• •

PSYCHOTHERAPY

--- Features In This Issue ---

The Role of Psychology and Psychotherapy in the Treatment of the Seriously Mentally III Client in the Community Mental Health Center

A Developmental Approach to Psychotherapy Supervision of Interns and Postdoctoral Fellows

Health Care Reform: An Update

The 1994 Mid-Winter Convention Highlights

Individual Psychotherapy in Chronic Disease I

Documentation Guidelines and Ethical Practice in Psychotherapy

VOL. 28. NO.4

APA and Psychologists' Future in Managed Care

Croatian Needs Assessment Project

OFFICIAL PUBUCAT10N OF DIVISION 29 OF THE AMERICAN PSYCHOLOGICAL ASSOCIATION

Winter 1993

Division of Psychotherapy of the American Psychological Association 1994 Officers and Committees

OFFICERS

President

Tommy T .. Stigall, Ph.D. The Psychology Group 701 S. Acadian Thruway Baton Rouge, LA 70806 Office: 504-387-3325 FAX: 5Q4..387-0140

Past President

Gerald P. Koocher, Ph.D. Dept. of Psychiatry Children's Hospital

300 Longwood Ave .. Boston, MA 02115-5737 Office: 617-735-6699 FAX: 617-730-0457

President-Elect

Stanley R. Graham, Ph.D. io W. 10th St.

New York, NY 10011 Office: 212-989;2391 FAX: 212-979-2415

Treasurer

Alice Rubenstein, Ed.D.,1992-1994 Monroe Psychotherapy Center 59-E Monroe Ave.

Pittsford, NY}ot534

Office: 716-586-0410

FAX: 716-586-2029

secretary

Diane J. Willis, Ph.D.,1994-1996 Child Study Center

1100 NE 13th 5t

Oklahoma City, OK 73117 Office: 405-271-5700

FAX: 405-271-8835

MEl\{8ERS~AT~LARGE Norman Abeles, Ph.D.,1994-1996 Department of Psychology

129 Psychology Research Bldg. Michigan Stal.e University East Lansing, MI 48824-1020 Office: 517-355-9564

FAX: 517-353-5437

Ernst Beier, Ph.D., 1994-1996 44 West Third South

Apt. #6(J7 South

Salt Lake City, UT 84101 Office: 801-581;7525 FAX: 801-581-5841

Moms Goodrnan, Ph.D., 1992-1994 96 Millburn AVe., Ste. 204 Millburn, NJ 07041

Office: 201-763-3350

Norine G. Johnson, Ph.D.,1993-1995 110 W. Squantum, #17

Quincy, MA 02171

Office': 617-471-2268

FAX: 617-323-2109

John Norcross, Ph.D.,1994-1996 Dept. of Psychology

University of Scranton Scranton, PA 1851(}..4501

Office: 717-941-7638

FAX: 717-941-6369

Lisa. M. Porche-Burks, Ph.D.,1992-1994 CSPP-Los Angeles

1000 S. Fremont Ave.

Alhambra, CA 91803-1360

Office: 818-284-2777

FAX; 818-284-1520

Wade H. Silverman, Ph.D.,1993-1995 1514 San Ignacio, Suite 100

Coral Gables, FL 33146

Office: 305-661-7844

FAX: 30>661-6664

Suzanne B. Sobel,. Ph.D.,1993-1995 1680 Highway AlA, Suile 5 Satellite. Beach, FL 32937

Office: 407-77'3--5944

Carl N. Zb:net. Ph.D.,1992-1994 University of Colorado Medical School 4200 E. 9th Avenue

Denver, CO 80262

Office: 303-270-8611

FAX: 303-270-5641

REPRESENTATIVES to APACOUNCIL

Donald K Freedhetm, Ph_D.,1993-1996 Dept of Psychology

Mather Memorial Bldg.

Case Western Reserve University Cleveland, OH 44106

Office: 216-368-2841

FAX: 216-368-4891

Ellen McGrath, Ph.D.1994-1997 380 Glenneyre, Ste. D

Laguna Beach, CA 92651 Office: 714-497-4333

FAX: 714-497-0913

LIAISONSIMONITORS

Administrative liaison Mathilda Canter, Ph.D. 4(85 E. Mcfzonald Or. Phoenix, AZ 85018

Office & Home: 602·840-2834 FAX: 602~840-3648

liaison to AP A Committee on Intemarional Relations in Psychology

Ernst G. Beier, Ph.D.

44 West Third Street South Apt #607 South

Salt Lake City, UT 84101 Office: 801-581-7390

Representatives to ICPEP Tommy T. Stigall, Ph.D. The Psychology Group 701 S. Acadian Thruway Balon Rouge, LA 70806 Office: 504-387-3325

FAX: 504-387-0140

Arthur Wiens, Ph.D.

Oregon Health Services University 3181 SW Sam Jackson Park Rd. Portland" OR 97201

Office: 50:3-494-8594

FAX: 503-494-3284

Representative to Interdivisional Task Force on Health Care Reform

Arthur L. Kovacs, Ph.D.

11859 Wilshire Blvd., Sle 510

Los Angeles, CA 90025

Office: 310-444-7858

FAX: 31(}..477-7270

EOITORSOFPUBUCATIONS

Psychotherapy Journal Wade H. Silverman. Ph.D. 1514 San. Ignado, Ste. 100 Coral. Gables, FL 33146 Office: 305-661-7844 FAX:305-661-6664

Psychotherapy Bulletin Linda F.Campbell, Ph.D.. University of Georgia

402 Aderhold Hall Athens, GA 30602·7142 Offioe: 706-542·1812

FAX: 706-542-4130

AD HOC COMMITTEES

Employee Benefits

Patricia Hannigan-Farley, Ph.D., Chair 24600 Center Ridge Rd. Ste. 420 Westlake, OH 44145

Office: 216-871-6800, Ext 19 FAX: 216-871-1159

Continuing Education William PolIa.c:k, Ph.D., Chair McClean Hospital

Dept. of Psychology & Education 115 Mill Street

Belmont, MA 02178

Office: 617-855-2230

FAX: 617-855-2349

PSYCHOTHERAPY BULLETIN

Published by the

DIVISION OF PSYCHOTHERAPY AlMERlCAN PSYCHOLOGICAL ASSCX:lATIQN

3875 N. 44th Street Suite 102 Phoenix,AJizona 85018 (602) 952-8656

EDITOR

Linda Campbell, Ph.D.

CONTRIBUTING EDITORS Medical Psychology David B. Adams, Ph.D.

PsYColumn Mathilda Canter, Ph.D.

Washington Scene Patrick Deleon, Ph.D.

Student Column Laura Meyers

Professional Liability Leon VandeCreek, Ph.D.

Finance

Jack Wiggins, Ph.D.

Substance Abuse Harry Wexler, Ph.D.

Gender Issues Gary Brooks, Ph.D.

STAFF

Central Office Administrator Pauline Wampler

Associate Administrator Norma Files

PSYCHOTHERAPY BULLETIN

Official Publication of Division 29 of the American Psychological Association

Volume 28, Number 4

Winter 1993

CONTENTS

President's Message ." .. " " 4

Editor's Column 5

Student Column , ,. " """.,, 6

Krasner A ward Interview " 7

Washington Scene " .. " " 9

Medical Psychology ." .. "" " .. " """ ,, 14

Feature: The Role of Psychology and Psychotherapy in the Treatment of the Seriously Mentally III Client in

the Community Mental Health Center ... " .. " ... """,,27

Featwe: A Developmental Approach to Psychotherapy Supervision of In-

terns and Postdoctoral Fellows " .. " .. "." 20

Featwe: Health Care Reform:

An Update 24

Feature: Individual Psychotherapy

in Chronic Disease I " " " " .. 29

Featwe: Documentation Guidelines

and Ethical Practice in Psychotherapy 33

Feature: AP A and Psychologists'

Future in Managed Care " 37

Feature: Croatian eeds Assessment Project ...... 39

Professional Liability 44

Substance Abuse "" 45

Task Force Update " .. " .. " 57

PRESIDENT'S MESSAGE .

Psychotherapy and Health Care Reform Tommy T. Stigall

As wildfires swept across southem California last fall, the politics of health care reform was heating up on Capitol Hill. In late September, the Clinton Administration unveiled its long-awaited legislative proposal on national television. In October, the plan was "officially delivered" to Congress as another highly publicized media event. In November, a revised Health Security Act was introduced in the l03rd Congress.

Political commentators and pundi ts are of the opinion that some form of federal health reform legislation is likely to be enacted by late summer of 1994. But there are at least a half-dozen very serious legislative alternatives to the President's ini tia ti ve pending in Congress, and the outcome as to final scope and shape of heal th care reform is far from certain. As House Minority Leader Robert Michael (R-IL) stated in October, the Clinton health care reform bill has been given "a new examination and diagnosis" and the Administration has "now come to Congress for a second opinion."

The health care reform legislative landscape includes a range of proposals from the Canadian-style "single payer plan" introduced by Rep. Jim McDermott (D-W A) to the far more conservative plan put forward by Sen. Phil Graham (R-TX) that proposes tax credits for IRA-like health savings accounts. McDermott is a medical doctor and psychiatrist, while Graham is an economist by training. Somewhere to the left of center is the Clinton plan, stressing universal coverage and HMO-style managed care as the delivery system of choice.

Other reference points on the legislative spectrum have been staked out by Sen. John Chafee (R-RI), Rep. Jim Cooper (D-1N), and Sen. Don Nickles (R~OK). These bills, closer to the political center, would provide increased. access to health care and greater freedom of choice for consumers. They also are less far-reaching in imposing tax increases and government control over health

4

care than either the Clinton or McDennott alternatives. But only the Health Security Act and the single-payer bill provide for true universal coverage-a principle the Administration says it will not abandon.

There has been strong opposition from the private insurance and small business community to the Clinton plan which adds significant costs to employer payrolls and limits consumer choice among insurance options. In recent weeks, big business interests have came out against the plan, while big labor remainssupportive. Organized medicine and health care providers are divided in their support or opposition. The increasing burden of managed care reform has some providers thinking that national health care reform may be preferable to slow torture by a thousand cuts from scores of managed care intermediaries and state reform initiatives.

Political endorsement of expanded coverage and reining in of health care costs is easy; the real battle in Congress will be over financing of health care reform. Philosophically, the debate will tum on whether to have more or less government control of the system. Pragmatically, the issue will be where to find the money to pay for expanded services without bankrupting the system This is the point at which mental health and psychotherapy benefits are most vulnerable.

AP A advocacy efforts have been directed toward persuading the Clinton Administration that it makes economic sense to include more generous outpatient psychotherapy benefits in health care reform .. These efforts have met with mixed results. Unfortunately, there is still a widespread perception that psychotherapy is a relatively innocuous procedure delivered by ancillary providers who do not have much responsibility for the overall care of the patient. There is also the view that, in order to constrain costs, it is necessary to limit access to mental health care.

A more informed and responsive public policy on the value of psychotherapy and access to psychological health care is needed. And Division 29 should be in the forefron t of ad vocacy for psychotherapy in the national heal th care reform debate.

In December, the Division 29 Execu ti ve Commi ttee met with APA Senior Policy Advisor Bryant Welch and Patrick DeLeon, administrative assistant to U.S. Senator Daniel Inouye and the Division's 1993 Distinguished Psychologist. The purpose of that meeting was to discuss how Division 29 might best use its resources to influence the outcome of national health care reform.

A number of alternatives were considered, but the overriding consensus was that strong grassroots contacts with members of Congress would be most effective.

Since Congress reconvened in January, and with increased scrutiny being given to the cost of health care reform, the political debate has begun to heat up again. Clear and persuasive cornrnunica tions from constituent psychologists engaged in practice, research and teaching of psychotherapy could help to insure that the result is more light and less smoke.

Is anybody out there listening?

EDITOR'S COLUMN

Linda Campbe/I

If we each had a new year's wish fulfilled, at least from the professional aspect of our lives, most of us would wish for a resolution to the health care reform debate and the accompanying managed ~are issues that would respect the quality of care, competence, and mental health services to the public that psychologists uniquely bring. Many of us would love never to hear the terms health care reform or managed care again. And yet, when we hear from one of us who has new information on "what's happening" it has the effect portrayed in the old TV commercial when E.F. Hu tton speaks .... and everyone in the room becomes dead silent.

What Can You Do?

So what do we do? We teach our clients that accepting responsibility and developing an internal sense of control increases their impact on their lives and empowers them. Are we practicingwhat we preach? Yes, to a great extent we are. We have mobilized financial, organiza tional, and human resources in ways that a few years back we wouldn't have thought possible. Are we doing all we can do? Maybe not!

Those who are representing us in health care reform matters are highly skilled and talented people who are performing, in some respects, miracles. We cannot simply give money and emotional support to them and then waIk away sayi ng we ha ve done our part. Those in Congress who sit on committees tha t will be redrafting the

health care reform legislation can make changes with the stroke of a pen that have profound effects. Many of you are Ii ving in districts tha tare represented in Congress by these committee members. Do you know who they are? Do they know who you are? The final form of heal th care and managed care at the national and then the state level will be determined by legislators on certain committees, who are responsive to their constituents. Are you one of those constituents? Find out by learning first who your U.S. and state representatives are and then learning on which committees they sit. If your representatives are participating in drafting the health care reform act, let them know your views.

Impact of Health Care Reform on Academic and Public Sector Psychologists

Health care reform is not a private practice issue. It is an issue that will impact all areas of psychology. Few people have actually read the Health Care Security Act. Those who have note a dramatic shift in training monies to specific med ical professionals which could diminish training for psychologists. Further, passages that describe service provision in the public sector can be interpreted as excluding psychologists. As mentioned in the article in this issue by Pat Del.eon, 'The Devil is in the details." Please read the articles in this same issue by Tommy Stigall, Pat DeLeon, and Ron Levant. Then take action!

5

The Impact of NAFf A on Psychologists

Russ Newman and Billie Hinnefeld of the Practice Directorate have very conscientiously and thoroughly reviewed the impact of NAFT A on the training and practice of psychology. A memo written by Russ and Billie gives an excellent overview and references points in the NAFTA agreement that could affect psychology. Your state psychological associations and the practice

divisions of APA have copies of this memo. There is no cause for alarm !Pyour state licensure laws incorporate the important guidelines and rules that protect quali ty of service and qualifications of service providers. As cited in the Newman/Hinnefeld memo, these might include education, experience, examina tion, conduct and ethics, and licensing reciproci ty provisions. Your state psychological association may wish to call this matter to the attention of your state licensure board or other appropriate state officials.

STUDENT COLUMN

Internship - Yet Another Jumping Off ~oint! Cynthia Webster

University of Tennessee

The transition from graduate student to professional intern, although exciting and eagerly anticipated, is often a very stressful period for the psychologist in training. Many interns experience their early weeks as a time of healing from the academic demands of their doctoral program and a welcomed opportunity to really begin focusing on their development as clinicians. Yet they may also be feeling a great deal of insecurity concerning the expectations of the new setting and their own ability to "measure up."

A brief check with several interns revealed some common transitional experiences. Although the n was quite small and the majority of responses came from interns working in university counseling centers, conversations with interns from other settings suggest that many interns can expect transitional experiences similar to those mentioned here.

Most interns begin the internship phase of their training without having recovered from relocation stress. Because the position is temporary, the intern may move without his/her spouse, partner, and/ or family. Even if accompanied by Significant others, friends are left behind, new support systems are not yet in place, and new environments quickly must become familiar. Interns greatly appreciate sites that allow ample orientation time and the opportunity for new interns to get acquainted with the setting and with each other in order to begin forming sup-

6

portive bonds. Support from fellow interns is a major factor in facilitating a positive transition.

The intern is expected to rapidly assume a professional role that includes much grea ter responsibility and authority than that required of the student. Ironically, this change is expected to occur just as the intern is adjusting to a new setting with different procedures and expectations regarding service provision. Furthermore, new supervisors providing intense supervision may trigger feelings of vulnerabili ty tha t had not been experienced since very early in the graduate program.

One potential pitfall for interns is the tendency to try newly learned clinical methods and techniques too quickly. The combina tion of exposure to supervisors who are introducing new ways of doing therapy and the intern's eagerness to develop clinical skills can lead to "trying on too much too fast" and a resulting loss of confidence and disappointment in self. One intern described an "unhappy surprise" not uncommon to interns, tha t of feeling that one's clinical skills have regressed. Often graduate students do their practicums a full year prior to internship and continue to see only a few, if any, clients in the months before arriving at their internship. As they are faced with many new experiences, the "rusty" feeling may become exaggerated, temporarily lowering self-confidence.

The transition often invol ves other unanticipated challenges. Another intern spoke of her expectation that integrating theoretical! didactic information into her clinical work would be a natural process. She found it frustrating to realize that such an integration does not occur spontaneously and that she often must access materials for further study and unde.rstanding. The reward has been that in bringing theoretical knowledge into practice, "what I thought I understood then, I am understanding now."

Transition also means a growing recognition that one came to the internship with valuable knowledge and skills that provide a sound base from which to continue development at a pace that works for the clinician and the client. As well as relearning the value if development as a process, the transition period often involves a realization that the internship (the last phase offormal training) is not a culminating experience. As one intern expressed, "I wish someone had said to me

'Internship is a last and first step.' I now realize that it is tying up one arena and propelling me into a brand new one."

Whatever the graduate student's clinical training has been prior to internship, he/she will face new challenges and opportunities related to psychotherapy theory and practice, diagnosis, methods of supervision, assessment, and many other areas of the profession of psychology. In spi te of the stress, most interns report a positive experience and feel a professionalism that was missing during their student years. It seems that the transitional period ends as the intern finds his/ her own rhythm for the internship dance, a way of maintaining a sense of balance within the off-balance position ofbeing somewhere between student and professional. It has been my experience that-an internship site that is committed to its training mission and which provides challenge within a supportive environment facilitates a relatively smooth transition.

Jack D. Krasner Memorial Award Interview

Linda Campbell

The Krasner Award was created in 1979 in honor of Dr. Jack Krasner. The award acknowledges psychologists, early in their careers, who are making unusually significant contributions in psychotherapy research, theory or practice. Dr. Annette Brodsky and Or. Gerald Koocher were the first Krasner Award recipients. Dr. Brodsky's professional acco mplishments since receiving the Krasner A ward are evidence of the important impact she has had in the field, particularly in psychotherapy training and research.

Interview with Dr. Annette Brodsky

Biography

Dr. Annette Brodsky is Chief Psychologist and Director of Training in the Department of Psychiatry at Harbor-UCLA Medical Center, Torrance, California. She is also adjunct professor of Medical Psychology in the Department of Psychiatry and Biobehavioral Sciences, UCLA School of Medicine and is a member of the Psychiatric Associates of Harbor-UCLA Medical Foundation, Inc. Dr. Brodsky has served in many profes-

sional capacities including President of the Psychology of Women Division, Chair of the APA Board of Professional Affairs and member of the California Psychological Association Board of Directors. She has made valuable contributions to scholarship and scientific advancement in psychology through publication of over 30 articles, three books, and numerous book chapters and monographs. Dr. Brodsky has been acknowledged for her professional contribu tions by being selected recipient of the AAAPP Distinguished Contribution to Research in the Public Interest Award, the AP A Cornmi ttee on Women Distinguished Career Award, and as an AP A Master Lecturer.

