BC PsyChologist J o u rn a l o f t h e B C Psych o l o g i c a l A s s o ciati o n Vo lu m e 7 • Is su e 2 • Sprin g 2018
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Ted Altar, Ph.D., R.Psych. Assistant Editors
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Rick Gambrel, B.Comm., LLB.
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Rick Gambrel, B.Comm., LLB. Priya Bangar
BOARD OF DIRECTORS
PRESIDENT Marilyn Chotem, Ed.D., R.Psych. VICE-PRESIDENT Martin Zakrzewski, Psy.D., R.Psych. TREASURER Sofia Khouw, M.A., R.Psych. DIRECTORS Ted Altar, Ph.D., R.Psych. Zarina Giannone, M.A. Michael Sheppard, Ph.D., R.Psych. Kamaljit Sidhu, Ph.D., R.Psych. Paul Swingle, Ph.D., R.Psych.
Table of Contents 5
Letter from the President
BCPA News & Events
Letter from the Executive Director
Closing the Access to Care Gap: How Internet Delivered CBT Can Improve the Health of Canadians Marissa Bowsfield, M.A. Candidate Joti Samra, Ph.D., R.Psych.
Addiction: A Hidden Problem in South Asian Communities Vanessa Epp, Psy.D. Candidate Marilyn Chotem, Ed.D., R.Psych. Integrative Divorce Services: Fresh Opportunities for Psychologists and for the Public Susan Gamache, Ph.D., R.Psych.
Contractors and Subcontractual Arrangements in Psychology Donald Hutcheon, C.Psychol. (U.K.), R.Psych.
High-Altitude Hypoxic Effects on Cognition and Potential Brain Damage Evan Hutcheon, B.Sc. (Hons.), Masters Candidate Donald Hutcheon, C.Psychol. (U.K.), R.Psych.
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Psychology Month 2018 Media Coverage
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Letter from the President M a rily n Ch o t e m , Ed. D, R. Psych .
Dr. Marilyn Chotem completed her Ed.D. in Educational Psychology and Counselling at McGill University in 1990. She has been a Registered Psychologist in BC since 1980. Her career began in substance abuse/dependence treatment programs in 1978. Since 1983, she has worked with diverse populations in a variety of settings, such as community mental health centers, hospital psychiatry and private practice.
D e a r Co l l e ag u e s ,
The new BCPA Board of Directors had their first meeting on January 19, 2018. We dedicated that meeting to a visioning session to focus our individual and collective resources for the 2018/2019 year. I was quite energized by the enthusiasm and creativity of the Board as a whole. I would say that we have a dedicated team with some great ideas. The Membership Committee now has five enthusiastic members (Dr. Kamaljit Sidhu, Dr. Michael Sheppard, Ms. Zarina Giannone, Ms. Sarika Vadrevu, and our Executive Director, Mr. Rick Gambrel) with ambitious ideas. A top priority for them will be doing a Members’ Survey. They also talked about increasing student memberships, building communities of psychologists in regional areas, mentoring and supervising new graduates, and looking at enhancing benefits for members. Dr. Ted Altar will continue to chair the Continuing Education Committee. He may be the only member, as well. Dr. Altar is hard working and thorough in his research for potential speakers, their qualifications, affordability, availability and relevance to members. We continue to draw topics of interest from the past Members’ Survey. Anyone interested in being on this committee, please let the office or Dr. Altar know. Dr. Altar also chairs the BC Psychologist quarterly journal. He and Dr. Marian Scholtmeijer are co-editing the journal. We would like to invite BC academic psychologists, practicing psychologists and graduate students to publish their articles in the BCPA journal. We would like the journal to have a BC focus. We will be approaching professors and graduate students at the provincial universities to encourage their submissions. Dr. Altar also hopes that academic psychologists will engage in practice-oriented research. If you have an article you would like to submit, please send it to firstname.lastname@example.org.
The Community Engagement Committee is also reported to be an energetic group with Dr. Patrick Myers, Ms. Beverley Kort, Ms. Susan Benson, Ms. Sofia Khouw, Ms. Priya Bangar and Mr. Rick Gambrel as its members. The CEC Committee and the office staff did an exemplary job of promoting psychology to the public during Psychology Month, February 2018. We also discussed ways to improve our public education publications, e.g., brochures and fact sheets. Also falling under the CEC Committee is a commercial that the Council of Professional Associations in Psychology (CPAP) and CPA jointly produced. The short commercial is an animated promotion of psychological services. All the provincial psychology associations were able to put their logo on the ad. The advertisement was posted on the weekly e-blast and BCPA’s social media sites and can be found on our website. Lastly, the Advocacy Committee (composed of myself, Dr. Martin Zakrzewski, Dr. Martin Phillips Hing, Dr. Wolfgang Linden, Ms. Vanessa Epp and Mr. Rick Gambrel) seeks to be a united front for all advocacy issues. We are focused on Recruitment and Retention issues (salaries and benefits that attract and keep psychologists in publicly funded positions), advocating for increased coverage for psychological services under Extended Health Benefit plans, and advocating for publicly funded access to psychological services. As you may be aware, there are reportedly 50% fewer medical doctors going into psychiatry. Psychologists are well positioned to assist with this anticipated reduction in services and increased public need, particularly in the realm of evidence-based assessments and treatments. The Advocacy Committee continues to liaise with the Ministry of Health and Ministry of Mental Health and Addictions. A comprehensive, wrap-around plan for healthcare delivery is reportedly soon to be announced which is anticipated to include increased access to psychological services. The announcements are likely to be out before you read this issue.
The delightful colours and fragrances of spring are coming soon. It is a season of renewal after the challenges of winter. Wishing all of you a joyful spring. Respectfully submitted,
BCPA News & Events Upcoming Workshops: •
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Marilyn Chotem, Ed.D., R.Psych. President, BCPA
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Letter from the Executive Director ri ck ga m b re l , b . Co m m . , LL B .
The Executive Director of the BCPA. Mr. Gambrel has a Bachelor of Commerce in Finance and a Law Degree from UBC. Prior to working at BCPA, he was a trial lawyer for over 30 years, as well as Managing Partner of a number of law firms. He is Past President of both the Trial Lawyers Association of BC and of White Rock Concerts, one of Canada’s leading classical music presenters. Contact: email@example.com
Sin ce I l a s t re p o r t e d t o yo u,
it has been a very
busy and successful time at BCPA. In January, President Marilyn Chotem and I attended the Leadership Conference presented by the CPA Practice Directorate and the Council of Professional Associations of Psychology (CPAP) in Ottawa, where I also represented you as a member of the governing body of the national professional liability insurance plan, brokered by BMS. I was also honoured to have been elected by the other psychology associations across Canada as Vice-Chair of CPAP. February was Psychology Month, a public education campaign to raise awareness among the public, government and business sectors about the role of psychology in our lives, jobs and communities. This was once again a most successful Psychology Month. BCPA presented 14 public talks in 6 cities (Vancouver, Surrey, Burnaby, Port Moody, Richmond and Victoria) and in 3 languages (English, Punjabi, and Mandarin). In conjunction with these talks, presenters did dozens of media interviews, reaching almost 5 million people through the biggest media outlets of the province. Thank you to our presenters and interviewees, and thank you to the BCPA staff who worked long hours in February to make this all happen. Also during Psychology Month, BCPA was an exhibitor at the Bottom Line Conference on workplace mental health, presented by CMHA. This allowed us to speak with dozens of employers and unions about the benefits of increasing annual coverage limits in extended health plans for psychological services. As you may know, Starbucks increased their limits to $5,000 per year and Manulife to $10,000. For me, March was a busy month. I first attended a three day international conference in Washington D.C. of CESPPA – the Committee of Executives State and
Provincial Psychology Associations – the international group for all the Executive Directors of psychology associations. At the conference, we participated in continuing professional development sessions to make us better E.D.s. I had the chance to also meet with APA leadership, including their new and dynamic CEO, Dr. Arthur Evans. At the end of three days of hard work, I moved right into another conference in Washington D.C., the APA Practice Leadership Conference – a conference concentrating on making us better advocates for psychology and teaching us how to better operate a successful association. I was on the planning committee for the conference (the APA Committee of State Leaders), which had over 400 attendees from associations all over North America. As past Chair of CESPPA and a member of the APA Committee of State Leaders, I was honoured to be on stage at the conference town hall. These next two months will just as busy with another workshop in May. I will also be attending, along with Dr. Chotem, the Health Sciences Association Convention, to meet with their executive on behalf of our association and our members who work in hospital settings. The staff and I continue to work hard for you and we feel gratified that we are making a difference for the profession and your clients.
