Portland Psychotherapy’s Clinical-Research Social Business Model Published in APA Journal – Psychology Research and Practice

Portland Psychotherapy’s Clinical-Research Social Business Model Published in APA Journal – Psychology Research and Practice

Many of those reading this blog probably already know that that in addition to providing science-based mental health services, Portland Psychotherapy is also a productive independent research center.

How we fund our research

What many of you may not know is how we go about funding that research. To our knowledge, we are the only organization of its kind to have set up a private mental health clinic and research center based on social business concepts in which the profits from the money-generating activities of the organization go back to serving the greater good (in this case, scientific research) rather than be used as profits for shareholders.

What we discuss in the article

We are very excited that the APA journal Psychology Research and Practice just published our article that outlines our model, which we call the clinical-research social business model. Among some of the things addressed in the article include:

  • An outline of our clinical-research social business model that is based on social enterprise concepts
  • How we overcame the barriers to conducting research outside of academia, including how we created an independent IRB and how to address infrastructure limitations such as assistants and access to journal articles
  • Benefits of conducting research outside of traditional academic settings
  • How we have shifted the contingencies around money in our model and structure our model such that intrinsic rewards such as mastery, autonomy, and purpose can serve as powerful motivators that advance more communal and creative goals.
  • Ideas about how our model might be applicable to other settings.

One thing we are very aware of at our center is that all our work depends upon a supportive community. If you are reading this, it is likely that YOU are a part of that community and we thank you for that. If you are interested in reading more about our model, how it came to be, and what your support of us has helped make happen, you can read the a pre-print of the article here.

Jenna LeJeune, Ph.D

Author: Jenna LeJeune, Ph.D

Jenna is a clinical psychologist who specializes in working with people who struggle with relationship and intimacy difficulties and with those who have a trauma history. Her research focuses on developing compassion-based interventions targeting stigma, shame, and chronic self-criticism.

Tips for Therapists Making the Change to ICD-10

Tips for Therapists Making the Change to ICD-10

In case you didn’t know already, starting October 1st 2015, insurance companies will start using the ICD-10 system for diagnostic codes, rather than the ICD-9/DSM codes. For any Date of Service (not date of claim submission) Sept. 30th or before, clinicians will still need to use the DSM codes. But any claims submitted for dates of service Oct. 1st or later will be rejected if they are not ICD codes. If you are a clinician billing insurance, you need to make this change or else you will be soon running into a lot of problems with rejecte claims.

What’s the difference between the DSM and the ICD system? Do I still need both of them?

DSM is a diagnostic determination guide. It can be a resource in providing information needed to make an accurate diagnosis, but it is a ICD 10 diagnosis (not a DSM diagnosis) that we are to now assign clients. It should be noted that the DSM may not be the ONLY or definitive source in determining diagnosis. According to the APA, “Psychologists might access that content through the DSM or through other resources such as the professional literature, practice guidelines or other accepted sources [to determine appropriate diagnosis]”.

Can’t we just have a simple chart that converts our DSM codes to ICD 10 codes?

No. The DSM V is NOT synonymous with the ICD-10. There are MANY more codes in the ICD-10 than there are in either the ICD-9 (which is roughly equivalent to DSM-IV) or the DSM V. There are approximately 14,000 codes in the ICD-9 but more than 68,000 codes in the ICD-10 (though of course we mental health professionals will only use a small fraction of those codes). While most of the ICD-10 codes are in the DSM V, some of the more specific ones are not. So, psychologists can’t simply convert DSM codes to ICD-10 codes automatically. PTSD is a good example of why a simple conversion from DSM V to ICD-10 isn’t going to be accurate. The DSM-V only has a code for PTSD “unspecified” type, while the ICD-10 has diagnostic codes for both PTSD “Acute” and “Chronic” types that are not in the DSM-V.

How can I find the correct diagnosis?

