OnlineTreatment Programs in the Mental Health Profession

This article is part two of a series of five that explores interesting, unique and noteworthy trends in the mental health profession. Understanding current and upcoming changes within our industry gives us the ability to identify new opportunities and challenges arising in the field so we may identify appropriate responses and successfully meet the demands of our dynamic profession. This exploration process empowers professionals to make more effective and rewarding business decisions both now and in the future. Examining these changes often brings about exciting opportunities if we, as clinicians, are able to look at these new service offerings and competitive influences in unique and creative ways.

Online Treatment programs

An interesting area arising within the industry is that of the online treatment program. This model goes beyond individual psychotherapy and offers a comprehensive approach to treatment that may include group work, interactive exercises, use of clinical tools, use of assessment applications and aftercare programming.

How State Budget Cuts Impact Continuity of Mental Health Care

Continuity of care between the inpatient and outpatient settings continues to be a challenge. Current hospital payments assume that hospitals are actively involved through discharge and the transition to outpatient settings and advocating for payments for outpatient providers to assist in this process is viewed as duplicative. This undermines mental health care providers' ability to smoothly transition clients between service settings.

Meeting the credentialing requirements for program services and mental health professionals has posed new challenges. Community behavioral health organizations employ professionals that may not meet private insurers' credentialing standards (for example, 3 years of post-licensure experience). Community providers have addressed this through contractual arrangements in which quality assurance and supervision requirements substitute for these credentialing standards. Services are billed under a supervisory protocol in which the supervising professional's national provider identifier is used.

Additionally, some programs offer services that rely on a combination of funding sources such as county, state, and private insurers. In these situations, counties sometimes want to limit private insurance clients' access to these programs because a portion of the overall program is covered by the county.

The Brain Controls Insulin Action

Insulin regulates blood glucose primarily by two mechanisms:
  1. Suppressing glucose production by the liver
  2. Enhancing glucose uptake by other tissues, particularly muscle and liver
Since the cells contained in liver, muscle and other tissues respond directly to insulin stimulation, most people don't think about the role of the brain in this process.  An interesting paper just published in Diabetes reminds us of the central role of the brain in glucose metabolism as well as body fat regulation (1).  Investigators showed that by inhibiting insulin signaling in the brains of mice, they could diminish insulin's ability to suppress liver glucose production by 20%, and its ability to promote glucose uptake by muscle tissue by 59%.  In other words, the majority of insulin's ability to cause muscle to take up glucose is mediated by its effect on the brain. 

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Harvard Food Law Society "Forum on Food Policy" TEDx Conference

Last Friday, it was my pleasure to attended and present at the Harvard Food Law Society's TEDx conference, Forum on Food Policy.  I had never been to Cambridge or Boston before, and I was struck by how European they feel compared to Seattle.  The conference was a great success, thanks to the dedicated efforts of the Food Law Society's presidents Nate Rosenberg, Krista DeBoer, and many other volunteers. 

Dr. Robert Lustig gave a keynote address on Thursday evening, which I unfortunately wasn't able to attend due to my flight schedule.  From what I heard, he focused on practical solutions for reducing national sugar consumption, such as instituting a sugar tax.  Dr. Lustig was a major presence at the conference, and perhaps partially due to his efforts, sugar was a central focus throughout the day.  Nearly everyone agrees that added sugar is harmful to the nation's health at current intakes, so the question kept coming up "how long is it going to take us to do something about it?"  As Dr. David Ludwig said, "...the obesity epidemic can be viewed as a disease of technology with a simple, but politically difficult solution".

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Protecting your medical tourism brand on the internet...beware the "brandjacker"!

To keep things simple, this blog has moved to the IMTJ web site. You can find the Health Tourism Blog here in future. Here's an extract of the latest blog post entitled: Protecting your brand on the internet...beware the "brandjacker"!"

The internet is a great place to market your medical tourism services but because it is difficult to police, it can be easy for a domain name speculator to hijack your brand. Businesses can find that having spent years developing and investing in a brand, one day along comes a domain name speculator or “brandjacker” who aims to profit from the brand value and customer loyalty that legitimate marketers have built.
“Brandjacking” is difficult to combat; the internet crosses international barriers. When someone hijacks your brand or trademark by registering domain names that are clearly related to your business, it can lead to complex and lengthy legal action to protect your marks. There is a set of guidelines about domain name registrations and dispute resolution published by ICANN (the Internet Corporation for Assigned Names and Numbers) that may be of help. See their Domain-Name Dispute-Resolution Policy .

