The Science of Observation Through The Senses

Do you feel like your therapist listens to you? Is there an appropriate time for a health care professional to touch you?

Listen to me, because I'm right here!

That’s an important question. In Washington State, touch between therapists and clients are limited to appropriate therapeutic touch, such as a handshake. However, I hold a license as a Registered Nurse, and there have numerous times when clients have shown me a wound that wasn’t healing, a mysterious rash on the arm, or presented with a cough that sounded more serious than the client was treating it [don’t worry: I always present my credentials, and ask a client if s/he would like my professional opinion on their medical question]. I might ask permission to touch near a wound to feel the temperature of the skin, or smell it to see if it is infected [or ask them to take a sniff if it’s within reach].  While I would never overstep the scope of my practice, I keep “Nurse Imei” ready for work when I’m in the therapy office, because it allows me to practice the best kind of medicine I know: the science of observation through the senses.

In an article posted on CNN.com, Abraham Verghese MD, Professor of Medicine and Senior Associate Chair for the Theory and Practice of Medicine, Stanford University, wrote:

The truth is, I love and embrace technology, and have no desire to return to the pre-CAT scan and pre-MRI days of old. But I see no reason to let new technology make us lose the abilities we have had for over a hundred years to make sophisticated diagnosis at the bedside. Indeed, it should make us so much better.

I feel the same as Dr. Verghese. I too love technology and how it has enhanced medical practice. But it shouldn’t prevent or distract us from observing the client with out own eyes, ears, hands, and olfactory nerves. What does this mean for those of us who conduct therapy sessions over the phone, or handle triage in this manner?

If you are thinking of trying therapy over the phone or Internet, your therapist should be thoroughly trained to conduct sessions in this manner.  My telephonic nurse triage training gave me excellent experience in listening to patients because I could not see them. I can’t see a grimace of pain, but I can ask and help a patient evaluate their pain level using an appropriate pain scale. I can’t see if there is blood in their urine, but I can ask a client to describe a color or a smell. I can hear over the phone is someone’s breath is labored, or if their thinking is foggy.

If you are a client attending F2F psychotherapy sessions, it is important that your therapist look — or attend — to you. Attending is a developed skill, requiring hours of learning to observe a person’s normative behaviors, both physical and emotional, while they are describing issues that arise. Even if your therapist takes copious notes, a good therapist is watching body language, eye movement, changes in the tone or strength of your voice, the shifting of your body when you are uncomfortable with a subject, and even the presence of sweat and color changes to your skin. It’s not uncommon for a trained counselor to mention when s/he believes you’re not being honest about your problems.

As an RN, I feel exceptionally lucky to have additional tools of observation to bring to the table. Many of these help cast light on the overall picture of mental health. For example, knowing the complications of long-term sleep issues on the heart, as well as its connection to the incidence of depression, would lead me to prioritize a client’s complaint of poor sleep because his partner wakes him up when he snores. With more observation and interviewing, I could find out that the client has sleep apnea, a condition that contributes to depression, heart disease, and problems with a relationship.

I received a book as gift at Christmas, “The Naked Lady Who Stood On Her Head” by psychiatrist Gary Small and Gigi Vorgan. The stories highlight the many physical observations an MD notes, and they are often so many, I wonder how those without more medical experience (such as a physician or a nurse) function holistically in the mental health office. I must conclude that the best therapists I know rely heavily on observing through their senses, and documenting everything that seems unusual or unexplained. Anything falling the medical category gets noted and referred to a physician.

The corporate client who walks into an office with the smell of body odor and urine alert any therapist to inquire about the patient’s strong odor as a contrast to his normative grooming habits. But if you were trained to detect the smell of ketones on the breath of a diabetic experiencing the beginning of a sharp rise in high blood sugar, these are skills that can’t be as effectively used over the phone or Internet. And that is an important problem in the world of telemedicine.

When Telemedicine Isn’t Going To Work

A woman who has the smell of alcohol on her breath while going through treatment for alcoholism is not going to be detected if she contracts for telemedicine sessions. It is the practitioner’s responsibility to determine who should receive “old fashioned” health care in-office, and the convenience of telemedicine sessions should not be offered to everyone.

