A Girl Not Named Sybil

By Debbie Nathan
The New York Times
Published October 14, 2011

Undated photo of
Shirley Mason

“What about Mama?” the psychiatrist asks her patient. “What’s Mama been doing to you, dear? . . . I know she gave you the enemas. And I know she filled your bladder up with cold water, and I know she used the flashlight on you, and I know she stuck the washcloth in your mouth, cotton in your nose so you couldn’t breathe. . . . What else did she do to you? It’s all right to talk about it now. . . . ”

“My mommy,” the patient says.

“Yes.”

“My mommy said that I was a bad little girl, and . . . she slapped me . . . with her knuckles. . . .”

“Mommy isn’t going to ever hurt you again,” the psychiatrist says at the close of the session. “Do you want to know something, Sweetie? I’m stronger than Mother.”

The transcript of this conversation is stored at John Jay College of Criminal Justice, in New York City, among the papers of Flora Schreiber, author of “Sybil,” the blockbuster book about a woman with 16 personalities. “Sybil” was published in 1973; within four years it had sold more than six million copies in the United States and hundreds of thousands abroad. A television adaptation broadcast in 1976 was seen by a fifth of all Americans. But Sybil’s story was not just gripping reading; it was instrumental in creating a new psychiatric diagnosis: multiple-personality disorder, or M.P.D., known today as dissociative-identity disorder.

Schreiber collaborated on the book with Dr. Cornelia Wilbur, the psychiatrist who asks, “What about Mama?” — and with Wilbur’s patient, whose name Schreiber changed to Sybil Dorsett. Schreiber worked from records of Sybil’s therapy, including thousands of pages of patient diaries and transcripts of tape-recorded therapy sessions. Before she died in the late 1980s, Schreiber stipulated that the material be archived at a library. For a decade after Schreiber’s death, Sybil’s identity remained unknown. To protect her privacy, librarians sealed her records. In 1998, two researchers discovered that her real name was Shirley Mason. In trying to track her down, they learned that she was dead, and the librarians at John Jay decided to unseal the Schreiber papers.

(cut)

One May afternoon in 1958, Mason walked into Wilbur’s office carrying a typed letter that ran to four pages. It began with Mason admitting that she was “none of the things I have pretended to be.

“I am not going to tell you there isn’t anything wrong,” the letter continued. “But it is not what I have led you to believe. . . . I do not have any multiple personalities. . . . I do not even have a ‘double.’ . . . I am all of them. I have been essentially lying.”

Before coming to New York, she wrote, she never pretended to have multiple personalities. As for her tales about “fugue” trips to Philadelphia, they were lies, too. Mason knew she had a problem. She “very, very, very much” wanted Wilbur’s help. To identify her real trouble and deal with it honestly, Mason wrote, she and Wilbur needed to stop demonizing her mother. It was true that she had been anxious and overly protective. But the “extreme things” — the rapes with the flashlights and bottles — were as fictional as the soap operas that she and her mother listened to on the radio. Her descriptions of gothic tortures “just sort of rolled out from somewhere, and once I had started and found you were interested, I continued. . . . Under pentothal,” Mason added, “I am much more original.”

Mason was the most important patient in Wilbur’s professional career. She was preserving the tape-recorded narcosynthesis interviews she was doing with Mason and preparing to speak about the case at professional meetings. Wilbur told her patient that the recantation was “a major defensive maneuver,” merely the ego’s attempt to trick itself into thinking it didn’t need therapy. But Mason did need it, badly, Wilbur insisted. She was denying that she’d been tortured by her mother; this showed she really had been tortured.

Mason went home and composed a new letter. “One Friday,” she wrote Wilbur, “ ‘someone’ stalked into your office, imitated me [and] had a paper written about how she had now become well and was confessing . . . that it had all been put on. Well, you knew better.”

Wilbur instructed her secretary to schedule five sessions a week with Mason. She started the pentothal again.

Mason developed more and more personalities, ending up with a total of 16. Her “memories” of Mattie’s torture — of being sexually assaulted by her mother with kitchen implements; of seeing Mattie Mason conducting orgies in the woods with teenage girls; of being buried alive in a grain silo in her father’s workshop — were flowing.

Mason’s roommate, horrified by the treatment Mason was receiving, urged Mason to terminate her sessions with Wilbur. Instead, Mason left the apartment they shared on the West Side and found a tiny place on East 78th Street where she could live alone, just a few blocks from Wilbur’s home and office on Park Avenue. Wilbur paid the deposit on the new apartment and showered Mason with gifts: old rugs and drapes from her office, a fur-trimmed winter coat — even a cat.

