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

Wednesday, August 31, 2011

Importing Research Based Anti-Bullying Program

University of Kansas

An interdisciplinary team of researchers at the University of Kansas plan to bring a highly successful anti-bullying effort, the KiVa program, to American schools. Starting as early as the 2012-13 school year, a pilot program could kick off in selected classrooms in Lawrence, Kan. If shown to be successful there, soon afterward the model could expand nationally.

KiVa, implemented in Finland in 2007, has impressed researchers with its proven reduction in bullying incidents. According to one recent study, KiVa "halved the risk of bullying others and of being victimized in one school year."

"Any time you see an intervention reported in the literature, if they work, they barely work," said Todd Little, KU professor of psychology and director of the Center for Research Methods and Data Analysis. "This is one of the first interventions we're seeing with effects that are impressive and pervasive. We here at KU are going to be the sole source for testing KiVa in the U.S."

The program takes a holistic approach to the bullying problem, including a rigorous classroom curriculum, videos, posters, a computer game and role-play exercises that are designed to make schools inhospitable to bullying. When bullying episodes do occur within the school, a small team of trained employees addresses the incident individually with the victim and bully or bullies to ensure bullying is ultimately stopped.

"The KiVa program targets the peer environment, trying to create an ecology where bullying is no longer tolerated," said Anne Williford, assistant professor of social welfare at KU. "Instead of targeting only a bully and victim for intervention, it targets the whole class, including kids who are uninvolved in bullying behavior. KiVa fosters skills to help students take actions, either large or small, to shift the peer ecology toward one that does not support bullying."

The researchers said the program works because it recognizes that bullies sometimes may earn higher social status from their behavior.

"People have traditionally framed bullying as social incompetence, thinking that bullies have low self-esteem or impulse problems," said Patricia Hawley, KU associate professor of developmental psychology. "But recent research shows that bullying perpetrators can be socially competent and can win esteem from their peers."

By changing perceptions of peers who are neither bullies nor victims, the program undercuts a social environment that supports bullying.

"It changes the rewards structure," Hawley said. "At the end of the day, the goals of the bully are like yours and mine — they want friendship and status. They have human goals, not pathological ones. With KiVa, bystanders are set up to win by intervening, and their status can go up. As a bystander, I can achieve goals of friendship and status by standing up to a bully."

In Lawrence schools, the KU researchers hope to compare instances of bullying and victimization in both intervention and control groups to establish the strength of the KiVa program in a U.S. setting.

School district officials welcomed the opportunity.

"We're pleased to have the opportunity to collaborate with Dr. Williford and KU's School of Social Welfare on the KiVa anti-bullying project," said Kim Bodensteiner, Lawrence USD 497's chief academic officer. "Given our experiences using other bullying prevention programs, Lawrence Public Schools' teachers and staff can provide valuable feedback to researchers during the development of KiVa program materials. We look forward to the possibility of participating in a future pilot study."

Results from the pilot program are to be measured by KU's Center for Research Methods and Data Analysis.

Tuesday, August 30, 2011

Is the Singularity Near? Chips that Behave Like Brains

By Jordan Robertson
AP Technology Writer

Computers, like humans, can learn. But when Google tries to fill in your search box based only on a few keystrokes, or your iPhone predicts words as you type a text message, it's only a narrow mimicry of what the human brain is capable.

The challenge in training a computer to behave like a human brain is technological and physiological, testing the limits of computer and brain science. But researchers from IBM Corp. say they've made a key step toward combining the two worlds.

The company announced Thursday that it has built two prototype chips that it says process data more like how humans digest information than the chips that now power PCs and supercomputers.

The chips represent a significant milestone in a six-year-long project that has involved 100 researchers and some $41 million in funding from the government's Defense Advanced Research Projects Agency, or DARPA. IBM has also committed an undisclosed amount of money.

The prototypes offer further evidence of the growing importance of "parallel processing," or computers doing multiple tasks simultaneously. That is important for rendering graphics and crunching large amounts of data.

The uses of the IBM chips so far are prosaic, such as steering a simulated car through a maze, or playing Pong. It may be a decade or longer before the chips make their way out of the lab and into actual products.

But what's important is not what the chips are doing, but how they're doing it, says Giulio Tononi, a professor of psychiatry at the University of Wisconsin at Madison who worked with IBM on the project.

The chips' ability to adapt to types of information that it wasn't specifically programmed to expect is a key feature.

Read the rest of the story here.

Monday, August 29, 2011

Repercussions of a Patient’s Suicide

by Robert M. Gordon, PhD, ABPP
The Pennsylvania Psychologist

Dr. Gordon
Psychologists approach their voice-mail messages knowing the full range of human drama might come pouring forth. Entering my 35th year of practice, I was a bit weary of hearing them. Freud warned us never to expect appreciation, no matter how hard one works, from the three impossible professions: parenting, governing, being a psychotherapist. I was not expecting to hear gratitude.

The first message was from five attorneys who were having drinks when they discovered they all had been in treatment with me. On the message, they joked that they were debating over who needed a tune-up. Their appreciation felt good. I will always remember that first message and the one that followed.

