Monday, December 11, 2017

An Open Letter to Kansas BSRB

“As long as he denies his own agency, real change is unlikely because his attention will be directed toward changing his environment rather than himself.” 
― Irvin D. Yalom, The Gift of Therapy: An Open Letter to a New Generation of Therapists and Their Patients

Dear Board Members, 
     The Behavioral Sciences Regulatory Board (BSRB) for marriage and family therapists in Kansas has failed to legislate concrete regulations regarding telehealth/telemedicine. At this time, your unofficial stance is to defer to the regulations set forward by HIPAA. While these regulations are helpful guidelines, there are certain factors which impact MFT's differently than other providers. Telehealth is not only here to stay, research suggests it will only grow larger in the coming years. It is estimated 7 million patients will use telehealth by 2018; this is up from 350k in 2013. Forty-two states have passed legislation regarding the use of telehealth. Twenty-nine states have passed laws requiring health plans to cover telehealth services. Telehealth is NOT going away. The "wait and see" approach is having direct impacts on therapist malpractice risk, income, and patient care.
     The reluctance of the BSRB to pass statutes guiding therapists on appropriate implementation, training, and understanding of telehealth will directly impact our ability to ethically and legally treat patients. Without regulations requiring HIPAA compliant telehealth services, therapists are open to lawsuits and accidental breaches of patient confidentiality. Without these regulations, MFT's are not restricted to operating within the state(s) where they are licensed, which puts an undue burden on other states and therapists to complete due diligence. Without these regulations, there is no baseline by which all MFT's can be held accountable, and this puts practitioners at risk for inadvertent malpractice. If there are no regulations regarding additional malpractice coverage to address the practice of telehealth, most providers will be unaware this should be purchased. 
     In 2015, the Board noted that Kansas was "not interested in being part of the “telepsychology compact”." This was supposed to be discussed in the next meeting, as it was clear nearly 3 years ago that the ubiquity of internet access and technology would make telehealth a meaningful option for more people than ever before. However, no legislation has been created or, as near as I can tell, suggested. This can impact MFT's ability to bill insurance companies. The Department for Health and Human Services Centers for Medicaid and Medicare Services (CMS) has outlined the requirements to bill for telehealth services. It is feasible that, without consistent definitions of terms, an MFT could bill for what the MFT considers telehealth, while it may not meet the criteria for CMS. There is an additional hindrance to patients covered by KanCare. KanCare has addressed telehealth, but our governing body has failed to do this. 
     The lack of these regulations will directly impact patient care. I have had a patient contact me and request I provide family therapy via telehealth for themselves and a family member living in another state. I declined as I was not licensed in the other state and they did not provide reciprocity. This patient contacted me after finding a therapist who would help and expressed frustration and anger at the incongruence within the profession. Patients entering college may travel out of state but not change residency; where do we stand on providing therapeutic support when there is no reciprocity offered by the other state? What about military personnel living overseas with the ability to participate in family therapy while deployed? 
     While regulations would not ensure complete congruence throughout all MFT practitioners, it will provide those who are compliant a reference source for patients. This is a critical step in maintaining cohesiveness within our profession and our ability to educate patients on our ethical requirements. 
     My suggestion is to create requirements which meet these criteria:
  1. Meet HIPAA guideline
  2. Establish specific criteria for HIPAA compliant software without making specific recommendations
  3. Require a telehealth component to our required ethics training
  4. Suggested malpractice coverage rates
  5. Requirement regarding participation in telehealth/text/phone therapy as it relates to participating in commercial providers (i.e. Talkspace)
  6. Clear regulations for providing telehealth therapy across state lines; particularly in regards to patients in college and the military
  7. Clear regulations on providing telehealth therapy for therapists living outside Kansas; will we offer case specific licensure at a reduced rate?
While there will be many cases not completely covered by your regulations, we must have a starting point. I urge the Board to begin addressing these issues in the next meeting. Please take steps to decrease our professional risk, increase our ethical practice, and protect our patients. We can no longer expect our environment to change. In our profession, we must be congruent and ask of ourselves the same thing we ask of our patients: To embrace our agency and begin changing what we can without externalizing our responsibility.

   Therapists, if you agree it is imperative the BSRB craft and implement regulations regarding MFT's providing telehealth, please contact the board.


Nathan D. Croy, MA, LCMFT

Nathan D. Croy, (C) 2017

Monday, November 13, 2017


Fear and hope are alike beneath it.
~Ralph Waldo Emerson

     Usually, the illustrations that accompany my posts are my own. I have written about this in the FAQ's section, but to summarize; my drawings are awful. I know it, you know it. However, art was once a big part of my life. There were experiences and thoughts I would not have been able to express in another way without it. As I grew older, I lost touch of that part of myself. That artistic aspect, without so much of a yelp or whine, simply faded away without my awareness or intent.

