Telehealth is my new best friend

On Sunday March 22, I stopped face-to-face sessions completely and went entirely online (telehealth). I decided at some point that I would do only online until the end of May and then re-assess. May is almost over, so I've been looking at statistics and thinking about safety, and have decided to stay solely online for now.

I know that some of my folks really prefer in-person sessions. Honestly, I do too. I find that it can be harder to connect with someone over the computer, and lately I've felt more tired than usual at the end of the day. However, safety is the top priority, and right now I think that dictates continued quarantining for my household and business.

I think the city opened back up too soon. Now, that is probably easier for me to say than for some folks. I have continued to work throughout the quarantine. I am able to do my work online just fine. My wife continues to work so our income really hasn't changed. I am definitely blessed as a small business owner to be able to work under these circumstances as so many other small business owners are in a very different place financially. I don't know what the right answer is; actually, I don't think there is a right answer. Keeping the city closed longer probably would be the right decision health-wise, but opening back up, at least to some extent, is better for business (at least in the short-term).

Even though the city is now mostly open, I don't have to re-enter myself. I have chosen to continue to self-quarantine; I do believe that is the right decision for myself, my family, and my business. Because I work in my home, if a client was infected but didn't know it, my family is at a higher risk of being exposed than if I worked in an office somewhere. I won't put my family in danger. However, it isn't all about my family. If I had a single client who was positive for Covid-19, then over the course of two weeks I would expose at least 50 people (besides my family) and that is definitely not something I am willing to do. So for now, I am going to keep my practice 100% online.

I don't know when this will change. I am tentatively saying I will be only telehealth until the end of June. Now, if I believe that we get to a safe place for face-to-face before the end of June, then I may shift to face-to-face sooner. We'll just have to wait and see how this plays out.

For those of you who prefer telehealth, I don't know if it will continue to be an option per insurance once we are past the Covid-19 crisis. If insurance continues to cover it, then I will be happy to continue to do it. Prior to the pandemic I already did telehealth if insurance wasn't involved. It may be that we'll be able to continue doing it, with insurance coverage, post pandemic; again, we'll just have to see how this plays out.

All of you, please stay safe. I think the best practice is to continue to wear face-masks right now when in public, and to limit social interactions, but I don't get to make the rules if you don't live in my house (heck, I live with two teenagers, I'm not sure I make the rules for them anymore given that I am now a stupid parent who knows NOTHING about their trials and tribulations). In any case, stay safe, and one of these days I look forward to seeing you again in person.

Meet my Therapy Animals

I work from home, and I have four cats and a dog. This means that various animals are typically present during sessions. Before the introductions, let me clarify one thing. Recently we have been hearing about service animals, therapy animals, and emotional support pets. I use the term "therapy animal" to describe my critters, because they do participate in therapy sessions. It is also true that they are providing emotional support, but none have been trained or specially designated as emotional support pets or service pets. They simply hang out during sessions and often interact with the clients. Because I am doing this in my home, there isn't any specific training or certification required. That having been said, let's meet the critters!

Nimbus was the original therapy cat. Starting the very first session I did at the house, he was there and providing support. He seems to have instincts around it that make him the perfect therapy cat. He generally positions himself close to the client so they can interact with him if they want, but if they don't he just naps. Often if a client becomes emotional he will move closer to them and reach out his paw to touch them, letting them know he is there if they want him. He is 10 years old now, and has been doing this work for the last three years.

Dobby was the second therapy cat. We got him as a kitten in April 2017, and he took to it immediately. He doesn't seem to have quite the instinct that Nimbus has, but is still quite good at interacting with clients in positive ways. He is now two years old and has been a therapy cat his whole life.

Darth Cola was the third therapy cat to join the group, but he didn't do so immediately. I worked from home for at least a year before he started hanging out in sessions and interacting with clients. Even now he often sits on his chair a little separate from the client, but he sometimes will move so he can give a little love. Cola is six years old now and has been working about a year and a half.

StormTrooper is the surprise addition to the therapy cat group. He has always been a pretty skittish guy, and up until this past April wouldn't spend any time in the room if a session was in progress. Then quite suddenly and without any explanation he started spending time in the therapy room, and will sometimes interact with clients (more often with me I guess). I don't know what happened that he suddenly decided to be a part of it, but I am glad that he did. He is currently eight years old.

