Author Archives: Jamilah

The Development of Behavior: A Synthesis of Developmental and Comparative Psychology

Bill Seay, PhD and Nathan Gottfried, PhD

1978, Houghton Mifflin Company

Comparative Psychology––Where has it gone? Merged into ethology or morphed into physiological psychology? Absorbed into behavioral neuroscience, biological and evolutionary psychology?

While many say the area is still thriving, comparative psychology is no longer listed at the Louisiana State University Psychology Department.

But once upon a time the department had its share of these “monkey men,” the affectionate term for those who observed the behavior of primates and then told us about the development, adaptation, or social structures of these close great-ape relatives.

One of those men is Dr. Billy Seay, now retired from both his work as Professor in comparative psychology and from his role as Dean of the LSU Honors College.

“Comparative psychology was the study of animal behavior,” he told the Times. But when asked if the objectivity that comparative often provided is missing these days, he said, “Objectivity requires constant attention and re-evaluation of thinking and point of view. Any field of science requires objectivity and constant vigilance.” And, he explained, it is available now as well as then in efforts of psychologists.

When Seay came to LSU as a young psychologist in 1964, he brought with him the distinction of having published in the then ground-breaking studies about mother-infant separation. Seay studied with the American primatologist, Harry F. Harlow, at the University of Wisconsin.

In his work at Wisconsin and with Harlow, Seay published “Mother-Infant Separation in Monkeys,” in the Journal of Child Psychology and Psychiatry, “Affectional Systems in Rhesus Monkeys,” and “Maternal Behavior of Socially Deprived Rhesus Monkeys,” and ‘Maternal Separation in Rhesus Monkeys,” in the Journal of Nervous and Mental Disease.

“Harlow provided his students with the resources of his laboratory, staff support, and considerable independence,” Seay explained. “When research was published he used a ‘post-Nobel’ style of authorship. Students were consistently the first author of research reports. Exception occurred only if he had an agreement with an editor to be first author. He would not coauthor dissertation publication. You were on your own.”

When Seay joined the LSU faculty in 1964, the primate center in Covington was just opening. He did his research there and found it easy to find funding for his work. “I had an National Science Foundation grant and repeated some of the Wisconsin rhesus monkey studies with another species, the Java monkey. I was also able to study the Patas monkey.”

But eventually funding became more scarce and Dr. Seay decided to take an offer to serve as the Director of the LSU Honors College and then the first Dean.

Seay worked with colleague and fellow LSU professor and development psychologist, Dr. Nathan Gottried, who passed away in 2012.

Together they authored The Development of Behavior: A Synthesis of Developmental and Comparative Psychology in 1978, which rested on the expertise of both men.

The Development of Behavior was ahead of its time. While debates still occur today about which influence––genetic, environmental, epigenetic, individual, etc.,––is dominant in development, Seay and Gottfried’s text explained the importance of five “sets” for determining behavior from all five directions. In Development, the authors approached behavior from the dynamic interplay of the Phylogenetic Set, the Ontogenetic Set, the Experiential Set, the Cultural Set, and the Individual Set.

“One hopes that what is not lost is that all behavior is multiply determined,” Seay told the Times. “There is not a single cause for any behavioral outcome,” he said.

In The Development of Behavior, Seay and Gottfried took each of these five Sets as a topic for Part I, “The Determinants of Behavior.” The text outlines the multiple and interdependent influences on human development, wrapping each one into the others to punctuate the complex interactions possible, even if yet to be discovered.

The chapter on the “Phylogenetic Set” shows that behavioral development is “species typical.” Authors include topics of reflexes, fixed action patterns, and learning dispositions. For the “Ontogenetic Set” the influence of maturation on behavior is described, and authors include topics of prenatal, neonatal, and sexual identity topics.

In the chapter for “Experiential Set” they cover learning, both classical conditioning and instrumental, and specific and nonspecific environmental dependence influences on behavior.

Chapters 5 and 6 are the “Cultural Set” and “Individual Set” and the authors lay out continuing explanations of development by shifting between Sets and the dynamic influences. Seay and Gottfried explain that cultural influences may not be dramatic, but rather subtle and out of conscious awareness. The chapter on the Individual Set makes clear that there is unique variation in all humans, coming from the individual set of influences.

For Part II, “The Development of Behavioral Processes,” the authors note that “all behavior is oriented and organized in some way,” and they select four behavioral processes to include for readers in showing how this occurs.

They include a chapter on “The Orientation of Behavior” with sources of information about the psychology of attention, perception, and motivation.

In “The Organization of Behavior,” places emphasis on development and schemas (the internal structures that are basic to organized behavior) and explain smiling, self-schemas, counting, and problem-solving schemas, for example. Descriptions of human and also animals are richly woven throughout.

Chapter 10 outlines “Affectional Relationships,” with reviews of attachment, love, affection and development, and includes attachment in humans, birds, mammals and topics of affection, development and heterosexual love and gender identity.

In remarking about the views in 1978, Seay told the Times, “Our point was that ambiguity with respect to personal gender identity,” he said, “would inhibit the development of adjustment. Self-doubt is always a problem. Uncertainty concerning femaleness and/or maleness is a serious form of self-doubt. I continue to believe that ‘the development of an unambiguous personal gender identity is very important for later adjustment.’ I think uncertainty may be a basis for disaster.”

The final section for behavioral processes, is “Social Organization,” Chapter 11. This chapter includes examples of temporary and permanent organization, with examples from bison, mallard ducks, wolves, and humans.

“I think that both biological and cognitive psychology fail to recognize the importance of culture in shaping and determining behavior,” Seay said about the awareness of cultural impacts. “The cultural setting is a determining factor with respect to the environment an individual encounters. Failure to recognize cultural influences on behavior limits understanding behavior.”

The chapter on “Variation in Adaptation” covers the broad issues of population adaptability, with examples of baboons and gorillas. And the closing chapter, “The Meaning of Development,” brings together the synthesis and framework for the text.

In their conclusions, the authors write: “The history of the species, the culture, and the individual always are to be seen in present behavior. The universals and particulars always interact. As much as we study present behavior and its foundations, the future behavior of the species and the individual cannot be predicted with certainty.”

Throughout the text, the authors place their emphasis on the variety of influences that merge to create behavior, that each can be influenced by the others, creating the unique, changing person. The approach in Development of Behavior is as rich and worthwhile today as it was in 1978.

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Tulane’s Dr. Barbarin to Work on White House Educational Initiative

Dr. Oscar Barbarin, Psychology Professor and Endowed Chair at Tulane, attended the Advisory Commission on Early Childhood Education as an invited participant on October 20. The Commission is part of the White House Initiative on African American Educational Excellence established by President Obama in a 2012 Executive Order.

The Commission’s goal is to better understand the current status of African-American students and the schools that support them. Members meeting in October discussed the approaches and proven programs that could be of benefit for youngsters and served as an introductory meeting for key experts in the field.

“We were trying to understand the quality of early childhood education and the most important components,” Dr. Barbarin told the Times. Barbarin’s research aims to shed light on the origins of what underlies a disproportionately high rate of poor school adjustment for AfricanAmerican and Latino children, a group he calls “boys of color” or “BOC.”

“Cooperation with peers and social competence are present when the boys enter Pre-K, but when they reach five, after kindergarten, we see a downward trend,” he explained. Barbarin and his team at Tulane are helping to discover the underlying psychology of these and other issues that could improve youngster’s social and educational outcomes.

In one of his longitudinal studies Barbarin found evidence that calls into question the common assumption that boys begin school already dealing with socioemotional issues that hamper their educational success. Instead, Barbarin found evidence that the development of BOC occurs along the same lines as White boys. So, the difficulties these boys experience in adolescence are not evident in Pre-kindergarten.

Barbarin suggests that a more likely explanation for these results and the higher risk for later problems in BOC could be that there is a poor fit in the kindergarten and following grades, between current educational methods and the children’s developmental sensitivities. He concluded that the downward trend in ratings of socio-emotional competence in boys of color was likely related to the educational design and didactic approaches common in kindergarten.

“The programs may not be varied enough,” Barbarin explained. “We need developmentally sensitive practices that take these factors into account,” he said to the Times.

Dr. Barbarin and his work were prominent in the 2013 special issue of the American Journal of Orthopsychiatry focusing on the development of African-American and Latino youngsters. Barbarin wrote the introduction to the special issue, titled “Development of Boys of Color.” He also provided several articles including, “Development of Social-Emotional Competence in Boys of Color: A Cross-Sectional Cohort Analysis from Pre-K to Second Grade,” and “A Longitudinal Examination of Socioemotional Learning in African American and Latino Boys Across the Transition from Pre-K to Kindergarten.”