Interview

1. What events or experiences would you consider the milestones of your career since receiving the Krasner Award?

A year after receiving the Krasner award, I made a major career move from being an associate professor in the academic psychology department of the University of Ala-

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barna, to being Chief Psychologist and Director of Internship Training at Harbor-UCLA Medical Center. While I continued to do research and publish in my main area of expertise, sex between therapists and patients, I became more focused on leading a predoctoral,and by 1983,a postdoctoral program to prepare clinicians for specialized work in medical settings.

Milestones in the last decade include the publication of the edited volume Psychotherapy with woman: An assessment of research and practice, which established a continuing interest and writing on psychotherapy (primarily, feminist)

issues. My various co-authors Rachel HareMustin, Laura Brown, and Sue Steinberg kept my perspective from becoming too insular to my own special interests, and permitted a broader theoretical outlook.

In 1987, my presentation to the American Heart Association on caregivers and patients of Artificial Inplantable Cardioverter Devices, was selected as one of 5 presentations, chosen from 8,000 submissions, to be featured on video, at the national convention attended by 27,000 AHA members. I still work with the 100+ member support group of AICD patients at Good Samaritan Hospital in Los Angeles.

I am most proud of my latest award from the APA Committee on Women for leadership in the psychology of women. This encompasses the generic brush that paints all the Specific scenes of my career forays.

In my research area of sex between patients and therapists, the book written with Carolyn Ba tes, Sex in the therapy hour: A case of professional incest, was another milestone that made my growing forensic practice as an expert witness in such cases more visible to the legal and consumer populations involved with individual cases. My current research involves the surveying of attorneys in such cases. Last year I received an award from American Association for Preventive and Applied Psychology for Distinguished research in the public interest.

Two surprising meanders from psychotherapy resulted in special acknowledgement. In 1984, I was selected for an American Bar Association special conference panel on surrogate motherhood ethics. I had been working with the psychological screening of the first ovum donors and recipients in the project at Harbor-UCLA that produced the first birth from this particular reproductive alternative.

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2. Has your professional work taken the course over time that you anticipated? How has it been different?

I like Band ura' s notion about chance encounters that can tum one's very focused plans toward unexpected directions. Certainly, my main career goals in the academic pursuit of the psychology of women has prevailed through my meanders. However, I would not have predicated that I would have joined the army for my internship, worked in an all-male military prison, taught lectures to over 150 students at a time, spoken to audiences of several hundred, presented a workshop on a cruise ship, hypnotized world class athletes, testified in open court about someone's sex life, counseled a woman abou t providing her ovum to be fertilized by another woman's husband and then inserted into that women's uterus, or provided relaxation images to a group of over 100 AICD patients who had survived near death experiences.

3. How has the profession in general and specifically your clinical area changed since 1980? How do you view these changes?

Of course, the downsizing of the peacetime economy and the arrival of managed care in the nation's health care systems has affected

the attitudes of clinicians toward their patients and their practices. Competition for even public sector patients has seen new interest in treatments for women and minorities and the poor. Accountability to the consumer means that new, more effective modes of treating special populations are more likely than previously to be sought in continuing education or funded by research monies.

The profession has shown drama tic changes in my specific clinical area. The increasing sanctions against sexual abuse in psychotherapy, and more generally, the criminalization and/or codification of sexual misconduct by doctors, lawyers, professors, and clergy has impacted the profession in many ways. Malpractice insurance has increased, consumer and practitioner knowledge has increased, and clinicians are more likely to be entangled in legal proceedings.

4. How do you view the psychotherapy process and has your perspective changed during your career? What experiences or observations have affected that view?

My observations of the range of "therapeutic" practices explained to me by the patients who have been referred to me as victims abused by therapists, and the records and notes of many of their "fully licensed" practitioners, has made me aware of how much leeway we permit therapists in the name of "psychotherapy". I am appalled at how easily individuals with inadequate training

and inappropriate relationship styles slip through the professional hurdles toward licensure. There is so little agreement on what constitutes a minimal criterion for a therapeutic process that only gross misconduct or obviously harmful practices are clearly below the standard of care in most venues. The latest conflicts over false memory syndromes, in my opinion, are largely due to slipshod training in marginal programs that do not respect the scientific, empirical basis of therapeutic technique. Instead, they consider personal experience as a recovered multiple personality or drug addict, for example, as a primary, if not sufficient criteria for a therapist.

5. Other than the area of health care reform, what do you see as the most important issues our profession is facing going into the twenty-first century?

Besides Health Care Reform issues, OUT profession has an iden tHy crisis, as other men tal heal th professions increasingly overla p training in psychotherapeutic skills. Clinical Psychology used to be more standardized, with all clinicians taught the same basic background in psychometrics, projective testing, research design and implementation. Now, like those psychiatrists who 1/ don't do" physical exams, some clinical psychologists 1/ don't do" testing, or research, or behavior modification. Psychologists' extra years of preparation to do the same treatment (psychotherapy) as nurses, social workers, psychiatrists, and counselors, does not impress most of the public.

WASHINGTON SCENE

The Health Security Act of 1993 - The NHI Debate Is Here Pat DeLeon

As the first session of the 103rd Congress ad- strengthen the economy will fail-let me say this journed, the Democratic leadership in both again; I feel so strongly about this - all of our Houses of Congress introduced legislation incor- efforts to strengthen the economy will fail unless po rating into specific bill language, the policy we also take this year - not next year, not five recommendations of the Clinton Administration years from now, but this year - bold steps to to drastically reform our nation's health care reform our health care system .... " For psycholsystem. Underscoring the seriousness of his ogy, the professional stakes could not be higher. personal commitment to this social policy objec-

tive, the President, during his February State of As one reviews the details of the 1364 page Senate the Union address, stated that "All our efforts to bill (5.1757), and/or the voluminous abstracts/

9

summaries that various "interested parties" ha ve developed, one gets the very real sense that we are no longer "doing business as usual", but instead that we are truly facing a major (if not revolutionary) restructuring of all aspects of our na Han's heal th deli very system - incl uding our practice, educational, and scientific underpinnings.

are provided by another person who is legally authorized to provide such services in the State in which the services are provided" - i.e., relying upon the various State Practice Acts to determine who should provide what services and under wha t condi tions, Here psychology would definitely be included, having been licensed! certified to practice autonomously in all states since 1977. Further, we are all very aware that throughout the Administration's policy pronouncements, a high priority has consistently been given to providing preventive and primary health care services. We would rhetorically ask: 'What is 'prevention' if it is not fundamentally behavioral science - that is, psychology?" And, is not what we typically do on an outpatient (or crisis intervention) basis truly "primary care"? Another componen t of the bill includes language to the effect that: "No State may, through licensure or otherwise, restrict the practice of any class of health professionals beyond what is justified by the skills and training of such professionals." For

psychology and professional nursing, this provision sounds like it must have been written with the issue of prescription privileges in mind. However, as a certain unnamed national figure recently exclaimed:

"The Devil is in the details". And there, we must be careful.

Given the mammoth nature of the bilI, one is seriously tempted to merely review the "mental health" benefit provisions and smile. The White House has recommended a very generous, phased-in approach, which by the year 2001 will result in mental health services finally being treated in the same manner as all other (i.e., physical or medical) health care services. True, there is an initial financial "bias" towards inpatient care and "medical management" - that is, if one pays attention to such details as "copayments", etc. - but, there is also very nice language about utilizing the services of "health professionals", and the projec-

tions from our AP A strategists

are that even as drafted, the bill It is unfortunately true, would allow a potential maximum of 150 days of outpatient therapy annually. Not bad at alI!

that "psychology" per se is only specifically

referenced in a very

It is unfortunately true, that "psychology" per se is only specifically referenced in a very limited provision of the bill-where we are included under the defi-

nition of "health professional"

for the specific purpose of automatic certification of "Essential Community Providers." This is a program that is exclusively targeted towards providing necessary care for underserved areas and populations, and also involves for example, migrant health centers, community health centers, family planning clinics, etc. Historically, very few psychologists have demonstrated any interest in this area; however, under this provision, those who do will be recognized by the evolving health plans/Alliances during a five year transition period.

limited provision of the bill ...

More satisfying is the more generic (and critical) definition section of the bill which defines the term "health professional services" as: "Professional services that - (A) are provided lawfully by a physician: or (B) would be described on subparagraph (A) if provided by a physician but

10

A closer look at the specifics of both the mental health and generic health care benefit provisions would clearly suggest that all inpatient care must be under the direction and supervision of a physician per se, as is the case under the current Medicare law - suggesting that our hard won state hospital practice laws in 11 + States would simply be pre-empted. Similarly, a closerreview of the Clinical Preventive Services benefit shows a heavy (if not exclusive) emphasis on providing traditional physical care; i.e., age-appropriate immunizations, tests, or clinician visits (with very strict limits) are specifically enumerated for such disease entities as tetanus, measles, and rubella, as are cholesterol level. mammograms, and pelvic examinations. The bill's definition of "clinician visit" is also clearly medical in orientation, including: "a complete medical history, an appropriate physical examination, risk assessment; targeted health .advice and counseling,

including nutrition counseling; and the administration of age-appropriate immunizations and tests specified .... " Interestingly, the bill's definition of "primary health services providers" inc1 udes: "a physician, a physician assistant, a nurse practitioner, ora certified nurse-mid-wife" - with "physician" being given the express meaning that it has under section 1861 (r) of the Social Security Act (Medicare); that is: "a doctor of medicine or osteopathy, a doctor of dental surgeryorofdentaI medicine, a doetorofpodiatric medicine, a doctor of optometry, and / or a chiropractor." Where is psychology? Haven't we known since the release of HeJ21thy People under President Carter that: " ... of the 10 leading causes of death in the United Sta tes, at least seven could be substantially reduced if persons at risk improved just five habits .... "(i.e., utilized behavioral science techniques)? Not to mention, aren't we convinced that 60+ percent of today's physician office visits are for ailments that are psychological rather than medical in nature?

Educatlon - A Particularly Troublesome Arena

From the beginning, the Clinton Administration has attempted to systematically link health professions' training resources with service delivery priorities. Their briefing documents indicate that the federal government's current Graduate Medical Education programs. primarily funded under Medicare, account for $6 billion annually. They have proposed the establishment of a National Council on Graduate Medical Education, which would include consumers of health, at least two categories of physicians, and "such others" as the Secretary determines to be appropriate. The underlying policy notion is for the Council to designate for each academic year the number of individuals who are to be authorized to be enrolled in eligible programs, with the requirement that, at a minimum, 55 percent of these positions will be in primary care (for this purpose "primary care" is limited to familymedicine, general internal medicine, general pediatrics, and obstetrics-gynecology). The Administration's original draft proposed various additional regional councils which would have distributed the actual allocations to individual training programs within each area of the nation; however, this approach now seems to have been centralized at the national level A similar approach has also been recommended for Graduate Nurse Training programs, with its

own National Council, at an estimated annual budget of $200 million. [Recall that for the coming year the entire mental health clinical training account will be $2.5 million, to be shared among all five/six core disciplines]. The clear intent is that all public training funds will be directly related to nationally determined health care priorities. There is, of course, very broad and permissive language in the bill which would allow the Secretary to fund some psychology programs (or other unspecified initiatives) if she/he should so desire; however, history would strongly suggest that without express authorization, this is simply very unlikely to occur.

One additional concrete example of programs for which we assume psychology will be deemed eligible, but for which we must still "do our homework" to overcome the "medical biases" of the bill: The Ad ministration has made very clear its commitment to address the truly pressing health care needs of rural America. And yet, the financial incentives proposed in the legislation again seem to ignore psychology's potential contributions - a special tax provision (non-refundable $1,000 per month tax credit) for those "physicians" who provide primary health services on a full-time basis in "health professional shortage areas (most often found in rural America) and $500 per month for qualified practitioners who are not "physicians" (i.e., physician assistants, nurse practitioners, and certified nurse-midwives). Under this particular initiative, "physician" is defined as those practitioners included under section 1861(r) of Medicare - i.e., recall above, this references almost everyone but psychology. How will our current psychology training programs survive wi thou t their fair share of these considerable federal financial incentives - we Sincerely doubt they can! The details can be absolutely crucial!

Prescription Privileges - The DoD Project Continues On Track

The Congress has now concluded its deliberations on the Fiscal Year 1994 Appropriations Bill for the Department of Defense and President Clinton has signed the bill into public law (P.L. 1~139). This year the House Appropriations Committee did not address the psychology prescription privilege project and, in fact, removed the somewhat restrictive bill language that had been included for several years which specifically referenced the recommendations of the

11

Army Surgeon General's 1990 "Blue Ribbon Panel". The Senate report noted: "The Committee has been pleased with the Department's efforts during the past year to significantly enhance the utilization and training of military psychologists. The Committee has been particularly pleased with the significant progress that has been made in modifying the psychology prescription privilege training program, based u pan DoD's ongoing experiences and the recommendations of the American College of Neuropsychopharmacology. The Conunittee understands that outside reviewers have been similarly impressed .... It is impor-

tant, however, that during the com- "Our third.clinical year consistspriingyeartherecruitment/assignment How will our cur- marily of experience on the Inpaof students .... be tightened up. rent psychology tient Psychiatry Service at Walter

Heal th Affairs is directed to ensure Reed Army Medical Center. We are

that a systematic assignment pro- training programs expected to provide the same clinicess is developed whereby each ser- survive wihtout cal services as psychiatric residents,

vice provides, at a minimum, two with the exception of ECT. We are

trainee slots .... in a timely process, their fair share of also assigned a number of outpabut notlater than February 28, 1994". these considerable tients, in order to develop prescrip-

The House-Senate conferees subse- tion skills in that setting. As we have

quently agreed to: If •••• delete a federal financial stated in earlier reports, we have

general provision detailing certain been in general, well received by

restrictions regarding this program, incentives... our psychiatric counterparts. Rela-

as proposed by the Senate. The con- tionships with residents have been

ferees expect the Department to con- collegial and our supervision has

tinue to provide regular and timely reports to the been impartial and of the highest quality". Congress on the status of the psychology prescription privilege training project". Interestingly, our colleagues within the little ApA are now attempting to directly influence the composition of the patient population which the two senior psychopharmacology fellows are working with, pursuant to an earlier House-Senate conference agreement. However, based upon this year's conference agreemen t, it will continue to be the responsibility of the DoD to make this and related clinical training programma tic decisions. The policy significance of the DoD training program continues to be that psychologists are being responsibly trained to prescribe.

The Light At The End Of The Tunnel

Drs. Morgan Sammons and John Sexton are nearing the completion of their three year journey to be credentialed to utilize psychotropic medications as an integral component of their therapeutic regimen. Their thoughts: "We are happy to report that after two and one half years, the first

12

iteration of the Psychopharmacology Demonstration Project is coming to a close. The last year ofourformal training will end in June, 1993. We then anticipate assignments in which we will be authorized to prescribe psychotropic drugs in our clinical practices. We also report with sarisfaction that the second iteration of the program is progressing nicely. The two Fellows in thai program have completed the first half of their didactic training year. Because the second generation is a more workable two-year model, those trainees will enter their year of clinical training as we are leaving ours".

''We have exposure to psychopharmacology. In addition to working with more severe forms of psychopathology, the volume of patients allows for a broad diagnostic mix as well as experience in recognizing medical problems which can be present along wi th mental disorders. Close contact with inpatients provides valuable experience in recognizing and managing side effects of psychotropic drugs. Less positive aspects of inpatient work exist, of course, chiefly in the form of lack of follow-up, but also in the voluminous paperwork involved in admitting, discharging, and managing hospitalized patients. Nevertheless, the overall experience is a powerful one, and we would strongly suggest that other training prograrns consider a combined inpatient/outpatient clinical year".

"In sum, we continue to progress. Our experience has been arduous but immensely valuable. The Demonstration Project has survived intensive opposition and monumental organizational hurdles, and a second iteration has already begun. Our impression is that support for prescrip-

tion privileges is growing rapidly in the field, and we look forward to the implementation of training programs at many other sites throughout the country".

cology experiences in their basic training. Several sta tescurrentl y have a requirement tha tTP A certification is automatically granted to those

graduating from an accredited school or college of optometry after January 1, 1991, and other states are in the process of implementing that in statute".

Final Thoughts

The policy

Jack Wiggins, our immediate APA Past-President, recently provided significance of the us with some very interesting back- D D tr ..

ground information regarding our 0·· auung pro-

colleagues in optometry and their certification requirements for prescriptive authority. Second year AP A Congressional Science Fellow, Debra Dunivin analyzed Jack's data and reported that: "A summary of responsibly trained requirements as specified in state optometry statutes and board rules for the 37 states permitting use of therapeutic pharmaceutical agents

(TPA) was reviewed. (Currently diagnostic pharmaceutical agents (DP A) are in use by optometrists in alISO states, Guam, D.C.)".

"Two sta tes require no additional course work or training beyond the original licensure. This is clearly the emerging trend as more schools of optometry include didactic and clinical pharma-

"About 25 states require examination as part of the certification and three states require only examination and no other requirements beyond original licensure. For those states requiring additional training (primarily to being those earlier graduates up to current expectations), requirements range from about 20 to 150 contact hours - usually a combination of didactic classroom study and

supervised clinical training expertenee. The median seems to be about 96 contact hours or approximately two and a half weeks of training. Surely, these hours would suggest that our doctorally prepared clinicians could handle any necessary additional training on a continuing education basis, without any disruption in their practices - in fact, they would probably enjoy the intellectual stimulation."

gram continues to be that psycho 10-

gists arebeing

to prescribe.

II

REQUEST FOR NOMINEES FOR THE

JACK D. KRASNER AWARD

In 1979, Division 29 created the Krasner Award in honor of Dr. Jack D. Krasner. The award acknowledges a member of the Division of Psychotherapy with a. doctorate earned within ten years of receiving the award. The award is given to a person who has made or is making unusually significant contribution(s) in psychotherapy research, theory, training, or practice. Please submit the names of those individuals you would like to nominate to the Central Office. Also, please be aware that self nominations are encouraged. Information needed by the selection committee includes a curriculum vita and two references from individuals who are familiar with the work of the nominee.