There’s nothing wrong with registering domain names that you may want to use in your existing or future business activities. I met a group of UK doctors once who had registered over 5,000 domain names related to various types of medical procedure. This was in the early days when you paid over $100 for a domain name! In our web publishing business, we own around 130 domain names... not that many... most of which are in active use for our sites. The problem arises when people start registering multiple domain names:
  • To obstruct the activities of an existing business by incorporating their brand or trademark into a domain name.
  • To divert visitors from an established web site (often by registering mis-spellings of domains).
  • To sell the name back to the brand owner at a premium. find out more about "brandjacking" in medical touris, read the full article at IMTJ: Go to Protecting your brand on the internet...beware the "brandjacker"!

Losing Fat With Simple Food-- Two Reader Anecdotes

Each week, I'm receiving more e-mails and comments from people who are successfully losing fat by eating simple (low reward) food, similar to what I described here.  In some cases, people are breaking through fat loss plateaus that they had reached on conventional low-carbohydrate, low-fat or paleo diets.  This concept can be applied to any type of diet, and I believe it is an important characteristic of ancestral food patterns.

At the Ancestral Health Symposium, I met two Whole Health Source readers, Aravind Balasubramanian and Kamal Patel, who were interested in trying a simple diet to lose fat and improve their health.  In addition, they wanted to break free of certain other high-reward activities in their lives that they felt were not constructive.  They recently embarked on an 8-week low-reward diet and lifestyle to test the effectiveness of the concepts.  Both of them had previously achieved a stable (in Aravind's case, reduced) weight on a paleo-ish diet prior to this experiment, but they still carried more fat than they wanted to.  They offered to write about their experience for WHS, and I thought other readers might find it informative.  Their story is below, followed by a few of my comments.

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Apple Hacks: 39 Apple Recipes, Games, Activities, and Crafts

This piece comes from October 2007, which was nice when you think about it.

The U.S. produced more than 9,816,000,000 pounds of apples last year, or just about 28,854,000,000 individual pieces of fruit. That’s a lot of apples. Maybe too many to eat.

Fortunately, there are dozens - no, hundreds - wait, THOUSANDS of other uses for those delightful orbs of deliciousness, and CHG has 43 of ‘em right here.

1. Predict your romantic fortune. According to, throwing an apple peel over your shoulder could reveal the identity of a boyfriend-or-girlfriend-to-be, since it, “would form the initial of your lover’s name.” I’m guessing X and Q don’t show up much.

2. Practice your pumpkin carving. Test-whittle a pumpkin pattern on its smaller, cheaper fruit cousin, and you’ll make fewer mistakes when it’s showtime.

3. Teach someone how to bunt. One of baseball’s most overlooked skills is also one of its most important, especially if you’re into squeeze plays. But bunting too hard is a surefire way to waste an out. At your team’s next practice, toss apples to your bunters-in-training. If the fruit gets smashed, the kids are using unnecessary force. If the apples fall and roll away unharmed, they’re halfway to Butlerville.

4. Play a Flexibility game. This is an easy, creative brain exercise revered by one of my favorite elementary school teachers. Place an apple in front of a few kids. Give them ten minutes to come up with as many non-food uses as possible. The winner gets the apple. (And gets to write a blog entry twenty years later about the many uses of apples.)

5. Practice magic. Nourish your inner Harry Blackstone with the good ol’ Orange to an Apple trick. (Scroll down for details.)

6. Shrink some heads. Both hideously effective and just plain hideous, shrunken apple heads are guaranteed to scare the beejeezus out of someone this Halloween. Fab Foods has instructions.

7. Exfoliate. Wikihow gives DIY instructions on a neat facial scrub. Make sure you’re not allergic before giving it a try. That would be bad.

8. Prevent every disease known to man. Apples’ health benefits are too numerous and mind-boggling, to list here, so I’ll let’s hand it over to the Apple lobby.

9. Teach a student driver how to accelerate and brake smoothly. The apple’s stable bottom and heavy top makes it a perfect balance tool. Place one on top of the driver’s car. In an unoccupied parking lot, have him speed up, speed down, and finally, brake. If the apple’s knocked off, he loses. If it stays on, it’s apple pie for all.