Rick Gambrel, B.Comm., LLB. Executive Director, BCPA
Closing the Access to Care Gap: How Internet Delivered CBT Can Improve the Health of Canadians Marissa B owsfield, b . a .
Marissa is a Master’s student in Clinical Psychology at Simon Fraser University and Research Associate and Practicum Student with Dr. Joti Samra, R.Psych. & Associates. jOTI sAMRA , pH . D. , R. Psych .
Dr. Samra pursues a full spectrum of research, consulting, and educational activities in the field of workplace health. She is the Lead Developer of Guarding Minds @ Work: A Workplace Guide to Psychological Health and Safety, and is a member of the Technical Committee that developed the National Standard of Canada for Psychological Health and Safety in the Workplace (CSA Z1003/BNQ9700). She is also the principal developer of Managing Emotions, a set of online, interactive assessment and training resources that strengthen the emotional intelligence skills of managers. Dr. Samra is the Program Lead for the Centre for Psychological Health Sciences at the University of Fredericton (getstarted.ufred. ca/PHS), where she has led the development of a suite of online courses and certificates in Psychological Health and Safety in the Workplace, Managing Psychological Health Issues at Work, and Resiliency Skills for Workers.
The problem with psychological health care lies not in the existence of effective treatments, but in the degree to which they are available and accessible to Canadians."
E C A D ES OF RIGOROUS RESEAR CH STEMMING FROM PSYCHOLOGY 'S E VID EN CE - BASE D PRAC TI CE
have resulted in the development of numerous empirically supported treatments for a range of psychological problems (e.g., APA Presidential Task Force on Evidence-Based Practice, 2006). For example, cognitive behavioural therapy (CBT), which will be the focus of this article, possesses an extensive evidence base demonstrating its efficacy in treating depression, insomnia, social anxiety disorder, panic disorder, and schizophrenia, among others1. Thus, we have psychological treatments that work, we know which problems they work best for, and we have psychological practitioners who are trained to administer them. So why are Canadians not receiving optimal psychological health care? MOV EMENT
There is growing public recognition among Canadians that psychological health is a key component of overall health and that the current provision of psychological health services in Canada is inadequate. It is well established that the global disease burden (e.g., cost, mortality) of psychological health disorders exceeds that of the burden associated with cancers (Mood Disorders Society of Canada, 2009) and estimates suggest that the lifetime prevalence rate of psychological disorders is 46% among Americans (Kessler et al., 2005). In Canada, 1 in 3 people will experience a psychological illness in their lifetime (Statistics Canada, 2012) and 1 in 5 people will experience a psychological problem or illness in any given year (Smetanin et al., 2011). The economic impact of psychological illness is staggering. In a recent report, the Word Health Organization (WHO) identified depression as the leading cause of disability worldwide (WHO, 2017) and the cost of psychological health problems in Canada is estimated to be more than $50 billion per year (Smetanin et al., 2011). Despite these high incidence rates and overwhelming cost, 45% of Canadians with a psychological health care need reported that their need for counseling specifically was unmet (Sunderland & Findlay, 2013). In contrast, 9% and 31% of Canadians with a psychological health care need reported that their need for medication and information, respectively, went unmet (Sunderland & Findlay, 2013). Movement toward psychological healthcare reform is incommensurate with the scope of the problem. In their 2012 report, The Mental Health Commission of Canada (MHCC) stated
See the American Psychological Association Division 12’s Psychological Treatments: http://www.div12.org/psychological-treatments/treatments
that “fragmented and underfunded mental health systems across the country are far from able to meet the mental health needs of Canadians” (MHCC, 2012, p. 52). The Canadian Psychological Association (CPA) similarly recognized a need for change when they commissioned a group of health economists and analysts to compile a report, which was published in 2013, on recommendations for alternative psychological health care models in Canada (report by Peachey, Hicks, & Adams, 2013). Although a review of their specific recommendations is beyond the scope of this article, the commissioning of the report is a clear indicator of recognition of the need for a change in the way we address psychological health care in Canada. One strategy for increasing access to psychological health care that is receiving growing attention is the use of Internet delivered CBT (iCBT). Administration of iCBT can take multiple forms (e.g., therapist-assisted versus self motivated) but the general framework is to deliver CBT-principled lessons and homework activities via the Internet. As a therapeutic approach, CBT lends itself well to online adaption (Gratzer & Goldbloom, 2016). Well-defined modules, a focus on psychoeducation, and clear, well-related homework activities make it straightforward to translate CBT to online platforms. Furthermore, iCBT, whether it is therapist-assisted or self-motivated, is much more affordable than traditional CBT sessions, which typically run about $200/50 minute session in B.C. In contrast, iCBT is often offered at no cost (e.g., Online Therapy Unit; MoodGYM) or at a minimal cost (e.g., THIS WAY UP). Furthermore, a single iCBT therapist can have up to 80 clients simultaneously (Hedman et al., 2013). Internet delivered CBT also eliminates other barriers that many Canadians may face in accessing traditional, in-person CBT:
iCBT actually work?” The empirical verdict is out and the answer is, yes, iCBT does work and for a range of psychological problems. Indeed, more than 100 controlled trials assessing the effectiveness of iCBT had been conducted by 2015 (Andersson, Rozental, Rück, & Carlbring, 2015) and that number is only growing. Let us now examine the evidence base for some of the most common health concerns for which iCBT’s effectiveness has been evaluated. Looking first at insomnia, an Internet adapted CBT treatment for insomnia called Sleep Healthy Using the Internet (SHUTi) produced significant improvements in insomnia severity in a sample of adults with chronic insomnia relative to an online education group (Ritterband et al., 2017). At one-year follow-up, 56.6% of participants achieved remission status and 68.7% were classified as treatment responders (Ritterband et al., 2017). Although SHUTi is not therapist-assisted, most participants completed all core components of the intervention (Ritterband et al., 2017). In their metaanalysis of randomized controlled trials (RCTs), Zachariae and colleagues (2015) found that iCBT for insomnia produced similar effect sizes to traditional, in-person CBT for insomnia at post-treatment and effects were typically maintained at follow-up (ranging from 4 to 48 weeks).
Turning next to depression, therapist guided iCBT, which included contact with a therapist before and during the treatment, resulted in effect sizes similar to those found for traditional, in-person psychotherapy in general (Andersson, Wagner, & Cuijpers, 2016; Johansson & Andersson, 2012). Furthermore, RCTs conducted by independent research teams have demonstrated the efficacy of iCBT for depression in Australia, Switzerland, Germany, the Netherlands, and the United States (Andersson et al., 2016). In a recent • Psychotherapists may have waitlists that are Canadian study, Hadjistavropoulos and colleagues months long. (2016) concluded that therapist-assisted iCBT produced • Geographic location/lack of transit may prevent large reductions in depressive symptoms among adults access to traditional psychotherapy. reporting depressive or anxious symptoms, regardless • Personal obligations/time constraints (e.g., caring for of whether assistance was provided by a registered family) may prevent people from seeking traditional provider, graduate student, or therapists trained in psychotherapy or attending regularly. psychology versus other related disciplines. • Stigma around psychological health problems and treatment may prevent people from seeking Finally, looking at anxiety and anxiety-related disorders, traditional psychotherapy. the conclusion is similar. In a meta-analysis of RCTs conducted by Andrews and colleagues (2010), iCBT Now, as consumers of research and practitioners produced large effect sizes relative to control groups of evidence-based psychology, you’re probably for social phobia, panic disorder, and generalized thinking, “Well, this is all well and good, but does anxiety disorder. Furthermore, adherence to iCBT was BC Psychologist
good, with 80% of participants in the median study of the meta-analysis completing all components of the treatment (Andrews et al., 2010). For social anxiety disorder (SAD; formerly social phobia), therapistassisted iCBT, produced superior reductions in SAD symptoms post-treatment and at one-year follow-up among a sample of adults diagnosed with SAD relative to an online forum control condition (Andersson, Carlbring, & Furmark, 2012). Consistent with the results of Hadjistavropoulos and colleagues (2016) with respect to depression, Andersson and colleagues (2012) found that the effects of iCBT on SAD were not moderated by therapist experience (i.e., licensed psychologists versus MSc. Psychology students). In a study comparing therapist-assisted, exposure-based iCBT to behavioural stress management for adults with severe health anxiety, iCBT produced significantly greater effects compared to behavioural stress management despite participants perceiving the treatments as equally credible (Hedman, et al., 2014).
to physical health care. Earlier this year the CPA recognized that the problem with psychological health care lies not in the existence of effective treatments, but in the degree to which they are available and accessible to Canadians (CPA, 2017). Of course, psychological health care comes with its own challenges. Counseling, for example, is time consuming and therapists are limited in the number of clients they can see. One potential solution to enhance the accessibility of psychological health care for Canadians is iCBT, which has been found to be effective for treating a range of health problems.
