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NJ PSYCHOLOGIST A Publication of the New Jersey Psychological Association

In this issue... Special Section: Implications of COVID-19 on Special Needs Individuals Ethics: “Relative Strangers” Ethical Practice and Surprise DNA Test Results Book Review: The Multiple Self-States Drawing Technique: Creative Assessment and Treatment with Children and Adolescents COVID-19 and Mental Health Among New Jersey’s Orthodox Jews

Table of Contents 2 President Message 2 Member News 3 2020 NJPA Executive Director End of Year Message – Leaning into the Crisis 4 Diversity: COVID-19 and Mental Health Among New Jersey’s Orthodox Jews 7 NJPAGS: The Importance of a Consistent Self-Care Practice 8 Ethics Update: “Relative Strangers” Ethical Practice and Surprise DNA Test Results 9 Classified Ad 9 Referral Network 10 NJPA Sustaining Members 11 APA Council of Representatives Report 12 Special Section: Importation of COVID-19 on Special Needs Individuals (3 CE) 21 Challenges, Changes, and Recommendations in Providing Neuropsychological Assessment on In-Patient Evaluations During the COVID-19 Pandemic 24 Keeping The Old Man Out 24 Welcome New Members! 25 2019-2021 CE Cycle Deadline 26 Existential Therapy as a Tool for Combatting the Deleterious Psychological Effects of Racism During COVID-19 29 Book Review: The Multiple Self-States Drawing Technique: Creative Assessment and Treatment with Children and Adolescents 32 Dues Renewal – Early Winter Special! NJPA Publication Disclaimers – February 2020 Preparation of Manuscripts All manuscripts submitted for publication must follow APA style and should be edited, proofread, and ready for publication. Please prepare your manuscript in a word-processing program compatible with MS Word using Times New Roman font in 12-point font, left flush. Please submit your manuscript via e-mail to the NJPA Central Office ATTN: Francine Conway at the e-mail addresses listed below.

Errors and Omissions The NJPA Central Office staff is responsible for the layout and formatting of the NJPA journal publication, the New Jersey Psychologist. The authors of the articles produce and edit the grammar and content of the articles and references. Under no circumstances shall NJPA be liable for any direct, indirect, incidental, special, punitive, or consequential damages that result in any way from your use of or inability to use the New Jersey Psychologist or its contents, that result from any services provided by anyone named in the New Jersey Psychologist, or that are in any way associated with any mistakes, errors, omissions, interruptions, deletion of files, errors, defects, delays in operation, or transmission or any failure of performance, or for any other damages associated with the New Jersey Psychologist. NJPA makes no warranties or guaranties concerning the accuracy or reliability of the content contained in the New Jersey Psychologist or other sites or materials to which it may link or reference, nor does any link or reference imply an endorsement by NJPA of those sites or materials or content contained therein. This disclaimer also applies to use of the New Jersey Psychologist articles posted on the NJPA website or the third party BeaconLive platform for homestudy continuing education learning.

Legal Advice Disclaimer The articles and forms found on the NJPA website, mentioned on NJPA social media platforms, and in the NJPA journal publication the New Jersey Psychologist are not intended as legal advice. Practice issues are complex and highly fact-specific and require legal expertise that will not be provided by such generalized articles or forms. The information should not be used as a substitute for obtaining personal legal advice and consultation prior to making decisions regarding individual circumstances.

Editorial Policy Articles accepted for publication will be copyrighted by NJPA, and NJPA will have the exclusive right to publish, license, and allow others to license, the article in all languages and in all media; however, authors of articles will have the right, upon receiving the written consent of NJPA, to freely use material otherwise published by NJPA in books or collections of readings authored by themselves. Please be advised that authors will not receive remuneration for any articles submitted to, or accepted by, the New Jersey Psychologist.

Who’s Who in NJPA 2020 Editorial Board

www.PsychologyNJ.org

Interim Editor: Aaron Gubi, PhD Members: Ashley Gorman, PhD Eric Herschman, PsyD Nathan McClelland, PhD Anthony Tasso, PhD Staff Liaison: Christine Gurriere

NJPA Executive Board

President: Lucy Sant’Anna Takagi, PsyD President-Elect: Daniel Lee, PsyD Past-President: Morgan Murray, PhD Treasurer: Daniel DaSilva, PhD Secretary: Mary Blakeslee, PhD Director of Academic Affairs: Francine Conway, PhD APA Council Representative: Rhonda Allen, PhD Members-At-Large: (A) Phyllis Bolling, PhD (A) Susan Esquilin, PhD (A) Aida Ismael-Lennon, PsyD (N) Alan Lee, PsyD (N) Nicole Rafanello, PhD (N) Aileen Torres, PhD Parliamentarian: Joseph Coyne, PhD Affiliate Caucus Chair: Phyllis Bolling, PhD ECP Chair: Christopher King, JD, PhD NJPAGS Chair: Chelsea Torres, MA, LPC CODI Co-Chairs: Phyllis Bolling, PhD and Susan Herschman, PsyD Affiliate Representatives: Northeast Counties Association of Psychologists: Nansie Ross, PsyD Essex/Union County Association of Psychologists: Sara Tedrick Parikh, PhD Mercer County Psychological Association: Loraine Washton, PhD Middlesex County Association of Psychologists: Tammy Dorff, PsyD and Rosalie DiSimmone-Weiss, PhD Monmouth/Ocean County Psychological Association: Deidre Waters, PsyD Morris County Psychological Association: TBD Somerset/Hunterdon County Psychological Association: Janie Feldman, PsyD South Jersey Psychological Association: Daniel Lee, PsyD Central Office Staff: Executive Director: Keira Boertzel-Smith, JD Director of Professional Affairs: Susan McGroarty, PhD Senior Communications Manager: Christine Gurriere Continuing Education & Event Coordinator: Ana DeMeo Membership Services Coordinator: Jennifer Cooper

Manuscripts should be sent to the Interim Editor: Francine Conway, PhD E-Mail: francine.conway@gsapp.rutgers.edu or NJPA Central Office E-Mail: NJPA@PsychologyNJ.org

Published by: New Jersey Psychological Association 354 Eisenhower Parkway, Plaza 1, Suite 1150 Livingston, NJ 07039 973-243-9800 • FAX: 973-243-9818 E-Mail: NJPA@PsychologyNJ.org Web: www.PsychologyNJ.org New Jersey Psychologist (USPS 7700, ISSN# 2326098X) is published quarterly by New Jersey Psychological Association, 354 Eisenhower Parkway, Suite 1150, Livingston, NJ 07039. Members receive New Jersey Psychologist as a membership benefit. Periodicals postage pending at West Orange, NJ and additional mailing offices. POSTMASTER: Send address changes to New Jersey Psychologist, 354 Eisenhower Parkway, Plaza 1, Suite 1150, Livingston, NJ 07039.

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Fall 2020

Reflections on COVID-19: “What is my life? Where is my life going?”

