Navigating the Intersection of Work and Mental Health
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Working Better and Stressing Less

Ideas on work and mental health

Why we need more transparency in health insurance: Part Two - Eliminating carve-outs

In the first of this series on reforming healthcare through transparency, I talked about a long-term vision for moving to a more direct care model of payment for health services. Today, I want to talk about the need to eliminate an increasingly common and opacifying practice specific to mental health care called behavioral health carve-outs. 

So let's talk about carve outs. Which health insurance company pays for your visits to your primary care physician? Which insurance company pays for your visits to a mental health practitioner? If you answer with two different companies, you have what's called a "carve out." 

Carve outs are essentially your primary insurance company outsourcing utilization management, paneling providers, and payment rules to a secondary insurance company that probably claims to be able to provide mental health care cheaper than your primary company. Those carve out companies are incentivized to keep behavioral health/mental health care spending as low as possible, thus saving your primary health insurance company money. However this practice creates a HUGE philosophical and operational disconnect in the healthcare delivery system.

If mental health conditions are health conditions just like any other medical condition (as is stated by parity laws all over the US), how can they possibly be "carved out" of your medical insurance plan to a company incentivized to keep behavioral health care spending lower? How will anyone see that I, as your counselor, helped reduce your medical care utilization over an entire year by helping you manage your anxiety and reduce your frequent visits to medical specialists, if the "carved out" insurance company is measuring my success only on how little I bill for your mental health care alone? 

Behavioral health carve outs seemed to provide savings when they started, especially when traditional medical insurers that never paid for behavioral healthcare before were faced with managing new panels of mental health practitioners and utilization management. However evidence is mounting that managing medical and mental health conditions in an integrated fashion is more effective.  Integrated care requires integrated payment systems and integrated incentives for quality, not silos. 

Health insurance companies would do well to promote the integration of electronic health record systems (EHRs) and helping individual practitioners access major medical system EHRs so they can collaborate more fluidly with clients' other medical care providers rather than concentrating on micro-level cost reductions. While concentrating on reducing utilization helps this quarter's numbers, it doesn't help the insurance companies or consumers long-term as a cost reduction strategy. 

Do you have a carve out? How has care access been for you? How coordinated are your insurance companies and providers? I'm eager to hear your experiences. 

 

 

 

 

Katie PlayfairComment
Why we need more transparency in health insurance: Part One - The long-term vision
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Sometime in the early to mid 1980s, I remember sitting in the lobby of my pediatrician's office, listening to my mom talk with the front desk staff about timing her payment to them and her insurance claim. I must have been due for a number of vaccines and preventive care and this visit was an expensive one. She and the office staff worked out a plan and when she sat down next to me, I asked her to explain insurance. Insurance then, was insurance against bad health years. Patients went to the doctor, paid their bills, and then submitted the receipts to the insurance company. If the patient or family had a bad year, the insurance would kick in and start paying the bills. If the patient was low on cash, they could work with the office staff to negotiate payment terms after their insurance claim payment came in. Patients paid doctors. Insurance companies paid patients back. 

I have a confession: There is a big part of me that wants those days back. I am sick of being a patient and a provider in today's system that puts the insurance company between providers and patients.

As a patient, I have occasionally stumbled upon my medical care providers doing fantastical coding to maximize their reimbursements from insurers. I can only notice those practices when I can actually get an itemized invoice which is more of a chore than you would think. I had an urgent surgery earlier this year and I had to make special phone calls to get a fully itemized receipts from the hospital and from my doctors. I couldn't BELIEVE some of the charges on them. Yet, I couldn't prove the charges to be false so I didn't fight them. Besides, I wasn't paying the bill. WHAT!? Did I actually just say that!? Yes I did. I had no incentive to go digging into itemized invoices, disputing fishy charges, because I felt like it was my insurance company's job. 

As a provider, I am so philosophically, ethically, and morally opposed to "creative coding," of my client's invoices, that I am persistently underpaid for services I provide. I do so many extra assessments, so much extra monitoring, and countless out of office interventions that I could easily be making thousands of dollars more per year but then I would be playing the game I hate. This cat-and-mouse medical coding game is played by the majority, however, so what happens in the end is that insurers have to cut reimbursement rates on the "bread and butter" codes mental health providers use (and probably other primary care providers as well), leading us to lose more and more revenue every year unless we're willing to engage in the game. 