The entire article can be found here.

Psychologist gets jail time for sex with patient

By Bruce Vielmetti
The Journal Sentinel

An Oak Creek psychologist convicted of starting a sexual relationship with a longtime patient in 2005 was sentenced Thursday to a year in jail.

Dr. Adamczak

Jeffrey Adamczak, 48, faced up to 7 1/2 years for sexual exploitation by a therapist.

But Milwaukee County Assistant District Attorney Jacob Manian said the state wasn't seeking prison, just accountability.

"This case has always been about protecting patients," Manian told Circuit Judge Rebecca Dallet.

Adamczak made a public apology to his wife for the affair and the public spectacle. He said it never should have happened and he'd never forgive himself.

"I'm truly paying the price for infidelity," he said.

Dallet corrected Adamczak, saying she wasn't sentencing him for having an affair, but for abusing the trust patients put in their psychotherapists.

"You took advantage of that relationship, used it and turned it around into a sexual relationship," she said. "That's the serious part."

The whole story can be found here.

Stories related to Dr. Adamczak can be found here.

Pediatric Emergency Department Visits for Psychiatric Care on the Rise

American Academy of Pediatrics
News Release
Published: October 14, 2011

BOSTON – Pediatric patients, primarily those who are underinsured (either without insurance or receiving Medicaid), are increasingly receiving psychiatric care in hospital emergency departments (EDs), according to an abstract presented Friday, Oct. 14, at the American Academy of Pediatrics (AAP) National Conference and Exhibition in Boston.

Researchers reviewed ED data, including patient age, sex, race, ethnicity, insurance status, and type of care received, from the National Hospital Ambulatory Medical Care Survey, between 1999 through 2007. The study, “Disproportionately Increasing Psychiatric Visits to the Pediatric Emergency Department Among the Underinsured,” found that over eight years, 279 million pediatric patients were seen in U.S. EDs, of which 2.8 percent were for psychiatric visits. The prevalence of psychiatric visits among pediatric patients increased from 2.4 percent in 1999 to 3 percent in 2007. The underinsured group initially accounted for 46 percent of pediatric ED visits in 1999, growing to 54 percent in 2007.

The results of this study are important for several reasons. First, the data show that, as anticipated, psychiatric visits by children to emergency departments continue to increase in number and as a percentage of all patients being seen in emergency departments, said lead study author Zachary Pittsenbarger, MD. “A second, and more novel finding, is that one group in particular is increasing beyond any other socio-demographic group, and that is the publicly insured.” he said.

“It has been found previously that the publicly insured have fewer treatment options and longer wait times for psychiatric disorders when not hospitalized,” Dr. Pittsenbarger said. “This new finding argues that limited outpatient mental health resources force those patients to seek the care they need in the emergency department.”

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The American Academy of Pediatrics is an organization of 60,000 primary care pediatricians, pediatric medical subspecialists and pediatric surgical specialists dedicated to the health, safety and well being of infants, children, adolescents and young adults. For more information, visit www.aap.org.

Canadian Psychological Association Supports National Action on Suicide

The Canadian Psychological Association (CPA) supports a call for national action on suicide. Suicide is the seconding leading cause of death among youth and reaches its highest rates in middle and even later life. The personal and societal costs of suicide are inestimable.

Suicide is a behaviour that is most often associated with a mental disorder like depression. As is the case for many mental health problems and disorders, there is no single cause that predicts it or a single intervention that prevents it. Suicide results from many and complex biological, psychological and social factors and successful national action on suicide will need to comprise them all.

In the view of the CPA, there are two very significant factors that stand in the way of persons with mental disorders and suicidal thoughts and behavior getting the help they need. The first is the stigma attached to talking about suicide and mental disorders. 

Being listened to and supported when talking about it will help ensure that a person in distress seeks out the professional help he or she needs. The second is the inaccessibility of mental health services and supports in Canada. Even those who ask for help may not receive it - often because it is not funded, or is underfunded, by public and private health insurance plans.

Psychologists are the country’s largest, regulated group of specialized mental health service providers. Psychological services are not funded by public health insurance plans and are underfunded by private health insurance plans. With cuts to the salaried mental health care resources of hospitals and schools, the needs of those with mental health problems are just not being met.

The entire news release can be found here.