The second message began, “Dr. Gordon. You do not know me, but Calvin always spoke highly of you. …”

How nice, I thought, Calvin is referring his friend. Calvin was 45 when he first came to me after the death of his widowed mother about 10 years ago. He was an only child. Calvin was friendly, but very shy. He occasionally dated but never married – except, perhaps, his profession: He was brilliant, a scientist devoted to his work. Calvin had lifelong obsessive-compulsive disorder and Asperger’s syndrome. Following the death of his mother, he had his first major depression. He was seeing a good therapist in his community and continued to see him for years. However, he had found my papers online and asked to see me for consultation. He hoped a psychodynamic approach might provide a more comprehensive perspective. As it turned out, the interpretations helped Calvin feel more deeply understood, which in turn deepened our therapeutic relationship.

Calvin traveled an hour and a half to see me, first weekly, then, after resolving his depression, about once a month for years. He had formed a strong attachment. Before leaving, he had the habit of shaking my hand three times, and saying three times, “Thank you.” One day, quite spontaneously as he left, he said, “I love you.” I said I loved him, too. Frankly, at first I said it to be gracious. But in time, I did feel love for Calvin.

I hadn’t seen him for quite a while, but last year Calvin was let go from his job. His work was his source of identity and reliable connection to this world. He fell into a severe depression. Medications were not working. His psychiatrist suggested hospitalization, but Calvin was terrified of it. He trusted my opinion and I told him it was now necessary. Eventually, only ECT brought him out of his psychotic depression. When I last saw Calvin a month before this call, he was better, but remained lost.

The voice continued, “When I hadn’t heard from Calvin for a few days, I went to his home. I found him in the kitchen. He had shot himself. …”

I felt an internal protest against his words. I heard someone crying and then realized my face was wet. My emotions had outraced my cognition. The tears flowed uncontrollably.

I called Calvin’s friend. I needed details to help process the unbelievable.

I went into professional autopilot for the rest of the day. That evening, as I told my wife, I cried again.

What made it awful was not just his death, but the horror that preceded it. I kept envisioning this gentle person who knew nothing of firearms, buying a powerful gun, writing out instructions so others would know what to do and be minimally inconvenienced. Then, all alone, feeling the most profound despair, squeezing the trigger. No good person should die that way.

Throughout more than 30 years, I had not lost a patient to suicide. To outsiders, I would tell of my skillful rescues. To fellow professionals, I confessed it was mainly luck. And now I was struggling not only with the first suicide of a patient, but the suicide of someone I cherished.

When part of a person wants to end suffering or punish someone from the grave, there is usually enough conflict to send out a verbal or nonverbal message that reads, “Please stop me.” However, when there is little conflict, a person just does it. I know we cannot control others. Nevertheless, I obsessively reviewed what I could have done.

In the weeks that followed, I would overreact to my patients’ suicidal thoughts. I went too soon to discussions of a safety contract, medication, interpersonal supports and even the possibility of hospitalization with clients who wished to die but who were not actively suicidal. For a period, my empathy was compromised by my anxiety. One patient said, “Relax. I am only sharing feelings. I would never kill myself.” If patients do not overtly tell us we are off-target, they may become more symptom-focused and banal in the narrative. They will re-enact how they shut down in the absence of empathy. Patients’ reactions provide immediate supervision to those open to hear it.

In time, my affects eased. However, they unconsciously surfaced as defenses. I would not take referrals if I thought the person was a potential suicide risk, such as someone suffering from borderline personality disorder or major depression. I considered reducing my hours. I shifted from mainly direct care to more diagnostic consultations and forensic work. These decisions were multi-determined, as are all rationalizations. But the fuel beneath was my fear of another suicide.

I found it helpful to share my feelings with close colleagues, but mostly with my wife, a psychoanalytic candidate and my best support. She knew how to listen with empathy, without resorting to psychological Band-Aids.

Then our Pennsylvania Psychologist editor, Dr. Andrea Nelken, wrote that she wanted to do a special issue on suicide in response to military and bullying deaths. She asked whether, if a client of mine had ever committed suicide, I would be willing to write about the experience.

She did not know I had lost my first patient to suicide just two months earlier. I did not want to do it. However, being a psychologist has taught me the value of honestly sharing our pain. Writing this has helped me to accept the reality of this tragedy, even while part of me waits for Calvin to shake my hand three times once again.

Sunday, August 28, 2011

NY judge won't order Gitmo doc probe

By JENNIFER PELTZ, Associated Press

NEW YORK – A judge has declined to force an investigation into whether an Army psychologist developed abusive interrogation techniques for detainees at Guantanamo Bay and should be stripped of his license, halting what civil-rights advocates have called the first court case amid a push to shed light on psychologists' role in terror suspects' interrogations.

The person who brought the case — another psychologist — doesn't have legal standing to do so, Manhattan Civil Court Judge Saliann Scarpulla said in a ruling filed Thursday.

Rights activists and some psychologists have pressed regulators in several states — unsuccessfully so far — to explore whether psychologists violated professional rules by designing or observing abusive interrogations.

