Forum Replies Created
-
Posts
-
Hi, I was trying to view the recording for session 5, and it says “You cannot view this recording. Cloud recording plan expired.” I think it’s also the case for session 4 (I’m able to access session 6). Could you assist? Thanks!
Hi Rachel.
I offer fully virtual mind body medicine & psychotherapy services in Mexico, and coaching for people elsewhere. When the pandemic started I closed my physical office, and for the time being I work only remotely from home (commutes in Mexico City are awful, so even patients I have here prefer meeting online).
In terms of insurance, I can’t offer any insights or tips – in Mexico, anything deemed to be complementary & alternative medicine / mental health is excluded from health insurance, and my non-clinical services are not covered by insurance.
For website creation, I’ve had a really good experience with Squarespace. They have great templates, the platform is really user friendly and the cost is very affordable – I use the Business option at $23 per month and built my own site (you can take a look here: https://liliagraue.com/). My navigation menu is less friendly than I would like because I have a bilingual site using a single domain, but it saves me a ton of money, and it works for now. And if your website is English only this is not an issue. You can also add an email address with your domain through Google Suite ($72/year). I use Acuity as an online scheduler (it’s actually been bought by Squarespace so the integration is pretty seamless) – it allows for integration with Stripe and Zoom, so people pay directly through my scheduler and Acuity generates the Zoom link and emails it in the confirmation email (which saves a lot of time). Acuity starts at $16 per month.
The only downside of Squarespace is that it’s less efficient with SEO than WordPress, but for another site I have hosted through WordPress I did have to hire a web designer to get it going and deal with all of the APIs – I can now edit it as I like but couldn’t have done it without a web designer.
Some friends of mine have used Wix and like it as well.
Links:
Squarespace https://www.squarespace.com/
Acuity https://acuityscheduling.com/
Wix https://www.wix.com/For billing, my Mexican patients pay by wire transfer, and overseas clients pay me through Stripe. It’s fantastic service, decent fees, and people don’t need an account like they do with PayPal. It allows for saving credit card info, recurrent or one time payments, creation of payment links, and all the functionality you need. At least in Mexico, Stripe is linked to my tax information, and getting my commissions invoice is super easy (for monthly deductions).
To sum up, in terms of tech/platform, I use Zoom, Squarespace, Acuity, and Stripe. I’ve used MailChimp in the past and might do so again.
For networking and referrals, I lean on building relationships with colleagues so we can do cross-referrals. I meet colleagues through trainings like these, as well as consultation groups. Other great sources of referrals are directory listings (eg PRT and upcoming OvidDx), as well as podcasts. I have a mostly hate-hate relationship with social media, so that’s not a resource I use. I used to have a mailing list (I used MailChimp and was super happy with it) and a blog, though I’m not currently doing that either because of time constraints. My experience has been that for 1:1 work, networking with colleagues, word of mouth from patients/clients and podcasts bring in a consistent flow of patients/clients, but in order to fill groups (if you do group work) you absolutely need a strong mailing list, a good number of followers with good engagement on social media, and/or a source of numerous referrals (like a clinic treating a specific condition or type of pain). My group offerings have filled up mostly through my mailing list.
My main tip for making it simple is to focus on your strengths and what you enjoy. Eg: I love and am skilled at building relationships with colleagues, doing speaking gigs and writing blogs/emails – all great sources of referrals. I hate social media, working at it is soul crushing, and for many years I invested a lot of time, energy, and even money on paid ads, without much success. In terms of marketing, it’s more efficient to invest on creating content for your blog, mailing list and YouTube channel, and podcast interviews (they’re all searchable by SEO and have a long internet life) than on social media (unless you’re super social media savvy or can hire a wonderful community manager) where posts have a really short life. Facebook groups are favored by some as a platform for self-promotion and marketing, but in my experience they’re a lot of hassle (especially the larger they become) and require serious admin labor, particularly if you want to make sure community guidelines are upheld and people aren’t harmed.