Hiestand's Sir Gandalf the Wise and Fluffy is the newest member of the therapy animal corp. He got him this past April and he has been in every single session since. His goal in life is to be a companion animal so he is perfect for the part. Currently he still does spend more time with me than with the clients (maybe I need some therapy pet love too), but he seems to be spending more and more life with the clients as he becomes more adjusted to the whole process. He is a Cavalier King Charles Spaniel and is seven months old.

In Memoriam: Norah was the original therapy dog, and worked hard from summer 2016 to August 2018. She was a wonderfully friendly companion and very good therapy dog, and will forever be missed.

Why losing my job was, ultimately, totally awesome

I graduated with my Ph.D. in psychology in 2010. When people would ask what I wanted to do, I had always said I wanted to work with LGBT folks. However, I was able to get a job with an agency working with adults with intellectual/developmental disabilities, so of course I took the job. I needed a year of supervision and a paycheck and the job provided both, so I went with it.

I stayed at that agency for about a year and a half, then went to a different, but similar, agency when I was opposed to some things I was expected to do (share session notes, when by my ethical mandate they must be confidential). So I started at the second agency in March 2011, and thought everything was good. I liked the clients, and my supervisor was awesome (a psychologist who had become my mentor) so that's what I did. I didn't love the job, but I didn't hate it, and it did meet my/our basic needs, so all was good, right?

In 2015 I had a conversation with folks at the Memphis Gay & Lesbian Community Center (now OutMemphis) and learned that they got calls on a daily basis from LGBT folks struggling to find a therapist. It was at that point that Hiestand Psychological Services was born, and I started seeing clients there on Sundays. I was now working six full days a week, but my work there was so fulfilling that I was good with it.

If I had been honest with myself at that time, I would have recognized that I was not being fulfilled by my regular job. While I did like my clients, many didn't really want to be in therapy so most sessions were a struggle just to get the client involved. There weren't any huge ethical issues like I had faced at the previous agency, but I was aware of some things that I wasn't terribly happy with. Still, it was a paycheck, and I needed a paycheck, so I just ignored the bigger picture.

Towards the end of 2015 my supervisor/mentor left the agency (and the state). At that time things started to unravel. At first I still tried to ignore it, because I needed that paycheck (right?!) and didn't think my private practice would support my family. It was immensely more fulfilling, and certainly supported me emotionally in a way that my regular job didn't, but dang it I needed that paycheck. However, in late August 2016 I lost that job and suddenly had to find another paycheck.

At first I assumed that I needed another job to be financially stable. I started sending in applications to any job openings I could find for psychologists in the area, but I also started growing my private practice to bring in some money while I found another job. I won't go into that whole experience; suffice it to say I didn't find another job. What I did find was that my private practice could support my family, and it was infinitely more satisfying than any of my previous "real jobs."

Fast forward to today. As my wife says, I have a thriving practice. I currently work six and a half days a week, harder than I've ever worked in a job before, but I love it. I do need to carve out a little less time working, but what I do is so fulfilling (most of it anyway, dealing with insurance is still a headache). I'm now doing what I always wanted to do , and more. Many of my clients full under the LGBT rainbow. I work with individuals, couples, and families who identify as lesbian, gay, bisexual, pansexual, transgender, gender non-conforming (non-binary, agender, bigender). I work with people who are confident in their identities, and I work with folks who are questioning their sexuality or gender identity. I work with monogamous folks and polyamorous folks. I work with asexuals, folks in the kink community (BDSM, Furries, Bronies). I work with cross-dressers. I work with all of the people who have struggled to find an open-minded therapist. I still address all of the typical mental health diagnoses (depression, anxiety, bipolar, PTSD, OCD, schizophrenia). I work in my home with therapy animals. While I am often tired in the evenings when I finally decide I've worked enough for the day, I go to bed every night satisfied with the work I do.

Losing my job was a really stressful thing for me. However, I never would have gone out on my own, so it pushed me to do just that. So many of the folks I work with aren't happy in their work life (and we definitely address this) but I am so thankful that I am doing what I always wanted to do. My wife is so supportive of me and my work. My parents have supported me (even when I wasn't confident that I could do this). My in-laws have been behind me, and friends and colleagues have always been willing to give advice and told me "you got this." And you know what, I do got this. Hiestand Psychological Services has gone from a dream to a reality, and I could not be happier with how it transformed to be not only my paycheck, but my career. I know over time it will evolve (eventually I want to have a few more therapists, as well as folks who offer other services). Today it is exactly what I need it to be, and I'm pretty my clients would agree.