The insurers are not all to blame

In our society's good-hearted effort to ensure much of the population receives good preventive and general healthcare, we've eliminated, via legislation and regulation, more transparent ways insurance companies once used to protect themselves against too many losses. Remember when you could only have 12 mental health visits a year? I am not advocating going back to a system where mental health conditions were treated differently than other medical conditions but share that example to make the point that when we make overt restrictions illegal, covert ones often take their place. 

Insurance companies are left with opaque means of restricting care. These include:

  1. Reducing reimbursements to providers to the extent that many fall out of network, resulting in a smaller available network and few clinicians with availability to see members. 
  2. Refusing to panel qualified clinicians, claiming a "sufficient panel" even while many members struggle to find someone to see them. 
  3. Claiming that services are "not medically necessary," according to best practice standards (with pretty weak evidence bases) buried deep in clinician provider guides that are not available to the general public. 
  4. Employing overly broad utilization management (UM) standards. "Utilization management," is the practice of creating rules about what is "clinically indicated" for various conditions. For example, an increasing number of companies have claimed that 45 minutes and not one hour, is a standard psychotherapy visit which limits the types of treatments clinicians can do since many protocols take 60-90 minutes per visit to complete. The insurance company says you don't need it, even if your provider disagrees. 
  5. Enacting and enforcing rules on providers that don't have time, energy, or money to fight back against rate decreases and restrictions. Primary care providers and mental health providers are some of the lowest paid and poorest resourced (in terms of administrative staff and time) workers in healthcare. When you lower their reimbursement rates or restrict care, they have little to fight back with, unlike better resourced specialists and hospital systems. 

A painful solution - Direct pay with insurance as a safety net

Do you want to know who a great investigator of confusing invoices is? A consumer who has to pay a bill that doesn't make any sense to them. Do you want to know who a great advocate for care they need is? The patient who needs the services. So despite my generally "liberal-leaning" attitudes, I've recently become all free market libertarian on insurance for everyday medical expenses. I would love to get the insurers out of the relationship between patients and doctors, let patients do some negotiating, and of course provide an appropriate safety net for people who can't afford to participate in this system. 

The problem is how to manage the transition from our current third-party payer system to a future in which consumers pay providers directly and get reimbursed by insurance. The cat-and-mouse coding and billing game between providers and insurers has driven up prices to levels where the average consumer can't pay cash for an average doctors visit. How does this inflation work? Let's say that dermatologists in your area are charging $100 for shave biopsies. The insurance company looks at this and says "ok... to account for variations in pricing we'll set our allowed amount (what the insurance company will pay) to $125." Once word gets around, dermatologists raise their prices to $125 to maximize reimbursements. Then the fanciest dermatologist in town, who used to charge $125 moves their rate to $150. The insurance company surveys the market and says "Hey... it looks like dermatologists are charging more for this procedure in this city. Let's move our allowed amount to $175, especially since there aren't enough dermatologists and we want our insured patients to get in." How does the community respond? They raise their rates to $175 and the elite doctor raises theirs to $200. Repeat this cycle a few times and suddenly you're paying $500 for a procedure that used to be $100. And although prior to this price inflation, consumers could afford to pay $100 directly to their doctor and wait to be paid back by insurance once it kicked in, they can't afford $500, where prices currently are set.

I picked on dermatologists and made up fake numbers for this example so that this discussion is not construed to be a discussion of therapy prices (I prefer to not go to jail for price fixing or whatever). The fact remains that I hear my colleagues all the time saying "Make sure you set your rate just above what your highest paying insurance panel pays, to maximize your reimbursement."  I get it... you gotta eat, but this is the kind of thinking that got us into this mess in the first place. 

Moving from direct third party payments for everyday medical expenses will require that prices get re-adjusted to levels that are accessible to consumers and will require that providers and patients actually negotiate fees and payment terms. This is less of an issue in therapy where prices are usually based on a transparent, per-hour charge and more of an issue with hospitals and procedures. The entire system has to change to one in which consumers and health care providers can have honest, clear discussions about charges. This is where I get stuck: I don't know how to get us from here to there. But I'm pretty sure we have to get THERE or all of healthcare will become so cumbersome and so expensive, that it won't work for anyone. 