13

14

MEDICAL PSYCHOLOGY

The Impact of Borderline Personality Disorder on Recovery from Illness & Injury: Clinical Errors in Diagnosis & Treatment

David B. Adams

Introduction

One of the most troublesome aspects of patient care is the differences in the ways patients respond to illness or injury. Patients 'With similar diagnoses do not recover at the same rate and have differing perceptions of their degree of impairment. What is a simple disorder to one individual becomes a disability to another. Individuals have a wide range of styles in compensating for their discomfort and limitations. Just as disorder and disabili ty are not synonymous, personali ty differences are not the same as personality disorder. An individual can be compulsive or dependent or conservative or unreliable, without necessarily having a personality disorder.

A personality disorder is a pervasive pattern of responding that not only interferes with interpersonal function (formation and maintenance of rela tionshi ps) but also interferes with occu pational functioning, making adjustment to daily employment difficult. Such individuals often have chaotic careers and are continually at odds with their colleagues and/or co-workers. Personality Disorder is not the same as a clinical disorder. Individuals with clinical disorders (such as major depression, post-traumatic stress disorder, or sexual disorder), are typically aware of the existence of their problem, They are made uncomfortable by their symptoms, and while they may be resistant to seeking professional care, they do seek relief from the symptoms.

Vulnerability to Clinical Disorder

Ind i viduals wi th personality disorder may make others very uncomfortable with their compulsivity, their dependency, their distrust, or their stubbornness, but often their disorder is so woven into the fabric of their daily existence that they experience little or no discomfort from

It is generally believed that one-in-ten adults ha ve personality characteristics that impair their daily functioning. Studies on chronic low back pain suggest that of those with chronic complaints of pain, more than half had a pre-existing personality disorder. It was sug-

gested that personality disorder con-

tributes both to vulnerability to a physical injury and to inability to recover from that injury. More importantly, personality disorders contribute to perceptions of disability.

Where two individuals may have ing problem, is that identical injuries, disorders or con-

ditions, the patient with the under- of anger and resentlying personality disorder is more likely to perceive him/herself asdisabled.

the disorder. Personality Disorder is best seen as the foundation from which clinical disorders emerge. If major depression or post-traumatic stress disorder is the "iceberg" in one's life, then disorders such as dependent personality disorder or antisocial personali ty disorder are the seas in which the iceberg must attempt to float. Indeed, most patients are quite unlikely to seek care for a personality disorder until their defective and maladaptive lifestyle has contributed to the emergence of clinical depression, generalized anxiety and/or addictive disorder.

Personality Disorder, it must be remembered, does not emerge as a result of an event occurring during adulthood. The preponderance of data suggests that such disorders result from a complex admixture of genetic predisposition and pathological experiences during early development. The personality disorder is most often considered crystallized by age eighteen and set like concrete by age thirty.

Interaction with Physical Disability

in the 1920s, it was used to describe patients who were so fragile that they appeared to be "on the borderline" of psychosis.

Most importantly, these patients were seen as dangerous and self-destructive, with periods of panic and rage-filled outbursts. They have an enfeebled sense of their own identity, are unable to cope with stress and are inordinately impulsive. They engage in manipulative suicidal gestures, are prone to see themselves as abandoned by others and are susceptible to substance abuse.

The Long Term Problems of Borderline Patients

If patients with Borderline Personality Disorder are followed over a ten year period, we find that if these patients are not in Alcoholics Anonymous (or Narcotics Anonymous, etc), their ability to recover from their addictions is decidedly low. Suicidal behavior is the most persistent characteristic of Borderline Personality Disorder. These patients often e.ngage in acts of self-mutilation and nonlethal suicidal gestures such as wrist cutting or modest drug overdoses. In one study, over eighty percent committed suicide within twenty years of first being diagnosed as having Borderline Personality Disorder. Most of the suicides occur in those under

thirty years of age and also occurs within four years of leaving an inpatient hospitalization.

Depression is misdiagnosed when, in reality, the underly-

Borderline Patients

It is estimated that six million Americans (or 2 percen t of the papula tion) suffer from borderline personality disorder. This represents three times the number of individuals suffering from schiz0- phrenia and comprises one-third of the inpatien t populations in most mental hospitals.

The term borderline personality disorder is often a confusing one. When the term was introduced

Anger and hostility were the most common motivations for the suicidal attempts ... not depression. Depression is misdiagnosed when, in reality, the underlying problem is that of anger and resentment. Many who committed suicide were not depressed but were anti-social

and killed themselves rather than face arrest. Alcohol is a major factor that has been shown to be associated with greater than one-third of suicides among Borderline patients. And it should be noted that next to suicide/legal altercations are the most common problem.

meni,

The Cause of Borderline Personality Disorder

Bo rderline patients are emotionally dysregulated (unstable mood); their insta bili ty after becoming even mildly ill or injured results in them falsely

15

a ttributing their mood, be it anger or depression, and even their addictions, to the physical problem. Aside from the genetic predisposition for their dysregulated mood and addiction, their Borderline condition appears to emerge from destructive mothers who are also Borderline. Additionally and importantly, Borderline Personality Disorder appears to arise from physical and sexual abuse, chiefly at the hands of the father.

Incest not Physical Injury Two-thirds of Borderline patients are women, there is a disproportionately high incidence of incest in the childhoods of these women, and they were as much as ten times more likely to have been an incest victim in contrast to non-Borderline women,

Prognosis of Outcome for Borderline Patients

sive parents, the consequent incidence of murder, prostitution and suicide .... "3.5 also quite high.

Treatment of the Borderline Employee

Globally, these patients are frequently misdiagnosed. They are first, and for prolonged periods, examined and tested medically for their complaints. Their impatience, low frustration tolerance, angry outbursts and the instability in their

lives is misperceived as arising from the:irphysical rondi tions, It is most often many months or years before the problem is seen as being psychological. And then ... the psychological problems themselves are seen as arising from the physical condition, be it injury or illness. Further, the psychological problem is then misdiagnosed as being major depression, post-traumatic stress disorder, or addictive disorder arising as a result of the physical condition.

With six million adults suffering

from Borderline

Personality Disorder, the probability

of an ill or injured

American worker

suffering from the

cant.

Those whose families accepted and supported them did wen, but hose whose families were hostile or fragmented did poorly. As noted, incest and other physical abuse was related to poor recovery and associated not only with the aforementioned suicidal trends but also with the commitment of violent crime. Thus, in families w here there is father-daughter incest, mother-son incest, alcoholic and / or physically / verbally abu-

16

Prostitu tion, criminal careers, multiple unstable relationships, periods of depression falsely attributedto external events, panic condition is signifi-

at the concept of being abandoned and other destructive patterns exhibi ted by Borderline patients are,

as noted, frequently seen features

of the disorder. Borderline pa-

tients who fared worse than others with this Personality Disorder were those who had anti-social characteristics: frequent altercations with law enforcement, infidelity, assaultive confronts tions with others, lack of remorse, inability to learn from punishingexperiences,and their lack of fulfillment for addiction, extreme shyness (avoidant behavioral styles), and chronic irascibility (irritability, poor frustration tolerance, impatience, etc). Borderline patients who were more likely to have favorable outcomes were those who were likeable, orderly, and highly in telligen t with artistic and / or musical talents.

The concept of a pre-existing, pre-determining and pre-disposing developmental psychological problem, related to external and early problems is the last to be considered.

Additionally, when finally treated psychologically, the patient is most often start on anti-depressant medication, treating the more apparent mood instability. (The anti-depressant, unfortunately, often becomes the means of the patient's consequent suicidal gestures). The patient is also put into psychotherapy. The employee languishes in psychotherapy and does not improve. The patient is seen too frequently and with inappropriate methodology, resulting in not only delayed recovery but fragmentatlon, deterioration and repeated hospitalizations prompted by suicidal threats and behaviors. Successful treatment is associated with gentle persuasion aimed at having the patientaccurately see the etiology of their problem, limit setting to prevent destructive and self -destructive behaviors, managing the patient's intense anger /rage and marked fear of abandonment, and insuring that they do not displace longstanding rage toward past figures in their lives upon those who now set limits upon them.

There are indications that these patients deteriorate when in group treatment, when see too frequently, and when seen without goals, structure and lack of understanding of the need for impulse control. A skilled doctor will focus as much upon the patient's anger as upon the patient's readily apparent and easily acknowledged depression. Approximately forty-percent of Borderline patients quit treatment abruptly, leave hospitals angrily, and falsely attribute their anger to the behavior of those whom they feel are unavailable or distant from them.

Summary

With six million adults suffering from Borderline Personality Disorder, the probability of an ill or injured American worker suffering from the condition is significant. Without awareness among

employees or health care providers regarding the cause and course of the disorder, treatment will be untimely and most often inappropriate, Participating in their distortion that the problem is exclusively physical in nature results in escalation of the problem. Inappropriate forms of psychological care is more deleterious than the absence of care since improper care can accelerate the self-assaultive behaviors and increase resistance to proper care, When an individual has become ill or injured in the work-place, when subjective complaints not only exceed objective findings but low frustration tolerance and anger-laden responses emerge, it becomes imperative that early psychological diagnosis including precise family and developmental history be obtained, Without such timely and aggressive methods ofintervention, theseindividuals rapidly drain available health care resources withoutstrides toward recovery.

FEATURE ARTICLE

The Role of Psychology and Psychotherapy in the Treatment of the Seriously Mentally III Clientin the Community Mental Health Center

Alan J. Kent

those who are diagnosed with a Major Affective Disorder or one of the Schizophrenics. Traditionally, psychologists have had limited roles in

the treatment of these individuals, In state hospital settings, the psychologist may have been involved in assessment or in developing the milieu programs, However, in the typical state facility which suffered from limited funding and overcrowded conditions, psychologists were often scarce on hospi tal staffs. Psychotherapeutic services were virtually non-existent in many state hospitals and warehousing of patients and overuse of medication

The role of professional psychology in the treatment of serious mental illness has received renewed attention in the psychological li terature in recent years (Dorfman, 1991; Smith, Schwebel, Dunn, & McIver, 1993;

Youngstrom, 1991). It can be ex- It is true that

pected that this role will continue to . • .•

evolve as changes in the health care limited fundmg did

syste~ impact upon ~he profession. not allow most

In this three-part senes, the role of

psychothera py and psychology in the treatment of the mentally ill will be reviewed, First, the structure and politics of the community mental the psychosocial health system will be examined and

the impact of managed. care will be and treatment needs

addressed. In the second essay, a of th most

case study will be presented to dem- e

onstrate the effectiveness of a pro- seriously ill

posed integrated. multi-disciplinary model of care. Finally, implications for psychology training and research

will be addressed.

community facilities to meet

were common.

With the advent of psychotropic medications and the ensuing deinstitutionalization movement,

many seriously mentally ill persons were discharged from state hospitals and transferred to communi ty heal th cen ters (CMHCs). It has often been argued that the dollars did notfollow the pa tients in to thecommu-

17

individuals.

For the purpose of this discussion, the serious mentally ill (SM1) consumer will be defined as

nity and that the SM! consumers were simply dumped onto the streets without adequate housing, support, and treatment. It is true that limited funding did not allow most community facilities to meet the psychosocial and treatment needs of the most seriously ill individuals. Additionally, those CMHCs which had psychologists on staff often utilized them for the treatment of the higher functioning "neurotic" client who was able to profi t from more traditional insight-orien ted psy~ cho therapy. Since SMI consumers were typically considered poor candidates for psychotherapy, they were often seen for monthly psychiatric visits to manage medication and they had similarly infrequent visits with bachelors level case managers who arranged for needed services. In essence, the most severely impaired consumers often received the most limited intensity of care provided by the least trained. staff.

ogy students seem excited about working wi this population and few practicing psycho 10 gis-= consider the SM! consumer desirable to wo: with.

Despite this trend, several psychologically base alternative models for working with the S}. consumer have been developed. Psychosocia rehabilitation (Anthony & Liberman, 1986), clin; cal case management {Harris & Bergman, 199::; assertive community treatment (Stein & Tes: 1980) and family intervention (Leff & Vaugh: (1985) all have been identified in the literaturand put in practice throughout the country. Whik some of these models include active roles fc~ psychologists and psychotherapy, others do no:

In general, ita ppears tha t contemporary writing' on the treatment of the seriousl mentally ill and the role of p~ chologistsha ve de-emphasized th~

importance of psychotherapy (i.e Smith, et.al., 1993).

... many in the

Over time, as state mental health systerns demanded that CMHCs focus their resources on the most seriously mentally ill, many centers dropped community are their "worried well" clientele and

along with them, the psychotherapy revisiting the role of

component of their programs and the psychotherapy in

psychologists who provided that treat- . .

ment. (As an example, a CMHC in the treatment

this community which formerly had of· the seriously. nearly twenty doctoral psychologists

now has none on staff, despite the fact mentally ill.

that their budget and case load have

probably quadrupled in the past de-

cade or so). In many cases, mental

health funding was directed almost exclusively towards case management and psychiatric services. It has been this author's experience that state bureaucratic officials and program developers have little knowledge about psychological services and frequently don't see psychologists or psychotherapy as necessary components of the community mental health service delivery system.

professional

While it is desirable for the community mental health system to direct its limited resources towards those most in need, it is distressing that this shift often resulted in the elimination of psychologically based interventionsand services. It appears that many psychologists were disenfranchised from the CMHC system and lost interest in working with the SMI population. However, institutional barriers alone are not responsible for psychology's limited role in the treat~ent of the seriously mentally ill, Few psychol-

18

There are many reasons why th!:: psychotherapy of serious menta. illness has diminished in impor ranee. Since research seems to su Fport the fact that some major mer tal illnesses may ha yea strong bie logical base, some believe that ps~ chological interventions have HIT ited Utility. Additionally, the literature seems to support the fac

that traditional psychotherap alone is not an effective treatment for seriou. mental illness (Levine, 1992). However, severs articulate essays by recovering mental healtl consumers (Recovering Patient, 1986; Ruocchio 1989) have questioned this notion. Additionally many in the professional community are revisiting the role of psychotherapy in the treatment 0: the seriously men tally ill. For example, Thompson, Griffith and Leaf (1990) have stated that the lack of psychotherapy in assertive community treatment (ACTI programs "constitutes a major gap in the ... model" (page 632). Additionally Leonard Stein, one of the founders of the ACT model has stated that "We believe that psychotherapy has the potential to be a useful intervention. . .Our seeming disinterest in. . .psychotherapy is not a gap in the model but is a gap in the resources" (Stein, 1990; page 650).

While the utility of traditional exploratory psychotherapy with the SMI population has long

been questioned in the literature (Rockland, 1993), others have maintained that. dynamic psychotherapy is the treatment of choice for serious mental illness (Karon & Vandenbos, 1981). However, the reality is t.hat while this debate continues, many community mental health systems have simply dropped psychotherapy from their service repertoire. Many centers nationwide have few, if any, psychologists left on staff. These centers may not offer any individual psychotherapy to their clientele and fewer still offer therapy to their seriously mentally ill consumers. This change is a result of funding shifts, systems changes, institutional barriers and ignorance. Many community mental health organizations and state funding sources seem not to value psychotherapy, doubt its cost-effectiveness, nor hire practitioners who are able to com-

petently provide it.

reform, and .funding cuts, clinically sound and cost-effective programs must be developed, A comprehensive outpatient program is typically less costly than long-term inpatient care. As sta te hospitals dose beds and managed care companies limit benefits, the cost-benefit of psychotherapy should not be overlooked. Further, the inclusion of psychologists in the Medicare program make it financially feasible to provide needed services to this population. Community mental health facilities can add psychologists to their staff to provide psychothera peu tic services to seriously mentally ill consumers and the positions could generally pay for themselves through Medicare and/or Medicaid billing. Additionally, psychotherapy for this population need not be unfocused and time-unlimited. Clear limits

can be established, even with a

chronic mentally ill individ ual, Further, psychotherapy services should be consumer-oriented and

support:ivf; eclectic focused on the persons' needs and desires. Individual, group, or family modalities should be utilized based on the particular treatment needs the consumer presents with.

However, a

It is suggested here that psychotherapy should be an integral part of the treatment package provided to seriously rnentallyill consumers who are interested in receiving it and who psychotherapy which

can benefit from it. Traditional. .

insight-oriented therapy would not 15 provided as part of

appear to be the treatment of choice a muIti..Jisciplinary for this population. However,a sup-

portive, eclectic model of psycho- treatmentprogram therapy which is provided as part of a multi-disciplinary treatment program can be valuable. Psychotherapy

with the seriously mentally ill consumer must focus on developing a positive therapeutic alliance, teaching problem solving skills, enhancing competencies, training in social skills, intervening in family environments, and providing crisis counseling. Psychotherapy cannot be provided in isola tion, but should be part of a comprehensive team approach which includes psychiatric services and case management. The psychiatrist, case manager and psychotherapist ought to work together as part of an outpatient treatment team that regularly meets and plans treatment. This approach has been utilized in this author's mental health center for the past year and anecdotal evidence suggests that the inclusion of psycho- REFERfJ\lCFS therapy in the treatment package can help to enhance consumer satisfaction with services and reduce recidivism. Further study and data collection are needed to confirm these findings.

model of

This paper does not suggest that psychotherapy is a panacea nor does it propose that it is the option for all, However, it is suggested that therapy provided by compe-

tently trained professionals (ideally psychologists) does have a role in the treatment of the seriously mentally ill. As a recovering schizophrenic has so poignantly stated:

can be valuable.

"The psychotherapist is the schizophrenic's bridge to the real world ... schizophrenia is a lonely and difficult disease. Anyone who can allevia te some of the pain and the feeling of being alone is eventually welcomed .... The important issue is somehow finding a way to get therapy to more schizophrenics who will accept it and to reach those who have not yet learned what therapy might do to ease their painful lives (Ruocchio, 1989; page 190)."

AIlthony, W.A., &: Liberman, R.P. (1986). The practice of psychiatric rehabilitation: Historical,conceptual and research base. Schrzophre:nia Bulletin, 12,542-549

As community mental heal theenters are faced with the pressure of managed care, health care

Dorfman, W. 0991}. Professional psychology's role in the treatment of thesertous.lly an .. d.persistenily menially. ill and their farpilies: Ch.allenges for !he 1990' a Psycho-therapy Ilf Prroa.te PractIce, 9,1-11.

19

Harris, M., & Bergman, H. (1993). Case management fur mentally ill patients: T1w!rY and practice. Langhorne, P A:

Harwood Academic Publishers.

Karon, B.P., & VandenBos, G.R (1981). Psychotherayy of schizophrenia: The treatmen: of choice. New York Jason Aronson.

Leff, J.P. & Vaughn, C. (1985). Expressedemotion in families; Its significance for men tal illness. New York: Guilford Press.

Levine, L.R (1992). Individual psychotherapy of persons with schizophrenia: A review and aitiq:ue. Unpublished doctoral dissertation. Nova University, Fort lauderdale, Florida.

Recovering Patient (1986). "Can we talk?": The schizophrenic patient in psychotherapy. American TournaI of Psychiatry, 143, 68-70.

Rockland, LH. (1993). A review of supportive psychotherapy,1986-1992. Hospital and Community Psychiatry, 44,1053-1060.

