Hello Again, Blog. Hello Again, Depression.

I’ve been gone for a long time. I just read the blog I posted in February. I was struggling then with an ever encroaching depression. I think it started perhaps right after my car wreck last November, but I remember times of feeling “happy” and of really having “fun,” you know, where the laugh actually goes all the way down, at least through Christmas. I enjoyed my visit to see family during the Christmas holidays, but I also remember a phone call from a patient that was just wearing and then the death of my friend’s father coming right at the end of the time I took off for Christmas. I felt like I didn’t have much “Christmas” time during the holidays themselves, and the 12 Days of Christmas have always been important for me. I know that by New Year’s Eve, I just didn’t quite have as much fun listening to my band as usual. My Achilles began giving me more and more problems, and I really could not ignore it anymore. I was getting treatment for pain related to the accident, but something just wasn’t “right.” By the time I wrote the last blog entry in February, a true depression was brewing.

Let me clarify a bit. I have what they call “double depression.” Whenever a depression lifts, I never get technically into what they call full remission. Some diagnose this as “double depression” because dysthymia is always there with episodes of full-blown depression interspersed. Dysthymia is a diagnosis given when someone does not meet full criteria of depression, but when it lasts for over two years. Think of it as the low-grade fever of depression. It’s not the full-blown flu, but it lingers and depletes energy over time. Dysthymia is the low-grade fever of the depressive spectrum. I often feel like depression is lingering around the edges of my life, sort of like an old picture fading around the outside. However, there are times when the depression “meets full criteria” and when it is a “full-blown.” It’s been a while since I’ve been here. Medication has kept the “full-blown” version at bay to some extent, but meds just weren’t working that well and were really expensive. I’ve played around with different meds, trying something cheaper when it seemed like the more expensive version wasn’t as effective anymore. I even tried a medication used in Europe for depression but used here only for fibromyalgia. I thought that maybe, somewhat like Cymbalta is supposed to do, this medication would give me some relief from both. Cymbalta had failed to do that and was very expensive for someone with no insurance like me. So, that is where I was from a clinical perspective when this depression just began to build and build.

By February, it was waiting in the wings for sure. I got extremely overwhelmed by all the requirements of the different insurance companies, by a reduction in pay once about six of my patients moved from being in foster care to being adopted, and by a huge upcoming change in how Medicaid would be managed for all the new adult patients I was taking on trying to make up for the loss in revenue from that change. This big change that was looming in Medicaid management was confusing, and I got different versions of what was going to happen depending on who I talked to, and all the people I was able to talk to had a vested interest in what I chose to do. Well, at least one really did, and he was the rudest. I decided that they were not telling me the entire truth because of how they acted and did not believe that my patients would be forced to change from their existing plan. And, if some did change, I would be able to bill as an out-of-network provider although I’d get a bit less. I figured at that time I could become a provider if I needed to, but that I’d be able to bill for out-of-network. Somehow, having not dealt directly with insurance other than the two companies that managed Medicaid, one for foster care and one for everyone else, I didn’t know anything about being out-of-network. I just thought that meant quite literally that you would be out of their network and billing them. I didn’t realize that even to be an out-of-network provider, one has to do a HUGE amount of paperwork and be approved to provide services. I thought that the massive paperwork was only required to become an in-network provider. I made a big mistake. It’s hard for me to estimate even how much money this has now cost me.

Back to my story…….I got overwhelmed. I decided not to go to a training provided by the “new” insurance companies that were going to “manage” Medicaid because I was overwhelmed and just scheduled patients and kept on seeing them. I went on with my life, my practice, trying to figure out how to get paid for two patients that I had that had other insurance, and the like. (I’d been led to believe they were simple Medicaid patients, but they had other insurance I learned after I’d started seeing them.) I knew those insurances would pay reasonably well if I could get in with them (didn’t know the part about Tricare requiring a doctor’s referral for an LPC, for most insurance companies that went out about 15-20 years ago), so I wanted to hire an assistant to help me figure out all the massive paperwork.

The assistant search story could go on and be about as boring as the details about insurance have been, so I’ll spare you a lot of the details. Someone suggested I have her granddaughter do it when I asked her for a suggestion. I knew that wasn’t going to work, but I gave it a try. I felt I owed it to the grandmother. I gave a very organized, paperwork “maven” friend a shot, too. It took me a very long time to find anyone who could make any progress. There were lots of dead ends and lots of different trails that were quite ridiculous. For BlueCross/BlueShield, you needed to be registered with something called CAQH, a sort of database for credentialing providers, but to get in with CAQH, you needed a “secret code” from an insurance company. It was a catch-22. (We’ve finally gotten through that, I think.)