As insurance becomes more expensive with out of pocket and deductible costs going higher and higher, my hope is that more clinicians will be brave and go to a direct care model, opting out of the coding and billing wars. I also hope that more companies offer their employees insurance plans that make use of high quality direct care clinicians. These plans need to come with education on how to find, negotiate with, and submit claims directly to their insurance company to protect against heavy financial losses. I'm trying to find the courage to change the model of my practice to enable this type of care and I'd love to hear from you if you're already further along on this journey. 

 

Katie PlayfairComment
When therapist grief shows up at work... sometimes you have to show it

In graduate school, we talk a lot about the ethics of self-disclosure (what you ought or ought not to tell your clients about yourself and your personal life). The general rule I follow is if the disclosure is for the benefit of the patient, it's ok. If the disclosure is for your own benefit, it's not ok. We usually have a lot of choice about how much our clients know about us but when it comes to some very visible things about ourselves or our health, we don't. I recently had an experience with a lot of forced disclosure and coming from a therapeutic tradition of very light disclosure, found myself thrust into the spotlight in my office in ways I wasn't accustomed to. Suddenly, I was put in a position where I sure that clients could see whether or not I practice personally what I preach as a professional. I want to tell you the story...

A month ago today, I had to tell my clients that I would not, in fact, be going on maternity leave in December. A lot of people have asked me if I regret telling people I was pregnant as early as I did, but I do not. First, I had to make modifications to my schedule to accommodate symptoms so disclosing was largely unavoidable without worrying folks that something else was wrong with me. Second, when I was last pregnant, I didn’t tell clients until midway through my pregnancy, only to find that Portland is such a small town, some had already found out through referring physicians, or friends of friends of friends. That seemed like a much worse outcome than telling folks earlier and having to take it back if something went wrong. And wrong it went.

A lot of clients have asked me how I’m doing and some have even probed into what the grief is like. I use a complex reflections to acknowledge their curiosity but get back to how it’s relevant to them because it’s not my therapy hour - it’s theirs. The truth is that I haven’t experienced much grief from losing that embryo. I truly and completely believe that our bodies are wise and that my body and the embryo knew that something was catastrophically wrong and did what it evolved to do. I don’t think that my experience is the only “right” way to process loss. I know my husband experienced the loss differently and his way is “right” too. My experience losing that particular pregnancy simply hasn’t been that sad. In fact, the day after I had a painless (but very expensive) surgery to tie up the loose ends from that pregnancy, I was full of energy and feeling “back to myself” after the first trimester fatigue and nausea I’d suffered in the weeks before.  

The grief for me has come from going back to the drawing board. It took us 3.5 years of reflection and contemplation to feel ready to try for a third child. Our second child, Malie, is intense in both wonderful and challenging ways. She needed more time to be a baby and to receive focused emotional care from us than her brother did. We were extremely ambivalent about trying for a third child and losing the pregnancy picked us up and dropped us back at the starting line of the decision-making process.

Three weeks after losing the pregnancy, Malie finished using diapers at night. We also passed along all of our baby things to someone close to us due the same month I was. The baby things took up almost our entire attic. Getting rid of the diapers and the equipment for caring for an infant (seriously how can such a small thing need so much stuff?!) was a literal and figurative weight off of us and left a large void where baby stuff used to be. How is it possible to be so relieved and feel so light yet so empty and sad at the same time?

Medical and biological realities also began to hit home. I will be at least 38 by the time any future child would be born and I’ve had two cesarean sections and one D&C (to complete the miscarriage). It’s likely that my uterus has scar tissue that makes it more dangerous to have another child. A growing national conversation about maternal mortality in the peripartum period has been loud for me as well. They had multiple units of blood on hand for my D&C procedure because apparently, it’s possible to bleed out from it. I didn’t need them but holy crap - blood transfusions?! What if I die in childbirth trying to have this third child that we want? I’m also just finally starting to get back into shape, hiking, walking, and doing yoga consistently for the first time since my two oldest children were born. I might actually get back to my pre-pregnancy fitness-level someday.  Do I want to put that off for another few years? If I do, will I suffer long-term consequences?

My kids are also starting to be really fun. I mean it’s not that babies and toddlers aren’t fun but they don’t appreciate the beauty of a hike, they can’t walk very far, and they really suck to travel with. I did take Malie with me to Japan when she was a baby but I came back saying “it was great but it was more of a trip than a vacation.” I did see beautiful things but I also was overwhelmed by caring for an infant by myself while traveling Japan. My kids are starting to make amazing observations about the world around them and they very nearly don’t need midday naps. Am I willing to subject them to the nap schedule of an eight month old who won’t sleep in the car seat or carrier? Will I miss out on some of their childhoods because I was in a fog of pregnancy, nursing, and the peripartum-near-depression that goes on for me from conception until my baby is two years old?