Ruocchio, P.]. (1989). How psychotherapy can help the schizophrenic patient. Hospital and Community Psychiatry,40,188-192.

Smith,G.B.,Schwebel.AI.,Dunn,RL, & McIver, 5.0. (1993).

Theroleofpsydl.ologists~ the treatm.ent,managem~nt, and prevention of Chronic mental illness. AmeTlca.n PsycJioJogis/, 48,966-971.

Stein, L.I. (1990). Comments by Leonard Stein. H05pjt~1 and Community PsychilltTy, 41, 649-651.

Stein, L.L, & Test, M.A. (1980). An alternative to mental hospital treatment. I: Conceptual model, treatment program, and clinical evaluation. Archives of General Psychiiltry, 37, 392-397.

Thompson, K5., Griffith, RE.,& Leaf, P.]. (1990). A Historical review of the madison model of community care. Hospital and Community Psychiatry, 41,625-634.

Youngstrom, N. (1991, May). Serious mental illness issues need leadership. APA Monitor, p27.

FEATURE ARTICLE

A Developmental Approach to Psychotherapy Supervision of Interns and Postdoctoral Fellows

Nadine [. Knslow Catherine Gray Deering

The process of learning the craft of psychotherapy and developing an identity as a psychotherapist parallels the course of human devel-

opment. After briefly reviewing the

stages in the learning processes of psychotherapists-In-training, this article discusses the applicability of these stages to the psychotherapy training of psychology predoctoral regression to earlier

interns and postdoctoral fellows. De- stages when trainees

velopmentally sensitive guidelines for . . .

clinical supervisors are offered. are confronted Wlth

guidelines regarding the conduct of psychotherapy and case management. They may identify closely with admired supervisors, typically those whom they perceive as benevolent and support-

ive. Stage Three, which may begin several months later, involves activity and continued dependency. During this phase, therapists begin to recognize their patients' view of them as "Healers", which influences their eva! ving self-concepts as psychotherapists. During this phase, psychotherapy trainees become more active participants in both the psychotherapy and the supervision.

•. .superoisors can expect to see

new supervisory relationships and! or clinical

AI though less dependent on supervisors, trainees remain relatively

compliant, particularly during times of clinical crisis. Stage Four is marked by trainees' growing awareness of their identi ty as a real psychotherapist and an internalization of their role as "Healer". This shift is associated with movement into a phase characterized by exuberance and taking charge. Psychotherapy

Freidman and Kaslow (1986) delineate six stages in the learning and supervisory process based on psychodynamic and developmental conceptualizations. Stage One, en- responsibilities. titled excitement and anticipatory

anxiety, is characterized by both en-

thusiasm and apprehension regarding the impending initial contact with patients. Once trainees begin work with their first patients, they enter Stage Two, consisting of dependency and identification. During this phase, trainees are highly dependent upon supervisors for concrete

20

trainees in this phase feel more effective and competent professionally, more sensitive to transference dynamics, more interested in the explora tion of their own countertransference reactions both in the supervision and their personal psychotherapy, and more identified with a particular theoretical orientation. Stage Five, which may be termed identity and independence, finds psychotherapy trainees amidst their professional adolescence. It is during this phase that more overt or covert power struggles between trainees and supervisors are normative. The internalization of the supervisory and clinical work provides a secure base from which trainees can experiment with more autonomous functioning. Their professional identities appear more cohesive to others and are experienced

by trainees as better consolidated.

Stage Six culminates in a sense of calmness a bout psychotherapeu tic endeavors and collegiality with peers, senior staff, and supervisors. progresses, fellcnvs

Trainees have more accurate per- create their unique ceptions of their own strengths and weaknesses, as well as those of their supervisors. During this phase they have a greater potential for in depth examination of transference and countertransference dynamics and a renewed enthusiasm for explor- clearer professional

ing new interventions as they feel confident in their extant therapeutic repertoire.

As the year(s)

their abilities. Their confidence is undermined further by their awareness of the discontinuities between their academic graduate training and their clinical internship program and the role and status differences between psychology and psychiatry trainees and faculty/staff. As interns attempt to reconcile these differences, they may find themsel ves more dependent upon their psychologist supervisors.

During the middle of the internship year, most interns find themselves in the midst of Stage Four, characterized by exuberance and taking charge. It is this time of the internship year that trainees typically find the most stimulating and exciting. They appreciate the opportunities to

experiment with myriad approaches to psychotherapeutic treatment with diverse patient populations and to assume other professional roles (e.g., consultation).

The latter period of the internship is marked by concerns regarding issues of separation and individuation, typical of Stage Five described earlier. Atthis point in the year, interns feel the full force of what Kaslow and Rice (1985) have termed professional adolescence. Similar to the adolescent phase of the life cycle during which the crisis of identity is central (Erikson, 1968), the crisis of professional

identity is prominent here. The task is for interns to function as professionalsandasswnetheidentityof"Healer". During this phase, they function more independen tly, intervene more acti vely and directly with their patients, and become increasingly comfortable with challenging or disagreeing with their supervisors (Lamb, Baker, Jennings & Yarns, 1982). However, the uncertainties about their fu ture professionalli yes and the regression associated with termination may undermine this developing sense of a cohesive professional identity and heighten the struggle of "who am I"?

roles in their settings, roles that. typically reflect

identities and deepening comm

itment to the work.

Development of Pre doctoral Interns

Although the developmental phases most characteristics of predoctoral interns include Stages Three, FOUT, and Five, supervisors can expect to see regression to earlier stages when trainees are confronted with new supervisory relationships and / or clinical responsibilities. Most interns approach the training year predominantly in Stage Three, eager to be active professionals, yet needing continued supervisory guidance and support. The struggle between activity and dependency is complicated by the stresses associated with adjusting to a new program, developing a sense of trust in the training staff, carving out a niche for themselves in this new work environment, attempting to prove their competencies quickly (as they are only there for one year), and perceiving the need to demonstrate their strengths when they feel insecure about

Development of Postdoctoral Fellows

As increasing attention has been paid to postdoctoral training in psychology (Belar et al., 1993), the unique developmental issues associated with the postdoctoral experience are being articulated (e.g., Kaslow, McCarthy, Rogers &

21

Summerville,1992). If the internship year is akin to a professional adolescence, then the postdoctoral fellowship year(s) may be viewed as professional young adulthood and conceptualized using adult developmental frameworks (e.g., Erikson, 1982; Levinson, Darrow, Klein, Levinson & McKee, 1978). The transition from predoctoral internship to postdoctoral training is typified by continued movement through Stage Five (identity and independence) and into Stage Six (calm and collegiality).

parenting styles accordingly, so do psychotherapy supervisors need to tailor their interventions to their trainees' phases of professional development Regardless of trainee's professional maturity, psychotherapy supervision is most efficacious when supervisors provide a secure "holding environment" in which trainees can progress and regress as needed. Of course, the particular qualities contributing to this holding environment are influenced by the personalities of both the supervisor and the supervisee.

During Stage One, when trainees' anxieties are diffuse and high, the essential element of the holding environment is the

supervisor's accurate empathy regarding the supervisee's concerns and vulnerabilities (Freidman & Kaslow, 1986). This mirroring reduces trainees' anxieties sufficiently to enable them to begin the psychotherapeutic endeavor. The basic holding functions recommended for supervisors of trainees during Stage Two (dependency and identification) are to help trainees organize the clinical material and anticipate predoctoral interns. those experiences that may over-

whelm and confuse novice psy-

chotherapists. In the internship and postdoctoral training years, these supervisory stances may be necessary during early days of new rotations, particularly when trainees are confronted with new responsibilities vis-a-vis clinical setting (e.g., inpatient), patient type (e.g., acutely psychotic, dangerous), or modality (e.g., group).

Early during the postdoctoral training period, trainees may feel destabilized by the lack of clarity of the postdoctoral role, and

may feel overwhelmed by the ex-

pectation that they assume increasing responsibility with less supervision. During this phase, it is essential for them to negotiate effectively issues of autonomy, role expectations, and status. This process of negotiation for role delineation may evoke power struggles typical of Stage Five. Like an older adolescent or young adul t, the postdoctoral fellow wants to be given full credibility and status, yet feels insecure about assuming increased power and accountability.

Guidelines for Supervisors

... Stage Three

functioning characterized by

activity and

continued depen-

deney, is a common starting point for

Just as parents need to be sensitive to their children's developmental needs and alter their

22

As the year(s) progresses, fellows create their unique roles in their settings, roles that typically reflect clearer professional identities and deepening commitment to the work. They autonomously make and evaluate clinical decisions based upon more firmly internalized and well-articulated clinical frames of reference. Their future professional goals become more established, their professional "true" selves emerge, and they become more creative and spontaneous. It is during this time that fellows articulate accura te assessments of their own competencies, are less defensive and more open to exploring their own processes in supervision, become more comfortable with asserting their own styles even when they conflict with those in authority, and are more capable of developing and sustaining genuinely collegial relationships. These shifts in self-presentation are indicative of Stage Six functioning.

As noted earlier, Stage Three functioning characterized by activity and continued dependency, is a common starting point for predoctoral interns. It is most helpful to trainees in this phase if supervisory sessions are patient focused. While trainees may strive to integrate clinical theory and practice during these sessions, it is important for supervisors to bear in mind that students' attempts at more sophisticated understandings of the clinical material usually surpass their ability to grasp fully the vicissitudes of the work. Supervisors are effective when they convey acceptance by limiting their critical comments, offer specific recommendations, maintain a consistent affective tone in the relationship, and avoid becoming overprotective (Freidman & Kaslow, 1986). It is useful to acknowledge the clinical

challenges inherent in the interns' more active and autonomous roles without overstating the case and escalating their anxieties.

As psychotherapy trainees manifest the increased exuberance and ability to take charge typical of Stage Four, their energies during supervisory sessions may shift from a focus on technique and patient management to more in depth exploration of transference and countertransference dynamics in the therapist-patient relationship. This work may be most fruitful when attention is paid ~o the parallel processes in the supervisory relationship (Deering, in press; Friedlander, Siegel & Brenock, 1989). It is only during Stage Four and beyond that psychotherapist trainees are mature enough to reflect on these interpersonal dynamics without undue defensiveness.

Identity and independence, the key tasks of Stage Five, are paramount during the latter part of the predoctoral internship year and the early months of the postdoctoral fellowship. It is suggested that supervisors balance their support for the therapist's increasing autonomy with their continued availability as a guide. Su pervtsors should affirm trainees' competencies,aci<nowledgetheir unique identities and talents, and avoid unnecessary power struggles. Trainees in this phase need to be afforded maximal flexibility to function independently, while simultaneously acknowledging that their supervisors maintain ultimate accountability and responsibility for their clinical care.

During the postdoctoral training period, psychothera pists usually evidence a sense of calm, experience a cohesive professional identity, and engage in fully collegial relationships (Stage Six). In the context of these conditions, supervisees may focus more freely on countertransference dynamics as they provide invaluable clues about their patients and their own intrapsychic and interpersonal struggles (Friedman & Kaslow, 1986). This intensive self-scru tiny in supervision may appear indistinguishable from the psychotherapeutic process. Their sense of relative calm and grea ter maturity often is disrupted temporarily by the termination work necessary

to transition from student status to independent practice. If effectively addressed, this termination work further solidifies their professional identities and is accompanied by increased self-confidence and appreciation for the training experience (Kaslow et al., 1992).

REFERENCES

Belar, CD., Bieliauskas, L.A., Klepac, R.K., Larsen, K.G., Stigall, T.T., & Zimet,CN. (1993). National Conference on Postdoctoral Training in Professional Psychology. American Psych%gist,48, 1284-1289.

Deering, CG. (in press). Parallel process in the supervision of child psychotherapy. American Journal of PsychotJtempy.

Erikson, E. (1968). Identity: Youth and crisis. New York: WW.

Norton.-

Erikson, EH. (1982). The life cycle completed: A review. New York: Norton.

Friedlander, M.L., Siegel,S., & Brenock, K. (1989). Parallel process in counseling and supervision: A case study. JuurtUll of Counseling Psychology, 36,149-157.

Friedman, D., & Kaslow, NJ. (1986). The development of professional identity in psychotherapists. In P.W. Kaslow (Ed.), Supl!TT1ision and training: Models, dilemmas, and challenges (pp. 29-49). New York: Haworth.

Kaslow, N.J., McCarthy, S.M., Rogers, J .H., & Summerville, M.S., (1992). Psychology postdoctoral training: A developmental perspective. Professional Psychology: Researd: and Practice, 23, 369~75.

Kaslow, N.]., & Rice, D.G. (1985). Developmental stresses of psychologyintemship training: What training staff can do to help. Professional Psychology: Research and Practice, 23,369·375.

Lamb, D.H., Baker, J.M., Jennings, M.L, & Yarris, E. (1982).

Passages of an internship in professional psychology. Professional Psychology,B, 661-669.

Levinson, D.J., Darrow, CN., Klein, E.B., Levinson, M.H., & McKee, B. (1978). The satSOnS of fl man's life. New York:

Knopf.

23

FEATURE ARTICLE

Health Care Reform: An Update Ronald F. Levant

National Health Insurance has always been misunderstood. At a legislative breakfast a few years ago, a congressman told the assembled group of psychologists that he recently asked a group of people from his district, "How many want national health insurance?" and not one person raised their hands. He then asked, "How many want the federal government to pay for your health insurance?" and all raised their hands.

Even though the Clinton's have

made Health Care Reform their pri-

ority, the situation hasn't gotten any better, in terms of people understanding the issues, as a recent cartoon from USA Today indicates: A poll-taker asks a couple, "Do you think people really understand Clinton's Health Care Plan?" The husband replies, "Sure ... We've already joined an HBO."

Health Care Reform:

The October Draft Plan

What is the plan? And, more to the heart of the matter, whatis the mental health benefit? TheOctoberdraft plan "leaked" by a congressman to NY Times indicated that the mental health benefi t had the following components:

4. 120 days of intensive outpatient therapy (partial hospitalization).

5. Outpatient limits to be removed, and co-payment goes down from 50% to 20%, by the year 2001 if there are sufficient cost savings.

What is Wrong With This Proposal?

The problems with this benefit structure are the same problems that we have with the structure of most mental health benefits - namely, they are weighted too heavily toward inpatient care. Inpatient care consumes between 67% and 80% of the mental health dollar (depending on whose numbers you are looking at). Furthermore, the "skyrocketing" costs of mental health care that are often cited to justify intensive utilization review is due principally to inpatient care, particularly two segments of such care - the hospitalization of adolescents in private psychiatric hospitals and the inpatient treatment of

substance abuse. BryantWe1ch, The APA Senior Policy Advisor, and the Practice Directorate staff, have been hitting this issue hard, using the theme that the existing mental health system is a "Waste and Want system" - care is wasted on such expensive residential treatments, while many in need of mental health care go untreated.

The problems with

this benefit struc-

ture are the same

problems that we have with the

structure of most mental health

benefits - namely,

they are weighted

too heavily toward

inpatient care.

1. 30 outpatient visits are covered at 50%.

2. Screening, assessment, diagnosis are covered at 80%.

3. 30 days of inpatient care are covered at 80%; an additional 30 days provided if required if patient's condition liposes a threa t to their own life or the life of another individual," or for the management of psychopharmacological or somatic therapies. A third set of 30 days to be provided by 1/98.

24

But there is another point that needs to get made here. A very important point. Some of us have been hearing from highly placed officials in some managed care companies that there are too many of us, and that 30% of us will, and should, go out of business. Well, folks, in a sense they are right. But the sense in which they are right is one which ignores the economics of the mental health ben-

I am happy to announce that something has been done to correct this problem. The AP A lobbying effort has been successful in expanding the outpatient therapy benefit in assessment needs to

the Health Security Act which was be carefully defined released in early November. In addition to the 30 outpatient visits (which despite our efforts to lobby against this discriminatory provision are still covered at only 50%), the plan now includes a provision for can vertinginpatient days to outpatient visits at the ratio of four visits for one day, if the visits are designed to "prevent hospitalization or to facilitate earlier hospital release." This would allow up to

150 visits per year, which would greatly facili tate the outpatient treatment of difficult cases, such as families with distressed adolescents, whose treatment all-too-often over-emphasizes hospitalization.

efit, which we have said is so heavily, wastefully, and unnecessarily slanted toward inpatient care. Let's take an average and say that 75% of the mental health dollar goes to inpatient care. In this marketplace, there will be too many outpatient providers. If on the other hand the artificial barriers that give the advantage to inpatient treatment were removed, then the mental health dollar might be split between inpatient and outpatient something like 50-50, and, in that scenario, there would likely be a greater need for outpatient services, and, certainly no surplus of providers.

The Health Security Act of 1993 The Mental Health Benefit

sparsely populated rural areas, where hospitals are in short supply.

One hundred and twenty days of intensive outpatient therapy (partial hospitalization) are provided as before. The co-payment rises from 20% to 50% for the second 60 days. Conversion of the inpatient benefit also applies here, at the ratio of one inpatient day to two partial hospitalization days. The problem for rural areas also applies to this benefit.

As before, outpatient visit limits are to be removed, and co-payment will go down from 50% to 20%, by the year 2001 if there are sufficient cost savings.

Point of Service Option

The legislative

Another victory concerned the nature of the health plans that must be offered. The original plan required each "Regional Health Alliance" to offer HMO's, PPO's, and a "fee for service" option. The latter was very weakly encouraged, because the Clinton Administration wishes to do away with fee-for-service health care. APA's efforts have been successful in expanding the requirements for state plans to offer fee-for-service-altematives to managed care. In addi tion, and

potentially even more significant, the legislation now requires that all managed care plans offer a "point of service" (POS) option. POS options require the reimbursement of all qualified providers, whether or not they are part of the managed care plan's network. This provision will go a long way to help ameliorate the negative effects of restrictive panels.

language for

to insure that

it includes psychodiagnostic

and

neuropsychological testing.

Screening, assessment, diagnosis are still covered at 80%. The legislative language for assessment needs to be carefully defined to insure that it includes psychodiagnostic and neuro-psychological testing.

Thirty days of inpatient care are covered at 80%; an addi tional Stl days are provided if required to deal with a life threatening condition, or to stabilize the patient through pharmacological or somatic therapies, as before. The additional 30 days slated to be provided by 1/98 has been eliminated. The continuing emphasis on hospital-based care is a problem particularly for

Pre-emption of State Restrictions of Scope on Practice

The Clinton plan calls for the preemption of sta te practice laws that "restrict the practice of any class of health professionals beyond what is justified by [their) skills or training." This provision may be helpful to appropriately trained psychologists in gaining hospi tal privileges and prescriptive authority, and will also be helpful to health psychologists working in general medical settings.

25

'Where Do We Go From Here?