Dr. Barbarin is one of the national experts looking at the socioemotional development of boys of color and the characteristics related to these youngsters’ overall development. Last month he was one of the experts featured in the lead article for Monitor, the national magazine published by the American Psychological Association.

The headline feature was “Building resilience in black boys.” Barbarin commented to Monitor about his work with BOC. “Part of the puzzle is trying to figure out what happens along the way that creates such disparate outcomes for them,” remarking on the greater risk for African-American boys to exhibit problems in school and social-emotional areas.

In the Monitor report Dr. Barbarin said that one issue is that youngsters may come from homes without the same support for school and school preparation. This can cause some to be behind in language skills and if the children do poorly in their beginning entry to education, it can become a self-fulfilling prophecy, he indicated to the Monitor. He also explained that teaching styles, what he termed “warm demanding” may help teachers when the teacher is struggling with ways to be more constructive with children that are challenging.

Dr. Barbarin is the co-editor of the Handbook of Child Development & Early Education, a 2009 text coauthored with Dr. Barbara H. Wasik. In the Handbook Barbarin points out that early childhood education and developmental science have developed along parallel, rather than perfectly aligned, tracks. He writes that there is need for the two disciplines, education and developmental science, to work more closely to produce innovations to benefit children and BOC.

Also included in the 2013 special issue of the Journal of Orthopsychiatry was “Socioemotional Trajectories in Black Boys Between Kindergarten and the Fifth Grade: The Role of Cognitive Skills and Family in Promoting Resiliency,” authored by Tulane’s Jeffrey Brown, Oscar Barbarin and Kristin Scott.

Kristin Scott, Dr.Barbarin, and Jeffery Brown also authored, “From Higher Order Thinking to Higher Order Behavior: Exploring the Relationship Between Early Cognitive Skills and Social Competence in Black Boys.”

Included in special issue was Tulane professor Dr. Michael Cunningham’s “School- and Community-Based Associations to Hypermasculine Attitudes in African American Adolescent Males,” coauthored with Dena Phillips Swanson and DeMarquis Hayes.

Dr. Barbarin coauthored “Development of SocialEmotional Competence in Boys of Color: A Cross-Sectional Cohort Analysis from Pre-K to Second Grade,” with Iheoma Iruka, Christine Harradine, Donna-Marie Winn, Marvin McKinney and Lorraine Taylor.

Barbarin and Ester Jean-Baptiste authored, “The Relation of Dialogic, Control, and Racial Socialization Practices to Early Academic and Social Competence: Effects of Gender, Ethnicity, and Family Socioeconomic Status.”

The President’s Commission on Early Childhood Education is chaired by Executive Director for the White House Initiative on African American (AA) Educational Excellence, David Johns. The group will work to identify and review research and programs and will be helpful in understanding the current status of African American students and the schools systems that serve them, and develop policies and practices that benefit students’ development and achievements. The White House Initiative on AA Education Excellence is to help AA students receive the education that prepares them for educational success, college completion, and productive careers. According to a previous White House announcement, one specific objective is to increase the percentage of African American children who enter kindergarten ready for success and improve access to highquality learning and development programs.

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How Much Do You Know About …?

Editor’s Note: We began looking at how much people know about different topics and decided to engage readers with quizzes on important areas. For this first article we asked two of our Louisiana experts to help us with suicide prevention.

Dr. William Schmitz, Jr., is a psychologist and President of the American Association of Suicidology. His colleague is Dr. April Foreman, Kansas psychologist and expert in suicide prevention, media, and education. Together they agreed to design a short quiz on suicide prevention basics. Here are the 10 questions. Answers are on the next page.

TRUE OR FALSE?
1. If someone denies feeling suicidal, then they are not high
risk for suicide.

2. Simply documenting lack of report of suicidal ideation, or
denial of suicidal ideation is sufficient assessment and
documentation of risk of suicide.

3. If someone reports suicidal ideation, but does not go to the
hospital, then having your patient sign a “No Harm” contract
is the standard of care you should meet.

4. When assessing for risk of suicide you should ask about
and document which of the following: Suicidal Ideation;
Suicide Planning; Intent to act on suicidal thoughts/feelings;
Rehearsal for suicide and self-harm.

5. When assessing suicide risk you should do which of the
following: 1) Assign a level of risk “low-medium-high,” with a
corresponding treatment response, even if someone denies
current suicidal ideation; 2) Prioritize assessing for “distal”
risk factors, such as family history, which are more predictive
than “proximal” risk factors such as agitation and current
stressors; 3) Assign a lower level risk of suicide for patients
who feel they are a burden vs. a higher level of risk patients
who have a history of exposure to life-threatening situations.

6. You should generally only assess for risk of suicide when
someone self-reports suicidal ideation, or if you are made
aware of a history of suicide attempt.

7. No harm contracts are sufficient safety planning, as long
as someone is in outpatient care.

8. When doing a basic 6-step safety plan, you should address
restricting the means of suicide. For most patients this will
mean restriction of access to guns.

9. Means restriction has been proved to be ineffective at
preventing suicide. If you help a patient plan to make it
difficult to get access to one means for killing themselves,
they will just find another means. No harm contracts are
preferred for this reason.

10. Inpatient care is the best standard of care for people
assessed at high risk of suicide.

ANSWERS

1. FALSE: Some studies indicate that the majority of people who die by suicide deny experiencing suicidal ideation at proximal mental health visits. It is more important to assess for overall risk factors, than to just ask about suicide, document it, and move on.

2. FALSE: If you are providing care under an independent license, then you are expected to know how to do a more thorough assessment of risk, and to document that clearly. If you are sued for malpractice, it is relatively easy for an attorney to demonstrate the standard of care for suicide risk assessment, intervention, and documentation, even though research shows that approximately 90% of Psychologists are not able to demonstrate knowledge of this standard.

3. FALSE: No Harm contracts are NOT the standard of care. An empirically based risk assessment and 6 step safety planning process is the accepted standard of care.

4. ALL OF THE ABOVE

5. NUMBER 1. Number 2 is false as both distal and proximal risk factors should be evaluated and addressed. Number 3 is false; as Perceived Burdensomeness, Thwarted Belonging, and Acquired Capability are all considered major risk factors for suicide.

6. FALSE: You should assess for risk of suicide at an initial intake, yearly, following all inpatient admissions, any time distress becomes more acute in the course of treatment, when a patient reports suicidal ideation, and regularly/frequently in the months after a suicide attempt.

7. FALSE: No harm contracts are not considered a standard of care, and have been empirical demonstrated not to significantly reduce risk of death by suicide. If you do a no-harm contract, and do not do the empirically validated 6-step safety plan, you have not met the understood standard of care, and may be in danger of malpractice. Inpatient or outpatient status is irrelevant. Many people in outpatient care remain at high risk for suicide.

8. TRUE: Self-inflicted gunshot wound is by far the most common way that someone dies by suicide–60-80% of cases. You should also ask about plans for suicide and restrict means used in those plan, as well as ask about means from prior attempts, and access to lethal types/quantities of medication.

9. FALSE: Research clearly shows that deaths by suicide significantly reduce after safety planning and means restriction. People who have their suicide plans interrupted by lack of access to lethal means to suicide often do not go on to attempt in other ways.

10. FALSE: When it comes to inpatient vs. outpatient treatment, providers should weigh the pros and cons of each approach and discuss that with high risk patients. Inpatient care is generally best to address acute issues such as immediate inability to keep one’s self alive or need to adjust medications under inpatient supervision. The majority of patients, however, can and should be treated on an outpatient basis using frequent contact with their mental health care team, safety planning, crisis contacts, and involvement of family/friends in safety and treatment planning. A 1-4 day stay in a hospital does not really have much long-term therapeutic benefit for most people with high risk of suicide.

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Invisible Forces Behind Health Care

by Julie Nelson

Last month the Department of Health and Hospitals declared that they would integrate behavioral health into medical care for the nearly 1 million on Medicaid in Louisiana.

This is an admirable goal, but not an easy one. Integrative health care––where psychology is combined with physical health care––has been repeatedly shown to lower costs and improve outcomes. But even after decades of evidence, nothing much has changed.

One of the reasons change comes so slow in the US health care system is because of the forces behind what is paid for and how much is paid, the CPT and RUC.

CPT and RUC, short for “Current Procedural Technology” and “The Relative Value Scale Update Committee,” are the behind-the-scenes forces that shape the landscape of health care in the US. It is a system created by organized medicine with government, insurance, and hospitals.