I tried to work through some of my issues at a Dance Workshop at the end of February. It was in one of those workshops that I finally mentally broke free from my former job and decided to go into private practice. I’d played around with the idea for a long time, but I was mired in just feeling bad about the current job I had then and the problems relating to my bosses. I just didn’t “get” why they always seemed so disappointed in me, and I was frustrated. At that workshop all those years ago, I was able to get clear about what I wanted to do. It was also when I decided that it would be important for me to work towards leaving on the best terms I could. It took me months to do it, and I worked hard before (and after) I left to make sure I left on good terms. I worked on some new things that I thought were real improvements. I gave 4 months notice. I came back to work, for free, after I’d left and the new person took over to help her get started. I’d had no one to teach me the job when I came in, so I wanted her to have all the support she could have. What I had decided to do at that workshop set a blueprint for me that I followed and that made me feel proud. I hoped to do the same thing at the workshop at the end of February. I was struggling with fatigue and with an injury to my Achilles tendon. I was having trouble really dancing down into my feelings. Usually, that type of dance is a format where I can really tap into what is going on inside of me, but it often takes a full three-day workshop to get the benefits. We work through different things over the three days, but there is an arc to the workshops that leads us through to a place where we can get really quiet inside and be able to hear what we really need to hear. Whether that is from the inner self or from God, it’s a mystery to me. But, it’s on that last day that I usually get freed up and get some clarity. I screwed up. I didn’t make it to that last day. I was just too tired and in too much pain to drive down to Austin one more time. I regret that now. I might have had that “moment of clarity” that I needed to lead me in the upcoming months.

So, then comes March. By the end of March, I realized I was NOT beating back that creeping depression. It wasn’t creeping as much as it was reaching fingers into every crevice of my being. I decided that even though I couldn’t yet get health insurance, I was going to pay out of pocket to see a psychiatrist. My therapist indicated that there weren’t any in the area that he’d even recommend anymore. I went over an hour away to see one. We decided to try Abilify. It would be an adjunct to the other med I was on for both depression and fibro. It has had good results with some patients. I hoped I’d be one of them. At first, it seemed like I was getting some good results, but not quite where I wanted to be. March, April, May came along. I tried varying dosages. I wasn’t getting the results I’d hoped for, but I so wanted to see improvement that I kept on trying.

May came. My 50th birthday. I had EXTREME anxiety about that date, about that number, about what that meant for my life, about if that meant I even had a life. At the same time, in fact, a few days before my birthday, my therapist of about 16 years let me know he was retiring. Interestingly, he told me that right after I told him about one of my worst birthdays when my boyfriend, then fiance, now former fiance, pretended to leave the evening before my birthday and how that upset me. Oops. Bad therapist. Actually, he’s been really good, but THAT was some uncharacteristically bad timing on his part. So, I was a bit stressed.

Ended up with an AMAZING birthday, and perhaps I’ll tell that story another day. But, it was good. It was a great day. There was a lot of reflection, along with a lot of partying. It surprised me how good it ended up being.

But, then back to the stress. Had to finish a bunch of CEUs to keep my license by the end of that month. Then, a notice from the one Medicaid company that they would not pay me until they had a copy of my new license. Oops. I sent in the stuff to renew right before it expired, and it took weeks to get a copy back. So, it took a few weeks to get that into that company and be able to bill and get paid. I wasn’t too worried, just a bit irritated. I had gotten a settlement, finally, from my car wreck. I knew I could make it through. I started making some progress on the forms for insurance for the few patients who had other insurances as their primary carriers. I had found someone to be an assistant for me! She made progress in just a few weeks that others had not been able to make in months, and I was working like crazy trying to fill in the blanks of the paperwork that she couldn’t do and to get it in. I was making progress!

Then, BAM! I was able to get it all settled and found out that I WASN’T getting paid, starting at different times, for almost half my caseload. They’d been switched to a new insurance. Remember that February blog and what I said about it above? Yeah. This is when it bit in the butt. I wasn’t getting paid for them AT ALL! I scrambled, my assistant scrambled. We had to get all sorts of paperwork done. I got to be an out-of-network provider because I did what was called a “case agreement,” and it was retroactive. We worked like crazy to get the actual contract done so I could eventually be an in-network provider. I had to write, for each patient, a request for more services. I had to bill as if the first time I saw them under their new insurance was like an initial evaluation even if I’d seen them for years. Then, I had to fill out a form for each to prove they needed more services. They didn’t receive them or answer my faxes, so I had to refax them to some big muckety-muck who’d helped me with the “case agreement” and the contract. It was this long, grueling process. And, I didn’t know if I’d ever get paid. I billed and waited. I’m still working on the billing from before I became in-network. I’m still getting dribbles of pay and more denials than anything.