National health care reform has entered the legisla tive arena, and, as you know, there are several competing plans for health care reform. One piece of conventional wisdom that we have been hearing for awhile is that the Clinton plan is likely to be the "high water mark", as far as mental health is concerned. There are many in Congress who see it - particularly psychotherapy - as a frill, like cosmetic

surgery. In addition, as many of

you know, there are others in Congress who think Clinton's numbers are too optimistic, so there will be attempts to find things to cut, and in this environment mental health is particularly vulnerable.

AP A' s Efforts

so far we have been influential way beyond the size of our budget.

State Health Reform

Alongside with National Health Care Reform, there will be state health care reform, because a lot of the reformed heal th care system is going to be left up to the states. My state, Massachusetts, is both ahead of and behind many states in this

process. The reason for our singulari ty in this regard is that we enacted a plan, Universal Health Care, in the Dukakis Era, but delayed its implementation until 1995. Many are skeptical about whether we can afford that plan.

One area that I

want to underscore is the need for psychologists to

particpate in grass roots lobbying

AP A is geared up to fight this. The Board of Directors recently declared health care reform to be a top priority of the Association. A Commission on National Health Care Reform, headed by Bryant WeIch, was established in August to coordina te the various aspects of the cam-

paign. The Practice Directorate has

been heavily involved for over a year. Recently, the Science and Education Directorates have been brought into the fold, since the Clinton Plan has many implications for the training of psychologists and for the funding of behavioral research.

What You Can Do

One area that I want to underscore is the need for psychologists to participate in grass roots lobbying efforts, and to participate in the formal political process, by working with candidates on their campaigns, and by making financial contributions to

their reelection efforts, at both the federal and state levels. At the federal level. participate in the federal grassroots network, and join AAP-PLAN (Association for the Advancement of Psychology - Psychologists for Legislative Action Now). At the state level participate in the state grassroots network, and join your state psychological association PAC. This is an area that we psychologists have been slow to catch on to. But I cannot overstate its importance to our future viability as a profession.

efforts, and to particpate in the

formal political

As far as The Practice Directorate goes, as a result of the $100 for 100 days fundraising drive which bra ugh t in over 1.2 million dollars (and to which you can still contribute if you have not yet done so), contributions from the APA general funds, and a special levy of payers of the special assessment in 1994, we anticipate a war chest of over 3 million dollars. Will this be enough? Who knows. Given the size of the budgets of some of the other organizations competing for their special interests in health care reform, it is small potatoes. But

26

process ...

I. This article represents the Clinton Adminis tration's proposal for the Heath Security Act as it existed on 11/ 30/93. The situation is fluid, and parts of the proposal may have changed by the time this articleispub/ished.

1994 MID-WINTER CONVENTION SCHEDULE:

Executive Committee Meeting

Board of Directors Meeting

Date:

Time:

Room:

Wednesday, March 9,1994 3:00 pm - 6:00 pm

Hopi

Date:

Time:

Room:

Date:

Time:

Buffet Dinner (Working Dinner) & Retreat Room:

Date:

Time:

Room:

Wednesday, March 9, 1994 6:00 pm - 8:00 pm

Hopi

Publication Board Meeting

Date:

Time:

Room:

Wednesday, March 9,1994 2:00pm

Mesa

Date:

Time:

Room:

Thursday, March 10, 1994 10:00 am - Noon

Hopi

Thursday, March 10,1994 2:00 pm - 5:00 pm

Hopi

Membership Meeting

Friday, March 11, 1994 4:00 pm - 5:00 pm Cochise

The Mid-Winter Convention

of the Divisions of Psychotherapy (29), Independent Practice (42), and Family Psychology (43) of the

American Psychological Association

March 1(}-13, 1994 Mountain Shadows Resort and Golf Club Scottsdale, Arizona

Theme of the Convention:

"Practicing Psychology:

Celebrating Our Value and Values"

For information contact:

Mid-Winter Central Office 3875 N. 44th Street, #102 Phoenix, AZ 85018 Phone (602) 952-8116 Fax (602) 952-8230

William Fishburn, Ed.D.

Mid-Winter Co-ordinator

27

Division 29 Executi

Gerald Koocher congratulated Richard Mikesell

on the 1993 Membership Campaign.

The Division of Psychotherapy presented Dr. Richard H. Mikesell with a token of their appreciation forasuccesful membership campaign.

EC members share a smile during the December meeting in Washington,D.C.

e Committee Meeting

10 & 11, 1993 gton, D.C.

Patrick DeLeon discusses the National Health Care Reform

I to r

Reuben Silver Tommy Stigall Stanley Graham.

1993 Executive Committee

I to r - Linda Campbell, Bulletin Editor; Reuben Silver, Past President; Tommy Stigall, Pres-Elect; Alice Rubensiien, Treasurer; Patricia Harrigan-Farly, Secy; Gerald Koocher, 1993 President; Mathilda Canter, Liaison; Stanley Graham, Pres-elect designate.

I j

Bryant Welch brings the Division 29 Executive Committee 'IIIIIIIIIIII up to date on developments surrounding the National Health Care Reform Act.

8000 7942
7000
6000
5000
4000
3000
2000
1000
0
1984 1985 1986 1987 1988 1989 1990 1991 1992 1993
30 DIVISION OF PSYCHOTHERAPY (Division 29) BECOMES APA'S SECOND LARGEST DIVISION

Richard H. Mikesell, Membership Chair Gerald P. Koocher, 1993 President Tommy T. Stigall, 1994 President

As a result of a comprehensive membership campaign conducted in the spring of 1993. the Division of Psychotherapy is now APA's second largest division. In response to a special membership offer the Division of Psychotherapy's membership increased by 2685 new members in 1993.

According to Richard H. Mikesell, Division 29 Membership Chair. "We are very pleased with the results which reflect the status or the Division of Psychotherapy in the field of psychology."

The following shows the year end (December 31) membership of Division 29 for the last len years.

FEATURE ARTICLE

Individual Psychotherapy in Chronic Disease I Bruce Schell

When disease strikes, it has an impact on the person tha t far exceeds the limits of the disease's symptoms. The more debilitating, chronic, life threatening or stigmatizing the disease, the more profound the impact. This series of three articles will explore the role of psychotherapy in moderating the disease course and alleviating some of the pernicious psychological effects of disease. The first article (this issue) will explore general issues and changes brought on by chronic disease; the impact of chronic disease is an interaction between the disease, "host" factors, and the patient's environment. The second article will consider treatment approaches and strategies to alleviate the effects of chronic disease upon the person. The third article will examine the physical and psychological impact of a specific disease and the role of psychotherapy in its treatment.

Chronic disease, whether it is rheumatoid arthritis, cancer, diabetes, or AIDS changes basicphysiological, psychological, and social parameters. The majority of patients adapt to their disease and its impact without requesting psychological assistance or being seen as in need of such assistance. However, the fact that the patient and the physician do not ask for help doesnot necessarily imply the need is not present. For example Frasure-Smith, et.al, (1993) demonstrated with patients who had suffered a heart attack that more seriously depressed patients had a significantly increased risk of premature death compared to non-depressed controls who had a similar heart attack. In that study 16% of the patients met criteria for major depression though only 8% were independently referred for "psychiatric consultation". A significant minori ty of patients' adjustment to the massive changes caused by chronic disease are at the sake of their quality of life and are accompanied by symptoms of their disquiet: noncompliance with medical treatments, failure to recover, excessive demands on the health care system, hostility, anxiety, and depression.

We may consider a person as composed ofphysical, emotional, psychic, and spiritual components. First I will present some general ideas on

health and disease as part of the background to my approach to each of the component areas of the person. Health is not an all or none phenomena, and disease onset, in general, is related to impaired ability of the organism to "fight off" the disease. Diseases, like accidents, are not randomly distributed, particularl y for adults in their middle years, but are an indica tion that the self / organism's ability to ward off disease was compromised. In a sense we each have a finite amount of resistance to life stressors. We each have a finite capacity to ward off the onslaught of pathogens in our environment once the disease process has started and to adapt to the effects of these pathogens. This finite amount is unique to each of us and is made up of a mixture of our genetic heritage, life experiences, support systems, and other health factors. Once we are struggling with disease, part of the task is to maximize our available resources to handle the di sease and its consequences. Factors that help to maintain and enhance health include: (1) diet, (2) exercise, (3) social relationships, (4) optimism, hope, etc., (5) early environmental effects at a psychological and physical level, (6) rest, (7) available financial resources. The research literature reveals the beneficial effects of a healthy lifestyle and the deleterious effects of violations of anyone of the above. Each area might be parceled ou t to a specialist and the ind ividua I can be dealt with piece-meal, or one professional might handle the vast majority.

I am not suggesting that we need to be experts in nutrition, physical therapy, etcetera, rather that, in working with the patient with a chronic disease our approach should be holistic. Engels (1977) described this approach when he called fora change in the wayhealthcarewasdelivered.

The psychologist is in a unique position to help patients evaluate the adequacy of their lives in each of those areas and to help provide the proper motivation for them to work out what maintains less than optimal health habits. I specifically used the term optimal to distinguish it from a goal of restoration of previous functioning. We as organisms have a great capacity to tolerate

31

poor health habits. We can consistently eat crummy diets, not exercise, ignore our needs for rest, etc. and see little apparent ill effects. This is particularly true for people in their 20' s. Formost people, sometime in their 30' s or 40' s, the cumulative effect of a lifetime of stressors begins to become apparent and the organism's capacity to tolerate abuse is impaired. Chronic disease places a tremendous strain on individuals, their social environment and sense of self. The chronicity of the stress gradually demands an increasing share of the person's available energy. To have the possibility of optimizing quality of life, patients must be hel ped to explore how to

maximize their remaining capac-

ity. Working with individuals at

this basic level helps them define areas of their life that they can continue to control which has beneficial effects (Antonosvky, 1992, Kobasa, 1982).

self-limitations and into our potential complexity. The great stories of our existence and our hope are lost if we remain trapped within the narrow confines of a limited biomechanical viewpoint. As we move from dealing with ourselves as a broken biomechanical object into the fullness of our human possibility, we can begin to connect our story with the great stories that have proceeded us. At that point, our unique tragedy becomes part of the fate of every human. The great dramas of our collective history then serve to illuminate our particular suffering and to remind us that even our suffering grounds us in

our species history. The movement away from a narrow alienating identification with the ex-

perience, to knowing it as part of the human condition tends to alleviate some of the bitterness. Instead of isolating individuals from life, their disease plunges them more deeply into it.

Chronic disease places a

tremendous strain

on individuals, their social

In addition to optimizing the physical health dimensions, we are also helping them develop a new relationship to their bodies and their symptoms. The contrast between traditional approaches to chronic disease and what I am describing has been

described by Ernie Benedict

(1989), a Mohawk elder: "The difference that exists is that the white doctor's medicine tends to be very mechanical. The person is repaired but he is not better than he was before. It is possible in the Indian way to be a better person after going through a sickness followed by the proper medicine."

Disease catapults us out of the realm of the known. Old goals, plans, and hopes suddenly seem impo ssible and lor irrelevant. We are forced to find a new way te make sense out of existence whid:

often requires that we explore ourselves at deeper depths than we have ever imagined. From the realization that we will never be as they were, we enter a world in which our healing involves finding a nev purpose and meaning to life, amidst the wreckage of the old. At the same time, we mus: struggle with the impact of our disease's sym~ toms and search for healing for our disease. It L no easy task. The known parameters of life have been changed. Relationships with loved ones are different. We are no longer a healthy, well person with all the benefi ts tha t confers. We are now the patient, the sick one, and roles have beer. changed. Our patienthood is now appended tc each of our roles. We are now a sick mom, sick dad, sick lover, sick employees, sick child, sick friend, etc. We are forever changed into someon who is sick.

environment and

sense of self.

A frequent benefit of successful psychotherapy is that the pa tient becomes a better person. For the patient with a chronic disease an important additional benefit may be to discover a meaning, often a transcendent one, that relates to the disability.

Every symptom brings with it a rich lushly detailed story filled with the twists and turns the symptoms have imposed upon mind and body. It is a story tha t frequently remains unfelt, unexpressed, and unknown in the patient's preoccupation with the limited biomechanical aspect of existence. It is the story that describes our losses, our craven fleeing from the overwhelming, and our heroic facing of the same. This story is the stuff of fairy tales and epics. It requires that we move out of our culturally imposed

32

Our sense of "I", our basic ego structure, is firs. and foremost based in the body. Freud was the first to comment that the structure upon whic our ego develops is that of the body. In observinz childhood development the child moves from a: inability to differentiate the environment' - beginning to differentiate it. The initial differeztiation is between the body and that which is

\

body, i.e., between self and not self. The self at this point is the bod y based self. Our sense of self is deeply linked to the known parameters of our own body and to the rhythms of that body. The rhythms of sleeping and waking, of activity and inactivity, of sexual excitement and its passing, and of a certain level of energy. There is generally enough flexibility to allow for minor deviations from this, as in the face of acute illness. Chronic disease, however, permanently changes our relationship to all of these parameters and with that changes fundamental aspects of our sense of I. We are thrust into an adaptation process which becomes increasingly difficult as more fundamental aspects of the former sense of self are disrupted. Weare frequently ill equipped to deal with the host of problems that arise and there are no cuI tural rituals to guide the way. The cultural assumption that our self is not changed by chronic disease compounds the difficulties inherent in surmounting these problems and integrating our changes.

I shall now tum to a few central ideas related to educational features of thepatient/psychotherapis t rela tionshi p tha t fadli tates the adjustment to disease and successfully working in psychotherapy. We are a pain-avoiding culture and have developed a host of methods to avoid any dysphoria; including addiction, overuse of prescribed medication and dissociation in its many guises. Patients, we, need to leama new relationship to our dysphoria. That involves beginning to teach that dysphoria is a signal to be attended to and that there is value in attending to it. For example, the pain of a twisted ankle tells us to not walk on that leg while the pain of a broken heart directs us to grieve our loss. Mentally, part of the educational process is to teach that disease is not an enemy to be overcome. It is this line of reasoning that converts the natural changes that ensue from disease or the aging process into signs of losses and evidence that we have fallen to the wayside in some grand battle. A frequent stage in treatment is the acknowledgement that at an essential level they did not cause their disease. However, to remain at that stage often results in an over-identification of the self as a victim which greatly restricts their healing and the movement into an identity that more fully encompasses their possibility and reality.

Frequently, the patient must be educated about the goals oftreatment and the methods involved. There is a tendency to view psychotherapy as predominately aimed at uncovering pathology

and unresolved issues and then working them through. With the patient who presents with chronic disease and disability, I have found a focus on mobilizing resources to maximize the strength and assets of the patient more effectively as it tends to more quickly contact the innate healing resources of the patient. In this way of working with patients there is more emphasis on heal th and healing, instead of pain and catharsis, in strengthening the patient's somatic awareness, instead of ego strengthening.

Disease imposes a relationship. It may not be a desired relationship, but is a relationship, none the less and there are attendant emotional reactions that not infrequen tl y affect the course of the adjustment to the disease and, at times, disease outcome.

The human organism is self-regula tory and reactive to its environment. As organisms we adapt to our environment in overt behavioral change and at basic cellular levels. The information for our adaptation includes material we are conscious of and material that is out of conscious awareness. For example, if over time we are deprived of enough calories to maintain body weight the organism begins to more efficiently utilize available calories (Willard, 1991). Without need of conscious thought the organism makes a number of complex biological changes in the face of the information, not enough calories. Further, at the organismic level we learn tha t the next time we recei ve the information, not enough calories, to more rapidly shift to a calorie conserving mode. This specific self regulatory capacity is the bane of dieters. Just as somatic conditions like hypothyroidism or pancreatic cancer can affect mood, it is dear that psyche can affect disease morbidity and mortality. Numerous studies have demonstrated the impact of mood and personality characteristics on the human organism (for example Levy er.al., 1988; Temoshok and Dreher, 1992; and PettingnaIe, ] 984). Wha t we do and what we think, over time, influences psyche and soma.

We will now look at the affect of chronic disease on the emotional self, the psyche, the physical self and the spiritual self. EmotionalLeuel: Erving Goffman (1963) in his book Stigma described in some detail the impact of being stigmatized upon the sense of self and social rei a tionships. A major stigma results in more marginal social relationships and a more ambivalent relationship to the self. A concomitant of that is frequently a sense of shame and not infrequently a desire to avoid

33

relationships. Varying studies have suggested that there is a fairly pronounced increase in anxiety and depression in relationship to chronic disease. The frequency of depression, for example, tends to be related to the sense of loss of control over one's life, the unpredictability of symptoms, and a loss of mobility. A normal adaptation process takes place as the patient adjusts to each new loss, which precipitates another emotional reaction. The emotional reaction tends to be similar to the previous emotional reaction; that is, if the person became depressed at the last loss, they will tend to become depressed again.

Stress is a normal concomitant of

chronic disease. The degree of stress is related to the amount of change required, the predictability or lack of predictability of the disease itself and the capacity of the individual and his/her sodal environment to flexibly adapt. Wi th chronicity, even minor stressors may produce increasing distress internally. This affects the immune system, decreasing its ability to protect the organism (for example Sieber et.al., 1992; Ader and Cohen, 1993). Prolonged stress is likely to put the individual at increased risk for other diseases normally controlled by

the immune system ranging from

colds to cancer. Chronic stress narrows the sense of options, increases dysfunctional behavior, and tends to override the optimum behavioral solutions in favor of increased food, drug, or alcohol consumption. Another important component in the affective domain is that of hope/hopelessness. The question that must be immediately raised is hope for what? Is there hope for a total recovery from disease? Is there hope for freedom from pain? Is the hope for peace and understanding? Is the sense of hopelessness coming from too narrow a vision of possibilities? Is it coming from the health care providers having carefully avoidedgivingfalsehopeandthereforeunknowingly giving the patient hopelessness?

ploration of their new relationship with them selves, their intimates, and the world. This is a: exploration that includes the search for the po tive as well as the negative. Part of the work, a this stage, is helping people to begin to know tha, their losses are in a context that recognizes tha:. their fate is the fate of all. A not infreque - outcome at this stage is for individuals, ove time, to become more accepting, less driven, anc to have an increased capacity to be intimate anc, love. However, some people become more bitter, angry, and disillusioned by life. This tends tc be an exacerbation of pre-morbid personalir

features. These people use their disease as confirmation of previ ously held beliefs about them selves and about life.

The frequency of

Physical level. In the face of <L chronic disease there is a power ful emotional change in relation ship to the disabled. part. It is rar for this to be a positive chan rather, this frequently involves sense of betrayal, anger, rejectior A given of life is that our bodi work fairly well. When our boo: ies no longer do so, there is a pre found sense of shock and loss :may be manifest in a subtle abazdorunent of the body or of disabled body part.

depression, for .

example, tends to be related to the sense of loss of control

over one's life, the unpredictability of

symptoms, and a loss of mobility.

