Blogging from the Convention

John Gavazzi & Rick Small

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

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

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

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

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

What factors make the dilemma difficult for the psychologist?

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

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

Feedback from workshop participants was uniformly positive.

For a copy of the slides, please email John.

A 12-year-old Models Advocacy

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

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

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

APA calls for psychologists inclusion in ACOs

Part of a psychologist's aspirational ethic is to urge government agencies to help our patients access appropriate psychological care.  This form of advocacy also advances our profession.  Here is a press release from the American Psychological Association that illustrates an important part of our collective professional responsibility.

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June 9, 2011—This week, APA sent a comment letter (PDF, 265KB) to the Department of Health and Human Services (HHS) regarding a draft proposal to establish Accountable Care Organizations (ACOs) in Medicare. Section 3022 of the Affordable Care Act requires the establishment of the Medicare Shared Saving Program, which is intended to encourage the development of ACOs.

ACOs, one of the reforms included in the Affordable Care Act, will allow hospitals, physicians and other Medicare providers and suppliers of services to establish a network that emphasizes primary and coordinated care. Medicare beneficiaries will enroll in an ACO as an alternative to fee-for-service delivery, where the ACO will coordinate their care in an effort to improve quality and contain cost increases. Medicare beneficiaries may still see providers of their choice but their care will be more carefully coordinated by the ACO.

The letter from APA Chief Executive Officer Norman B. Anderson, PhD, and APA Executive Director for Professional Practice Katherine C. Nordal, PhD, to HHS Secretary Kathleen Sebelius, dated June 6, 2011, addresses a specific portion of the proposal regarding health care professionals who may participate in ACOs.

In the letter, Drs. Nordal and Anderson urge inclusion of clinical psychologists as participants in ACOs, therefore ensuring better access of Medicare beneficiaries to mental health, substance use disorder and behavioral health services. The letter is a recent example of APA’s ongoing advocacy to promote psychologists as key players in primary care as it develops.

Among Anderson and Nordal’s comments:

- APA agrees with Sebelius’ decision to expand the list of providers eligible to

  participate in ACOs to include clinical psychologists and other providers not

  specifically named in the statute. 

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

  primary care team. 

- Including clinical psychologists in ACOs ensures the integration of mental,

  substance use disorder and behavioral health with physical health and a more

  comprehensive integrated care system.

APA is asking HHS to retain and implement this provision in the proposed rule in the final draft. We anticipate that HHS will finalize the rule in the coming months.

APA and the APA Practice Organization will continue to evaluate and provide input on proposed rules of interest to practicing psychologists. 

For more information, contact the Government Relations department by email or at (202) 336-5870.

Self-Care and Building Resilience

by John Gavazzi, PsyD ABPP

Ethics Chair

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

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

Psychologists must remain aware of the requirements of our work and plan for stressors in order to function well. By engaging in healthy self-care activities, we are better able to take care of personal lives, and ourselves, which ultimately lead to better treatment for our clients.

APA recently published a document for psychologists to educate their patients on “Building Your Resilience.”  While APA geared the document for patients, psychologists may want to review the suggestions to help build their resilience.  Here are some of the suggestions:

Find positive ways to reduce stress and negative feelings

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

Look for opportunities for self-discovery

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

Nurture a positive view of yourself

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

Keep things in perspective

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

Maintain a hopeful outlook

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

Take care of yourself.

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

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

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.