Ethics, Diversity, and Multiculturalism

Samuel Knapp, Ed.D., ABPP

Director of Professional Affairs

Recent years have seen an emphasis on multiculturalism and diversity issues within psychology* both by addressing the ability of professional psychologists to serve the health care needs of cultural minorities, and by increasing the number of psychologists from ethnically diverse backgrounds. The two strategies may be synergistic. For example, graduate programs with a critical mass of diverse students may find that the minority students will teach (even if informally) the European American students to become more culturally competent.

This movement has a foundation in the underlying ethical foundations of our profession. Sometimes psychologists use the word ethics to refer to the minimal standards of conduct that apply to all psychologists and that could be the basis of a disciplinary action by a licensing board or malpractice suit. The enforceable Standards of the APA Ethics Code specifically state that psychologists should not discriminate unfairly (Standard 3.01, Unfair Discrimination) nor harass (Standard 3.03, Harassment) based on age, gender, gender identity, sexual orientation, race, culture, national origin, language, religion, disability, or socioeconomic status. In addition, psychologists should ensure that they are competent when working with diverse populations (Standard 2.01b, Competence); ensure that they use tests Awhose validity and reliability have been established for use with members of the population tested@ (9.02b, Assessments); interpret tests with consideration of linguistic and cultural differences (Standard 9.06); and ensure that consent is obtained when using interpreters (9.03c).

Ethics also refers to the General or Aspirational Principles that follow the Preamble in the APA Ethics Code. Unlike the enforceable Standards, which can be the basis for a disciplinary complaint against a psychologist, the General Principles are guides for psychologists on how to excel in their professional roles. They can also inform the ethical decision making process. The General Principles state, among other things, that psychologists Aare aware of and respect cultural, individual, and role differences, including those based on age, gender, gender identity, race, ethnicity, culture, national origins, religion, sexual orientation, language, and socioeconomic status.@ (Principle E, Respect for People=s Rights and Dignity).

Finally, ethics refers to personal overarching moral perspectives derived from philosophical or religious instruction or study which inform our day-to-day behavior. The enforceable Standards, General (Aspirational) Principles, and personal sense of morality can overlap considerably. For example, a psychologist who has a personal moral perspective, perhaps based on religious instruction, who believes in the universality of human rights and dignity, would easily see that reflected in General Principle E, and operationalized in the directive to avoid unfair discrimination or harassment of individuals based on incidental demographic factors.

Few psychologists end up being disciplined specifically for violating enforceable ethical standards related to diversity or multiculturalism. In that sense, diversity and multiculturalism have only a small overlap with ethics. However, many psychologists struggle over how to implement the General (Aspirational) principles and their personal sense of morality when providing professional services to diverse populations. In that sense, diversity and multiculturalism are deeply intertwined with ethics.

The emphasis on a diverse or multicultural perspective appears to rest primarily on two overarching ethical principles. First, diversity or multiculturalism is justified on the basis of justice, in that it helps ensure a more equal access to quality psychological services to persons from traditionally marginalized groups who otherwise would not find them available.

Also, diversity and multiculturalism are justified on the basis of beneficence and nonmaleficence in that psychologists with a diverse or multicultural perspective will do better at treating patients and will reduce the likelihood that they will harm patients. Although many authors have argued that a diverse or multicultural perspective will improve outcomes, this relationship was verified by the meta-analysis of Griner and Smith (2006) who found that interventions targeted to specific cultural groups were more effective than generic interventions provided to heterogeneous groups. AOverall, culturally adapted interventions resulted in significant client improvement across a variety of conditions and outcome measures@ (p. 541). In other words, psychologists should be able to upgrade the quality of their services to multicultural patients by accommodating multicultural perspectives into their treatment.

Striving for excellence requires more than just good intentions; it requires a conscientious effort at self-reflection and training. For example, consider the experience of one psychologist supervisor who was trying very conscientiously to develop a supervisory relationship based on her deeply held moral values of trust and empowerment. This supervisor was very committed to feminist ideas of equality and power sharing. She told her internship students that they should feel free to challenge her during supervision. For some students this was very empowering and helped them to become more comfortable in sharing their thoughts openly. For another student, the comment created anxiety because it is normative in her Asian culture to show great respect for hierarchy and not to challenge authority directly. Fortunately, the student was able to receive advice on how to approach her supervisor about this issue.

Here is another example from my personal experience. About 30 years ago I temporarily worked in an urban mental health clinic after working in very rural mental health centers for several years where I commonly introduced myself to my adult patients by my first name and used their first names as well. However, when I took a job in an urban inner city mental health clinic, in my effort to be egalitarian, I continued to introduce myself to my adult patients, who were mostly African American, by my first name and used their first names as well. However, an African American social worker explained to me that African American males are used to being called by their first names by all Whites, regardless of their age or status. It would be more respectful, she explained, if I called them by their surname and later asked permission to use their first name. Therefore, I became aware of a personal blind spot. I learned that my greeting style, which appeared appropriate and egalitarian in rural Pennsylvania, came across quite differently with inner city African American patients.

