Social Environment and Suicide

Suicide awareness and prevention is a significant concern among psychologists.  Having a strong knowledge base about suicide risk factors will help psychologists function at their highest levels.  In a previous blog post, a military study highlighted unit cohesion as a factor in decreasing suicidal ideation. Here is an abstract from the journal Pediatrics that indicates how the social environment plays a role in teenage suicide rates.

The Social Environment and Suicide Attempts in Lesbian, Gay, and Bisexual Youth

OBJECTIVE: To determine whether the social environment surrounding lesbian, gay, and bisexual youth may contribute to their higher rates of suicide attempts, controlling for individual-level risk factors.

METHODS: A total of 31 852 11th grade students (1413 [4.4%] lesbian, gay, and bisexual individuals) in Oregon completed the Oregon Healthy Teens survey in 2006–2008. We created a composite index of the social environment in 34 counties, including (1) the proportion of same-sex couples, (2) the proportion of registered Democrats, (3) the presence of gay-straight alliances in schools, and (4) school policies (nondiscrimination and antibullying) that specifically protected lesbian, gay, and bisexual students.

RESULTS: Lesbian, gay, and bisexual youth were significantly more likely to attempt suicide in the previous 12 months, compared with heterosexuals (21.5% vs 4.2%). Among lesbian, gay, and bisexual youth, the risk of attempting suicide was 20% greater in unsupportive environments compared to supportive environments. A more supportive social environment was significantly associated with fewer suicide attempts, controlling for sociodemographic variables and multiple risk factors for suicide attempts, including depressive symptoms, binge drinking, peer victimization, and physical abuse by an adult (odds ratio: 0.97 [95% confidence interval: 0.96–0.99]).

CONCLUSIONS: This study documents an association between an objective measure of the social environment and suicide attempts among lesbian, gay, and bisexual youth. The social environment appears to confer risk for suicide attempts over and above individual-level risk factors. These results have important implications for the development of policies and interventions to reduce sexual orientation–related disparities in suicide attempts.

Hopefully, this research will shed light on the importance of environmental influences and risk factors relating to suicide.  Prevention programs, suicide awareness among professionals, and competent suicide assessments are keys to decreasing the silent epidemic of teen suicide, especially with GLBT youth.

NYT: Breaches Lead to Push to Protect Medical Data

How private is our medical information?

Will electronic record keeping increase the likelihood of breaches of confidentiality?

Here is the beginning of an article from The New York Times by Milton Freudenheim.  The article highlights the how the level of carelessness with health information has forced government regulators to increase enforcement, including significant fines.  Confidentiality is the cornerstone of our profession.  This article heightens awareness about the entire healthcare system, not psychology in particular.

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Federal health officials call it the Wall of Shame. It’s a government Web page that lists nearly 300 hospitals, doctors and insurance companies that have reported significant breaches of medical privacy in the last couple of years.

Such lapses, frightening to consumers, could impede the Obama administration’s effort to shift the nation to electronic health care records.

“People need to be assured that their health records are secure and private,” Kathleen Sebelius, secretary of health and human services, said in an interview by phone. “I feel equally strongly that conversion to electronic health records may be one of the most transformative issues in the delivery of health care, lowering medical errors, reducing costs and helping to improve the quality of outcomes.”

So the administration is making new efforts to enforce existing rules about medical privacy and security. But some health care experts wonder if the current rules are enough or whether stronger laws are needed, for example making it a crime for someone to use information obtained improperly.

“The consequences of breaches matter,” conceded Dr. Farzad Mostashari, a former New York public hospitals official who recently became the Obama administration’s national coordinator for health information technology. “People say they are afraid that if their private information becomes known, they may not be able to get health insurance.”

In the last two years, personal medical records of at least 7.8 million people have been improperly exposed, according to the government data. One particularly egregious case involved information about 1.7 million patients, staff members, contractors and suppliers of Bronx hospitals and clinics operated by the Health and Hospitals Corporation, the New York public health agency. Their electronic files were stolen from an unlocked van belonging to a record management company.