In general, you can find the correct corresponding ICD 10 code for most of the DSM diagnoses listed in the back of the DSM V. However, there are some ICD10 codes that aren’t listed in the DSM V, as in the case mentioned above about PTSD. So you can’t just rely on the DSM. Instead, we suggest crosschecking your diagnosis using one of several “crosswalk” tools available online. Two such resources would be:

  1. ICD-10 Code Lookup
  2. ICD-10 Tabular List

Need for specificity, particular in relation to substance use disorders

One factor accounting for the increased number of codes in the ICD-10 pertains to the number of specifiers for the different diagnoses in the ICD 10. This is especially true for the substance use disorders. The increased use of specifiers is a main difference many clinicians will need to become familiar with as they move forward using the ICD-10 system starting Oct. 1st. It is important to be as specific as possible in selecting ICD-10-CM codes — that is, when known, use the code structure to indicate severity or other meaningful diagnostic information. Try to avoid “unspecified” diagnoses, as plans may not reimburse for them — plans are looking for increasing specificity in diagnosis.

No More NOS – “Unspecified” versus “Other Specified” diagnoses.

When the DSM switched from IV to V, the NOS specifier was replaced with two options “Unspecified” and “Other Specified”. The ICD 10 also uses this distinction. “Other Specified Disorder” allows the clinician to specify the reason that the criteria for a specific disorder are not met (it is required to give reason(s) why the criteria are not met in the diagnosis field).  An example of this would be other specified depressive disorder, short-duration depressive episode, 9 days.

“Unspecified Disorder” allows the clinician the option to forgo specification.  This would be used instead of deferring a diagnosis when a client does not meet criteria AND the provider cannot specify due to inadequate info.  This will likely not be an acceptable reimbursable diagnosis.

It has been suggested that when you have the choice between an “Unspecified” and “Other Specified” diagnosis and both seem equally valid, choose the latter, and document in the chart what criteria were not met for you to use another diagnoses of this category.

How do I diagnose substance use disorders with the ICD-10?

This is probably the biggest category of changes from the DSM to ICD-10 system. The APA has created a very useful step-by-step guideline for diagnosing substance use problems using the ICD-10 system that can be accessed here.

Jenna LeJeune, Ph.D

Author: Jenna LeJeune, Ph.D

Jenna is a clinical psychologist who specializes in working with people who struggle with relationship and intimacy difficulties and with those who have a trauma history. Her research focuses on developing compassion-based interventions targeting stigma, shame, and chronic self-criticism.

New resource: a dictionary of terms commonly used in transgender and gender nonconforming communities

New resource: a dictionary of terms commonly used in transgender and gender nonconforming communities

APA has a new set of guidelines for psychologists working with transgender and gender nonconforming people (TGNC). In an appendix to those guidelines, APA included a very useful index defining many of the terms used within the TGNC community. Terminology of this sort is rapidly evolving and it can be difficult to stay abreast of it all. The index APA included in its guidelines is a helpful resource as psychologists strive towards treating others in a respectful and culturally competent way. For example, the term “transgender” has rapidly become part of American lexicon, especially since Caitlyn Jenner told her story in Vanity Fair magazine earlier this summer. However, although I’m familiar with the term, I’ve never heard the term “cisgender” used in the popular media. The APA terminology index defines “cisgender” as “An adjective used to describe a person whose gender identity and gender expression align with sex assigned at birth; a person who is not TGNC.” Only using a term to describe one experience/group implies that those in that group are “not the norm”; you’re either transgender or you’re “normal.” By knowing and using terms like cisgender to describe people whose experience isn’t that of those in the TGNC community, we make a small but important statement affirming the equality of all experiences of gender identity. If you’re interested in updating your knowledge of terms commonly used in the TGNC community, go to the appendix of the APA document.

Jenna LeJeune, Ph.D

Author: Jenna LeJeune, Ph.D

Jenna is a clinical psychologist who specializes in working with people who struggle with relationship and intimacy difficulties and with those who have a trauma history. Her research focuses on developing compassion-based interventions targeting stigma, shame, and chronic self-criticism.

A woman and her voices: The case for a functional contextual view of psychosis.

A woman and her voices: The case for a functional contextual view of psychosis.

