Cathartic Response to Anxiety Overload

Photo by boram kim on Unsplash

How familiar are you with your body’s response to anxiety? Perhaps you already know the symptoms of how your body shows you that you’re feeling anxious. Symptoms like elevated heart rate, sweaty palms, flushed face, clammy skin, muscle tension, tension headaches, shallow breathing, uncontrolled worry, rumination, and more. Mild anxiety can serve as a motivator to ease our discomfort by spurring us into action. But what about when it becomes unbearable? An anxiety attack. An 8 our of 10 on the discomfort scale?  As humans, we can only sustain this level of discomfort for so long. Our bodies want to express or expel the discomfort to get back to our baseline of functioning, most easily accessed through cathartic release. Let’s take a look at some predictable choices the body has for cathartic release to return to baseline.

1.     Crying. Although clients may feel apologetic or uncomfortable with their own tears, it’s not uncommon for them to report feeling better or at least more neutral after a really good cry. This cathartic release is a common option their body chooses when feeling high levels of anxiety, with or without their consent. As therapists, we can support them in identifying safe spaces for crying if they feel uncomfortable with the expression or have a childhood chalked full of messages saying they shouldn’t cry. Therapeutically, crying can be a healthy outlet for anxiety.

2.     Screaming. Have you heard of scream therapy? Children have been encouraged to scream to regulate their little bodies. Adults may embrace this outlet on rollercoasters or a well-insulated car or soft pillow. As another expression of expelling strong emotions, it can be effective under the right conditions.

3.     Orgasm. Underrated yet effective! This is a more challenging cathartic release because of the blocks to libido and sexual arousal that can occur in states of high anxiety, especially in women. Yet the benefits of orgasm have been documented, including relaxation, more youthful appearance, and of course, stress relief!

4.     Comfort in Food. Have you noticed times where you are feeling stressed or anxious and crave comfort food? This is the body’s response to elevated cortisol levels, also known as stress hormones. When cortisol levels spike, we crave fatty or sugary foods. Seeking foods we enjoy can also be an emotional response to stress, such as seeking dopamine, the “feel good” hormone to feel happier or using food to fill the void of needs that remain unmet.

5.     Exercise/Movement. This is a cathartic release that is often found low on our coping list because of the assumption that we need to go to a gym to exercise. However, exercise is all about movement which increases oxygen intake and blood flow, both of which help us feel less anxious. Imagine being able to trick your brain from recognizing an elevated heart rate as an anxiety attack to an elevated heart rate due to movement or exercise? Not only does working our muscles give us some relief, the pleasant sensation of tired muscles or a loose, jelly-like feeling to our limbs after intentional exercise can be an enjoyable sensation after the discomfort of anxiety. Movement also serves to increase our breath, which can be a strategic response to anxiety which tends to make our breathing shallow and strained at our lungs instead of deep, restorative breaths at our belly.

Now that you’ve explored five possible cathartic release options to strong emotions including anxiety, which are you most likely to choose? Is there one outlet you’ve forgotten that deserves some experimentation to see how it works for you? As you can imagine, not all of these cathartic release tools are options depending on being in the community versus being at home. Yet in the therapy space, these outlets are seen as tools that can serve as homework to try, gathering data on what works best for your body in response to elevated anxiety you want to shift.

What Pilots can Teach Perfectioneurs

Pilots and Perfectioneurs have a lot in common. Pilots can serve as examples of Perfectioneurs. The archetype of pilots is often one of confidence, charisma, attention to detail, and assertiveness, placing them one step away from the steamrolling potential of overworked Perfectioneurs. 

Pilot or Perfectioneur?

·      Maintains attention to detail

·      Works long hours

·      Defines identity by what they do

·      Prefers jobs where they are in control 

Make no mistake, we absolutely want people who are driven and have attention to detail flying various aircraft. It is directly connected to our well-being and safety as passengers. We also want to know that the people selected to hold this responsibility are performing at their best. Fit for duty. Therefore it’s no surprise that Aviation Psychologist Dr. Paul Dicken’s guide for pilots to re-enter the workforce during COVID-19 has been downloaded 65,000+ times since its release! 

Being a licensed therapist married to a pilot, I was excited to interview Dr. Dickens as one of 11 Accredited Aviation Psychologists in the EU. His passion for this work was palpable over Zoom and we found ourselves in easy conversation on the similarities between pilots and perfectionists. It’s not surprising then, to recognize that his suggestions in the areas of physical, cognitive, emotional, and relational needs compliment the work-life balance criteria for many other professionals attempting to adapt during COVID-19.

