IOP saga

Because of how disruptive my OCD has been, I’ve been trying to get into the intensive outpatient (IOP) program at my clinic. IOP treatment is administered by a team of three to five clinicians. It would be doing the same types of exposure therapies I’m doing now, but for longer periods of time every day. It would include frequent visits to administer treatment in my home. It also includes psychiatric consultation to administer and monitor medication. There are two tiers of IOP treatment: 20-hours-per-week and 10-hours-per-week. The clinic likes to start patients off at 20 hours per week because that is proven to be the most effective. It’s designed to be a totally immersive treatment and I’m told it works best when the patient approaches treatment with the attitude that he or she is going to tackle everything all at once and come out the other end in remission.

These treatments are expensive. They are respectively $6000 per week and $3000 per week. There is no way I could pay for this out of pocket. That’s why I was excited when I found out my insurance company would cover the entire treatment (or so I thought).

When I first discussed the IOP treatment option with Dr. Osborne about two months ago he asked me if my insurance was Premera (Premera has a history of covering in full for pretty much all of the their patients who request the IOP treatment). I said yes because I thought it was. My insurance is actually with Blue Cross Blue Shield (BSBC) of Nebraska which shares the same blue cross logo as Premera and I’d seen the Premera name on other insurance forms of mine. Because of this I just thought BSBC was subsidiary to Premera. Turns out that’s not the case. BSBC does contract with Premera to pay claims in the state of Washington (don’t ask me how or why… this insurance stuff is confusing, but this is why I had seen the Premera name connected with my insurance), but Premera has nothing to do with approving treatment in my case. BSBC will be the ones to approve (or not approve). The clinic’s history in dealing with insurance companies other than Premera is that they’re more likely to decline IOP treatment.

Great. This was going to be more complicated than we thought. If my insurance had been held directly with Premera it would have been a simple approval process that would have taken a couple days and I could have started treatment six weeks ago. Instead my clinic had to go through a complicated pre-approval and negotiation.

The first attempt at getting approval for the treatment was not successful. It was clear BSBC didn’t understand the treatment and the coverage the clinic was asking for. The first response was basically “your insurance policy covers x number of mental health visits per year.” They didn’t understand that the clinic wanted to set up an agreement for payment above and beyond what was stated in my policy. It took them a few weeks for them to first understand the treatment and another couple weeks to get on board, but eventually after a phone call with Dr. Osborne they agreed that the treatment is necessary.

But that was only the beginning.

I learned that the people at BSBC who approve the treatment are different from the payments people who determine coverage limits. The payments people initially said they would cover $500 per day. This is well short of the $1200 per day cost of the full IOP option. There was another week or two of negotiations and BSBC eventually agreed to $800 per day (only two-thirds of the $1200). Additionally, BSBC won’t allow the clinic to bill $800 to insurance and then balance bill me the remaining $400 (I’m uncertain why this is). Even if they did, I still wouldn’t be able to afford $400 per day.

It seemed like we were at an impasse… until I asked a question.

I talked to my clinic to get clarification on one point: did BSBC agree to pay for two-thirds of the treatment cost, or did they actually agree to $800 (two different things)? The answer was $800. The reduced 10-hour IOP option of treatment is only $600 per day, so I asked why not just do that. The initial response was that the IOP team usually likes to start people at 20 hours per week because it is the most effective. After a while they typically taper patients off to the 10-hour tier. I had to do some internal negotiations with the clinic to convince them that the 10 hour per week option was still better than nothing, and eventually we all agreed.

So… the pieces are all now finally in place. Dr. Osborne and the clinic are rallying behind me. Work has made accommodations. Insurance is on board and has approved the treatment.

So, after six weeks, it looks like I will finally be able to begin IOP starting next Monday!

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Two weeks = progress

It’s now been two weeks since I went on leave from work. What have I done with that time? Here are the things I’ve accomplished so far. (Some of these things may seem small to an outside observer, but let me assure you that these have all been monumental for me and represent substantial efforts to take back control from OCD. Most of these were not easy and involved elements of exposure.)

