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

Friday, July 15, 2011

Time to concentrate on human factors in mental illness

Sami Timimi consultant child and adolescent psychiatrist
NHS Lincolnshire, Lincoln, UK
BMJ 2011;343:d4377

Drug companies losing interest in psychiatry is great news for psychiatry and mental health services but most of all for patients.1 Other research funding sources may also recognize that a focus on the brain is not a credible, evidence based choice likely to contribute to better care for those who have mental distress. Drug companies have found mental health highly lucrative, with multibillion pound blockbuster drugs such as the misnamed (for marketing purposes) antidepressants and antipsychotics. Sooner or later it would become apparent that the evidence based cupboard was empty—that all of the drugs were of dubious effectiveness, had varying degrees of neurotoxicity, created abnormal mental states (which can be lifesaving for some at certain points in their distress) rather than corrected them, and were different from illicit drugs only through who provides them and how they are subsequently used rather than because of discoveries of some particular therapeutic potency.

In biological psychiatry a reliance on psychotropic drugs has encouraged some remarkable developments such as an increase in the numbers and a worsening of the long term prognosis for those categorised as mentally ill,2 and an increase in stigma that is associated with the model that mental illness is “an illness like any other illness.”3 Freed from the corrupting shackles of the pharmaceutical industry we can put money into better understanding the factors that have the biggest effects on outcome: social factors outside of treatment and the therapeutic relationship within treatment.4

Competing interests: None declared.

1 Wise J. Research into treatments for mental illness is under threat. BMJ 2011;342:d3747. (14 June.)
2 Whitaker R. Anatomy of an epidemic . Crown, 2010.
3 Read J, Haslam N, Sayce L, Davies E. Prejudice and schizophrenia: a review of the
‘mental illness is an illness like any other’ approach. Acta Psychiatr Scand 2006;114:303-18.
4 Timimi S. Campaign to Abolish Psychiatric Diagnostic Systems such as ICD and DSM (CAPSID). 2011. Available at: www.criticalpsychiatry.net/?p=527.

Thursday, July 14, 2011

Positive Coaching and Ethical Practices


In the high stakes world of elite level athletics, coaches are king -- but that lofty perch can prove a sword of Damocles. More often than not they're regarded as the undisputed authority on what it takes to train an athlete to maximal performance potential, and being placed on a pedestal doesn't allow for proper reflection about their coaching practices or any margin of error when there are Olympic finals and medals at stake.

As a consequence, that doesn't always mean they're always doing the right thing for their athletes, says Dr. Jim Denison an expert in coach education at the Faculty of Physical Education and Recreation at the University of Alberta, and co-author of a new paper on positive coaching and ethical practices for athlete development. 

"Coaching is complex, continually changing and influenced greatly by the context, athletes' circumstances and the developing relationship between the coach and the athlete.

"Good coaching, as we talk about it in our paper, means thinking about these complexities and dealing with them positively, proactively and ethically," he says.

Denison says one of the greatest dangers is that coaches can become set in their ways and practices of working with athletes, positioning themselves as experts, who brook no criticism or questioning of their expertise. "They become entrenched in methodologies that worked in the past and they expect those methodologies to continue to work," says Denison.

"There's good research that shows that when coaches achieve this expert status they tend to want to maintain that," he says, "so admitting that you don't know becomes a threat to their expertise."

Once on the pedestal, he adds, "it's hard for that person to express uncertainty, or be open to new ways of looking at a problem or consulting with others." Athletes play their part too in entrenching the idea of the coach as oracle, placing great faith and confidence in their coach, expecting him or her to help them deliver the performance of their lives. If they don't, consequences are often dire: the coach is fired, the athlete finds another coach or the athlete quits the sport.

Denison, a sport sociologist and coach educator who directs the Canadian Athletics Coaching Centre, is working to break down these harmful paradigms. He says coaches need to take an integrated approach to coaching and look at their athletes as individuals rather than trying to find a system or template they can apply to all and, importantly, learn to "problemetize" an issue before coming up with a solution. In essence that means thinking critically about a problem, determining whether it is in fact a problem, and having the confidence to look at themselves because their behaviour might be contributing to a problem.

"Often the most successful coaches are the ones who are most willing to adopt a lifelong learning approach and to admit that they don't know," says Denison, who advocates "problem-setting" -- determining whether there is indeed a problem, before "problem-solving."

He gives the example of athletes reaching a plateau in their training. "This is common in swimming and running," he says. "Many coaches see that as a problem because the logic of sport and coaching is that you continue to progress, but that doesn't always happen. If you see an athlete's plateau as a problem, you've already made the assumption that it needs to be fixed. A coach must first ask whether it is a problem because a plateau can be a good thing: it shows that the athlete has reached a standard level of performance. But you're bringing with you the assumption that the athlete should be improving continuously."

