The AAMFT Blog

Día de Muertos (Day of the Dead)

This week I have been interviewing local people here in Mexico City about their thoughts about the upcoming Día de Muertos (Day of the Dead). As with most spiritual traditions, people hold varied thoughts and feelings about this celebration.  The origins are Pre-Hispanic and were practiced by the indigenous people of this area for over 3000 years, yet for many Mexicans the tradition now may be intertwined with their Catholic faith. For most people, this beautiful tradition is characterized by a playful celebration with death and an opportunity to remember, honor and visit with family and friends who have passed from this life onto the next one.  A few of the common traditions include a visit to the Panteón, building an ofrenda, marigolds (cempasúchil or the “flowers of the dead”), pan de muerto and sugar skulls.

A visit to the panteón (the grave of one’s loved ones) on November 2^nd is perhaps the most traditional Day of the Dead activity. The family typically will clean the gravesite and decorate it with fresh flowers. Often families will create breathtaking art using flower petals and seeds. This can be a time of complex emotions, ranging from profound and often communal mourning to intense celebratory parties. Families may bring music, food and liquor for this family reunion and will have varied means to remember, honor and show respect to the departed. This can be a powerful way to keep the memory of loved ones alive, to introduce the younger generation to their ancestors as well as to the concept of death. It can also be a way for family members to continue working and renegotiating their relationships with those who have died or to address ongoing issues of loss. For many people, this is a literal opportunity to feel the presence of those they love who are no longer alive and to converse with them. One sad side note, given the importance of this practice for many Mexicans, is that a number of people I spoke with reported that they no longer go to visit the panteón due to concerns about safety and a lack of faith in overall security here in Mexico.

Another typical activity related to the Day of the Dead is for people to construct an ofrenda in their home. This is a type of alter which is decorated with colorful flowers and with items loved by the person who has died. Usually a photo of the person will be placed on the ofrenda along with personal items (e.g. their pipe, glasses, etc). It is also very common to place favorite foods, drinks and other items like mole, tequila, cigarettes, tamales, fruits, or tortillas. Often copal (a sacred type of incense) and candles will be burning. There is also almost always some Pan de Muerto and Calaveras (skeleton imagery, particularly sugar skulls).

Pan de Muerto is a sweet bread that is often covered with bright colored sugars. It is a medium for artful expression itself and can be shaped into many different forms such as skeletons and other death related items. Brightly decorated sugar skulls are also often placed on the ofrenda or grave with the name of a departed soul written on the forehead. Historically, while this bread and other food items were offered to dead, who consumed its aroma, it also provided for the kin of the deceased. 

Cempasúchil flowers (marigolds) are found everywhere in Mexico during the Day of the Dead celebrations. The petals are believed to create a path for the souls of family members who have died to follow. In some communities there will be long paths of Cempasúchil petals that create a path from the pantéon to the ofrenda in the family’s home.

The rich and layered traditions linked to the Day of the Dead create numerous possibilities for therapeutic dialogues with Mexican clients. Engaging in some of the rituals associated with this celebration might even be useful to consider as an intervention in some situations. It is just important to keep in mind that, just as sugary marshmallow Peeps sold around Easter do not capture the profound feelings many people may have about Christ’s death and resurrection, the commercialized version of the Day of Dead that many may be familiar with does not capture the deep meaning of this holiday. It should also be remembered that the Day of the Dead and Halloween have completely different origins even if the two sometimes get linked.  Perhaps, just be curious and avoid assumptions. As with most things, there is no single story about the Day of the Dead, but it does create an opportunity for profound dialogues about family, national identity, and loss.

In my conversations this week, I have noticed that the holiday creates a context for discussing existential issues like life and death. In regard to death, several comments I heard this week oddly led me to think about the movie The Godfather. There is a scene where Michael Corleone recounts a lesson he learned from his Mafia boss father Don Vito Corleone where he states; "I've learnt many things from my father in this room. He told me ‘Keep your friends close, but enemies closer.’" In some ways this dictum (or dicho in Spanish) captures some themes I have heard about the playful relationship Mexicans often create with death. Several told me that because they are scared of death, they keep this ‘enemy” close to them and by making fun of death and engaging with it more directly, it allows them to keep an eye on death and to take back a little control.

¡Feliz Día de Muertos!

Dr. Jason J. Platt is a Full Professor and the Program Director of the Masters in International Counseling Psychology program at Alliant International University’s Mexico City Campus. He is the founder of the CSPP Spanish Language, Class and Cultural Immersion program and the Certificate in Latin American Family Therapy. In addition to the Mexico programs, Dr. Platt has facilitated immersion education programs in India, Cambodia and Vietnam. His family of seven adopted siblings from five different countries, with varied but often traumatic histories, has invariably influenced his career choices and commitment to being part of research and educational efforts that will better prepare clinicians to work with international and impoverished communities.

ICD-10/DSM-5 Additions: What You Need to Know

You may recall that on October 1, 2015 diagnosis codes changed from the 9^th edition of the International Classification of Diseases and Related Health Problems ICD-9 to the 10^th edition, also known as ICD-10. For the first time in over three decades, new codes were implemented for all diagnoses, and the total number of medical diagnostic codes increased five-fold—from approximately 13,000 to 69,000.  In recognition of the enormous overhaul to this system and the adjustments that come with it, The Centers for Medicare and Medicaid Services (CMS) had allowed a grace period of a year, while also introducing additional codes to the repertoire.

