Welcome to the Nexus of Ethics, Psychology, Morality, Philosophy and Health Care

Welcome to the nexus of ethics, psychology, morality, technology, health care, and philosophy

Thursday, June 30, 2011

Living the Good Lie

By Mimi Swartz
The New York Times Magazine

Denis Flanigan isn’t hiding anything. A 42-year-old psychotherapist in Houston, he has a straightforward manner that meshes nicely with his no-nonsense buzz cut and neatly clipped goatee. Unlike many mental-health professionals, Flanigan puts personal items on display in his office, including a photo of his partner, who is attractive, and male. For his patients’ amusement he has on hand an S-and-M Barbie as well as a Tickle Me Freud doll. (“It’s so, so . . . wrong,” Flanigan told me, in a tone that signaled he believed it was exactly right.) Flanigan’s no-secrets policy extends to his Web site, where he writes that he “has frequently been asked to speak on the gay and lesbian experience and mental health, transgender concerns and body-modification issues.” A member of the American Psychiatric Association, Flanigan has also served as Mr. Prime Choice Texas, winning a contest “designed for men 40 years or older who represent the masculine aesthetic embraced by the leather/Levi/uniform/fetish community.” In his own words, he identifies as a “militant homosexual.”

So it comes as a bit of a surprise to learn that when potential clients come to Flanigan’s office to discuss their sexual orientation — in particular whether they should reveal their homosexuality to friends, family or employers — his first response is to ask, in a neutral tone, “Why do you want to do that?” Flanigan has a 20-year history of gay activism behind him, so you might expect that his primary goal would be to help gay clients discover and cultivate their most authentic selves. As Jonathan Ned Katz wrote in “Gay American History” in 1976, “Therapists who do not help their homosexual patients to fully explore the possibility of homosexuality as a legitimate option have not helped to expand those individuals’ freedom.”

Flanigan doesn’t disagree with Katz. “I’m a very strong believer in people’s rights,” he said one gray morning at a Starbucks in Houston. But during his early training, he encountered a few clients who either would not come out of the closet or suffered mightily when they did. Christians of the kind who earnestly believed that the Bible deplored homosexuality were particularly troubled as they tried to reconcile their faith with their sexual orientation. The more Flanigan studied this conundrum, the more he came to see it as intractable. Some gay evangelicals truly believe that to follow their sexual orientation means abandonment by a church that provides them with emotional and social sustenance — not to mention eternal damnation. Keeping their sexual orientation a secret, however, means giving up any opportunity to have fulfilling relationships as gay men and women.

“When these clash, what do you do?” Flanigan recalled thinking, and when he began to research the topic about a decade ago, he found few answers beyond the obvious. Antigay religious groups would not condone homosexuality; they thought gays should just give up their orientation, and the most extreme among them offered frightening “conversion” practices. Nonreligious gays thought the conflicted should just walk away from churches that won’t accept homosexuals as they are. “Which trumps which?” Flanigan asked himself. “Religion or sexual orientation?”

The entire article can be found here.

Wednesday, June 29, 2011

Nurse's suicide highlights twin tragedies of medical errors

by JoNel Aleccia
Health writer - msnbc.com

For registered nurse Kimberly Hiatt, the horror began last Sept. 14, the moment she realized she’d overdosed a fragile baby with 10 times too much medication.

Stunned, she told nearby staff at the Cardiac Intensive Care Unit at Seattle Children’s Hospital what had happened. “It was in the line of, ‘Oh my God, I have given too much calcium,’” recalled a fellow nurse, Michelle Asplin, in a statement to state investigators.

In Hiatt’s 24-year career, all of it at Seattle Children’s, dispensing 1.4 grams of calcium chloride — instead of the correct dose of 140 milligrams — was the only serious medical mistake she’d ever made, public investigation records show.

“She was devastated, just devastated,” said Lyn Hiatt, 49, of Seattle, Kim’s partner and co-parent of their two children, Eli, 18, and Sydney, 16.

That mistake turned out to be the beginning of an unraveled life, contributing not only to the death of the child, 8-month-old Kaia Zautner, but also to Hiatt’s firing, a state nursing commission investigation — and Hiatt's suicide on April 3 at age 50.

Hiatt’s dismissal — and her death — raise larger questions about the impact of errors on providers, the so-called “second victims” of medical mistakes. That’s a phrase coined a decade ago by Dr. Albert Wu, a professor of health policy and management at the Johns Hopkins Bloomberg School of Public Health.