     Then I read Rollo May's The Courage to Create. This work was a challenge to reclaim a part of myself long abandoned. Every time I publish a post with one of my illustrations, it is a stretch. There is an element of shame and embarrassment with each one! And that is precisely the point of publishing them. 

     However, on this rare occasion, I'm off the hook. I recently had the privilege to dialogue with an incredible artist named Nicola Samori regarding his piece: L'Occhio Occidentale (The Occidental Eye). To me, it is a fascinating study in hope. A man, shrouded in shadow, reaching up and out with hard-worked hands, looks to the sky with a stone face; not fully formed. Or not yet carved. As one hand reaches out, another reaches in. There is fear. There is also hope.

     When working with clients and discussing hope, therapists must be sensitive to the reality that hope can be a burden. Sometimes, it is too heavy a burden. In those times, the healthy response of the therapist must be the placeholder for hope and then provide it in small doses to families and individuals as they come to us. We must always have hope.

     Hope is never fully formed. Like the man in shadow, it sits reaching out, and in, waiting to come to fruition. There is no certainty where hope exists. This is the dialectic tension which exists in the relationship between hope and certainty. Where there is certainty there is no need for hope. Where there is hope, there is also fear. If we hope for one outcome, in the same breath we are stating we are fearful the alternative may occur. But in this very tension there exists a positivity!

     Within every fear there is a positive hope. There is a distinct difference between a negative hope ("I hope something bad does NOT happen.") and a positive hope ("I hope something good DOES happen!"). A negative hope does not instill peace. Instead, it encourages nearly non-stop avoidance. A negative hope does not facilitate calm, but creates anxiety. Positive hope is a meaningful goal or practical dream! Goals, when they are congruent with our values, can be a boon to any individual or family, when they are ready to create them.

Negative hope says, "I'll never let that happen again".

Positive hope says, "I'll do better next time".

     A special thank you to Nicola Samori for taking time to discuss his painting with me and providing permission to use it in this post. 

 L'Occhio Occidentale (The Occidental Eye), 2013, Oil on copper. by Nicola Samori

Wednesday, April 26, 2017

Mobile ExCommunication: Keeping Tech in Check

"Freedom is thus not the opposite to determinism. Freedom is the individual's capacity to know that he is the determined one, to pause between stimulus and response and thus to throw his weight, however slight it may be, on the side of one particular response among several possible ones."
~Rollo May, Psychology and the Human Dilemma (p. 175)

     Mobile technology is nearly ubiquitous and has advanced our ability to access information, people, and ideas in amazing ways. Television, gaming consoles, phones, tablets, e-readers, and even digital paper have transformed the way we connect with one another. Friends are no longer constrained by distance or mobility. Scientific ideas, education, medical advancements, politics, and the majority of the human race is advancing at an unprecedented rate. Tech is no longer an optional luxury, but an integral part of daily life.
     Yet, most family therapists could attest to the increasing frequency of complaints parents and spouses have regarding the feeling of having to compete for attention with electronics. Even though tech has proffered new and easily accessible ways to connect, it seems the art of genuine connection is being threatened.
     Here are a few ways families and individuals can help put technology in its place and foster better offline relationships. We're going to channel the great chef, Emeril Lagasse, and remember these helpful guidelines with the acronym BAM! Now, let's take it up a notch!

Boundaries: Does My Tech Have a Place?
     The first step for integrating technology in a healthy way with your family and by establishing healthy boundaries. It is not uncommon to establish boundaries on time/length on television or game-play, but this can be more difficult with phones. They are so easy to access! The phrase "real quick" is the most frequent lie we tell ourselves and others about "just checking" electronics. That is why it is so crucial to establish and agree on boundaries as a family. If the family is not in agreement prior to establishing these expectations, it will become a source of contention rather than an increase in cohesion. There are three areas I encourage people to focus on:

