Examination of the Effectiveness of the Mental Health Environment of Care Checklist in Reducing Suicide on Inpatient Mental Health Units

Archives of General Psychiatry
Bradley V. Watts, MD, MPH; Yinong Young-Xu, ScD, MA, MS; Peter D. Mills, PhD, MS; Joseph M. DeRosier, PE, CSP; Jan Kemp, RN, PhD; Brian Shiner, MD, MPH; William E. Duncan, MD, PhD
Arch Gen Psychiatry. 2012;69(6):588-592. doi:10.1001/archgenpsychiatry.2011.1514

Abstract

Objective  To evaluate the effect of identification and abatement of hazards on inpatient suicides in the Veterans Health Administration (VHA).

Design, Setting, and Patients  The effect of implementation of a checklist (the Mental Health Environment of Care Checklist) and abatement process designed to remove suicide hazards from inpatient mental health units in all VHA hospitals was examined by measuring change in the rate of suicides before and after the intervention.

Intervention  Implementation of the Mental Health Environment of Care Checklist.

Results  Implementation of the Mental Health Environment of Care Checklist was associated with a reduction in the rate of completed inpatient suicide in VHA hospitals nationally.

Conclusions  Use of the Mental Health Environment of Care Checklist was associated with a substantial reduction in the inpatient suicide rate occurring on VHA mental health units. Use of the checklist in non-VHA hospitals may be warranted.

The entire article is free here.

Thanks to Ken Pope for this information.

An article about psychologists using checklists to reduce treatment  failure is here.

A Chance to Walk the Talk at the Ethics Educators Conference

By Jeff Sternlieb, PhD
The Pennsylvania Psychologist
June 2012

During the 2011 annual PPA Ethics Educators Conference, an exchange occurred that could, met with the right attitude, guide our organization in creating safe learning spaces. Here’s what happened:

The exchange

The chair of the Ethics Committee began by identifying the content of the program for the day and then introduced the “luminaries” present: past presidents of PPA and significant contributors to ethics education. He ended with a specific request to be respectful of each other in our exchange of ideas and then introduced the morning’s presenters.

When the first pair of presenters described their roles, the second made a comment about being a longtime sidekick – Robin to the first one’s Batman. Immediately, someone in the audience remarked, “Oh, I guess that means you’re gay,” chuckling as though it were a joke. A ripple of laughter from the audience quickly subsided as the presenters moved on without any comment about the “joke,” even though it occurred minutes after the Ethics chair requested sensitivity.

My thoughts

Immediately I struggled. I wondered whether anyone would respond to the remark. I believed we were all, through our silence, colluding with the “joke” and placing in an unfair position anyone who was gay or simply cognizant of the impact of such comments on any minority member.

I shared my concern with a colleague next to me, who did not seem to consider it nearly as significant. I was considering what I should do, but doing or saying nothing was not an option. Two choices occurred to me: say something to the entire group, potentially embarrassing the person who made the remark, or say something to him at the break. The former had the potential to interfere with the ethics program; the latter might determine the speaker’s awareness of the remark’s impact and intent to address it in the larger group. I chose the latter.

The conversation

When I asked the quipster whether he was aware of the possible impact of his comment, he indicated that not only was he aware, but that he had already addressed it during a small-group discussion. He said he regretted it the minute it came out of his mouth, and that he worked with a number of gay clients in a setting in which his comment would have been heard differently. It struck me as a justification rather than an understanding of its potentially negative impact in the current context. He said he appreciated that I brought the concern to him but made no offer to discuss it with the larger group. He had not heard the term “microaggression” when I used it. Included in his small discussion group had been the Ethics chair, who approached while we were talking and asked whether I would be willing to share my experience with the larger group. I agreed.

The organic process

After the morning break, one psychologist, new to the Ethics Educators Conference, questioned how the earlier comment had impacted the learning, sharing environment. This opened the opportunity to share these issues in a natural way, and the Ethics chair publicly invited me to share what we discussed during break. This person’s independent concern supported my belief that such comments have an impact. Save for those who speak out, we cannot know how many others have been affected.