Psyche level. Chronic disease literally changes people's relationship to themselves and all aspects of their world. The degree of change is related to the extent of adjustment necessary. An important task at this level is to validate sense of loss and other feelings individuals have about the disease. This is facilitated through the ex-

34

Part of the work, at this level, is support the exploration of a changed body ar learning this new body's abilities. The prima; obstacles are the desire to have the former hoc back and avoidance of the necessary stages - learning one's relationship to this new body.

Supporting and encouraging the long-term vieof rehabilitation versus the short-term results often valuable in helping people discover ho again.

Just as primary patients have been dramaticaf impacted by disability so have their caretaker and loved. ones. The more profound the impa on the patient, the more profound the impact on those individuals. Some research sugges that caretakers are more highly stressed, t:lE patients. Work with this population may invol educating them about the psychological im

of chronic disease on care givers and care reeer ers, This information may help to moralize reactions, short term crisis intervention d relationship or disease transition, family ~

therapy as the family struggles with changes in roles, expectations and futures.

S~rituallevel. Psychologists have traditionally s ied away from addressing this dimension. However, we are a nation that overwhelmingly believes in a higher power. Job's lament "Why me 0 God?" is, at some level, the cry of every patient with chronic disease. The answer, that satisfies, is found in the exploration of the patient's spiritual and existential foundations. Across the major religions there are traditions that treat disease as a teacher of transcendent meanings. To understand chronic disease as having a purpose changes it from a random, unknowable, meaningless accident to an event that has meaning, purpose, and is partially knowable.

We are experts in the treatment of the human response to adverse events. However, until the last few decades we have not included medical illness among the adverse events treated by psychologists. Across cultures and throughoutmuch of western history disease has been understood as a biopsychosocial event and treatment proceeded accordingly. We are in the midst of returning to that treatment viewpoint both to provide palliative relief and to promote healing. I have suggested. that psychologists take an acti ve role in assessing whether patients are utilizing all their capacity to heal at psyche and somatic levels. This involves an active collaborative relationship with other members of the health care system including physicians, nurses, and physical therapists. Maximizing the ability to heal at the psyche level includes coming to grips wi th the impact of chronic disease on the sense of self, ad justing to a new self, and working through social, physical, and temporal changes. At the somatic level the psychologists may promote healingthrough supporting dietary changes, new exercise regimes, biofeedback, relaxation approaches,and through use of focused imagery to

promote specific healing. This article has touched upon some general features of chronic disease and its psychological treatment, in the next article we will examine some specifics of treatment.

REFERENCES

Ader, R. and Cohen, N. (1993). Psychoneurolmmunology:

Conditiening and stress. Annual Review Psychology, 44, 5~5.

Antonovsky, A. (1992) Can attitudes contribute to. health?

Advances, 8(4), 33-49

Benedict, E., in Achtenberg, J.(1985) [17lQgery in Healing.

Boston: New Science Library.

Engel, C. (1977) The need for a new medical model: A challenge fer biomedicine. Science, 196, 129-136.

Frasure-Smith, N., Lesperance, F., Talajic, M.(1993) Depression follewing myocardial infarction. Journal of the American Me.dica/ AsSllCiatian, 270(15), 1819-1825.

Go.ffrmm. E. (1963) Stigma. New Jersey: Prentice Hall. Kobasa.S.(1982) Commitment and copingin stress resistance among lawyers. Journal of PerSllM.lity and Social Psychol- 0gy/42,7r1l-717.

Levy, 5., Lee, J., Bagley, C, and Lippman, M.(1988) Survival Hazards Analysis in First Recurrent Breast Cancer Patients: Seven-year Fellow-up. Psychosomatic Medicine, 5O,5~528.

Pettingaie, K.W.(l984) Coping and Cancer Prognosis, JourlUll ofPsych05OT1latic Research, 28, 363--364.

Sieber, W., Rodin, J., Larson, L., Ortega, S., Cumminggs, N., Levy, S., Whiteside, T., and Herberman, R (1993) Modulation of human natural killer cell activity by exposure to uncontrollable stress. BTain, &hatlior ,and Immu.nity, 6, 141-156.

Temoshok, L. and Dreher, H.(1992) The Type C Connection.

New York: Random House.

Willard, M.(1991) Obesity: Types and treatments. Archives of Family Practice, 43,(6),2099-2108.

FEATURE ARTICLE

Documentation Guidelines and Ethical Practice in Psychotherapy Jeffrey E. Barnett

A new set of guidelines have recently been promulgated which have a direct impact on now AP A members document the services they provide. These Record Keeping Guidelines (AI' A, 1993) provide general guidance on minimall>:: acceptable standards as formulated by AP A s

Committee on Professional Practice and Standards (COPPS). It is reported that these guidelines reflect a compromise position on the widely held views of psychologists on documentation. While many practitioners may feel that documentation requirements are intrusive and un-

35

needed, the realities of the healthcare marketplace in recent years have necessitated such guidelines. In addition to reviewing the specific guidelines and discussing ways to effectively meet them, this brief article will attempt to illustrate the potential benefits of adhering to such guidelines.

ing these goals. He cites several steps clinicians must take to meet the profession's reasonable standard of care (Simon, 1988). It is pointed out that most. experts (e.g. Harris, 1990) see a cri tical relationship between effective risk management and the important elements of documentation and consultation. It is further stated that these "two elements are the twin pillars of liability prevention and that good documentation provides a durable contemporaneous record, not only of wha t happened, bu t of the exercise of themental health professional's judgement, the risk-benefit analysis, and the patient's ability to participate in planning his or her own trea tment" (Guthiel, 1990 in Bongar, 1992). By using adequate documentation the clinician may have a

tangible record which helps verify actions taken to meet the reasonBy using adequate able standard of care.

These new guidelines are based in part on the General Guidelines for Providers of Psychological Services (AP A, 1987) and on relevant sections of the Ethical Principles of Psychologists and Code of Conduct (AP A, 1992). It is not intended that psychologists will use these new record keeping guidelines in place of the Ethical Principles of Psychologists and Code of Conduct, but along with them. It is important to

understand that the record keeping guidelines are intended to provide psychologists with guidance and minimal standards toconsider in decision making. Psychologists are ca u tioned to consider the spirit and intent of these guidelines when making decisions relevant to the documentation of psychological services. Additionally, psychologists must consider relevant state la ws as many states ha ve statutes of relevance to documentstion, record retention, record disposition, confidentiality of records,

and related issues.

documentation, the

Bongar further points outthat "psychologists must be aware of the vital importance of the written case record. In cases of malpractice, courts and juries often have been observed to opera te on the simplistic principle that if it isn't written down, it didn't happen" (pp. 24-25). He further strongly states that "there is no substitu te for a timely thoughtful, and complete chart

record .. " (p.2S). .

A second reason, and potential benefit, for actively follOwing these record keeping guidelines concerns the Ii tigious environment in which psychotherapists now find themselves functioning. It is widely accepted that the written clinical notes are typically the psychotherapists's only record of what actually transpired in treatment. Many psychologists have found that thorough documentation has proven invaluable in legal proceedings. Many recent ethics complain ts and malpractice suits have addressed the quaIi ty and appropriateness of services provided. Psychologists are obligated to meet a certain standard of care and level of competence in the treatment they provide (see Standard 1.04, Boundaries of Competence and Principle A: Competence, AP A, 1992). Without adequate documentation, the psychotherapist has little chance of proving just what treatment actually occurred, the rationale and appropriateness of the techniques utilized, and the patient's response to trea trnent, As stated by Bennett et al, (1990) "Records can provide factual information on a case requiring evidence

clinician may have a tangible record which helps verify

actions taken to

meet the reasonable standard of care.

Some psychologists might question the need for such guidelines and wonder why this issue is being given this level of attention. Several authors (e.g. Barnett, 1991; Bongar, 1992) have highlighted several of the reasons for giving great attention to how clinical work is documented. One issue is that adequate documentation hel ps a clinician to provide a tangible record of services provided. This often proves helpful to the psychotherapist in treatment planning, monitoring progress, and documenting risk management efforts. Additionally, as a result of maintai ning adequate documentation throughout the course of treatment, many psychotherapists find that they are then in a better position to respond to the requests of utilization review organizetions and managed care entities.

With regard to the issues of effective risk managernentand providing appropria te care, Bongar (1992) has illustrated how appropriate documentation assists the psychotherapist in accomplish-

36

of meeting the standards of care." Without adequate documentation it is often most difficul t to prove what actually occurred in treatment (p.76).

As pointed out by Weiner and Wettstein (1993) "Courts and external review bodies view the absence of documentation in the record about an event as evidence that it never occurred, no matter what the subsequent claims of the clinicians" (p.179). They further comment that "An inadequate record will itself be seen as evidence of sub-standard care, no rna tter what care was actually provided" (p.179).

At times the issue of treatment outcome is secondary to the rationale behind a clinician's decision making. While psychotherapists cannot guarantee an effective outcome to all treatment, the decision making process uti-

lized in selecting one particular

treatment approach over another

is often crucial in helping to demonstrate a good faith effort to meet the reasonable standard of care. Thus, documenting the decisionmaking process, to include why one treatment alternative was selected over another, may at times prove very helpful to psychotherapists. As further pointed. out by Weiner and Wettstein, "Records are most useful when they reveal the clinician's thinking and decision making about the patient's care rather than simply documenting that it occurred (p. 179).

to that patient's treatment should be documented along with all treatment contracts and agreements. It is also important to document all consultations with other healthcare providers, supervisors, and colleagues, detailing the issues addressed, the reasons why, recommendations made, and the outcome.

These guidelines also point out that documentation must be of sufficient detail to meet a variety of objectives. As discussed earlier, this may help the psychologist to provide better care and to meet ethical and legal requirements. It may also be of help in meeting the requirements of insurance companies, utilization reviewers and third party payers. Additionally, the records may be utilized by other psychologists or health care providers. Adequate documenta tion may prove

to be of great value to a former patient who seeks treatment at a later date. As pointed out in sec-

tion 1: Content of Records, the detail should be "sufficient to permi t planning for continui ty in the event that another psychologist takes over delivery of services, including in the event of death, disability, and retirement" (p, 985). The ultimate goal of these requirements is to benefit the pa· tient or client by ensuring both better treatment and a continuity in the care provided.

... all contacts with

other persons relevant to that

patient's treatment should be docu-

menied along with all treatment

contracts and

agreements.

In addition to the relevant clinical information to be included in the treatment record, it is also important to include all written agreements, contracts, financial arrangements, and

any release of information obtained. It is important that patients make fully informed decisions in treatment. A fully informed written consent to treatment that stipulates possible limits of confidentiality and possible uses of the inforrnatlon contained in the record are important as well. As discussed in the record keeping guidelines "These guidelines assume that no record is free from disclosure all the time, regardless of the wishes of the client or the psychologist" (p.985). Psychologists therefore take grea t care in constructing the written record only including information pertinenttothetIeatrnentbeingprovided. Care should be taken to "adequatelyidentify impressions and tentative conclusions as such" (APA, p.98S). In recording the psychologist's observations it is important to rely on behavioral descriptions of a

37

In one national survey of the im-

pact of the increased threat of malpractice litigation on clinical practice (Wilbert and Fulero, 1988) practitioners detailed steps they have taken to protect themselves. Of those surveyed 62 % sta ted that they are more likely to inform clients of the specific limits of confidentiality at the outset of treatment and 54% reported that they keep more thorough records as a direct result of the risk of malpractice litigation.

Specific issues to be included in developing adequate documentation of services provided are detailed in the record keeping guidelines. These incl ude a record of all patient contacts, the rationale behind treatment decisions, the patient's response to treatment interventions, and 0ngoing progress or difficulties encountered, Additionally, all contacts with other persons relevant

patient's behavior, attitude, and effort rather than statements laden with value judgements and personal opinions.

It is helpful to consider Weiner and Wettstein's guidance that "Generally, specific observations about the patient are more useful to those who may review the record at some future time than the clinician's impressions about the patient; which will be difficult to interpret" (p. 179). Again, care should be taken not only because others may have access to the record for review purposes, but also to help ensure that the record is as useful as possible if utilized in subsequent treatment efforts for a patient.

complete record for a period of three years after treatment has been terminated. Additionally, a written summary of the patient's treatment or the complete record itself must be maintained for an additional 12 year period. With regard to minors, the complete record must be maintained until the patient reaches three years beyond the age of majority. Relevant state law should be consulted for the definition of the age of rnajori ty in that jurisdiction.

These guidelines very clearly state that these record retention requirements are to be adhered to only in the absence of relevant federal, state,

and local laws. In one state, Maryland, for example, psychologists are required under licensure laws These record keep- to maintain the complete trea tment record for at least a period of five years. Psychologists should consult the relevant laws in individual jurisdictions for similar guidance.

Psychologists should also take care to document services provided in a timely manner. Should this not be possible for some reason the record should then include the date the service was provided as well as

the date (or time) that the notes maintain the com-

were written. Additionally, rea- plete record for a A final area addressed in AP A's

sonable care should be taken to Record Keeping Guidelines is tha

ensure the confidentiality of period oj three years of the disposition of obsolete records. This includes limiting ac- ft h records. The point is made tha

cess to records by unauthorized a er treatment as "When records are to be disposed

individuals, ensuring adequate been terminated. of, this is done in an appropriate

storage of records, striving to main- manner tha t ensures nondisclosure

tain control over any release of in- (or preserves confidentiality)" (p,

formation contained in clinical 986). Similarguidance isprovided

records, as well as guarding against the misuse of in Standard 5.04, Maintenance of Records, of the records. The record keepingguideUnesacknowl- Ethical Principles of Psychologists and Code of edge that there may be institutional constraints Conduct which states: "Psychologists maintain and state laws which may impact on these ef- appropriate confidentiality in creating, storing. forts. Psychologistsmust be aware of such guide- accessing, transferring, and disposing of records lines, rules, and laws and work within them to under their control, whether these are written, best achieve these goals. automated, or in any other medium" (p, 1606). Thus, great care must be taken to ensure that in the process of disposing of outdated, obsolete, or otherwise unneeded records that others are not provided inappropriate exposure or access to these records. The "Psychologist's Legal Handbook" (Stromberg, et al., 1988) recommends that records not simply be placed in the trash, since methods of trash collection an disposal can be haphazard and can result in confidential rna tenals being seen by others. Instead, it is recommended that records be shredded or otherwise destroyed (p, 403). And again, as is indicated throughout the Ethical Principles of Psychologists and Code of Conduct as well as the Recore. Keeping Guidelines, psychologists are ref ~ to relevant local, state and federal laws to

ing guidlines require psychologists to

When aspects of a clinical record have become outdated, these guidelines provide dear guidance to help prevent a misuse of that material. "Psychologists ensure that when disclosing such information that its outdated nature and limited utility are noted using professional judgement and complying with applicable law" (p. 985). In some states, healthcare providers may withhold information from a treatment record when such release is fel t to be harmful or not otherwise in the patient's best interest in the provider's opinion.

Clear guidance on record retention is provided in these guidelines as well. These record keeping guidelines require psychologists to maintain the

38

compliance. Both of these documents make it clear that they are not intended to supersede or otherwise be used in place of relevant laws.

It is hoped that by adherence to these guidelines psychologists will be assisted in providing better ongoing and future care. Additional benefits include helping psychotherapists to meetutilization review and other third party reviews along with providing assistance in demonstrating that the reasonable standard of care has been met in cases where litigation or other challenges to the appropriateness of care are raised.

REFERENCES

American Psychological Association. (1987). General guidelines for providers of psychological services, American Psyclwlogist, 42, 1-12.

American Psychological Association. (1992). Ethical principles of psychologists and code of conduct. American Psyclwlogist, 47, 1597-1611.

American Psychological Association. (1993). Record keeping guidelines. American Psychologist, 48,984--986.

Barnett, J.E. (1991). Ethical guidelines for documentation in psychotherapy and supervision. TheMaryland Psyclw/ogist, 5,7-9.

Bennett, B.E., Bryant, B.K., Vanden Bos, G.R. & Greenwood A. (1990). Professional liability and risk management. Washington, D.C,: American Psychological Association.

Bongar, B. (1992). Effective risk management and the suicidal patient. Register Report, 18, 1, 3, 21, 22-25.

Gutheil, T.G. (1990). Argument for the defendant-expert opinion: Death in hindsight. In RI. Simon (Ed.) Review ofOinical Psychiatry and the Law (pp. 335-339). WaShington, D.C: American Psychiatric Association.

Harris, EA (October 1988). Legal issues in professional practice.

Workshop materials for the Massachusetts Psychological Association, Northampton, Massachusetts.

Simon, R.I. (1988). Concise guide to clinical psychiatry and the law. WaShington D.C.: American Psychlatric Press.

Stromberg, CD., Haggarty, D.J., Leibenluft, RF., McMillan, M.H., Mishkin, E., Rubin, B.L., & Trilling, H.R. (1988). The psychologist's legal handbook. Washington, D.C: The Council for the National Register of Health Service Providers in Psychology.

Weiner, B.A. & Wettstein, RM. (1993). Legal issues in mental health care. New York: Plenum Press.

Wilbert, j.R, & Fulero, S.M. (1988). Impact of malpractice litigation on professional psychology: Survey of practitioners. Professional Psychology: Research and Practice, 19, 379-382.

FEATURE ARTICLE

APA and Psychologists' Future in Managed Care Carl N. Zimet

It appears likely

that each state will

have considerable

power in designing and implementing

its own plan, possibly even a single

It has been a relatively short period of time in which the world of heal th care coverage has been turned upside down. In the early

1970s, it appeared that a national health care plan was about to be passed by Congress and signed by the President. Not a single bill of the many that were introduced in Congressatthat time included psychologists as independent providers. Under the most favorable bill, psychologist could be reimbursed for services only on referral from a physician,

The national health plan failed at the last minute and a radical shift occurred. Health care was taken

over by corporate-for-profit busi-

nesses. With it came a shift in thepowe:r relationship between the provider of health care services a nd the health care industry. The centerpieces of these new health care firms was managed care

which provided the financial power and control to dictate treatment variables.

The Clinton health security plan is now on the table. While the final picture is yet to emerge as it gets modified by Congress, this new national plan will, without a doubt, recognize psychologists as independent providers. It appears likely tha t each state will have considerable power in designing and implementing i ts own plan, possibly even a single payer plan. However, no matter what the national health bill will look like and what each of the states will decide, there is a little doubt that all plans will

have some type of managed care component.

The degree of saturationofrnanaged care around the country today is quite variable, the general picture being that it gets greater as one goes from

39

payer plan.

east to west. However, that is changing. Wi thin the next two to three years, managed care will become a fact of life to almost all mental health practitioners. As much as we dislike the system of oversight and its sometimes harsh limitations, it will not disappear.