“Insanity – a perfectly rational adjustment to an insane world.”

– R. D. Laing, Scottish psychiatrist

When I teach “Abnormal Psychology,” one of the first things I do is tell the students that we will no longer be referring to the class as “Abnormal” psychology but rather, “The Psychology of Human Suffering.” Much of the course focuses on helping students see how those who suffer in ways that happen to be associated with a diagnostic label are not fundamentally different from those who suffer in ways that are yet to be pathologized.  A main message is that mental health is not an “us” versus “them” problem. Rather, we all struggle and suffer. Some forms of suffering we happen to label with names that are written in a book called the DSM and others we label with names that aren’t in that particular book. Usually toward the end of the semester, students are generally on-board with this alternative to the traditional medical model view of mental illness.

But then comes the final chapter of the course: Schizophrenia and psychosis. The reaction is predictable and goes something like this: “OK, I can get that people who experience what we call ‘Depression’ or ‘Panic Disorder’ or even ‘PTSD’ aren’t fundamentally different than me, but psychosis?!? Those people are really crazy! Right?” Of all the psychiatric diagnoses we put on people, the one that we still cling to as being fundamentally “crazy” or as being a “brain disease” is psychosis, usually defined as people hearing or seeing things that others don’t hear or see. It’s a very common presumption, even probably among we mental health professionals. Even look at the phrase we frequently use to describe the phenomenon; we describe people who have these experiences as “SMI patients” (i.e. “serious mental illness”). This presumption of pathology is so tenacious that it’s been difficult for me to help my students question it in the same way they have come to question some of the other presumptions they have.

So I was delighted a few weeks ago when I came across this inspiring and refreshing TED talk through my Upworthy feed this week. In it, Eleanor Longden, international speaker, doctoral candidate in Psychology, and voice hearer, describes her experience hearing voices and how unhelpful she found the pathologizing approach taken by the mainstream establishment. She talks of how the psychiatric and psychological establishment was solely focused on trying to figure out what was “wrong” with her, and then, following their assumption of pathology, try to “fix” her (i.e. make her voices stop or at least make her stop acknowledging that she hears voices) by doing whatever means necessary. The result was that they were largely unsuccessful and even made it worse.

I found Ms. Longden’s story both inspiring and very consistent with some of the assumptions of Acceptance and Commitment Therapy (ACT) and contextual behavioral science in general . Contexual behavioral scientists, which would include ACT therapists, would not view hearing voices as inherently problematic. Rather, from perspective contextual scientific perspective, the experience of hearing voices needs to be examined in the same way we would explore any other behavior –contextually. While hearing voices is not inherently pathological or even problematic, they ways that people react to voice hearing often makes things worse.  The focus is less on the voices themselves as problematic, but instead how the voices are responded to and function in a person’s life.

Research seems to support this contextual non-pathologizing view of psychosis. To date there are at least 8 empirical studies, including 3 randomized controlled trials, demonstrating the effectiveness of ACT for people who experience psychosis. In ACT, the focus is not on decreasing a particular symptom, such as the hearing of voices, but rather on increasing flexible, adaptive functioning across a wide variety of contexts, including contexts in which the person may be hearing voices. And the data suggest that this approach tends to increase quality of life, and decrease a whole host of problematic outcomes, including rehospitalization, by some pretty astonishing rates.

If you are interested in learning more about ACT for psychosis, the protocol is available for free on the Association for Contextual Behavioral Science (ACBS) website. You do need to be a member of ACBS to get access to the protocol, but ACBS has “values based” dues which start at $10 per year. Those dues also get you access to the Journal for Contextual Behavioral Science as well as all the incredible wealth of resources and information available on the ACBS website.

Does Ms. Longden have a unique experience that falls outside the normal range of the bell curve? Probably. Does her experience of hearing voices result in suffering for her? At times. But does treating her experience as some disease, some pathology that must be stamped out at all costs help her live a fuller and richer life? Unfortunately not.  ACT and Contextual Behavioral Science offer an alternative that holds incredible promise for helping us all live meaningful, productive lives as Ms. Longden is doing.