This brief review of the empirical base for iCBT is in no way comprehensive, nor does it acknowledge limitations of the studies or other considerations around iCBT (e.g., client privacy/security of health information)2. However, it provides a snapshot of the current body of evidence for iCBT, which indicates that iCBT is an effective treatment for a range of psychological problems. As an example of what widespread, publiclyfunded iCBT might look like in Canada, we can turn to Australia, where iCBT programs (e.g., MoodGYM, THIS WAY UP, MindSpot) have been developed and disseminated in an effort to increase the accessibility of psychological services to Australians, many of whom experience geographic barriers to traditional care (Gratzer & Goldbloom, 2016). Research conducted on these programs suggests that they are effective, although therapist assistance may be critical in preventing drop-out (for a review see Gratzer & Goldbloom, 2016). Canadians, perhaps now more than ever, are in need of psychological health services. If we can agree that psychological health is a core component of overall health, then it follows that psychological health care should be prioritized on a level that is comparable
2 For more research, see the work of Gerhard Andersson, Ph.D (http://www.gerhardandersson.se) and Heather Hadjistavropoulos, Ph.D (https://www.uregina.ca/arts/ psychology/faculty-staff/faculty/hadjistavropoulos-heather.html)
R e fe r e n ce s
Andersson, G., Carlbring, P., Furmark, T. (2012). Therapist experience and knowledge acquisition in internet-delivered CBT for social anxiety disorder: A randomized controlled trial. PLoS One, 7, 1-10. Andersson, G., Rozental, A., Rück, C., Carlbring, P. (2015). Guided internet-delivered CBT: Can it really be as good as seeing a therapist? The Behavior Therapist, 38, 123-126. Andersson, G., Wagner, B., Cuijpers, P. (2016). ICBT for depression. In N. Lindefors & G. Andersson (Eds.), Guided internet-based treatments in psychiatry (pp. 17-32). Switzerland: Springer International Publishing. Andrews, G., Cuijpers, P., Craske, M. G., McEvoy, P., Titov, N. (2010). Computer therapy for the anxiety and depressive disorders is effective, acceptable and practical health care: A meta-analysis. PLoS One, 5, 1-6. APA Presidential Task Force on Evidence-Based Practice. (2006). Evidence-based practice in psychology. American Psychologist, 61, 271-285. Canadian Psychological Association. (2017). Targeting funds for better access to quality mental health care for Canadians. Recommendations to government from the Canadian Psychological Association (CPA). Retrieved from http://www.cpa.ca/ docs/File/Government%20Relations/Targeting%20funds%20for%20better%20access%20to%20quality%20mental%20 health%20care%20for%20Canadians%20February%202017final.pdf Gratzer, D. & Goldbloom, D. (2016). Making evidence-based psychotherapy more accessible in Canada. The Canadian Journal of Psychiatry, 61, 618-623. Hadjistavropoulos, H. D., Nugent, M. M., Alberts, N. M., Staples, L., Dear, B. F., Titov, N. (2016). Transdiagnostic Internet delivered cognitive behaviour therapy in Canada: An open trial comparing results of a specialized online clinic and nonspecialized community clinics. Journal of Anxiety Disorders, 42, 19-29. Hedman, E., Axelsson, E., Görling, A., Ritzman, C., Ronnheden, M., El Alaoui, S., . . . Ljótsson, B. (2014). Internet-delivered exposure- based cognitive-behavioural therapy and behavioural stress management for severe health anxiety: randomized controlled trial. The British Journal of Psychiatry, 205, 307-314. Hedman, E., Ljótsson, B., Rück, C., Bergstrom, J., Andersson, G., Kaldo, V., . . . Lindefors, N. (2013). Effectiveness of internet-based cognitive behaviour therapy for panic disorder in routine psychiatric care. Acta Psychiatrica Scandinavica, 128, 457–67. Johansson, R. & Andersson, G. (2012). Internet-based psychological treatments for depression. Expert Reviews, 12, 861-870. Kessler, R. C., Berglund, P., Demler, O., Jin, R., Merikangas, K. R., & Walters, E. E. (2005). Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Archives of General Psychiatry, 62, 593-602. Mental Health Commission of Canada (2012). Changing directions, changing lives: The mental health strategy for Canada. Retrieved from http://strategy.mentalhealthcommission.ca/pdf/strategy-images-en.pdf Mood Disorders Society of Canada. (2009). Quick facts: Mental illness and addiction in Canada. Retrieved from http://www. mooddisorderscanada.ca/documents/Media%20Room/Quick%20Facts%203rd%20Edition% 20Eng%20Nov%2012%2009.pdf Peachey, D., Hicks, V., & Adams, O. (2013). An imperative for change: Access to psychological services for Canada. Retrieved from http://www.cpa.ca/docs/File/Position/An_Imperative_for_Change.pdf Ritterband, L. M., Thorndike, F. P., Ingersoll, K. S., Lord, H. R., Gonder-Frederick, L., Frederick, C., . . . Morin, C. M. (2017). Effect of a web-based cognitive behavior therapy for insomnia intervention with 1-year follow-up: A randomized clinical trial. JAMA Psychiatry, 74, 68-75. Smetanin, P., Stiff, D., Briante, C., Adair, C., Ahmad, S. & Khan, M. (2011). The life and economic impact of major mental illnesses in Canada: 2011 to 2041. RiskAnalytica, on behalf of the Mental Health Commission of Canada. Statistics Canada. (2012). Health at a glance: Mental and substance use disorders in Canada. Retrieved from http://www.statcan.gc.ca/ pub/82-624-x/2013001/article/11855-eng.htm Sunderland, A. & Findlay, L. C. (2013). Perceived need for mental health care in Canada: Results from the 2012 Canadian Community Health Survey – Mental Health. Statistics Canada Health Reports, 24, 3-9. World Health Organization. (2001). The world health report 2001. Mental Health. New Understanding. New Hope. Geneva WHO World Health Organization. (2017). Depression and other common mental disorders: Global health estimates. Retrieved from http://apps. who.int/iris/bitstream/10665/254610/1/WHO-MSD-MER-2017.2-eng.pdf?ua=1 Zachariae, R., Lyby, M. S., Ritterband, L. M., & O’Toole, M. S. (2016). Efficacy of internet-delivered cognitive behavioral therapy for insomnia – A systematic review and meta-analysis of randomized controlled trials. Sleep Medicine Reviews, 30, 1-10.
Addiction: A Hidden Problem in South Asian Communities Vane ssa Epp, Psy. D. Candidate
Ms. Epp is completing her Psy.D in Clinical Psychology at Adler University. She is planning to specialize in trauma work, with the goal of working as a hospital psychologist. She is currently under the supervision of Dr. Chotem as part of her Social Justice Practicum. Marilyn Chotem , Ed. D. , R. Psych .
Dr. Marilyn Chotem completed her Ed.D. in Educational Psychology and Counselling at McGill University in 1990. She has been a Registered Psychologist in BC since 1980. Her career began in substance abuse/dependence treatment programs in 1978. Since 1983, she has worked with diverse populations in a variety of settings, such as, community mental health centers, hospital psychiatry and private practice.