Some recognizable tips from Dr. Dicken’s guide Cleared for Take Off! A Pilot’s Guide to Returning to Flyinginclude: 

·      Set sleep patterns and sleep hygiene rituals

·      Adopt an exercise regimen

·      Gear up for work mode through reading materials and visualization

·      Practice self-awareness to identify how you feel about returning to work

·      Prepare your family for the transition back to work

Meaningful and relevant, these tips apply to entrepreneurs, first responders, and perfectionists as well. Let’s take it a step further to see how pilots address psychological safety at all stages of flight, captured in the acronym IMSAFE and created by the Federal Aviation Administration (FAA).

Illness- Do I have any symptoms?

Medication- Have I taken any over the counter or prescription drugs?

Stress- Am I under psychological pressure from the job? Am I worried about financial problems, health problems, or family discord?

Alcohol-Have I been drinking within 8 hours?

Fatigue- Am I tired or not adequately rested?

Emotion- Am I emotionally upset?

What if we modified the IMSAFE acronym for people during COVID-19 in order to capture what we are tracking as mental health and wellness needs during this challenging time?

Illness- Do I have any symptoms of illness?

Medication- Do I take prescription or over the counter drugs? Do they pose any risk to my functioning? Are they helpful to my functioning?

Stress- In this time of unknown, what’s my current stress level? Does it fluctuate? When?

Alcohol- Am I drinking out of a desire to cope or fight boredom?

Fatigue- How tired do I feel? Am I getting enough sleep? Too much sleep?

Emotion- Am I aware of how I feel? Where do I fall on the spectrum between anxious and numb?

IMSAFE poses some important questions to ask ourselves as we attempt to adapt and change during COVID-19. Change is difficult, especially for professionals that covet feelings of being in control. Therefore pilots and the FAA have a lot to teach us about the importance of checklists to gauge our functioning since it’s subject to change. Perhaps we can consider checking in on our functioning with the IMSAFE acronym. Maybe the tips from Dr. Dicken’s guide can help individuals preparing to return to work. Either way, pilots have a lot to offer perfectionists including disarming resistance and normalizing the vulnerability of adjustment. It’s possible that these resources will pave the way for additional conversations on coping during COVID-19, allowing perfectionist pilots to be the role models of adaptive functioning and pivoting during a pandemic.

Connect with Dr. Dickens on LinkedIn

Check out Dr. Dicken’s full guide here.

See more tips for pilots with the IMSAFE protocol here.

Medicaid Mastery in your Practice

Disclaimer: Medicaid in each State and Region have different expectations. I am not employed by Medicaid, therefore any information conveyed here is subject to change and should be further explored by you and your Medicaid Liaison. This blog is not meant to train or advise you on how to bill Medicaid for your services but as a base from which to understand an overview of generally accepted practices from a Medicaid standpoint in the State of Colorado with regards to paperwork compliance.

You hear the word AUDIT and maybe the first image you think of is an agent in the movie The Matrix. The uniform dress code, authoritative air, serious tone, and unreadable face? Perhaps you envision an auditor setting up camp in your office for three days straight, going through your files with a fine-tooth comb?

Reducing Audit Anxiety

Medicaid can be scary and it can also be rewarding in being able to work with the clients you love serve. Luckily, for many private practice therapists in Colorado who are Medicaid Providers, an audit doesn’t look quite as intense as a Matrix movie scene.  In my experience so far, an audit request from Medicaid (at least in Colorado) comes in the mail and tends to be packaged as a request for several progress notes or documents on various clients, to then mail or fax back to Medicaid within 30 days for review. At that point, you would get a percentage grade of compliance and written suggestions for improvement going forward as a Medicaid provider. From this basic explanation, some of you are breathing a sigh of relief knowing that you have your paperwork ready and able to send off in a timely manner.

Solutions in The Super Six

But what about those of you who aren’t feeling so confident? To be honest, we know that the majority of therapists did not get into this profession for paperwork. You were called to this work to help others and to make a difference. In an effort to streamline your process and continue meaningful work with your clients, please allow me to introduce you to The Super Six paperwork items Medicaid (in Colorado) requires for compliance.