10. Soften brown sugar. Oh, Reader's Digest, you crafty minx. I had no idea it was possible to do this: “place an apple wedge in a self-sealing plastic bag with the chunk of hardened brown sugar. Tightly seal the bag and put it in a dry place for a day or two. Your sugar will once again be soft enough to use.” Now, if you could only improve that joke page…

11. Facial! According to the Washington Post, apples make people look pretty. Mix a grated one with a little honey and apply it to your face. Poof! Instant beauty. (Or at least, a very tasty visage.)

12. Stick ‘em in a vase. Pretending you’re on Trading Spaces has never been so easy. Grab a dozen Granny Smiths, pile them in a clear, tall container, and place strategically. Instant class for less than $4.

13. Make a stamp. Apples make great (albeit temporary) decorative stamps. Whether it’s cards, letters, or wrapping paper, the Washington Post claims all you have to do is, “[Slice] the fruit horizontally, exposing the inside star shape. Or create more elaborate designs -- hearts, moons, Hitchcock's profile -- with a small knife. Then stick a fork in the rounded side of the fruit, dip it in paint and press the stamp on paper.”

14. Host an apple tasting. From Lifehacker: Buy a dozen or so different apples, invite some friends over, and eat. Pair with wine, cheese, and/or chocolate for the ultimate in inexpensive luxury.

15. Ripen a tomato. Take five under-ripe tomatoes and one ripe apple. Place in a paper bag. Wait a few days. Marvel at the results.

16. Learn to Juggle. Over a couch or couch-like surface, preferably.

17. Treat a horse, rabbit, or turtle. People aren’t the only animals that dig a nice MacIntosh. Head to your nearest stable or petting zoo, and (with the permission of the owners) make a mammal and/or amphibian happy. Especially fun with kids. (Make sure to shred the fruit before feeding it to a turtle. Otherwise, Choke City.)

18. De-salt a dish. Oversalting is a ginormous problem for those of us who prefer our sodium intake on the tongue-withering side. Reader's Digest says, “When you find yourself getting heavy-handed with the saltshaker, simply drop a few apple (or potato) wedges in your pot. After cooking for another 10 minutes or so, remove the wedges -- along with the excess salt.” Chemistry at work!

19. Make stuff smell good. Huge props to Meredith at Like Merchant Ships on this one. She simmers a few apples along with various spicery, and her house ends up more fragrant than a Pillsbury factory. NICE. Instructions included in the link.

20. Build apple animals. Grab some toothpicks, a few gum drops, a handful of marshmallows and go to town. They make inspired, bizarrely fun holiday decorations, especially for Halloween and Thanksgiving.

21. Support some candles. I wish I’d thought of this one. Instead, Reader's Digest trumped me again. You rascally malcontents! “Use an apple corer to carve a hole three-quarters of the way down into a pair of large apples, insert a tall decorative candle into each hole, surround the apples with a few leaves, branches, or flowers.”

22. Create an apple-head doll. Hey! It’s a doll that, uh, ages. (Yay?) I’m not so sure how I feel about this one, but (once again) the Washington Post seems to think it’s a good idea: “Peel an apple and let it hang-dry for a couple of days, so that the fruit shrivels into an old-lady face. Decorate the face with wire (for granny glasses) and seeds (for beady eyes), and attach it to a small bottle for the body. Dress up.”

23. Save the cakes! Storing a cake with half an apple will keep it alive for days longer than its projected lifespan. See, the apple absorbs all the mold-breeding moisture, leaving the confection nearly as fresh as the day it was baked. (I would say, “yummo” here, but honestly, that word makes me homicidal.)

24. Juice up a chicken. Marcella Hazan does this, but with lemons. 1) Grab a roaster chicken. 2) Stick an apple up its butt. 3) Roast. 4) Enjoy your a dewy, drippingly moist bird. Reader’s Digest has more.

25. Bob for them suckers. Oh, it looks easy enough, but Bobbing for Apples is the "Stairway to Heaven" of Halloween party games: only the chosen ones are really good at it.

26. Teach math and/or the fundamentals of gravity. According to some studies, kids respond better to hands-on lessons than those learned by rote memory. Apples are good tools for teaching addition, subtraction, and basic Newtonian physics. (Plus, is there anything more entertaining than dropping fruit on childrens’ heads?)

27. Decorate a Christmas tree. String some garland or build your own ornaments. If you have a dog or particularly bizarre cat, just remember to place ‘em high up.

28. Practice your knife skills. Whether you’re peeling its skin, coring the center, or chopping it up into eraser-sized pieces, the apple is one of the few foods suited for both pairing and chef’s knives. Hone your technique on a few dozen Cortlands (and use the detritus in applesauce).

