LPCC

http://calpcc.org/lpcc

Licensed Professional Clinical Counselor, wow. I am waking up to the new, at least new to me, licensure for mental health practitioners. George goes to a therapist, but does George know the educational background or the licensure of that therapist? Is that relevant to George? Is it relevant to George’s insurance company? Why should George care, and should his therapist have full disclosure about his education. Some therapists are physicians, some have PhDs in psychology, some have PhDs in non-related fields, some have PsyDs, some have EdDs, and all these folks are called “doctor”. Then, there are therapists, some of whom are LCSWs, some are MFTs, some are LPCCs, some are RNs, and some are NPs. The difference in licensure also speaks to a difference in mandatory continuing education. Some licenses require ongoing ethics training, whereas others do not. An MD needs continuing education, but they can learn about emergency medicine or wilderness medicine; they are not mandated to have continuing education in their field.

Newer psychiatrists need to take their Board examinations every ten years ( I do not, because apparently I have a grandfather), but does the patient know if their psychiatrist is board-certified, and if they are, if they have re-upped at the appropriate time? What about the RN? How does going to nursing school prepare you to become a psychotherapist? Some RNs go on to further training, such as psychoanalytic training, but this is not required. Their nurse’s license allows them to put up that shingle and get malpractice insurance. What about that PsyD that follows after some therapists name? This is a doctorate, without the rigors of a PhD, that is offered by many mental health training programs, but most folks who get a PsyD are licensed as MFTs, and so they practice under one license, but they get the respect of their highest degree. All that is fine, but what should the patient know?

Now, we add on to the complexity, by California becoming the 50th state to introduce another license, that of the LPCC. Why? Please tell me why we need another silo of mental health practitioners? I can understand that the Affordable Care Act is going to result in an  an explosion in terms of the mental health needs of the newly insured. There are not enough clinics, practitioners, physical space, to see the projected demand for mental health intervention. There are going to be limits to the number of sessions one can access, but there are also going to be limits as to what kind of professional one can see. The adage is that everyone should work to the maximum utility of their license. In other words, a physician should not spend their time at the xerox machine (I am old, I know). So what can an LPCC do that an MFT cannot do? When does the LPCC say “this is beyond my scope”? Medication management is the most obvious dividing line, but even this issue is debatable in certain states like Louisiana and New Mexico where psychologists can prescribe. Also, how am I so isolated that I am only now hearing about the LPCC? I am an active volunteer faculty member at UCLA and I am on the mental health board at the Venice Family Clinic, and I work with many mental health students in training, and yet I had no idea this license existed until very recently. This makes me curious, but at the same time, I have a strong hunch that the answer is political and not clinical. Each degree program creates new schools, new licensing fees, new continuing education requirements, which create a demand for administration and teachers. Still, I want to know more. Please tell.

 

Oh, one more thing, on the Board’s website http://www.bbs.ca.gov/, I found the following:

 

“There is no restriction regarding the assessment and treatment of children in LPCC statute or regulation.”

 

That quote will be for another rant, I mean post.

Why Cognition Only Goes So Far

http://www.latimes.com/news/opinion/commentary/la-oe-wood-neal-habits-dieting-bloomberg-20130809,0,5731193.story

“Habitual behavior implicates parts of the brain that have relatively sparse connections to other brain areas involved in conscious decision-making (willpower) and goal setting. In effect, our bad habits represent neural islands, pretty much cut off from our thoughtful planning. We really can be of two minds — knowing and wanting to do the right thing but also unconsciously driven by habits triggered by the everyday contexts in which we live. In other words, willpower has limited command over our habitual mind. On top of that, exerting it is arduous, unpleasant and hence typically short-lived.”

Behavior is multi-determined. We can know what to do and then not do it. This applies to eating, relationship choice, and career decisions. Today’s LA Times Op-Ed article about changing eating patterns by Wendy Wood and David Neal outlines this issue. Understanding the depth of the human brain allows us to appreciate the complexity of behavior change. Merely understanding that eating too much sugar is “bad for your health” does not address the other brain structures which trump this understanding. These other brain areas can be habit areas, where our brains work on auto-pilot, or they can be in deep emotional areas where we want immediate satisfaction at the expense of long-term problems. Our brain is in constant conflict with itself, thereby giving us conflict in decision-making. We must balance out routines that are familiar, with the anxiety of a new activity. For some, this anxiety is coded as excitement and so fresh experiences are constantly wanted. For others, the comfort of sameness is more important than a new adventure. For most of us, we seek a balance, but finding this balance is the art of living. How do we enjoy food, without eating to excess? How do we not use food, as an outlet for sensual gratification? Understanding the basics of nutrition does not address the deeper meanings we attribute to the act of eating. These “neural islands” as stated above, describe how a person can be at war with himself. Psychotherapy attempts to bring these islands together to form a continent of understanding and awareness. Behavior can change, but not quickly, and not without harnessing all of the factors that go into that behavior. Cognition is only one piece.