It’s meant to describe the twin casualties caused by a serious medical mistake: The first victim is the patient, the person hurt or killed by a preventable error — but the second victim is the person who has to live with the aftermath of making it.

No question, the patients are the top concern in a nation where 1 in 7 Medicare patients experience serious harm because of medical errors and hospital infections each year, and 180,000 patients die, according to a November 2010 study by the Department of Health and Human Services’ Office of Inspector General.

That’s nearly double the 98,000 deaths attributed to preventable errors in the pivotal 2000 report “To Err is Human,” by the Institute of Medicine, which galvanized the nation's patient safety movement.

In reality, though, the doctors, nurses and other medical workers who commit errors are often traumatized as well, with reactions that range from anxiety and sleeping problems to doubt about their professional abilities — and thoughts of suicide, according to two recent studies.

Surgeons who believed they made medical errors were more than three times as likely to have considered suicide as those who didn’t, according to a January survey of more nearly 8,000 participants published in the Archives of Surgery.

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 The entire story can be found here.

Tuesday, June 28, 2011

When Colleagues Make Mistakes

By Stephen A. Ragusea, PsyD, ABPP
Guest Blogger

At least once a month, I receive a telephone call from a Florida psychologist who tells me that he or she knows that a colleague -- or a practitioner of a different profession -- is guilty of committing an ethical violation.  The psychologist then typically asks if I agree with their appraisal of the situation and expresses frustration regarding the problem.  Finally, they ask what they should do, often expecting that the Florida Psychological Associaton (FPA) will handle the problem.  They often express surprise when I remind them that, according to our Ethical Principles, their first responsibility is to have a little talk with the alleged offender. 

The American Psychological Association’s Ethical Principles of Psychologists and Code of Conduct (2002) suggests that our first obligation in these situations is to first seek an “informal” solution through professional consultation.  Specifically, Principle 1.04 states:

1.04 Informal Resolution of Ethical Violations

When psychologists believe that there may have been an ethical violation by another psychologist, they attempt to resolve the issue by bringing it to the attention of that individual, if an informal resolution appears appropriate and the intervention does not violate any confidentiality rights that may be involved. (See also Standards 1.02, Conflicts Between Ethics and Law, Regulations, or Other Governing Legal Authority, and 1.03, Conflicts Between Ethics and Organizational Demands.)

But what happens if the offender isn’t willing to change or just pretends to seriously address the problem?  Or what happens if they insist the problem doesn’t exist?  I then explain that it may be necessary for them to report the matter to the appropriate professional board.  At that point, we consider Principle 1.05.  If the alleged offender is a psychologist, then the problem would be reported to the Florida Board of Psychology at 850- 488-0595, or referred to the APA Ethics Committee.   If, however, the practitioner is a member of a different profession, then the appropriate professional board must be contacted.  However, one must always remember that the ethical standards of the individual’s profession are those that apply, not those of the American Psychological Association.  Psychology’s ethical standards only apply to psychologists.  Of course, if the individual isn’t a member of any recognized profession, ethical considerations are unenforceable and little can be done as long as the person is functioning within the law.

1.05 Reporting Ethical Violations

If an apparent ethical violation has substantially harmed or is likely to substantially harm a person or organization and is not appropriate for informal resolution under Standard 1.04, Informal Resolution of Ethical Violations, or is not resolved properly in that fashion, psychologists take further action appropriate to the situation.  Such action might include referral to state or national committees on professional ethics, to state licensing boards, or to the appropriate institutional authorities. This standard does not apply when an intervention would violate confidentiality rights or when psychologists have been retained to review the work of another psychologist whose professional conduct is in question.  (See also Standard 1.02, Conflicts Between Ethics and Law, Regulations, or Other Governing Legal Authority.)

For a variety of reasons, psychologists are often unwilling to confront these problems in either way outlined above.  For example, sometimes psychologists are afraid of insulting the other professional or sometimes they fear some form of retribution.  However, we must all have a little courage and remember that it part of our own ethical duty to address these matters in a productive, professional, and effective manner.  We’re all in this together and we’re all trying to serve humanity well.  Don't be afraid to make a constructive intervention; we can all do better!

Sunday, June 26, 2011

Twisted ethics of an expert witness

Seattle Times staff reporters

Stuart Greenberg was at the top of his profession: a renowned forensic psychologist who in court could determine which parent got custody of a child, or whether a jury believed a claim of sexual assault. Trouble is, he built his career on hypocrisy and lies, and as a result, he destroyed lives, including his own.