In New York, rights advocates focused on John F. Leso, saying he developed "psychologically and physically abusive" interrogation techniques for use on detainees at Guantanamo Bay, Cuba.

The state Office of Professional Discipline, which oversees psychologists, declined last year to look into Leso. The agency said that his Army work is outside its purview and that the agency isn't in a position to address larger questions about the appropriateness of detainee interrogation methods.
The decision spurred the San Francisco-based Center for Justice and Accountability, the New York Civil Liberties Union and psychologist Steven Reisner to sue the agency last fall and ask the judge to force a review of techniques developed by Leso, who holds a New York psychologists' license.

"The ruling is unfortunate, as Dr. Reisner's claims raise serious and fundamental questions that should have their day in court," Center for Justice and Accountability lawyer Kathy Roberts said in a statement.

She said the groups are considering an appeal but also keeping their eye on proposed state legislation that would require investigating any allegation that a health care professional has participated in torture or other improper treatment.

Representatives for the state professional discipline office and the state Attorney General's office didn't immediately return calls. No contact information was immediately available for Leso, who isn't named in the court case and never chose to weigh in with a filing of his own. An Army spokesman didn't immediately return a call about Leso.

The rest of the story can be read here.

Saturday, August 27, 2011

Psychologist withdraws SJC appeal on license

BY: Colman M Herman and Bruce Mohl
A female psychologist who had sex with a former patient is withdrawing her court appeal seeking the return of her license.

Brookline psychologist Mary O’Neill acknowledged having a sexual relationship with her patient, Eric MacLeish, just weeks after his therapy sessions ended. The standard punishment in such cases is permanent license revocation, but O’Neill filed an appeal with the state Supreme Judicial Court arguing that her license should be only temporarily suspended because her lapse in judgment was caused by the collapse of her own marriage.

The case was scheduled to be heard next month, but SJC Clerk Susan Mellen said O’Neill’s attorney told her he is withdrawing the appeal. Mellen said some paperwork must be completed before the withdrawal is official, but she says she has already told the SJC justices not to bother studying the case files. The Associated Press reported that O’Neill’s attorney  confirmed he was withdrawing the appeal, but gave no reason for the decision. The attorney could not be reached by CommonWealth.

The case was the focus of a lengthy article on CommonWealth’s website that dealt with the legal issues involved as well as O’Neill’s high-profile patient, MacLeish. MacLeish is an attorney who represented many of the clients who sued the Catholic Archdiocese of Boston alleging priests had sexually abused them. The case brought MacLeish national attention, but court records indicate it also scarred him emotionally and made him realize that he had been sexually abused as a child at the hands of a teacher at a boarding school in England and by a scoutmaster associated with the school.

In 2004, MacLeish turned to O’Neill for help. She diagnosed him with post-traumatic stress disorder and treated him for 10 sessions between August and September 2004. Shortly after those sessions ended, the two were sleeping together.

Linda Jorgenson, a Massachusetts attorney who has represented hundreds of people who have claimed their therapists abused them sexually, said she couldn’t understand why O'Neill would withdraw her appeal. "Her briefs have been filed. All that is left is for the oral argument to take place in September,” she said. “I don't see anything that she had to lose by waiting for the court to issue its ruling."

Thanks to Gary Schoener for the information.

The reader can find the earlier blog post here.

Friday, August 26, 2011

Should you blow the whistle?

What to do when you suspect your adviser or research supervisor of ethical misconduct.

By Cassandra Willyard

After graduating with a master’s in counseling, “Jackie Frank” (not her real name) decided to get some research experience before applying to a PhD program. She took a position at a small medical center where a researcher had a grant to study post-traumatic stress disorder and substance abuse. As part of the job, Frank interviewed study volunteers to assess the severity of their condition — and that’s when she noticed something fishy was going on.
“Our supervisor framed leading questions and expected you to do that as well,” Frank says. The researchers, she believes, were trying to manipulate the study results “to make a bolder, statistically significant statement.”
Frank later noticed that some of data had been changed. “At that point, I knew we didn’t have the same ethical values,” she says.
Frank debated whether to “suck it up,” but ultimately decided to leave before her funding ran out. In her exit interview, she brought up her concerns and handed in a formal letter detailing her observations. Not long after, she heard that the lead researcher was under investigation for possible misconduct.
Nearly every graduate student faces ethical uncertainties, says Melissa Anderson, PhD, a professor of higher education at the University of Minnesota in Minneapolis who studies research integrity. But these quandaries become even more complicated when you suspect that your superior is involved in ethical misconduct.
“Graduate students, like all other researchers, are working at the frontier of knowledge,” she says. “And with every new thing, there’s the potential for new ethical complications.” The line between “cleaning up” and “cherry picking” data can be fuzzy, for example. And students may not be privy to all the nuances of a study’s protocol.
Even if ethical misconduct is clear, whistle-blowing may not always be the best option for you, says Michael Zigmond, PhD, a neurology professor at the University of Pittsburgh and associate director of an ethics workshop for graduate students. If you’re a fourth-year student and your adviser adds the head of the department to your paper even though he didn’t do any work, bringing it to the authorities’ attention may not be worth the potential damage to your career. On the other hand, if you’re working for a professor in another department and you witness sketchy research practices, quitting quietly and sharing your concerns in an exit interview — as Frank did — might be a good way to go.
Here’s some tried-and-true advice on how to navigate these and other ethical quagmires:
Review the evidence. Avoid jumping to conclusions, Anderson says. You may not know the whole story. Reflect on your communications with the person you suspect of wrongdoing. What led you to suspect something isn’t quite right? Is there evidence to support what your gut is telling you?
If you don’t know what constitutes misconduct, consult your university’s guidelines or the U.S. Office of Research Integrity’s handbook on responsible conduct of research. Every university that receives federal research funding is obligated to adopt the federal definition of scientific misconduct — fabrication, falsification or plagiarism — and some institutions may have even stricter definitions.
Then write notes about any ethical violations you suspect, suggests Anderson. Be sure to jot down the details of every conversation: What was said, who was present, where it occurred, and the date and time. Save your emails, both the ones you send and the ones you receive. Keeping track of what you see can help you form a conclusion and provides invaluable documentation if you decide to report the situation. “Good recordkeeping throughout a research collaboration is important in any case,” she says. “But it becomes really important when something bad is going on.”
The rest of the story is here.