Hope is the Cure

Fear keeps us stuck in situations in which we are unhappy; fear that things can even change, or fear of what that change might look like. Perhaps we are struggling with depression or anxiety, and we don't believe that things can get better. Maybe we are unhappy in our relationship, but we don't address it for fear of what may happen. Many people feel stuck in jobs in which they are unhappy, but fear of loss of income prevents us from looking for a better way. Many of the people I work with struggle with gender identity issues but are, understandably, fearful of what making changes will bring.

In all of these situations, we lack the hope that things can get better. Change is hard. We are afraid of what that change will look like. What if things do change but nothing gets better? We may not be aware of it, but fear clouds hope for so many people. Let me give an example from my own life in which fear kept me stuck without hope that things can get better.

Before I was doing my private practice full time I had a job, but was very unhappy. I was working for an agency as a psychologist, but my work wasn't fulfilling and there were a number of issues that I felt powerless to change. I knew that I wanted to have a private practice, but I didn't know how to make that happen. I had significant financial responsibilities, and didn't think I had the financial resources to consider making changes. I had bills to pay, and making sure I was able to do that kept me stuck in unhappiness.

Then I unexpectedly lost my job. I immediately started looking for another job, because I thought that was my only good option. I was fearful of financial consequences and didn't have the hope that I could make private practice work. I did start building my private practice (at the time it was already established but was very small) in order to have some income, but my focus was on finding another job based on my belief that was the only way I would have financial security.

I never did find another job in the way I thought I needed. During the time I was looking, my private practice was building, and shockingly I was able to pay all of my bills. Yes, my finances were very tight, but everything got paid.

There wasn't a single moment when I realized that private practice was all I needed. No ah-ha moment, no instant where suddenly I knew it would work. However, over time my fear of financial insecurity was replaced by the hope that I could really do this. I was working from home so that I wouldn't have all of the financial obligations associated with maintaining an office elsewhere. Even when I started to realize that the private practice was really working, I still thought working from home was a temporary thing until I could afford a "real" office. It's now a year and a half later, and I'm still working from my home office. I am as financially secure as I was when I was working for someone else. I'm also amazingly more happy than I was when I had a boss and a paycheck every two weeks.

I didn't have the confidence that I could do it on my own. This fear of failure kept me stuck. In my case it wasn't by choice that I depended on my private practice, it was by necessity when I suddenly found myself without a "real" job. I can now say that losing my job was the best thing that could have happened. I wouldn't have attempted to go out on my own - fear made me believe I couldn't do it. But somewhere in there hope took root and Hiestand Psychological Services is all I need. Having a home office is fairly unusual, but I realized it really works. So many of my clients comment that they love the home setting an opposed to a commercial office. And having my pets around also significantly adds to the work I do in ways I couldn't have even imagined.

What are you afraid of? Where in your life is hope clouded by fear? Know that change can happen, even if we aren't sure what that change will look like. I wouldn't have a job if people or situations couldn't change. When we find that hope, even if it is just a spark, we can go on to make significant changes in our lives for the better. Fear is a disease; hope is its only cure.

Insurance Update

When I started my private practice almost 2 years ago, I didn't fool with getting on insurance panels - I knew it would be a headache and decided to just use a sliding scale. However, when I went full-time with the practice, I knew I needed to go ahead and get on some insurance panels. I started the process months ago, and it has definitely been a headache. Here is where things stand.

Magellan: I have a contract and am finalizing a few details, but basically ready to bill.

Cigna: I have a contract but before I can start billing they have to check my credentials. They say it won't be more than a month (I'm not holding my breath).

Blue Cross Blue Shield: I have submitted all the documentation that I am aware of and am waiting on a decision. I do think this decision will be favorable, but don't know how much longer it will take.

Humana: They denied my initial application, but I appealed it and I think they are going to offer me a contract. Again, not sure of the timeline.

Aetna: I have submitted the initial application but haven't heard anything from them.

United: Initially they stated they are not contracting with any more psychologists in this area. I have appealed it but haven't gotten an answer.

Amerigroup: Will submit my initial application once I have a Medicaid number - they require that before they will consider an application.