Yet, I also feel like “people” will be disappointed if we don’t try again. I know my parents will be disappointed. The kids say they’ll be disappointed. I’m sure my clients who knew I was pregnant will wonder “what ever happened to the third kid idea,” even if they never ask. I’m not a big fan of disappointing people. It’s uncomfortable.

As we struggle with relief and pain, emptiness and lightness, one life path or another, I’ve come to the conclusion that this is the first time I’ve had to acutely face my limited time on Earth. Statistically speaking, I probably have 42 years left to live, if all goes well. Perhaps I have 62 as a lot of ladies in my family die near the century mark. But either way, I’m approaching the end of my childbearing years. It’s now or never and I keep trying to consult my old-lady self to figure out what she’d tell me to do. There are two versions of her though: One version who tells me to go for it because the painful part of pregnancy, infancy, and toddlerhood go fast in big picture and another version that tells me that I can have many more adventures with my husband and two wonderful kids if I double down on making life fun for the four of us rather than diluting efforts on five. Approaching the mid-life mark, I can see why people say that “life starts at 40,” and I have so many hopes, dreams, and plans for my mid and late life that I couldn’t have imagined in my 20s, when my vision for life kind of stopped at having kids. Do I want to spend another two to four years pregnant and nursing (I’m 6 years in, already)?

In the end, I don’t know what we’ll decide. There’s no biological certainty to our decisions at this time and there may not be any until I actually hit menopause but I’m having a more and more difficult time imagining going through pregnancy again. The stakes with regard to my health are becoming higher and I’m not sure if I can shake the words, “Do you know your blood type? We like to have plenty of units of blood on hand for this procedure,” from my brain. I’m not in the same boat as the mom who had two low-risk vaginal deliveries. I’m a 38 year old with two c-sections and if my graying hair and wrinkling skin are any indication, my body isn’t as young or as strong as it was when my first two were born. I think if you’re going to see us with a baby in the future, it probably won’t be from my tummy… but we still don’t know if we’ll be taking those baby clothes back when our friends are through with them.

While I can't be certain of what we'll decide and why, I do feel like I've walked through this experience practicing what I preach. It's not comfortable or easy but it feels like a good process. 

Katie PlayfairComment
Is career counseling billable to insurance?

The short answer is, "sometimes." Coverage for any condition through medical insurance hinges on the idea of "medical necessity." So generally, counseling is covered so long as it is providing an evidence-based service designed to treat a diagnosis. 

If you need help with your resume, that is not a medical diagnosis. If you want another job because you're kind of bored at your current one, that is not a medical diagnosis. However if you're super stressed out and sound like the definition below, you probably DO have a medical diagnosis. 

" Emotional or behavioral symptoms develop in response to an identifiable stressor or stressors within 3 months of the onset of the stressor(s) plus either or both of (1) marked distress that is out of proportion to the severity or intensity of the stressor, even when external context and cultural factors that might influence symptom severity and presentation are taken into account and/or (2) significant impairment in social, occupational, or other areas of functioning.

The stress-related disturbance does not meet criteria for another mental disorder and is not merely an exacerbation of a preexisting mental disorder. The symptoms do not represent normal bereavement. After the termination of the stressor (or its consequences), the symptoms persist for no longer than an additional 6 months." - DSM V Definition of Adjustment Disorder

If you have a medical diagnosis, it is LIKELY (but not certain) that your medical insurance will consider counseling a covered expense. So if your job is creating significant stress in your life and you are having clinically relevant symptoms in response to that stress, your insurance may cover counseling that focuses on helping you cope with and improve functioning with that stress. Also, if you already have a mental health diagnosis and your work is exacerbating your symptoms, career counseling can likely be covered by insurance IF it helps improve your functioning with your mental health diagnosis. 

You're not entitled to insurance coverage if it's not medical necessity

Here's where things can get awkward: Sometimes I'm contacted by folks who want to use their medical insurance for career counseling but who don't actually have a medical diagnosis. I always feel a little bit bad explaining that I cannot in good faith, bill an insurance company for a service that is not medically necessary. However, I'm also not willing to go to jail... so I have to explain to folks, at least once a month, that I cannot commit insurance fraud because it would be less expensive for the client. 