N.Y. Still Pursues Case Against Whistle-Blower

By Danny Hakim
The New York Times

The Cuomo administration is continuing to pursue a two-year-old disciplinary case against Jeffrey Monsour, a state employee at the Office for People With Developmental Disabilities who has been an outspoken critic of the agency’s management.

Mr. Monsour, 50, a direct-care worker, is accused of getting into an argument with a co-worker in front of a resident in 2009. The state is seeking a four-week suspension, a penalty that exceeds those imposed on many employees who committed acts of abuse or neglect against developmentally disabled people.

Mr. Monsour has long been a gadfly within the office, which runs more than 1,000 group homes and institutions. Over the years, he has filed many Freedom of Information requests examining its practices, annoying agency officials, and he sees the case being brought against him as their latest attempt at retribution.
The case highlights the agency’s haphazard approach to discipline.

Mr. Monsour was written about by The New York Times in March; that article told of a state worker who, while being investigated by the police in a case of sexual assault against a severely disabled resident, returned to his job without penalty, despite witness testimony and DNA evidence implicating the employee. That worker was eventually convicted of endangering an incompetent person, a charge stemming from the assault case, and was jailed. Another worker described in the article racked up multiple offenses, including twice punching residents in the face, before losing his job.

This year, Gov. Andrew M. Cuomo forced out the agency’s commissioner, installing Courtney Burke, a policy expert, in the position, and he has asked Clarence J. Sundram, a former regulator, to lead a broad review of the agency’s practices. Seeking to add predictability to the disciplinary system, the administration recently negotiated a plan with the Civil Service Employees Association to create a matrix of punishments for various offenses.

But it has continued to pursue the case against Mr. Monsour.

Last month, after prodding by The Times and Mr. Monsour’s lawyer, the administration took the unusual step of turning over nearly 200 pages of transcripts from Mr. Monsour’s arbitration proceedings, offering a rare window into a continuing disciplinary case involving a state employee.

The rest of the story can be found here.

Thursday, August 25, 2011

California medical board fails to discipline 710 troubled doctors

By Molly Hennessy-Fiske, Los Angeles Times

California's medical board failed to discipline 710 troubled doctors even as they were disciplined by hospitals, surgical centers and other healthcare organizations in the state, according to a report released Tuesday.

The report by Washington, D.C.-based nonprofit Public Citizen was based on an analysis of doctors' records in the National Practitioner Data Bank from 1990 to 2009. The Department of Health & Human Services uses the data bank to track doctors' discipline, medical malpractice payments and other actions. The data released to Public Citizen did not name the doctors or their workplaces.

Of the doctors who escaped state discipline in California, 35% had racked up more than one disciplinary action from another entity, according to the report.

"If the hospital or HMO has taken action, why hasn't the board?" asked Dr. Sidney Wolfe, director of Public Citizen's health research group. "That's something that as a physician or a patient I would be worried about. Hospitals rarely discipline doctors. When they do, it's usually for very serious infractions."

Jennifer Simoes, a Medical Board spokeswoman, said officials have reviewed the report but more analysis is needed.

"We believe more data needs to be obtained, but like many state agencies, we have a 20% vacancy rate and we're trying to focus on our core functions," she said, noting that board officials had been contacted by Public Citizen about investigating the report's findings. "We told them we would do it when we had the resources." She said a state hiring freeze contributed to other deficiencies noted in the report.

At least 102 of the doctors who escaped discipline in California had their privileges to practice at a given facility suspended, limited or revoked after peer reviews, according to the report.

The entire story can be read here.

Wednesday, August 24, 2011

Retractions Of Scientific Studies Are Surging

By Ed Silverman

Over the past decade, the number of medical journals that have issued retractions has climbed precipitously. Since 2001, the overall number of papers that were published in research journals increased 44 percent, but at the same time, the number of papers that were retracted climbed more than 15-fold, according to The Wall Street Journal, citing data from Thomson Reuters.