Denison says the assumptions we hold and that influence how we diagnose a problem may not be positive, healthy or ethical. "If you challenge your assumptions, what looks like a problem isn't always a problem."

At the coaching centre Denison and his team have developed a national coach mentorship program in partnership with Athletics Canada to enable this cultural shift from being the unquestioned expert to the thoughtful coach. "To us (at the CACC) you cannot begin to 'problemetize' until you acknowledge and recognize that the knowledge you have is socially constructed based on a lot of take-for-granted ideas and traditions that have become dominant. We invite coaches to think more critically about how they think and what they do, to 'problemetize' their assumptions and to open their minds to look at their coaching practices critically and with the opportunity to try new things without feeling threatened by change."

Wednesday, July 13, 2011

Sports Concussions & Psychology

Here is a brief video on psychologists' role in sports psychology and concussions.  The video features PPA's Drs. Rex Gatto and Don McAleer.

Teen Athletes Should Get Concussion Test Score Before Play

-- Robert Preidt

(HealthDay News) -- Individual concussion baselines need to be created for young athletes at the start of a playing season for them to be accurately diagnosed and treated if they suffer a concussion during the season, researchers report.

The investigators also noted that the sex of the players affects the scores on a standardized concussion assessment tool.

The study included 1,134 high school athletes in the Phoenix area who completed a brief questionnaire regarding their concussion history and were given a score based on the new Sport Concussion Assessment Tool-2 (SCAT2).

There were 872 males and 262 females, average age 15, included in the study. The predominant sports were football for the males and volleyball for the females.

Females scored significantly higher than males on the SCAT2 total score, and athletes with a prior history of concussion scored much lower on the SCAT2 than those with no history of concussion.

The findings were slated for presentation Thursday at the annual meeting of the American Orthopaedic Society for Sports Medicine (AOSSM) in San Diego.

"Our results showed that otherwise healthy adolescent athletes do display some variability in results so establishing each player's own baseline before the season starts and then comparing it to test results following a concussion leads to more accurate diagnosis and treatment," study author Dr. Anikar Chhabra, of the Orthopaedic Clinic Association in Phoenix, said in an AOSSM news release.

"This data provides the first insight into how the SCAT2 scores can be used and interpreted as a sideline concussion tool and as an initial baseline analysis. With concussions accounting for approximately 9% of all high school athletic injuries, accurately utilizing assessments like these to quickly determine an athlete's return-to-play probability is critical to long-term athletic and educational performance," Chhabra said.

Because this study was presented at a medical meeting, the data and conclusions should be viewed as preliminary until published in a peer-reviewed journal.

Tuesday, July 12, 2011

Ethics Opinion Tackles 'Friend' Requests



This article is about the ethics for lawyers.  Simultaneously, it is an interesting read about how professionals are trying to use social networking sites to their advantage.

          *          *          *          * 
by Cynthia Foster
The Recorder

Enterprising lawyers beware: using Facebook as an investigative tool may get you into trouble with the bar, says an ethics opinion from the San Diego County Bar Association.

The opinion concludes that sending a Facebook "friend request" to a represented party violates California Rule of Professional Conduct 2-100 and could be cause for discipline. The opinion's author, Daniel Eaton, said it's the first to confront ex parte communication through social media.

Eaton, an employment defense partner at Seltzer Caplan McMahon Vitek in San Diego, said the bar association's ethics committee considered whether lawyers could approach Facebook the way they approach the wider, public Internet — checking a company's website for information related to a matter, for instance.

"Lawyers are making very wide use of social media, and we wanted to test the proposition that lawyers could use social media to reach out to parties that are represented. Is that a legitimate form of the kind of broad investigation that lawyers engage in using the Internet?" Eaton said.

He didn't think so. But other members of the ethics committee, including its co-chair, San Diego County Deputy District Attorney Wendy Patrick, were dubious.
"When you just hear the proposition it kind of takes you aback, because how could a friend request concern the subject matter of representation? It doesn't appear on its face to violate the rule," she said.

Patrick, who is also vice chair of the State Bar's Committee on Professional Responsibility and Conduct, said she was won over to Eaton's position after reading his research. The rest of the committee was, too. The opinion, which Eaton said was the lengthiest he could remember the committee ever voting on, passed unanimously in May and was approved by the association's board last week.

The opinion is not binding in state court, but according to CRPC Rule 1-100 should be used by attorneys as a behavioral guide. Eaton said the committee was surprised to find that no other associations had directly addressed the link between social media communication and ex parte communication.

According to the opinion, lawyers who try to friend opposing parties as an investigative tool are attempting to deceive them.

"And who needs friends like that?" said Patrick.