This is the challenge, I suppose, of being a practitioner who provides both medical services (mental health counseling) and consulting services. 

The good news for you, if you're currently looking into career counseling but are not highly distressed by your job situation, is that career counseling NOT secondary to a mental health concern like anxiety or depression, is often VERY FAST. Clients who present with career issues alone typically see me for six to 10 sessions. At my rates today, that's $600-$1,000 in total. That's not cheap - but it's not like a hospital visit. 

So even though your medical insurance may not cover career counseling, it's not the worst type of "non-covered service" to have to pay out of pocket for. 

 

Katie PlayfairComment
What do counselors do when not seeing clients?

I often hear this question after friends, family, or acquaintances ask me about the business side of being a counselor. It usually goes like this:

Friend: "Wow, so your hourly rate is $100 per hour. I wish I made $100/hour."

Me: "Me too."

Friend: "But you do." 

Me: "Not really. After you factor in continuing education, bookkeeping, taxes, notes, insurance billing, taxes, consultation, case management, and other non-billable activities along with overhead expenses, it's not nearly that." 

Friend: "Oh so how many clients do you see a week?"

Me: "Perhaps 12-20, depending on the week." 

Friend: "Oh.. what do you do with the rest of your time?" 

That's when I start telling the story that I will tell you today. What goes on in the secret lives of counselors? 

Activities shared by most mental health folks

There are some things all mental health practitioners have to do outside of seeing clients. Most of these are shared by all counselors whether in private practice or employed but some are only for folks who are self-employed. 

Scheduling

This probably sounds trivial to folks not in mental health or perhaps outside healthcare in general but scheduling takes up a lot of time over the course of our careers. First, we set our schedules based on the demands of our personal and professional lives. We determine which days we want to/need to work, what times fit the other demands on our schedules, when our office space(s) are available, and when our clients can see us. Both we and our clients get sick, take vacations, and have life changes that require us to change appointment times. This one has been on my mind recently because I've been making major changes to my schedule to accommodate my son's new school schedule starting in September, and it's taken hours of time to get clients into times that I think will work long-term. Managing our schedules is also important in that we have to figure out what times and days we're most likely to be high-performing for our clients. When are we sharpest? When are we most empathic? Those are our ideal times to work. 

Record keeping

We are legally required to keep medical records on our clients about the treatment they've received from us and what money has exchanged hands between us. I have a very lightweight system that is entirely paperless, allows clients to complete questionnaires using HIPAA compliant medical records systems, and minimizes time for me to complete documentation. It still takes approximately ten minutes per office visit to complete records of the visit and associated billing and payment documentation. 

Insurance billing

Not everyone does their own insurance billing but many of us with small practices do. In addition to the ten minutes mentioned above, filing an insurance claim on behalf of our clients takes an extra two or three minutes and once payment comes in, it can take up to five minutes to reconcile each claim. Those of us who are in network with insurance companies may be asked for medical records when companies perform audits and typically the time that it takes to compile and send those records, we cannot bill for. 

Case management

Counselors often coordinate with other medical providers such as medical doctors, naturopaths, acupuncturists, prescribers, and sometimes family and community members, to further our clients' mental health. This time is often non-billable to insurance companies and most of us don't charge clients unless it's a particularly complicated issue outside the norms of our practices. 

Crisis management

At any given time, most of us mental health folks have at least one person in crisis with whom we are staying in closer contact than once a week. Sometimes this work is billable but most often it's not. It's part of providing good care. 

Office housekeeping

Most of us do not rent space in Class A buildings (like the big fancy high rises in downtown). Many of us have to do our office space housekeeping ourselves. It may only take 20 minutes a week, but it's overhead. 

Business management

If you're an individual practitioner, you have to do your own bookkeeping, taxes, marketing, advertising, client screening, and in counseling, referring prospective clients who do not fit your practice, to other mental health providers. I know I spend at least two hours a week providing referral services to folks who call or email my practice but whom I cannot work with personally, to other colleagues. 

Continuing education

I read approximately one hour a day on professional subjects, in addition to attending continuing education courses both in person and online. I do this to maintain my license and also to learn new skills to help my clients. My choices of continuing education are almost always based on trying to help a client who I feel needs a new approach that I am competent to offer but need some more knowledge about or practice delivering.