Put another way, there were just 22 retraction notices that appeared in journals 10 years ago, but 139 were published in 2006 and by last year, the number reached 339. Through July of this year, there were a total 210 retractions, according to Thomson Reuters Web of Science, which maintains an index of 11,600 peer-reviewed journals.

Meanwhile, retractions related to fraud rose more than sevenfold between 2004 and 2009, exceeding a twofold rise traced to mistakes, according to an analysis published in the Journal of Medical Ethics. After studying 742 papers that were withdrawn from 2000 to 2010, the analysis found that 73.5 percent were retracted simply for error, but 26.6 percent were retracted for fraud. Ominously, 31.8 percent of retracted papers were not noted as retracted (read the abstract).

The conclusion? Either there is more fraud or more policing? Ivan Oransky, the executive editor of Reuters Health and a co-founder of the Retraction Watch blog that began recently in response to the spate of retractions, writes us that the simple use of eyeballs and software that can detect plagiarism has made it possible to root out bad papers.

He also notes, however, that there are more journals, which explains why there are more papers, in general, being published. “So the question is whether there have been more retractions per paper published,” Oransky writes, and then points to this chart to note that were, indeed, many more.

“That’s really no surprise, given the increasing numbers of eyeballs on studies, and the introduction of plagiarism detection software. It’s unclear whether the actual amount of misconduct and legitimate error has grown; it may just be that we’re picking up on more of it,” he continues. “What makes it difficult to tell is a problem we often see at Retraction Watch: Opaque and unhelpful retraction notices saying only ‘this study was withdrawn by the authors.’ How does that make for transparent science? We think journals can do a lot better, by demanding that authors and institutions come clean about what went wrong.”

And why is there more fraud? As the Wall Street Journal notes, there is a lot to be gained - by both researchers and journal editors - to publish influential papers. “The stakes are so high,” The Lancet editor Richard Horton tells the Journal. “A single paper in Lancet and you get your chair and you get your money. It’s your passport to success.”

The entire story can be read here.

Tuesday, August 23, 2011

Psychologists with Cancer: Clinical, Ethical, and Practical Challenges

Helen L. Coons, Ph.D., ABPP
Jana N. Martin, Ph.D.
From The Pennsylvania Psychologist

Psychologists living with cancer face clinical, ethical and practical challenges while coping with their own diagnosis and treatments. This brief article offers several suggestions to psychologists in practice and other professional settings who are coping with an early or advanced diagnosis of cancer.

Seek support and supervision. While most individuals are remarkably resilient in coping with cancer and its treatments, a new or recurrent diagnosis and the complex treatment decisions which follow can be highly stressful and frightening. Reaching out to colleagues early for support and supervision is important for psychologists with cancer. Ask colleagues if they know psychologists (or other mental health providers) who have experienced cancer treatment. Practical, informational and emotional support from someone with an insiders’ view is invaluable. The PPA listserv and APA Division listservs may also be helpful in identifying other psychologists with cancer.

Formal supervision from a respected colleague is essential to address clinical, ethical and practical issues that emerge as psychologists cope with cancer, and to support them in developing a practice management plan during and after treatments.

Develop a practice management plan. A cancer diagnosis will typically be followed by  treatment decisions related to surgery, chemotherapy, and/or radiation as well as acute, late, and long-term side effects. At any point in the treatment course, psychologists often face a series of challenging questions related to their practice and other professional roles. Some individuals are too ill, tired, or uncomfortable to work during treatment; some will have to work to maintain their income; and most will likely work part- or full-time with breaks for treatment. Psychologists undergoing cancer treatment are confronted with questions such as: (1) should they continue to see patients, teach, supervise, etc; (2) should they work full- or part-time; (3) if, how and when to disclose their diagnosis to patients, keeping in the mind their practice focus (e.g., children, teens, adults); (4) how to deal with breaks in treatment resulting from additional surgery or side effects of chemotherapy and/or radiation; (5) whether or not to treat patients who have or had cancer, are “at risk” for cancer, have lost a loved one to cancer, have significant attachment issues, or require a high degree of treatment consistency, etc; and (6) clinical, ethical and practical issues when closing a practice. Developing a practice management plan in consultation with a supervisor to address these and other questions can be helpful and empowering (Coons, 2010).

A practice management plan during and after cancer treatment may include creating flexibility in the psychologist’s schedule. For example, some psychologists reduce their patient and teaching load, and/or block their schedule after each chemotherapy cycle when side effects (e.g., nausea, fatigue, pain, low blood counts, etc.) are more likely to emerge and may adversely affect one’s ability to work. Some individuals undergoing chemotherapy have also shifted the focus of their clinical work to more testing or consultation so that they can schedule evaluations between cycles when they have more energy. Others have found that the familiarity of work is a healthy break from cancer treatment. A management plan should include finding colleagues to be on standby to call and re-schedule clients (who have provided informed consent) so that psychologists do not have to explain to patients how they are feeling.