Medicare: I have submitted all the paperwork and am waiting on the answer.

Medicaid: I have submitted all the paperwork here as well, so just waiting.

At the moment I think this covers it. As contracts become real I will notify folks.

Religion and Psychotherapy

We live in a time where religion/spirituality is sometimes seen as not belonging. We are likely aware of the frequent disagreement about the role of religion in our government. Controversies around laws with religious content are very common at the moment. However, this isn't primarily a political blog, it is a blog about psychology. Another question we sometimes have to deal with is the role of religion/spirituality in the therapy room.

To be completely transparent, I am a Christian. I was raised in the United Methodist Church, and I continue to identify with that denomination today. Recently I have also been incorporating some additional spirituality into my life, meditation practices that could be considered more a part of Buddhist thought. Thus, religion and spirituality are important parts of my personal life.

As important as religion and spirituality are to me personally, when I am working with a client, my beliefs are not relevant. Early in my work with an individual I will ask them about their personal religious/spiritual beliefs. If they do have beliefs that are important in their life, I need to know so that our work can include their beliefs (as relevant). If they don't have specific beliefs, then our work won't include a spiritual component.

Living in the South, religion (Christianity) is a very visible part of the landscape. We don't have to go far to see multiple churches of varying denominations. However, there are folks who are not interested in religion, possibly because it has never been a part of their life, and possibly because they have been hurt by the religious beliefs of others. For these individuals it is inappropriate to expect psychotherapy to include religion; it is unethical for a therapist to try to include religious beliefs when the client does not want that.

Religious beliefs/spirituality are very personal endeavors. If you are contemplating therapy and want religion to be included, make that known to the therapist. If you do not want religious thought to inform your therapy, make that known as well. It is appropriate for you to ask your therapist how they utilize religion in the therapy room, and if their response isn't comfortable for you, then that therapist is not a good fit for you.

Why do people cut?

One concerning thing that I find myself working with a decent number of folks on is cutting. It seems more common than I would have thought, especially in adolescents and young adults. It's not a new phenomenon, but it does seem to be happening more now because kids are hearing about it and trying it out for themselves. While overall it is still a socially unacceptable practice, I think there likely is more acceptance of it with adolescent peers. I haven't gotten the impression that it is considered "cool", but I think there is less stigma around it in the younger population.

Cutting is something I have never been inclined to do. In order to better understand it, I've had to do research and also get information from folks I work with who do it. Cutting typically IS NOT simply a cry for attention. Most of the time when folks do it, they do it on a part of their body that is relatively easy to conceal (arms, upper legs, sometimes abdomen) because they don't want other folks to find out. If it isn't a cry for attention or help, then why do people do it?

I almost didn't include this image. It's hard to look at. However, this topic is hard to talk about anyway, and this is the main reason people do it. Although it seldom lasts long, individuals who cut swear that it takes away their mental/emotional pain, even if only for a minute. Physical pain (of any sort) causes the release of endorphins in our bodies that act to reduce pain. When an individual causes physical pain and then goes through the healing process for it, they feel better and are able to temporarily ignore their emotional pain. A cut or cuts may represent the emotional pain they experience, but are easier to manage. It can also give people some sense of control over the pain in their body. Finally, a physical cut is something that can be seen, it is real; although emotional pain is absolutely as real, because we can't see it it may feel less real to some people.

Cutting is generally not a suicide attempt. However, it is still a risky practice and so one we want to stop and prevent. Cutting may result in scarring that will be present the rest of the life, and most people really don't want that. While I have heard people state that they want the scars to remind them of what they have been, in most cases this isn't a permanent sentiment. More importantly, cutting can result in unintentional injury, sometimes of a serious nature. A cut that accidentally goes too deep or hits a major vessel can become an emergency situation.

Treatment for cutting involves identifying and implementing alternative coping skills. While we absolutely should communicate to people who are cutting that it is not a healthy practice, and parents absolutely can limit access to devices to cut with (although, honestly, if someone wants to cut they will find something - in a pinch paper will do the trick), people will not stop until they have other ways to deal with their emotional pain. I don't believe punishment for cutting is appropriate, other than taking away objects they can use which may include personal property like pocket knives. Folks who cut should be approached with care and compassion, and psychotherapy is the best treatment. For those of us who don't understand it, cutting can be a really scary practice. Fortunately, it is a practice that can be halted with supportive therapy.