This trend was already apparent several years ago to those in the health care arena. The American Medical Association stopped. fighting managed care in the late 19805. It realized that even this major medical power group could not halt its growth. The American Psychological Association (AP A), on the other hand, intensified its attack on managed care over the

last few years. Its virulent opposi-

tion to managed care has been ineffective in stopping the managed care movement. Rather APA's intransigence has caused us to be viewed asa self-serving guild unwilling to participate in a move for reform of a health care system that has run amuck, However, APA's unremitting attacks on managed care were exactly what the practitioner community wanted to hear. It was a politically correct positionand the more strident a stance taken, the more kudos did APA's Practice Directorate receive. Instead of seeking kud os, we needed for AP A to pr~ vide leadership, we needed a vi-

sian, we needed to find ways to

impact and to modify managed

care programs. The Practice Directorate took the unilateral position of attacking managed care, with no alternate point of view permitted. The result is that we are now in the unenviable posttion of having had no influences in shaping the health security plan.

ship with the White House at this crucial timeas a national health plan is being developed.

Wecarmot shirk the question why the AP A president was snubbed in this manner. We have a lobbyist on the Hill-how could this have occurred? We deserve to know and APA has a responsibility to inform us.

Whether or not the managed competition cornponent of the proposed health initiative remains intact, the majority of patients seen by psychologists will come through large health care plans. That is likely to mean that the solo practi tioner is

going to be at a major disadvantage and is not likely to survive in that type of practice in the next century.

Whether or not the There will be exceptions. Those practitioners with a wealthy clienmanaged competi- tele will not be impacted. How-

tion component of ever, for most psychologists and other mental health care providers. the proposed health . it will mean participating in or . . ti ti - -.' working for a company that holds a tnt: ta roe remains mental health contract. Eventually

intact, the majority it is likely that most health provid-

ers, induding physicians, will beof patients seen by come employees oflocal or regiona,

psychologists will corporate networks.

come through large health care plans.

It makes little sense to demand unlimited numberof therapy sessions. for our patients. That is out of step with society at large and even out o'

step with the liberal political elementin Congress that has been su~ portive of psychology.

Just how little influence psychology has became sharply etched by a recent event that speaks powerfully to this issue. President Clinton invited leaders in the health care fields to a reception in the Rose Garden just prior to presenting his health care plan to Congress. Not only was AP A's president not invited, but to add to the injury, in the day following this event, the Whi te House called APA to make sure it understood that the president of APA was pointedly not invited for that occasion.

It would be very hard to think of a much more drastic statement about psychology' s relation-

40

We must look reality in the face, unpleasant as i::: may be, and prepare ourselves for the future. Being a doornsayer Is not a favorite role for anyone, but denial is a very primitive defense mechanism that does not work well in the long run. Thus, it is not surprising that these changes are producing fear for professional survival among psychologists. We have been led to believe by AP A that by fighting managed care we will win and that integrated care with its 52 unreviewed sessions will be the compromise. We are finding out otherwise. APA's intransigence has robbed us of the opportunity to be influential in developing standards for managed care. It is still not too late for AP A to bring psychology in line with the other professions i::. taking proactive roles with managed care cornpanies, even if they do require utilization ,<;views in fewer than 52 sessions.

FEATURE ARTICLE

Croatian Needs Assessment Proj eet Joseph F. Cvitkovic

Thanks to grants from the Center for Trauma Information and Education of Cincinnati, Ohio and the Psychotherapy Division of the American Psychological Association, I had the opportunity to travel to Croatia to conduct a psychological needs assessment on September 6, 1993 through September 14, 1993. Ellin Bloch, Ph.D., President of the Trauma Center and Co-Chairperson of the Psychotherapy Division's Trauma Response and Research Committee was largely responsible for this support. Ray Fowler, Chief Executive Officer of AP A also endorsed. the project.

horrible victimization of civilians and children led me to want to know first hand how this could be.

My greatest hope was to find some glimmer of light in this travesty and to find something good in my ancestral home. Hopefully, I didn't ha ve to be embarrassed by my name and nationality, because of a sense of collective guilt for some of the events which occurred in the history of this territory.

This project began about a year

ago when I was reading an article I lost track of times in USA Today about the impact of the war in fanner Yugoslavia on the civilian population. To my amazement the villagers depicted in the article were my cousins. In facti the article was written by a distant cousin, who I did not know existed. This cousin, Sherry Ricchiardi, Ph. D., teaches journal-

ism at Indiana University in Indi-

ana, and is currently a Senior Fulbright Scholar at Zagreb University. I wrote her a letter and we developed a correspondence which provided the encouragement for me to explore the role of psychologists in Croatia. She has helped me to uncover roots and insight that would forever have been hidden from me.

Arrival

Arriving in Zagreb Airport was an I was greeted with experience in and of itself. There, behind the desk of the customs office, checking my passport, was a large muscular soldier with his AK47 at his side. He took my passport without looking directly at me and began to study it. Soon, very

slowly and deliberately, he looked up at me and sternly said, "Where are your roots?" "Duga Resa", I said, "a little village outside of Karlovac," He looked intent and moved toward me, and then smiled gently as he said, IIWelcome Home."

hugs, tears, and

genuine expressions of appreciation.

I discovered that the Croatian Psychological Association had issued an Urgent Appeal for Help from the International Community. The International Office of APA received the appeal but we lacked specifics as to the actual needs of psychologists in Croatia.

So, there I was, my first trip to the land of my forbearers, on the plane to a war zone with my new found cousin. Ambivalence abounded with concerns about my own safety, and with mixed images of my ancestors being ruthless killers, or possibly just gentle peasants. What would psychologists be like in Eastern Europe? WouJd I be accepted? But, the drive to understand this culture and the need to gain personal insight into the

Relief and slight a chill moved through me, but that was the beginning of a sense of belonging. I lost track of the number of times I was greeted with hugs, tears, and genuine expressions of appreciation.

The Country

I found the atmosphere and culture of Zagreb to be one of gentleness and kindness. Despite the constant threat of being bombed or mortar attack, the air was filled with soft music, flowers filled the parks, and the outdoor cafes were crowded with friends talking over their beers, and young lovers, arm in arm, strolled the many parks.

Yet. the signs of the devastated economy and hardships of extensive medical and housing needs

41

were everywhere on the outskirts of the city. Hotels and office buildings had been converted to refugee centers. The store shelves were very bare and only a few of each item were available. I was told by one of the representatives at the United States Embassy that there were over 350,000 Muslim. Croat and Serb refugees in Croatia and the government do not receive any substantial foreign aid. The Croatian people house, clothe, feed, and provide for their medical care with an economic depression that makes the Great Depression in the United States seem insignificant.

Post Trawnatic Stress

And so I learned first hand that throughout last two years, the war in the former Yugosla 'has had devastating effects on countless childr and civilians. The incidence of post trauma' stress disorders and other catastrophic tions have rendered hundreds of thousands displaced children and adults in unbearably cruciating psychological trauma and pain.

Estimates from some research conducted the University of Zagreb and UNICEF indica that in Croatia alone, over 40% the population suffer from traumatic stress disorders. For

ample, psychologists and abandonment are ists who have spent time in refugee centers and villages report _ significant increase in eneuresis facial tics and tremors, and i1' creased aggressiveness and figh ing among children. There is leo discipline because parents are fatigued to manage routir

parenting. At times fathers "'bring their guns home and an 'crease in shooting among childn has also been noted.

By contrast the mystical city of

Dubrovnik on the Adriatic was marred with signs of mortar shells throughout the city. Roofs of houses were collapsed from shells fired from the sea. This ancient city was attacked with the primary intent of destroying something sacred and cherished to the people. We had breakfast with the military commander for Croatian forces of Dubrovnik, Before the war, he was

the director of the Dubrovnik Arts

Fair, which was one of Europe's finest. Inasober tone, he expressed his fear that without stronger assistance from the Western nations, Croa tia may become another Ireland, wi th ongoing terrorism.

The feelings of

widespread since

no one is on

the horizon to

save them.

He also expressed his observation that even funerals were different now, because as soldiers died, their families entered into the group of those who paid dearly for the country. "One gets immune to death after awhile," he said. There is somewhat of a rift in the country in that the villagers and those from the coastal towns believe, and probably rightfully so, that they have sacrificed more for their country than those in the major capital city of Zagreb.

We also toured several burned out and shelled villages in which mile after mile of houses, churches and buildings were burned, blown up and riddled "With bullet holes. Crucifixes and religious statues were shot and desecrated. In the town of Slovenia, not a house was left standing without some form of destruction. The only sign of life consisted of an occasional rooster or hen walking through the yards or along the side of the road. On some of the trees, certificates were hung commemorating the soldiers and people who died on the spot.

42

Many men report an increased interest in ha . children and there is an increase in pregnan.. due to a sense that "if I am going to die, at leas will have an heir." In a way, this reflects psychological need to find a creative action ~ response to the sense of helplessness.

In the villages, there is no entertainment or . to relax. The stress and hardship of the war _ constant. For the last two years, this continu.. pressure of the possibility of attack and the·u.:rooted nature of refugee life causes the farnilie, constant turmoil.

High rates of major depression with sympto of weight loss, sleeplessness and a sense of hoP=-' lessness were reported. by several psychologis Even in the refugee centers, a1 though efforts a.:. made to try to make people comfortable, crowd conditions and lack of adequate medicine an, other health supplies create condi Hans that in the United States would consider appalling

There is a greater fear of being crippled a jured, because if you would be killed, at least. would escape these conditions. If you handicapped, you would have to continue -

Teachers were

taught to interpret

the symbolism in

an even greater hell. There is a sense of being held hostage in one's own country by many who live in villages, and towns. The feelings of abandonment are widespread since no one is on the horizon to save them. Even the songs written to vocalize the fears and longings of the people include prayers and wishes to Europe to help stop the war.

Current Aid

Through UNICEF and other international organizations, some aid has been provided in the countries of Croatia, Slovenia, and Serbia. However, it is clear that this aid has been far from adequate. Requests for assistance have been hindered by cumbersome bureau-

cratic constraints. Several well

organized and developed programs are already in existence in Croatia. However,theseprograms are in Significant need of consultation and funding to provide long term effectiveness. Manyconsultants have come into the country, spent a week or two looking around, and then leave without Significant impact.

He and others express a sense of despair and sadness that when the country voted to secede from the former Yugoslavia, they perceived this to be a vote away from a communist regime to become a democratic country. There is a widespread feeling expressed over and over again to me, that there is a sense of misunderstanding, isolation, and abandonment by the west. There was a longing to be a part of western Europe and a movement closer to the United States, but instead they found themselves locked in what appears to be a hopeless quagmire of ancient ethic and religious fears. Initially, there was a sense of purpose and hope due to what is perceived as a cause of individual self rule and freedom. Now, as war drags on and the economy worsens, it is difficult to have hope.

The Role of Psychologists In October 1992 the Ministry of Education, for the Government of Croatia, with support from UNICEF, implemented a project aimed at reducing the psychological effects of the war on children. Plans consist of invovling all schools in Croatia with the overall objectives of reducing the psychological suffering among the displaced, refugee and war affected children, and to increase the a wareness in the general population about

the psychological effects of war on children.

To reach these objectives, school psychologists and teachers were trained to provide ed uca tional seminars in their schools and communities and to identify psychological trauma through screening procedures, and to offer therapeutic help through the school psychologists. A specific art-therapy program was utilized to help children work through their war experiences. Parents were also educated about the project and it's content through the parents meetings.

The project has a strong preventive component to help reduce post traumatic stress syndromes. Information is disseminated in local communities through educational seminars and through the mass media.

the children's drawings so that they could help the child

Lack of pain medication, antibiotics, and lack of cancer drugs have created excrueia tingly painful conditions for people with serious and painful medical conditions. Dr.

I van Fattorini, Medical Director of

the Women and ChildrensHospital informed me that when relief medications were sent to Croa tia after the war started, the medications were dated from 1976 and medical supplies were from WWII. They were not only useless, but extremely dangerous and life threatening. There is an increase in skin disorders, in part related to poor water conditions in the countryside. Zagreb itself had dean and sanitary water, but the farther you travel from the city, the more unsanitary the water becomes. Thereisa lack of medications for the skin disorders, and so the condi lions become very severe before they receive any medical attention, if they are treated at all.

work through the

trauma experience.

Dr. Fattorini was particularly intense when he noted that children treated at his hospital were also Muslim and Serbian children. Like many otherprofessionaIworkersIspokewith,heeIaborated on what he felt was an important point that has been lost by much of the international community. That is, he expressed his sense of the complex causes of this tragedy.

Many children reported seeing people shot, killed, mutilated and in high crisis areas, children experienced unbelievable experiences such as witnessing terrible atrocities. One creative jewel is the project under the direction of Arpad Barath,

43

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ously experienced. The rape camps and torture goes far beyond anything one would have been taught in the classroom.

One psychologist indicated that American psychologists could be of much help to them regarding the development of ethical standards for psychologists. Assistance would be helpful in developing models for the independent practice of psychology as a separate entity from medicine and govenunent control, and in the development of philanthropic activities and community development.

this trip to Croatia. This was both a painful and uplifting experience that has forever changed my life, More than I dreamed possible, I have found a part of my identity that would have forever been hidden from me. The level of creativity and sensitivi ty wi thin the Croa tian psychological communi ty and the society itself demonstrated clearly to me that there is hope for this war tom and ravaged country. However, some of this hope does rest with the larger international community.

We as psychologists in the United State are of course troubled by our own problems in the form of managed care and the upcoming national health care programs. However, the world has shrunk, old boundaries ha ve collapsed and empires have crumpled. The world economy and the increase in nationalism and even tribalism provide Significant likelihood that the situation informer Yugoslavia may

be only the beginning of international challenges for psychologists around the world. Our future is very much tied to the fate of our colleagues around the world. This bond will provide exciting challenges and opportunities for all of us.

On an immediate note, there are

needs for psychological testing supplies (particularly neuro-psychological testing, intelligence tests, and measures for attention deficit disorders), lap top computers, paper for fax machines, and biofeedback equipment. Funding for therapy projects is urgently needed because due to the war economy, psychological services are low priority for government

funding. By the time funding gets through the government and military, there is basically no funding. From my understanding, psychologists earn about $100 per month, and that buys very little.

This was both a painful and uplift-

ing experience' that has forever changed my life.

Several psychologists noted the need for a peer 8U pport system. A sort of "buddy system" could be developed. In this regard, we may be able to develop correspondence with Croatian psychologists and even develop a stronger exchange program in which they may be able to travel to the United States for a "time out" period from the exhaustive and burn out problems of working extensively in war time conditions. It would be worthwhile for more psychologists from the United States to travel to Croatia to learn from some of the amazing work they have done under conditions that Arpad Barath described as one of Dante's Purgatoria.

I received numerous requests for journals, articles and literature related to post traumatic stress disorders. In this regard it will be extremely helpful to try to link our computer data bases for psychological literature to countries like Croatia. Particularly during national disasters like that in former Yugoslavia, the need for quick access to relevant and recent literature is extremely important and valuable.

Conclusions

I cannot thank EUin Bloch and Sherry Ricchiardi enough for encouraging and helping me to make

The Center for Trauma Information and Education, The American Psychological ASSOCiation's International Affairs Office, The Public Interest Directorate, and Division 29 Task Force on Trauma Response and Research appear to be the primary groups which are in a position to organize the efforts to follow-up on the results of this needs assessment. There are plans to develop a monograph in conjunction with the World Federation of Mental Health to highlight roles and procedures for psychologists to interact with other psychologists working in troubled countries around the world.

The challenges are great, but the potential for psychology to have a major role in world development are exciting and dynamic. 'Through our knowledge and skills as psychologists, we can transcend geographic, poli tical and ethnic boundaries to reach out to our friends and colleagues around the world who share our mission of alleviating human suffering.

I would very much appreciate hearing from any psychologists interested in becoming a part of the team which will provide ongoing interaction and help to psychologists in Croatia or the other Balkan countries.

45

PROFESSIONAL LIABILITY

Psychologists' Worries About Malpractice: Surveys of Risk Management Workshop Participants

Samuel Knapp, Leon VandeCreek, and Anna Phillips

more sensitized. to the risks of malpractice than licensed psychologists at large.

Currently, little is known about the demographics and business practices of psychologists who worry frequently about malpractice. Psychologists who attended six different

risk management workshops in

Pennsylvania in Fall, 1992, and Those psychologists Spring, 1993, were surveyed to determine the degree to which they worry about malpractice. It is hoped tha t the results of these surveys will be useful in developing risk management programs and reducing negligent behavior.

who were most satisfied with their

careers tended to worry much less about malpractice.

In the Fall of 1992, participants at three risk management workshops

were asked to complete a survey on the logistics of their practices, instances of negligence and potential negligence, and the degree to which they worried about malpractice. One hundred and nineteen workshop participants responded.

In the Spring of 1993, participants at three more risk management workshops were also asked to complete a survey. This survey differed slightly from the first in that the questions concerning negligence were more probing; they asked about specific types of negligence. Ninety-seven workshop participants completed the survey. The survey was also sent to psychologists who had attended one of the fall workshops, and 88 of them responded.

The fall survey asked psychologists to indicate the degree to which they worried about malpractice on a likert-type scale of 1 to 5. The average response was 3. Twenty-three percent of the respondents rated themselves a 4 or a 5 (indicating a great degree of worry). In a random survey of licensed psychologists in Ohio, Wilbe.rt and Fulero (1988) found that 14% of their respondents worried frequently about malpractice. Comparison of the figures suggests that risk management workshop participants might be

46

The fall survey data also suggest that few patients actually file malpractice complaints. Only one « 1 %) of the fall survey respondents had a malpractice sui t filed against him or her, and only 7 (6%) of the respondents had ever been threatened with malpractice. Wilbert and Fulero (1988) found that only 2% of their Ohio sample had been charged with malpractice but that a much larger percen tage, 17% had been threatened with malpractice.

Twenty-six percent of the fall survey sample reported having been in a si tuation which caused them to fear an ethical complain t or a malpractice suit, a figure comparable to the 27% of the Wilbert and Fulero (1988) sample who responded the same to a similar question. The more detailed spring survey induded questions about a wide variety of incidents which frequently occasion malpractice suits: suicide, homicide, child custody evaluations, and fee disputes, among other things. It was expected tha t invol vement in these types of incidents would increase the degree to which psychologists worry about malpractice. Surprising! y, invol vement in such stressfu I events did not show a significant correlation with worry about malpractice. Worry about malpractice was correlated, however, with the amount of professional supervision received, with worry increasing as the amount of supervision increased, and with career dissa tisfaction, Those psychologists who were most satisfied with their careers tended to worry much less about malpractice. It is possible tha t their career satisfaction gave them a false sense of immunity,or conversely that their worry led them to be less satisfied with their profession.