Technology has not caught up with our imagination. Some day we might have “smell-o-vision”, but as of today, we can’t smell through the phone. Someday, we’ll have more home devices that can measure heart rates and give us audio of a minute’s worth of auscultation (currently, there is an app that can do this for the heart, but it has not been approved for professional use). Until then, clients and providers should consider when therapy sessions are appropriate for phone and Internet, and when they should be seeing a helping professional face to face.

What do you think? What happens when clients leave the medical office saying, “My doctor didn’t listen to me, ” or “She barely even took a look at my symptoms”? How can we integrate crucial emerging telemedicine technologies with the need for old-fashioned observation?

How Therapists Learn To Talk About Sex

When it comes to talking about sex, it seems like all roads lead to Rome it. It does not make a difference if a person comes to my office to talk about depression, worries about a child’s progress in school, or thoughts about the future. If therapy sessions last long enough to build a trustworthy and meaningful connection, nearly every client will eventually bring up the topic of sex. Some clients seek therapy specifically around sexual issues arising in their relationships, and sex becomes the primary lens into the relational style of the client. If you are considering therapy for the first time, you’ll likely want to choose a therapist who feels comfortable talking about your sexual concerns, questions, and interests. Developing that comfort has a lot to do with how therapists learn (or don’t learn!) about how to talk about sex.

Can you talk to your therapist about sexual issues?

While therapists in training and therapists in practice are expected to read a lot of material about sex, sexuality, and sexual dysfunction, therapists spend many hours listening to the stories of others, drawing from their own experiences, and learning the language of their client’s world in order to speak into the delicate issues arising in the lives of their clients. But as the subtle nuances of social circles and relationships evolve to include those who practice less “traditional” forms of sexual expression, such as hookups, sexting, “friends with benefits”, polyamorous couples and tribes, BDSM and kink, shared erotica, experimental or temporary gay or lesbian sex, clients express how difficult it is to find therapists who are comfortable and knowledgeable about the new sexual landscape. Even those who want to improve their sexual connection in a monogamous and committed relationship need to know that their therapist isn’t going to choke on his or her words when talking about sex.


From MGMhd on Youtube, a clip from “Everything You Wanted To Know About Sex (but were afraid to ask)”.

How Therapists Learn To Talk About Sex

The main ways therapists learn to talk about sex are not surprising.
1. They recall the good elements of how they learned about sex and sexuality.
2. They read books, both textbooks and popular literature and publications.
3. They practice talking about sexual issues in their training.
4. They receive supervision from a qualified professional, and receive feedback on how they are addressing the sexual issues of their client’s stories.
5. They may have completed additional coursework on specific sexual disorders or dysfunction arising from issues of sexual abuse.
6. They learn from discussing their own sexual concerns with a therapist, which is a requirement of most Master degree programs.

BTW, sex therapists have additional coursework and specific licensure requirements to call themselves sex therapists. Not every client will wish to seek a sex therapist, but all therapists share a minimum amount of hours studying about sexual issues addressed in therapy sessions.

How Therapists Can Learn To Talk More Effectively About Sex
Here are a few more ways therapists can improve the way they talk to their clients about sex, and how you as a client can find out if your therapist is comfortable addressing sexual issues.

1. Therapists can spend time carefully listening to how their clients talk about sex, such as lingo and terminology, body language, current interests, areas of shame, confidence, or experiences.
2. Therapists can regularly share and post resources that might help their clients expand their knowledge base about sex. For example, if you are a young, lesbian woman with concerns about recent sexual experiences, your therapist should know how to direct some of your concerns to available A/V material and books that support what you are learning in the therapeutic hour.
3. Therapists can spend time attending community-based workshops on sex and sexual expression that might better meet the needs of their clients.
4. Therapists can attend CEU’s (continuing education units) required for licensure renewal that are related to sexual topics. While these tend to be clinical in nature, such as “Addressing The Needs of the AIDS-affected Family”, how the clinician discusses those needs to the family, including sexual content, will help therapists build stronger rapport with their clients.