NJPA President Lucy Sant’Anna Takagi, PsyD

uring a session with a patient this week, I heard the above question in a lost, frustrated, sad, and fearful tone. My patient has a traumatic history. The current COVID-19 pandemic not only arose deep fears that had been previously addressed, but it also added a sense of impotence, of being locked up or stuck in a world that is unpredictable and potentially harmful. My patient is not alone in having childhood trauma resurfacing with the impact of this virus. Other patients with early childhood trauma also feel stuck, lost, and frozen in planning next steps. Some also feel angry at authority figures. When our sense of safety and the predictability of our routines are shattered, we all tend to regress emotionally. Sometimes changes can be pleasurable, but changes that result in interpersonal losses can be devastating. COVID-19 brought unpredictable changes to our lives. Although we vary in how we cope with stress and stressful events, all of us have an innate tendency to habituate to routines and to long for permanence. When our routine changes, either because of a natural disaster, terroristic attack, relocation, underemployment or unemployment, abuse, violence, death,

illness, and/or COVID, the stress can become overwhelming and so can our sense of loneliness, fear, and frustration. COVID-19 has unearthed our most primitive fears. Fear of, and possibly, losing our parents, children, grandchildren, loved ones, and friends during this pandemic threatens not only our relationships with important people in our lives, but our hope for life’s continuity in a manner we can bear. Some of our love rituals no longer are. Our loved ones are sick and unaccompanied at hospitals. Funerals and death services are not being attended in-person. Being sick, possibly dying without loved ones around, or not being present at someone’s funeral services are deeply threatening to all of us, but we endure and become creative in managing significant events. Shivas are conducted virtually. Birthdays are celebrated through honking car parades. Psychotherapy and medical appointments get done online. Nonprofit organizations organize food deliveries to the needy and healthcare workers work non-stop in triple shifts, selflessly caring for the ill. We hold the hope that this will be temporary, that things will resume to normal. We comply with the lockdown. Many of us focus on the individual impact of traumatic experiences, but traumatic experiences can also be triggered by macro-systemic legislative, political, and cultural changes. All leaders become particularly challenged during a crisis. Just like parental figures during a child’s illness, leaders have the responsibility to care and protect people who depend on them while they themselves may also feel vulnerable

without knowing what to do. Many leaders experience profound loneliness, sadness, and unbearable responsibility. Leaders can, however, combat stereotypes, shame, and model help seeking behaviors, but they can also be selfish, selfcentered, reactive, and defensive. For some of my patients, being at the receiving end of a leader who cannot be accountable for his/her possible wrongdoing, can be deeply shaming. Conversely, during distress and desperation, being exposed to a leader’s ability to be humble take responsibility induces safety, understanding, and containment. It can be transformative. We heal in love and safety. During times of turmoil and emotional distress, seeking a professional psychologist to talk to can be extremely helpful. However, finding the right fit is not always easy. The right fit results from speaking with someone that makes one feel understood and cared for. One negative experience with a professional does not mean the positive one is not just around the corner. When it works, psychotherapy is transformative, but most importantly, as another one of my patients said, “It feels like I am still dealing with my problems myself, but I am not alone. I know you are there and you are a participant and a witness to my suffering.” It is my belief that, more than ever during this crisis, having our safe space, experiencing compassion for ourselves and for others, and being able to be comforted by someone who loves us and who we love, brings hope and healing. Hope brings strength. Strength makes us tolerate not knowing where life goes, but no matter where it goes, we are not alone. ❖

MEMBER NEWS Ruth Lijtmaer, PhD presented the paper: Destruction and survival in a dangerous journey in panel: Ethnic Conflict and Multigenerational Trauma through the lens of Psychohistory, Psychoanalysis, and Cinema Analysis at the 43rd Annual Conference of IPA (International Psychohistory Association). 5-20-20 to 5-22-20.ONLINE Presentation. She had two published papers: Silenced and Unsilenced: Why didn’t they talk before? Otherwise/Uncut, Spring IFPE on line journal of the International Forum for Psychoanalytic Education (2020). http://ifpe.wordpress.com/ and Personal reflections on the demands on the analyst in these chaotic times in the CPPNJ (Center for Psychotherapy and Psychoanalysis) Newsletter June 2020. Peggy Rothbaum, PhD contributed the article “Taking Care of Those Who Protect Animals During the Pandemic.” Animal Care & Control Today, (2020) 26-29. Dr. Rothbaum also helped to organize NJ Sews in Unity. The group makes and donates washable masks. She was mentioned in this article: New Jersey Sews in Unity-Making a Difference During Covid-19 <https://www.womanaroundtown.com/sections/living-around/new-jersey-sews-in-unity-making-a-difference-during-covid-19/> 2

New Jersey Psychologist

2020 NJPA Executive Director End of Year Message – Leaning into the Crisis

Executive Director, Keira Boertzel-Smith, JD

ince March 2020, we all faced extraordinary challenges. Through these long months, NJPA drew upon our distinct strengths, leaning into our longstanding ethos of NJPA leadership, membership, and Central Office team innovation, creativity, and a commitment to the NJPA mission, science of psychology, and psychologists. However stressful this 2020 crisis has been for the association, and to each of us personally, I would certainly be remiss to not reflect and acknowledge the unexpected benefits coming out of the 2020 crisis. 1. 2020 Visibility: NJPA aggressively worked together with the American Psychological Association, other state associations, state departments, and our Government

Affairs Agent, on important advocacy efforts related to COVID-19. Due to COVID-19, I also began talking more regularly with the Board of Psychological Examiners (BoPE) and BoPE liaison, Ronald Silikovitz, PhD. These efforts bring more visibility to psychology, psychologists, and NJPA, and led to building new relationship roots. 2. 2020 Virtual Education: Ready or not, NJPA promptly learned how transfer live programs into virtual continuing education programs. We were happy to share this new found knowledge with the NJPA Affiliates though conversations and a virtual program training. 3. 2020 Freedom and Flexibility: Virtual platforms allow for wider meeting participation and more flexibility attending NJPA meetings. This brought more frequent NJPA collaborative efforts between NJPA committees and with outside organizations and legislators. 4. 2020 Human Connection and Availability: NJPA Central Office staff worked harder than ever to stay connected

and to be available each day despite our remote set up. Day and night, we used our computers, phones, texts, emails, and car drop offs to get NJPA work done. 5. 2020 E-Publications: NJPA Central Office began to take advantage of, and rethinking, the creative power of electronic publications (2020 Mid-Year Report and Fall Conference Brochure). Electronic publications allow NJPA to save money, provide instant delivery, and create visuals and hyperlink to videos and other documents. We will continue using e-publications throughout 2021. 6. 2020 Communication tools: NJPA explored using our website, emails, social media, podcasts, e-publications, the LISTSERV, conference calls, and Zoom meetings in a more organized manner. To read more about our 2020 efforts, please read the 2020 NJPA Mid-Year Report, Advocacy Report, and the most recent NJPA Foundation Flash. Thank you to everyone for being a part of 2020 NJPA learning opportunities, human connections, and resilience in the face of the COVID-19 crisis. ❖

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Fall 2020

DIVERSITY

COVID-19 and Mental Health Among New Jersey’s Orthodox Jews Steven Pirutinsky, PhD, CHEMED, Lakewood, NJ & Touro College, New York, NY