  1. Daily exposures to triggering words. This literally involves writing or typing the words (as well as variations of the words) over and over again and again. I typically do this from ten to twenty minutes a day. Then I read the words out loud while recording myself. Then I listen to the recordings. In the last two weeks Dr. Osborne and I have covered eighteen words. These are all words that have caused me in the past to engage in OCD rituals. The goal from here on out is to not engage in OCD rituals when I come across these words in real life.
  2. Developed a couple more exposure scripts. See Live from EBT post from May 8. This is similar to the word exposure where I record the scripts and then listen to them over and over again.
  3. Almost completely stopped washing my hands in the sink (but replaced with something else). This has been a huge step on taking back some of the time that OCD was wasting. Hand washing has been my primary compulsive and ritualistic behavior and has eaten up so much time, energy, and emotion (sometimes a single hand washing episode could last as long as thirty minutes). It had to stop. So, I forced it by replacing the sink hand washing with decontamination via hand wipes. It’s still a compulsive and ritualistic behavior, but it takes far less time and energy and Dr. Osborne agrees it is a step in the right direction.
  4. Started wearing the new clothes I recently bought. I’ve mentioned that shopping is difficult because things get contaminated especially easily. This is probably mostly because I have conditioned myself to be extra sensitive when I go shopping and I come across triggers that contaminate stuff before I even get it home from the store or out of the bag to use it (a reminder that “contamination” for me means that objects get negatively associated with other unwanted or obsessive thoughts). I’ve needed new clothes for a while and I finally was able to buy some and start wearing them.
  5. Cleaned and replaced the rug on my kitchen floor. This was also a big step for me. About a month or two ago, when work was at its peak and taking all my mental capacity, I had left a single grocery bag on the kitchen floor for several days. Most of the things in the bag were non perishable so I didn’t really think about. Besides, I had my work project to worry about and finish up. Well, in the bottom of the bag was a half-gallon carton of milk. I discovered one day by stepping on a soaking wet rug that the milk had spoiled and burst the container. (Yes! Gross!) I wadded up the rug and put it in the corner because I didn’t want to deal with it and I still had my project to finish up. I knew to get the rug clean would involve a fair amount of OCD compulsive behaviors. This was sort of a catalyst and the starting point of a lot of the messes in my kitchen. This is when more and more grocery and garbage bags started piling up.
  6. Unloaded and disposed of six+ bags of groceries that had accumulated on the floor of my kitchen. See above. It’s such a relief to have these out of the way.
  7. Cleared out and disposed of five+ large bags of trash that had accumulated in my apartment. OCD was making it difficult to get the trash bags out of the apartment (see Unblock Me post from a few days ago). But, with some effort I was able to get rid of them. It was also such a relief to get them out of the apartment. The goal from here on out is to immediately take out the trash and not let any more accumulate.
  8. Went running for the first time in months. There are many OCD barriers to running. The beautiful weather we’ve been having in Seattle has motivated me to break through these barriers and I have now been on two runs. It felt great to get out and exercise in this way once again. I’ve missed this.
  9. Started image exposures. My OCD brain has catalogued a bunch of disturbing images that I’ve seen mostly in movies or on tv. These images surface frequently. When they surface they make me feel “contaminated” and cause me to engage in compulsive behaviors. This week we started exposing to some of these images. There are two levels of exposure we’ve been working on. First is imaginal exposure where I recall or replay the image in my mind and then describe out loud to Dr. Osborne the image in my head. I then repeat this several times with the same image. The next level of exposure is to actually watch or look at the image over and over again. We picked two scenes from a tv show available on Netflix and started watching them over and over. I watched each of these scenes ten times yesterday and ten times today. Today we picked a third image and my homework is to begin exposure to it.

The good news is I can already feel a shift in how I am responding to obsessive thoughts and it has confirmed to me that taking time off of work to focus on treatment was the right choice for me. This is only the beginning, though, and I have a lot of work still ahead of me.

Unblock Me!

Right now I feel like my life is a game of Unblock Me.

The goal of this game is to get the red block out of the puzzle through the gate on the left, but in order to do that you need to slide the other blocks out of the way. But there are rules. Blocks can only be slid in the direction of their orientation, horizontally or vertically. It often takes twenty or more moves to clear the path to get the red block out.

As I’ve mentioned in previous posts, my apartment is very cluttered and there are many “blocks” (both mental and physical) in the way of achieving my goals, no matter how small. There are so many little things in my way. To do something simple like take out the trash requires I move twenty other “blocks” out of the way first.

An example… the shoes outside my front door.

OCD doesn’t allow the shoes inside my apartment because they bring in contamination from the outside world. The accumulation of shoes outside my front door has very literally formed a block that impedes my access in and out of the apartment. OCD has rules about which shoes can be used when I leave my apartment, depending on where I’m going and what I’m doing. There are rules about how and where I can step and how I can put the shoes on. This makes chores like taking out the trash challenging.

So, I’ve been trying to come up with a solution to get the shoes out of the way. I thought maybe putting a shoe rack outside my front door might do the trick. I already have a shoe rack in my guest room with another pair of shoes on it… but it’s contaminated. Block. I would need to complete a decontamination ritual (cleaning wipes) to get the rack “clean” and to a point where I would feel comfortable using it. To complete this ritual I would also need to move and decontaminate the contaminated shoes that are on the rack. Block. Where do I put those shoes after I’ve decontaminated them? I would have to clean or clear another spot in my guest room (which is already pretty crowded) so I can put them where they’re not going to get contaminated again or where they’re not going to contaminate something else. Block. I have another shoe rack in my storage unit a mile away from my house. Getting there and back is a chore. Block. I could go try to buy a new rack, but I keep getting triggered when I go shopping and new things I buy are getting contaminated before I even get home. Block.

…I think I like the iPhone version of this game much better!