Or consider this last example: A psychologist sometimes worked with Spanish-surnamed patients and was always careful to ensure that they were comfortable using English (or getting an interpreter if they were not). One patient with a Spanish surname reported that she felt comfortable conducting psychotherapy in English. She related a background of substantial trauma and strife, but did so in a detached manner. However, research shows that the affect associated with a traumatic event can be captured more intensely through the use of the patient's primary language at the time that the trauma occurred. Relating the trauma in a language that was learned subsequently does not evoke the intensity of feeling or vividness of imagery as it would if the patient had used the original language. A psychologist who was not aware of this fact might miss the emotional significance of certain past events.

These are just a sample of the issues that can arise and where a knowledge of cultural or diversity factors can improve relationships and outcomes. Many questions arise, such as how can psychologists evaluate the functioning in a diverse family without unfairly pathologizing culturally normative relationships (e.g., averting eyes in some cultures is not a sign of shyness, but a normative sign of respect)? What teaching technique can help psychologists become more alert to their blind spots (e.g., well meaning people may have implicit prejudices outside of their conscious awareness; Knapp, 2007)? How should psychologists respond when patients make racist, homophobic, or sexist remarks? How, or can, English speakers supervise trainees who treat patients where English is not a primary language? How does diversity inform effective practice? When or how to incorporate folk healing remedies or strategies into therapy? How to accurately evaluate refugees in light of stressful or traumatic experiences that they may have encountered? How to respond when patients’ religious beliefs appear to harm their functioning or adjustment? Continued reflection, dialogue, and training will help conscientious psychologists address these issues, and help them to fulfill their aspirations to be just and helpful health care professionals.

References

Griner, D., & Smith, T. (2006). Culturally adapted mental health interventions: A meta-analytic review. Psychotherapy: Theory, Research, Practice, 43, 531-548.

Knapp, S. (2007, January). Implicit prejudice: The bad news and the good news. Pennsylvania Psychologist, 6-7.

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*The words diversity and multiculturalism are sometimes used synonymously. However, many use the term multiculturalism to refer to ethnic or racial groups, whereas diversity is a broader term that includes multiculturalism and other aspects of identity such as religion, gender, sexual orientation, disability, or socioeconomic status.

How Should Psychologists Respond to Hateful Comments?

Samuel Knapp, Ed.D., ABPP

Director of Professional Affairs

Conventional words for ethnic groups vary over time, and what is acceptable for a group in one period of time would be viewed as offensive in another time or context. However, at times patients will use words or comments directed at others because of their race, gender, or sexual orientation that clearly offend standards of decency. How should psychologists respond in such situations? Should they ignore the comment or directly confront the patient about the terms that were used?

Discretion is needed to determine when a word is intended as offensive or not. For example, Hawaiians refer to European American residents of Hawaii as haole (pronounced “howlee”). At times it is delivered as a factual statement, “He is a haole” (a white person who lives in Hawaii), and European American residents of Hawaii commonly refer to themselves as haole. However, it could be used as an insult if it were combined with certain adjectives, voice intonations, or hand gestures (Rare storm, 2011).

The conduct of psychologists in addressing hurtful speech, as in other aspects of professional behavior, should be guided by adherence to overarching ethical standards. So, when a patient makes an ethnic slur, the response of the psychologist should be guided by the principles of beneficence (acting to promote the well-being of the patient), nonmaleficence (acting to avoid harming the patient), general beneficence (acting to promote the welfare of the public in general), or other ethical principles.

The context of the comment may be relevant. It is important to know if the comment is related to the patient’s presenting problem, or activated as a function of the perceived characteristics of the therapist (Bartoli & Pyati, 2009). However, I am aware of a few situations where patients have made such intense hate-filled and vitriolic comments (addressed towards groups represented by the psychologist) that a decision was made to refer the patient elsewhere.

In some situations the principle of beneficence (welfare of the patient) may be operative. For example, a young person may use an ethnic term in a manner that an adult considers offensive. Here it is most likely appropriate for correction or feedback because the person might not understand the implications or ways in which the words come across. An educational or non-judgmental exchange could help the young person understand the implications of this speech and how it might impair their social relationships in the future.