For cost-effectiveness, I never had a lot of money to invest, so I built/grew slow and steady, organically, and I’ve always been a one-woman show, so I don’t have a VA or community manager. If you do have a ton of money to invest to begin with, hiring someone to create an amazing website with lots of valuable content and great SEO is a good strategy, and a VA could be a good idea too.
I hope this is useful and I wish you success with your practice.
Apologies for a duplicate post, having some challenges with the forum today.
Here’s another one from the British Journal of Community Nursing, with an emphasis on women’s health issues.
Below is a background summary from an ongoing clinical trial. Full paper here, also downloadable for free in pdf: https://trialsjournal.biomedcentral.com/articles/10.1186/s13063-021-05727-2
Lipedema was first described in 1940 by Allen and Hines [1] and has a registered diagnosis in the International Classification of Diseases [2] (ICD-10_GM Version 2020) coded stage-specifically (ICD10-E88.20, E88.21, E88.22, and E88.28). This disease, almost exclusively affecting females, is characterised by a symmetrical bilateral increase of the adipose tissue in the upper and/or lower extremities. It is unresponsive to physical activity or dietary intervention [3, 4]. A large proportion of the patients also shows the involvement of the arms [5]. Lipedema is associated with pain of the adipose tissue, increased touch sensitivity, feeling of tension in the affected regions and an increased tendency to haematoma after minor traumas [6]. Data on the prevalence of lipedema is limited. The prevalence of lipedema may be between 10 and 18% among women [7,8,9]. Child et al. estimated the prevalence within the female population as 1 in 72,000 [3]. However, lipedema is often misdiagnosed as obesity or lymphedema and therefore is incorrectly treated [3, 5]. Shivat et al. have established lipedema diagnostic algorithm to guide clinicians in making the correct diagnosis [10].
The aetiology of lipedema is unknown, but a genetic disposition is likely since lipedema is often seen in patients with a family history of this disease. X-linked dominant or gender-limiting autosomal dominant inheritance is assumed [3]. An important factor in the pathophysiology of lipedema is the increased capillary permeability, which leads to orthostatic edema and seems to be responsible for the increased tissue sensitivity in response to touch and pressure. Increased capillary fragility could explain the tendency towards haematoma formation [11].
The course of the disease is individual: some patients develop lipedema at a lower degree of severity and with stabilisation. Other patients show progression after stressful situations like pregnancy or surgery [12]. The onset of lipedema is common in teenage years, but is also observed after pregnancy or even menopause [3, 13].
Lipedema is divided into three stages according to skin morphology and palpation: stage I is characterised by smooth skin surface, thickened subcutis and small-nosed fat structure. In stage II, nodules appear in the fatty tissue and the skin surface is uneven, while in stage III, the tissue is hardened and rough with the presence of large deforming fat flaps [4].
The comprehensive decongestive therapy (CDT) is part of the standard conservative treatment [6]. Originally developed for the treatment of lymphedema, improvement has also been seen in patients with lipedema (reduction in leg circumference, tension, and pressure pain). As the treatment success is short-term, therapy is permanently necessary [4, 12].
CDT consists of a combination of lymphatic drainage, compression therapy (usually flat-knitted compression stockings), skin care and physical activity. It is unclear whether CDT influences the progression of pain in addition to the abovementioned benefits. However, the specific fat accumulation and distribution with the accompanying pain and tendency to form haematomas remain [5]. Physical activity, if necessary in combination with a dietary intervention, aims to reduce or prevent obesity, which has a negative prognostic influence on the development of lipedema [6, 10].