Goals

It dawned on me today as I was fumbling through my messy apartment and feeling down about my current state of being that I really should have a set of goals to guide me, particularly as I step into more immersive treatment. I need a vision of what I want my life to be at the end of treatment (or even earlier) to help encourage and motivate me… something that says “this is why I’m pushing back against OCD.”

So, here we go. Here is my attempt at goal setting. (You can just assume that OCD is getting in the way of all of these things.)

  1. Have a clean and comfortable living space. I want a space where I can move around freely and uninhibited; a place where I’m not constantly stumbling over and around the messes OCD has generated. A space that is free of clutter. A space where I can sit where I want to sit, touch what I want to touch, look where I want to look, and do what I need to do to take ownership of my life and be an adult.
  2. Wear the clothes I want to wear. OCD has limited my wardrobe to a few select outfits. I have lots of great stylish clothes that OCD tells me I can’t wear. I want to open back up my whole wardrobe and be able to wear what I want without hesitation.
  3. Exercise when and where and how I want to. OCD has been interrupting my exercise in three ways: it interrupts my workouts while at the gym, it limits the attire that I can wear when I workout (see #2), and it often prevents me from even exercising in the first place. I want to be able to go for a run when I feel like it, wear the clothes appropriate for the activity, and get through a workout without having to stop and ritualize at all.
  4. Eat what I want and when I want, particularly healthy home cooked meals. OCD doesn’t allow me to eat food that I’ve touched with my bare hands. I don’t cook my own food anymore. I don’t touch or prepare fresh fruits and vegetables. Both obsessions and compulsions often prevent me from eating. When I have a window of time where obsessions or compulsions aren’t in the way I eat whatever is quick, easy, and available. And I’m often starved by this point so I eat larger portions than I have in the past. I want to prepare my own healthy meals I prepare with my bare hands and do it on my own terms and not those dictated by OCD.
  5. Achieve some sort of inner peace or spiritual comfort. Admittedly, this is a little ambiguous, and I’m not quite sure what exactly it means. I think part of it is being OK and living with the uncertainty that OCD tries so hard to resolve. Also, I think I’ve been unsettled for a long time and I’ve never been totally ok or happy with who I am. I have a suspicion that OCD will ultimately be the thing that allows me to accept and love who I am.
  6. Have a daily routine that is set enough to help me be productive, but flexible enough so it doesn’t become ritual. OCD has totally disrupted my productive routines and replaced them with it’s own rituals. It’s messed with my work schedule and made me late for appointments. I want to be able to hold a schedule, be on time for appointments, and do all of the productive daily things adults do.
  7. Pursue and engage in hobbies on a regular basis. I had a friend recently ask me what hobbies I had outside of work. I realized that right now I don’t really do anything and that’s because OCD takes up so much of my time. I want the freedom to reintroduce old hobbies. I want to start dancing, skiing, boating, etc. again. I want the freedom to try new hobbies.
  8. Engage in social interactions and activities on a regular basis without fear. I’ve noticed that I’ve started to enjoy large social engagements like parties less and less. There is an element of unpredictability and the possibility of my OCD being set off increases with each additional person. I want to attend and engage in parties and enjoy myself. I want to go to dinner at a friends house and enjoy myself.
  9. Be present in my relationships. OCD can be very distracting and can divert my attention from loved ones. It seizes my attention, making it difficult to be fully engaged in thought and conversation and can make the other person feel ignored or less important than my OCD. I want to be fully present in all my relationships so my loved ones feel heard and appreciated.
  10. Reclaim my weekends. I have dreaded the weekends for a long time now. The weekend has been a time to try to unbury myself from the OCD mountain that has accumulated during the week. I want to look forward to the weekend. I want to get back to a place where the weekend is a time to have fun and enjoy life.
  11. Travel with ease and comfort, but without fear. Travel is difficult. The process of packing a bag is challenging. There is typically lots of ritualizing involved, trying to keep things from getting contaminated. Additionally, it’s difficult to pack up and take all my other OCD routines and rituals with me. I want to be able to travel freely and not have to worry about taking my OCD baggage with me. I want to be able to pack a bag and not worry about the spread of contamination.
  12. Ride public transportation without fear. Any ride on public transportation makes me tense. This is based on a history of unpleasant experiences, and because of those things I’m constantly on the lookout for things that activate my OCD. I want to be able to take a bus ride and relax and be OK with all of the unexpected things that are likely to come up.
  13. Attend and participate in cultural activities. This includes listening to music, going to concerts, plays, reading books, etc. OCD has restricted all of these activities. I want to be free to experience the joy of these activities without fear.
  14. Go shopping without fear and purchase new things when I need. I have a collection of brand new items that I haven’t used because they got negatively associated with a specific obsessive thought. Shopping for new things like clothes and other household items is difficult because I’m in fear of new obsessive thoughts getting attached to whatever it is I need to buy. I want to be able to buy what I need, when I need (or sometimes want it) it without this fear.