29. Jazz up a floral arrangement. For your next bouquet, think outside the flower box by adding one or two color-coordinated apples to the party. Meredith has a great example over here.

30. Kiss up to a teacher. If your wife, husband, sister, roommate, uncle, best friend, or second cousin by marriage twice removed is about to launch a teaching career, slip a Red Delicious into their lunchbox with a note. They’ll mist up in the cafeteria.

31. Devise a centerpiece. Stack ‘em, line ‘em up, or stick ‘em in a bowl – anyway you position them, apples are elegant, easy objets d’art in any mealtime setting.

32. Play Pass the Apple. A super-neat variation on the ol’ fashioned relay race, Pass the Apple involves each runner tucking a piece of fruit under his chin, then transferring it to the next runner’s chin without using his hands.

33. Carve a bird. Fruit sculpture is impressive and fairly easy when compared to other hobbies, like say, quantum physics. This apple bird tutorial will get you started.

34. Give a gift. Whether you’re canning or making Apple Pie in a Jar, every person on the face of the earth (except Kim Jong Il and other various psychopaths) loves receiving food for special occasions. Homemade apple products are an inexpensive way to please minds, hearts, and gaping maws.

35. Target practice. Do you shoot things at other things? Save money (and perhaps someone’s eye) by setting apples up as bulls-eyes. On the less-destructive side, they also make fabulous targets for practicing your curveball. (PLEASE BE CAREFUL.)

36. Paint. There’s a reason so many painters start on bowls of fruit – it’s a good way to learn fundamental shading and coloring. Unpack those brushes and get started, folks.

37. Design a wreath. At first, I pictured this as a dozen apples affixed to a straw circlet, rotting over my mom’s mantle. Ooo – wrong. has a good example of how it should really be done.

38. Play apple toss. It’s like cornhole, but with buckets. And apples. And no bean bags. And … ah, just take a look.

39. Cook. This would be a pretty awful cooking blog if there was no actual cooking involved. So, BEHOLD the following light, relatively inexpensive recipes, garnered from Cooking Light, Food Network, Pick Your Own, All Recipes, and my Ma:
Apple Brown Betty
Apple Butter
Apple Cake


The Case for the Food Reward Hypothesis of Obesity, Part II

In this post, I'll explore whether or not the scientific evidence is consistent with the predictions of the food reward hypothesis, as outlined in the last post.

Before diving in, I'd like to address the critique that the food reward concept is a tautology or relies on circular reasoning (or is not testable/falsifiable).  This critique has no logical basis.  The reward and palatability value of a food is not defined by its effect on energy intake or body fatness.  In the research setting, food reward is measured by the ability of food or food-related stimuli to reinforce or motivate behavior (e.g., 1).  In humans, palatability is measured by having a person taste a food and rate its pleasantness in a standardized, quantifiable manner, or sometimes by looking at brain activity by fMRI or related techniques (2).  In rodents, it is measured by observing stereotyped facial responses to palatable and unpalatable foods, which are similar to those seen in human infants.  It is not a tautology or circular reasoning to say that the reinforcing value or pleasantness of food influences food intake and body fatness. These are quantifiable concepts and as I will explain, their relationship with food intake and body fatness can be, and already has been, tested in a controlled manner. 

1.   Increasing the reward/palatability value of the diet should cause fat gain in animals and humans

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The Case for the Food Reward Hypothesis of Obesity, Part I


When you want to investigate something using the scientific method, first you create a model that you hope describes a natural phenomenon-- this is called a hypothesis.  Then you go about testing that model against reality, under controlled conditions, to see if it has any predictive power.  There is rarely a single experiment, or single study, that can demonstrate that a hypothesis is correct.  Most important hypotheses require many mutually buttressing lines of evidence from multiple research groups before they're widely accepted.  Although it's not necessary, understanding the mechanism by which an effect occurs, and having that mechanism be consistent with the hypothesis, adds substantially to the case.

With that in mind, this post will go into greater detail on the evidence supporting food reward and palatability as major factors in the regulation of food intake and body fatness.  There is a large amount of supportive evidence at this point, which is rapidly expanding due to the efforts of many brilliant researchers, however for the sake of clarity and brevity, so far I've only given a "tip of the iceberg" view of it.  But there are two types of people who want more detail: (1) the skeptics, and (2) scientifically inclined people who want mechanism.  This post is for them.  It will get technical at times, as there is no other way to convey the material effectively.

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