David H. Rosmarin, PhD McLean Hospital/ Harvard Medical School, Belmont, MA

ince its outbreak, COVID-19 rapidly spread into a deadly global pandemic threating physical health, overwhelming governments and hospitals, and closing schools and businesses. Both the illness and social distancing measures present challenges to mental health reflected in rising levels of symptoms of panic disorder, anxiety, depression, and post-traumatic stress (Rajkumar, 2020). New Jersey has been particularly affected with high prevalence and widespread community transmission (Centers for Disease Control, 2020) prompting the adoption of extraordinary interventions including restricting people to their homes and closing the majority of public venues. According to numerous media reports, New Jersey’s Orthodox Jewish community was particularly hardhit, and the current paper focuses on their experience of COVID-19. Orthodox Jewish Community Orthodox Judaism is a broad categorization including a variety of religious cultures unified by acceptance of the Divine origins of the Torah (the Jewish Bible) and the Talmudic interpretation of it. While there is a range in culture and practice from more traditional ultraOrthodox to modern-Orthodox subsects, all Orthodox Jews strictly adhere to religious laws that infuse everyday life with both obligation and meaning. Observance of some religious laws (e.g., ritual baths, communal prayer, marriage ceremonies, circumcision) were signifi4

cantly impacted by public health orders. Stay-at-home restrictions were also particularly stressful, as Orthodox culture is collective, communal, and familial culture that highly values social interaction (Heilman, 2000). In addition, ultra-Orthodox communities tend to be composed of large families (Pirutinsky, Schechter, Kor, & Rosmarin, 2015) of low socioeconomic status (Pearson & Geronimus, 2011) who eschew widespread access to smartphones and the Internet, that have become uniquely important to daily life under social distancing conditions. Finally, beyond direct impact, conspiracy theories about COVID-19 have targeted Jews, echoing old libels related to past pandemics (e.g., Cohn, 2007), and anti-Semitic incidents have increased 18% since the outbreak (Heller, 2020). Method To explore this experience, we gathered data throughout the peak of the epidemic in the tristate area (March 29th 2020 until April 22nd 2020) using an online survey that included both items assessing exposure to COVID-19, related attitudes, and the impact of COVID-19, as well as scales measuring anxiety (GAD-7, Spitzer et al., 2006), depression (PHQ-9, Kroenke & Spitzer, 2002), stress (PSS, Cohen et al., 1983), trauma (IES, Weiss, 2007), and coping (Brief Coping Scale, Carver, 1997). We also examined religious involvement (DUREL, Koenig & Büssing, 2010), and use of religion as a coping strategy (JCOPE, Rosmarin et al., 2009). Links to our survey were distributed through various websites, news outlets, and synagogue email lists. The resulting sample included 353 Orthodox Jewish adults residing in New Jersey, who were 59% female, ranged in age from 18 to 83 (M = 36.23, SD = 13.43), and most were married (81%) or single/never-married (14%) with a large average household size (M = 5.13, SD = 2.44). Reported ethnicity was largely White (96%) and most held college or post-graduate degrees (63%). Specific Orthodox affiliations included 74% Ultra-Orthodox (5% Hassidic, 1% Chabad/Lubavitch, 68% Yeshiva Orthodox), and 23% Modern-

Orthodox. While the sample was selfselected and likely non-representative, this article reviews some of the key findings to illustrate the unique challenges and coping methods relevant to this community. Exposure to COVID-19 Orthodox Jews in our sample reported high levels of exposure to COVID-19 with 35% reported having a confirmed or suspected infection, 62% reported direct contact with someone infected, and 75% reported that someone close to them was infected. Yet, this does not appear to be due to laxity in adherence to legal and medical guidelines. On the contrary, 91% reported adhering “very much” to social distancing requirements, safe handwashing practices, and isolation/quarantine with only 0.3% reporting adhering “not very much” or “not at all.” Moreover, Orthodox Judaism views caring for physical health as a religious value, as evidenced by strongly worded public health advisories issued by many Orthodox Jewish institutions (e.g., Agudas Yisroel, Orthodox Union, Hatzalah), and consistently, 91% of participants reported that God works through doctors, 97% that God wants them to take care of their health, and 85% were confident in their local health services. This matches many media reports suggesting that these communities are largely adhering to guidelines (e.g., Davis & Contreras, 2020), as well as Google mobility data indicating that New Jersey counties with large Orthodox populations experienced enormously reduced activity at retail, entertainment, and work locations (Google, 2020). So, what explains the higher level of contagion? While we do not have direct data, it is likely due to several factors, such as: 1) Orthodox Jews tend to live in dense areas and gather frequently for prayer, events, and religious studies; 2) Large families living together increasing the likelihood of exposure; 3) Initial spreading of COVID-19 occurred during festive Jewish holidays (Purim, Passover) when many travel and gather with friends and family. New Jersey Psychologist

Impact of COVID-19 Despite higher risk and exposure to COVID-19, respondents to our survey on average reported only slightly more than “a little bit” of impact in 12 different key life domains (M = 2.30, SD = .99). However, dependent measures ANOVA suggested that there were significant differences between specific domains of impact (F(11, 3465) = 95.32, p < .001, η2 = .23) with work (M = 3.24, SD = .96), family (M = 2.71, SD = 1.07), fitness (M = 2.67, SD = 1.08), and finances (M = 2.62, SD = 1.03) emerging as areas of higher impact, while faith in G-d (M = 1.34, SD = .79), religious observance (M = 1.88, SD = 1.07), and character (M = 1.95, SD = .91) were minimally impacted by COVID-19 with mean responses in the “not at all (1)” to “a little bit (2)” range. We also found that the vast majority of respondents (83%) reported that COVID-19 had a positive impact on their lives, such as spending more time with family, refocusing on important priorities, engaging in new activities, and reconnecting with friends and family. Finally, in terms of mental health, during the initial weeks of the COVID-19 pandemic, only 13% of respondents reported experiencing significant anxiety (GAD-7 > 9) and 13% depression (PHQ-9 > 9), although 25% reported some trauma symptoms related to COVID-19 (IES > 24) and 48% significant stress (PSS > 6). Surprisingly, average impact of COVID-19 across all 12 domains did not significantly correlate with infection, exposure, and having a close friend/family member infected. That is the degree of distress across domains was statistically equivalent between those directly exposed and those who were not. However, it was weakly and positively correlated with secondary exposure via social media (r2(352) = .12, p = .03) and more one-on-one conversations about COVID-19 (r2(352) = .17, p = .002). Even more surprising, participants reporting a confirmed or suspected infection reported small to moderately greater overall positive impact of COVID19 (“The COVID-19 crisis has had a positive impact on my life, (e.g., more time with family, refocusing on priorities)”; r2(352) = .22, p < .001). There were no significant correlations between various demographics and impact, although family size weakly, positively correlated with higher positive impact (r2(348) = .16, p = .003), reflecting Fall 2020