As of October 1, 2016 these additional codes must be used in place of the old ICD-10 codes, or you will likely see your claims denied. In fact, the incorrect use of ICD-10 is going to affect significantly your practice and your reimbursement.  And while CMS allowed a one-year grace period for incorrect coding, that period has ended and attention to proper coding and notation is the standard. Movement to ICD-10 coding requires everyone using the ICD-10 to be as precise as possible.

For mental health professionals, like marriage and family therapists (MFTs), the updates affect 14 mental health diagnoses and may extend beyond these in requiring tighter and more specific diagnostic processes. To view a list of the old and new codes, click here.

A number of ICD-10 codes have been updated so that new DSM-5 diagnoses have their own individual codes rather than sharing codes with older diagnoses. In essence, it should now be clearer which diagnosis you are giving when using a code. However, it is also important to note that these 14 codes will no longer match those in the DSM-5.  Mental health providers should continue to use the DSM-5 to determine the correct diagnosis, but be sure to use the new codes for these 14 diagnoses.

Keep in mind that the interface between the DSM-5 and ICD-10 is such that the DSM-5 is meant to be a guide to help clinicians choose the correct ICD-10 code.  And we all know that this can be tricky when a client presents with most, but not all, of the criteria for a particular diagnosis. Until now, such cases had been covered using “unspecified codes.” However, the current move toward specificity, along with the view that there are incongruities between the DSM-5 and the CMS code sets, discourages the use of unspecified codes when diagnosing clients.

What this means for your practice is that you need to be proficient when applying the DSM-5 to ICD-10.  The impact of this change does not end at billing and coding. All clinicians are responsible for documenting their diagnostic and treatment services properly.  Client records must contain adequate information to support any diagnostic (ICD-10) and treatment (CPT) codes that are applied to a given clinical encounter. And while it is true that the greater detail and specificity provided by ICD-10 make reimbursement more likely, good documentation is necessary for proper coding. Ultimately, we are responsible for diagnostic coding, and a good understanding of ICD-10 is at the core of being able to do that well.

Managing Client Information in the Context of Couples, Family, or Group Treatment

So far in the Legal and Ethics FAQ blog series, we’ve explored the first few sentences of Standard 2.2 in the AAMFT Code of Ethics in some depth. As you’ll recall, Standard 2.2 states:

Marriage and family therapists do not disclose client confidences except by written authorization or waiver, or where mandated or permitted by law. Verbal authorization will not be sufficient except in emergency situations, unless prohibited by law. When providing couple, family or group treatment, the therapist does not disclose information outside the treatment context without a written authorization from each individual competent to execute a waiver. In the context of couple, family or group treatment, the therapist may not reveal any individual’s confidences to others in the client unit without the prior written permission of that individual.

With this post, we’re going to discuss the last sentence of Standard 2.2. That sentence states:

In the context of couple, family or group treatment, the therapist may not reveal any individual’s confidences to others in the client unit without the prior written permission of that individual.

Imagine a scenario where a therapist meets with one part of the client unit individually and learns of a specific issue that could affect the treatment of the larger client unit. Or, imagine a scenario where a therapist gets between session contacts from one member of the client unit. These scenarios, and more, may cause a therapist to wonder whether they can or should share information obtained from an individual client with the larger client unit.

The importance of having a clearly articulated policy on how MFTs will manage individual confidences in the context of couple, family, or group treatment cannot be overstated. MFTs need to determine early on what their policy will be so that they can clearly communicate the policy to clients and refer back to the policy as needed during the course of their work with clients.

When choosing a policy, MFTs have various options. Some may choose to adopt a policy stating that information shared by an individual in the context of couple, family, or group treatment will not be kept confidential from the larger client unit. Some may adopt a policy stating that the therapist will determine, at their discretion, whether information needs to be shared with the larger client unit. Some therapists may adopt a policy stating that all information shared by an individual in the context of couple, family, or group treatment will remain confidential and will not be shared with the larger client unit. (See, Habrel & Oberle, 2012.)

If an MFT chooses to adopt a policy stating that information shared by an individual in the context of couple, family, or group treatment will remain confidential and will not be shared with the larger client unit, the MFT will need to be prepared to handle other issues that could arise (e.g. conflicts of interest, breaches of confidentiality, bias, risks to the therapeutic relationship, risks related to treatment progress).

For this reason, the concept of a “no secrets policy” has emerged. Under a “no secrets policy” the MFT would spell out their information sharing practices, which could include sharing all information obtained from an individual in the context of couples, family, or group treatment, or sharing information obtained from an individual at the therapist’s discretion. Typically, the decision about whether to share information would involve an analysis to determine whether sharing the information would be in the client or client unit’s best interests, whether sharing is clinically indicated, whether sharing would benefit the treatment of the larger client unit, etc. Some policies may also discuss working with the individual towards a self-disclosure to the larger client unit, while reserving the therapist’s ability to make the disclosure if the individual does not share the information.

In determining what their policy will be, it is advisable that MFTs look to applicable laws as well. When drafting policies and informed consent documents, it is advisable to work with a local attorney to ensure that all policies and documents adhere to applicable laws.

References

Habrel, E., & Oberle, K. (2012, March/April). Confidentiality and informed consent with couples and adolescents. Family Therapy Magazine, (11)2, 24-27.

Red Cross Recruiting LMFTs to Serve as Disaster Mental Health Volunteers on the East Coast

The American Red Cross is currently recruiting LMFTs and other independently-licensed mental health providers to deploy to states affected by Hurricane Matthew. Please see this flyer for more information. Independently-licensed MFTs are eligible to serve as Red Cross disaster mental health (DMH) volunteers. You do not have to be a current Red Cross DMH volunteer to participate in this deployment.