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.

and

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.

The Ethics Committee: Part 2

As part of our mission, the Ethics Committee educates members about ethics through home study continuing education courses.  For the Certificate in Ethics Education, the committee created six courses totaling 21 credits to help psychologists create a broad knowledge base on ethics education.  This video explains the Certificate of Completion in Ethics Education.

Additional information about the Certificate of Completion in Ethics Education can be found here.

The actual courses can be found by reading PPA's Home Study CE Page.

An article on this certificate will soon be published in The Pennsylvania Psychologist.

Vignette 3: A new referral?

A psychologist had an intake appointment with a new client.  As soon as he looked at the intake form, he realized that she is the ex-wife of his former client.  The therapy with the ex-husband was brief, and he focused on how he wanted to leave the marriage. The prospective client was using her maiden name and gave no indication that she had known about her ex-husband’s treatment with the psychologist.

When asked about the reason for the referral, she said that her physician had referred her for anxiety. During the session, she stated that he is still in communication with her ex-husband because they share three children.

What are the ethical issues for this scenario?

What emotional reactions may occur for the psychologist?

Should the psychologist treat the woman?

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.