Starting in the 1990s, liposuction has emerged as the most important surgical intervention for lipedema. The pathologically altered subcutaneous fatty tissue is surgically removed without damaging the lymphatic system. Liposuction methods are tumescent anaesthesia (TA) and water-assisted liposuction (WAL). In TA, several litres of an anaesthetic solution are infused into the subcutaneous area (‘wet technique’) so that the fat cells swell and vessels constrict. Then, the subcutaneous fat is suctioned off by a very fine, blunt, vibrating cannula (power/vibration-assisted liposuction, PAL). In WAL, a jet of water releases the fat cells from the connective tissue and a mixture of fat cells, water and tumescent solution is aspirated [14,15,16]. This method is a tissue-friendly surgical method and minimises the risk of injuring vascular, lymphatic and nerve structures [4, 14, 17,18,19]. TA is standard for surgical treatment nowadays and recommended as the method of choice in the guidelines for lipedema [6].
Liposuction leads to reduction of lipedema-specific fat accumulation and distribution, pain sensitivity, edema, tendency to haematoma and restriction of movement [4, 19]. An improvement in the quality of life and a decrease in the need for conservative therapy has been shown [4, 11, 20,21,22].
In summary, clinical experiences as well as small trials demonstrate a positive effect of liposuction in lipedema with respect to pain, movement improvement and quality of life. However, controlled and randomised clinical trials comparing conservative and surgical treatments with valid statistical methods are missing. There is no evidence that surgical treatment is equivalent or even superior to conservative treatment with respect to pain in lipedema stages I, II and III. Therefore, a large-scale randomised controlled investigator-blinded trial will be performed with the aim to provide a definitive answer.
Liposuction is therefore discussed as a useful addition to or even alternative therapy for CDT, especially in the early stages of lipedema in order to prevent possible long-term effects such as the development of secondary lymphedema and disease progression, to improve the quality of life and to reduce the need for CDT [4, 11, 20,21,22].
Below is a background summary from an ongoing clinical trial. Full paper here, also downloadable for free in pdf: https://trialsjournal.biomedcentral.com/articles/10.1186/s13063-021-05727-2
Lipedema was first described in 1940 by Allen and Hines [1] and has a registered diagnosis in the International Classification of Diseases [2] (ICD-10_GM Version 2020) coded stage-specifically (ICD10-E88.20, E88.21, E88.22, and E88.28). This disease, almost exclusively affecting females, is characterised by a symmetrical bilateral increase of the adipose tissue in the upper and/or lower extremities. It is unresponsive to physical activity or dietary intervention [3, 4]. A large proportion of the patients also shows the involvement of the arms [5]. Lipedema is associated with pain of the adipose tissue, increased touch sensitivity, feeling of tension in the affected regions and an increased tendency to haematoma after minor traumas [6]. Data on the prevalence of lipedema is limited. The prevalence of lipedema may be between 10 and 18% among women [7,8,9]. Child et al. estimated the prevalence within the female population as 1 in 72,000 [3]. However, lipedema is often misdiagnosed as obesity or lymphedema and therefore is incorrectly treated [3, 5]. Shivat et al. have established lipedema diagnostic algorithm to guide clinicians in making the correct diagnosis [10].
The aetiology of lipedema is unknown, but a genetic disposition is likely since lipedema is often seen in patients with a family history of this disease. X-linked dominant or gender-limiting autosomal dominant inheritance is assumed [3]. An important factor in the pathophysiology of lipedema is the increased capillary permeability, which leads to orthostatic edema and seems to be responsible for the increased tissue sensitivity in response to touch and pressure. Increased capillary fragility could explain the tendency towards haematoma formation [11].
The course of the disease is individual: some patients develop lipedema at a lower degree of severity and with stabilisation. Other patients show progression after stressful situations like pregnancy or surgery [12]. The onset of lipedema is common in teenage years, but is also observed after pregnancy or even menopause [3, 13].
Lipedema is divided into three stages according to skin morphology and palpation: stage I is characterised by smooth skin surface, thickened subcutis and small-nosed fat structure. In stage II, nodules appear in the fatty tissue and the skin surface is uneven, while in stage III, the tissue is hardened and rough with the presence of large deforming fat flaps [4].