To uncover the secrets Stuart Greenberg had buried, The Seattle Times got court files unsealed in the superior courts of King and Thurston counties. Through a motion filed by the state Attorney General's Office, the newspaper also got an order lifted that barred public inspection of Greenberg's disciplinary history. Reporters obtained other documents — for example, Greenberg's emails at the University of Washington — through public-records requests, and interviewed colleagues of Greenberg, as well as parents he had evaluated.

Earlier this year, a four-page document with a bland title, "Stipulation for Dismissal with Prejudice," was filed in a civil matter percolating on the King County Courthouse's ninth floor. Hardly anyone took notice. Most everyone had moved on.
But that document — filed by lawyers tangled up in the estate of Stuart Greenberg, a nationally renowned psychologist whose life ended in scandal — signaled the end of a tortuous undertaking.
Greenberg had proved such a toxic force — a poison coursing through the state's court system — that it took more than three years for lawyers and judges to sift through his victims and account for the damage done.
For a quarter century Greenberg testified as an expert in forensic psychology, an inscrutable field with immense power. Purporting to offer insight into the human condition, he evaluated more than 2,000 children, teenagers and adults. His word could determine which parent received custody of a child, or whether a jury believed a claim of sexual assault, or what damages might be awarded for emotional distress.
At conferences and in classrooms, in Washington and beyond, he taught others to do what he did. He became his profession's gatekeeper, quizzing aspirants, judging others' work, writing the national-certification exam. His peers elected him their national president.
But his formidable career was built upon a foundation of hypocrisy and lies. In the years since Greenberg's death, while court officials wrestled over his estate, The Seattle Times worked to unearth Greenberg's secrets, getting court records unsealed and disciplinary records opened.
Those records are a testament to Greenberg's cunning. They show how he played the courts for a fool. He played state regulators for a fool. He played his fellow psychologists for a fool. And were it not for a hidden camera, he might have gotten away with it.
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The entire story can be found here.
Special thanks to Ken Pope for this story.

Saturday, June 25, 2011

Suicide Kit Stirs Controversy

The Los Angeles Times published an article entitled Woman selling 'suicide kits' reignites right-to-die debate.  Below, a portion of the article is posted.  A prior blog referenced Switzerland's decision to allow non-citizens a place to end their lives.  There is no requirement for medical or psychological supervision in Switzerland.  And, there is no requisite medical or psychological supervision for these kits.


Reporting from El Cajon, Calif.

--  Sharlotte Hydorn peddles a product touted for its deadly simplicity. Inside her butterfly-decorated boxes are clear plastic bags and medical-grade tubing. A customer places the bag over his head, connects the tubing from the bag to a helium tank, turns the valve and breathes. The so-called suicide kit asphyxiates a customer within minutes.

Orders come from all over the world, from people young and old, depressed and terminally ill. "People commit suicide by jumping out of windows and buildings, and hanging themselves," said the 91-year-old former elementary school science teacher. Her product, she says, ends lives peacefully, leaving people "eternally sleepy."

In December, one of Hydorn's $60 devices was found over the head of a dead 29-year-old man from Eugene, Ore. His death triggered a wave of media attention that doubled her orders to 100 per month, but placed Hydorn under scrutiny from politicians and law enforcement agencies that culminated last week with a raid of her ranch-style home outside San Diego.

FBI agents seized dozens of boxes ready for shipment as part of an investigation into possible mail or wire fraud violations and whether Hydorn has violated a law prohibiting the sale of adulterated and mishandled medical devices. In Oregon, where assisted-suicide is legal under certain conditions, lawmakers have introduced a bill that would outlaw any device sold with the intent that another person use it to commit suicide.

Hydorn has been compared to Jack Kevorkian, the physician who went to prison in 1999 for assisting suicides. But the Dr. Death image doesn't fit this gregarious woman who dispenses advice on dying with a neighborly demeanor that is disarming.

Wearing a wide-brimmed hat and sunglasses, the tall and slender woman told reporters last week that hers is a mission of compassion. The "exit bags" end lives of suffering through humane means, she said. The federal investigation leaves her more bewildered than concerned, and she almost laughs at the prospect of going to prison.

"Do I look like a criminal?" Hydorn said, standing on her manicured front lawn.

Her critics would say yes. Even people who believe in assisted-suicide said she peddles the product without knowing the circumstances or identities of the buyers. While some suicidal people are rational, others are not, said Alan Berman, executive director of the American Assn. for Suicidology, a suicide-prevention organization.