Health care is the largest industry in the country, accounting for 18 percent of the Gross Domestic Product and about $2.8 trillion in sales. At the same time the U.S. trails peer nations in health but leads in costs. Various reasons have been suggested for this conundrum: aging population, high tech solutions, and chronic illness (heart disease, stroke, cancer) are at the top of most lists.

Chronic illness is a big part of the problem. The CDC estimates that three lifestyle factors– –poor diet, inactivity, and smoking––account for 80 percent of heart disease and stroke, 80 percent of type 2 diabetes, and 40 percent of cancer. Psychologists have pointed to the connections between lifestyle and behavior for decades. In an interview with primary care psychologist Dr. Michele Larzelere, she said there is scientific agreement for a 30 to 60 percent reduction in medical use with integrated behavioral health services.

But psychology and other groups have not been able to garner a place at the medical table. California Attorney David Ries of Human Capital Specialists tried to persuade federal Rule makers to include psychologists in the bonus plan for Accountable Care Organizations (ACOs) but failed. He told the Times that the final Rules were very disappointing. “The broad recognition of the importance of behavioral health to overall wellness indicates that ACOs are unlikely to achieve their treatment objectives under the clinical model proposed by the proposed rules,” he said.

Not surprisingly, primary care doctors, the specialty closest to the patient, are carrying water for behavioral health. In a special issue of the American Psychologist on Primary Care and Psychology (May 2014), Dr. Susan McDaniel and primary care leader Dr. Frank deGruy reviewed evidence that for each primary care physician added to a social system, “allcause mortality decreases by 5.3 percent.” Conversely, for every specialist added the mortality rate goes up 2 percent.

Dr. David Carmouche, Chief Medical Director and Senior VP at Blue Cross Blue Shield of Louisiana (BCBS) is working to build primary care back into programs. “Our strategy is to engage providers in communication so that patients develop a trusted relationship with a primary care provider,” Carmouche told the Times.

Still, when a person gets really sick, care becomes expensive. The top 1 percent spends $51,951, the top 5 percent spends $17,401, while the bottom 50 percent spends $850 or less on yearly health care, says Kaiser Health.

In “The Anatomy of Health Care in the United States” (November 2013, JAMA) authors contradict several common assumptions about the rise in costs. While medical costs are driven by chronic disease, they say, it is not due to an aging population. They show that 67 percent of those with chronic illnesses are younger than 65, and when trauma is included, about 80 percent of the total health care cost is accounted for by those under 65.

The authors, a group of physicians and MBAs, write that the common view that higher costs are being driven by the aging population and increased demand for services is wrong. They show that 91 percent of the increase in healthcare costs in the last decade was due to an increase in prices.

Overall, the US health care picture indicates two main issues. Prices are unreasonably high and we aren’t treating the right health problems. Both can be explained by the forces of the CPT/RUC.

At a recent meeting of the Louisiana Psychological Association, Dr. Tony Puente spoke about coming health care changes and CPT codes. Those attending were well familiar with using CPT codes, required to bill for health services. But Puente also spoke briefly about how CPT codes are developed. It turns out to be a system steeped in politics and power.

Officially, “CPT is a set of codes and descriptors for reporting medical services and procedures which provides a common language to accurately describe services in the health care profession,” writes the American Medical Association (AMA). CPT is owned by the Center for Medicare and Medicaid Services (CMS), leased to AMA, who then copyrights it.

CPT codes begin with three hundred “Advisors and Experts” who hammer things out and then attempt to influence the CPT Editorial Panel. The 17-member Panel makes the final decisions on which codes will be approved.

The 300 advisors come primarily from the AMA House of Delegates. They represent 109 medical specialties and they form into about 20 teams to lobby the Panel. The Panel includes 11 physicians from the Medical Societies, two representatives from insurance (Blue Cross Blue Shield and America’s Health Insurance Plans) and someone from the Center for Medicare and Medicaid Services (CMS). Then there are two people from the Health Care Professional Advisory Committee, the only representatives who are nonphysicians.

“Essentially the CPT tries to divvy it up in a way that is theoretically and empirically, and diplomatically and politically, correct.” Dr. Puente said. “That it is a very demanding and a very transparent activity.”

Actually, it is not transparent. Information about CPT negotiations is restricted, meetings are closed and participants have to sign confidentiality agreements and can be barred from future meetings if they disclose any information. No press is allowed.

The CPT system is dominated by organized medicine. “Every seat at the table has a vested interest, mostly not supporting your proposed code,” said Dr. Travis Thompson, professor, psychologist, and leader in the Association for Behavior Analysis International. He was speaking after it took him and colleagues three years to muscle through codes for the treatment of autism.

While the CPT approval is a first leg of a long journey, another element of this behind-thescenes influence is the a panel known as AMA/ Specialty Relative Value Scale Update Committee, or simply RUC. Since 1991 members of the RUC establish the value or price for the CPT codes. Somehow this is not considered price-fixing.

“The RUC Advisory Committee was constructed to allow participation by every specialty seated in the AMA House of Delegates, say AMA documents. “The RUC Advisors serve as advocates for their specialty, while RUC members must exercise independent judgment and are not involved in their specialty’s presentations.” But authors do not explain how a physician is to separate from his or her beliefs or biases.

There are 28 voting members on RUC, most who represent medicine specialties such as anesthesiology, cardiology, dermatology, emergency medicine, general surgery, neurology, neurosurgery, obstetrics, oncology, psychiatry, and so on.

The group’s design reflects the composition of the medical profession, rather than reflecting the needs of the consumer. But even within the medical family this led to problems because of an underrepresentation and undervaluing of primary care.In 1992 the Medicare payment for a primary care type office visit was $31 while cataract surgery was $941 and a lumbar spine MRI was $485.

While things have improved somewhat, there has been trouble in paradise. In a report on RUC and Primary Care, AMA Board of Trustees wrote, “The intense RUC review did lead to a divisive debate within medicine …” Trying to calm the waters, they said, “The Board of Trustees believes that organized medicine should work together to support the RUC’s efforts.”

Outcomes of these forces can be seen in how the profession is reshaping itself. The Robert Graham Center for Policy Studies in Family Medicine and Primary Care produced a 2009 report that explained disincentives for medical students to choose a career in primary care over one of the specialties, and why shortages are becoming severe. Figure 10 from the Center’s report, compares the grow of incomes for primary care and specialty physicians.

Control of the CPT and RUC have helped shaped health care toward high tech/high price, services, less primary care, and probably lower quality primary care because these physicians might push toward higher volume to help make up for differences.

Dr. Puente explained to psychologists this past spring that the CMS would set the bar under the ACA, but that decisions would shift from national level to the state level. And they have.

Louisiana Department of Health and Hospitals (DHH) considers family medicine, general internal medicine, and pediatric medicine to be primary care. Fee schedules for Medicaid posted by the DHH indicate that office visits are paid at $25.78 to $40.83. For a more expanded office visit the fee is $49.16 to $70.63. Office visits of high complexity can be paid nearly $200.

But the fee for removing a foreign body from the eye in an out-patient, ambulatory setting ranges from $269.57 to $509.99. Or, for removing an ear lesion the physician can bill $412.84 to $805.45.

At the same time Medicaid fee for a Behavioral Health Counseling Therapy session is $17.02. Mental Health Assessment is $23.65. And, MultiSystemic Therapy is $32.83. While Medication Management is $46.32, a situation to drive providers to medication as the first treatment. Hopefully, the recent announcement to review and build integrated care will help.

The social and political influences stemming from the CPT and RUC systems appear not only to have helped create major barriers for those outside of medicine to make contributions, they has blocked innovation, quality and driven up prices.

“If you can’t describe the process, you don’t know what you’re doing,” wrote Edward Demming about quality. The system we have seems to be one of confusion, rather than insight, of entitlement, rather than performance.

The customer is not empowered and is almost entirely absent from the process that creates services. Considering what we know about conditions that support quality outcomes, any arrangement where the customer and vendor are so distanced from each other is doomed to perform poorly.

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La Supreme Court Ruling Points to Need for Specialized Training

Handling of Sexual Abuse Allegations 

By Dr. Alan Taylor

In October the Louisiana Supreme Court ruled on a child custody case that included allegations of child sexual abuse. The court upheld the original trial court’s conclusions, and dismissed the appeals court’s objections, finding them without merit, but not before even more confusion and potential emotional anguish may have occurred.