The comprehensive decongestive therapy (CDT) is part of the standard conservative treatment [6]. Originally developed for the treatment of lymphedema, improvement has also been seen in patients with lipedema (reduction in leg circumference, tension, and pressure pain). As the treatment success is short-term, therapy is permanently necessary [4, 12].
CDT consists of a combination of lymphatic drainage, compression therapy (usually flat-knitted compression stockings), skin care and physical activity. It is unclear whether CDT influences the progression of pain in addition to the abovementioned benefits. However, the specific fat accumulation and distribution with the accompanying pain and tendency to form haematomas remain [5]. Physical activity, if necessary in combination with a dietary intervention, aims to reduce or prevent obesity, which has a negative prognostic influence on the development of lipedema [6, 10].
Starting in the 1990s, liposuction has emerged as the most important surgical intervention for lipedema. The pathologically altered subcutaneous fatty tissue is surgically removed without damaging the lymphatic system. Liposuction methods are tumescent anaesthesia (TA) and water-assisted liposuction (WAL). In TA, several litres of an anaesthetic solution are infused into the subcutaneous area (‘wet technique’) so that the fat cells swell and vessels constrict. Then, the subcutaneous fat is suctioned off by a very fine, blunt, vibrating cannula (power/vibration-assisted liposuction, PAL). In WAL, a jet of water releases the fat cells from the connective tissue and a mixture of fat cells, water and tumescent solution is aspirated [14,15,16]. This method is a tissue-friendly surgical method and minimises the risk of injuring vascular, lymphatic and nerve structures [4, 14, 17,18,19]. TA is standard for surgical treatment nowadays and recommended as the method of choice in the guidelines for lipedema [6].
Liposuction leads to reduction of lipedema-specific fat accumulation and distribution, pain sensitivity, edema, tendency to haematoma and restriction of movement [4, 19]. An improvement in the quality of life and a decrease in the need for conservative therapy has been shown [4, 11, 20,21,22].
Liposuction is therefore discussed as a useful addition to or even alternative therapy for CDT, especially in the early stages of lipedema in order to prevent possible long-term effects such as the development of secondary lymphedema and disease progression, to improve the quality of life and to reduce the need for CDT [4, 11, 20,21,22].
In summary, clinical experiences as well as small trials demonstrate a positive effect of liposuction in lipedema with respect to pain, movement improvement and quality of life. However, controlled and randomised clinical trials comparing conservative and surgical treatments with valid statistical methods are missing. There is no evidence that surgical treatment is equivalent or even superior to conservative treatment with respect to pain in lipedema stages I, II and III. Therefore, a large-scale randomised controlled investigator-blinded trial will be performed with the aim to provide a definitive answer.
Hi everyone! Thank you for starting this thread Dawn 🙂 It’s wonderful to get to know you all a little bit more.
I’m Lilia Graue, physician, psychotherapist, educator and coach in Mexico City, where I’ve practiced for over 20 years in the fields of mental health, eating disorders, and medical family therapy, as well as in medical education. I currently have a private mind-body medicine practice, and offer bodymind (re)learning for wellbeing and ease coaching for people around the world in English and Spanish. Most of the people I support experience anxiety, depression, chronic primary pain / symptoms, struggles with food and body, and complex trauma. I’m also a medical advisor for The Better Mind Center in LA and offer training and mentoring for healthcare professionals.
In 2020 I found Curable and recovered from a chronic back pain process that started with an injury, involved 3 surgeries and lasted almost 10 years. Since recovering, I’ve trained in PRT, EAET, Explain Pain (NOI), ISTDP, and Freedom from Chronic Pain, and have become a certified SSP (Safe and Sound Protocol) provider. Like Karin, I’d done some training in mindbody medicine several years ago through the Harvard group, and I am still astounded that the program didn’t include anything about nociplastic pain, specifically about the possibility of recovery. Before Curable, everything I’d found as both a patient and provider in the mindbody field was for pain management, not pain recovery, and this shift has been life changing for me.