Read the rest of the article here.

Friday, June 24, 2011

Psychologist Seeks Return of License

By Colman Herman
June 22, 2011

A female psychologist is asking the state's Supreme Judicial Court for her license back even though she violated one of the cardinal rules of her profession by having sex with a former patient.

The standard punishment for someone in the medical and related professions who has sex with a patient or former patient is permanent revocation of his or her license. Officials at several of the boards that oversee health professionals said they couldn’t recall an instance where a practitioner who had sex with a patient failed to lose his or her license.

But Brookline psychologist Mary O'Neill says she deserves another chance. She acknowledges beginning a sexual relationship with her patient, Eric MacLeish, just weeks after his therapy sessions ended, yet says her license shouldn’t be permanently revoked because her lapse in judgment was caused by a marriage that had collapsed.

O’Neill petitioned a single justice of the Supreme Judicial Court to review her license revocation by the Board of Registration in Psychology.  Subsequently, she and the board jointly asked the full court to hear the case, which it agreed to do. Oral arguments are scheduled for this fall.

O’Neill is arguing that the psychology board “arbitrarily and capriciously” refused to consider the mitigating evidence she presented. Rather than revoking her license, she says the board should have suspended her license for a year and then allowed her to resume work on a probationary basis for a year. She says she would continue to receive personal psychotherapy and have her work supervised by a peer. O’Neill also says she would do 100 hours of community service.

The psychology board’s regulations adopt the code of conduct of the American Psychology Association. The code states that “psychologists do not engage in sexual intimacies with current therapy clients/patients” nor with “former clients for at least two years after cessation of therapy.” Beyond two years, sex between a psychologist and patient is permitted only if the therapist can prove there has been no exploitation. The regulations also say it is not a defense to say the patient consented. The regulations were crafted to prevent psychologists from exploiting the tremendous power they often have over their patients and former patients.

In its April 2010 decision, the psychology board held that O’Neill’s marriage crisis “no doubt exacted a significant emotional toll” on her and that her “marriage crisis can be understood to have ‘clouded’ her judgment.” But the board nonetheless revoked her license, saying her care was the “antithesis of treatment” and her “conduct abrogates a basic tenet of the psychology profession: trust.”

The entire article can be found here.

Thanks to Ken Pope for this story.

Thursday, June 23, 2011

Colleague Assistance

A recent article in the Monitor on Psychology by Rebecca Clay highlights several important points about colleague assistance and your ethical responsibilities as a psychologist.  The article features our own Sam Knapp.

The article, When A Colleague is Impaired, can be found here.  A portion of it is reproduced below.

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A psychologist friend of yours is undergoing a divorce so wrenching, you sense she can barely get up in the morning, let alone provide effective therapy.

A colleague in your building stumbles as he walks down the hall, and you smell alcohol on his breath.

You’ve heard that an older colleague has become forgetful, sometimes seems confused and has even fallen asleep during a session.

How do you ethically handle such scenarios?

APA’s Code of Ethics requires psychologists to recognize when their own personal problems might interfere with their effectiveness and take action. But when it’s someone else who has the problem, knowing what to do can be difficult.
“On the one hand, people want to do something; on the other, they don’t want to get someone in trouble where they might lose their license,” says Michael O. Ranney, executive director of the Ohio Psychological Association. “For many people, it’s a difficult ethical dilemma — what to do and how to do it.”

The approach Ranney and other experts recommend? Step in early and take advantage of a colleague assistance program or other forms of help offered by your state, provincial or territorial psychological association (SPTA). Reporting someone to the state licensing board should be a last resort, they emphasize.

Preventing problems

Getting other psychologists the help they need is an ethical duty just like getting help for yourself, says Stephen Behnke, JD, PhD, director of APA’s Ethics Office.

“All of our training, all of our experience is to promote health and well-being, and that should begin in our own community of psychologists,” he says. “It absolutely should be an ethical responsibility that we take on as psychologists to be that supportive community to our colleagues in distress.”

Stopping problems before they escalate is key, Behnke and others agree.
One way to do that is to develop and maintain a network of social relations with other psychologists, says Sam Knapp, EdD, director of professional affairs at the Pennsylvania Psychological Association. Work on meeting your colleagues and reach out to them in good times and bad.

“If you find out that a colleague has just had a death in the family or a divorce or some kind of event like that, send them a card or call them up and express condolences,” says Knapp. “Ninety-nine percent of the time they’re not going to slip into impairment, but they’re going to appreciate it and feel that they can confide in you about other things.”