The case was a strongly contested one where some, well- meaning health professionals became involved, but who did not have the specific knowledge to understand the complications that can be encountered in these cases.
In a guest article for this issue of the Times, Baton Rouge forensic and clinical psychologist, Dr. Alan Taylor, describes the problems in this type of case as “iatrogenic effects of legal and mental health practices.” The lower appeal court’s reversal was due to a lack of understanding that Taylor portrays as: “The first error is an assumption of expertise where it is lacking, and the second error is failure to recognize expertise when it is present.”
Forensic and clinical psychologist Dr. Alicia Pellegrin was the court-appointed expert in the case, and like Taylor, is a member of the Association of Family and Conciliation Courts (AFCC), an organization providing specialized training in this complex area of practice.

Pellegrin said that the case and others like it point to the need for more training and understanding in this demanding sub-specialty. “It is imperative that anyone working in this field have an understanding of child development, including language and cognitive processes,” she said, “child psychopathology, family systems, the legal statutes in the state in which one practices, and an understanding of relevant case law.”

Pellegrin told the Times, “One of our important functions can sometimes be simply to provide education to Judges that can inform their decisions that affect the most vulnerable in our society, our children. Towards that end, one must understand the effects of divorce on children and the particular vulnerabilities that certain children bring to the process. Finally because one or more serious allegations often arise in the context of a custody dispute, an understanding of child sexual abuse, domestic violence, and substance abuse, is critical.”
We present Dr. Taylor’s article in this special report and also cover aspects of the upcoming conference to be held in New Orleans by the Association of Family and Conciliation Courts, a premier provider of training and multidisciplinary thought in this complicated and important sub-discipline in psychology.

A recent Louisiana Supreme Court case (Louisiana Supreme Court case No. 2014- CJ1119) involved a custody battle where allegations of sexual abuse surfaced and caused a great deal of anguish and damage. This case illustrates what I call the iatrogenic effects of legal and mental health practices in custody cases with sexual abuse allegations. Serious mistakes can be made in both the legal and mental health systems that cause great harm to families and set bad precedents for managing these difficult cases. Although this case involved a custody battle, the handling of sexual abuse allegations in general is a volatile topic in all arenas – civil or criminal, public or private.

The first error is an assumption of expertise where it is lacking, and the second error is failure to recognize expertise when it is present.

The issues, problems, and solutions to handling sexual abuse allegations can be the subject of many articles, but this one will concentrate on some conceptual and practical points to ponder.

A Two Part Recipe for Bad Outcomes

1. The illogical assumption that because a person or agency works with a certain population, this makes him/them an expert regarding that population (substance abuse, sexual abuse, or domestic violence)
Coupled with

2. The more disadvantaged and overlooked the population being served, the poorer the training and resources available to the frontline staff who serve them (this is a statement of empathy, not disrespect). A great and unfair burden falls on staff with limited training and experience.

Do not expect expertise from this combination. In settings that deal with the worst human problems, training should focus on collecting data as objectively and clearly as possible at the lower levels, but analyzing and drawing conclusions is a higher-level function that requires professional training and experience. In many cases with sexual abuse allegations, this higher level function is never performed or significantly delayed while misguided efforts to help compound the problems.

A Case Example

To illustrate the forces at work and the complexity of ethical and professional issues, the following and unfortunately “typical” case is offered.
Assume a divorce proceeding involving two parents and a preschool aged child 4 to 5 years old. At a point shortly after the initial separation, allegations are made by the mother on behalf of the child that indicate possible sexual abuse. There is no history of previous allegations being made.

To support these claims, the mother (often advised by her attorney) takes the child to a pediatrician for an exam. The pediatrician sees only the child and the mother and receives all of the background information from the mother. Physical findings are negative. The mother subsequently takes the child to a mental health professional and relates information concerning the child’s behavior and reasons for suspected abuse. The mental health professional obtains information only from the mother and child, but is told about the previous pediatric examination. The physician may also have already made a mandated report which is described by the mother as a “finding” regarding abuse.

The mental health professional does not contact the other parent, who has not been informed of the appointment or the allegations. Based on some behavioral evidence and statements given, the mental health professional may also make a report to child protection authorities, who proceed with an investigation.

The OCS investigation automatically stops any visitation between the suspected parent and child. Pleadings are filed in court to eliminate visitation or have it supervised (often in an ex parte hearing in which information from the evaluations is presented for the first time). The judge “out of an excess of caution” concurs that visitation will be suspended until further evaluation can be completed.

The accused person is not allowed to have contact with the child and, should he become angry and upset with the mother, may find himself under a temporary restraining order. The accused parent may also be denied access to schools or information about the child and may find communication with daycare personnel cut off. This parent is often advised by his attorney to refuse to have any contact with previous evaluators who have seen the mother and/or child, as these people will be considered biased.

An independent custody evaluation may be requested where a petition is made to the court to require all parties to participate. However, the court may instead require that the accused parent undergo a mental health evaluation concerning their emotional stability, propensity for abuse, or fitness to proceed as a parent with visitation. The person performing this evaluation may have no access to the children or the accusing parent.

By this time, an array of as many as five or six mental health professionals may have become involved, none of whom has contemporary and comprehensive information about the history preceding the allegations, events subsequent to the allegations, results of other assessments, or contact with all involved parties. The evaluator may then be called to court to present findings, often as a witness for the particular party they have assessed. The length of this process may take from two to three months to a year or more, during which the accused parent may have little or no opportunity to meet or interact with their child.

If a full court hearing is completed and there are no definitive findings of abuse, the length of time with no contact and the resulting estrangement often necessitates meetings in a therapist’s office or supervised visitation on an infrequent basis to attempt a restoration of the parent/child relationship and progress toward a more normal course of visitation. In some cases, especially if the allegations have been adamantly maintained or supplemented throughout the process, there will be an immediate resumption of fresh allegations once visitation is resumed, setting the stage for another round.

The negative impacts on a child in the preceding section include the following:

1. The child suddenly and often inexplicably loses contact with the accused parent.

2. The child becomes the “litmus test” whose behavior, thoughts, and feelings are intensely scrutinized for any clues that might suggest or support allegations of abuse.

3. A child who reports information may have this information edited and reflected back by their parent, with interpretations or suggestions about what the child remembers or has experienced, along with comments about the intentions of the other parent. The child is exposed to an intense focus on sexual topics and behavior. Multiple evaluations suggest to the child that information of a sexual nature is considered highly important and attended to very closely. Care is often taken to reassure the child that producing and elaborating this material both in language and behavior will bring no negative consequences and indeed may bring praise.

4. Multiple evaluations imply that many adults are interested in and concerned about the sexually charged behavior. The child is led to assume that something “bad” or “wrong” has or was occurring during the time spent with the other parent. Often caretakers and teachers are alerted to observe the child’s behavior and are given background information suggesting reasons why they need to be concerned.

Do’s and Don’ts for Mental Health Professionals

• Whenever receiving an initial referral concerning a child, always ask whether there is an intact family situation. If not, ask what type of custody and visitation arrangements are in place, to be sure there is no underlying agenda.

• If it appears that the information developed from assessment or treatment is quite likely to be used in a forensic setting, immediately make it clear there will be strict rules and conditions agreed to before any services will be provided.

• The best practice is to perform only court-ordered evaluations that allow access to all parents and children. The next best practice would be that both parents be notified and informed of the nature and reason for the services with full access to information and participation by both. With extreme caution: agree to see one party only for a specific purpose, not relating to custody itself, with a clear explanation of the limitations in making any interpretations involving the other parties. Finally, a collaborative approach with other involved professionals is likely to be a good idea.

For Custody Evaluators:

1. Be aware of contamination effects from the number of previous assessments.

2. Do not use questionable or unsubstantiated assessment methods such as dolls.

3. Develop a model and structured approach in terms of interpreting data for relevance and weight (for example, timing of allegations, alternative explanations for normal developmental behavior, possible other potential perpetrators, information from other evaluations, etc.).

4. Remember that there is no expert instrument or procedure that can say whether sexual abuse did or did not take place.

Summary

It takes a brave soul to venture into the arena of high conflict custody battles, as well as any other areas that involve allegations of sexual or physical abuse. These cases are complex and problematic, in that concrete and objective information is scarce, with a considerable amount at stake in terms of emotional and legal consequences. Most judges dread situations in which there is ambiguous evidence and the need to make findings that pose a risk of failure to act on legitimate abuse allegations versus severe damage to parental access to relationships with
children. Attorneys who are advocating for a parent risk failing to act in the best interest of the children. Attorneys should never advise a client to get an evaluation or treatment concerning a child without notifying the other parent and providing an opportunity for them to participate in the
process. There should not be a contest to see who gets to court or the professional’s office
first. Mental health practitioners are presumably guided by children’s best interest, but there are often forces at work that involve multiple roles and becoming manipulated into questionable ethical positions. 