Part-timers

Many counselors in private practice are "part-time," which can mean seeing anywhere from five to 24 clients per week. There is no absolute definition of "full-time" but my personal definition of full time counseling is 25 or more client contact hours a week in private practice, given the overhead required to maintain that practice. 

Side gigs

Many counselors I know do some other paid work in addition to counseling. One of my friends helps run their family business. I've done technology consulting. Some folks I know do social justice advocacy work and sometimes get grants to do it. I'm currently writing a workbook for individuals who need career guidance. Side gigs offer two benefits: 1. They can bring in an extra stream if income and 2. they give you an outlet to meet people while working. The fact is, counselors can't be friends with their clients and sometimes it's nice to do some work where you can be friends with your clients and colleagues, hence doing non-mental health work part-time. 

Family stuff

Probably largely because I am a mom and a counselor, I know a lot of other parent-counselors who spend part of their time doing counseling work and part of their time caring for young children. 

Counseling requires many of the same skills as parenting. I'm not comparing my clients to young children, of course! It's just that holding space for someone who is vulnerable and having a hard time is something we're trained to do as counselors and that we have to do (however imperfectly) in parenting our children as well. On one hand, being a parent can enhance your ability to be a counselor by forcing you to practice your clinical skills when exhausted, personally challenged, and not your best. On the other hand, since it uses some of the same "mental muscles," I often see parent counselors working part time when financially possible, in order to allow themselves enough rest time to do a good job of both roles. 

House and hobbies

Many of you know that I have an office based out of an ADU on my property. Therefore, keeping my house maintained and my yard well kept is both a personal and professional pursuit. Today I spent my entire "day off" reengineering the drip-line irrigation system - something I hope will keep me from the endless hours of hand-watering I did over this last 100 degree weekend, when the lines weren't working correctly. 

I notice many of my counselor-friends have hobbies like gardening, cooking, or building/making things with their hands. Having very realistic, tangible hobbies can be a relief from occupational stress, "practicing what you preach," to clients who need stress relief. In other cases, some of us are "kinesthetic thinkers" and do our best thinking about client issues when moving our bodies. 

Nutrition and Health

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Physical health has a large impact on psychological health so it's probably no surprise that counselors can be real health nuts and foodies. Some have adopted particular styles of eating due to ethical and global environmental concerns. I have met more vegans and learned more about plant based diets since becoming a counselor than before I entered this profession. Others are on a relentless quest to experiment on themselves to find nutritional solutions to mood problems (for the record, nutrition is NOT in our scope of practice but since many clients present to counseling wanting to avoid medical treatment for their challenges, we like to be aware of many treatment approaches so we can refer to professionals who can help.). My interest in nutrition and food is more about culture and how our relationships with and around food influence our mental health. Rather than focusing on the food itself, I like to help my clients frame cooking for themselves and their loved ones as self-care. Or perhaps for someone who is struggling with their relationship with food, help them eat mindfully and pay attention to their body's cues on taste, hunger, and fullness. Food can be good medicine for mental health conditions, even if it's the behavior around food rather than the food itself that actually changes. 

Activism

Counselors work very hard to have an impact on improving healthcare and social problems. The truth is, we're new to the medical establishment and have little power compared to physicians, hospitals, and insurance companies. That said, we're very squeaky little wheels. In Oregon, we have several mental health associations, each with their own lobbyist in Salem. Nationally, each of our major professional organizations fights hard for license portability, coverage of mental health conditions as any other medical condition, and other ways to increase mental health access and funding. Sadly, sometimes psychologists, psychiatrists, prescribing mental health nurse practitioners, counselors, and social workers fight between groups but mostly, it's pretty collaborative and usually disagreements are the result of good debates on scope of practice issues. Most counselors contribute in some capacity to activism. My personal focus is on educating the private sector on how to improve the health of their employees. I also try to help the counselors political action group when I can. 

Some of my colleagues do amazing grass roots work, going directly to the public to educate, support, and improve access to mental health care. You'll see them at local farmers markets, rallies, and community events with big signs indicating they are mental health practitioners there to provide information. 

So are they like everyone else?