It’s not just personal issues that can cause problems, he adds. A patient’s suicide, for example, could plunge a psychologist into depression.

Once other psychologists become comfortable with you, says Knapp, they might ask for a referral for therapy or substance abuse treatment. They might seek consultation on a case they’re having trouble with. Or they might just want someone to talk to.

Tuesday, June 21, 2011

What Should I Wear to Work?

by Sam Knapp, EdD, ABPP
Director of Professional Affairs

What should psychologists wear to their offices? Should I wear formal attire, casual attire, or business formal? As with the use of names and titles, the standards for dress vary according to context, such as the services being provided, the clientele being seen, the preferences of the psychologist, local customs, and other factors. For example, when going to court, formal attire is mandatory and doctoral level psychologists would generally refer to themselves as “doctor” in court. Generally, psychologists who provide services to upscale clients will dress differently from those who provide services to lower income patients. Problems can occur if psychologists who work with upscale clients dress too informally, in that the patients may not consider them professional enough. On the other hand, psychologists who work with lower income patients may appear “uppity” or out of touch if they dress too formally.

Women have to be careful because some men may misinterpret clothing perceived as too attractive, especially in combination with the use of first names, as an invitation to a boundary crossing. Psychologists who treat children often wear more casual clothing, especially if they do play therapy or other therapies requiring movement or getting on the floor. Also, some children view adults in formal attire as authoritarian and might be less likely to open up. Psychologists who work in hospitals or other institutions often wear softer and more comfortable shoes to accommodate the walking that they have to do as part of their jobs.

Local customs also influence dress choices. Other parts of the United States tend to be more informal in their dress, as are some rural parts of Pennsylvania. In Key West, Florida, Dr. Stephen Ragusea, a Florida psychologist transplanted from Pennsylvania, says he is the only psychologist (or professional) he knows who wears a shirt and tie, and health care professionals commonly wear Hawaiian shirts there. One younger psychologist from Hawaii resisted wearing skirts because she had a tattoo on her ankle. Although tattoos and body piercing are common among Hawaiians and many younger persons even on the Mainland, some older persons in Pennsylvania view them as disreputable. Although teenage clients might think it is cool to have a therapist with body piercing, their parents often feel quite differently.

Sunday, June 19, 2011

The Ethics Committee: Part 3

This is the third and final installment of what we do as the Ethics Committee. 

We hope that these three blog posts give PPA’s membership a better idea of what we do.  The hope is also that other state associations learn from what we are doing.  If there are Ethics Committees in other state associations that engage in some creative activities, we would certainly enjoy hearing about them.


·    PPA staff will respond to requests from members for consultation on ethical issues and often supplement their telephone or email consultations by referencing articles on the PPA Web site.

·    Ethics Committee members often respond to ethical issues that PPA members post on the PPA listserv, which has more than 700 subscribers.

·    For a fee PPA members may receive up to 3 hours per year of legal consultation from psychologist/attorneys through a legal consultation plan.

Resources for Ethics Educators

·    The Ethics Committee hosts an annual one-day workshop for Pennsylvania psychologists who teach ethics. For purposes of this conference, an ethics educator is defined broadly to include those who teach ethics in graduate school, teach ethics continuing education programs, supervise interns, belong to the ethics committees of local psychological associations, or who otherwise express an interest in teaching ethics. Topics include in-depth presentations on ethics as well as teaching strategies.

·    The Ethics Committee gives the annual Patricia M. Bricklin Award consisting of $500 to a Pennsylvania graduate student who submits the best work product (such as a paper) on ethics.

·    The Ethics Committee gives an annual award to a Pennsylvania psychologist who has made an outstanding contribution to ethics education.

·    Ethics Educators may use vignettes created by the Ethics Committee. For several years, the Ethics Committee posted an ethical dilemma on the PPA Bulletin Board. This allowed psychologists to comment on the dilemma, read the comments of other psychologists, and comment on the comments if they so choose. Several of these vignettes have had several thousand hits. We now post ethical vignettes on our Ethics Blog.

As a final thought on this theme, I invite those who are interested to visit our wikispace.  We stay organized via our wiki.  As a non-member, you can see the wiki, but not edit it.

Saturday, June 18, 2011

Does your office appearance matter?

From research.news.osu

People may judge the quality and qualifications of psychotherapists simply by what their offices look like, a new study suggests.

After only viewing photos of offices, study participants gave higher marks to psychotherapists whose offices were neat and orderly, decorated with soft touches like pillows and throw rugs, and which featured personal touches like diplomas and framed photos.