I billed for about $3,700 on one report I got back. I expected to get paid about $1,200 because of how little they pay in percentage of what is the actual going rate. And, I got paid about $500 after all their denials. Whether I ever even get what the cut-rate amounts owed to me is anyone’s guess.

So, this all sounds like it’s been about work for the most part. It has been a huge component of what I’ve been going through. I’ve been trying to keep on moving in other areas of my life. I had friends helping me trying to fix up my home which is not only in bad repair, but looks like a hoarder’s mess since I developed fibromyalgia and tried to start a private practice at about the same time. I wanted to make some progress on it and felt that might lift my spirits. Usually, with mounting depression, I would not have been able to do much. But, my best friend and some other friends really pulled me along. I also just kept fighting, kept hoping that the depression was not going to overwhelm me.

I kept on with that medication change, too. That, as it turned out, was maybe not the best idea. At one point, I had a bad reaction from the medication. When the dose got higher, I developed severe anxiety. I was anxious all the time. There was that churning in my gut all the time. I woke up with it. I went to sleep with it. I sat and tried to calm it while I worked with my own patients. I could keep it at a dull roar at times when working with patients, but it was still there. I tried so hard to listen, to be present, but I’d catch myself watching my watch more and more. I woke up early, which is not good for me. I had more problems with my Achilles, so exercising to calm myself was not as much of an option. I was crawling out of my skin. I backed off the dosage, and I had a little relief. However, it as if once that switch was flipped, I really could not get back to not being so anxious.

It was then that the depression really began to sweep in.

Then, one other thing happened. Some of my patients had been adopted by people I thought were wonderful people. I kept seeing the kids, and they were some of the patients for whom I worked on BlueCross/BlueShield. I really thought highly of these people and was continuing to work with the kids as they transitioned into their adoptive home. And, then I noticed the dogs were missing. I asked about the dogs. They had taken them to the pound. The pound! The dogs had been digging out of the yard, and they just didn’t want them to get hit by a car. They’d tried a kennel, but the dogs had dug under it. (They had NOT tried paying the dogs any attention.) I was frantic. These were dogs I knew, and now they were very likely to be killed. Dogs do NOT often make it out of the pound alive. I became obsessed. I posted their pictures everywhere and contacted every rescue I could. I thought I had a rescue lined up two different times. I ended up getting the dogs out of the pound on my own, signed out to me. I later got a local rescue to take us on, to take official custody of them, as long as I’d be their foster because they had no room. I didn’t plan on having two big extra dogs. I knew I couldn’t afford it. (The local shelter/rescue is at least paying the medical bills, but one still needs something done to help her back legs.) I didn’t plan for my own dog, who is 14, to get a severe ear infection that cost me about $500 so far. I knew my other dog would not like having them here. He’s had some problems with other dogs in the past, and I don’t know how he would act if left out with them for any real length of time. He’s extremely anxious, and he could get to where he just got aggressive because he is so anxious. I just don’t know. what he might do. (He just was barking outside. I called him in. He didn’t want to come in through the dog door because “they” were in here. I called him in anyway. He got spooked because there was no room around them and because my exercise ball was in the way. I had to grab his collar and make him run the “gauntlet” through the “other” dogs, past the exercise ball, and on into the back room. He’s a HUGE dog. He wanted to just turn around and run outside again, but I’m pretty sure he was barking because he’d rather be inside.) Oh, and my two lovely foster dogs? Escape artists. They dug out of their former backyard, so that had been a factor in addition to my dog (and the rules of fostering given by the rescue/shelter) that makes me crate them when I’m at work and at night. (I have to fight one of them to get her in the crate. She has broken out of other crates several times and out of the garage once.) So, I have had a lot of dog worries, to say the least. My dogs are my family. I am a staunch believer that dogs are family and should be treated as such. I have little patience for anyone who does not think of a dog as a life-long commitment.