I shared my reaction, thought process, and conversation. I then invited the quipster to share his perspective, and he did, explaining that he worked with a largely gay clientele, apologizing to anyone he might have offended, and repeating that he had regretted his remark immediately after making it.

Audience reactions

Some participants thanked the new attendee for her courage in raising this issue, while others commended the quipster for his apology. One asked what the fuss was about, saying she did not recall hearing any offensive remarks. One person rejected the idea that he was collusive, having heard the remark less negatively. Another asked how this had become Jeff Sternlieb’s issue. Others expressed discomfort at censoring comments that might be seen as offensive to any one person, resisting “political correctness.” One participant noted a significant bias toward calling on male participants to the exclusion of women.

Analysis

All comments struck me as introductory and reactive. No one sought clarification. We did not converse. While no time was scheduled to explore these issues, I was surprised at the lack of informal discussion during lunch or break. These issues seemed too hot to handle and we seemed too uncomfortable to talk about them. Though the exchange introduced the opportunity to learn, our inability to talk effectively stopped us from naming our experience and the concepts involved, including:

·         Privilege. Those of us with privilege – especially we who are white, male, heterosexual, and relatively financially secure ­– tend to minimize the perspectives of those who are marginalized. While none of us want an environment in which we cannot talk about race, sexual orientation, or gender because we are afraid of offending others, we seem to do the opposite: fail to take others seriously when insensitivity is identified. Just because clients or friends are gay does not give us the freedom to make jokes about being gay, particularly among those we may not know well. When any group is singled out, it impacts all groups who have been marginalized.

·         Collusion can be active or passive. Active collusion involves direct participation in the offense, and might involve adding to an initial insult or joke, thus amplifying the impact. This “joining in” sanctions the remark, making it easier for others to “pile on” with similar comments and more difficult for anyone to object. Passive collusion consists of saying or doing nothing, thereby lending tacit support to an unacceptable statement. To object may be seen as a personal affront, discomfiting, or unnecessarily confrontational.

·         Microaggressions are comments that may seem innocent, harmless, or even complimentary but contain demeaning implications or hidden messages. They “...are the brief and everyday slights, insults, indignities and denigrating messages” sent to minorities in subtle, unintended discrimination (Sue, 2010). Sue describes three types: micro-assaults, micro-insults, and micro-invalidations. A useful website, http://microaggressions.com, lists many examples of such comments.

·         Political correctness. The primary reason we should not joke about people’s race, gender, or sexual orientation is that these characteristics are personal. In the context of a professional exploration of issues, a reference might not be microaggressive, but a joke about a minority made as an aside is a personal affront, and to not recognize it as such IS to collude.

·         Misapplication of Golden Rule. The Golden Rule, “Do unto others as you would have others do unto you,” does not address individual and group preferences; we cannot assume that because a remark might not offend us that it won’t offend others. An alternate rule, the “Platinum Rule,” can be helpful: “Treat others as they want to be treated,” which would require asking rather than assuming.

The fact that one seemingly simple comment raises so many questions, issues, and reactions suggests we in PPA have a lot more to learn. Having a Committee on Multiculturalism and a host of resources (including a CE program) is not a guarantee of progress. Having this experience in vivo can teach more than any didactic exercise.

The comment one person made could have been made by any of us. The real challenge, in my view, is how we respond.

Reference

Sue, D. W. (2010). Microaggressions in everyday life:  Race, gender and sexual orientation. New York, NY: John Wiley and Sons.

Two South Florida doctors, 3 others convicted on Medicare fraud charges

A Miami federal jury convicted five people of Medicare-related fraud in a case involving the nation’s biggest mental-health racket.

By Jay Weaver
The Miami Herald
Originally published on June 1, 2012

Two South Florida doctors stared in disbelief — then teared up as they turned to relatives for comfort — after a federal jury found them guilty Friday of conspiring to defraud Medicare through the nation’s biggest mental-health racket.