Pace yourself during and after treatment. Throughout and after cancer treatment, psychologists need to be mindful of their physical, emotional and cognitive well-being. Psychologists have an ethical obligation to ensure that their own physical and psychological well-being is healthy enough to care for patients, teach, supervise, etc. Fatigue, pain, nausea and vomiting and the medications used to treat these symptoms or side effects may compromise some individuals’ ability to meet the demands of clinical practice. Chemotherapy and other medications used in cancer treatment, for example, can diminish cognitive functioning. While changes in concentration, memory, processing speed, and the ability to multitask are likely to be mild and time-limited, high level clinical decision-making is essential for differential diagnosis and treatment. Psychologists undergoing cancer treatment must evaluate if they are healthy enough to meet the demands of practice and other professional responsibilities.

Designate a clinical power of attorney. Consistent with the APA Ethical Principles of Psychologists and Code of Conduct (2002), psychologists are obligated to ensure that patients will be taken care of if they are not able to meet professional responsibilities because of personal problems or when there are interruptions in therapy or termination. While many psychologists with cancer will continue to practice during and after treatment, it is important to designate a clinical power of attorney in the event that the psychologist is unable to take care of patients. This colleague should be able to access the psychologist’s office (i.e., they have door and file keys), patient lists, appointment schedules, and records; will contact patients and can either reschedule or provide care to patients, or refer them to other colleagues with the appropriate clinical expertise. See Pope and Vasquez, (2007); Spayd & O’Leary Wiley (2009); and www.apapracticecentral.org for more detailed discussions on closing a practice.

Personal experience with cancer and expertise in psychosocial oncology.  Psychologists who undergo their own cancer treatment will have a special understanding of the experience faced by so many adults across the life span. After treatment, they may even consider taking care of patients with cancer. While well meaning, the psychologist’s own treatment experience is very different from having the expertise in psychosocial oncology necessary to provide evidence-based assessment and treatment to adults with early and advanced cancers. Treating patients with cancer requires a highly specialized fund of knowledge and clinical competencies to ensure quality care and outcomes. While psychologists may want to help others deal with this challenge, they still have the ethical obligation to practice within their scope of expertise. Again, supervision from a respected colleague can be invaluable to sort out if and when a psychologist should treat others with or affected by cancer.


American Psychological Association (2002). Ethical principles of psychologists and code of conduct. Washington, DC: Author.

Coons, H. L. (2010). Psychologists with early and advanced breast cancer: Clinical, ethical and practical challenges. Manuscript submitted for publication.

Pope, K. S., & Vasquez, M. J. T. (2007). Ethics in psychotherapy and counseling: A practical guide. San Francisco: John Wiley.

Spayd, C. S., & O’Leary Wiley, M. (2009, December). Closing a professional practice: Clinical and practical considerations. The Pennsylvania Psychologist, 69(11), 15-17.

Helen L. Coons, Ph.D., ABPP, is a board certified clinical health psychologist who is President and Clinical Director of Women’s Mental Health Associates in Philadelphia. She has specialized in psychosocial oncology for 30 years, mentors psychologists and other health care providers with cancer, and underwent treatment for breast cancer. Dr. Coons may be reached at hcoons@verizon.net or 215-732-5590.

Jana N. Martin, Ph.D., is a licensed psychologist in independent practice in Long Beach, CA. Some of her work with children, adults, and families has focused on coping with chronic diseases such as cancer, and she is in remission from lymphoma. She may be reached at drjanamartin@verizon.net.

Professional Competence in the Face of Life-Threatening Illness

The new issue of *Professional Psychology* includes an article: "Preventing Problems of Professional Competence in the Face of Life-Threatening Illness."

The authors are W. Brad Johnson & Jeffrey E. Barnett.

Psychologists are human. Like our clients, we are nearly certain to encounter difficult life stressors such as relational break-downs, emotional low points, phase-of-life problems, serious medical challenges, or the onset of cognitive decline. Sadly, being a psychologist does little to insulate us from life's tribulations.

At some point during his or her career, nearly every mental health professional will confront a significant health problem. Medical issues may run the gamut from relatively minor (e.g., pneumonia, minor surgery, thyroid dysfunction) to life-threatening (e.g., cardiovascular disease requiring open heart surgery, neuromuscular disorders with a short life-expectancy, various forms of cancer).

Because many psychologists expect to work beyond the typical retirement age, with nearly a fifth reporting that they plan to work until death (Guy, Stark, Poelstra, & Souder, 1987), the probability of life-threatening medical diagnoses occurring during the course of one's career are significant.

But even early career psychologists are vulnerable to life-altering and potentially fatal medical problems (Philip, 1993).

Recent epidemiologic data for U. S. adults between the ages of 45 and 64 indicate that 13% suffer from some form of heart disease and 9.4% have been diagnosed with cancer; between the ages of 65 and 74, these numbers jump to 25.8% for heart disease and 22.5% for cancer (Centers for Disease Control & Prevention, 2010).

Although practitioner emotional health is considered essential and fundamental to the delivery of competent services (Vasquez, 1992), few things may threaten a psychologist's emotional stability more acutely than the diagnosis of a life-threatening illness.