perhaps the emotional and social benefits of being able to spend time with a larger family group. There were also small, but significant, gender differences with women reporting higher levels of negative impact than men on family (t(350) = 2.70, p = .007) and emotions (t(327) = 3.34, p = .001), that may reflect increased housekeeping and childcare responsibilities and severely curtailed outside assistance. There were no significant differences between respondents from different sub-communities (e.g., “Ultra-Orthodox” versus “Modern Orthodox”). Coping with COVID What might explain how Orthodox Jews appear to have high levels of exposure and risk for COVID-19, and low levels of impact and mental health concerns? One possibility is that community members drew upon the deep religious, spiritual, and social supports available within this community (Pirutinsky, 2020). Decades of research shows that religious individuals use spirituality and religion to cope with stress (Pargament, 2001; Koenig, 2018), and accordingly, Bentzen (2020) noted that by March 2020, the number of Google searches of “prayer” had reached a record high and that rates correspond to the trajectory of the pandemic. This turn to religion appears generally beneficial for most, since religion and spirituality involve a framework of meaning-making associated with decreased distress, provide a source of attitudes and cognitions that reframes negative events, and include practices, such as prayer, religious study, and mindfulness all of which are linked to lower negative affect (Rosmarin et al., 2020; Rosmarin & Koenig, 2020). Our data support these ideas. Religious variables correlated with lower impact and distress across the board. Specifically, higher intrinsic religiosity was correlated with less anxiety (r2(317) = -.20, p < .001), less depression (r2(316) = -.26, p < .001), less stress (r2(328) = -.22, p < .001), and fewer trauma symptoms (r2(327) = -.14, p = .009), and moderately correlated with greater positive impact of COVID-19 (r2(352) = .20, p < .001). Positive religious coping was similarly related to less anxiety (r2(301) = -.18, p = .002), depression (r2(301) = -.26, p < .001), stress (r2(314) = -.26, p < .001), and more positive impact (r2(325) = .27, p < .001), while

negative religious coping correlated with greater anxiety (r2(315) = .42, p < .001), depression (r2(314) = .37, p < .001), stress (r2(326) = .36, p < .001), and trauma (r2(325) = .41, p < .001). In terms of specific areas of impact, most were uncorrelated with religious variables with the exception of negative emotions, life satisfaction, and character. This suggests that while religiosity did not mitigate the direct economic, social, and life difficulties of COVID-19, it did relate to emotional reactions. In addition to religion and spirituality, several other coping methods emerged as both frequent and correlated with less distress across domains1. These included accepting reality and learning to live with it, looking for something good in it, taking action, and finding comfort in religious beliefs and prayer all of which correlated with less impact and better mental health. On the other hand, negative coping methods, such as denying reality, giving up, using alcohol or other drugs, expressing negative feelings to others, and blaming yourself were far less frequent and correlated with more impact and poorer mental health. Finally, another factor suggested by the qualitative data we collected is the high level of social and community support available within the Orthodox Jewish community. Charity and kindness are core values within this highly collective community (Oppenheimer, 2014; Pirutinsky, 2020), and there are thousands of organizations that provide substantive support for a myriad of specific challenges. Throughout this crisis, existing organizations mobilized and provide medical care, referrals, transportation, food, financial support, social services, education, children’s activities and programs, entertainment, and religious services. Individuals adapted in similar ways. For example, media reports suggest that Orthodox Jews have been donating plasma at record levels (Stack, 2020), and qualitative responses to our survey suggest that social activism has helped both the recipients and providers and may be another factor underlying the low rates of distress reported above. ❖ Conclusion In conclusion, while the Orthodox Jewish community appears to have high rates of exposure to COVID-19, our data suggest that its members are generally 5

adhering to medical and governmental guidelines, experiencing limited negative impact and less than expected levels of clinical distress, and fairly high levels of positive impact. Lower distress appears to be correlated with religious and spiritual factors, acceptance, and active coping often in the form of social engagement with others. Thus, it appears, that this ancient religious community is drawing upon its time-tested religious and communal resources to deal with this global tragedy, and that these approaches appear to be moderating the psychological impact. About the Authors Steven Pirutinsky, PhD is associate professor at Touro College (New York, NY), Director of Research at the Center for Anxiety (New York, NY) and maintains a clinical practice in Lakewood, NJ. His research focuses primarily on the intersections between spirituality, religion, culture, mental health, and well-being, particularly within the Orthodox Jewish community. David H. Rosmarin, PhD, ABPP is an assistant professor in the Department of Psychiatry at Harvard Medical School, and founder/director of the Center for Anxiety. He is a board certified psychologist, clinical innovator, and prolific researcher who has authored over 50 peer-reviewed publications and 100 abstracts focused on spirituality and mental health. He is also the author of Spirituality, Religion & Cognitive Behavioral Therapy: A Guide for Clinicians. Footnotes 1 Statistics underlying this section are available by request. References Bentzen, J. S. (2020). In Crisis, We Pray: Religiosity and the COVID-19 Pandemic. Copenhagen, Denmark: University of Copenhagen. Carver, C. S. (1997). You want to measure coping but your protocol’s too long: Consider the Brief COPE. International Journal of Behavioral Medicine, 4, 92100. Centers for Disease Control (2020). Cases of Coronavirus Disease (COVID-19) in the U.S. Retrieved from <https:// www.cdc.gov/coronavirus/2019-ncov/ cases-updates/cases-in-us.html> on 6/22/2020.

Cohn, S. K. (2007). The Black Death and the burning of Jews. Past and Present, 196, 3-36. Cohen, S., Kamarck, T., & Mermelstein, R. (1983). A global measure of perceived stress. Journal of Health and Social Behavior, 24, 386-396. Davis, M., & Contreras, G. M. (2020, March 20). Coronavirus: Orthodox Jewish leaders close Lakewood synagogues, citing ‘mortal threat.’ Asbury Park Press, Retrieved from https://www.app.com/story/news/ health/2020/03/20/coronavirus-lakewood-orthodox-jewish-covid-19-shulssynagogues/2885030001/ Google (2020). COVID-19 Community Mobility Report for New Jersey (April 4th). Retrieved from https://www. google.com/covid19/mobility/ Heilman, S. C. (2000). Defenders of the faith: Inside ultra-orthodox Jewry. Berkeley, CA: University of California Press. Heller, J. (April 20, 2020). Coronavirus crisis stoking anti-Semitism worldwide: Report. Reuters. Retrieved from https:// www.reuters.com/article/us-healthcoronavirus-israel-antisemitis/coronavirus-crisis-stoking-anti-semitism-worldwide-report-idUSKBN22219C Koenig, H. G. (2018). Religion and mental health: Research and clinical applications. Cambridge, MA: Academic Press. Koenig, H. G., & Büssing, A. (2010). The Duke University Religion Index (DUREL): A five-item measure for use in epidemological studies. Religions, 1, 78-85. Kroenke, K., & Spitzer, R. L. (2002). The PHQ-9: a new depression diagnostic and severity measure. Psychiatric Annals, 32, 509-515. Oppenheimer, M. (2014, October 19). The Beggars of Lakewood. New York Times. Retrieved from https://www. nytimes.com/2014/10/19/magazine/ the-beggars-of-lakewood.html Pargament, K. I. (2001). The psychology of religion and coping: Theory, research, practice. New York: Guilford Press. Pearson, J. A., & Geronimus, A. T. (2011). Race/ethnicity, socioeconomic characteristics, coethnic social ties, and health: evidence from the national Jewish population survey. American Journal of Public Health, 101, 1314-1321.