  1. Amount: 
    • Money: The amount of money someone can spend on a device, how they get that money, and how it works into a budget can be a fantastic opportunity to build trust and teach budgeting skills. Dave Ramsey has some great tools to help children learn how to manage money! There are several tools online for this, but this is what I have used.
    • Devices: Confession time! I have three tablets at home that I haven't meaningfully used in a year. THREE. I even have an extra smart-watch! Older devices can be re-purposed in all kinds of creative ways (children's tablets, picture frames, security system, etc), sold online, given to friends, used for shooting practice, whatever! The issue is, do we need this stuff to stick around or is it just junking up our life? Prior to getting something new, what are the rules about managing the old? With my wife's purses, there is a rule: No new purses until you get rid of one old purse. This may sound cruel, but it was born of necessity (love you honey!).
  2. Access: 
    • Length of time: How much time, per day, can we spend on a devices? Does this include time spent for work or school? Does listening to music while exercising count? Be specific!
    • Times of day: Rather than specific times of day, I have found it can be very helpful to identify general times when electronics should not interfere with family. An hour before bedtime, during meals, and after 9:00 at night. This helps people be more intentional about when they're on their phone and more aware of what is going on at home. 
    • Physical restrictions: Is there a centralized place in the home for electronics? Do they have a house that's not your pocket? In addition, do electronics go into bedrooms? I would discourage this for EVERYONE. You can use an alarm clock that's not your phone. Want your children to sleep better? Want to connect with your spouse more? Leave the phones, TV's, gaming consoles, tablets, iPod's, laptops, smartwatches, VR units, and whatever else out of the bedroom. 
    • Electronic Restrictions: Security is important and there can be sensitive information on cellphones. However, if there have been breaches of trust in relationship, security may not be an option for you. Discuss this with your spouse or children if it's necessary for work. Be willing to show what you can, when asked, with a positive attitude. In addition, is there a time of day when the Wi-Fi can be turned off? Do we really need to be connected 24/7?
  3. Age:
    • GPS tracking: This is a really cool feature of new phones! Pull up the right app and you can see exactly where you child/spouse is! If you're going to use this feature, be honest with your children/spouse. Otherwise, it will serve to break more trust than it creates. Also, remember this: These apps only tell you where the phone is, not the person. A dead battery can result in all kinds of panic when this is the primary way of "knowing" where a loved one is. It's cool to have and it's not a substitute for regular communication prior to going somewhere. 
    • Strangers: We teach our children not to talk to strangers, and then we give them a camera and access to the entire planet that's full of strangers. Educate yourself on dangers and protect your children from catfishing, schemes, and human trafficking. Just like you would in real life!
    • When to buy: Children mature at different rates. Some 7 year old children can handle a full featured phone. Others I wouldn't trust with a stick. I can tell you the rule in our house is that our children can have a phone when they can afford to pay for a phone and the accompanying plan. That is the level of responsibility we are looking for prior to offering someone unfettered access to anyone with a wifi signal. 
Alternatives: Is There Something Better Than My Tech?
     In an attempt to encourage better engagement in personal relationships, parents and spouses can accidentally engage in a power dynamic that further injures the very attachment they seek to strengthen. Here's a fictional example:
Jennie: "Tom, why don't you put the phone down and hang out with me?"
Tom, staring intently at his phone: "I just have to finish this email real quick!"
Jennie: "If you cared about me as much as you did that stupid email, our relationship might be better!"
Tom, looking angry and dejected: "This is for work! The thing I do to bring home money so we can eat and do all the stuff you enjoy doing!" 
     I don't know an actual Tom and Jennie, but I suspect all of us have been guilty of being a Tom or Jennie at some point. Jennie, focusing on Tom's engagement with his phone to the exclusion of her, has interpreted his behavior as a rejection of her. She wants Tom to notice her, but has gone about it in a way that makes Tom want to spend even more time in his phone!
     Both Tom and Jennie have this in common: a sense of rejection. Tom feels rejected because, in his mind, he's working diligently to "bring home the bacon". Jennie feels rejected because Tom is paying attention to his phone when he could be paying attention to her. Here's the challenge: What are Tom and Jennie doing to cultivate a relationship where spending time together is a better alternative than spending time on the phone?
     One of the most seducing aspects of technology is its relentless availability. There is a persistent, nonjudgmental, and welcoming invitation to connect. Are families, friends, and couples, working to provide that same welcome? Neither Jennie or Tom are necessarily "at fault" here. We can talk about why Tom shouldn't be on his phone or why Jennie shouldn't be yelling at him. But that only solves one problem: boundaries around the phone. There is often an underlying issue of connection! In our relationships, we must be willing to ask what we're offering that's an alternative to technology.

Modeling: Do as I Do
     When people are struggling with addictions, it's not uncommon to enlist the help of family members and the support networks to get involved in with treatment. If a family member is dependent on alcohol, it's not very fair the rest of the family still gets to drink and keep alcohol in the home. At best, it's unsupportive; at worst, it provides unnecessary temptation. However, many families regularly, and subconsciously, engage in this undermining behavior when it comes to electronics.
     How often do you ride in the car without listening to the radio? Is the television on just as background noise? Is the phone always within arms reach? There are many subtle ways to communicate the message of tech-dependence. If you want your children or your spouse to engage with technology in healthy ways, we must be willing to model this behavior ourselves!

     Using BAM can help provide a framework where families and individual can put tech in its place in order to encourage healthy relationship with others. We must be willing to implement this framework in our own lives, in an intentional way, and with support from others. Technology, when kept in its proper place, can enrich our lives, work, and relationships.
     Please share how your family has kept tech in check!

Mobile ExCommunication
Nathan D. Croy, (C) 2017

Tuesday, March 7, 2017


“All real living is meeting.” 