The affected patients got the disquieting news that their medical and personal information, like Social Security numbers, had been violated when their health care providers notified them under federal rules.

Showing just how lax security can be, the inspector general of the Department of Health and Human Services said two weeks ago that the agency had found dozens of vulnerabilities in systems to protect records of patients at seven large hospitals in New York, California, Illinois, Texas, Massachusetts, Georgia and Missouri. Auditors cited such problems as personal information that was not encrypted and was stored on computers that could be easily used by unauthorized users.

The Internet's Ethical Challenges

A common theme on this blog is the nexus of psychology and ethics on the internet.  The capacity to communicate, interact and build relationships at a distance is becoming increasingly easy and affordable.  From a number of discussions with college students, some individuals actually prefer texting and skyping to outdated emailing and talking on the phone.

Psychologists will continue to venture into telepsychology and building relationships over the internet.  As clinical practice continues to move into this brave new world, psychologists need to consider the ethical implications of new technologies with their work as well as their personal lives.

Sara Martin from the APA's Monitor wrote a story entitled The Internet's Ethical Challenges.  A portion of the article is listed below.  The information just begins to scratch the surface of ethical issues related to a psychologist's presence on the internet.

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Should you Google your clients?

Should you ‘friend’ a student on Facebook?

APA’s Ethics Director Stephen Behnke answers those questions and more.

No form of client communication is 100 percent guaranteed to be private. Conversations can be overheard, e-mails can be sent to the wrong recipients and phone conversation can be listened to by others.

But in today’s age of e-mail, Facebook, Twitter and other social media, psychologists have to be more aware than ever of the ethical pitfalls they can fall into by using these types of communication.

“It’s easy not to be fully mindful about the possibility of disclosure with these communications because we use these technologies so often in our social lives,” says Stephen Behnke, PhD, JD, director of APA’s Ethics Office. “It’s something that we haven’t gotten into the habit of thinking about.”


Stephen Benhke


The Monitor sat down with Behnke to discuss the ethical aspects of the Internet for psychology practitioners and how to think about them.

Does the APA Ethics Code guide practitioners on social media?

Yes. The current Ethics Code was drafted between 1997 and 2002. While it doesn’t use the terms “social media,” “Google” or “Facebook,” the code is very clear that it applies to all psychologists’ professional activities and to electronic communication, which of course social media is.



As we look at the Ethics Code, the sections that are particularly relevant to social media are on privacy and confidentiality, multiple relationships and the section on therapy. The Ethics Code does not prohibit all social relationships, but it does call on psychologists to ask, “How does this particular relationship fit with the treatment relationship?”

Is the APA Ethics Office seeing any particular problems in the use of social media?



Everyone is communicating with these new technologies, but our ethical obligation is to be thoughtful about how the Ethics Code applies to these communications and how the laws and regulations apply.

For example, if you are communicating with your client via e-mail or text messaging, those communications might be considered part of your client’s record. Also, you want to consider who else might have access to the communication, something the client him- or herself may not be fully mindful of. When you communicate with clients, the communication may be kept on a server so anyone with access to that server may have access to your communications. Confidentiality should be front and center in your thinking.



Also, consider the form of communication you are using, given the kind of treatment you are providing. For example, there are two very different scenarios from a clinical perspective: In one scenario, you’ve been working with a client face-to-face and you know the client’s clinical issues. Then the client goes away on vacation and you have one or two phone sessions, or a session or two on Skype. A very different scenario is that the psychologist treats a client online, a client he or she has never met or seen. In this case, the psychologist has to be very mindful of the kind of treatment he or she can provide. What sorts of issues are appropriate to treat in that manner? How do the relevant jurisdiction’s laws and regulations apply to the work you are doing?