Long ago, I used to occasionally watch a late-night TV show featuring a call-in sex-advice spot similar to what cable TV has with Dr. Drew. Not only was it entertaining (the show included the star’s outtake moments breaking condoms over outrageously-bulbous dildos), it was also informative. People would call in with questions about various sexual practices, and she would non-judgmentally answer their questions. I watched the show because I felt all therapists should be this comfortable and informative talking and listening to people who are talking about sex.

While therapy is less about advice-giving, clients are reading the reactions of their therapist when they bring up sensitive stories about their sexual practices. A less experienced therapist (or an uncomfortable therapist) may be sending messages to the client that discourage open dialogue, but even experienced therapists who encounter clients with less-familiar (to the therapist) sexual practices should take immediate steps to: 1) inform a client when a topic is less familiar, and 2) educate him or herself about the topic in a reasonable period of time.

Uh, So What Happens If Your Therapist Says Something Stupid
Let’s say you picked a therapist, things are going well, and you start talking about sexual issues in your current relationship. Your therapist squirms, and talks about something else. You address the topic again. Your therapist looks at you like you’re an alien with three heads. Then he says something completely “wrong” to you, and you’re beside yourself with frustration, but since he’s the “expert”, you hold your tongue. Both of you look at your feet, and the last minutes of the session feel like a waste. You look at his website, and double-check that the therapist has listed “sexual issues” or “non-judgmental counseling” among the aspects of his practice. Now what?

I recommend you bring this up during your next session. Ask directly, “What kind of experience do you have addressing these concerns?” If you believe your therapist has misrepresented his scope of practice or experience, you have the right to terminate therapy and to break any signed contracts without fear of litigation. I know of at least one client who saw a therapist for five sessions before the therapist admitted that he did not support the kind of sexual practice the client stated he wished to address in the initial therapy session. While I find this unethical, it is not illegal. It is not uncommon for potential clients to ask directly such questions as, “How much experience do you have addressing lesbian issues?” Substitute lesbian for just about anything else you can think of that might be met with discrimination! An trustworthy counselor should meet your question with a direct answer and with understanding.

If you sense that your therapist can’t address your sexual issues, you might want to consider asking for a referral for another therapist. At the very least, it could provide your therapist with some pointed feedback on how he or she could have been of more help to you. If you see your therapist making reasonable efforts to help you explore your sexual concerns, you may decide to stick with the therapist. I can’t tell you enough how my first gay and lesbian clients over 10 years ago were so very patient with me as I learned how to better address their issues, even though I made it clear that I am a heterosexual woman. By allowing me to learn from them, I’ve been recommended several times over to the gay and open-relationship communities in the Seattle area. It had to start somewhere. I will forever be grateful to those who played guinea pig. Still, as a consumer you should know that as a professional, I made it clear that I was not claiming experience that I did not possess. Take the time to familiarize yourself with the claims of any therapist you are seeking to hire, and request a short interview by phone or in person to answer questions about their practice, methodology, and experience.

Attention Seattle-Area Therapists
If you are a therapist reading this article, thank you for taking the time to consider how you can improve the way you talk with your clients about sex. If you are in the Seattle area, Babeland is hosting a free event for medical professionals focused on products “that could help your patients whether they’re going through menopause, are pre-orgasmic, or have concerns with erection or ejaculation control.” It’s one thing to know about the existence of some of these pleasure-enhancing tools, but it’s another when your client’s lives are directly affected by how much you know or can recommend they try new pathways to improving their sex lives.

How Facebook Can Affect Your Insurance Coverage

How Facebook Can Affect Your Insurance Benefits
by Imei Hsu, RN, MAC, LMHC

With over 500 million users of Facebook worldwide, you shouldn’t be surprised who is on Facebook these days. Your dentist, your employer, your friends and family, and even your health insurance company may have a presence on Facebook. While it’s fun to set up events, get-togethers, and give your social network a slice-of-life status update a couple of times a day, you shouldn’t be surprised who is looking at your updates. Here’s how Facebook updates can affect your health insurance coverage.

What could your Facebook updates and photos be telling your insurer?