     In providing marriage and family therapy, we almost always come to an issue of trust. How do we restore broken trust, how do we maintain healthy trust, and what do we do when we fear our trust will be misplaced? Many people struggle to even know how to create trust. 
     Trust has most often been born out of shared experience. When people spend time together, and there are multiple exposures to positive interactions, trust is created. To quote Buber again, “Man wishes to be confirmed in his being by man, and wishes to have a presence in the being of the other…Secretly and bashfully he watches for a YES which allows him to be and which can come to him only from one human person to another.” In other words, when we receive permission from someone to be ourselves, in a shared experience, trust grows. 

Creating Space
     These days, finding time to intentionally create shared experiences is very difficult. Most families work two jobs, have children, and still need to find time to sleep! Having "date night" is a luxury many people cannot afford. For my wife and I, this became the case. To resolve this, we created something called a microdate. Microdates are just like regular dates, but they last less than 30 minutes. They require some planning, but they're a fantastic way to ensure we set aside time to be with one another. 
     For us, our microdates happen before we have to pick the kids up from daycare, and after work. We will meet for happy hour, and just talk. Sometimes we talk/vent about the day, tell jokes, talk politics, or just hang out. These shared experiences are crucial to maintaining healthy relationships and trust. Try them out!

Guidelines for Microdates
  • Inexpensive
    • Happy hour specials for appetizers, meeting in a park, or light exercise together
  • Less than 30 minutes
    • This encourages being attentive with our attention
  • Outside the home
    • Reduces distraction or temptation to clean/prep/nap! 
  • Planned
    • This decreases anxiety in those who MUST have things planned out and don't want to feel rushed
  • No more than once a week
    • Too many microdates and they will become another chore!

(C) Nathan D. Croy, 2017

Saturday, February 18, 2017

Moana & Frankl

Gramma Tala: But without her heart, Te Fiti began to crumble, giving birth to a terrible darkness.
~Disney’s Moana

"Love is the only way to grasp another human being in the innermost core of his personality. No one can become fully aware of the very essence of another human being unless he loves him."
~Viktor Frankl in Man’s Search for Meaning

            It should go without saying, but if you haven’t seen Moana, there will be spoilers ahead! With that out of the way, let’s jump right in!

The Story
            Moana is a Disney movie about a Hawaiian princess who saves her people from a destructive force unleashed by a demigod called Maui. There are several existential themes throughout the movie, but I want to focus on the stolen heart of Te Fiti as it relates to Frankl’s Logotherapy.
            Te Fiti is the god of creation and life. When Maui steals her heart, a new beast called Te Ka shows up. Te Ka, composed of magma and spewing black, acrid, smoke from its form, quickly begins destroying all the life Te Fiti had created. The poison from Te Ka, a black nothingness which destroys the essence of everything it touches, begins to spread across the land. This threatens the livelihood of Moana’s people and becomes the impetus for her journey away from safety and towards freedom.
            In the process of restoring Te Fiti’s heart, Moana and Maui discover Te Ka and Te Fiti are one in the same. Without her heart, the creative powers of Te Fiti became the consuming force of Te Ka. A force of empty nothingness which devoured life.

Existential Theme
            The tensions between creation and consumption, life and death, safety and freedom, are reflected in various ways in the movie. Maui’s internal struggle to trust others, Moana’s bind between being true to self and meeting the expectations of others, and the tribe’s willingness to reclaim their identity as explorers are all variations on this theme. This theme was also poignantly, and powerfully, encapsulated in Viktor Frankl’s Logotherapy. (More information on Logotherapy is available HERE)
            Frankl believed that, without meaning, without the opportunity to express our true self in a way that matters, we will feel like nothing. An emptiness will begin to consume us and those around us. To fill this void, we will substitute consumption for creation. Any entertaining action momentarily relieves us from the awareness of our inability to express our true self. This leads to addiction, destruction, self-harm, and anything else. In Amusing Ourselves to Death, Neil Postman identifies how modern access to entertainment has dulled our connection to self for this very reason. Yet, like Te Fiti, without our heart (self), all our actions are ultimately destructive.

Family Film Friday
Here are some questions you may want to discuss with your family after watching Moana:
            *Why did Maui have to restore the heart? Why couldn’t Te Fiti get it herself?
            *Has it ever felt like someone took your heart? What did you do? 
            *Have we ever taken your heart on accident? (Great for feedback on parenting) 
            *Have you ever been angry, like Te Ka, and not known why? What did you do?
            *What was more difficult for Maui: Putting back the heart, or learning to trust Moana? Why?
            *When you get angry, hopefully less angry than Te Ka, what do you think we could do to help give your heart back?
(C) Nathan D. Croy, 2017

*This is the first in a series of posts for Family Film Friday. The goal of these posts is to provide families an opportunity to discuss meaningful existential themes in movies which are accessible to people of all ages.