That’s an example of how the technology is out in front of us. We have this wonderful new technology that allows us to offer services to folks who may never have had access to a psychologist. At the same time, the ethical, legal and regulatory infrastructure to support the technology is not yet in place. A good deal of thought and care must go into how we use the technology, given how it may affect our clients and what it means for our professional lives.



APA needs to be involved in developing that ethical, legal and regulatory infrastructure and needs to be front and center on this.

What do you want members to know about using Facebook?

People are generally aware that what they put on their Facebook pages may be publicly accessible. Even with privacy settings, there are ways that people can get access to your information.



My recommendation is to educate yourself about privacy settings and how you can make your page as private as you want it to be. Also, educate yourself about how the technology works and be mindful of the information you make available about yourself. Historically, psychology has talked a lot about the clinical implications of self-disclosure, but this is several orders of magnitude greater, because now anyone sitting in their home or library with access to a terminal can find out an enormous amount of information about you.

Facebook is a wonderful way to social network, to be part of a community. And of course psychologists are going to use this, as is every segment of the population. But psychologists have special ethical issues they need to think through to determine how this technology is going to affect their work.

Cultivating a Role in Parenting Coordination

There is an excellent introductory article for psychologists who are considering expanding their practice as a parenting coordinator.

APA’s Good Practice interviewed Helen T. Brantley, PhD, about  the new guidelines for the Practice of Parenting Coordination.  This hyperlink will take the reader directly to the .pdf file from APA.

Here are the first three paragraphs of the article.

The process of parenting coordination is designed to help parents or guardians involved in high conflict custody disputes implement and comply with parenting plans, make timely decisions consistent with children’s developmental and psychological needs, and reduce the amount of damaging conflict between caretaking adults to which children are exposed. 

The American Psychological Association (APA) Practice Directorate has been involved for the past several years with developing parenting coordination as an emerging practice area for psychologists. The association appointed a task force in 2008 to draft parenting coordination guidelines. APA’s Council of Representatives approved the proposed guidelines as policy in February 2011.

Good Practice interviewed Helen T. Brantley, PhD, chair of the guidelines development task force, about the content and uses of the guidelines and how psychologists can prepare themselves to practice as parenting coordinators.

In order to access the article, the reader needs to be an APA member.  This magazine is another benefit of membership from our national organization.

These guidelines will help psychologists understand the role of the psychologist-as-parent-coordinator, minimum requirements of this specialized role, and ethical issues related to becoming a Parent Coordinator.

The Ethics Committee: Part 1

This post is the first of several that will describe what we do as part of the Ethics Committee.  In the distant past, one role of the committee was to adjudicate ethics complaints lodged against PPA members.  We no longer conduct ethics investigations.  The Pennsylvania Psychological Association refers individuals with ethics complaints to the State Board of Psychology and/or the American Psychological Association.

As a committee, there are plenty of other goals and activities related to ethics and ethics education.  The Pennsylvania Psychological Association provides our mission via the bylaws.  Part of our mission is:

The committee shall provide information to the membership and to the public about the formal ethical principles and the evolving standards of practice of psychologists. Such information shall be distributed regularly and proactively as well as in response to inquiries.

PPA, through its Ethics and other committees, works to help members understand and fulfill their ethical mandates.

Continuing Education

• PPA’s Continuing Education Committee sponsors workshops and home study ethics CE courses. Also, Ethics Committee members and PPA staff sometimes present ethics CE programs for agencies or local psychological associations in the state. Using mostly articles published in the Pennsylvania Psychologist, PPA offers a certificate of completion to psychologists who complete a sequence of home study ethics courses.
• Members of PPA’s Colleague Assistance Committee often present at CE programs to promote self-care and provide referrals for psychologists in distress.
• Members of PPA’s Child Custody Committee often present at CE programs to promote high ethical standards in psychologists who provide services to divorcing families. In addition to having its own e-group, where committee members can consult with each other on issues related to custody, its members have participated in several interdisciplinary conferences with attorneys, judges, psychiatrists, and other professionals involved in child custody determinations.