While we are seeing a growing awareness around topics of mental health and addiction, stigma and shame still act as barriers to treatment, especially in the South Asian Communities."
a n a da's cu rre n t d ru g crisis im pac t s e v e ryo n e ,
In British Columbia, addiction tears apart the lives of many individuals and the alarming rates of overdose and death are calling for psychologists to be vigilant in their approach to treatment and identification of substance use concerns. However, what about the populations that do not openly speak about addiction? With addiction being a focus of headlines, healthcare systems and politicians alike, why is it that many individuals suffer in secrecy? re ga rd l e s s o f t h e ir pat h in life .
According to the 2016 Canadian census, approximately 8% (365,705) of individuals in British Columbia (BC) identify themselves as South Asian. As these communities continue to grow in BC, there is an increased need for culturally-sensitive services targeted at the prevention and treatment of mental health concerns within this population. The economic costs of mental illness in Canada are of great significance, with one report estimating the total annual cost as upwards of $51 billion dollars (Smetanin et al., 2011). Several social determinants of mental health exist in the South Asian populations of Vancouver, including socioeconomic status, acculturation, and behavioural factors (Islam et al., 2014). One of the leading mental health concerns in these communities is the use of stimulant drugs among different workers such as construction personnel, taxi drivers, and truck drivers. Thiese et al. (2015) reported that many truck drivers are offered high income to drive long distances in short periods of time. To successfully complete these jobs, drivers are turning to stimulants to stay awake for longer periods of time. These drivers begin to build up a tolerance and experience significant financial strain to sustain their drug habits. These financial strains lead to relationship problems, housing concerns, and an overall deterioration in oneâ€™s quality of life. Despite the negative impact of drug use, marginalized communities continue to avoid seeking services from mainstream agencies (Herald, 2017). While we are seeing a growing awareness around topics of mental health and addiction, stigma and shame still act as barriers to treatment, especially in the South Asian Communities (Herald, 2017). Islam et al. (ibid) examined the prevalence rates and characteristics of mental health concerns in Canadian South Asian populations. In their analysis, South Asian individuals with a diagnosis of major depression reported the highest rate of unmet mental health care needs, with 48% of individuals receiving a diagnosis but not treatment. For South Asian immigrant groups, the self-reported levels of stress were high. Low income, loss of social status and networks, low literacy, lack of employment, and language
barriers all contributed as strong risk factors of poor mental health. Chaudhry (2016) outlines stigma in South Asian culture as an experience that occurs between the stigmatized individual and the stigmatizer, both of whom are heavily influenced by their own set of cultural beliefs. In order to successfully combat the stigmatization of addiction, we need to analyze it within the cultural context in which it occurs. Prior literature has examined the effects of individualistic versus collectivistic cultures on the stigmatization of addiction, with many authors concluding that cultural norms and societal attitudes are a large factor in the spread of negative attitudes towards mental health and addiction (Chaudhry, 2016). In South Asian communities specifically, the current literature outlines three possible sources of addiction stigma:
Identify individual levels of acculturation and enculturation as these highly influence treatment outcomes. Understanding the degree to which an individual identifies with certain values can help to inform treatment planning. Consider unique client characteristics such as beliefs and attitudes. Regardless of an individual’s ethnicity, treatment is not a “one-size fits all” approach. Ensure sensitivity to topics of oppression. Allow more opportunity for psychoeducation regarding the psychotherapy process. Work to understand a client’s mental health literacy level. When doing assessments, provide interpreter services for both the assessment and feedback sessions.
To summarize, the current drug crisis is a nationwide issue that effects everyone, regardless of their 1. Social status and public view are important cultural identity or socioeconomic status. As rates of factors in many collectivist cultures. South Asian addiction continue to rise, psychologists have skills cultures place high value on outward appearance. and training to assist with prevention, psychodiagnostic As a result, addiction is often a topic that is assessments, and oversight of treatment programs. silenced, and great effort is placed on keeping Psychologists can work to prevent addiction by these concerns within the family. identifying and treating children at risk of future mental 2. A lack of (westernized) understanding leads to health and addiction problems, educating school inaccurate beliefs about mental illness and aged children, and helping with post-operation pain its effects on the individual and surrounding management and non-pharmaceutical alternatives community. for management of chronic pain. More importantly, 3. Several mental health concerns (including addiction) regardless of what role the psychologist is taking, are seen as a weakness of the individual, and creating a culturally sensitive space is essential. By blame is often placed on people struggling with providing culturally sensitive solutions for the treatment these issues. This response often promotes silence of addiction, we are helping to provide easy access to rather than treatment and recovery. resources that are not typically utilized. Many individuals fail to pursue mainstream treatment options for fear of promoting stigma or bringing shame to their family. As a result, the South Asian communities are underserved when it comes to treatment of addiction. To help combat this, the health authorities in Vancouver have put forth different initiatives to promote accessibility to mental health services, with clinics such as the Roshni Clinic offering culturally-tailored services for addiction and recovery. Psychologists looking to be culturally sensitive towards South Asian clients, must work with them to understand the role of the individual, their family, and the community system as determinants of one’s mental health (Chiu, et al., 2016). Five suggestions (Wang & Kim, 2011) have been made to help promote a culturally-sensitive practice for working with addiction in our South Asian communities:
For more information on how to promote a culturally sensitive practice when working with South Asian communities, visit Fraser Health’s diversity page at http://www.fraserhealth.ca/health-professionals/ professional-resources/diversity-services/.
R e fe r e n ce s
Canadian Centre on Substance Use and Addiction. (2017). Prescription Opioids. Retrieved from: http://www.ccdus.ca/Resource%20 Library/CCSA-Canadian-Drug-Summary-Prescription-Opioids- 2017-en.pdf Chaudry, T. (2016). The stigma of mental illness in South Asian cultures. Honors Thesis Collection. Retrieved from: https://repository. wellesley.edu/cgi/viewcontent.cgi?article=1537&context=thesiscollection Chiu, M., Lebenbaum, M., Newman, A.M., Zaheer, J., and Kurdyak, P. (2016). Ethnic differences in mental illness severity: A population-based study of Chinese and South Asian patients in Ontario, Canada. Journal of Clinical Psychiatry, 77(9). doi: 10.4088/JCP.15m10086. Islam, F. Khanlou, N. & Tamim, H. (2014). South Asian populations in Canada: migration and mental health. BMC Psychiatry, 14(154). doi: 10.1186/1471-244X-14-154 Potkins, M. (2017). Opioid addiction grows in the South Asian community. Calgrary Herald. Retrieved from: http://calgaryherald.com/tag/ opioid-crisis. Smetanin, P., Still, D., Briante, C., Adair, C.E., Ahmad, S., and Khan, M. (2011). The life and economic impact of major mental illnesses in Canada, 2011-2041. Prepared for the Mental Health Commission of Canada. Toronto: Risk Analytical Thiese, M.S., Moffit, G.M., Hanowski, R.J., Kales, S.N., Porter, R.J., and Hegman, K.T. (2015). Repeated cross-sectional assessment of commercial truck driver health. Journal of Occupational and Environmental Medicine, 57(9). doi: 10.1097/ JOM.0000000000000522 Wang S. & Kim, B.S.K. (2001). Therapist Multicultural Competence, Asian American Participantsâ€™ Cultural Values, and Counseling Process. Journal of Counseling Psychology, 57(4). pp. 394-401
Integrative Divorce Services: Fresh Opportunities for Psychologists and for the Public
h e pu rp ose o f t his a r ti cl e is t o in vit e b .c .
to explore and get involved in the rapidly evolving domain of Integrated Divorce Services. This term refers to the many ways in which psychologists, legal professionals, and financial professionals are now working together to promote the health and well-being of families experiencing parental separation and divorce – and all without ever going to court. Integrated Divorce Services support the family system by integrating the different elements found in most divorce processes – the legal, financial and relational or emotional aspects for both adults and children. Although our disciplines are distinct, for families, these aspects are interwoven into the fabric of daily life. Integrated Divorce Services protect the public by encouraging professionals to bridge to each other and to the family. These services also expand the possibilities for consensual divorce options to more families thereby reducing the need for litigation and at the same time focusing on protecting and strengthening the individuals and the relationships in the family.
Susan Gamache , Ph . d. , r. psych .
