term problem, and make the clients like me a whole bunch, but in the long run simply encourages dependence.

When therapists do that--encourage this sort of dependency--one thing definitely happens: They get a steady income. Therapists that hang onto clients for years and years just for the income are few and far between. Thank goodness. But, it is a clinical quagmire to hang onto clients for years without referring out for a psychological evaluation, a psychiatric consult, even a trip to the pediatrician to rule out medical concerns. You have to be able to justify, clinically and quantitatively, why you've been doing counseling with same child year after year.

It is a sad reflection on clinical training for psychotherapists in all disciplines that we apparently need the government to limit the number of counseling sessions a child on Medicaid can have in one year. I've done supervision with social work licensure candidates, and had interns come to my practice, who ask how they are supposed to start a counseling session. That's weird enough, but I've only had one or two over the years that have also asked how to know when to terminate. Its not because their master's programs are doing such a great job of teaching that, it is because no one has emphasized the importance of knowing when (and how)to stop.

Therapy works when the client feels able to tackle life's challenges--without calling the therapist for validation.