Enter Natalie Blanchard, a 30 year old IBM technician from Quebec. She has released her story The Los Angeles Times in 2009 about a medical leave she took in 2008 on the recommendation of her doctor. She was being treated for depression, and her doctor had suggested that she go on vacation. While on medical leave, had been receiving monthly disability benefits from her insurance plan, but these were severed without warning after the first year. Blanchard claimed that her insurance company had crawled her Facebook page, discovering pictures of her on her vacation. As you can guess, most vacation pictures include sunshine, smiles, eating and drinking, and what most of us would consider the “high life”. Her insurer considered her ready to return to work, and therefore benefits were terminated.

In the lawsuit that is scheduled to go to court in January 2012, Blanchard claims her insurer assumed this was a case of fraud based on her Facebook pictures and status updates, and that the insurer terminated benefits with studying the background of her benefits. She also claimed her doctor was not contacted before the benefits were terminated. If you don’t know this, it is standard practice in medical cases that the treating physician or nurse is contacted by an insurer case consultant (often times a medical practitioner) to determine the need for benefit based on the medical history of the client.

As a therapist, I find this trend alarming. But even if you’re not a clinician, you should be concerned. The original articles were released in 2009 and 2010, yet I consistently see people using their Social Media updates such as Facebook without an awareness of who might be tracking their posts. I also find it disturbing because disease and dysfunction does not follow a consistant pathway of suffering 100% of the time in ways that can be detected from the smiling face of a person on vacation.

Case in point: a friend of a close friend spent time skiing, running, and sharing meals with my friend all the way up to about a couple of weeks before she took overdosed in a hotel room. Her suicide note indicated that she had been planning her suicide for some time, but her friends and family were shocked. The months before her suicide had been filled with smiley-faced pictures of herself traveling around the world, a brief but intense romance, and dreams of the future. At her wake, the guests were still in a state of shock and grief, and to this day, I am sometimes haunted by her vibrancy and verve.

During the years of her struggle with depression, she had done what so many others do: they fight it, they get professional help, they try to live life the best they can, and when there are moments when the depression lifts, they go on vacations, eat and drink, fall in love, and struggle on. Those momentary lifts do not mean the depression is over and done with. Clinicians understand that a lift in depression can also be a time when a severely depressed person has just enough energy to plan a thoughtfully executed suicide.

While the insurer of Natalie Blanchard claims they did not terminate her disability benefits based on her Facebook status updates and photos, they are not denying that these updates and photos were viewed. What should you learn from this?

1. Insurers can and do look at your Facebook status updates and photos, and you cannot legally stop them from this practice. They have the right to search for evidence of fraud or foul practice. Any business can do the same thing. In January 2010, Mark Zuckerberg declared to the world that privacy in the online age was over.

2. You can change your privacy settings on Facebook to limit who can see your posts. However, you should understand that your Terms of Use on Facebook does not ensure your privacy, and Facebook’s position has never been to ensure your privacy.

3. Educate your physician’s office. If you are using insurance benefits for your healthcare and need special coverage based on a medical condition, discuss with your doctor your concerns. Your doctor should be directly contact anytime your benefits are increased, decreased, or terminated based on your medical condition.

4. Take a moment to consider what it is you are sharing on Facebook, Twitter, and other Social Media platforms every time you type. Notice what ads come up on your page when you type in keywords like cancer. At minimum, bots crawl your pages and emails on certain platforms, using keywords to generate ads that are sent to you. Test this: mention that you’re watching your weight, and see how many ads come up for everything from P90x to weight loss yoga. In a similar way, insurers can sift through your public posts to see what you’re broadcasting, and this can be used as evidence against you in a similar way lawyers are using this for divorce cases and employers are using it when interviewing a potential candidate for hire.

This post is not about scaring the bajesus out of you. It’s about educating users so that you can enjoy the best that the Internet has to offer while protecting your best interests. Now go: Skype, text, update, and post your photos. Only be careful, and if you’re not sure how something will be construed, save it for your private enjoyment.

For another link to the story about Natalie Blanchard’s case, take a look at this law blog.