Pirutinsky, S. (2020). I created the evil inclination and I created Torah its antidote: An Indigenous Jewish Psychology. In T. A. Sisemore & J. J. Knabbs (Eds.), The Psychology of World Religions and Spiritualties: An Indigenous Perspective. Philadelphia, PA: Templeton University Press. Pirutinsky, S., Schechter, I., Kor, A., & Rosmarin, D. (2015). Family size and psychological functioning in the Orthodox Jewish community. Mental Health, Religion & Culture, 18, 218230. Rajkumar, R. P. (2020). COVID-19 and mental health: A review of the existing literature. Asian Journal of Psychiatry. Advanced online publication. doi: 10.1016/j.ajp.2020.102066 Rosmarin, D. H., & Koenig, H. G. (Eds.). (2020). Handbook of spirituality, religion, and mental health. Cambridge, MA: Academic Press. Rosmarin, D. H., Pargament, K. I., Krumrei, E. J., & Flannelly, K. J. (2009). Religious coping among Jews: Development and initial validation of the JCOPE. Journal of Clinical Psychology, 65, 670-683. Rosmarin, D. H., Pargament, K. I., & Koenig, H. G. (2020). Spirituality and mental health: challenges and opportunities. The Lancet: Psychiatry. Advanced online publication doi: 10.1016/ S2215-0366(20)30048-1 Spitzer, R. L., Kroenke, K., Williams, J. B., & Löwe, B. (2006). A brief measure for assessing generalized anxiety disorder: the GAD-7. Archives of Internal Medicine, 166, 1092-1097. Stack, L. (2020, May 12). Hasidic Jews Hit Hard by the COVID Outbreak Flock to Donate Plasma. New York Times. Retrieved from https://www.nytimes. com/2020/05/12/nyregion/virus-orthodox-plasma-donation.html Weiss, D. S. (2007). The Impact of Event Scale: Revised. In: J. P. Wilson & C. S. Tang (eds.) Cross-Cultural Assessment of Psychological Trauma and PTSD. Boston, MA: Springer.

New Jersey Psychologist

NJ PSYCHOLOGICAL ASSOCIATION OF GRADUATE STUDENTS (NJPAGS)

The Importance of a Consistent Self-Care Practice

Chelsea Torres, MA, LPC

fter serving one year as NJPAGS chair-elect, and now ending my year as NJPAGS chair, I have become intimately familiar with the importance of self-care. It is inevitable that we all will experience distress at some point in our lives whether in our personal lives or in our professional lives or both. Mental health professionals are often at a higher risk of experiencing symptoms of distress, more specifically, symptoms of burnout. Symptoms of burnout can include feelings of emotional depletion, a reduced sense of satisfaction or fulfillment in your work, personal symptoms of distress such as irritability, substance use, or fatigue, and a loss of empathy (Carter & Barnett, 2014, pp. 29–30). It is not uncommon for these professionals to focus on the needs of the client and neglect their own needs. For these reasons, mental health professionals are urged to employ self-care strategies and interventions, such as taking regularly scheduled breaks and/or vacations, setting and maintaining healthy boundaries for yourself and the clients you work with, developing a self-care plan, and actively strive to maintain a healthy life/work balance (Carter & Barnett, 2014; APA, 2014). Graduate programs often remind and educate future mental health professionals on how to practice self-care, but as we move further along in our careers it can be easy to forget. Some aspects of the mental health profession that can contribute to burnout are our work setting, the type of client we are treating, lack of progress with a particular client, long work hours, perhaps being on call, client emergencies, crises or suicide attempts, aggressive clients, professional isolation, fear of malpractice claims, ethical complaints, licensing board complaints, paperwork, administrative responsibilities, lack of resources, receiving negative feedback, insurance and reim-

Fall 2020

bursements, and not feeling appreciated (Barnett, 2014). Barnett (2014) noted the impact from personal lives that can also contribute to burnout, such as family, relationships, health, finances, mental health, etc. It is not only important for our own wellbeing to attend to our selfcare, it is also imperative as mental health professionals, so we do not place the clients we serve at risk. If we are suffering from burnout or compassion fatigue, we cannot be as effective in our jobs as mental health professionals. The effects of burnout can place mental health professionals at great risk of violating the most basic tenets of the ethical principles, beneficence and nonmaleficence, and place clients at risk of harm (Barnett, 2014). There are some resources where mental health providers can assess their quality of self-care (APA, 2014). The American Psychological Association offers a great list of links to assist in finding a work-life balance, creating a self-care action plan, finding a peer consultation group, and many other self-care tips (APA, 2014). It is imperative that providers have insight about their mental health, and it is best to be proactive rather than reactive. One issue related to reactivity could be ethical issues in which a mental health professional begins to engage in substandard practice of client care or is more susceptible to professional errors as a result of prolonged symptoms of burnout that have been ignored (Carter & Barnett, 2014, pp. 30–35). Some warning signs of burnout can include poor sleep, an inability to focus, poor diet, isolation, feeling depressed, anxious, and/ or irritable, somatic symptoms, not finding as much enjoyment out of your job as you once did, and negative attitudes toward yourself or your clients (Carter & Barnett, 2014, pp. 30-31). Some great ways to prevent burnout are to exercise regularly, engage in peer support groups and clinical supervision, participate in personal counseling/psychotherapy, regularly engage in hobbies or activities that interest you and that are unrelated to work, and incorporate relaxation exercises such as mindfulness or yoga (Barnett, 2014). These activities are great for practicing self-care once we begin to feel symptoms of burn out. Rather than waiting for these symptoms

to appear, however, we can begin, today, to practice self-care daily as a way of taking a proactive approach and creating a culture of prevention. Self-care is an ongoing effort and a lifelong process. As former NJPAGS chair elect and current NJPAGS chair, I have had to be consistent and diligent with my self-care routine. I practice self-care daily with mindfulness, exercise, spending time with family and friends, eating a well-balanced diet, spending time with my two dogs, constantly remaining as organized as possible, and maintaining proper sleep hygiene. It may sound, and even feel, overwhelming to try to engage in these activities daily and consistently. Most of these activities, however, are deemed enjoyable by the person participating in them and the long-term benefits of engaging in these activities are innumerable. Mental health professionals must remember that their ability to provide exceptional treatment to their clients is dependent upon their own well-being and their ability to engage in self-care regularly (Carter & Barnett, 2014, p. 193). Ultimately, personal life experiences and situations are likely to change. This means that your self-care plan may need to be revisited and modified to meet your current needs. It is recommended that mental health professionals perform self-care assessments regularly while also assessing current sources of distress to amend their self-care plan as needed. ❖ References American Psychological Association. (2014, April). Self-care resources for psychologists. Monitor on Psychology, 45(4). http:// www.apa.org/monitor/2014/04/self-care Barnett, J. (2014, December). Distress, burnout, self-care, and the promotion of wellness for psychotherapists and trainees: Issues, implications, and recommendations. [Web article]. Retrieved from: <http:// www.societyforpsychotherapy.org/distresstherapist-burnout-self-care-promotionwellness-psychotherapists-trainees-issuesimplications-recommendations> Carter, L. A., & Barnett, J. E. (2014). SelfCare for Clinicians in Training: A Guide To Psychological Wellness For Graduate Students In Psychology (1st ed.). Oxford University Press. 7