Uncharted waters: Expanding a psychotherapy practice in uncertain times.

Uncharted waters: Expanding a psychotherapy practice in uncertain times.

“We’ll never make it!”

Glum from Gulliver’s Travels by Jonathan Swift

It started as early as my first year of college, some 20-odd years ago. I was in an abnormal psychology classroom in Boston, eager to finally get moving on my wished-for career as a psychologist that I had dreamed about for years. A professor I was working with at the time (AKA Dr. Glum) seemed determined to crush my hopes and dreams of becoming a clinical psychologist. “You’ll never make it.” “There’s no future in seeing therapy clients unless you want to work 70 hours a week in a community mental health center.” “And you can forget about getting to do research unless you happen to draw the golden ticket and get an academic job, but those are pretty much going the way of the dinosaur too.” While I might be taking some liberty on Dr. Glum’s actual words, there was a clear message she was trying to impart to us. The field of outpatient psychotherapy practice was on its deathbed and we’d better run the other way, fast!

I’ve heard this mantra of “you’ll never make it” throughout much of my training and well into my career. I still hear it today on professional listservs, among concerned graduate students, and even by those of us practicing in the field. Even just this week a colleague on a professional listserv posted a link to short cartoon about the futility of attempting to become a clinical psychologist. I found the video both somewhat offensive and tired– it’s still beating the same old “you’ll never make it” tune.

Of course much of what is being said has merit. We do have the problem of too many psychologists compared to demand. And we do need to be responsive to the changing landscape of healthcare in our country. But, is it impossible for a resourceful, skilled, well-trained psychologist to be successful in developing an outpatient clinical practice in this era? I choose to believe ABSOLUTELY NOT!

In fact, we here at Portland Psychotherapy continue to expand. We continue to invest in the concept that there will be a continued demand for quality, science-based outpatient psychotherapy. And I believe that demand extends to those in solo private practices as well. I know we are often looking for referrals to other providers who practice science-based psychotherapy and are frustrated when our “go to” referrals are often full. There is, and I think there will continue to be, demand for clinicians who are exceptional at what they do.

So rather than giving up, maybe the thing to do is focus on what makes us unique. In the case of clinical psychology, what I think us unique among other mental health providers is our strong foundation in and commitment to science. That means not only practicing “evidence-based” therapy, but also “science-based” therapy. For me, that also means being a true scientist-practitioner, one whose clinical work is informed by research. And just as science is always progressing, so too does our field need to continue to progress.

I maintain that all of the fear-mongering that’s been tossed around for at least the last 20 years is both destructive and disingenuous. Even with the glut of psychologists, it’s not like people are going unemployed. The APA Center for Workplace Studies reports that less than 1% of psychologists (Ph.D. or Psy.D.) can’t find a job. Dr. Glum was wrong! It is possible to develop a thriving clinical practice. It’s even possible to research in private practice, like we do at Portland Psychotherapy. So, if this is your passion, become exceptional at what you do, focus on what makes your contribution unique, and be resourceful. Rather than trying to scare off our competition with the “you’ll never make it” cries, join forces with other like-minded colleagues who are dedicated to being exceptional at what they do, let others know about your excellent work through good marketing, and work together to help support each other.

UPCOMING TRAINING EVENTS

How to be Experiential in Acceptance and Commitment Therapy

Jason Luoma, Ph.D.
April 23, 2021 from 12-1pm

Acceptance and commitment therapy (ACT) is, at its core, an experiential treatment, but is frequently delivered in a non-experiential way. Experiential learning involves going beyond verbal discussion, insight, and explanations of experience. But how do we do this in ACT and how do we know when we are spending too much time engaged in non-experiential modes of learning? This workshop will outline a simple model you can use to identify when you are in less or more experiential modes during therapy and easy methods to switch to more experiential modes. You will then have a chance to practice it in breakout groups and get feedback. Read More.