Monday, July 11, 2011

"No suicide" contracts

Is a No-Suicide Contract an effective strategy?

By John D. Gavazzi, PsyD, ABPP

When presenting on ethics, a frequent question in Pennsylvania relates to the use of no-suicide contracts with suicidal patients.  No-suicide agreements are also known as “no-harm” agreements, safety agreements, or some other term indicating that the client will not harm him or herself prior to the next appointment.  The question is: Should I use a no-suicide contract with suicidal patients?

During workshops, my response has been, as a stand-alone intervention, I do not recommend this strategy for a number of reasons.

First, there is no research-based evidence that demonstrates the effectiveness of no-suicide contracts.  When a suicidal client signs the contract, there is no guarantee that this will motivate a patient from not acting on a suicidal ideation or impulse.

Second, some workshop participants commented that they use the contract as part of the assessment.  The rationale is that if the patient does not sign the contract, then the person is at a higher risk for attempting suicide.  Again, there is no research to support this assumption.  There may be many reasons for a patient not sign a no-suicide contract; none of which are related to the likelihood of the patient attempting suicide.

Third, the use of the term “contract” implies a legal element to the agreement.  There is nothing legal about the “contract”.  The use of a “no-suicide contract,” as a stand-alone intervention, does not provide a good risk management strategy.  A no-suicide contract does not mean that the psychologist has met the standard of care.

Fourth, depending on how it is used, a no-suicide contract may interfere with the therapeutic alliance.  A patient may interpret that the psychologist is more interested in risk management (avoidance of a lawsuit) than the patient’s own well-being.  This is especially true when the discussion of suicide is a prominent part of the patient’s clinical presentation or a frequent topic of therapy sessions.

No-suicide contracts may have their place within the larger context of therapy or suicide assessment and prevention.  Using some “quality enhancing strategies” may help with the development and use of a no-suicide contract.

First, the psychologist needs to complete an adequate assessment of suicide potential for a patient.  Issues such as depression, hopeless, helplessness, and a lack of connection to others are several important variables.  Thomas Joyner wrote an excellent book on suicide (Myths of Suicide) that may help psychologists with the evaluation process, although reading this book is not a substitute for sufficient training on this topic.

Second, any agreement, especially one relating to suicide prevention, usually works best when a psychologist incorporates patient input into its development.  Comparable to other aspects of psychotherapy, the more the patient collaborates in the process, the greater the likelihood of a positive outcome.  Suicide prevention is like all clinical interventions, which must be understood within the larger context of the unique therapeutic alliance with that person.

Third, the treating psychologist may want to reframe the agreement in less legalistic terms that promotes the potential for a successful treatment outcome.  One such example is a “Commitment to Treatment” form.  In a recent article from The Pennsylvania Psychologist, Norman Weismann captures the essence of this treatment form.  The “Commitment to Treatment” Form:
details the patient’s responsibilities in the treatment process, such as attending all the sessions, setting goals, and voicing thoughts and feelings openly and honestly, including feelings about whether the treatment process is working.  It also contains a statement that the patient agrees to make a commitment to living. In addition, the patient is asked to agree to implement a crisis response plan should suicidal thoughts increase in intensity and frequency.  The crisis response plan is a written list of actions the patient agrees to take when thinking of suicide, written on an index card (Crisis Card) that is kept available 24/7.”
This excerpt highlights the fourth essential point.  Any agreement relating to suicide prevention needs to incorporate a plan to prevent suicidal behavior.

The most important component for psychologists is to have appropriate education, training, and supervision or consultation when dealing with suicidal patients.  A “no suicide contract, ” in and of itself,  in unlikely to meet the needs of the patient or the standard of care.  A comprehensive approach is needed when working with suicidal patients.

I also recommend an excellent article by Stephen J. Edwards & Mark D. Sachmann entitled No-Suicide Contracts, No-Suicide Agreements, and No-Suicide Assurances: A Study of Their Nature, Utilization, Perceived Effectiveness, and Potential to Cause Harm in Crisis: The Journal of Crisis Intervention and Suicide Prevention.

Reference
Weissberg, N. C. (2011). Working with Adult Suicidal Patients. The Pennsylvania Psychologist Quarterly, 71(6), 8-10.