Dr. Susan Gamache is a Registered Psychologist and Clinical Fellow in Marriage & Family Therapy. In addition to general practice, Susan works extensively with marital transitions in both consensual models and with court-involved families.
psych o l o g is t s
For the purpose of this article, we will take a brief look at three models of Integrated Divorce Services: Collaborative Divorce, Integrative Mediation and the REACH program.
Collaborative Divorce has at its core an agreement by lawyers to limit the scope of their representation to settlement negotiations only, by means of a written agreement (Deal, 2013; Webb & Ousky, 2006). The possibility of having non-adversarial legal representation is a powerful addition to the spectrum of consensual dispute resolution. In addition to legal professionals, Collaborative Divorce teams include professionals from the therapeutic and financial domains to bring the best of their disciplines to work in integrated processes (Cameron, 2004; Fagerstrom, Kalish, Nurse, Ross, Thompson, Wilde & Worlfum, 1997; Tesler, & Thompson, 2006).
Integrated Divorce Services support the family system by integrating the different elements found in most divorce processes – the legal, financial and relational or emotional."
The non-legal team members are also protected by the written agreement such that no information from the collaborative process can be introduced into court except that which is otherwise compellable. This agreement also waives confidentiality to the level of the team. Collaborative Law provides a way for clients to have legal representation premised on a problem-solving rather than an adversarial template. However, without the structure of the court
process, a troubled or volatile emotional family relationship system can threaten the process. The Collaborative Divorce team provides support to the resolution of the legal issues by bringing therapeutic and family therapy knowledge and skills to the table. The therapeutic professionals work to stabilize the family system, support the parents to communicate with each other, and focus on the childrenâ€™s needs (Gamache, 2013, 2015, 2017.) Each parent has an aligned relationship with their respective therapeutic professional, while the children work with a child therapist who is neutral to both parents. All the professionals stay connected as a team. Financial professionals bring their expertise to the team to address financial issues. Taken together, the combined structure of what has been termed Collaborative Divorce covers all of the elements of the divorce process for families: legal, financial, emotional/relational, and those that relate to the children. The trajectories of these innovations are only just beginning as those of us within the fertile territory of the Collaborative Divorce community witness the development of different approaches, team structures and processes emerging as Collaborative professionals develop their thinking and their practices.
Integrative Mediation Although mediation predates Collaborative Divorce, it was within the Collaborative Divorce communities that the legal, therapeutic and financial professionals came together to form interdisciplinary professional communities and networks. For example, in Vancouver, we have been holding dinner meetings ten times per year for the past 18 years. These meetings give professionals a chance to meet, share a meal, and hear a speaker such as â€œIntegrative Mediation,â€? presented by Dr. Stephen Sulmeyer, lawyer and clinical psychologist, mediator and Collaborative Divorce practitioner in 2017. Integrative Mediation has been strongly influenced by the Collaborative Divorce movement. Random lawyers and Mental Health Professionals have been co-mediating since at least the 1970s, and continue to do so. However, Collaborative Divorce is the first consensual modality to fully embrace the interdisciplinary approach. As such, the model for Integrative Mediation was consolidated by and 16
enhanced by the Collaborative Divorce community. For example, in California, Integrative Mediation Bay Area grew out of the Collaborative Divorce Community already established in the San Francisco Bay area. In Integrative Mediation, as in traditional mediation, the professionals act as neutrals to the parties. There may be a lawyer mediator, psychologist mediator and/or a financial mediator involved, bridging their work together for the benefit of the family. The parties may meet with the neutrals separately or together as is appropriate to the situation. The professionals work as a team, sharing information as necessary. Any given process may have joint meetings and/or individual ones. The professional team, together with the parties, can decide what is needed in order to support the best steps forward. Given that both Integrative Mediation and Collaborative Divorce are consensual process choices outside the court system, there is overlap between them. Many professionals working in the Collaborative model also chose to practice in the Integrative Mediation model and vice versa. Whether Collaborative Divorce or Integrative Mediation is the better option for any particular family depends on the family and the situation. Do one or the other of the parties need legal or emotional advocacy? How complex are the tasks to be resolved? What are the preferences of the parties for neutral support or representation in the legal and/or therapeutic domain?
REACH: Re-Unification and Co-parenting in High Conflict and Complexity The REACH team is yet another off-shoot from the Collaborative Divorce community (Gamache & Leask, 2016; Colby & Gamache, 2018). REACH uses the team model developed in Collaborative Divorce to address disrupted parent-child relationships during or postseparation, in situations of high conflict and complexity. The goal of the REACH team is to support both the family in distress as well as the judiciary and the officers of the court while keeping the therapeutic team external to the litigation process. REACH integrates therapeutic evaluation and in-depth therapeutic treatment services together with various court services to support children and families, judiciary and other officers of the court and create pathways out of the court process to resolution that may include
and as a team member with the rest of the team. on-going therapeutic support. The team structure Parent Therapists also facilitate feedback from the also supports the team members as the work evolves Child Therapist to the parents such that the Child within the troubled family system. The REACH contract waives confidentiality to the level of the team and clearly Therapist is able to focus on the children and does not need to address parental conflict. The Court articulates the relationship of the team to the court Designate may be a lawyer or a psychologist. They process. are the bridge from the therapeutic team to court or officers of the court such as lawyers or Parenting A REACH team includes psychologists with strong Coordinators. The Court Designate provides backgrounds in family systems and separation and feedback to the court and holds parents accountable divorce. Each team is made up of 4 members: a Child to court orders. The Court Designate also provides a Therapist(s), a Parent Therapist for each parent, and a point of intake for the parents. Court Designate. The REACH process generally starts with a court order stipulating that the family participate Psychologists are well situated to include Integrated in the REACH program. Divorce Services in their repertoire of services offered to the public. As these and future initiatives continue Similar to the Collaborative Divorce model, the Child to grow and develop, there are many opportunities to Therapist provides ongoing therapy to the children, get involved. I believe the public also has the right to works with the REACH Parent Therapists to assist access psychologists for these types of services. Not the parents and works as a team member to support only do psychologists have high levels of education the work of the Parent Therapists with the respective and strong experience, many parents have extended parent. The Parent Therapists work directly with medical benefits that can help reduce the costs of their respective parent in individual meetings, in joint separation and divorce. meetings with the other Parent and Parent Therapists
R e fe r e n ce s
Cameron, N., (2004) Collaborative Practice: Deepening the Dialogue, Continuing Legal Education Society of BC. Deal, D. (2013). The definition of collaborative divorce: moving from branding to unification. The Collaborative Review, 2013, Volume 13, Issue 1. Fagerstrom, K., Kalish, M., Nurse, A., Ross, N., Thompson, P., Wilde, D., Worlfum, T. (1997). Divorce: A Problem to be Solved, Not a Battle to be Fought. Brookwood Publishing: Orinda Gamache, S. (2015). Family peacemaking with an interdisciplinary team: A therapist’s perspective. Family Court Review, 53(3) 378 – 387. Gamache, S. (2013). Locating and defining divorce coaching for the family therapist. The Collaborative Review, Journal of the International Academy of Collaborative Professionals 13(1). Gamache, S. (2011). The inner life of the collaborative practice (cp) group. The Collaborative Review, Journal of the International Academy of Collaborative Professionals 11(4). Gamache, S. (2005). Collaborative practice: A new model to address children's best interest in divorce. Louisiana Law Review. 1455 – 1485. Colby, R & Gamache, S. (2018). REACH: A community program for disrupted parent-child relationships 4 yrs. in. Association of Family and Conciliation Courts Conference, Washington DC, June. Gamache, S. & Leask, P. (2016). Courts and therapists: Together at last. Association of Family and Conciliation Courts Conference, Seattle, WA, June. Tesler, P. & Thompson, P. (2006). Collaborative Divorce. Harper Collins. Webb, S. & Ousky, R. (2006). The Collaborative Way to Divorce. New York: Hudson Street Press.
Contractors and Subcontractual Arrangements in Psychology D o n a l d H u t ch e o n , C . Psych o l . (U. K .), R. Psych .
Dr. Don Hutcheon has a private practice in Port Coquitlam and also works in Chilliwack at Brian Atkinson & Associates since 2013.
