Insulated, but Isolated: Part I

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Insulated, but Isolated: Part I

One of my primary interests is in “self-containment.” I’ve never attempted to discretely define this before as I understand it in a more felt than articulated way. My interpretation of it has to do with how you feel held. Our skin is one of the first that comes to mind as one of our first - and perhaps most foundational - containers to our existence. It holds us together and sets the limits of our physical boundedness. We then evolve to understand and appreciate not just the physical container of our house, but also the containing functions of our social units (e.g. family, church). The laws and norms of our institutions, generation, and culture provide us with a reassuring feeling of structure, or containment.

Containers are designed to keep the desired in and the undesired out. They, by design, INSULATE, which, by nature, can ISOLATE. This is the potential problem. There is a high amount of emphasis in this society on self-sufficiency and independence. There is also a high belief in this society about logic (“neat and contained”) > feelings (“messy and uncontained”). Both of these can put significant (even if unconscious) pressure on us to self-contain.

What does that even mean or look like?

Imagine that you are wanting a raise at work. You’ve been at this company for just over a year and you have a new car that you need to make payments on. You think you’ve been doing a good job but are also aware that a year is not a short time, but also not a long time. Is this enough time to warrant a raise? You dropped a hint to your boss last week but she seemed to ignore it. Say something again? Making payments on your car is a real stressor for you, but is this a good enough reason? You know that your co-workers also have their own stressors too. You even know that some of them have been there longer than you and are also doing good work and you’re pretty sure they haven’t gotten a raise. What makes you so special? Why should they make exceptions for you? Especially when they talked about budget in the last meeting and it doesn’t seem like there are extra funds to go around. Guilt sets in. Doubt sets in. And you realize sometime in this train of thought your hand moved up to your head and five hairs are now lying on the desk before you.

This vignette captures the common way we can get stuck in our heads. The problem is when this becomes our default and regular mode of being. We stop looking beyond ourselves for answers or comfort, and become invested in this process of figuring it out ourselves. We have stopped engaging others in our thinking, enlisting our friends or teachers in compassion, seeking out places to discharge energy, or trusting in others' ability to validate and accept us. We have interrupted feeling and diverted all our energy instead into thinking. Our preoccupation with our minds also keeps us out of our bodies (which is different than enacting on our bodies). We fail to develop trust in ourselves to be able to bear the uncertainty of what will happen. We switch to neurotic analyses to predict outcomes like the one above under the false (but desperate) belief that we can know (and thus control) everything… if only we think about it thoroughly enough. However, there will never be a degree to which our thinking can substitute for simply approaching our boss with our needs and concerns. There is no way our private analyses can make up for the bond that can be created between people having a lived conversation. And there is no way internal predictions can produce anything more reliable-feeling than actual conclusions. When we self-contain, we never end up as satisfied or as soothed as we do when experiences are shared with others and lived out beyond our own heads.

.. Stay tuned for Part II! ...

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For individuals seeking insurance reimbursement

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For individuals seeking insurance reimbursement

I'm including this post on behalf of current clients and potential ones who are seeking insurance reimbursement for their body-focused, repetitive behavior (BFRB) treatment.


If you have a PPO: You have the freedom to choose any healthcare provider you want (which includes me!) and receive benefits. You are guaranteed some financial assistance; however, your out-of-network reimbursement (e.g. 40%) will not be as generous as your in-network reimbursement (e.g. 80%). (These numbers are for illustration, you will have to speak with your insurance company to learn the details of your particular plan.) If you are feeling ambitious and would like to pursue the higher reimbursement rate, the following is for you...

If you have another type of plan, like an EPO or HMO: You must stay within the contracted network of providers (which does not include me) to receive benefits. You will be paying out of pocket to see me... unless you get an exception. The following will guide you on how to get your insurance company to help pay for your BFRB treatment...


The magic term here is a "network gap exception." Insurance companies won't advertise it because of the cost to them, but these provisions were designed for cases like BFRBs. This article (<-- click there!) provides a more detailed explanation:

"A network gap exception is a tool health insurance companies use to compensate for gaps in their network of contracted health care providers. When your health insurer grants you a network gap exception, also known as a clinical gap exception, it’s allowing you to get health care from an out-of-network provider while paying the lower in-network cost-sharing fees."

In short, if an insurance company does not have an in-network provider for your condition nearby, by law they must cover you to see an out-of-network specialist. In an attempt to not have to subsidize, they will provide you with a list of names of providers who treat "anxiety" or "depression" or "OCD" or maybe have seen a patient or two with hair pulling issues, but THIS IS NOT AN APPROPRIATE REFERRAL. You need a BFRB SPECIALIST and I still have not encountered a single insurance company who has one on their panel. Your insurance company may also refer to a "single case agreement," but THIS IS ALSO NOT WHAT YOU WANT. You need them to bridge the gap in their network as your right and their obligation.