The 12-person Miami jury convicted psychiatrists Mark Willner of Weston and Alberto Ayala of Coral Gables, the medical directors for American Therapeutic Corp., for their roles in a $205 million scheme to fleece the taxpayer-funded program for the elderly and disabled. The jurors found them not guilty on other healthcare fraud offenses.

In addition, the jury convicted Vanja Abreu, Ph.D, program director for American Therapeutic in Miami-Dade, of the same healthcare-fraud conspiracy offense, and two other defendants, Hilario Morris and Curtis Gates, of paying kickbacks to residential home operators in exchange for providing patients.

The entire story is here.

Thanks to Steve Ragusea for this story.

Judge sends suspended Doc back to work

By Andy Fox
WAVY.com
Originally published on June 7, 2012

A local psychologist who is often called on by local courts to give advice on child custody decisions is back in business.

WAVY.com first told you earlier this week the Virginia Psychology Board indefinitely suspended Dr. Brian Wald for inappropriate relations with a client.

But a trip to court changed that. The Judge basically overruled the Psychology Board, allowing Dr. Wald to go back to work until the matter is settled in court in September. The Judge set several conditions: Wald must take an ethics course, he must continue his own therapy, he must have supervision during clinical cases and he is prohibited from participating in parental custody cases in Norfolk.

Here is a video of the local newscast.

The entire article is here. A prior blog entry can be found here.

Our moral motivations

Humans have evolved from being driven by self-interest to being team players who want their lives to count for something, argues University of Virginia psychologist Jonathan Haidt.

By Kirsten Weir
The Monitor on Psychology
June 2012, Vol 43, No. 6
Print version: page 24

In the midst of a superheated election, in which truth is hard to come by and personal attacks are commonplace, it's hard to imagine politics having much to do with morality. However, in his new book, "The Righteous Mind," positive psychology pioneer Jonathan Haidt, PhD, argues that even our divisive political system arose from a deep-seated human need to work toward a greater good.

In his search for the roots of morality, he explores our species' evolution from our individualistic primate ancestors to deeply cooperative human beings, and describes how religious and political institutions helped enable that transformation.

The Monitor spoke with Haidt about his research and how we might bring politics — and psychology — back to their moral roots.

The entire article is here.

Senator questions $2m NIH grant to disgraced psychiatric researcher

By Bob Roehr
British Medical Journal
Originally published June 1, 2012

Dr. Nemeroff

The US senator Charles Grassley has called on the National Institutes of Health to justify its decision to award a five year $2,000,000 grant to the prominent but disgraced psychiatric researcher Charles Nemeroff, "despite past ethical problems."

"It is troubling that NIH continues to provide limited federal dollars to individuals who have previously had grant funding suspended for failure to disclose conflicts of interest," Grassley wrote in a 29 May letter to the director of the NIH, Francis Collins.

He asked Collins to provide full documentation of communications concerning Nemeroff and the grant within two weeks.

The information is here.

Thanks to Ken Pope for this information.

There are other blog entries here and here about Dr. Nemeroff.

Alzheimer's research fraud case set for trial

By Toni Clarke
Reuters Health News
Last updated May 11, 2012

Two Harvard teaching hospitals and a prominent Alzheimer's disease researcher accused of using falsified data to obtain a government research grant are set to stand trial after a federal appeals court said this week that a lower court erred when it dismissed the case.

The lawsuit accuses Marilyn Albert, a former professor of psychiatry at Harvard Medical School, and Massachusetts General Hospital (MGH), where she was conducting research, of submitting a grant application based on manipulated data.

The data showed results from a trial were scientifically significant when in fact they were not, according to the lawsuit.

Brigham and Women's Hospital, which collaborated on the research, is also a defendant in the case. The lawsuit was brought in 2006 under the False Claims Act, a 150-year-old federal law designed to recover government funds appropriated through fraud.

This is the first time a lawsuit dealing with alleged scientific fraud has been allowed to progress to trial under the False Claims Act, according to Michael Kohn, a lawyer with Kohn, Kohn & Colapinto in Washington, D.C.