The Violent Brain

www.latimes.com/…/la-na-prisoner-brains-20130715,0,5130358.story‎

The anterior cingulate cortex(ACC)  fires, giving the person a feeling for what others experience, otherwise known as empathy. It stands to reason that those who have an ACC which fires with more intensity are going to have a greater sense for what others experience. So, the researchers from Kent Kiehl’s laboratory found that when scanning violent inmates, those with low ACC firing are more likely to be repeat offenders. As Michael Haederle reported in today’s LA Times…

 

“The trove of data they have gathered has revealed telltale abnormalities in the structure and functioning of psychopaths’ brains. On the whole, they have

less gray matter in the paralimbic system — believed to help regulate emotion — which may help account for their characteristic glibness, pathological lying,

lack of empathy and tendency to act impulsively.”

The nature/nurture argument returns. Empathy and impulsivity seem to be largely innate qualities, such that if we can measure brain activity in convicted criminals, we would get a better sense of a person’s predisposition towards further heinous crimes. Yes, this is not perfect, and so biological data can be used to convict criminals who should be given a second chance. However, this does not mean that further exploration about how brain activity predicts behavior should not be done. In other words, this report is an exciting development in understanding how brain function influences judgment.

Judy Garland

 

Thinking about Judy Garland, having  just seen “End of the Rainbow” http://articles.latimes.com/2013/mar/16/entertainment/la-et-cm-tracie-bennett-end-rainbow-20130317, with fellow psychiatrists, we engaged in a heated debate about the nature of her suffering. ?Bipolar, ?ADHD, was the launching pad for the discussion, and yet my thoughts turned to her horribly sad childhood in which, she made money for the studios, and in the process, she was fed prescription drugs to keep the “machine” going. “Trauma,” I said firmly, in trying to understand this icon. She seemed robbed of a time in her life to “play” even though some might say that acting is a form of playing, Judy Garland had to play like she was told and so, by definition, this was not the kind of play in which she could make up her own rules, and have a time in her life in which her activities were inconsequential. This left an inner emptiness, a “zombie state,” as a colleague of mine says, in which she could never experience the sensation of being alive, but rather she enlisted her superego to do what she “was supposed to,” thereby leaving her feeling without satisfaction or fulfillment. She never had a chance to experience her ego, as her superego was running her life, from such an early age. Her many husbands, it seems to me, provided this superego, until one of them tired of the emptiness. She never seemed to know herself, to know her ego, and as such, she could never find a path towards happiness. As Ray Bolger, her co-star in the Wizard of Oz, succinctly stated, “”she just plain wore out.” Like a machine, the gears could no longer turn. Sad, sad, and sad. There is no diagnosis, as far as I can see, but only an incredibly talented woman who never developed a sense of herself. What do we call that? I call that child abuse.

Tiger Woods: Why We Care

This is part of my series on the mental health and the media.

Tiger Woods rose to stardom and now he is falling. We viewers love the story. First, we enjoy having heroes. Heroes makes us feel that we can achieve anything that we want. They affirm life. We identify with super stars and we begin to believe that we can also do anything that we set out to do. We feel empowered. Then, after a while, we begin to grow envious of our heroes. Tiger is getting a lot of attention. We stop identifying with Tiger and now we secretly hope for his decline. Sure enough, there is a scandal. We, the viewing public, are excited. We were excited to see him rise to the top and we are equally excited to see him fall.

As a viewing public, we are prey to marketing experts. These marketing geniuses know that they can create an image that the public wants to believe in. A salesman relies on common sense. In particular, the common sense that people want to feel good about someone so that they can feel good about their own lives. Sports icons, like all stars, give us hope in our world and in our selves.

Everyone loves to know a secret. It makes them feel special. This power in knowledge kept hidden is thrilling. Tiger had many secrets. We, the viewing public, felt excited to know about them. Privacy is respected, but secrecy is stimulating.

In 2007 we learned for former North Carolina Sen. John Edwards’ affair. Again, the public expressed shock and contempt, after believing that he was a “family man” standing by his wife who had a diagnosis of breast cancer, and his three living children. The shock was ours because we believed the image. We wanted to believe the image.

According to Robin Abcarian of the Los Angeles Times, on December 11, 2009, Woods announced that he would leave professional golf for an indefinite period to work on healing his marriage. “He asked his fans, colleagues and business partners for two things: understanding and privacy.” Understanding is not an issue. We all understand succumbing to temptation. Privacy, on the other hand, is another matter. He marketed himself to promote products. Name recognition made him profitable. Publicity made him rich. Now, he wants privacy so that he can then re-enter the public  eye and get publicity again.

Indeed, Tiger Woods will be back. Not only, do we, the viewing public, love a new hero, and then love to see the hero fall, we also love a come back. It is as if Tiger knows this. He is asking for a reprieve from the publicity, so that he can come back a “new man”. We want this redemption for him. We want this for ourselves.