I recommend you read over this (<-- click there!) article as well, and consult me for further advice and the necessary diagnostic and procedure codes for your inquiry. Keep good documentation of your conversations (including reference #'s), and remember to set your network gap exception to the maximum allowable time frame. BFRB work is long-term work! Dealing with insurance companies will test your will and patience, but if you stay committed you can prevail!

 

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BFRB Group - Call for New Members!

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BFRB Group - Call for New Members!

Back in April, I began a new psychotherapy group which oriented group members to the body-focused, repetitive behaviors (e.g. hair pulling, skin picking, nail biting) they possess. We reviewed the demographic backdrop to these behaviors, treatment options, and factors such as motivation that affect treatment outcomes. We began exploring our own pulling/picking profiles and uncovering the emotional and sensory factors that feed into them. I started this group to foster understanding, and even more so, to foster relationships with people and not just our bodies. In the safe and controlled space of a psychotherapy group dedicated to BFRB sufferers, we can begin to heal shame and rely on one another. This group that began this last year proved incredibly rich and fulfilling, and lasted approximately 6 months. Since then, I have come to feel even more convinced of the importance of having this additional space for encountering sameness, difference, sharing, and receiving with like peers.

Beginning in 2016, I'd like to start a second chapter with new members and a revitalized curriculum. The curriculum would include familiar and unfamiliar components, but with a more dedicated focus and more collaborative approach. In addition to overt behavioral management of the BFRBs, we would tackle discomfort, relationships, self-compassion, and self-assertion experientially and through guided conversations.

I am aiming to begin this group January 2016, but will adjust according to members' availability and when we attain a critical mass. Meeting time would be Mondays from 5:55 - 7:10 pm, and meeting place would be my usual office at Post and Divisadero in San Francisco. Session fee would be $75/session, which if you submit for reimbursement can be claimed on your insurance superbill as well.

If you have any interest in the group, please let me know by email: dr.nmayeda@gmail.com, or by phone: 415-735-0029 in the next couple of weeks. Again, please reach out to me if you have any interest at all. Your inquiry will by no means by a commitment, just a chance to get more information so we can mutually determine fit.

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On Being Vulnerable

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On Being Vulnerable

Last night I finally got around to listening to the podcast The Courage to be Vulnerable (<-- click to listen!), in which host Krista Tippett has a conversation with Brené Brown. I don't normally listen to a lot of podcasts, but this one came recommended and the topic felt relevant. I have been becoming increasingly convinced that this one thing - vulnerability -  stands at the root of our imprisonment and in turn our freedom. Our absolute fear of it grants it its power to bind and oppress us, and keeps us oppressing ourselves similarly. We keep feeding this belief that in order to stay safe, we must successfully control our present lives, our future lives, our friends' beliefs, our family's beliefs, our employer's impressions, our Facebook network's impressions, the list goes on and on...

But it is exhausting and we are tired. And maybe these things aren't meant to be guaranteed. Maybe safety is borne out of experiences of survival, and maybe as long as we are proofing our lives to make sure life can't actually happen, we can never grow the confidence that we CAN live it. We never get to test our resilience, invest in faith, or witness our incredible ability to relate around our fears and imperfections. In essence, we never get to celebrate our humanity, or enjoy exhaling deeply knowing securely we can relax into it.

This podcast delves into vulnerability as it defines our personality expression, biases different genders, and applies to parenting. It also has EVERYTHING to do with the fundamental struggle for people suffering from BFRB's. Whether it was designed to address this group or not, it is completely relevant to them and so I highly encourage you to have a listen. Brené Brown, in the first segment, makes mention of character qualities she found in her research to be antithetical to a "wholehearted" life (essentially, able to give and receive love fully even if you're getting hurt). I thought this list screamed BFRB traits, but you can evaluate for yourself:

  • Perfectionism
  • Judgment
  • Exhaustion as a Status Symbol
  • Productivity as Self Worth
  • Cool
  • What do People Think
  • Performing
  • Proving
  • Quest for Certainty

Lastly, I'll leave you with some noteworthy quotes spoken by Brené in this episode:

  • "Does this mean that our capacity for wholeheartedness can never be greater than our willigness to be broken hearted?"
  • "Choosing to live disappointed because it's easier than feeling disappointment."
  • "I don't want to spend every ounce of energy I have ducking and weaving."
  • "Hope is a function of struggle."

Hope you enjoy and come out feeling more compassionate, brave, and encouraged!

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New BFRB Group!

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New BFRB Group!

Hello Bay Area!

I am starting a new psychotherapy group for sufferers of body-focused, repetitive behaviors April 13, 2015! The target is to have 4-8 individuals meeting for 75 mins weekly on Mondays at 5:30 pm. In this group, you will learn about the why's and what's of hair pulling, skin picking, and nail biting, and be able to explore how to manage them within your life uniquely. Most importantly, it will open up a safe space for you to tell your story and obtain support from others who can understand your struggle. This group will involve these important relational pieces, as well as the didactic ones.