ETHICS UPDATE

“Relative Strangers” Ethical Practice and Surprise DNA Test Results

Sarah Dougherty, PsyD, EdM, MS

aybe you are one of the more than 30 million people who has taken a cheek swab or spit into a tube and unceremoniously mailed off your sample for DNA testing by one of the dozen or more major direct-to-consumer DNA testing companies. Who are you? Where did your people come from? Were weird Aunt Ursula’s stories about the family really true? Alternatively, suppose your client is struggling with the impact of unexpected results from a DNA test. Would you know what to do? Maybe they have learned they are not their father’s biological child. Maybe they have discovered they have 26 half-siblings. Maybe they have unearthed the fact that their beloved great-grandfather had a second, secret family. At first glance, you may feel well equipped for the case. You might employ a little Family Systems theory, or maybe some CBT around core beliefs. Maybe you have worked with a few adopted clients. However, working with someone struggling with a DNA surprise may bring up some less obvious considerations, some practical, some clinical, some ethical, such that it is worth thinking about the sort of skill set that might suit the case: Ethical Principles of Psychologists and Code of Conduct 2.01 Boundaries of Competence (a) Psychologists provide services, teach, and conduct research with populations and in areas only within the boundaries of their competence, based on their education, training, supervised experience, consultation, study, or professional experience. (c) Psychologists planning to provide services, teach, or conduct research involving populations, areas, techniques, or technologies new to them undertake

relevant education, training, supervised experience, consultation, or study. (e) In those emerging areas in which generally recognized standards for preparatory training do not yet exist, psychologists nevertheless take reasonable steps to ensure the competence of their work and to protect clients/patients, students, supervisees, research participants, organizational clients, and others from harm. Practical Considerations First, it can be helpful to have some familiarity with how DNA tests, such as those sold by Ancestry, 23andMe, and My Heritage actually work. There’s not much point hashing through your client’s familial angst if it turns out to have been based on misunderstood test results. For example, if your client is concerned because she and her sibling both took DNA tests, but her sibling is not showing up as a close relative, make sure both siblings have their preferences set to “share information.” It also helps to be familiar with the differences between how companies pool data, how results are determined, and how ethnicity and kinship predictions are made; these are some of the more common ways test results can be misread. So why should a psychologist care about any of this? Commercial DNA testing is powerful stuff, and for some, the kits have opened a Pandora’s box. Advertising makes DNA testing seem like fun. That’s not to say that it isn’t an interesting and enjoyable endeavor. However, never before has so much personal information been so readily available, and the potential ramifications so left to chance. Those with “secrets” have good reason to worry, even if they have never submitted their own DNA sample for testing. The sizable DNA database, coupled with millions of online records dating back centuries and across continents, including birth records, military records, marriage licenses, census records, and death records, have made anonymity increasingly difficult. Ancestry. com that boasts the largest market share, with more than 15 million subscribers, entices customers with the provocative

tagline, “Behind every question is a story.” Well, yeah. Of course, not everyone who submits a DNA sample for testing gets life altering results. You may never have a client who is thrown such an existential curveball. But the odds might be better than you would guess. According to the Pew Research Center, as of July 2019, one in seven US adults had their DNA tested by a direct-to-consumer service such as Ancestry or 23andMe. Participants reported the following motivations: 87% - To learn more about where family came from 36% - To connect with family they did not know about 36% - To learn about family health and medical information Participants also reported the following results and reactions: 38% were surprised by geographic heritage 27% were surprised by racial implications of heritage 27% discovered unknown relatives 26% were surprised by medical information Clinical implications and Yellow Flags: Initially, your job is to offer support and to bear witness, much as you might for a client who has experienced the death of someone close to them. With time, the client hopefully will be able to create a revised narrative incorporating the newly discovered information. Until then, however, your client may feel blindsided. They may lose trust in family members they perceive as having initiated or perpetuated the secret. They may experience anger, denial, or depression, or they may mourn their previous, more “innocent” world view. How the information was revealed, that is, by a DNA test rather than by a family member, may be as relevant, if not more so, than the information itself. What is your client’s relationship to the secret? 1.) Who owns/owned the original secret? What is or was your client’s personal relationship with them? Is the “guilty party” still living, or has there been a kind New Jersey Psychologist

of genealogical infidelity? How broad is the potential ripple effect? 2.) Has your client’s own secret been exposed? Often, though not always, the secret holder may feel relieved that the truth has been uncovered. However, there also may be significant trauma and/or shame associated with the secret. 3.) Has your client been “found,” or have they been blindsided by an estranged or unknown relative? Has their spouse been found by previously unknown kin? 4.) Has your client uncovered the family secret unwittingly? Or were they searching intentionally for a suspected truth? A client may regret having uncovered the secret and feel unduly burdened by the responsibility of what to do with the information. Alternatively, they may feel outraged that such a

secret was kept from them and wonder who else was in on the subterfuge. They may feel the new information sheds light on previously unexplained family dynamics. 5.) Is your client searching for, or have they found, a long-lost relative, such as an adoptee searching for a birthparent? If so, do you know how to support someone who is searching? Finally, it may be worth considering your own relationship to the secret. Does your client’s DNA “story” elicit your inner sleuth or problem solver? Does your client, who may be feeling particularly untethered, and who may be actively seeking connection, compel you to ally with them in ways that are different from how you typically relate to clients? Uncovered secrets can take on a life of their own, and

it may be necessary for you to help the client slow down and carefully consider the ramifications of the family secret. Therapists are trained to help clients unpack difficult personal experiences and navigate the often complex emotions they may evoke. In that sense, working with a client struggling with a DNA surprise may feel like familiar territory. The technology is new, and the ability for anybody with a little saliva and a valid credit card to “deep dive” into their family tree is newer still. With the suddenness of a jack-in-the-box, an unexpected DNA test result may bring profound upheaval to a client’s sense of self and their place in the world. It is the therapist’s role to help the client to integrate their new-found truth and to embrace their evolving identity. ❖

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Fall 2020

Thank you 2020 Sustaining Members! By advancing your level of membership to Sustaining Membership status, you have generously demonstrated your additional support of your professional association. We thank you for your commitment and dedication to your organization! Mitch Abrams, PsyD Rhonda Allen, PhD Amy Altenhaus, PhD Mark Aronson, EdD Alyssa Austern, PsyD Jeffrey Axelbank, PsyD Kyle Barr, IV, PsyD Thomas Barrett, PhD Louis Barretti, PhD Leslie Becker Phelps, PhD Emily Becker-Weidman, PhD Margaret Beekman, PhD Elaine Belz, PhD Roderick Bennett, PhD Todd Bennett, PsyD Rhea Bensman, PsyD Helen Berman, PhD Nancy Bloom, PsyD Monica Blum, PhD Alice Bontempo, PsyD Randy Bressler, PsyD Richard Brewster, PsyD Natalie Brown, PhD Charles Buchbauer, PhD Linda Busch, PhD Diane Cabush, PsyD Dina Cagliostro, PhD Rosemarie Ciccarello, PhD Karen Cocco, PhD Sidney Cohen, PhD Stacey Cohen-Meissner, PhD Deniz Colak, PhD Anthony Comerford, PhD Louise Conley, PhD John Corbisiero, PhD Mark Cox, PhD Joseph Coyne, PhD Stephanie Coyne, PhD Daniel DaSilva, PhD Richard Dauber, PhD Bernice Davis, PsyD Joseph DeMeyer, PhD Promila Dhillon, PhD Phyllis DiAmbrosio, PhD John Diepold, Jr, PhD Rosalie DiSimone-Weiss, PhD Charles Dodgen, PhD Rosalind Dorlen, PsyD Edward Dougherty, EdD Frank Dyer, PhD Linda Earley, PsyD Peter Economou, PhD Daniel Edelman, PsyD Lynn Egan, PsyD