Interaction between the general contractor and subcontractor relies on the skills of analysis, initiation from both parties working together, and on capacities for trust, personal feedback, mutual support, and shared problem-solving."
P Prior to commencing the article, I wish to thank Dr. John re a m b l e
Anderson, R. Psych., and note, in particular, his comments to a recent BCPA conference speaker, which piqued my interest in the arrangement between general (primary) contractors and the subcontracted psychologist. As most of us are aware, “employee positions” are going the way of the Dodo bird in this province, causing many psychologists during the past decade to market their services as subcontractors. With this in mind, let’s begin with some basic information regarding the working arrangement of these two contractual positions. To start, an organization can be bureaucratic without being centralized. Mintzberg (1989) states that this occurs when a work situation requires a professional interface between two separate contracted positions with a stated purpose – that is, to increase the probability of getting the job done effectively and efficiently. For example, an organization’s general contractor, who may or may not be a licensed psychologist, subcontracts a licensed psychologist to use their specific area of expertise to complete a designated job function (e.g., assessing-treating a specific clinical population). The general contractor coordinates the implementation of each subcontractor’s specialized skill-set via case consultation/ management, allowing the specialist to work for the organization’s operating core. In doing so, the subcontractor is provided with the power and control to complete the job within a predetermined contracted arrangement. The other option is an open-ended arrangement, which allows the subcontractor to work at the organization for an indefinite period because of the rarity of their area of expertise. The complexity of the working relationship between the two contractors ensures that considerable discretion remains in the application of their respective jobs. Of note: it is best to remember that the operating core of the organization is the key part of the professional organization and requires a competent, expertly trained support staff that is very focused on serving the activities of the operating core. The general contractor’s role is selecting the best subcontractors to achieve the best results in serving the operating core. Let’s move on.
Subcontractor versus Contractor: Understanding the Difference In the field of psychology and for-profit clinics/agencies, the senior psychologist of the organization may be requested to subcontract a licensed psychologist to carry a specialized caseload and be paid, most often, by a split-fee system. In the province of British 18
Columbia that usually means a 60%-40% differential (higher amount to the registered psychologist, lower amount to the clinic/agency).
In essence, the person in each role scratches the other’s back. Furthermore, depending on the subcontracted arrangement, be it with a formal written contract, or, in the writer’s case, a verbal arrangement To clarify roles, a contractor describes a person, with a trusted colleague, the subcontracted business or organization that enters into a contract psychologist may be responsible for providing their with another person, business or organization for work, own materials and equipment (e.g., psychometric usually at a fixed price (e.g., ICBC $145 per hour; RCMP instruments, computer/laptop, vehicle) to complete the $184 per hour; VAC $190 per hour). Independent assignment. contractors and subcontractors can both be described as a form of contractor. The term Contractor is simply a From the writer’s vantage point, and during the past shortened form of the words and is used informally. The thirty years of subcontracted arrangements, the clinic/agency contractor is the person, identified by the contractors and subcontractors work hand-in-hand to President – CEO or a designate within the organization complete an assignment. The contractor acts as the that seeks to obtain contracts from government – manager of the project, serving as the central point of ministerial organizations etc., who require help with a communication and organizer, while the subcontractor clientele in need of psychological services. completes the work. A contractor hires a subcontractor to do a job, but there is no supervisor-subordinate A subcontracted psychologist offers a particular set of relationship between them (Davis, 2017). Whether skills which they perform for the clinic/agency. The key you’re a primary, general contractor, or a subcontractor, point is that subcontractors form agreements with the your rights and responsibilities as an independent contractor, not with the originating client group seeking contractor remain the same. Alternatively, compared help. In addition, successful contractors often specialize with contractors, employees of an organization have very in one or more areas of psychology, making it easier to different rights and obligations. Employees have benefits network with known psychology subcontractors and in which most often include: a pre-determined paid wage, this way access their area of speciality. set hours of work, entitlement to paid holiday leave and sick leave, and entitlement to superannuation. Highlighting the real difference between a contractor and a subcontractor is the title. Subcontracting services Let me return to a prior point made regarding in psychology most often involve an individual who is contractual arrangements between a general contractor a business. In the writer’s experience, and supported and the subcontracted psychologist. There are two by the literature, subcontracting psychologists are not basic options, the first is a written agreement, which considered an employee of the contractor, but rather helps protect both parties’ interests. It describes the an independent contractor with specific expertise in a services and materials provided by the subcontractor, psychological specialty. In addition, while contractors price of work, and warranties of both parties. Other generate referrals and engage in networking with important clauses include insurance, default, change customers to find appropriate work, subcontractors are requirements throughout the contracted period, and engaged in networking with the contractors that have indemnification. In my personal experience, I have not work for them. used a formal written contract for many years due to the collegial professional relationship/trust developed Of note: an obvious point – the sine qua non of a with the General Contractors with whom I associate. successful contractor is hiring subcontractors that are Either approach works; it simply depends on the trusted experts and have a reputation for completing nature of the working relationship developed between quality work and acting in good faith when it comes both parties, history together on previous contracts to the business arrangement with the contractor. This and expectations that match the nature of the service entails the subcontractor’s professionalism in both their provided. More along this line below. business dealings with contractors and their behavior Developing a Strong Working Relationship in the work environment. The contractor should be acutely aware that the scope of the contracted projects Organizational development has been described by taken on should expand with the number of quality, professional subcontractors to which they have access. Sargent (1983) as collaborative problem-solving, a BC Psychologist
strategy for planned change and methods utilized to increase organizational effectiveness. These factors are also involved in the successful working relationship between the contractor and the subcontractor. Beer, a Harvard Business Professor, has discussed “next step” thinking and encourages healthy support systems, internal working structures within an organization, and collaborative involvement, as these factors increase participation in decision-making and in working toward mutually agreed upon goals (as cited in Sargent, 1983, p. 114). These factors highlight the factors which contribute towards the development of a successful working relationship between the general contractor and the subcontractor, who work as an interdependent team.
work in a variety of ways (contractor), depending on the tasks (subcontractor); making both the stable and temporary systems of the organization more effective by designing built-in mechanisms for improvement (subcontractor); moving toward high collaboration and low competition between working parties (contractorsubcontractor); reducing conflict within the infrastructure of an organization by addressing manageable “bits” of the problems that arise (contractor-subcontractor interdependency); and making decisions on the basis of the source of information, rather than the organizational role (both contractors influencing the outcome based on their mutual efforts in identifying and rectifying the problems that arise).
Beckhard (1969) describes the values implicit in organizational development, which can also be observed in a successful collaboration between the subcontractor and the general contractor. These values include developing a viable system that can organize
In sum, the interaction between the general contractor and subcontractor relies on the skills of analysis, initiation from both parties working together and on capacities for trust, personal feedback, mutual support, and shared problem-solving.
R e fe r e n ce s
Bechart, R. (1969). Organizational development: Strategies and models. Reading, MA.: Addison-Wesley. Davis, J. (2017). Prime contractors vs. subcontractors. Career Trend. Retrieved from https://careertrend.com/info-8469298-prime- contractors-vs-subcontractors.html Mintzberg, H. (1989). Minzberg on management: Inside our strange world of organizations. New York, NY: The Free Press. Sargent, A. G. (1983). The androgynous manager: Blending male & female management styles for today’s organization. New York, NY: American Management Organizations.