Update: Even though the group has begun, it is not too late to join! But please inquire sooner rather than later to minimize the lag in curriculum. Thank you and looking forward to meeting you!

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Obtaining Treatment

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Obtaining Treatment

In a study of trichotillomania, it was revealed that only 19.1% of respondents had received psychotherapy, and 30.7% a behavioral intervention (e.g. self-monitoring, habit reversal), for their hair pulling symptoms (Flessner et al., 2006). These findings illustrate that majority of individuals are not seeking help, and that majority of providers are not informed to recognize or ask about pulling. Only 3.1% of those reporting treatment felt that their provider was an expert on trichotillomania, which clearly pertains to another finding: 74.5% rated their hair pulling as minimally improved to very much worse following treatment! This issue is illustrative of a broad problem: Sufferers need (1) to recognize when their BFRBs are problematic, (2) to be informed that help exists, and (3) to be able to enlist help from a competent provider.

These three issues each have their own complications. In the first issue, recognition is complicated by the fact that some amount of picking/pulling/biting is normal. This makes it easy to overlook the behavior with rationalizations or minimization about it as a form of grooming, development, etc., any of which can be true! The point is that it may be benign… or it may be something that warrants clinical attention. BFRBs can seriously impair daily functioning and bring on lasting physical damage, social avoidance, and feelings of shame, anxiety, and depression. No matter if it’s a child, teen, or adult, if someone is regularly picking, pulling, or biting, there’s good evidence something’s underneath that they feel they have to resolve auto-sensuously. And I don’t want people to have to suffer alone.

The second issue is more systemic. There is no single, reliable, or comprehensive place to find a therapist. And there is little education guiding people into knowing what they are looking for. Mental health remains one of those elusive and ambiguous fields that leaves individuals feeling around in the dark. Sufferers are limited in their awareness of providers, and providers are similarly limited in their awareness of each other. The TLC site is one of the most unified for BFRB sufferers, but still can only offer listings of those who opt to be listed. Referrals still rely primarily on word of mouth so ask around, and ask others to ask too. When you arrange a meeting with a therapist, know that it may take multiple, in-person sessions to get a sense of the fit. Therapy is built on the relationship, so listen to your subjective feelings of comfort with and trust in the therapist, and allow that to be a priority. People have all different personalities and work in all different ways, so “good” and “bad” will be more about personal taste.

Last but not least, the third issue involves enlisting help from a competent provider. In general, the underlying mechanisms for BFRBs and the extent of their impact are vaguely understood. Given the lack of attention and literature, it is especially hard to find a therapist who is familiar with, let alone specializes in BFRBs. More commonly, you’ll find a therapist who has heard of trichotillomania, for example, or has happened to encounter a client or two with it. A competent provider is one who can manage the hair pulling, skin picking, and nail biting through recognition of it as part of an entire impulsive, compulsive, anxious, depressed, desperate, and lonely picture. The focus needs to be on the person, not just the behavior. Commonly, other impulsive behaviors, such as binge eating, are co-occurring but not assessed, so take the time to invest in a therapist who can think globally, compassionately, and smartly on these issues.

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Why We Pull, Pick, and Bite

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Why We Pull, Pick, and Bite

Basic principles of operant conditioning tell us that behaviors are usually maintained because they deliver pleasure (positive reinforcement), or because they relieve some source of displeasure, like anxiety and tension (negative reinforcement). The answer to the "Why?" in terms of body-focused, repetitive behaviors, such as hair pulling, skin picking, and nail biting, may be more an "AND" situation: These behaviors are both positively AND negatively reinforced. While they may provide subtle stimulation, they are also an important source of distraction or dissociation... which brings me to my next "AND"...

Body-focused, repetitive, behaviors, better known as "BFRBs," are behaviors AND much more than just behaviors. They are physical means of emotional coping. BFRBs allow us to reduce our attention (cognitive narrowing) to a simpler and thus more tolerable level of experience - basic, objective, and rote sensations of the body. In this process, we get to distance ourselves from all of the harsh judgments we hold about ourselves, and fear that others may hold about us. This explains why BFRBs often arise while we are doing or thinking about a task we tie to our performance; for example, writing a paper. It is also our mere awareness of ourselves in these behaviors that keep them going. We judge ourselves for succumbing to pulling, picking, and biting and not ___(fill in the blank with whatever else we are "supposed" to be doing)___, and that makes returning to reality even harder. We wrap ourselves up in our sensations to create an autistic bubble where we are insulated from uncomfortable, emotional feelings.

Stay tuned for more on the autistic bubble and treatment implications...

 

 

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