The entire story is here.

Clinical Considerations When Working With Lesbian Clients

By Jeanne L. Stanley, PhD
The Pennsylvania Psychologist
June 2012

One challenge of working with lesbian clients lies in never assuming all concerns relate to sexual identity issues, while also acknowledging the potential impact of sexual identity. Also important is understanding the intersection of our clients’ sexual orientation with other socio-cultural identities, including age, citizenship status, ability, ethnicity, gender, race, religion, and socioeconomic status. A client’s socio-cultural identities are at times independent, interdependent, and multiplicative, and are best understood individual by individual (Stanley, 2004).

A difference exists between a lesbian’s self-identification and behavior. For example a female client married to a man may not be heterosexual. A recent study found that 67% of “exclusively straight” women had questioned or were questioning their sexual orientation (Morgan & Thompson, 2011). Conversely, a client who identifies as lesbian may never have had a same-sex experience. Fifty percent of self-identified lesbian adolescents had not had same-sex contacts (Savin-Williams, 2005). It is therefore better to ask a client, “With what gender or genders are you sexually active, if you are so?” as well as how they identify themselves, rather than to focus solely on labels. For some women, sexual behavior or attraction is not the basis for their identification as lesbian. In this context, Klein, Sepekoff and Wolf (1990) were instrumental in helping psychologists broaden their understanding of sexual identity to include other factors, such as attraction, emotional connection, and community affiliation.

Coming out to oneself about one’s sexual identity can happen at any age. Sexual orientation may be static over a lifetime or more fluid (Diamond, 2008). I recently met with a 71-year-old client who described experiencing sexual attraction toward women for the first time. Assuming that sexual identity is static may lead mental health professionals to miss subtle comments by clients who may be reaching out for support regarding their orientation.

As they consider coming out for the first time, clients benefit from thorough exploration of the “why” and “how” of their communication. It is useful for clients to choose carefully whom to tell first, in order to identify those with whom they are likely to have a positive experience. Reviewing how particular people have handled potentially disconcerting information in the past may prepare the client.

Coming out is an ongoing, lifelong process. While clients may focus on the major coming-out events, such as telling parents, spouses, friends, and work colleagues about their sexual identity, the decision of whether to come out and the possible consequences may arise daily.  Checking into a hotel as a same-sex couple and assuring the clerk that indeed you would like one queen-sized bed rather than two double beds, or receiving an invitation for one to a cousin’s wedding, even though you have been with your spouse for fifteen years, can take a toll on even the most “out” and empowered individuals. A high school reunion full of questions about relationship status may lead an otherwise “out” lesbian to retreat back into the closet for the night. It is especially important for mental health professionals to be able to normalize for clients the process of “recycling” through the coming-out process based upon life circumstances and to give them a place to discuss their present contexts without pathologizing their needs and decisions. 

Facing subtle and more overt forms of discrimination leads lesbian, gay, bisexual, and transgender (LGBT) individuals to seek mental health support services on a higher average than their heterosexual counterparts (Israel, Grocheva, Burnes, & Walther, 2008). Lesbian clients are not more emotionally “flawed” than their heterosexual counterparts; rather the chronic, overt discrimination and prejudice they experience can lead to higher rates of depression, anxiety, and substance abuse. The importance of screening for depression, anxiety, addictions, self-harming behaviors, and suicidality is therefore essential in our initial and continued work with lesbian clients. 

Support from family of origin and/or family of choice (i.e., friends and mentors) plays a crucial role for many lesbians. Therefore, it may be useful to connect lesbian clients to affinity groups related to their interests and their work, whether through local or national venues. LGBT psychologists may find support and recognition through membership in APA’s Division 44. Clients in non-urban areas may benefit from online support groups and other social networking sites. Support for lesbians is often found in their friendships, which may differ in important ways from heterosexual friendships. It is not uncommon for lesbians to work to maintain friendships with their ex-partners (Weinstock & Rothblum, 2004; Stanley, 1996).

