Chapter Six from Carpe Diem - Seize the Day, Treatise on my Mental Health Experiences

Chapter 6

My Private Practice Life

“A Very Rewarding Personal Experience”

      I have dabbled in private practice my whole life, but have spent most of my time doing it since I have been semi-retired. I have been licensed in multiple states, most currently in Florida. I still maintain my license in NC, and am certified with the National Health Register as well as am on the medical staff for Lee Health System. I have a full scope practice using a systems approach to treatment, and spend most of my efforts dealing with adults, geriatrics, veterans and the developmentally disabled. My patients include those that are diagnosed with bipolar disorders, attention deficit-hyperactivity disorders, depression, anxiety disorders, personality disorders, addiction, relationship issues, geriatric problems, cognitive and intellectual disabilities, and trauma. I have never been board certified nor have I ever sought it out. Currently, I am an independent contractor working for myself (D J Koehn Consulting Services Inc.) doing cognitive behavior therapy, dialectic behavior therapy, mindfulness, bio-feedback and psychological testing. Besides clinical work, my group is seeking services that industrial/organizational psychology offers to companies and businesses (see www.koehnconsulting.com).

      Some of the most frustrating things about private practice is the insurance industry – it's difficult to figure out how to get tagged to it and get paid what you are even worth. The administrative hassles are astronomical, so I minimize my involvement and leave it up to my administrative assistant (my wife who enjoys the work) for most insurance programs, and an experienced contractor to deal with Medicare. Many psychologists move towards self-pay just to avoid the insurance debacle – but it is not good for those potential patients who cannot afford it and are looking for help. Medicaid patients are poorly attended to when it comes to mental health issues, typically receiving less competent clinic services than what they could get from private practice.  

      Besides doing private practice on my own, I have worked for two different practice groups. Both are as different as day and night in the way they dealt with business. One group was non-interactive between members of the group and basically cold in their demeanor. The owners were in it for themselves and kept close hold on revenue generation. Both owners were competent psychologists and employed a variety of interns from surrounding colleges to help out around the office and hired post-docs to do clinical and testing work under their supervision. The other group grew in a way out of the other group practice. One licensed psychologist who did not like the conditions of her employment went out on her own to establish her own group. Not long after, I joined her to help her grow her business. Shortly after I joined her practice, a post doc that worked for me in the addiction business, joined her group. She became licensed and now still works for the group. The business manager is the owner’s husband and offers a refreshing breathe of air as to transparency and honesty in comparison to the interaction with the previous business manager from the other group. The group’s interactions are always respectful of each other’s capability and they are constantly looking to improve our trade and next generation of service. 

      To maintain one’s license as a psychologist, you must continue to take many hours of continuing education every two years.  In the state of Florida, the requirement is forty hours with domestic violence (every four years) and ethnics (every two years) being a fixed requirement. Each credit must be approved by the state and recorded in their tracker system called CE Broker. For most psychologists there is huge push put on the last six months prior to the due date to make sure the requirement is met.

      Patients seeking help in private practice for the most part really want help and are willing to do their required homework. It is very gratifying work and keeps you on your toes. Based on being referred and initially vetted/screened by myself, there is an intake session where you review the person’s issues and background information. They get to know you and you get to know them and see if it is a good fit.  After this initial session, an analysis of the information takes place and is documented as an initially clinical assessment that includes a diagnosis. What follows, are a series of therapy sessions where goals are defined and applied, treatment occurs, and practice of therapy techniques and tactics happens back in the home and social environment. Progress notes are documented after every session. 

      Sometimes referrals (self, vocational rehabilitation, court, law firms, agencies, Veterans Affair, Worker’s Compensation, Employee Assistance Program) require psychological services to include testing where a battery of tests are applied (intellectual, cognitive, adaptive, behavioral, career, aptitude, autism, emotional, and personality) based on suspected need. The testing session can take from four to eight hours in length with the follow-up comprehensive written report requiring an additional six to eight hours to write up. Normally, there is a two week turnaround time requirement. Most psychologists get paid a lot less for the level of work performed. They charge less than the effort put into doing an assessment because of fear that others will do it for less or the fact that insurance companies will only pay for so many hours. 

      A major difficulty with referrals as well as with regular patients are no shows/cancellations. Typically one has a twenty four cancellation policy, where the individual is responsible to pay the self-rate for the hour missed. Rarely, do I enforce this policy unless the individual does not have a legitimate excuse. Missing appointments is very common when Vocational Rehabilitation (VR) is involved – they do not reimburse you for missed appointments by their clients. Many psychologists shy away from these type of referrals because they have blocked a whole day to do the evaluation only to find the patient does not show up. 