Yes and no. Any given counselor who practices part time probably has a private life that looks, from the outside, a lot like anyone else's. However what I think folks should know is that mental health professionals often find ways of integrating their professions into many other aspects of their time when not seeing clients directly. It's difficult to hear the challenges and sometimes systemic injustices suffered by our clients and not try to do something about it, most of your waking hours. Whether it's that we're on call because our clients often have our 24/7 contact information, or because we're trying to fix broken things about the world to make it a mentally healthy place, being a counselor isn't a hat that we can take off when we're not actively counseling people. So even if it doesn't always look like we're working (especially us "part-timers,") we might be. 

Katie PlayfairComment
Do you want to try out some career development activities?

As many of you know, I've been working to develop some online content to help share the career development process I coach clients through, with a wider audience. I hope to launch this content on a more integrated/interactive platform sometime soon but in the meantime, grab a plain ole notebook and follow along....  

Over the next several weeks, we will introduce and walk you through a framework to make major and minor career and life decisions. While you may have started this journey because you’re struggling in your career right now, we hope this system is one that you can apply over and over again in your life to make value-congruent decisions that bring you professional and personal contentment.

About the author

I’m Katie Playfair, a Licensed Professional Counselor (License OR4080) based in Portland, Oregon. Counseling is my second career. Previously, I was a management consultant in technology companies and it was there that I observed how painful anxiety could be and how much harm ineffective coping mechanisms caused to both people and their teams.

Today, I use cognitive-behavioral (CBT) and acceptance and commitment therapy (ACT) techniques to help clients address mental health and career issues. CBT is a behavioral treatment paradigm that focuses on helping clients change their behaviors first. Evidence shows that behavioral change can facilitate changes in thoughts and feelings. ACT is a nuanced paradigm that, from a client perspective, focuses on mindfulness and values. Although this career development program is not a substitute for mental health treatment, we will draw on principles and practices from CBT and ACT to help you make better career decisions.

 

What this course is

Together, we will use a variety of mediums to help you build psychological and practical skills to help you build a value-congruent career. While this course is focused on career, the skills we teach in this course can be applied to other areas of your life as well. Many of the concepts we will use to help you explore and take action in your career come from Acceptance and Commitment Therapy or ACT (pronounced “act”). ACT was developed as a psychotherapy paradigm by Steven Hayes and refined by him and others since its inception (Hayes & Wilson, 1994). We will use ACT to help you notice your experiences, identify your values, and take action on things that are important to your career. You may find that these skills generalize to other parts of your life.  

We will also use practical exercises such as looking through your resume, LinkedIn profile, personal websites, and personal brand briefly during this course. Although these are ancillary activities, we will provide some guidance on these practical issues.

What this program is not

This online course is NOT a substitute for professional therapy or medical advice. In professional therapy, the counselor provides consistent assessment and treatment of conditions including mental health disorders. Online self-help resources do not allow for that personalization or two-way communication. If you have any history of mental health symptoms, please complete this course only WITH the guidance of your mental health professional.

Maximizing impact and value

Changing how you approach your career and possibly even your life can take a lot of time and practice. Reading these instructions may bring you some benefit alone but we recommend engaging with the material more thoroughly by taking time to read it and complete homework assignments. If you don’t have time to do a bit of homework every day, save these emails and access the system when you do have time!

We also recommend that you keep a journal throughout this process so that you can engage better with the material and so that you have a record of how you got “unstuck” this time so you can repeat it in the future. If you don’t like journaling, please consider the “journal assignments” each day to be personal reflections that you can do by simply thinking.

Homework

Get a journal or notebook if you want to use one (we REALLY encourage this).  Additionally, consider what kind of time commitment you want to make to the program. What will make YOU feel successful? Write down your commitment and block the time you’re willing to commit.

References & Further Reading

Hayes, Steven C.; Luoma, Jason B.; Bond, Frank W.; Masuda, Akihiko; Lillis, Jason (2006). "Acceptance and Commitment Therapy: Model, processes and outcomes".Behaviour Research and Therapy44 (1): 1–25.doi:10.1016/j.brat.2005.06.006PMID 16300724.

Hayes, S. C. & Wilson, K. G. (1994). Acceptance and commitment therapy: Altering the verbal support for experiential avoidance. The Behavior Analyst, 17, 289-303.

Öst, L.G. (March 2008). "Efficacy of the third wave of behavioral therapies: a systematic review and meta-analysis". Behaviour research and therapy. 46 (3): 296–321.