High-Altitude Hypoxic Effects on Cognition and Potential Brain Damage Introduction to Hypoxia
leads to cerebral hypoxia and various cognitive impairments. Hypoxia can be caused by multiple factors (e.g. anemia, ischemia, hypoxic hypoxia), but this review will focus on hypoxic hypoxia (i.e. not enough oxygen being available at the lungs) due to being at a high altitude. Oxygen always comprises 20.9% of the air we breathe; however, at higher altitudes, the partial pressure of oxygen is reduced. This lower partial pressure of oxygen results in inadequate gas exchange at the lungs, as the partial pressure of inspired oxygen is what drives gas exchange at the lungs. Hypoxia can lead to a range of cognitive impairments such as: memory impairment, slower reaction times, psychomotor impairment, short-term memory impairment, attentional deficits, working memory deficits, euphoria, duress, and hallucinations (Wilson, Newman, & Imray, 2009). I will briefly review some of the cognitive impairments and structural damage due to hypoxic hypoxia. D e cre a se in ox yg e n d e liv e ry t o t h e b r ain
Cognitive Studies of Hypoxia Asmaro, Mayall, and Ferguson (2013) studied the effect of hypoxia on cognitive tasks at 17,500 feet and 25,000 feet. They found that participants self-reported feelings of euphoria and positive well-being at 17,5000 feet, and self-reported feelings of confusion, anxiety, and irritability at 25,000 feet. Participants completed a Stroop task, digit span forward and digit-span backward task, and a trail-making task at sea level and at both altitudes. Unsurprisingly, participants performed significantly worse at 25,000 feet when compared to 17,500 feet in all tasks, suggesting an impairment in executive functions, especially working and short-term memory. Research by Malle et al. (2013) also found a significant decline in working memory at 31,000 feet when participants completed the paced auditory serial addition task, with the hypoxic participants showing significantly lower correct responses when compared to sea level controls. Asmaro et al. (2013) found that participants reported being unaware of their cognitive impairment at altitude, and only becoming aware of the impairment once they were no longer hypoxic. The combination of euphoria and unawareness of one’s cognitive impairments makes hypoxia especially dangerous, as sufferers often do not feel a need to take supplementary oxygen to regain normal cognition.
Eva n H u t ch e o n , B . Sc .(H o n s .), M a s t e rs c a n d idat e
Evan Hutcheon is a graduate student in the Biomedical Physiology-Kinesiology Graduate Department at Simon Fraser University. His Master's research is on hypoxsic effects on attention at high altitudes. D o n a l d H u t ch e o n , C . Psych o l . (U. K .), R. Psych .
Dr. Don Hutcheon has a private practice in Port Coquitlam and also works in Chilliwack at Brian Atkinson & Associates since 2013.
Euphoria and unawareness of one’s cognitive impairments makes hypoxia especially dangerous, as sufferers often do not feel a need to take supplementary oxygen to regain normal cognition."
Griva et al. (2017) conducted a similar study during a trek to Mount Everest base camp (17,600 feet) involving a greater number of
neurophysiological measurements. All participants exhibited a significant decline in attention, verbal ability, executive function, verbal and learning memory, and psychomotor function. Memory and psychomotor function deficits were only evident at 17,600 feet and not at a lower testing altitude of 11,500 feet, at which all other cognitive functions started to show a decline. Interestingly, participantsâ€™ cognitive performance was lower upon descent to Kathmandu (4,700 feet) when compared to baseline pre-ascent values, and even those recorded at 11,500 feet. Therefore, descent to a lower altitude does not immediately restore cognitive performance after exposure to hypoxia. This suggests that long term effects of hypoxic hypoxia may exist.
EEG Studies of Hypoxia Several studies have looked at the effects of hypoxia on brain activity with an EEG. Hypobaric hypoxia has been found to cause a decrease in the auditory evoked potential P300 amplitude, and an increase in its latency and reaction time with no change in N1 amplitude or latency (Wesensten et al., 1993) . A similar study found the same increase in P300 latency, but no change in amplitude, with P300 latency returning to normal after the participants were given supplementary oxygen at altitude (Hayashi, Matsuzawa, Kubo, & Kobayashi, 2005). These authors suggest that the increase in P300 latency could be caused by a decrease in the auditory signal reaching the auditory cortex, a decrease in cognitive processing speed, or a combination of both. Papadelis, Kourtidou-Papadeli, Bamidis, Maglaveras, and Pappas (2007) found increases in total power, theta and alpha power, and a decrease in approximate entropy during hypoxia, while earlier studies found a decrease in alpha power and an increase in theta power (Kraaier, Van Huffelen, & Wieneke, 1988; Ozaki, Watanabe, & Suzuki, 1995). The difference in alpha power may be due to the earlier studies recording EEG with eyes closed, and the later study recording with eyes open. Adaptation to high altitude exposure may affect response inhibition, as lowlanders living at high altitude for three years were found to have delayed latency of NoGo-N2, larger N2 and smaller P3 amplitudes when compared to lowland controls (Ma, Wang, Wu, Luo, & Han, 2015). In a previous study, they also found that for a voluntary spatial discrimination task, N1 amplitude was larger and P3 amplitude was smaller only for high perceptual load conditions for the group living at altitude when compared to lowland 22
controls (Wang et al., 2015). These studies show that some alteration of brain activity is occurring with hypoxic hypoxia. Magnetic Resonance Imaging (MRI) Studies on Hypoxia Given the cognitive detriments exhibited due to hypoxic hypoxia, one would expect to find structural changes or damage in the brain, which can be identified by an MRI. Verges et al. (2016) had participants stay at 14270 feet for six days, after which they underwent a MRI examination. They found a significant increase in white matter and white matter apparent diffusion coefficient, no decrease in grey matter, and a significant reduction in cerebral spinal fluid. The increase in white matter and white matter apparent diffusion coefficient were correlated, which led the authors to postulate that the increase in white matter volume was due to an increase in extracellular water. Similarly, Fan et al. (2016) looked at lowland participants sent to the Qinghai-Tibetan plateau for a month, with MRI taken during the trip. No significant changes were found in scores of Beck Depression Inventory and Beck Anxiety Inventory, and digit span backwards test. They did find an increase in grey and white matter with enlarged cortical surface area over the whole brain, and these changes returned to normal upon return to sea level. In the white matter tracts, they found decreases in fractional anisotropy, which Fan et al. (2016) took to suggest that vasogenic edema had occurred in the white matter during their exposure to high altitude. Kottke et al. (2015) looked at climbers after summiting 23,380 feet with MRI done on descent from altitude, after participants had spent 31 days at altitude. They found a small but significant decrease in white matter volume, cerebral spinal fluid increase, and no indication of cerebral damage indicated by white matter hyperintensities or global cortical atrophy. Similarly, a decrease in white matter volume has also been found in sufferers of obstructive sleep apnea (sufferers of obstructive sleep apnea become hypoxic during sleep) (Kumar et al., 2014). This suggests that prolonged hypoxia can result in decreases in white matter volume. The contradicting results of some researchers finding an increase in white matter, and others finding a decrease warrants further investigation. Another study looking at climbers found evidence of brain damage after their stay at high altitude. Fayed, Modrego, and Morales (2006) took MRIs of professional
and amateur climbers 7-15 days after climbing some of the worldâ€™s larger peaks, and again three years later for those who exhibited lesions during the first scan. Out of the group that went to Mount Everest (29,029 feet) (n=13), one had a normal MRI scan, one had a subcortical lesion, eleven had enlargements of the Virchow-Robin spaces, and eight had cortical atrophy. The second group (n=8) summited Aconcagua (22,837 feet) with none displaying a normal MRI scan. Specifically, eight had cortical atrophy, seven had enlargement of the Virchow-Robin spaces, and four had subcortical lesions. Two of the climbers had symptoms of brain edema, with one exhibiting nominal aphasia until recovery six months later. The follow-up MRIs performed three years later on the four subjects who showed subcortical lesions showed that the lesions and Virchow-Robin spaces had persisted. Interestingly, those climbers deemed professional did not show any lesions; only the
amateurs did. The enlarged Virchow-Robin spaces were found in the subcortical regions of the brain. Virchow-Robin spaces are cerebral spinal fluid spaces surrounding small cerebral blood vessels, and they are visible on a MRI following a large increase in volume (Favaretto et al., 2017). What these enlarged spaces mean is still unclear; however, VirchowRobin space volume has been inversely correlated with cognitive performance in patients with multiple sclerosis (Favaretto et al., 2017). They may also play a role in the cognitive impairment associated with hypoxic hypoxia. More studies are needed to study the effects of cognitive impairment and potential brain damage due to hypobaric hypoxia. As shown with the previously mentioned MRI studies, some studies find an increase in white matter while others do not (Fan et al., 2016; Kottke et al., 2015; Verges et al., 2016). This seeming contradiction in results highlights the need for further studies in the field.