      Infrequent, but on occasion I have been involved in job fitness evaluations. Here, a third party hires you specifically to evaluate the “goodness” of an employee to return to work for a given company. Normally, this requires a clinical interview which focuses on a series of questions the company/third party want addressed to which a report is generated based on the interview and documentation provided to you. The report is sent back to the third party without the employee knowing the results and being told that this information cannot be shared with them.

      That brings up two important confidentiality topics when dealing with outpatients – Health Insurance Portability and Accountability Act (HIPAA) requirements and informed consent. Patient records are to be encrypted when electronically documented so others cannot obtain what has been documented about the patient. Printed documentation must be behind a double lock combination of a door and file cabinet. Great effort must be placed on never to expose or share either verbally or in writing, personal/mental health information without the informed consent of the patient stating who specifically can be involved, for what and for what length of time – there is zero tolerance for any violation. The only exception is if the patient is being covered by health insurance. The insurance company can have access to certain critical information to validate that mental health service has been provided. 

BRITTA’S DILEMMA/DEBACLE                                          

      Seven years into her battle, to have access to her children is when Britta came to me for mental health services. She dropped off literally a duffle bag of documentation that included court documents, filings, health evaluations, etc. for me to review and gain some perspective of her situation. Over the course of time I saw her for ten therapy sessions – she was always timely and worked hard on her issues. Britta has a superior IQ score and mirror images symptoms similar to those patients who have Attention Deficit Hyperactive Disorder, combined. What happened to her over the years is downright disheartening and a demonstration of the sad state affairs in the court system.

      Originally when she got divorced from her estranged ex-husband (a well-known professional in the community making a lucrative income), she was given fifty-fifty custody of her four children. Today she has no custody of her children and is required by the court to accomplish twelve hours of therapeutic supervision before she can have unsupervised visits with them. She has gone through at least seven different mental health counselors including me who acted in the capacity as the therapeutic visitation supervisor and still has not accomplished the requirement. There are many reasons as to why this has not happened – some deal with the biases on the part of those mental health counselors assigned to the supervisor role as well as judges being more supportive for her ex-husband, to my suspicions as to the outright sabotaging of sessions by her ex-husband who camouflage them through the actions of his children and his current wife, to Britta being her own worst enemy and not knowing when to back off, and to Britta representing herself at times in court rather than being represented by her own lawyer. Britta’s frustration and resistance to complying with the court’s decisions has to do with the fact that she has to pay for these sessions and that she in her heart knows that the sessions should not have been part the court decision in the first place. She knows that even if she completes the required sessions, she will still have to battle getting her parenting rights re-established – a real major uphill climb!

      Let me explain as succinctly as I can as to why Britta is so exasperated. The mental health forensic people here are a small group who know each other and can be quite figuratively “close knit” with each other. The contesting person with money typically gets their way. When there is high conflict in divorce cases involving children the court will assigned a parent coordinator and parent evaluator.  The parent coordinator originally assigned to this case always found in favor of the father and not Britta regarding custody and parenting issues (This has also happened to other patients I have seen who also have had this same parent coordinator). The parent evaluator whose reports the court has used over the years as a bible regarding the course of action left out two major pieces of evidence in drawing her conclusions about both parents. First, the father’s alleged sexual abuse of his oldest child was not mentioned or investigated. Also, the extent of his physical abuse of Britta was not documented which culminated in her having traumatic brain injury manifesting itself like ADHD – validated by medical evidence. Both pieces of evidence if true and exposed, would have put Britta on a different yellow brick road journey with her four children. As such, the oldest is now graduating next semester from college, the second oldest has entered college this fall, the third daughter is in high school, and the youngest is in middle school. The saga continues with no apparent resolution in sight. The best Britta can hope for is that as the girls reach adult age and not under their dad’s control, they will seek their mom out – the oldest has done this, hopefully the others will see it similarly and also want to again establish a mother-daughter relationship.

      As an added note, I have personally had two sessions with her oldest daughter within the last year who states that she has seen her dad when they were still a family physically abuse her mother. She also has been steadfast in her claim that her dad sexually abused her over a three year period between the ages of nine through twelve. As an adult, she would have to file charges but is not willing to do so because it would be difficult to prove after such a lengthy lapse in time as well as go through all the consternation she would have to experience. That said, she will need therapy to help her deal with this “supposed” past sexual trauma to regain a healthy mental mindset.