So, here I am with these people I really used to respect whose dogs I now have. They have lost my respect, but I still work with their kids. Because the dogs stayed local and might be at local adoption events, possibly with me, I felt I had to tell them that I had the dogs. Even if I hadn’t, I would feel very uncomfortable. The little girl still plays with her two stuffed dogs when we do play therapy. She calls them Dixie and Coco. That’s the names of the actual dogs. How they thought it wouldn’t impact her, I don’t know. But, she was very worried for a long time about the dogs. I have a feeling that for as long as she lives, the fact that they suddenly got rid of the dogs will always make her wonder if they won’t suddenly get rid of her. How could they be so cruel to the dogs, and how could they be so stupid about children? They also have a teen who plans to become a vet someday. Why she didn’t speak up makes me really question her. I stood up to my mom when we took in a dog that we did not know was pregnant and she wanted to put the puppies to sleep. I don’t believe that girl has “always” cared about animals and wanted to be a vet. Either that, or she is really ignorant of what happens at the pound. Anyway, how do you not speak up when your parents take away your dogs, you’re a huge animal lover/vet-wannabe, and the dogs are going to the POUND???? I wonder if it will matter to her when she learns how animals often die of illnesses caught in the pound, how some pound use gas chambers, how even if they use “euthanasia” in a pound that they don’t give the pain-killer before administering that drug like they do when they use it on someone’s sick or elderly pet at the vet? How will either of those kids feel? Their irresponsible parents won’t be liars when they say that the dogs were not “put to sleep” in the pound. They have a home. Hopefully, they will have either the same home or two different homes that will be “forever” soon.

If my stress level was not enough with these two dogs, I had ANOTHER foster family who took their dogs to the pound. The mom had been out of the country, the dad had not made sure that they adult foster girls had cleaned up after the dogs, the mom heard through her bio daughter that the house smelled bad, she was afraid that “the state” would find out and remove her foster girls, she didn’t feel she could expect her husband to make the girls clean up, so she had him take the dogs to the pound. She said she’d had good results having dogs get adopted out of the pound. REALLY???? Like hell. My respect for her is so low now. I used to think of foster parents more like colleagues than as parents of patients. So, they were a bit closer to friends, people I often respected. I know not everyone takes care of animals the same. There are people who think I’m terrible for crating the dogs during the day. (Heck, I think it’s pretty horrible for now, too, and I hope they get a home where it’s not needed soon.) I have another family that I love and even think of as “my” family who do not take care of animals the same way I do. But, they’ve never disappointed me like these two families have. Not to this extent.

I had a patient who “had” to get rid of her dog, who she should never have gotten, when she had a baby because her lazy-ass husband never came home to let the dog out or clean up after the dog. Now, they have given the baby up for adoption. I thought they gave the dog to a friend and had been told she was doing well. Something went awry, and the friend gave her away again. She ended up at a shelter. They got a call about her. They could have gone to get her even if it would have cost them $25. She could still be there! But, my patient has talked about getting a puppy because she’s lonely now at home. She talks about all she wants for her upcoming birthday. When I point out that her dog, the dog she still says she “loves” and still calls her “baby” might yet be alive, she says she might call about her. But, then she points out how much it would be to get her out. Really?!!! I KNOW this is a (supposedly) “mentally retarded” person. I know this is someone with her own history of abuse. I know this is someone who is mentally ill. But, REALLY?!!! What the fuck!

I’ve run out of patience with people. I am so literally sick about all these dogs, dogs I have petted and held on my lap and played with when I’ve done therapy, being just thrown away that I cannot stand it. My trust in people is at an all time low. My trust in my own judgment of people is pretty bad, too. I know that someday one of my patients or one of the parents or someone else may come across my blog and be able to tell what I wrote. I have some of this shielded on FB, but that won’t keep it completely from being seen or heard. If they found out now, I could lose a patient or two. I haven’t told anything too personal about the people, so ethically I think I’m ok. Unless you know my caseload, you can’t even guess at identifying who I’m talking about. Well, unless you happen to know someone who has done something as abhorrent as I’m talking about……If someone stumbles across my blog and actually reads this particular entry, this long and overwrought entry, and figures out I was talking about them, well, maybe it’s good they know how much my trust and respect in them plummeted. And, that even goes for the actual patient. I’m sick of this much lack of concern for other creatures. We wonder why there is such widespread cruelty against animals and even against children. It’s because “good people” don’t care or don’t want to know. I do some bad things. I do some things that are wrong or even illegal. I’m sure people can, and do, judge me based on these things. I judge me, too. But, we’re talking about other living creatures here. I am just sick since these things have happened.