"People seem to agree on what the office of a good therapist would look like and, especially, what it wouldn't look like," said Jack Nasar, co-author of the study and professor of city and regional planning at Ohio State University.

"Whether it is through cultural learning or something else, people think they can judge therapists just based on their office environment."

Nasar conducted the study with Ann Sloan Devlin, professor of psychology at Connecticut College.

Their study appears online in the Journal of Counseling Psychology and will appear in a future print edition.


The entire press release can be found here.

Thursday, June 16, 2011

British Psychological Society Critiques DSM-5

The British Psychological Society

The British Psychological Society responds to the new DSM-5.   A prior blog post looked at some criticism of the DSM-5.  The British Psychological Association offers a more formal, 26-page critique.  The entire document can be found here.  The first part of the critique is posted for your review.


The Society is concerned that clients and the general public are negatively affected by the continued and continuous medicalisation of their natural and normal responses to their experiences; responses which undoubtedly have distressing consequences which demand helping responses, but which do not reflect illnesses so much as normal individual variation.

We therefore do welcome the proposal to include a profile of rating the severity of different symptoms over the preceding month. This is attractive, not only because it focuses on specific problems (see below), but because it introduces the concept of variability more fully into the system. That said, we have more concerns than plaudits.

The putative diagnoses presented in DSM-V are clearly based largely on social norms, with 'symptoms' that all rely on subjective judgments, with little confirmatory physical 'signs' or evidence of biological causation. The criteria are not value-free, but rather reflect current normative social expectations. Many researchers have pointed out that psychiatric diagnoses are plagued by problems of reliability, validity, prognostic value, and co-morbidity.

Diagnostic categories do not predict response to medication or other interventions whereas more specific formulations or symptom clusters might (Moncrieff, 2007).

Finally, disorders categorised as ‘not otherwise specified’ are huge (running at 30% of all personality disorder diagnoses for example).

Personality disorder and psychoses are particularly troublesome as they are not adequately normed on the general population, where community surveys regularly report much higher prevalence and incidence than would be expected. This problem – as well as threatening the validity of the approach – has significant implications. If community samples show high levels of ‘prevalence’, social factors are minimised, and the continuum with normality is ignored. Then many of the people who describe normal forms of distress like feeling bereaved after three months, or traumatised by military conflict for more than a month, will meet diagnostic criteria.

In this context, we have significant concerns over consideration of inclusion of both “at-risk mental state” (prodrome) and “attenuated psychosis syndrome”. We recognise that the first proposal has now been dropped – and we welcome this. But the concept of “attenuated psychosis system” appears very worrying; it could be seen as an opportunity to stigmatize eccentric people, and to lower the threshold for achieving a diagnosis of psychosis

Diagnostic systems such as these therefore fall short of the criteria for legitimate medical diagnoses. They certainly identify troubling or troubled people, but do not meet the criteria for categorisation demanded for a field of science or medicine (with a very few exceptions such as dementia.) We are also concerned that systems such as this are based on identifying problems as located within individuals.  This misses the relational context of problems and the undeniable social causation of many such problems. For psychologists, our wellbeing and mental health stem from our frameworks of understanding of the world, frameworks which are themselves the product of the experiences and learning through our lives.

Wednesday, June 15, 2011

Blogging from the Convention

John Gavazzi & Rick Small
Today, Rick Small and John Gavazzi presented an advanced ethics workshop on ethical decision-making.  The workshop addressed relational ethics: a blend of positive ethics, psychological culture, and patient-focused care.  They used the Acculturation Model (Gottlieb, Handelsman, and Knapp) as a means to introduce how relationships with the community of psychologists is an important factor in understanding the ethical culture of psychology.  Bridging from that model, they highlighted how ethical decisions can be understood within that framework. 

Rick and John also described the differences between remedial ethics and positive ethics.  They also touched upon principle-based ethics as a means to identify competing ethical principles that are sometimes found in ethical conflicts.  Since there is no ethical decision-making strategy within APA's Code, they explained how knowledge of ethics, emotional factors, cognitive biases and situational factors combine to make the best decision possible.  Simultaneously, the outcomes of these decisions are ambiguous at the time the decisions are made, which can lead to anxiety and uncertainty.

Relational ethics accentuates that ethical decisions play out within the psychologist's relationship to the patient.  Relational ethics includes a commitment to both the relationship and high quality of care.  Relational ethics combines psychologist factors with the clinical features of the patient.