Publications

• Members of the Ethics Committee regularly write or solicit articles for PPA’s publication, the Pennsylvania Psychologist.  Many of these are then placed in the “Members Only” section of the PPA Web site and have been combined into home studies or online CE courses. Members of other committees, such as the Colleague Assistance, Forensic and Criminal Justice, or Child Custody Committees, may also write articles on ethics related to their specific concerns.
• PPA publishes Pennsylvania Law, Ethics, and Psychology (Knapp, VandeCreek, Tepper, & Baturin, 2010) which reviews the laws and ethics codes relevant to Pennsylvania psychologists. It is now in its fifth edition and is often used in ethics courses in psychology doctoral programs.

We also view this blog as an extension of our goal to educate the public and our members about ethics and ethical principles.

More to follow.

Distance Therapy Comes of Age: Article Review

John D. Gavazzi, PsyD ABPP
Ethics Chair

A friend recommended that I read Distance Therapy Comes of Age by Robert Epstein in the magazine Scientific American Mind.  While the title seemed appealing, the article treats telehealth and e-therapy quite superficially.  There is little in the way of empirical support for conclusions made in the article.

The article indicates that there is an "avalanche of evidence" supporting the efficacy of e-therapy.  I reviewed one of the sources for this article, "Current Directions in Videoconferencing Tele-Mental Health Research" by Richardson and others.  Here is one important quote from the article that undermines the overall conclusion of the article:

"Compared to symptom reduction and cost effectiveness, satisfaction is a simple variable to measure, and it is perceived to be a necessary first step for the development of good therapist-client relationships (Rees & Haythornthwaite, 2004). However a common weakness of tele-mental health research, particularly in small studies and novel demonstrations, has been to overemphasize patient satisfaction as being the same as clinical effectiveness. Furthermore, the majority of studies examining satisfaction with tele-mental health have typically used study-specific measures of this outcome, and the psychometric properties of these instruments are largely unknown. Finally, we do not know whether patient satisfaction with tele-mental health would remain as high in the presence of alternative mental health services, or if ratings of high satisfaction are a by-product of simply being pleased to receive any service at all."

Additionally, one of the "Fast Facts" in the article states "brief therapeutic communiques using mobile phones can help combat eating disorder, alcohol abuse, cigarette smoking and anxiety, among other problems."  The author cites research from Kristin Heron and Joshua Smyth to support the point; however, there is no reference given as to who published this research or where to find it.

There were some positive components to the article.  The first is a quote from Gerry Koocher, which states "the important thing is that you're practicing competently, no matter how you are delivering the therapy."  Koocher also made the important points that e-therapy may not be appropriate for everyone as well as the potential for fraud exists.

Psychologists need more definitive information and guidelines about telepsychology and e-therapy to practice at the highest level.

Fortunately, there is positive movement for psychologists interested in telehealth, e-therapy, and telepsychology.  The Committee for the Advancement of Psychology recently announced the formation of a new Task Force on Telepsychology.

We are pleased to announce the members of the newly formed Task Force on Telepsychology.  The Task Force members represent the American Psychological Association (APA), the Association of State and Provincial Psychology Boards (ASPPB), and the American Psychological Association Insurance Trust (APAIT).  The purpose of the Task Force will be to develop telepsychology guidelines that will provide direction to psychologists as they navigate the numerous ethical, regulatory, legal and practice issues that arise in their use of technology in the delivery of psychological services.  We want to acknowledge and thank these new members for their leadership and commitment to participate in this multi-organizational Task Force.

Psychologists will need to rely on credible sources of information before embarking in e-therapy and telepsychology.  Some interesting issues include informed consent, practicing across state lines, and the overall efficacy of telepsychology. 

This blog will update our readers on recent research about the effectiveness of telepsychology as well as any outcomes from the Task Force on Telepsychology.  Psychologists need to be informed on the ethical, legal, and competent practice of telepsychology.