Courts should strongly discourage ex parte or one-sided presentations of “evaluations” or treatment findings where the source of the information is compromised by lack of access to all
information. Appointing an independent practitioner who has full access to all relevant parties, persons, and information is definitely the best practice.

The Louisiana Supreme Court case illustrates the major need for more training and education at all levels (attorneys, judges, and mental health professionals) to avoid the collateral damage done in attempting to work with cases involving sexual abuse
allegations. One of the best available resources would be the Association of Family Conciliation Courts, which has addressed this serious issue over the years in journal articles, training/workshops, and provision of model standards and guidelines for competent and ethical practice. Every national annual conference addresses the problems and developments in this area with reports from leading researchers and practitioners. May 27-29th of this year will afford a golden opportunity for practitioners and educators as the National Conference is held in New Orleans.

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Meds Do More Harm than Good? Robert Whitaker Makes His Case To Marriage & Family Therapists

In his keynote presentation to the Louisiana Marriage and Family Therapist Association on February 20, Robert Whitaker pointed to fallacies behind the rampant use of pharmaceuticals as first-line treatment for psychological problems, Cont’d pg 3 drawing on long-term studies, population statistics, and a lack of scientific theory behind the $70 billion global psychiatric drug market. Whitaker, an investigative journalist, is the author of Mad in America and Anatomy of an Epidemic: Magic Bullets, Psychiatric Drugs, and the Astonishing Rise of Mental Illness in America.

He laid out three hours of research showing that while short-term benefits give the impression of benefit, the longterm outcomes portray a very different and disturbing picture. In a review of research, experts, critiques of theory, and epidemiological data, Whitaker puts forth a compelling argument that antidepressants do more harm that good, that schizophrenics do better off medication than on, and that children taking stimulates are more likely to progress to chronic illness than if they go without medication.

Whitaker built on his Anatomy of an Epidemic, the first book to lay out an investigation of the long-term outcomes for those taking psychiatric drugs, and to place in a cultural and historical context, and call into question conclusions built primarily on short-term perspectives.

Whitaker told the audience that that psychiatric drugs were designed around a model of “chemical imbalance” in the brain that arose in the 1970s based on the dopamine theory of schizophrenia and serotonin theory of depression. However, evidence never confirmed these theories. As early as 1984, he explained, the National Institute for Mental Health (NIMH) wrote, “Elevations or decrements in the functioning of serotonergic systems per se are not likely to be associated with depression.” By 2011 Ronald Pies wrote for a Psychiatric Times review, “In truth, the chemical imbalance notion was always a kind of urban legend, never a theory seriously propounded by well-informed psychiatrists.”

Despite this prescribing increased over time, said Whitaker. At the same time, the drugs cause long-standing changes in the brain, something that has been known for almost 20 years. In 1996 the former director of HIMH, Stephen Hyman, said that psychiatric medications “create perturbations in neurotransmitter functions” and cause “substantial and long– lasting alterations in neural function.”

Whitaker outlined for the attendees how the illusion of benefit happens. One example is that antipsychotics reduce the “target symptoms” by disrupting the way the brain works. And this same effect causes a relapse when the drug is stopped. Physicians see in the short run that symptoms are reduced and that patients relapse if they go off the drug. But the drug creates a new set of problems for the patient compared to the long-term and to those not on the medications.

Looking at population statistics over time, Whitaker showed that in the 1920s, 30s, and 40s, the recovery from depression was high. The majority of those with depression experienced only a single episode. And only 13 percent fell into the chronic area. But by the 1960s and early years of antidepressant use, researchers were seeing a “shortening the intervals” between episodes, and a “change to a more chronic course.” By the 1980s both the National Institute of Mental Health and the American Psychiatric Association had a new view––that depression was recurrent and chronic. By 1997 researchers reported that 50 percent relapsed and only 3 percent went into remission. The longer the patient had been on antidepressant the higher the relapse rate, Whitaker told the audience. By comparing studies for national and international sources, he showed that those not mediated fared as well or better than those receiving the medications. He found much the same pattern with other illnesses, including bipolar illness.

Long-term research on medications with children, such as stimulates for ADHD, are consistent. In the 1990s NIMH looked at long-term improvements for the use of stimulants and found none. William Pelham, from the State University of New York at Buffalo and one of the principal investigators in that study, said, “We need to confess to parents that we’ve found no benefit. None. And we think that with drugs, the benefits should outweigh the risks.”

The routine use of psychotropics has been coming under fire and gaining notice in the psychological and behavioral health communities. In 2013 the Louisiana Psychological Association hosted Dr. Irving Kirsch, author of another line of books on the small clinical benefit of medications. Kirsch stunned the audience at a Tulane conference with facts on science, politics, and the antidepressant drug industry. He showed strong evidence that antidepressants are 75 percent placebo and that FDA approvals are skewed to favor drug companies. Kirsch’s exhaustive research is included in his 2011 book, The Emperor’s New Drugs: Exploding the Anti-depressant Myth.

Coverage of the work of Whitaker and Kirsch and others have stimulated more research and debate, and been picked up by major news outlets.

In a 2010 article in Journal of the American Medical Association (JAMA), researchers followed Kirsch and concluded that antidepressants have minimal use for mild or moderate depression.

The theme went to Newsweek, “Why Antidepressants Are No Better Than Placebos,” and to The New Yorker, “Head Case: Can psychiatry be a science?” The author, Louis Menand, pointed to Kirsch’s book, and also Gary Greenberg’s Manufacturing Depression, to highlight problems in the psychiatric industry. But Richard Friedman, M.D., criticized the research and warned, “Before You Quit Antidepressants…” in the New York Times.

Last year, Mehmet Oz (Dr. Oz) took the antidepressant issue to task on his popular daytime television show, with a hard-hitting special, “The Truth About Antidepressants,” where he said, “Antidepressants don’t work for most patients. They can even make your problems worse.”

Discussion at the February Louisiana Marriage and Family Therapists conference included a straightforward dialogue about the rights of patients and in particular of parents, to obtain a fully informed understanding of the limitations of these medications and a list of the harm.

Dr. Judith G. Miranti, Director of Counseling programs at Xavier University of Louisiana and a Clinical Fellow of the American Association for Marriage and Family Therapy, told the Times that the presentation was enlightening. But, “… morally perplexing to me as a mental health practitioner,” she said.

“Much to my disappointment, I learned from Mr. Whitaker’s research, that there was no evidence to support the long-term positive outcome regarding academic achievement. Instead, the results showed that the conditioned worsened with longer use of the stimulants. This presents for me a moral and ethical dilemma,” she said. “Now I realize before I would ever recommend psychotropic medications to treat certain symptoms/conditions that I would disclose to my clients the short and long terms effects of the medications.”

Tom Moore, marriage and family therapist and Director of the Red River Institute noted the importance for informed consumers.

“Medical practitioners who treat their patients with psychotropic medications run the greatest risk for doing their patients harm,” Moore said, “but are among all mental health providers least likely to inform their patients of the potential ineffectiveness— and harmfulness– of the form of treatment they employ. In light of the wide spread use of drug therapy in this country by so large a number of licensed medical practitioners, this certainly represents a major public health concern that must be addressed by the state regulatory bodies that oversee medical practice.”

Dr. Matt Morris, President of the Louisiana Marriage and Family Therapists Association and Associate Professor of Counseling at Our Lady of Holy Cross College, told the Times that the theme of “therapeutic alternatives to psychotropic medications particularly as a first-line intervention,” was very well received by attendees. “Robert Whitaker and Dr. Jackie Sparks,” Morris said, “were extremely competent presenters who enriched our conference greatly.”

 

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IOM Sides with Psychological Science

In an April 10, 2015 report, Institute of Medicine (IOM) authors sided with psychological science saying that not only should psychological testing be routinely performed in many types of Social Security Disability claims, but that the use of symptom validity testing in particular is needed when there are questions of credibility.

The IOM’s findings are another volley in the now decade-long debate between psychological scientists and policy makers at the Social Security Administration (SSA). The IOM began its review in 2013 after members of Congress and the Office of Inspector General put pressure on the SSA to change its policy. Instead of complying, the agency said it disagreed and would seek out an independent review from the IOM. If the SSA follows the IOM recommendations it could save taxpayers between $20 billion and an estimated $68 billion or more, per year.