Rick and John finished the lecture portion of the presentation with quality enhancing strategies related to documentation and redundant protections.

Finally, Rick and John provided participants with several ethical dilemmas.  The workshop participants discussed the vignettes, focusing on the following questions.

What factors make the dilemma difficult for the psychologist?

What would his/her emotional reactions be to the content of the scenario?

What types of redundant protections and documentation issues would be helpful for the dilemma?

Feedback from workshop participants was uniformly positive.

For a copy of the slides, please email John.

Sunday, June 12, 2011

A 12-year-old Models Advocacy

Sometimes, psychologists do not recognize the many ways in which we can advocate for our patients.  In this case, a 12-year-old started a petition for the Boston Red Sox to become involved in an anti-bullying, anti-suicide video for the project "It Gets Better."

In the recent past, psychologists won a major victory for access to psychological services. We achieved mental health parity, but there is much work to do.

Join with APA and your state psychological organization.  No one else will advocate for psychology and our patients.  It is up to you to join, volunteer, and participate in advocacy for the profession and our patients. If a 12-year-old can do it, then certainly others can.

Saturday, June 11, 2011

APA calls for psychologists inclusion in ACOs

Part of a psychologist's aspirational ethic is to urge government agencies to help our patients access appropriate psychological care.  This form of advocacy also advances our profession.  Here is a press release from the American Psychological Association that illustrates an important part of our collective professional responsibility.
June 9, 2011—This week, APA sent a comment letter (PDF, 265KB) to the Department of Health and Human Services (HHS) regarding a draft proposal to establish Accountable Care Organizations (ACOs) in Medicare. Section 3022 of the Affordable Care Act requires the establishment of the Medicare Shared Saving Program, which is intended to encourage the development of ACOs.
ACOs, one of the reforms included in the Affordable Care Act, will allow hospitals, physicians and other Medicare providers and suppliers of services to establish a network that emphasizes primary and coordinated care. Medicare beneficiaries will enroll in an ACO as an alternative to fee-for-service delivery, where the ACO will coordinate their care in an effort to improve quality and contain cost increases. Medicare beneficiaries may still see providers of their choice but their care will be more carefully coordinated by the ACO.
The letter from APA Chief Executive Officer Norman B. Anderson, PhD, and APA Executive Director for Professional Practice Katherine C. Nordal, PhD, to HHS Secretary Kathleen Sebelius, dated June 6, 2011, addresses a specific portion of the proposal regarding health care professionals who may participate in ACOs.
In the letter, Drs. Nordal and Anderson urge inclusion of clinical psychologists as participants in ACOs, therefore ensuring better access of Medicare beneficiaries to mental health, substance use disorder and behavioral health services. The letter is a recent example of APA’s ongoing advocacy to promote psychologists as key players in primary care as it develops.
Among Anderson and Nordal’s comments:

- APA agrees with Sebelius’ decision to expand the list of providers eligible to
  participate in ACOs to include clinical psychologists and other providers not
  specifically named in the statute. 

- Clinical psychologists should be incentivized to provide care as part of the ACO
  primary care team. 

- Including clinical psychologists in ACOs ensures the integration of mental,
  substance use disorder and behavioral health with physical health and a more
  comprehensive integrated care system.

APA is asking HHS to retain and implement this provision in the proposed rule in the final draft. We anticipate that HHS will finalize the rule in the coming months.
APA and the APA Practice Organization will continue to evaluate and provide input on proposed rules of interest to practicing psychologists. 
For more information, contact the Government Relations department by email or at (202) 336-5870.

Friday, June 10, 2011

Self-Care and Building Resilience

by John Gavazzi, PsyD ABPP
Ethics Chair

Psychologists aim for excellence in all of their professional roles. We often do not realize that average, everyday concerns, such as balancing professional stresses with personal life, reflect important aspirational ethical considerations. Within the domain of positive ethics, psychologists must be attuned to self-care and engage. Because, within the context of psychotherapy, we use ourselves as an instrument of our trade, self-care is essential to effective treatment.  Unless we take optimal care of ourselves, it is less likely that psychologists can provide the best possible services.

Ironically, while we encourage our clients to meet their own needs, psychologists often neglect their own self-care. There are a number of terms used to describe the occupational hazards of practicing psychotherapy, including “burnout” and “compassion fatigue.” Because working therapeutically with others involves empathy, this necessary and often rewarding emotional connection can also be the source of physical and emotional difficulties for the treating psychologist. We all know that whether a client is depressed, manic, traumatized, anxious, or cycling in chaos, the psychologist uses his or her cognitive and emotional resources as part of treatment. Combine the need to use extensive cognitive and emotional skills with long hours, managed care shenanigans, HIPAA requirements, and any other stressor of maintaining a practice, it is easy to see how working as a psychologist can be physically and emotionally exhausting.