The Ethics of Leadership in Psychology

Stephen A. Ragusea, Psy D, ABPP

Guest Blog

It is often said that psychologists have the most complex and demanding set of ethics of all the professions.  Whether or not that is so, we are clearly obligated to behave ethically in our professional lives, and certainly providing leadership is part of that professional existence.

The essence of leadership may be examined in a variety of ways (Thompson 2008) and the ethics of leadership in the field of psychology may similarly be perceived from different perspectives.  Think about the problems caused by ethical mistakes made by leaders that are now significant parts of our collective history. For example, the words Nixon, Enron, and Madoff bring forth a flood of memories about ethical breaches of leadership that clearly impacted the recent past.  Within psychology, the name Abu Ghraib now has special meaning and the debate within psychology about our leadership role there is ongoing.  Of course, these are extreme examples provided to emphasize the importance of ethical leadership.

As psychologists, our Ethical Standards provide us with much general guidance.  We are advised by our Ethical Principles that in all our work as psychologists we should act with “Beneficence… Fidelity and Responsibility… Integrity… Justice… and…Respect for People’s Rights and Dignity….” That’s a significant list of demands. We’re just human beings, after all.  But, we psychologists tend to demand a lot from ourselves. 

It is noteworthy and perhaps surprising that nothing in the Ethical Principles of Psychologists and Code of Conduct (2002) specifically addresses our leadership roles. Yet, psychologists function in leadership positions wherever they work and that includes their efforts within psychological organizations.  So, we must look to other sources for guidance on leadership ethics.

A literature review quickly reveals that little psychological research has been done on ethics in leadership, despite its importance in our world. In fact, it seems that the subject of ethical leadership is more likely to be considered by business scholars than psychologists.  However, there has been some research and scholarly writing done by psychologists, which we can peruse.

On a fundamental level, we psychologists seem to agree that leadership may be described as a “basic tension between altruism and egoism.  That is, some leaders balance the development of themselves and their subordinates, raising the aspirations of both the leaders and the led in the process…. Other leaders wield power to satisfy their own needs and have little regard for either helping the development of their subordinates or behaving in socially constructive ways.” (Turner 2002). 

When considering ethical matters, both psychologists and business professionals tend to embrace models of leadership such as Transformational Leadership. Within that model, leaders provide a vision for change and then endeavor to inspire the other members of the group to pursue that transforming vision.  This model is seen as morally superior and stands in contrast to other models of leadership that involve the direct control of others through coercive transactions.   Such transactional models are tempting for a variety of reasons.  For example they have the advantage of being, at least temporarily, expedient.

Indeed, transactional leadership has been utilized in organizations and nations throughout history and is very often effective for a limited time.  Such was the case with Attila, who served as King of the Huns from 433-453 (Wess 1989).   However, as Gandhi pointed out, “all through history…there have been tyrants…and for a time they seem invincible but in the end, they always fall.  Think of it, always.” Therefore, from both ethical and effectiveness perspectives, it appears that more altruistic leadership based on inspiration is usually superior to self-centered intimidation in most realms.

For that reason alone, it is would be wise for all of us involved in leadership roles to remember that we are primarily there to serve our profession and our patients, not ourselves.  And, research suggests that we lead best by sharing a vision that inspires others to action.  In so doing, we embrace our core ethical principles of “Beneficence… Fidelity and Responsibility… Integrity… Justice… and…Respect for People’s Rights and Dignity….” And, that is our ethical obligation.

References

American Psychological Association. (2002). Ethical principles of psychologists and code of conduct. American Psychologist,Vol. 57, 1060-1073.

 

Roberts, Wess (1989). Leadership Secrets of Attila the Hun, New York, Warner Books.

Thompson, A.D., Grahek, M., and Ryan, E.P. (2008).  The Search for Worthy Leadership.  Consulting Psychology Journal: Practice and Research. Vol. 60, 4, 366-382.