At the center of the debate is New Orleans clinical neuropsychologist, Dr. Michael Chafetz, one of a small group of psychological scientists around the country who began to notice disturbing patterns as he went about performing routine disability evaluations as a consulting psychologist. The controversy hinges on the agency’s steadfast resistance to using modern psychometrictools to measure malingering despite the consensus in scientific circles these tools are needed for accuracy. This position also runs counter to other federal agencies and private industry.

On the surface of the issue, the debate has involved the use of symptom validity tests, known as SVTs, in disability evaluations. But underneath, the politically sensitive and disturbing problem of malingering in disability claims is at issue. As psychological science has improved its methods, research with SVTs has shown that up to 40 percent or more of claims include some level of malingering. This can be an especially thorny issue in claims of mental impairment (low IQ), in emotional disorders such as depression, and in some physical claims, such as chronic pain. 

In the IOM report, titled Psychological Testing in the Service of Disability Determination, authors recommend the use of standardized psychological tests, administered and interpreted by psychologists, for mental disorders and whenever somatic complaints are not fully supported by physical test results. They also recommend the use of SVTs when needed for accuracy. Chafetz and colleagues collected archived data to understand the accuracy of their results, also called validity, research that the SSA does not do for itself. But the reception for their efforts has not always been welcoming.

In 2007 Dr. Michael Chafetz and coauthors published the first peer-reviewed research article about malingering in Social Security claims, “Malingering on the Social Security Disability Consultative Examination: A New Rating Scale,” in Archives of Clinical Neuropsychology.

Prior to this, in 2003, Chafetz had shared his research with the local Disability Determinations Service (DDS) for a training workshop, “Malingering on the DDS consultative examination in psychology.” The DDS coordinator congratulated him on his research efforts and thanked him for the workshop, according to internal emails obtained by the Times.

But after publication of the 2007 article, DDS severed their relationship with Chafetz. He had previously performed almost 1,000 disability evaluations for the agency over the years, without complaint. According to emails obtained from DDS, the officials were concerned about the article and study of claimant results, and were in contact with the regional office about what to do about Chafetz. The emails were not specific on the reason for his release. Chafetz has repeatedly declined to comment on this issue, saying that it is private and that the agency had the right to discontinue with him at any time. However, along with colleagues in other areas of the country, Chafetz continued to do basic research, using anonymous claimant data, and in particular, the use of SVTs. The researchers began to see troublingly high “base rates.” As part of a series of research articles, researchers have found base-rates of malingering in social security claims of 41.8 percent. This is higher than the 30 percent that is typically found in legal cases.

Researchers have also demonstrated that malingering is “dose dependent.” There are higher levels of malingering in those seeking the higher benefits or compensation, and also higher levels when the claimant is seeking federal dollars. Chafetz has also described malingering by “proxy,” where children were coached to fake by a parent.

One of SSA’s complaints is that low-IQ individuals, those seeking benefits for intellectual disability, are unfairly labeled as malingering. However, in a study titled, “To Work or Not To Work: Motivation (Not Low IQ) Determines Symptom Validity Test Findings,” Chafetz and colleagues Drs. Erica Prentkowski and Aparna Rao cast doubt on this concern. They compared three groups of low IQ individuals. One group was seeking disability benefits, another group was seeking employment, and a third group was trying to get custody of their children. Only those seeking compensation scored high on malingering. Chafetz and colleagues have published 15 articles on the topic. He has presented his work repeatedly, including at the American Psychological Association and the Louisiana Psychological Association (LPA). Recently Chafetz has authored Intellectual Disability: Criminal and Forensic Issues, published by Oxford Press, which includes many of these issues.

However at one point, officials at DDS sent a letter to all of its consulting psychologists cautioning them about the content of a presentation by Chafetz, hosted by LPA. DDS officials were not willing to provide comment on the matter.

Psychologists have had little success influencing SSA positions. In 2008 the president of the National Academy of Neuropsychology, president of the American Academy of Clinical Neuropsychology (AACN), and others, joined in signing a letter by Chafetz sent to SSA advocating the use of validity tests. According to Chafetz, shortly after that the AACN created a committee on the issues and held a teleconference with SSA to discuss the issues. In 2010, the neuropsychology division of the American Psychological Association also created a task force that then provided guidance on new SSA rules.

By 2012 U.S. Senator Tom Coburn became involved in trying to update procedures at the SSA. Coburn, now retired, is known for his efforts to uncover government waste. In 2011, through the U.S. Senate Permanent Subcommittee on Investigations, committee on Homeland Security and Governmental Affairs, Coburn was studying problems with backlogs in disability appeals. Appeals rose from 12,000 in 1999 to 817,000 in 2012, according to the U.S. Budget Office. The increase had to be processed by Administrative Law Judges (ALJs) who were struggling with extremely high case loads causing years long wait times for decisions.

Coburn’s research found errors rates of 25 percent and insufficient evidence in decisions by ALJs. Some judges approved appeals simply because they did not have time to study the case, according to a report by the Cato Institute. Senator Coburn was referred to Chafetz by an ALJ, Chafetz explained to the Times. And in September 2012, Chafetz provided a special presentation in the public interest for Coburn’s office, through the Louisiana Psychological Association Online Academy.

By January 30, 2013, Coburn wrote to SSA Commissioner, Michael Astrue, asking that the agency fund psychological tests that measure malingering.

“… the agency’s decision stands in stark contrast to current scientific research and findings,” Coburn said and pointed out the support for use of symptom validity tests to identify malingering in psychological evaluations. “In fact, there is broad consensus within the medical community that malingering is a problem and must be addressed,” he wrote.

Coburn noted that there could be $20 billion in a single year of benefits for “malingered mental disorders alone.” He also said, “Translating these base-rates of malingering to benefit payments is alarming.” And, “If one considers that ‘disability,’ which is defined as an inability to work, can be feigned no matter what the illness, then the agency spent approximately $68 billion (or 40 percent of $170 billion in total net benefit payments) in 2011 on disability beneficiaries who were likely malingering.”

Coburn criticized the SSA, saying “… the agency has no idea of its inability to measure the impact of the fraud occurring under its own roof.”

In March 2013, Chairman for the U.S. Committee on Oversight and Government Reform, Darrell Issa, wrote Acting SSA Commissioner Carolyn Colvin. Issa pointed to a number of OIG recommendations that SSA had not implemented. These included improvements to continuing disability reviews, reporting to Congress, conducting of additional work related reviews, revisions to benefit payments, and prosecuting false applications. According to Issa’s letter, the recommendations either had not been implemented or the outcome was unknown. Issa and coauthors also sited Coburn’s findings and the agency’s failure to address “insufficient, contradictory or incomplete evidence,” in disability claims.

In April 2013, Chafetz was asked to present for the Inspector General’s Office (OIG) and by September 2013 the OIG released a report pointing to flaws in SSA’s policy. In “Congressional Response Report: The Social Security Administration’s Policy on Symptom Validity Tests in Determining Disability Claims,” the OIG investigators said that the SSA runs contrary to scientific and medical consensus, other federal agencies such as Veterans Affairs, and standard practice in the private insurance sector, when it refuses to allow the use of SVTs.

The OIG concluded, “While SSA does not allow the purchase of SVTs for its disability determinations, we found that medical literature, national neuropsychological organizations, other Federal agencies, and private disability insurance providers support the use of SVTs in determining disability claims.”

The SSA was still resistant. Their response was authored by a CPA and Financial Manger, Mr. Gary Hatcher.

Mr. Hatcher wrote, “We believe that tests cannot prove malingering, as there are no tests that conclusively determine the presence of inaccurate patient self-reporting. We do not give greater weight to a test than to other symptom validity factors.”

“In addition,” Hatcher wrote, “we plan to seek external expertise on psychological tests from the Institute of Medicine [IOM] to include an examination of published research and studies on SVTs, including those published by Dr. Chafetz. Our goal is to determine the effectiveness and costs of requiring and purchasing SVTs under our disability programs, as well as their applicability to anyone who claims they are disabled.”

Hatcher concluded, “We provided technical comments and listings from medical literature on the shortcomings of SVTs at the staff level.” And, “We have no further comments,” he said.

Last week the Times asked the IOM if there was a committee or other action to address the report findings and the IOM said that while they work closely with SSA, this has not been addressed as yet. As of this date, the Times has not found any public response from the SSA about the April report.

IOM Recommendations

1. The SSA should require psychological testing for “all applicants” when claims relate to either a) mental disorders unaccompanied by cognitive complaints; or b) claims where “somatic symptoms are disproportionate to medical findings.” Statements of validity should be included, which “could include” symptom validity tests.