R e fe r e n ce s
Asmaro, D., Mayall, J., & Ferguson, S. (2013). Cognition at altitude: Impairment in executive and memory processes under hypoxic conditions. Aviation, Space, and Environmental Medicine, 84(11), 1159–1165. Fan, C., Zhao, Y., Yu, Q., Yin, W., Liu, H., Lin, J., … Zhang, J. (2016). Reversible brain abnormalities in people without signs of mountain sickness during high-altitude exposure. Scientific Reports, 6(1), 1-12. https://doi.org/10.1038/srep33596 Favaretto, A., Lazzarotto, A., Riccardi, A., Pravato, S., Margoni, M., Causin, F., … Gallo, P. (2017). Enlarged Virchow Robin spaces associate with cognitive decline in multiple sclerosis. PloS One, 12(10), e0185626. https://doi.org/10.1371/journal.pone.0185626 Fayed, N., Modrego, P. J., & Morales, H. (2006). Evidence of brain damage after high-altitude climbing by means of magnetic resonance imaging. The American Journal of Medicine, 119(2), 168.e1-168.e6. https://doi.org/10.1016/j.amjmed.2005.07.062 Griva, K., Stygall, J., Wilson, M. H., Martin, D., Levett, D., Mitchell, K., … Caudwell Xtreme Everest Research Group. (2017). Caudwell Xtreme Everest: A prospective study of the effects of environmental hypoxia on cognitive functioning. PloS One, 12(3), e0174277. https://doi.org/10.1371/journal.pone.0174277 Hayashi, R., Matsuzawa, Y., Kubo, K., & Kobayashi, T. (2005). Effects of simulated high altitude on event-related potential (P300) and auditory brain-stem responses. Clinical Neurophysiology, 116(6), 1471–1476. https://doi.org/10.1016/j.clinph.2005.02.020 Kinsman, T. A., Hahn, A. G., Gore, C. J., Wilsmore, B. R., Martin, D. T., & Chow, C.-M. (2002). Respiratory events and periodic breathing in cyclists sleeping at 2,650-m simulated altitude. Journal of Applied Physiology (Bethesda, Md.: 1985), 92(5), 2114–2118. https://doi.org/10.1152/japplphysiol.00737.2001 Kottke, R., Pichler Hefti, J., Rummel, C., Hauf, M., Hefti, U., & Merz, T. M. (2015). Morphological brain changes after climbing to extreme altitudes--A prospective cohort study. PloS One, 10(10), e0141097. https://doi.org/10.1371/journal.pone.0141097 Kraaier, V., Van Huffelen, A. C., & Wieneke, G. H. (1988). Quantitative EEG changes due to hypobaric hypoxia in normal subjects. Electroencephalography and Clinical Neurophysiology, 69(4), 303–312. Kumar, R., Pham, T. T., Macey, P. M., Woo, M. A., Yan-Go, F. L., & Harper, R. M. (2014). Abnormal myelin and axonal integrity in recently diagnosed patients with obstructive sleep apnea. Sleep, 37(4), 723–732. https://doi.org/10.5665/sleep.3578 Ma, H., Wang, Y., Wu, J., Luo, P., & Han, B. (2015). Long-term exposure to high altitude affects response inhibition in the conflict- monitoring stage. Scientific Reports, 5, 13701. https://doi.org/10.1038/srep13701 Malle, C., Quinette, P., Laisney, M., Bourrilhon, C., Boissin, J., Desgranges, B., … Piérard, C. (2013). Working memory impairment in pilots exposed to acute hypobaric hypoxia. Aviation, Space, and Environmental Medicine, 84(8), 773–779. Ozaki, H., Watanabe, S., & Suzuki, H. (1995). Topographic EEG changes due to hypobaric hypoxia at simulated high altitude. Electroencephalography and Clinical Neurophysiology, 94(5), 349–356. Papadelis, C., Kourtidou-Papadeli, C., Bamidis, P. D., Maglaveras, N., & Pappas, K. (2007). The effect of hypobaric hypoxia on multichannel EEG signal complexity. Clinical Neurophysiology: Official Journal of the International Federation of Clinical Neurophysiology, 118(1), 31–52. https://doi.org/10.1016/j.clinph.2006.09.008 Schou, L., Østergaard, B., Rasmussen, L. S., Rydahl-Hansen, S., & Phanareth, K. (2012). Cognitive dysfunction in patients with chronic obstructive pulmonary disease—A systematic review. Respiratory Medicine, 106(8), 1071–1081. https://doi. org/10.1016/j.rmed.2012.03.013 Verges, S., Rupp, T., Villien, M., Lamalle, L., Troprés, I., Poquet, C., … Krainik, A. (2016). Multiparametric magnetic resonance investigation of brain adaptations to 6 Days at 4350 m. Frontiers in Physiology, 7, 393. https://doi.org/10.3389/ fphys.2016.00393 Wang, Y., Ma, H., Fu, S., Guo, S., Yang, X., Luo, P., & Han, B. (2015). Long-term exposure to high altitude affects voluntary spatial attention at early and late processing stages. Scientific Reports, 4(1). https://doi.org/10.1038/srep04443 Wesensten, N. J., Crowley, J., Balkin, T., Kamimori, G., Iwanyk, E., Pearson, N., … Cymerman, A. (1993). Effects of simulated high altitude exposure on long-latency event-related brain potentials and performance. Aviation, Space, and Environmental Medicine, 64(1), 30–36. Wilson, M. H., Newman, S., & Imray, C. H. (2009). The cerebral effects of ascent to high altitudes. The Lancet Neurology, 8(2), 175–191. https://doi.org/10.1016/S1474-4422(09)70014-6 Windsor, J. S. (2008 December 5). Voices in the air. British Medical Journal, 337, a2667–a2667. https://doi.org/10.1136/bmj.a2667
Promoting Self-Recovery from Substance Misuse and Gambling Problems with Brief Motivational Interventions Workshop Presented by Dr. David Hodgins Friday, May 11th, 2018 9:00AM – 4:30PM @ University Golf Club House 5185 University Blvd., Vancouver, BC V6T 1X5 Sponsored by: Chuck Jung Associates (www.chuckjung.com/home) Continuing Education Credits: 6 About the Workshop This workshop will be comprised of three sections. First, the stage will be set by reviewing research and clinical experience with recovery from substance and gambling addictions, with a focus on natural recovery processes. Recovery without the assistance of treatment is the most common recovery pathway, but clinicians can promote and support individuals as well as re-direct them to treatment if warranted. Second, models of brief interventions, both advice oriented and motivational, will be described. Finally, the basic principles and techniques of motivational interviewing as applied to brief addiction interventions will be presented.
Motivational interviewing is a directive, client-centred approach to therapy that helps individuals identify and resolve ambivalence about making lifestyle changes. Didactic instruction, video clip examples and role plays will used.
Learning objectives: • Participants will learn about natural recovery processes from addictions. • Participants will understand the brief intervention models developed for alcohol and other addictions. • Participants will learn the philosophy and principles of the motivational interviewing approach • Participants will learn basic motivational interviewing techniques. • Participants will explore how motivational techniques can be integrated into their treatment interventions. About the Presenter David C. Hodgins, Ph.D., R.Psych. is a professor in the program of Clinical Psychology in the Department of Psychology, University of Calgary. He is also a research coordinator with the Alberta Gaming Research Institute. He is registered as a Clinical Psychologist in Alberta. His research interests focus on various aspects of addictive behaviours including relapse and recovery from substance abuse and gambling disorders. How to register for this workshop • Mail this form to: BC Psychological Association 402 – 1177 West Broadway Vancouver, BC V6H 1G3 • Fax 604–730–0502 or Call 604–730–0501 • Go online: http://psychologists.bc.ca
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Polo Health + Longevity Centre on Columbia street in New Westminster is looking to expand our team! We are an award winning established multidisciplinary and fully integrated health clinic located in the rapidly growing community of New Westminster, BC. We are looking for a Registered Psychologist to work amongst a dynamic team of other health professionals including Naturopathic Doctors, Clinical Counsellors, Holistic Nutritionists, Medical physicians and more. Our clinic has exceptional street parking and easy sky train access, making it a convenient location for your patients. Full-time administrative staff ensure the clinic runs smoothly and efficiently. Part-time hours are available on a room rental basis. Please send all resumes and inquiries to drallanapolo@ gmail.com. Visit www.polohealth.com for more information on our Integrated Health Centre and team.
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