1)    CCAR: Colorado Client Assessment Record

The CCAR is an administrative document that provides a snapshot of client functioning at intake, update, and discharge. It’s currently on hold indefinitely by State Medicaid who is reporting updates to their system as of July 1, 2018. So far any of you starting with Medicaid in Colorado, you are in the clear! And for those of you working with clients prior to July 2018, you’ll want to have a CCAR (or several) included in your client file.

2)    Mental Health Assessment

Just as it sounds, the Mental Health Assessment is part of your formal intake to explore symptoms, client needs, and justification for a mental health diagnosis. It also serves as a temporary treatment plan as you continue to build rapport and in further sessions to refine and confirm your goals with your client. Mental Health Assessments cover a significant span of questions including mental health history, family history, legal involvement, substance use, trauma, developmental milestones, and more.

3)    Treatment Plan(s)

A treatment plan is an outline of goals and means to make progress in therapy. Many therapists have adopted the SMART acronym as a framework for formatting a therapeutic treatment plan, which stands for Smart, Measurable, Attainable, Realistic, and Timely. Treatment plans should address the diagnoses given to a client at intake and reflect means of making progress towards those goals. Treatment plans should be updated regularly, recommended as every six months. Lastly, treatment plans should be personalized to each client including capturing in their own words what they would like to accomplish in therapy with you.

4)    Progress Notes

The meat of the therapeutic file, progress notes provide the trail of progress made in the therapeutic relationship. An auditor expects to see what you contributed in each session as the provider, the client’s response to the therapeutic interventions offered, the progress made in each session, and the intention of future sessions. SOAP or DAP notes are an acceptable format with some minor tweaks for Medicaid compliance.

5)    Discharge Summary

When a client in no longer working with you in therapy, planned or unplanned, Medicaid desires a summary of the client at discharge. This document tends to be placed at the top of a file as a snapshot of closure from services including frequency of sessions, medication(s) at time of discharge, recommendations, and designation of discharge as positive, negative, or neutral. Designation can be interpreted by you as the therapist, with some examples being a positive discharge if finished with their identified goals, negative discharge if the client disengaged or ghosted therapy, or neutral for when a client changes insurance funding or moves out of state, preventing them from continuing in therapy with you as their provider.

6)    Medicaid Client Rights

The last of The Super Six is a document provided by Medicaid as providers are contracted and approved to see Medicaid members as clients. Similar to your own mandatory disclosure statement, the Medicaid Client Rights is a document that outlines your client’s rights in using Medicaid for medical and mental health services, including items such as each member has the right to the best fit therapist, right to access their file, right to file a grievance, and more.

The Evolution of EHR

So you’ve got the paperwork down, knowing that Medicaid still loves paper files and client signatures throughout. But what if you are wanting to go paperless with an EHR (Electronic Health Record)? The good news is that EHRs have really simplified paperwork compliance, allowing the writing of notes, signing of documents, and billing of claims, all with the click of a button! With that being said, you will still need to modify templates in any EHR you use, knowing that they aren’t automatically Medicaid compliant. 

Some suggested modifications and tips for EHR and compliance include:

a.     Identifying the place of service on your session progress note (i.e. office, community, group home, client home)

b.     Ensuring your full legal name and credentials are reflected in the note as you lock it to electronically sign it 

c.     Writing and signing/locking your notes within seven (7) business days of the completed session

d.     Indicating the next scheduled session with full date and time to show intention of continued therapeutic work

e.     Including the Medicaid number/identifier for your client in each note

Final Tips for Avoiding an Audit

The paperwork may feel cumbersome, but if you can master it, you can master any other private insurance’s requirements for compliance as many find Medicaid to be the most rigorous! Allow yourself to adopt new strategies to refine your paperwork process and feel confident that you can pass an audit! Keeping confidence in mind, here are some final tips to help you master Medicaid!

1.     Never collect money from a Medicaid client or their family

2.     Obtain client signatures on your Mental Health Assessment and every treatment plan

3.     Be cautious of billing case management if working within a traditional outpatient therapist role, this is one element that increases risk for audit due to others’ misuse.

4.     Be sure to explore compliance needs within your state and region and move forward implementing changes as soon as you become aware of them

You’ve done it! You’ve utilized this blog as an initial framework and checklist for Medicaid Mastery and Audit Avoidance! Congratulations on your hard work and welcome to the Medicaid family!