Psychologists must remain aware of the requirements of our work and plan for stressors in order to function well. By engaging in healthy self-care activities, we are better able to take care of personal lives, and ourselves, which ultimately lead to better treatment for our clients.
APA recently published a document for psychologists to educate their patients on “Building Your Resilience.”  While APA geared the document for patients, psychologists may want to review the suggestions to help build their resilience.  Here are some of the suggestions:

Find positive ways to reduce stress and negative feelings

Following a stressful event, many people feel they need to turn away from the negative thoughts and feelings they are experiencing. Positive distractions such as exercising, going to a movie or reading a book can help renew you so you can re-focus on meeting challenges in your life. Avoid numbing your unpleasant feelings with alcohol or drugs.

Look for opportunities for self-discovery

People often learn something about themselves and may find that they have grown in some respect as a result of their struggle with loss. Many people who have experienced tragedies and hardship have reported better relationships, greater sense of strength even while feeling vulnerable, increased sense of self-worth, a more developed spirituality and heightened appreciation for life.

Nurture a positive view of yourself

Developing confidence in your ability to solve problems and trusting your instincts helps build resilience.

Keep things in perspective

Even when facing very painful events, try to consider the stressful situation in a broader context and keep a long-term perspective. Avoid blowing the event out of proportion. Strong emotional reactions to adversity are normal and typically lessen over time.

Maintain a hopeful outlook

An optimistic outlook enables you to expect that good things will happen in your life. Try visualizing what you want, rather than worrying about what you fear.

Take care of yourself.

Pay attention to your own needs and feelings. Engage in activities that you enjoy and find relaxing and that contribute to good health, including regular exercise and healthy eating. Taking care of yourself helps keep your mind and body primed to deal with situations that require resilience.

We all could use these types of reminders from time to time.

Wednesday, June 8, 2011

DSM-5 Article: The Social Construction of Diagnoses?

by John Gavazzi, PsyD, ABPP
Ethics Chair

While some may want to think that psychiatric diagnoses are objective categories that truly reflect an individual's mental, emotional, and physiological condition, there are others who view diagnoses as value-laden, socially constructed concepts that may not be the most useful tools in understanding and treating the patients with whom we work.

There is an interesting article from the Seattle Times sheds light on the social construction of DSM-V diagnoses: Key Diagnostic Deadline Draws Near for Psychiatrists and "New" DSM conditions.  Here are some highlights:

But molecular tests and brain scans based on those discoveries aren't yet ready for diagnostic use, and that leaves the authors of the upcoming book with the same problem that vexed their predecessors: how to distinguish a mental illness from the rainbow of normal human behavior.

Much of the discussion at the American Psychiatric Association meeting centered on fears that, without solid scientific evidence, additions or deletions in their new bible of mental health could do more harm than good.

"The brain is so darn complicated," said Dr. David Axelson, director of the Child and Adolescent Bipolar Services program at the Western Psychiatric Institute in Pittsburgh.

As with each edition, the controversies dogging DSM-5 center on the proposed "new" conditions. Among the questions:
Is there a distinct mood disorder that occurs in some women before their periods?
Is hoarding a brain-based illness?
Can the sorrow accompanying bereavement swell into a certifiable mental disorder?

Even when concepts are not at issue, nomenclature sometimes is. Suggestions include replacing the word "anxiety" with "worry," and scrapping the terms "addiction," "dependence" and "substance abuse" in favor of "substance-use disorder."

"We have to be very careful about our choice of language and precise criteria," said Dr. David J. Kupfer, the DSM-5 task force chairman and director of research at Western Psychiatric Institute and Clinic. Slight word changes could translate into making a disorder much more prevalent — or much more rare, he said.

In another room, doctors debated whether a patient must have impaired function — such as problems in personal relationships — to qualify as having a mental disorder. "If your life is humming along just fine despite gambling 30 hours a week, do you really have a gambling addiction?" one psychiatrist asked with a note of exasperation in his voice.

Yes, a colleague responded: "The person just doesn't know he has a problem yet."

The reader can draw his or her own conclusions from the article.  For me, it is difficult to see how DSM-V can be taken too seriously as an empirically-based reference book.