The overarching ethical principle of general beneficence holds that psychologists should act to protect the public in general. Consequently, it would seem that, according to this principle, psychologists should address hate-filled comments. However, this ethical principle should be balanced with concerns about beneficence or the welfare of the patient. One patient of mine made a derogatory comment about an ethnic group which I corrected, with as much tact as I could manage. The patient was embarrassed, apologized, and corrected himself. However, if the comment were made in the context of a psychotic episode, disclosure of suicidal intent, or other indication of serious emotional crisis, I probably would have ignored the comment altogether and focused entirely on the patient’s well-being. If the patient had made the comment in response to a particularly upsetting or stressful event, I might have deferred addressing the issue to a time when the patient could get more perspective on the situation.

It is often best to avoid assuming that there will always be a false dichotomy between general beneficence and beneficence. Except in extreme circumstances when patient welfare is at stake or when the hateful comments represent extreme social deviance, psychologists can often find a way to address the issue without harming the therapeutic relationship. Anger and judgmental attitudes should be avoided. Patients are more likely to respond positively to comments made in a calm and direct manner (e.g., “let’s use another word, it makes you come across as prejudiced”).

References

Bartoli, E., & Pyati, A. (2009). Addressing clients’ racism and racial prejudice in individual psychotherapy: Therapeutic considerations. Psychotherapy: Theory, Research, Practice, Training, 46, 145-157.

Rare storm over races ruffles a mixed society. (2011). New York Times. Retrieved from here. 

Adults With Mental Health Issues More Likely to Be Uninsured

Uninsurance Among Nonelderly Adults With and Without Frequent Mental and Physical Distress in the United States

Psychiatr Serv 62:1131-1137, October 2011
doi: 10.1176/appi.ps.62.10.1131

Tara W. Strine, Ph.D., M.P.H., Matthew Zack, M.D., M.P.H., Satvinder Dhingra, M.P.H., Benjamin Druss, M.D., M.P.H. and Eduardo Simoes, M.D., M.P.H.

OBJECTIVES: This research describes uninsurance rates over time among nonelderly adults in the United States with or without frequent physical and mental distress and provides estimates of uninsurance by frequent mental distress status and sociodemographic characteristics nationally and by state.

METHODS: Data from the 1993 through 2009 Behavioral Risk Factor Surveillance System, a telephone survey that uses random-digit dialing, were used to examine the prevalence of uninsurance among nearly 3 million respondents by self-report of frequent physical and frequent mental distress and sociodemographic characteristics, response year, and state of residence.

RESULTS: After adjustment for sociodemographic characteristics, uninsurance among adults aged 18 to 64 years was markedly higher among those with frequent mental distress only (22.6%) and those with both frequent mental and frequent physical distress (21.8%) than among those with frequent physical distress only (17.7%). The prevalence of uninsurance did not differ markedly between those with only frequent mental distress and those with both frequent mental distress and frequent physical distress. The prevalence of uninsurance among those with frequent mental distress only and those with neither frequent mental distress nor frequent physical distress increased significantly over time.

CONCLUSIONS: Uninsurance rates among nonelderly adults with frequent mental distress were disproportionately high. The results of this analysis can be used as baseline data to assess whether implementation of the Affordable Care Act is accompanied by changes in health care access, utilization, and self-reported measures of health, particularly among those with mental illness. (Psychiatric Services 62:1131–1137, 2011)

Link to full article is here.

VA reports records breach

By Howard Altman

The Tampa Tribune

The Department of Veterans Affairs is investigating the "inappropriate removal" from the James A. Haley Veterans' Hospital of records that contain personal information about hundreds of veterans who had received treatment there.

"This is an active, open investigation," said Haley spokeswoman Carolyn Clark, who would not say where the records were taken from, who took them, or why.

Someone used the information taken from Haley to open at least one debit card account in the name of one of the hospital's patients, according to Tampa police records.

The security breach was reported to the hospital by the VA's Office of Inspector General, said Clark, who would not say when the records were discovered missing. The VA's Office of Inspector General declined comment, referring questions to the Tampa Police Department.

Veterans whose information was compromised say they are livid.

"This is unacceptable," said Navy veteran John Toborg, who found out about the security breach at Haley last week when he received a letter from the hospital stating his records, which contained his name and Social Security number, were "inappropriately removed" from the hospital.

The entire story can be found here.

Using Vignettes: A Canadian Perspective

Canadian Psychology recently published an article about using vignettes as a teaching tool.  This article is helpful for those use ethics vignettes.  Below, there is the first and last page of the article to provide some sense of what the article covers.

Can Psych Vignettes