These days I’m geeking out on the sciences of complexity, culturally bound syndromes, different understandings for the experience of persistent pain and other symptoms, and the search for language that describes the embodied experience and emphasizes the oneness and interconnectedness of our bodymind and our ability to adapt and heal through intentional practices including mindfulness and different forms of somatic awareness.
I live with my partner and our three cats, and love baking, making sourdough, swimming, reading, traveling, being in nature, and Sundays at the Philharmonic.
I love her work. This interview with her is from a while back, but so rich: https://onbeing.org/programs/rachel-yehuda-how-trauma-and-resilience-cross-generations-nov2017/
It explores how we can flourish beyond the traumas large and small that mark each of our lives and those of our families and communities.
Hi Becca, thank you for sharing these thought provoking reflections and case.
I have some notes from the EAET & ISTDP training I thought I’d share.
From the EAET training:
A consideration about the “right emotion”, ie what’s appropriate for the situation, and looking for two possibilities:
– secondary (defensive) anger is not the “right”/core emotion, but it is blocking hurt, sadness, connection
or
– anger is the “right” emotion but at the wrong target
Encourage the person to explore if there is a part of them that feels angry, guilty, ashamed, sad, longing for connection.From the ISTDP training:
Allan Abbass was very emphatic about the fact that “it’s not about the rage, but about the guilt over the rage” – we feel guilty and/or ashamed that we feel such anger or rage, because we’re good people and we don’t really want to hurt our loved one, even though they might have hurt us. There is guilt laden rage because of attachment. It is really important to keep bringing back the guilt every time the rage arises to protect the patient. He elicits rage and the wish to act it out and then the guilt that the person experiences from having hurt someone in this imaginary scenario, so he’s not encouraging murderous rage or even catharsis, just making space for the complexity of it all. He surfaces how there is a part of the patient that responds somatically to the feeling as though it was the same as the action. And when the activation/anxiety goes up, he goes to recap and reflecting, he doesn’t keep pushing. He helps patients connect to the awareness that they’re a good person, and highlights the need to keep the love and positive feelings in there as well.He deliberately acts in ways that are mildly irritating for the patient throughout the session, at the same time as building a strong therapeutic alliance to elicit the full range of emotions in the patient, so that anger/frustration will surface in the relationship in real time and it can then be worked with (engaging transference to work with emotions in the context of the therapeutic relationship), at the same time that there is appreciation for the fact that the therapist is there to support the patient in finding freedom from symptoms. He stays steady, careful to keep the patient safe and not push beyond threshold, while at the same time not shying away from anything and staying calm.
Something that has been very clear to me from observing therapists skilled in ISTDP and EAET is that they are incredibly comfortable and skilled in welcoming and handling conflict and frustration, particularly in the context of the therapeutic relationship.
Hi Karin, thank you for bringing guided practices into the conversation. I’ve recorded guided practices in Spanish for my patients (mindfulness, self-compassion, somatic tracking, toggling back and forth between difficult sensations and pleasant/neutral sensations, and visualizations), and throughout our work together I’ve shared several with my patient, her family and professional caregivers (we would do them together in session and then I’d share a recording). It’s been hit and miss, to be honest; some days she’s willing to try and practice, most days she isn’t. In general, her motivation to engage with any kind of practice, including breath and movement, is very low. She does like massages, so we’ve brought in a massage therapist to see her twice a week, and her caregivers also regularly offer massages. Among the practices we’ve explored together, visualizations have been the most successful – she has a really hard time tuning into sensations and the self-compassion practices don’t really resonate with her. I like your suggestion to ask her caregivers to offer that option more often, and see how it goes.
Thank you for this, and I’d love to hear more about other practices that have been useful with the hospice/palliative medicine population you work with.
Thanks so much for sharing this article, Becca.
I appreciate your remarks regarding the lumping together and confounding of results, Alicia.
And Howard, Paul Garner’s story is fascinating, and I’m always struck by people’s intense reactions to it in the comment section.