Sunday, July 10, 2011

Managed Care Enters The Exam Room As Insurers Buy Doctor Groups


Now, that touch could get a lot more personal.  United's health services wing is quietly taking control of doctors who treat patients covered by United plans in several areas of the country -- buying medical groups and launching physician management companies, for example.
It's the latest sign that the barrier between companies that provide health coverage and those that actually provide care to patients is crumbling.
Other large insurers, including Humana and WellPoint, have announced deals involving doctors in recent months, part of a strategy to curb rising health costs that could cut into profits and to weather new challenges to their business arising from the federal health law. But United is the biggest insurer by revenue, making the trend much more significant.
Many patients insured by these companies are going to see much tighter management of their care.
"Health care costs are still going to rise," said Wayne DeVeydt, chief financial officer of WellPoint, which entered the business of running clinics in June with the announcement that it would acquire CareMore, a health plan operator based near Los Angeles that owns 26 clinics. "But the only way to stem those costs in the long term is to manage care on the front end."
That means enlisting doctors. Their orders drive most health care spending, including the wasteful share: treating heart patients with expensive stents when cheaper drugs might work, or overusing high-tech imaging devices, for example. By managing doctors directly, insurers believe they can reshape the practice of medicine - and protect their profits.
Read the rest of the story from Kaiser Health News.

Saturday, July 9, 2011

Psychiatric Bed Study in England

Medical News Today

According to a recent study published on bmj.com, in the last 21 years hospitals across England have seen a tremendous increase in the number of patients being detained for mental illness while concurrently there has been a reduction in the number of beds for patients with this disorder. The study was conducted by experienced researchers from the Warwick University, University of London & Queen Mary, and the Newcastle University.

The research has revealed that the reduction in the number of beds for mental illness, which was actually done as part of a policy to maximize the community alternatives for hospital stay, had a direct correlation with the increasing number of involuntary patient admittance to psychiatric centres.

In recent years, with an objective to deinstitutionalise the care of the mentally ill in developed nations, the number of beds for mental illness have been cut back. To achieve this objective, several changes have also been made to the legislation in the UK such as the introduction of the Mental Health Act 1983. Despite efforts such as crisis resolution home treatment, assertive outreach and availability of community
mental health teams, a number of countries have seen an increase in the involuntary patient admittance to psychiatric centres.

The increasing use of compulsory detention is quite displeasing among both, the patients and the healthcare providers. Huge expenses involved with in-patient care also make it a source of concern to service providers and commissioners.

The analysis was performed by scientists based on the data available publically in the NHS Information Centre and the Department of Health. The researchers took a note of the hospital activity statistics on the NHS mental illness bed provision and involuntary patient admittance rates, between 1988 and 2008.

It was found that for these two decades, the involuntary patient admittance rates increased from 40.2 % to 65.6 % per 100,000 adults/ year, while at the same time there was a decrease of 62 % in the number of beds for mental illness per 100,000 adults.

When a time delay of one year was applied, a substantial association between these variables was found, with bed reductions preceding the number of involuntary patient admittance. Ultimately, in the following year, the results showed that there was one extra involuntary patient admission for every two beds closed.

The information about the clinical reasons for admissions were not mentioned in the dataset that was analysed; however the authors of the study have stated that it is unlikely that the increase reflects "
an otherwise unreported dramatic increase in the prevalence of severe mental disorders in England."  

The researchers conclude,

We emphasise that this paper does not suggest that bed closures are intrinsically inappropriate. This strategy may well be a reasonable course of action; but the bed mix needs to be examined more closely and the rate and consequences of bed closures may need to be considered more carefully. Overall, this study provides important evidence for the need to anticipate the effects of bed closures.

More students are hospitalized for mental health problems

Print version: page 12

An increased awareness of mental health issues is leading to more college students being hospitalized for psychological reasons, according to new data from the Association for University and College Counseling Center Directors (AUCCCD).

More than 3,700 students were hospitalized for suicide threats and other mental health issues in 2010, a significant jump from the 2,069 hospitalizations reported in 2006, the first year the survey was conducted. The survey found a rate of 7.93 hospitalizations per 10,000 students last year, up from 5.39 hospitalizations per 10,000 students in 2008, a 47 percent increase.

Anxiety was the most commonly cited complaint bringing students in to counseling centers last year, edging out depression as the top reason for seeing a counselor.

One factor driving the increase is that more universities are establishing “students of concern committees,” which coordinate the treatment of students with mental health and behavioral issues who have come to the attention of professors, campus police and residence hall advisers, says Victor M. Barr, PhD, director of the University of Tennessee at Knoxville counseling center.

Compared with years past, most institutions now have specific written policies to help students get treatment and to monitor their progress, Barr says.

The survey also found that:
  • 75 percent of directors reported needing additional psychiatric services for students.
  • 25 percent of students seen in counseling centers were already taking psychotropic medications.
As a result of increased demand for services, campus counseling centers are getting budget approval from their institutions to hire more psychiatrists and bring on more case managers to track treatment referrals, says Dan Jones, PhD, AUCCCD president and counseling center director at Appalachian State University.

“It used to be that counseling centers would give clients a list of three therapists and leave it in the client’s hands to get treatment when referred out,” Jones says.