Susan Esquilin, PhD Sean Evers, PhD Roberta Fallig, PhD Janie Feldman, PsyD Sandra Feldman, PhD Stephen Feldman, PhD Dennis Finger, EdD Yesenia Flores, PsyD Resa Fogel, PhD Pamela Foley, PhD Kenneth Freundlich, PhD Antonia Fried, PsyD Mark Friedman, PhD Thomas Frio, PhD Abisola Gallagher, EdD Jacqueline Gallios, PsyD David Gelber, PhD Nouriman Ghahary, PhD Kevin Giangrasso, PsyD Leslie Gilbert, PhD Rachel Gingold, PhD Marc Gironda, PsyD Ronald Gironda, PhD Linda Glazer, PsyD Elizabeth Goldberg, PhD Gary Goldberg, PhD Ruth Goldston, PhD Lois Goorwitz, PhD Ora Gourarie, PsyD Susan Grossbard, PsyD Hadassah Gurfein, PhD Mathias Hagovsky, PhD Cynthia Haines, PsyD Osna Haller, PhD Raymond Hanbury, PhD Graham Hartke, PsyD Steven Hartman, PhD John Hennessy, PhD Susan Herschman, PsyD Lauraine Hollyer, PhD Ann Nikolai Houston, PhD Christine Hudson, PhD Jeri Isaacson, PhD Lisa Jacobs, PhD Alison Johnson, PsyD Nancy Just, PhD Jeffrey Kahn, PhD Paula Kaplan-Reiss, PhD Robert Karlin, PhD Charles Katz, PhD Toby Kaufman, PhD Thomas Kavanagh, PsyD Richard Kessler, PhD Lisa Kestler, PhD Stanley Keyles, PsyD

Joel Kleinman, PhD Eileen Kohutis, PhD Steven Korner, PhD Deirdre Kramer, PhD David Krauss, PhD Phyllis Lakin, PhD Robin Lang, PsyD Paul Lehrer, PhD Roman Lemega, PhD Ilana Lev-El, PsyD Robert Levine, PhD Monica LIntott, PhD Neal Litinger, PhD John LoConte, PhD Rebecca Loomis, PhD Wendy Loonin, PhD Alfredo Lowe, PhD Mark Lowenthal, PsyD Konstantin Lukin, PhD Marilyn Lyga, PhD David MacIsaac, PhD Daniel Mahoney, EdD Stanley Mandel, EdD Bonnie Markham, PhD, PsyD Donald Marks, PsyD Nicole Martell, PsyD Neil Massoth, PhD Shirley Matthews, PhD John McInerney, PhD Edward Merski, PsyD Jacqueline Mesnik, PhD Marshall Mintz, PsyD Barry Mitchell, PsyD Noreen Mohle, PhD Ruth Mollod, PhD Sharon Ryan Montgomery, PsyD Caridad Moreno, PhD Sandra Morrow, PhD Daniel Moss, PhD Morgan Murray, PhD Susan Neigher, PhD Jeffrey Newenhouse, PsyD Daniel Noll, PhD Cheryl Notari, PhD Carly Orenstein, PsyD David Panzer, PsyD Craig Pearl, PsyD Francesca Peckman, PsyD Nicole J. Rafanello, PhD Rich Rapkin, PsyD Howard Rappaport, PsyD Gina Rayfield, PhD Lori Rayner-Grossi, EdD Ann Reese, PhD, PsyD Ellen Reicher, PhD

AnnaMarie Resnikoff, PhD Laura Richardson, PhD Deborah Riviere, EdD Marion Rollings, PhD Amelia Romanowsky, PsyD Barbara Rosenberg, PhD Lori Aks Rosenberg, PsyD Gianine Rosenblum, PhD Elissa Rozov, PhD Anne Rybowski, PhD Nicole Safonte-Strumolo, PhD Joseph Salerno, PsyD Carole Salvador, PsyD Jayne Schachter, PhD Peter Schild, EdD Margot Schwartz, PsyD Nancie Senet, PhD Eileen Senior, PsyD Laura Shack-Finger, EdD Arline Shaffer, PhD William Shinefield, PsyD Nancy Sidhu, PhD Frank Sileo, PhD Ronald Silikovitz, PhD Jeffrey Singer, PhD Pierce Skinner, PsyD Tamara Sofair-Fisch, PhD Robert Staffin, PsyD Mary Ellen Stanisci, PhD Jakob Steinberg, PhD Deana Stevens, PsyD Julie Stewart, PsyD Jeffrey Stone, PhD Vincent Stranges, PhD Ben Susswein, PhD Lucy Sant’Anna Takagi, PsyD Anthony Tasso, PhD H. Augustus Taylor, PhD Tamsen Thorpe, PhD Barbara Tocco, EdD Andrea Urman, PsyD Jonathan Wall, PsyD Virginia Walters, PsyD Beth Watchman, PhD Virginia Waters, PhD Daniel Watter, EdD Allen Weg, EdD Ida Welsh, PhD Aaron Welt, PhD Norbert Wetzel, ThD Philip Witt, PhD James Wulach, PhD, JD Joshua Zavin, PhD Michael Zito, PhD

New Jersey Psychologist

APA COUNCIL REPORT

APA Council of Representatives Report

Rhonda Allen, PhD Council of Representatives (NJ) (2019-22)

he Council of Representatives of the American Psychological Association met virtually August 5-6, 2020. It was evident that a great deal of work and preparation went into making this online meeting a success. Although there were obvious limitations, much of the meeting proceeded similarly to our in-person meetings. The following is a summary of the major decisions and votes at this meeting. Some of what is reported below is excerpted from a meeting summary provided to council members from APA. APA issued a lengthy policy/position statement addressing the COVID-19 pandemic. This COVID-19 statement recognizes the multi-pronged calamities of a global pandemic. The health crisis coupled with widespread anti-racism protests has resulted in a mental health crisis with a disproportionate impact on marginalized populations. APA CEO, Dr. Arthur Evans, spoke to the COVID crisis. He stated that this pandemic is syndemic and has exacerbated and highlighted the inequities in differential groups. The economic impact and fallout from the pandemic has a direct relationship to psychological distress and racial inequities and injustice. He quoted Dr. George Miller, APA president in 1969, challenging us to figure out how “we can give psychology away.” The resolution highlights the role of psychology, as the science of behavior, in efforts to help increase adherence to physical distancing, mask wearing, and handwashing. Noting the devastating number of hospitalizations and deaths from the coronavirus, the resolution points to the contributions of psychologists in addressing widespread stress, anxiety, depression, and hopelessness. It passed by an overwhelming 98.8% of the vote.