Alicia, thank you so much for your kind and wise words about the care of my patient, the challenges in working with the elderly when there is cognitive decline, how to best offer loving and compassionate presence to folks facing the pain and fear that come with late stage aging, and how to approach resistance, it’s very helpful and supportive. And yes, humor is such a great tool.
LiliaAlicia and Howard, and everyone else who’d like to chime in, I have a question and a case related to the question.
Question:
Have you worked with elderly patients with cognitive decline? If so, are there specific suggestions you’d offer for working with this population?Case:
I’ve been working with an 82 yo F with Parkinson’s, depression, cognitive decline, vasculitis, hypertension and hyponatremia, who was referred to me for post-herpetic neuralgia, and it’s been really challenging.The greatest success so far has been with her children, who were very open to psychoeducation about primary pain and to working through the fear/avoidance cycle. They have stopped organizing around the pain, and have made significant shifts in how they relate to her, in addition to organizing more family gatherings and more frequent visits with her children and grandchildren, which brings her joy. They are making the best of her good days and keeping her company on not-so-good days, and she recently went on a short trip to the beach with one of her daughters and her family.
She and I have established a good rapport, and during the time we’ve been working together she has grown in willingness to engage socially, with ups and downs. Her children have shared that she seems more engaged and in general her mood has had a positive trend.
In terms of the pain, we haven’t had much success with the neural repatterning toolkit – psychoeducation has been incredibly difficult; she will sometimes agree to have me guide her through somatic tracking, mindfulness and compassion practices, and sometimes she won’t; she refuses to practice in-between sessions; any and every time we come near difficult events/emotions she gets intense pain but denies any connection between her emotions and pain (other than that the pain seems to come at random times, and is not triggered by movement); she refuses to engage in physical movement beyond two days a week during her PT sessions (her mobility is quite limited – her muscle mass is very very low, she can walk with the help of a walker with the tiniest steps, and for most of the day she sits on a recliner), and won’t leave her room unless her children are visiting (and even then it’s a struggle unless it’s a large family gathering downstairs). She’s had several episodes of severe hyponatremia and UTIs during the time we’ve been working together, with associated lethargy. She has a history of poor health in childhood, lost her father to suicide in her teens, and her husband has had an extramarital relationship for decades – they keep separate lives though they live in the same house and will both be present for family gatherings and celebrations. During the pandemic several of her friends and elderly relatives died, and the remaining ones are not meeting anymore like they used to. She has live-in nurses and both they and her children have tried everything to encourage her to be more active and/or do guided practices, but she gets combative. There have been episodes during which she refuses to bathe or to get up to urinate for a few days, which usually ends with a UTI.
My role in her medical team is in the psychosocial domain. She has a neurologist, a geriatrician, and a rheumatologist seeing to the medical aspects, and her daughter is also a physician.
Any insights or suggestions would be much appreciated, thank you!
Hi all, here’s the link to the papers I mentioned today re predictive processing, POTS and threat conditioning.
https://drive.google.com/file/d/17cPkE0P8CNK3dRBWZSYektvAQ0JPJAtX/view?usp=sharing (Norcliffe-Kaufmann et al, 2022, Fear conditioning as a pathogenic mechanism in the postural tachycardia syndrome)
https://drive.google.com/file/d/1P6F5QDUz3DryFYTrEEthNC9NPk8-VIjR/view?usp=sharing (LeDoux, 2014, Coming to terms with fear)
Hi all, here are the two papers I mentioned today re predictive processing, POTS, and fear/threat conditioning.
Norcliffe-Kaufmann, 2022, Fear conditioning as a pathogenic mechanism in the postural tachycardia syndrome https://drive.google.com/file/d/17cPkE0P8CNK3dRBWZSYektvAQ0JPJAtX/view?usp=sharing
LeDoux 2014, Coming to terms with fear https://drive.google.com/file/d/1P6F5QDUz3DryFYTrEEthNC9NPk8-VIjR/view?usp=sharing