2. The SSA should require standardized cognitive testing for “all applicants” when claims do not include objective, medical evidence. Again, a statement of validity should be included, and could include performance or symptom validity testing.

3. The SSA should require that testing be performed by “qualified specialists properly trained in the administration and interpretation of standardized psychological tests.” The IOM says the specialist must be licensed or certified to administer and interpret psychological tests.

4. The SSA should conduct research to investigate the “accuracy and consistency of SSA’s disability determinations with and without the use of recommended psychological testing.”

5. The SSA (in collaboration with other agencies) should evaluate the impact of these recommendations on its outcomes, including backlogged cases, time delays, number of appeals, accuracy, and “Effect on state-tostate variation in disability allowance rates…” 6. The SSA and other agencies should support a program of research to “investigate the value of standardized assessment, including psychological testing, in disability determinations.”

[Editor’s Note: The IOM report can be obtained from the Academy of Sciences at IOM website under the section on reports. See Dr. Chafetz’s book reviewed in this month’s Bookshelf. Also see “OIG Shakes Its Finger at SSA,” and “Did SSA Try to Kill the Messenger,” in October 2013 issue of the Times (Vol. 5, No 2).]

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Meditation: It IS What You Think

by Susan Andrews, PhD

From The Psychology Times, Vol. 6, No. 4

Years ago when first learning to meditate, I saw a T-shirt I liked with this logo on it. That slogan says it all. As psychologists, we know the importance of monitoring our thoughts and how interrelated thinking and feeling really are. A major cause of stress and one of the most important stress solutions has to do with our thoughts and our thinking. Turns out that Stress IS what you think, too. So here we have a Zen moment; both a stressed state of mind and a calm focused state of mind are related to our thinking.

The mind is an amazing thing. To a large extent, the negative consequences of stress are directly due to a busy mind. You do not have to be physically busy to have a busy mind. Most professionals would say they spend the day thinking and they might agree that thinking all day – without lifting a single shovel – is fatiguing.

If you are almost always thinking and worrying over a problem or you continue to dwell on the events of the day even after they are over, that is a chronic issue and your cortisol levels are likely to remain high. Cortisol levels do not drop until your mind calms and becomes quiet or still. So the longer you remain mentally active, even if you are lying in bed or sitting in an easy chair, the longer your high levels of cortisol will remain. And, that leads to an exhausting list of bad things, physically, mentally and emotionally. Let’s just say it does not lead to longevity and happiness.

Meditation, on the other hand, is a great antidote to stress caused by too busy a mind. In the past, meditation seemed more strange or alien to the Western mind. But, with the gradual advance of information about different forms of meditation and the acceptance of meditation as having value, it has actually become easier to learn and to include in your daily practice. Sanskrit words and chanting are no longer required. The rapid spread of Mindfulness is an excellent example. This technique takes minutes to learn and very little more to perfect. It is so simple that it is recommended for children and found helpful with children who are having problems with attention and/or with behavior. The book, Sitting Still Like A Frog: Mindfulness Exercises for Kids (and their parents) by Eline Snell, (2013) was featured at a 2014 LPA workshop by Dr. Michelle Moore. This book comes with a CD that has a number of great 5-minute Mindfulness exercises. I have recommended this book to many of my patients, old and young. It is inexpensive and easy to use. I recommend it for everyone who needs to learn this simple meditation technique.

Mindfulness is growing in popularity across the country. It is recommended for so many different reasons:

  • stress relief and pain relief
  • taking mental breaks during a busy day
  • assistance falling asleep
  • combat depression and/or anxiety

Do yourself a favor: Give Mindfulness a try.

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The Chicago School at Xavier Prepares for 1st Class

This September the first class of doctoral students will start at the new PsyD program in clinical psychology offered by The Chicago School of Professional Psychology at Xavier University of Louisiana in New Orleans (XULA). The effort is innovative in a number of ways, including getting a head start on aligning with new standards for “Health Service Psychologists” to be approved later this year by the American Psychological Association. The Xavier based program is also innovative because it will focus on applied clinical psychology specifically for the diverse and multicultural context in south Louisiana, and on “growing PsyD Psychologists here,” explained Dr. Christoph Leonhard, department chair for the new program.

“We developed the program to meet the needs of local social service providers of psychological services and of the community,” he said, “and frankly, to provide culturally competent services by people who understand this community, which is a very unique place in many ways.” The Chicago School of Professional Psychology (TCSPP) program will be admitting about 15 doctoral students this fall. The program is hosted by Xavier, the highly ranked New Orleans institution which is the nation’s only Roman Catholic Historically Black College and University (HBCU). “We have applicants from current students in all the HBCUs in the area,” said Leonhard, “including Southern, Dillard, and certainly Xavier. We also have applicants who have already completed their undergraduate degrees at the local institutions. So far, we only have one applicant without a prior connection to the area.” The Chicago School developed and will manage the curriculum and faculty for the new program, and XULA provides support services and hosts the department on its campus. The PsyD (Doctor of Psychology) degree is the only program of its kind in the state, and the only other clinical psychology training after that at Louisiana State University in Baton Rouge. Clinical neuropsychologist and Assistant Professor in Clinical Psychology in the new program, Dr. Matthew Holcomb, said, “… the PsyD program at Xavier was inspired by the need that southern Louisiana currently has for well trained and qualified clinicians.” He pointed out that from the beginning Leonhard has developed relationships with area agencies for practicum training and externships for the students. “Given that we are a PsyD program, which is invested and emphasizes exposing students to direct clinical work, our students are going to have first-hand experience addressing the multicultural needs of the area, as well as developing an impressive network of professional contacts,” said Holcomb. Holcomb will help train the PsyD students in brain-behavior relationships and assessment practices, his own clinical and research interests being in pediatric neuropsychology.

The program organizers have limited their recruitment to students inside Louisiana. Leonhard hopes to grow PsyD psychologists here, and who will remain here, in order to serve the sometimes unique needs of the Louisiana culture. “Studies indicate that newly graduated psychologists who have to leave the state to get an advanced degree do not return,” said Leonhard. “So the emphasis of this program is to educate and train our own.” To help them reach this goal, Leonhard and his colleagues created an Advisory Committee of local professionals, including two area psychologists, Dr. Janet Matthews and Dr. Michele Larzelere. Dr. Matthews explained that she has met with many of the candidates for faculty and administrators in the new program.

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Dr. Christoph Leonhard, department Chair for the Chicago School of Professional Psychology at Xavier, at his desk. Dr. Leonhard has designed the machine he’s sitting on to help stem the problems for people who have to sit all day at a desk. He has a background in behavioral medicine and health services.

“We have also discussed student recruitment processes, curriculum issues, and overall program philosophy,” Matthews told the Times. “This program is designed specifically to meet community needs,” she said, a topic Matthews knows well, having taught at Loyola for three decades and retiring last year. “With the focus on primary care/integrated care, and cultural diversity issues,” she said, it is ideal for the Greater New Orleans area.” “It has been my experience teaching here for the past 30 years that we have local students who would make solid psychologists but cannot, will not leave the community.” Matthews believes that the new program will allow them to remain in the area, and help assist what she views as an underserved community, in terms of psychological services, she noted. The doctoral students in the TCSPP program at Xavier will complete studies in four models of intervention: Cognitive Behavioral, Psychodynamic, Humanistic Existential, and Systems. The program includes a Research Clerkship model where the students are paired with mentors from the faculty. Three years of practicum and one year internship are included in the 106 total credit hours that will take five years to complete, and while not yet accredited by the American Psychological Association (APA) the program will prepare students to sit for the psychologist licensing exam.

The PsyD program at Xavier will take full advantage of the changes in approach brought about by the Patient Protection and Affordable Care Act (ACA) that requires prevention and a focus on primary care and community health. APA will be shifting its training model later this year in response to ACA, and the Chicago Professional School at Xavier will align with these changes. “To be in compliance with what the ACA calls for, we’re now going to be training health service psychologists– –psychologists that provide health service, mental health being a health service, said Leonhard. “Basically the APA is shifting to a new accreditation model for selfstudies due after September 2016, and they are abandoning the G&P, the Guidelines and Principles,” he said, and there will be “new opportunities for clinical psychologists to be health service providers in interprofessional care teams, including in primary care.” “One of the things that most people don’t know about the Patient and Affordable Care Act is that it mandates interprofessional care teams throughout health care but importantly, in primary care,” he said.