Unfortunately, psychologists are not always effective when it comes to accepting their own vulnerabilities, taking time for self-care, and identifying decrements in their own competence due to either emotional or physical distress (Barnett & Johnson, 2008).

In this article, we direct our focus to the prospect of a life-threatening illness in the psychologist and the subsequent implications for professional competence.

By life-threatening we mean a terminal disease or a progressive medical condition leading to increasing disability and, in most cases, premature death.

Although psychologists are enjoined by the Ethical Principles of Psychologists and Code of Conduct (American Psychological Association; APA, 2010) to ensure their own competence, psychologists struggling with life-altering medical problems may be especially vulnerable to problems in this area.

We highlight how seriously ill and subsequently distressed psychologists may be ineffective at self-assessing and monitoring their professional competence, as well as in making essential decisions about continued clinical practice.

We conclude with numerous recommendations for psychologists designed to both prevent and manage threats to professional competence caused by a life-threatening illness.

Thanks to Ken Pope for this information.

Monday, August 22, 2011

Norway: Insanity Defense Not Likely

It's unlikely that the right-wing extremist who admitted killing dozens in Norway last week will be declared legally insane because he appears to have been in control of his actions, the head of the panel that will review his psychiatric evaluation told The Associated Press.

The decision on Anders Behring Breivik's mental state will determine whether he can be held criminally liable and punished with a prison sentence or sent to a psychiatric ward for treatment.

The July 22 attacks were so carefully planned and executed that it would be difficult to argue they were the work of a delusional madman, said Dr. Tarjei Rygnestad, who heads the Norwegian Board of Forensic Medicine.

In Norway, an insanity defense requires that a defendant be in a state of psychosis while committing the crime with which he or she is charged. That means the defendant has lost contact with reality to the point that he's no longer in control of his own actions.
"It's not very likely he was psychotic," Rygnestad told the AP.

The forensic board must review and approve the examination by two court-appointed psychiatrists before the report goes to the judge hearing the case. The judge will then decide whether Breivik can be held criminally liable.

Rygnestad told the AP a psychotic person can only perform simple tasks. Even driving from downtown Oslo to the lake northwest of the capital, where Breivik opened fire at a political youth camp, would be too complicated.

"If you have voices in your head telling you to do this and that, it will disturb everything, and driving a car is very complex," Rygnestad said.

"How he prepared" for the rampage — meticulously acquiring the materials and skills he needed to carry out his attack while maintaining silence to avoid detection — argues against psychosis, Rygnestad added.

By his own account, the 32-year-old Norwegian spent years plotting the attack. On July 22, he set off a car bomb that killed eight people in downtown Oslo's government district, then drove north to a youth camp on Utoya, a small lake island set amid a quiet countryside of pines and spruces.

There, he spent 90 minutes executing 69 people, mostly teenage members of the youth wing of Norway's governing Labor Party.

The entire story can be found here.

Sunday, August 21, 2011

Expert Witnesses on Trial

State legislators, physician organizations and courts are taking steps to ensure that the experts provide ethical and appropriate testimony.

By Alicia Gallegos, amednews staff.

The ideal goal of an expert witness during testimony is to be "an indifferent advocate for the truth," said neurosurgeon Jeffrey Segal, MD.

Too often, though, physicians make careers as such experts and use unethical tactics to sway jurors, said Dr. Segal, founder and CEO of Medical Justice, a company that sells medical liability insurance and provides legal resources to combat frivolous claims.

"Expert witnesses are the weak or strong link in any medical liability case," he said.

Lawmakers, physician organizations and courts are taking steps to combat unethical testimony by these so-called hired guns.

In recent years, several states have enacted tighter restrictions on expert witness testimony in medical negligence cases. At the same time, more medical associations and state medical boards have created standards for proper expert witness testimony and acted against experts who violate those rules.

Courts also are taking stronger stances against questionable experts. For example, high courts in Arizona and Maryland in 2009 upheld as constitutional state restrictions against expert witnesses.

"There is a growing awareness on the part of expert witnesses -- for both sides -- that what they are doing is not necessarily going to be kept behind closed doors, which definitely was not the case 10 years ago," said Louise B. Andrew, MD, an attorney and independent consultant for physicians on litigation and expert witness issues. "They can't just go and say whatever they are paid to say and expect that peers will never know."

Florida is the latest state to pass restrictions on the use of expert witnesses in medical liability cases. Under a law signed July 1 by the governor, out-of-state physicians offering expert testimony must apply for a certificate to testify. The state medical board can discipline them if they provide deceptive testimony.

"Before, there was absolutely no accountability for what [expert witnesses] did in Florida," said Jeff Scott, general counsel for the Florida Medical Assn. With the new law, "you can't come into Florida and testify falsely and hope to get away with it."

At least 30 states have similar expert witness laws. Some statutes, such as Arizona's, require witnesses to practice in the same specialty as the physician defendant. Others, like Maryland's, mandate that doctors spend a certain amount of time actively practicing medicine.

The whole story can be found here.