Psychologists who see lesbian couples need to consider some of the unique aspects of working with them. If one member of the couple is out to family and friends but the other partner is not because of fear of losing her job or being rejected by her parents or siblings, the disparity may strongly impact their relationship. Domestic violence in lesbian couples may also manifest in unique ways: An angry member of the relationship might threaten to “out” the closeted partner, thereby using the knowledge of her sexual identity to exert control. Working with lesbians who are married to men may involve conflicted feelings about coming out to their husbands and/or children. Their own mixed feelings such as excitement, shame, joy, and fear may interact with the reactions of friends, parents, and neighbors. Support groups are often useful for married or recently divorced lesbians to gain affirmation in their lives.

Unique issues for lesbians considering children range from legal issues (some states do not allow same-sex couple adoptions), to refusals by hospitals to recognize the non-pregnant female partner, to deciding which partner will be the biological mother. Today’s psychologist needs to have at least a basic understanding of fertility, adoption, and donor options for lesbian clients. Lesbian parents may also experience homophobia from teachers, school districts, Boy Scout troops, and others. Psychologists must be aware of local, state, and national laws regarding the protection of LGBT clients in order to best meet their needs. For up-to-date resources for such information in Pennsylvania, see http://www.hrc.org/laws-and-legislation/state/c/pennsylvania.

Lesbian psychologists are also affected by the interconnected nature of the lesbian community (Kessler & Waehler 2005; Brown, 1988).  It is not unusual for lesbians to recommend their own mental health provider to friends and colleagues or for a lesbian psychologist to become well known in the community. Given the limited number of lesbian gatherings, a lesbian psychologist may run into clients socially. Consequently, early in therapy a discussion of professional boundaries may be particularly useful.

Finally, all psychologists benefit from ongoing self-introspection and awareness in regard to their own internalized homophobia. None of us, regardless of orientation, are immune from it. Riddle’s (1990) scale, which ranges from repulsion to nurturance, is a useful measure to assess one’s level of personal comfort regarding sexual orientation. We are ethically bound to recognize our limitations and to refer lesbian clients or consult if our biases or ignorance of a culture may be barriers to treatment. PPA’s Multicultural Resource Guide as well as other online resources may assist you in finding LGBT-affirmative therapists in your area for your client and continuing education trainings for yourself. Since we never know whether we may be working with lesbian clients, we must ensure we are providing a supportive and affirming environment for clients of all sexual orientations. 

References are available from the author at jstanley@gradschoolcoaching.com or on the PPA website, www.PaPsy.org.

Massachusetts Debates ‘Death With Dignity’

By Paula Span
The New Old Age Blog: Caring and Coping
The New York Times
Originally published May 29, 2012

Consider this an update. Last fall, when I talked with some of the 350 volunteers circulating petitions, they sounded confident about collecting 70,000 certified signatures by the end of the year. They more than succeeded, which meant the state legislature had until May 1 to act. It didn’t — to no one’s surprise — so volunteers for the organization backing the referendum, Dignity 2012, have headed back out with their clipboards.

If they can gather another 11,000 signatures by July 2, the public will decide whether the state’s physicians can lawfully prescribe medications with which terminally ill patients can end their lives. (You can read the exact language here.)

Oregon enacted essentially the same law allowing self-administration of lethal drugs in 1997, and Washington in 2009. Though their adversaries often used “slippery slope” arguments, the number of residents who have taken advantage of the laws remains quite small. After meeting all the requirements and undergoing the mandated waiting periods, 114 people received lethal prescriptions last year in Oregon and 103 in Washington. In both states, about a third of those who qualified ultimately decided not to use the drugs.
But the controversy was intense in those states, with contentious public debate and expensive media campaigns, and it will be this round, too. In both camps, fund-raising has already begun.

“It has potent national implications,” the Rev. J. Brian Hehir, secretary for health care and social services at the Roman Catholic Archdiocese of Boston, said of the referendum. “We are talking about fundamental human values, deeply personal choices.”

The entire blog entry is here.