Dr. Michele Larzelere is one of the local psychologists who serve on the Advisory Committee and who sees this benefit: “It’s wonderful that the TCSPP at Xavier University training program will be helping to address the nation-wide need for psychologists with primary care competency.” “Since primary care is an excellent way to reach underserved and minority populations, the PsyD program will also be expanding Xavier’s efforts toward its core mission,” Larzelere said, “and providing a tremendous service to the population of Louisiana.” Leonhard has developed the training design to match both the local needs and the new healthcare law and training directions. “So what we’re doing is setting up this program from the word ‘go’ to be in compliance with the new Standards of Accreditation,” Leonhard said. “There is a lot of emphasis about getting out of the silo early. So for example, we’re talking to the Xavier College of Pharmacy about doing some co-training with the Doctor of Pharmacy students here, in interviewing patients,” he said. “And they actually just got a modern interview lab on campus which is basically like a mock hospital room where you can train people how to interview.”

“We used to train people just in one profession––as psychologists, or as physicians, or as pharmacists or as physical therapists and somehow later on they were supposed to figure out how to be part of a multidisciplinary team,” Leonhard said, “So now the emphasis is on interprofessionalism, where the different professions are co-equal participants in the enterprise to improve the patient’s health.” While there are still a lot of unknowns as to exactly how ACA will unfold, Leonhard believes this will be a good step. “I think key is getting psychologists to be the behavioral health providers in the interprofessional teams, especially board certified psychologists,” he said. But the change in training focus will also include changes in the traditional methods. “For example, I’m just rewriting the Psychometrics course syllabus where the scales that are being used in primary care are very different from the battery type testing that a lot of times psychologists do. Because, it is very quick––its five items, seven items,” said Leonhard. “It’s oftentimes tests and scales that psychologists aren’t really familiar with, that physicians use to assess substance use potential or depression, anxiety disorders. Just on the quick, because when you’re in primary care, it’s very fast.” Dr. Janet Matthews also noted that another advantage of the new program is the focus on evaluation methods and outcomes research methods. “As students move into their practicum sites, they will be trained to help those sites do the type of outcome evaluations that is becoming more of a requirement for funding,” she said. “In this way, their work can influence both the quality of current service and also support future growth”. The new program offers two formal focus area — Clinical Psychology in a Diverse and Multicultural Context and Behavioral Medicine/Health Psychology – which Leonhard and his team at Xavier hope to help meet this growing need and to train psychologists for the healthcare services of the future.

Xavier University of Louisiana serves more than 3,000 students at its location in New Orleans, Louisiana and is accredited by the Commission on Colleges of the Southern Association of Colleges and Schools. Xavier’s Psychology Department, chaired by Dr. Elliott Hammer, will be part of the supporting structure for the program, but is separate in decision-making from the new program. The Chicago School of Professional Psychology is licensed by the Board of Regents of the State of Louisiana. TCSPP owns and provides oversight for the curriculum for the Clinical Psychology PsyD program. Tuition is currently $1,260 per credit hour. While the program is not APA accredited at this time, the curriculum prepares graduates for the psychologist licensing exam and to meet requirements for licensure in Louisiana. For more information see www.TheChicagoSchool.edu/XULA.

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The Unexpectedly Fascinating Research with the Brony Fandom

What’s a Brony? For that matter, what’s a Fandom? Dr. Marsha Redden, long-time Louisiana psychologist, now retired and transplanted to South Carolina where she’s licensed and studying at University of South Carolina– Upstate, has a bit of an idea. Redden and her colleagues have been researching the fan group who call themselves “Bronies,” the unexpected fan group of boys and young men––the average age is 21––who follow the animated television show, My Little Pony: Friendship is Magic. The series, produced by Hasbro, targets the market segment of preadolescent girls and their parents. But the show won critical acclaim and, according to online bloggers, appealed to many of the fans of other animated shows like Pokemon, Robot Unicorn Attack, and Nyan Cat. These young males appreciated the show’s artanimation, music, and story line: a quest against the dark and destructive side of human nature with moral courage, love, and tolerance.

After 2010 these fans began to connect on the Internet and adopted the name Brony (singular) to describe themselves, combining “bro” and “pony,” for boys who like ponies. A polarizing online battle between Bronies and their critics, crystallized the group and the fandom began to thrive.

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Past President of the Louisiana Psychological Association Dr. John Fanning (L) speaks with Brony Fandom researchers from SLU, William Schmidt and Megan Simon. The two work with SLU psychology faculty member Daniel Chadborn in social psychology research and help understand new forms of group identity.

The phenomenon has carried Redden and her colleagues along with it. Redden has appeared in two films and she presented at fan conferences of 10,000 plus, speaking to standing room only audiences. “To our knowledge,” Dr. Redden said, “this is the first time psychologists have studied a fandom from the beginning.” She and colleague Daniel Chadborn, psychology faculty member from Southeastern Louisiana University (SLU), and Drs. Patrick Edwards and Jan Griffin from USC-Upstate, have collected data on 50,000 fans. The research team has looked at the demographics of the Bronies and presented research that has both helped explain the unique fandom, and helped deal with stereotyping. What have they found? Eighty-six percent of the Brony fandom are male, the average age is 21 with a range of 14 to 57, and 70 percent are students and 33 percent employed full or part-time. In sexual orientation, 84 percent describe themselves as heterosexual, 1.7 describe themselves as homosexual, 10.3 as bisexual, and 3.8 as asexual.

As a group, Bronies tend to be higher in Introversion, Agreeableness, and also in Absorption, a trait that seems related to artistic enjoyment and interests. The fandom appears to serve a strong “Social Function” for the Bronies, helping them expand friendship networks, and also a strong “Guidance Function” which helps support and make moral choices. The psychologists’ research has been fully embraced by the Bronies. “In the fandom I am known as ‘Dr. Sci Entific,’ Redden told the Times, “and you haven’t lived until you’ve gotten a standing ovation from 1,000 people or had a line waiting for you to sign autographs.” This is every summer at BronyCon. Redden has even autographed Diagnostic and Statistical Manuals.

While fan clubs have been around forever, the boost that telecommunications have added to overcoming geographical distances has helped to create some large and unique fandoms such as the Bronies. The researchers appear to be the first psychologists who have been able to compare fans and non-fans, and study the evolution of the fans as they grew and matured, explained Redden. “It is also the first time a fandom has been studied in this depth,” she said. “We have data on their demographics, sexuality, religion, hobbies, social behavior, drug behavior, to mention just a few. In all we have over 50,000 respondents in the data pool so you can see that the stats is a giant project.” The database is so big, she said, she’s retaking statistics courses. SLU undergraduate coordinator Daniel Chadborn and his students, William Schmidt and Megan Simon, have produced a host of presentations and presented at APA, the Louisiana Psychological Association, Southeastern Psychological Association, and will present at the upcoming Southwestern Psychological Association (SWPA). Chadborn joined the research group in 2012. “… I was looking into identity and personality types of table top role playing gamers,” he said, when he discovered the Brony reseachers. Chadborn has found it interesting that the “… fandom offers a large motivated population––our second survey took in close to 20,000 survey responses on a 45 plus minute long battery of surveys––and that is first and foremost what we have found supports the idea that fandoms, and especially the Bronies, are a positive group and offers a majority of its members positive benefits.” “It was also interesting to examine a fandom or group that had the potential to expand and last much longer than a few months,” Chadborn said, “and one that we could gather information and track changes from the beginning, rather than 10 plus years down the line or more if you look at groups like the Trekkers/Trekkies.”

He is also interested in the universal purposes of fan and leisure activity involvement. He and students Schmidt and Simon are examining fandom as a whole including focus of identification, fan interactions, size, and the universal traits of fandoms. They will be presenting some of their work at the upcoming Southwestern Psychological Association. Their results suggests that fandoms can offer three functions: a sense of guidance, inspiration, purpose, or sense of uniqueness; a way to share a liked interest; and stress relief. Chadborn, Schmidt and Simon are examining fandom as a whole including focus of identification, fan interactions, size, and the universal traits of fandom. And have concluded that “… regardless of where a fan’s interest lies, the purposes and functions the fandom and interest serve are the same.”

The Brony researchers have been interviewed in two films, distributed internationally and now on Netflix: The Extremely Unexpected Adult Fans of My Little Pony, produced by John De Lancie, and A Brony Tale, produced by Bret Hodge. “There is even a t-shirt, with the logo,” Redden said. The “WWAPD factor” logo and tshirt emerged after Redden commented on the issue of moral guidance and the “What Would a Pony Do” factor. “Many therapists and parents have written to thank us for doing this work because now they know what THEY are dealing with,” said Dr. Redden. To find more information go to www.bronystudy.com and click on the FAQ’s at the top or the Results section.

 

 

 

 

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