Saturday, August 20, 2011

McGill reprimands prof over ghostwriting scandal

By AARON DERFEL, Gazette Health Reporter
Barbara Sherwin
McGill University has formally reprimanded senior professor and researcher Barbara Sherwin for failing to acknowledge a ghostwriter hired by drug company Wyeth Pharmaceuticals in a paper Sherwin wrote in 2000.
However, the university has decided against sanctioning Sherwin, who is a James McGill professor of psychology, obstetrics and gynecology.
In August 2009, Sherwin's name appeared in court documents in a class-action suit launched by 8,400 women against Wyeth. The documents revealed that Wyeth paid a New Jersey professional-writing firm, DesignWrite, to produce a paper on treatment options for ageassociated memory loss that was eventually published in the Journal of the American Geriatrics Society.
Sherwin was listed as the sole author of that paper, even though Karen Mittleman, an employee of DesignWrite, was involved in the process. The paper was published just when critics started raising doubts about hormone-replacement therapy.
Wyeth - through DesignWrite - had commissioned at least 40 scientific papers endorsing the therapy. The drug company (now part of Pfizer) had a vested interest in HRT, as sales of its hormone drugs soared to almost $2 billion in 2001.
Shortly after the revelations from the court documents were made public, Sherwin issued a written statement in which she admitted to making "an error" in agreeing to have her name attached to the article without making it clear that there was another author.
"I believe the article, which was peer-reviewed, represented sound and thorough scholarship, and in no way could be construed as promotion for any particular product or company," her statement read.
Still, an eight-month investigation found that Sherwin should have credited Mittleman.
The entire story can be read here.

Ghostwritten medical articles called fraud

CBC News

It's fraudulent for academics to give their names to medical articles ghostwritten by pharmaceutical industry writers, say two Canadian law professors who call for potential legal sanctions.

Studies suggest that industry-driven drug trials and industry-sponsored publications are more likely to downplay a drug's harms and exaggerate a drug's virtues, said Trudo Lemmens, a law professor at the University of Toronto. The integrity of medical research is also harmed by ghostwritten articles, he said.

Ghostwriting is part of marketing that can distort the evidence on a drug, Lemmens said. Industry authors are concealed to insert marketing messages and academic experts are recruited as "guest" authors to lend credibility despite not fulfilling criteria for authorship, such as participating in the design of the study, gathering data, analyzing the results and writing up of the findings.

Class actions involving drugs such as Vioxx, hormone replacement therapy and antidepressants suggest guest authors often fail to meet criteria for authorship, according to the policy paper in Tuesday's issue of Public Library of Science's journal PloS Medicine.

In the article, Lemmens and his colleague Prof. Simon Stern argue that legal remedies are needed for medical ghostwriting since medical journals, academic institutions and professional disciplinary bodies haven't succeeded in enforcing sanctions against the practice.

The institutions have divided loyalties, the authors say, which may explain why they've been slow to act. For example, universities wish to protect academic integrity while also protecting their employees from unjust accusation.

A legal response could act as a powerful deterrent, Stern said.

"Our theory does not depend on the accuracy of the data," Lemmens said in an email. "False representation of authorship is in our view fraud, regardless of the accuracy of the reporting."

Doctors and patients perceive published studies to be independent assessments made by academic experts, the authors noted.

Ghostwritten publications are used in court to support a manufacturer's arguments about a drug's safety and effectiveness, and academic experts who appear as witnesses for pharmaceutical and medical device companies also boost their credibility with the publications on their CV, Lemmens said.

The entire story can be found here.

Friday, August 19, 2011

Texas: Doctoral Degree in Psychology Required for Independent Practice

Austin, TX Today, Judge Rhonda Hurley in Travis County District Court, Austin, Texas, upheld the ruling that the entry level to independent practice of psychology in Texas is the doctoral degree. Judge Hurley ruled that the Texas State Board of Examiners of Psychologists (TSBEP) has the authority to regulate the practice of Licensed Psychological Associates (LPAs) through its rule making authority which states only doctoraltrained, Licensed Psychologists may practice independently.

In September, 2010 the organization which represents Licensed Psychological Associates, the Texas Association of Psychological Associates (TAPA), filed a lawsuit in Austin, Texas, against the TSBEP on the grounds that the Board has no statutory authority to prevent Licensed Psychological Associates from practicing independently. According to Texas statute, Licensed Psychological Associates are defined as individuals trained in psychology at the Master’s level. By Board Rule, LPAs must practice under the supervision of a doctoraltrained Licensed Psychologist. The Texas Psychological Association (TPA) was granted permission by the court to intervene in this case; arguing the intention of the legislature was that only doctoraltrained individuals could provide independent psychological services. TPA claimed that TSBEP rule, which clearly states the supervision requirement for LPAs, does define how psychology is to be practiced in this state even though the supervision requirement is void in the statute.

David White, TPA’s Executive Director, states “We thank Judge Hurley for her judgment in this case and for clarifying this issue that has been debated for so many years in the psychology community. We appreciate the services provided by Licensed Psychological Associates but are fully committed to assuring that independent psychological practice in Texas remains solely for individuals trained at the doctoral level.”