Ethical & Legal Considerations in Psychedelic Integration Therapy

Jason Luoma, Ph.D. and Brian Pilecki, Ph.D.
May 7, 2021 from 12-2pm

This workshop is based on extensive research and writing we have conducted into the legal and ethical issues of working with psychedelics in the current regulatory climate, as well as clinical practice doing harm reduction and integration therapy with psychedelics. It is informed by consultation with multiple experts on harm reduction, as well as attorneys knowledgeable about criminal and civil matters relating to drug use and professional practice. We will share with you all we know so that you can be more informed in the decisions you are making in your practice and be better able to decide whether to jump into this kind of work if you are considering it. Read More.


Case Conceptualization in Acceptance and Commitment Therapy

Jason Luoma, Ph.D. and Brian Pilecki, Ph.D.
May 21, 2021 from 12-2pm

This workshop provides a chance to learn concrete methods for conceptualizing cases from the perspective of Acceptance and Commitment Therapy. Formulating a useful case conceptualization is a foundational clinical skill that is essential in delivering effective treatment, and one that can be often overlooked in the process of working with clients. Participants will learn several formats for doing formal case conceptualization outside of session as a means to further develop knowledge and skill with ACT theory, as well as to learn a means to enhance treatment planning. The importance of ongoing case conceptualization throughout a course of treatment will be emphasized, as well as common pitfalls in conceptualizing client problems. Participants will also have a chance to practice newly learned skills with a case in breakout groups. Read More.


ACT Precision Training: In-Session Case Conceptualization in Acceptance and Commitment Therapy to Help You be Focused and Strategic in Your Interventions

Jason Luoma, Ph.D. and Jenna LeJeune, Ph.D
June 18, 2021 from 12-2pm

This workshop provides a chance to learn and practice in-session, in-the-moment case conceptualization of cases from the perspective of Acceptance and Commitment Therapy. This workshop focuses on helping you use ACT theory & in-session clinical markers to make more precise and strategic interventions. The main goal of this workshop is to help you become more adept at identifying in-session client behaviors that are indicators for particular ACT processes that are likely to be most relevant. The workshop uses a process we call ACT Circuit Training, which involves intensive analysis of a video of an ACT session and intentional practice in conceptualizing client behavior and generating possible ACT responses, followed by discussion and feedback. Read More.


ACT Agility Training: In-Session Case Conceptualization in Acceptance and Commitment Therapy to Increase Flexible Responding

Jason Luoma, Ph.D. and Jenna LeJeune, Ph.D
July 16, 2021 from 12-2pm

This workshop provides a chance to learn and practice in-session, in-the-moment case conceptualization of cases from the perspective of Acceptance and Commitment Therapy. This workshop is intended to help therapists be more flexible and nimble in their use of ACT processes, strengthening their ability to fluidly shift as needed between processes within sessions. Therapist learning ACT often develop tunnel vision, focusing too much on particular processes or responding rigidly when more flexibility is needed. Read More.


Therapy and Research in Psychedelic Science (TRIPS) Seminar Series

Second Friday of each month from 12:00 PM – 1:00 PM (PT)

TRIPS is an online seminar series that hosts speakers discussing science-informed presentations and discussions about psychedelics to educate healthcare professionals. This series was created to guide healthcare providers and students preparing to be professionals towards the most relevant, pragmatic, and essential information about psychedelic-assisted therapy, changing legal statuses, and harm reduction approaches in order to better serve clients and communities. This seminar series is a fundraiser for our clinical trial of MDMA-assisted psychotherapy for social anxiety disorder that Portland Psychotherapy investigators are preparing for and starting in the Fall of 2021. All proceeds after presenter remuneration will go to fund this clinical trial. Read more.

April 9th, 2021 – Ketamine 101: An Introduction to Ketamine-Assisted Psychotherapy with Gregory Wells, Ph.D.
May 14th, 2021  Research on MDMA and Psychedelic-Assisted Therapy: An Overview of the Evidence for Clinicians with Jason Luoma, Ph.D.
June 11th, 2021 Becoming a Psychedelic-Informed Therapist: Toward Developing Your Own Practice with Nathan Gates, M.A., LCPC