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.

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.

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.