Am I my mental illness?

Most of the folks I work with meet the criteria for one or more mental illnesses; I meet the criteria of one (Major Depressive Disorder). For some folks it's a temporary thing - you are feeling sad/depressed, but it is linked to something that you will deal with, and then you will no longer meet the criteria. This is especially common for things such as depression and anxiety. For others, your mental illness is something you are going to live with for much of your life. You will learn ways to cope with it, you will be able to effectively manage it, but it is going to be something you will have to address on and off, possibly for the rest of your life.

For those of us who do live with mental illness long term, it can become very easy to identify with our mental illness. I could think about myself as a depressed person, but that isn't accurate most of the time. Yes, there are times when I have to actively manage depression, times when I experience depression, times when I suppose I am a depressed person. But it would be unhealthy for me to incorporate depression into my sense of self. I live WITH depression, but I AM NOT depression. While it may be a part of my life, it does not define me.

If I identify with depression, I am giving depression power and control in my life that it doesn't deserve. By making depression part of my sense of self, I am guaranteeing that it will play a prominent role in my life. I don't want depression to play a prominent role in my life. I accept it is a part, but I do not accept that it is who I am.

For a long time now, I have used a visualization for my depression. This is what my depression looks like:

except the creature is all green, not purple. It is a ghastly obnoxious dancing green dinosaur. It is not of me. It is a separate entity that at times I have to attend to. Sometimes it is much harder to do this, to maintain the distance needed to control the beast. I have lived with it for over 30 years now, but it will never be me. Barney the Depression Dinosaur, you will never get to be me.

Couples Counseling

Couples counseling. Couples start counseling for different reasons and at different times in their relationships. Often, they wait until things get really bad before they start counseling, and that reduces the chances that counseling will be effective. It is far better to start therapy before things get too bad for the best chance of working things through.

Sometimes couples start therapy as more of a preventative measure. They start therapy when there aren't any significant concerns, and so use it to deal with things as soon as they come up. That way issues don't usually get too serious before they are working through them. This is a really nice way to stay on track with your partner.

A third option is pre-marital therapy. This is counseling done prior to getting married during which potential issues can be identified and discussed. The state of Tennessee offers a significant discount on the fee for the marriage license to couples who have done acceptable pre-marital counseling, and I am able to do this work. It requires at least four hours of therapy, so isn't a huge commitment, and can be a really nice way to be prepared for some of the challenges that often arise in marriages. Good relationships do take work, but doing that work can help us maintain healthy and fulfilling relationships.

My ad on Psych Today

You can visit my page at Psychology Today:
https://therapists.psychologytoday.com/rms/prof_detail.php?profid=311392&sid=1485113618.6495_10129&name=Hiestand&search=Hiestand&ref=1&tr=ResultsName

Emotions: the Good, the Bad, and the Ugly...

Emotions. Some of us are all in tune with our emotions while others avoid emotions like the plague. Sometimes in therapy we focus on them while other times we focus on other things. When we think about emotions, we know there are lots of them...

Lots of times one of the things people want when they go to therapy is to stop feeling certain emotions. Frequently clients tell me they don't want to feel sad, anxious, depressed, angry, lonely, or scared. But is it a good goal to want to eradicate these feelings from our lives?

Most of the time, emotions serve a useful purpose (note I didn't say a pleasant purpose). Negative emotions alert us that there is something in our environment we need to attend to. Anxiety tells us there is something we need to attend to, to fix. If we are anxious about money, we need to take steps to improve our financial situations. When we are frustrated, perhaps we need to work something out with our spouse, co-workers, or friends, to alleviate the frustration. Fear lets us respond to keep ourselves safe. Sadness is a normal response to loss in our lives.

There are certainly times that emotions are too extreme. People may experience anxiety that is bad enough that it actually prevents them from responding. Depression may be so crippling that it is almost impossible to function. When emotions are this extreme, it is certainly reasonable to want them to go away, because in these cases they aren't being helpful.

None of us likes to feel bad, but emotions - the good, the bad, and the ugly - normally do serve a purpose. Therapy can help us reduce the extreme emotions, and it can help us learn to cope with emotions so that we can work through them. As nice as it might be to never experience the negative stuff, they are important and we need to learn from them and react in appropriate ways. When we actively address them, we can learn and grow, and that's a pretty great goal.