For Patients

The Therapy: ISTDP

The therapy I practice, ISTDP, is probably different from any other therapy that you might have had, that friends or family have described to you, that you have read about, or seen on TV or in movies. While it is “talk therapy,” and while insight is an important component of the work, ISTDP recognizes that insight alone often does not bring lasting therapeutic change. As a result, a central focus of ISTDP therapy is on helping patients face aspects of their inner lives that they avoid, including a visceral experience of avoided feelings. Without this key component, the talking  of “talk therapy” runs the risk of being a form of intellectualized avoidance.

Changing longstanding habitual patterns of thought, feeling, and behavior is not comfortable.  It does not need to involve excruciating pain or overwhelming anxiety—in fact, those get in the way—but ISTDP recognizes that change will inevitably have uncomfortable aspects. If your goal in therapy is to have a soothing “time out” from your difficulties, this is probably not the therapy for you. If your goal is to face your difficulties and move beyond them sooner rather than later, it is probably worth a try.

In most forms of therapy, the first session is primarily focused on gathering history and perhaps making a diagnosis.  The initial ISTDP session, known as a “trial therapy,” lasts 2-3 hours and is focused less on history and more on doing the therapy. This means that in the initial session you can try out ISTDP and often get a sense of whether it may be helpful for your difficulties. Subsequent sessions are typically 45 minutes once a week, though some patients benefit from longer sessions, usually 60-75 minutes.

“Short-term” does not refer to specific number of sessions, but to a commitment to bring meaningful change as rapidly as possible. ISTDP therapies tend to run about 20 to 60 sessions, though some are shorter and some are longer.

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Video Recording

For patients who give permission, I generally make video recording of sessions. This can provide a number of benefits, all depending on what you give me permission to do:

  • Many patients have reported that watching video of sessions has been very helpful to them. Patients who watch the video generally only watch a small number of sessions, but some watch almost every session. Some report that it is like having another session of therapy for free.
  • I sometimes review the video myself, or with one or more therapist colleagues, which helps me improve the therapy I give both to you and to others.
  • I sometimes use video recordings for research, or for the training I give to other therapists, which in turn helps other patients.

For more information, see my “Authorization to Record Psychotherapy” form (link below).

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Insurance

I am an in-network provider for “commercial” Tufts Health Plans. This means that I can take Tufts HMO and PPO plans, but I am not a provider for Tufts “Network Health” plans. For some patients with a Blue Cross/Blue Shield HMO, I have been able to get “single-case agreements” so that my services are covered.

I am not in-network for any other providers, such as Blue Cross/Blue Shield, Medicare, MassHealth, Harvard Pilgrim, Aetna, Cigna, United HealthCare. However, if your insurance has an out-of-network benefit (e.g., a PPO plan), it should cover a significant portion of the cost.

For patients with out-of-network benefits:

  • I will have you pay my fee at each session.
  • I can provide you with a monthly “superbill” (receipt) that you can submit to your insurer to receive reimbursement from them.
  • In considering this option, please be aware that: (a) Your plan may have a substantial deductible before you get any reimbursement at all. (b) If your insurer says that they will “pay 80%,” they are referring to 80% of what they deem “usual and customary” (“U&C”) for the services I provide. That is generally substantially less than what I charge. (For example, Blue Cross’s U&C is about $190 for a 45-minute appointment, and $220 for a longer appointment.) You will be responsible for 100% of my fees above whatever their number is. Finally, (c) generally only the U&C part of any claim goes toward satisfying your deductible or out-of-pocket maximum.

If you are using insurance, you should check with your insurer before the first session to find out whether you need prior authorization or referral; typically there will be a “mental health” phone number on your insurance card. You will need to track how many sessions are authorized before re-authorization is required. When necessary, I can work with you around obtaining re-authorization. In general this is fairly straightforward and I do not charge for it. With certain insurers it has proved to be very time-consuming, and in that case I do bill at my clinical rate for administrative time, which is not covered by insurance.

Please note that some insurers have incorrectly told patients that I am “in-network” because of my affiliation with Beth Israel Deaconess Medical Center (BIDMC), where I periodically do consultation work. To be in-network for treatment in my practice, I must be listed under an office address in Belmont, MA.

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Fees

The “sticker price” for my sessions is very high. This is because some insurances will reimburse me at those rates, and a few people can afford to pay them out-of-pocket. Most people cannot, and in those cases I happily adjust my rate downward by pre-arrangement. The downward-adjusted rate is still high. If you are trying to figure out how much your out-of-network insurance might cover, you will need to find out out how much they pay for certain billing codes (“CPT codes”), known as their “usual and customary rate.” I generally bill two CPT codes for each session. For the initial session it is 99204+90838; for a 45″ session it is 99213+90836; and for a 60-75″ session it is 99213+90838.

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Cancelations and Lateness

For cancelations with less than 24 hours notice, I charge my full fee, generally with exceptions for significant illness or family emergencies. If you contact me before your appointment time and we are able to reschedule, I generally do not charge even if it is within 24 hours. 

Insurance will only pay for the time a patient is with me; it will not cover missed sessions.

For patients who arrive late, I still charge my full fee. In some cases of significant delay, I can only bill insurance for a shorter appointment, resulting in lower reimbursement. If the reimbursement is coming to me, I bill the patient for the difference between what the insurance pays for the shorter appointment and what they would have paid for the full-length appointment.

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Electronic Health Record (EHR) and Patient Portal

I use an EHR system called SimplePractice. The system includes a “patient portal,” which can be used for secure messaging and a few other functions. (That said, most patients seem to prefer the convenience of emailing directly, even though the security of email cannot be guaranteed.)

For patients who have enrolled with the portal, it can be accessed at https://natkuhnmd.clientsecure.me. The portal uses “passwordless login”—instead of setting a password, the system emails you a link when your ask to log on.

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Intake and Other Forms

New patients generally fill out intake forms through my EHR system. Filling out the forms is not a guarantee that we will do therapy together. That is a decision that we will make at the end of an initial evaluation (“trial therapy”) session.

The portal intake process will ask you to provide

  • demographic information;
  • some basic history;
  • authorization for insurance authorization, as applicable;
  • acknowledgment of my practice policies (also available here);
  • acknowledgment of an outline of my privacy policies (click here for the full privacy policy).

The following forms are not distributed as part of the portal intake. They can be downloaded on the portal, or here:

To fill out these forms, you can download them, check or un-check the various options as you prefer, print, and sign. You can scan or photograph the signed document and upload it to the portal, or you can mail it to me.

If you are not able to open these documents, you may need to download the Adobe Acrobat Reader.

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