Turner, N., Barling, J., Epitropaki, O., Butcher, V. and Milner, C. (2002). Transformational Leadership and Moral Reasoning.  Journal of Applied Psychology.  Vol. 87, 2, 304-311.

Social Connection and Suicide

 John D. Gavazzi, PsyD, ABPP

Chair of the Ethics Committee

In Thomas Joiner's book, Myths About Suicide, he notes that suicide risk is related, in part, to a person's sense of connection with other individuals.  This factor is not the only or main factor in determining risk for suicide, but an important clinical variable in the assessment process.  When an individual reports stronger interpersonal connections with others or a greater the sense of belonging to a group, there is a lower likelihood of an individual committing suicide.  He gives numerous examples in his book (as well as other pertinent risk factors when assessing suicide).

The reason to post about social connectedness and suicide relates to a study to be presented to the American Psychiatric Association on military unit cohesion and suicidal ideation.  Here is a summary of the research:

Unit cohesion appears to be an important factor in determining whether soldiers think about suicide during a period after combat exposure, according to a study presented at the American Psychiatric Association Annual Meeting.

U.S. Army researchers surveyed more than 1,600 soldiers from two combat brigades who had been deployed once. The survey was designed to measure of combat exposure, unit cohesion and self-reported thoughts of suicide. Soldiers who reported higher combat exposure and lower unit cohesion had the greatest odds for reporting suicidal thoughts during the previous four weeks. In addition, soldiers with similar combat exposure were more likely to have suicidal thoughts if they reported less unit cohesion.

This brief description highlights how perceived social connection via group cohesion can the reduce the risk of suicidal ideation.  This study supports the research and writing of Dr. Joiner.

As an aside, I strongly recommend the book to every psychologist and psychologist-in-training due to his research and insights on suicidal ideation and behavior.

We're Blogging for Mental Health



"Informed journalists can have a significant impact on public understanding of mental health issues as they shape debate and trends with the words and pictures they convey. They influence their peers and stimulate discussion among the general public, and an informed public can reduce stigma and discrimination."

- Rosalynn Carter

We are participating in the American Psychological Association's program Blogging for Mental Health.  The overarching goal of this program is to help people recognize the importance of good mental health, overcome stigma, and seek out professional mental health services when needed. 

We decided to highlight an advocate of mental health issues and treatment services, who also has made significant efforts to decrease the stigma surrounding mental health.



Former First Lady
Rosalynn Carter


Rosalynn Carter has been a major advocate for mental health awareness and mental health services.  She supported mental health parity and collaborated with many others to help push this legislative initiative for years.  The Mental Health Parity law was enacted in October 2008.

"Blogging for Mental Health" seems to be a natural extension of Mrs. Carter's project to help raise awareness about mental health through journalism.  While blogging is not officially journalism, the blogosphere is a new medium in which to advocate, educate, heighten awareness, and reduce stigma about mental health issues and mental health treatment.  As psychologists, public education is an aspirational ethic.  Aspirational ethics exemplify the highest standards and best practices of our profession (and not a minimum requirement).

Rosalynn Carter Fellowships for Mental Health Journalism provide money for journalists to promote mental health awareness.  The quote listed above summarizes her position on this program.  More specifically, the goals of Mrs. Carter's project include:

•  Increase accurate reporting on mental health issues and decrease incorrect, stereotypical information
• Help journalists produce high-quality work that reflects an understanding of mental health issues through exposure to well-established resources in the field
• Develop a cadre of better-informed print and electronic journalists who will more accurately report information through newspapers, magazines, radio, television, film, and the Internet and influence their peers to do the same.

We thank and salute Mrs. Carter for her program, her advocacy, and her tireless efforts on behalf of those who suffer with mental health issues.  She demonstrates our aspirational ethic of educating the public on psychological issues and treatment.