So, take some genetics and a history of depression. Take the fact that past depressions tend to indicate the increased likelihood of subsequent depressions. It’s like the brain chemistry getting into a rut, or a groove like on an old record when it skipped. (Remember records?) Take some overall financial problems and add to that just not getting paid. Add to that some huge scrambling to do paperwork and get one’s “ducks in a row.” Take questions about the future of a practice, an increased workload and decreased compensation, farther distances driving to see patients. Take a failed med trial that not only led to deflated hope but to a real increased anxiety. Take the usual ongoing struggles of life with fibromyalgia and trying to break free from its grip. Take a big birthday and some need to figure out where life goes from here. Take the impending loss of an important, long-term, supportive relationship. Take the added stress of two extra dogs in a home and how that stress multiplied for the human as it impacted the resident dogs. Take an obsessive and exhausting fight to help those dogs and now the difficulty of having to place them for adoption when one has lost trust in people. Just take it all. Now. Full blown depression.

I want to re-engineer my career and make it work. That’s a hard thing. I don’t know for sure where to start, my confidence is not that great given all I’ve been through lately (and getting routinely underpaid by insurance companies has not really helped that I realize), and I am very uncomfortable and leery of marketing. I don’t trust myself in hiring people to help because most of the times that has not worked out well. Having lost trust in people in general lately does not make that easier. I’m trying to push on ahead and just do “the next thing,” even though at times I don’t have a clue what that is. But, I need a viable work life. That is part of overall healing because I not only can’t afford treatment without it, I can’t handle the ongoing stress and hope to get well. I don’t want to work for someone else necessarily. (Oh, forgot the whole stress of applying for and interviewing for another job that I felt I might HAVE to take but didn’t really want to take. Was all “green lighted,” but the requisite huge amount of paperwork has not shown up, so maybe that’s a good thing.)

I decided to work last week rather than try the psychiatrist again last week. I recognize meds will probably be part of the overall process of getting out of this depression, but I am not sure that they are the first thing that needs to happen now. There seem to be more pressing issues. I know that with the right meds, with some relief of the depression, I might be better able to create that life I want. But, money took precedent for now. And, I needed a bit of a break from trying meds. I felt so deflated when they didn’t work.

I’m trying to function. I’m doing things I normally do. My best friend helped me put up Halloween decorations in spite of my not really feeling like doing it. It’s been a big tradition for me and for the neighborhood. I’ll be in costume as will my personal dogs (the fosters would try to escape every time I opened the door) and giving out candy. It’s not a fun and happy Halloween like last year was. We seemed to celebrate fall and Halloween for about two months last year. There were all sorts of activities and events we did. It was a grand time. It was right before the depression started to creep in, and it was an especially good time. I’m glad I had that before the descent. But, now, a year later, I’m just trying to keep moving. I’ll do as much of the “normal” things I can as this season proceeds.

You’re probably not all caught up, but it’s a start. There’s been a lot that has happened since I wrote my last blog. If you made it to this point, I congratulate you. I’m actually astonished. I don’t think I’d read anyone’s blog if it was this long! But, it fills in the blanks. I haven’t written because of life events, but more than that, I haven’t written because of an increasing and deepening depression. That’s a shame in a way because the whole point of this blog is to chronicle the experiences of dealing with mental illness and a chronic illness while actually working as a mental health therapist. It’s supposed to be about what it’s like to life with such an illness while trying to treat it at the same time. And, I stopped writing the blog as it got worse. I have written a lot on FB. I have needed that immediate response, but I have neglected my own blog. And, I believed that this was valuable not only for myself but perhaps for others along the way. I let myself down and let down anyone who might want to follow my journey. I needed to try to catch you, and myself, up. I needed to give this blog something by way of explanation.

Something about my depression this time, I’ve gotten very wordy when I write. I’m not so good at listening, not just to my patients, but even to my best friend. I don’t always even want to talk. But, I write. I should have been writing here. I hope I can bring myself back to this page because perhaps this, too, will be part of my healing. And, perhaps it will lead to things I’ve never imagined, positive things I hope.

So, dear reader, I wish you well. If you are on a journey that includes mental health issues, chronic health issues, or even if you are just working on treating those or living with those struggling with those issues, I hope this lends some light on the subject.

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~ by Janice Holladay on October 30, 2012.

2 Responses to “Hello Again, Blog. Hello Again, Depression.”

  1. Wow, you’ve been through a lot. Glad that you’re writing on your blog again. Writing has been the thing that saved me. I’ve written blogs through many tears, where I’ve hardly been able to see the computer screen, but I feel better when I’m done. Writing has helped me get through the hard times, dealing with my mom’s loss. I also live with chronic pain – it started as headaches about 8 years ago, then got worse (neck, back of head, shoulders), and stayed. I hope things get better for you. That your days start getting brighter and the depression that weighs so heavily on you starts to lift. Take care.

    • Thank you! I hope that the depression begins to lift soon as well. I do need to take the time to write and write and write. I thank you for reading my blog and my story.

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