Worry about malpractice was also correlated about malpractice. It is possible that the queswith sexual contact with clients, a finding that is tions contained in the survey were stated in a not at all surprising. Out of the 185 psychologists manner which obscured the correlations with surveyed, however, only two reported engaging may exist among many of the above issues and in this very high-risk behavior. Increased worry worry over malpractice. Equally possible is that

abou t malpractice was not found to ----- worry about malpractice is rela ted

be correlated with increases in the to features unique to each psy-

incidence of other types of bound- ... on the whole, chologist and not to the issues cov-

ary violations, such as transference hi' h ered in the surveys.

and countertransference issues. psyc 0 ogists w 0

Lastly, it appears that, on the whole, psychologists who attend risk management workshops are not more Ii kel y to be guil ty of negligence than psychologists in general. The 185 risk management workshop attendees who completed the surveys reported about the same number of incidents of potential negligence as the random sample of Ohio licensed psychologists surveyed by Wilbert and Fulero (1988).

attend risk management workshops are not more likely to be guilty of negligence than psychologists in general.

The spring survey data also revealed that psychologists who worry about malpractice are also more likely to seek consultation from other mental health professionals. It is possible that their worries inspired them to seek consultation. However, it is also possible that, for some, worry about malpractice resul ted from past misconduct and that consultation was sought in reference to that misconduct.

Educational level, amount of participation in continuing education activities, work site, and perceived su pporti veness of one's work envi ronment were not found to correlate with worry

REFERENCES

Wilbert,1-, & Fulero, S. (1988). Impact of ma.lpra.ctice litigation on professional psychology: Survey of practitioners. Professional PsychOlogy: Research and Practice, l2, 379-382.

SUBTANCE ABUSE

Harry K. Wexler

The ADD and Substance Abuse Connection

In the past decade, empirical research has shown tha t, contrary to myth, most children with Attention Defici t Disorder (ADD, also known as Attention Deficit Hyperactivity Disorder or ADHD) do not outgrow their symptoms. Rather, between sixty and seventy percent of children with ADD experience lifelong symptoms of the disorder; these include inattention, irnplustvity, and motor hyperactivity. These symptoms can severely affect relationships, job performance, and self-esteem. There is now a growing body of evidence suggesting a strong connection between ADD and antisocial behavior, inducting substance abuse.

An emerging bod y of research suggests that ADD is highly correlated with intelligence, creativity,

and high levels of achievement among the ad ul ts who have been able to overcome the social and educational hurdles of ADD and attain accepted roles in society (Hartmann, 1993). In fact, an unusually large number of "energetic" artists, writers, business executives and other professionals are being identified as having ADO. However, many of these "high funcrio ni ng" ADD adults report feelings of inadequacy and shame because they are unable to attain the level of performance of which they know they are capable. Clinical experience has shown that ADD adults tend to "self-medicate," perhaps unconsciously attempting to normalize their attention patterns. Substance abuse among high functioning individuals may, in many cases, be a reflection of adult ADD.

47

TASK FORCE UPDATE

Trauma Response and Research Ellin L. Bloch and Joseph Cvitkovic

Representatives of Division 29 (Psychotherapy), The Center for Trauma Information and Education (CTIE), and the World Federation for Mental Health met in Washington on October 13th with Henry Tomes, Ph.D., Execu tive Director,and Paul Donnelly, Staff Liaison, Public Interent Directorate, and with Joan Buchanan, Director of APA's Office on International Affairs. Also attending were Sherry Ricchiardi, Senior Fulbright Scholar in J oumalism at the Uni versi ty of Zagreb, Croatia, and Dolores Bandula, Director of the Pittsburgh-Zagreb Sister City Project and researcher on women's issues. The meeting's purpose: to address potentialleveis of impact on the part of psychology on encouraging public health models of trauma prevention/intervention in countries experiencing war and violent internal strife. At this meeting a model program of interven tion for Croatia's child victims was described, as well as extensive information gathered from a recent needs-assessment trip to Zagreb by Joseph Cvitkovic, Ph.D. Reports from Belgrade were also shared regarding the trauma suffered by women, children, and the elderly in Serbia and Montenegro. The unique and numerous roles psychology can play were discussed, highlighting alleviation of victim's suffering through developing models for global assistance, including international professional communication using state-of-the-art technology; empowering psychologists abroad and supporting the advancement of psychology in emerging nations; pooling clinical and scientific resources; and creating networks for professional collaboration and consultation.

The most extensive trauma intervention project for war-afflicted children is currently being conducted in Croatia under the direction of Arpad Barath, Ph.D. In addition to training workshops for health professionals and art teachers and dissemination of trauma prevention information through the media, the centerpiece of the project, a model public health program, is an innovative art and expressive therapy for Croatian, Muslim,

and Serbian children ages 6-14. The children, who endure traumatic stress disorders, depression, anxiety, separation and loss, nightmares, and family upheaval are being reached through "Images of My Childhood in Croa tia since 1991," a program which moves each child through seven expressive stages of images of life before the war, fear and anger felt during the war, and finally through paintings and poetry expressing hope, love and "messages to the world." Initial data analysis indicates the national average of children scoring on standardized measures of post-traumatic stress disorders has significantly decreased (p <.001) both in relation to baseline levels taken at pre-intervention and to control populations (n=5,823). Many more children remain to be reached through this project, among them those who have witnessed atrocities and murder. Parents in Croatian villages have difficulty caring for their child ren' s emotional needs because of the overwhelming stress of the ongoing threat of attack. The school setting - even w hen maintained in shelters - has proven ideal for reaching both children and their caretakers.

Professionals delivering this model art therapy program and other services - including such parent self-help groups as "Mothers of the Missing" -are themselves victims of what Dr. Barath has described as "this merciless war, this comer of Dan te' s Purga tory." Psychologists work without adequate supplies, testing materials, computers, journals and books. They have expressed needs for peer consultation and support (a "buddy system"), consultation regarding work with rape and torture victims, development of independent practice models, and assistance dealing with problems induced by burnout. Since psychological interventions are only minimally funded, war-time needs and a troubled economy mean that our colleagues do much of the work on their own time and, in many cases, wi th their own money - when the average salary is $100 U.S. and inflation, high.

Reprinted with permissionn. from the AP A Public Interest Directorate

49

While the challenge is great, the potential for an international collaborative effort in the public health arena of trauma intervention is significant. As psychologists we can transcend geographic, political, and ethnic boundaries to reach outto colleagues around the world who share the mission of alleviating human suffering. With information at hand from Croatian psychologists, the October meeting outlined the following list of professional needs abroad:

1. Professional Materials

• Journals, books, audiotapes on psychological trauma

• Testing materials and supplies

2. Professional Supplies and Equipment

• Computers; laptop computers

• Fax machines, fax paper

• Biofeedback equipment

• General office supplies

3. Professional Consultation

• Computer networking and data base for literature

• Planning training workshops

• Practice and record-keeping guidelines; ethical guidelines

• Development of models of independent practice and organization

• Neuropsychological testing (adults and children)

• Attention deficit disorder: assessment and treatment

4. Professional Collaboration

• "Buddy system"

• Psychologist exchange/travel program

• Research

50

The immediate needs prioritized at the meeting are: (1) Donations of journals, books, and tapes, and testing material for use with children and adults; (2) Implementation of a "buddy system"; and (3) Professional consultation and donations of material for training workshops. Division 29 and the Office for International Affairs will coordina te journals, books, tapes, and testing rna terialso Funds to further psychological tra uma intervention for children will be raised in part via national exhibition of an extensive, unusual portfolio of watercolor and tempera paintings and poetry created through the art therapeutic propjet and donated by Dr. Barath. CTIE will be coordinating and organizing the public exhibit and seeking grants and donations for its support. The exhibit will open in Cincinnati in early 1994, tra vel to Pi ttsburgh in la te spring, and then made available nationally.

We welcome hearing from psychologists in all fields who are interesting in the Croatia project and / or in learning a bou t similar projects in other Balkan countries. Those wishing to assist in any capacity or by donation of funds for the national children's art exhibit should contact:

Ellin L. Bloch, Ph.D. CTIE

P.O. Box 55409

Cincinnati, Ohio 45254-0409 (513)321-4667

A network list of psychologists will be maintained and updated, and circulated on a regular basis to network participants.

Report on APA Committee of International Relations Ernst G. Beier

Division 29 Liaison to AP A International Committee

The AP A Committee of International Relations met in Washington early October. This meeting was part of a Consolidated Meeting of many of the major committees of the AP A, and we had some joint meetings with some other commi ttees present. The Committee on Minority Affairs, discussed an agenda on South Africa. The Committee on Gay and Lesbian Concerns want AP A to endorse an international march on the United Nations, sponsor a convention program on international human rights issues, and endorse the wri ting of a report on sexual minorities. We also met with Gary VandenBoss, APA Publications Director, to discuss the problems of publica tions ofr-lon-English publica tions. We heard from one of the committees which donated current subscriptions of AP A journals to interna tional institutions, and we also heard from the Editorial Mentor Project. The project encourages the publications of international scholars for whom English is not their native language and who need help with their papers. There are APA travel grants given to members who wish to attend

international meetings. Also, new policies were discussed. Short time visits for Russian psy~ choiogists to US departments were discussed. Grants for workshops in Mental Health in Central America were discussed. The fate of a Singapore psychology professor who had been dismissed from a university for wha t he believed were political reasons was discussed. Various AP A Divisions (Div 7 and 38) made proposals regarding the internationalization of psychology, andyour representative tested the waters (with positive results) by stating that some present and former members of the CIRP are in the process of founding a Division of International Psychology with rather specific goals, such as one to one contacts.

My intent here was not to give the specific action of the two day session but to acquaint our members with the large scope of'activities of this committee, which at this meeting was chaired by Brewster Smith. The AP A staff members are Joan Buchanan and Marion Wood.

BOOK REVIEWERS NEEDED

As the newly appointed Associate Editor /Book Review Editor of Psychotherapy: Theory, Research, Practice, and Training, I would like to have available as broad a selection of potential book reviewers as possible.

Reviewers must be willing to read a book and write a balanced, collegial review within two mon ths of receipt. We expect to begin reviews in January, 1994, in conjunction with the term of the new Editor, Dr. Wade Silverman,

Anyone interested in serving as a reviewer should send the following: (1) A cover letter sta ting your areas of professional interest in relation to reviews; (2) A current c. v.; (3) A brief writing sample or extract from a published paper, whether refereed or not

Minority and woman reviewers are especially encouraged to apply. Newcomers without past experience reviewing are also welcome. Send all materials to the following address:

T. Richard Saunders, Ph.D. 200 Forbes Street Suite 303 Annapolis, MD21401 41(}-268~8188

51

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THIS IS A RECOMMENDATION for having our library subscribe to the Psychotherapy Bulletin, 3875 N. 44th Street, Suite 102, Phoenix, AZ. 85018

Please include this title in the next serials review meeting with my reoommendation. Thank you!

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1 2 3 N PU .BLlCATION OUTLET: My cu rre nt research requires a publications out letl n this exact area. I need this journal to keep up to date with its editorial direotions and interests.

1 2 3 N PREDICTED BENEFIT FOR LIBRARY: My evaluation of this journal's contents and direction is very high, and it is likely to be both clted and/or indexed/abstracted heavily if not already. Including this journal in our library will, in my assessment, add to the library's success in fulfilling overall department, faculty, and student needs.

1 2 3NOWN AFFILIATION & DISSEMINATION: I am a member of this journal's sponsoring Society and/or editorial board. I regularly receive my own personal copy of the journal and will be recommending articles on a regular basis to students and colleagues. The library's help in providing the material is most appreciated. The Publisher, Division 29, understands the importance of faculty support for improved library funding.

~23N

Please send the original copy of this form to your library. and a copy to Division 29. Thank you. Division of Psychotherapy, 3875 N. 44th Street, Ste 102, Phoenix. AZ. 85018

ANNOUNCEMENT

Proposal for the Formation ofa New APA Division

Ernst G. Beier

We, the undersigned, solicit signatures for a petition to start the establishment of a new and much needed AP A Division of International Psychology.

The aim of the division is to facilitate a friendly sense of cooperation among psychologists around the globe, with the hope that this cooperation will lead to a useful exchange of cornrnunication, as well as collaborative research efforts.

This division would bring members of the American Psychological Association and members of foreign associations together, will sponsor conferences and meetings of special interest groups, both in the areas of research and in clinical practice. It would encourage members to engage in international research efforts by providing both contact with interested parties eventually providing an outlet for publications and a forum for papers and a symposia on international issues. It would help to arrange for APA members interested in attending international conventions to travel together. An International Division would stimulate other divisions to think of problems internationally. Other benefits of the division would include learning about the daily academic and/or clinical work of our colleagues abroad. Exchange visits across continents by psychologists will enhance communication and bring opportunities for workshops and lectures both in the USA and abroad. Eventually the division would provide outlets and publish a newsletter and a journal, recognizing scholars in the areas of international issues. The division would coordinate its work with the APA Committee on International Relations in Psychology (CIRP) which has done so much in this area even though there are activities, such as person to person contacts, which a division of international psychology would be able to do more adequately.

With the growing awareness of our global existence we feel that the Division of International Psychology as part of the American Psychological Associa tion will in a small way, contribu te toward better professional relations around the world.

We are very excited about the many possibilities which a Division of International Psychology will offer to its members. We need 675 signatures from current AP A Psychology members who share our interests and want to assist to establish such a division. Once we do have these signatures we shall present this plan to the APA Council of Representatives. We would be most appreciative if you would fill out the form below and sent it to the address listed. Thank You!

L.L. Adler, E.G. Beier, P.M. Culbertson, P.L. Denmark

We would much appreciate if you would send the signed statement below to:

Ernst G. Beier, Ph.D.

Department of Psychology University of Utah Salt Lake City, Utah 84112

53

54

"The undersigned is a Member of Fellow of the American Psychological Association and wishes to support the establishment of an AP A Division of International Psychology within the AP A and agrees to become a member of such a division upon its establishment. Among the aims of this new division are opportunities for grassroots contacts with psychologists from different countries and cultures, for enhanced communication with psychologist abroad and for the encouragement of cross-cultural research".

Name(s) _

Address(es) _

Member of APA 0 Yes 0 No

Fellow of APA 0 Yes 0 No

Signature __

AP A Divisionis) _

Thank You!

Ernst G. Beier

Division of Psychotherapy of the American Psychological Association 1994 Officers and Committees

STANDING COMMITTEES

Education and Training

Arthur N. Wiens, Ph.D., Chair Oregon Health Sciences University 3181 S.w. Sam Jackson Park Road Portland, OR 97201-3098

Office: 503-494-8594 FAU<:5~494-3284

Fellows

Suzanne B. Sobel, Ph.D., Chair 1680 Highway AlA, Suite 5 Satellite Beach, FL 32937 Office: 407-773-5944

Finance

Alice Rubenstein, EcLD., Chair Monroe Psychotherapy Center 59-E Monroe Avenue Pittsford, NY 14534

Office: 716-586-0410

FAX: 716-586-2029

Gender Issues

Gary R Brooks, Ph.D., Co-Chair Psychology Service, 116 134 D.E.Teague V A Center

Temple, TX 76504

Office: 817-7784811

Barbara Wainrib, Ph.D., Co-Chair RD. #1, Box 1290

Moretown, VT 05660

Office: 514-481-8272 F~;514-484-2864

Membership

Richard H. Mikesell, Ph.D., Chair 4801 Wisconsin Avenue, N.W. Suite 503

Washington, DC 20016 Office:202-9~7498 FAU<: 202-9~3745

Multicultural Affairs

Sam S. Hill, III, Psy.D., Chair Texas A&M University

4417 Carlow Circle '

Corpus Christi, TX 78413 Office: 512-994-2394

FAX: 512-994-5844

Nominations and Elections Stanley R. Graham, Ph.D., Chair lOW. 10th Street

New York, NY 10011

Office: 212-989-2391 FAU<:212-979-2415

Professional A wards

Gerald P. Koocher, Ph.D., Otair Dept. of Psychiatry

Children's Hospital

300 Longwood Avenue Boston, MA 02115-5737 Office: 617-735-6699 FAX: 617-730-0457

Professional Practice

Ellen McGrath, Ph.D. Chair 380 Glenneyre, Ste. D Laguna Beach, CA 92651 Office: n 4-497-4333 FAO<:714-497~13

1994 Program

EdwardF. Bourg, Ph.D.,Otairl994-1995 1005 Atlantic Ave.

Alameda, CA 94501

Office: 510-523-2300

F~: 510-521-5121

Karen Kovacs, Ph.D., Chair Designate 1994-1995

2929 Connecticut Avenue, NW.#602 Washington, DC 20008

Office: 202-225-2836 FAO<:202-225-1716

Nerine G. Johnson, Ph.D., Past Chair 1994-1995

110 West Squantum, #17 Quincy, MA 02171 Office: 617-471-2268 F~:617-323-2109

Student Development Abraham W. Wolf, Ph.D., Qair Metro Health Medical Center 2500 Metro Health Drive Oeveland,OH44109-1998 Office: 216-459-4647

FAU<: 216-778-8412

Publications Board

Herbert J. Freudenberger, Ph.D., Chair 18 East 87th Street

New York, NY 10128

Office: 212-427-8500

DIVISION OF PSYCHOTHERAPY (29)

Central Office

3875 N. 44th Street, Suite 102 Phoenix, Arizona 85018 (602) 952-8656

FAX: (602) 952-8230

TASK FORCES

Task Force on Children &; Adolescents Alice Rubenstein, Ed.D., Chair Monroe Pyschotherapy Center

59 E. Monroe Avenue

Pittsford, NY 14534

Office: n6-58(K)410

Task Force on Aging

Norman Abeles, Ph.D., Chair Department of Psychology

129 Psychology Research Bldg. Michigan State University

East Lansing, MI 48824-1020 Office: 517-355-9564

FAX: 517-353-5437

Task Force On Men's Roles and Psychotherapy

Richard F. Lazur, Psy.D, Chair LaZLU & Lazur, Ltd.

741 Sesame Street

Anchorage, AK 99503-6641 Office: 907-562-1933

FAX: 907-562-1931

Task Force on Trauma Response and Research

Ellin Bloch, Ph.D., Co-Chair Behavioral Science Center 2522 Highland A venue Cincinnati, OH 45219 Office: 513-221-8545

F~: 513-861-2:724

Jon Perez, Ph.D., Co-Chair

Apache Behavioral Health Services P.O. Box 2954

Pinetop, AZ 85935

C>ffice: 602-338-4811

FAU<: 602-338-4930

MID-WINTER

March 9-13, 1994

Convention Coordinator William R. Fishburn, Ed.D.

Associate Coordinator Leon VandeCreek, Ph.D.

Program Chair

Louise Silverstein, Ph.D.

Continuing Education Chair Barry Schlosser, Ph.D.

DIVISION OF PSYCHOTHERAPY American Psychological Association 3875 N. 44th si, Suite 102 Phoenix, AZ 85018

Non-Pront Organization U.S. Postage PAID Phoenix, fJ\Z 85018 Permit No. 311

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CLEVELAND OH 44109