Fall 2020

OTHER COUNCIL VOTES In further action, the APA council: Voted on a bylaw change that would offer voting seats on the Council of Representatives to members of the Ethnic Minority Psychology Associations (EMPAs). The five EMPAs covered by the proposed bylaws amendment are the American Arab, Middle Eastern and North African Psychological Association, the Asian American Psychological Association, Association of Black Psychologists, National Latinx Psychological Association, and the Society of Indian Psychologists. This was the fourth time since 2007 that the council has addressed this question. The presenters of the motion cited the confluence of COVID, racial unrest, and deep-rooted health disparities affecting people of color in the United States in urging its passage. Because of the almost universal support for the proposed EMPA bylaws amendment, the council voted not to include pro and con statements when it goes to the membership. The bylaw amendment will, however, include an explanatory statement. The vote will be sent to membership in November. During its second day of meeting, the council voted unanimously to receive the Report of the Work Group on Enhancing Council’s Effectiveness as a Policymaking Body. The report outlines recommendations on how the council can more effectively carry out its role to direct and inform policy, and advance APA’s strategic priorities, through an inclusive and collaborative approach reflecting a wide range of perspectives. The council also revisited the issue of changing the bylaws to allow graduate students in psychology to vote in APA elections. An almost identical bylaw change passed council in August 2019, but fell 58 votes short of passing the full membership. After much debate surrounding whether these voting privileges should be reserved exclusively for doctoral level graduate students, the council passed the measure by 115 to 38, with 5 abstentions. This bylaw change would create a new membership category for master’s and doctoral students who, after a year as graduate student members,

would have the right to vote in the APA president-elect and board member-atlarge elections and the bylaw amendment and apportionment ballots. In the case of this proposed bylaw amendment, after considerable debate, the council voted to include pro and con statements, along with an explanatory statement, when it is sent to the full membership on November 2nd. I look forward to representing New Jersey at the next Council of Representatives meeting in February 2021 in Washington, DC, or virtually. Until then, I wish everyone good health and peace. ❖ Respectfully submitted, Rhonda Allen, PhD Council of Representatives (NJ) (2019-22)

E-Publication Decision for 2021 (One Year Commitment) On September 18, 2020, the NJPA Executive Board approved a motion to move from a print journal to an e-publication. Our Finance Committee is closely monitoring our financial health throughout the COVID-19 Crisis. It began with the governor’s Executive Order to shut down New Jersey in March, 2020. In preparation for 2021, the Finance Committee is reviewing all NJPA expenses and sources of income. One large expense is the publication of our journals and annual report. Due to the financial uncertainty, the Finance Committee decided to move to e-publications for 2021. NJPA consulted with the North Carolina Psychological Association (NCPA) who successfully transitioned to e-publications two years ago, using FlowPaper, which is a cloudbased software. The e-publication will allow for digital links, more visuals, as well as the traditional articles and the ability for members to download and print. This is a cost savings and a dynamic and interactive new way for members to engage with our association. NCPA testimonial: The digital newsletter is quite an upgrade from the printed version- it’s full color, has a magazine look and feel and advertisers love it because there are live links embedded for their respective companies.

SPECIAL SECTION

Introduction to support the emotional, behavioral, and educational needs of all individuals.

Salena Justice, MA NCSP

his section is intended to disseminate information regarding the implications of COVID-19 on the treatment of individuals with Autism Spectrum Disorder, Intellectual Developmental Disability, and other special needs. During such difficult and uncharted times, it is crucial that psychologists have the competence and understanding

We would like to thank the following authors for their contributions: Christina Galese, MS, Kristen Parente, BS, Keri Giordano, PsyD, and Adrienne Garro, PhD, who shared Supporting Students with Special Needs and Their Families During Remote Learning; Elisabeth G. Endrikat, PsyD, who contributed the Autism Spectrum Disorder (ASD) in Schools: Challenges Faced During COVID-19, and Preparing for the Return to School; and Wendy F. Aita, PhD, who authored Intellectual Developmental Disabilities and Impact of Comorbidity with Psychiatric Diagnoses,

Trauma, and Physical and Mental Health Vulnerability to COVID-19: Implications for Treatment. ❖ About the Author Salena Justice, MA, is a 5th year doctoral student in the combined School and Clinical Psychology Doctoral Program at Kean University. She is completing her doctoral internship this year at the Passaic County Technical Institute. Instructions for obtaining CE credit: Visit <www.psychologynj.org> and find the CE Homestudy Library link under the Learn Tab. Earn 3 CE for these three special section articles.

Intellectual Developmental Disabilities and Impact of Comorbidity with Psychiatric Diagnoses, Trauma, and Physical and Mental Health Vulnerability to COVID-19: Implications for Treatment

Wendy Aita, PhD What is IDD? evelopmental disability is defined as a severe, chronic disability of an individual that begins in childhood or manifested before the person reaches 22 years of age, is likely to continue indefinitely, results in substantial functional limitations, reflects a need for coordinated and continues specialized care, and is attributable to intellectual disability or related conditions that include cerebral palsy, epilepsy, autism, or other neurological conditions, affecting 1.2 to 1.65% of the United States population (Developmental Disabilities Act, 2000). In New Jersey, there are approximately 25,000 individuals identified as having a developmental disability (DHS, 2019).

Intellectual Disability (ID) is classified in the DSM-5 as a neurodevelopmental disorder. Significant changes were made to the definition from DSM-IV to DSM-5 secondary to a gradual shift in political and public perception. “Intellectual disability” in DSM-5 (American Psychiatric Association, 2013) replaces the term “mental retardation” used in the DSM-IV (American Psychiatric Association, 2000). Rosa’s Law (2010), signed into United States public law in 2010, also removed references to “mental retardation” in federal law and replaced them with “intellectual disability” reflecting efforts to use less stigmatizing language. DSM-5 criteria for intellectual disability includes three categories: significant limitations in intellectual functioning, limitations in adaptive behavior, and onset during the developmental period. Intellectual disability is categorized as mild, moderate, severe, or profound based on measured intellectual functioning and associated levels of functional impairment. The DSM-5 discourages

over-reliance on IQ scores and recognizes greater emphasis on adaptive behavior (APA, 2013). In the literature, the term Intellectual Developmental Disability (IDD) is used interchangeably with Intellectual Disability (ID). Comorbidity with psychiatric disorders Psychiatric disorders can affect persons of any age, race, religion, income, or level of intelligence. Between 30-40% of all persons with IDD are dually diagnosed with a psychiatric disorder (Cooper et al., 2007; Lunsky, Klein-Geltink, & Yates, 2013; NADD) and 10-20% have challenging behaviors (self-injury, aggression, destructive behavior) severe enough to impair daily life. Psychiatric disorders have been shown to be three to four times higher in individuals with IDD than individuals in the general population, and include illnesses such as major depressive disorder, bipolar disorders, anxiety disorders, impulse control disorders, personality disorders New Jersey Psychologist

and schizophrenia (O’Brien, 2002; Bradley et al., 2011). Severity of IDD is related to severity of psychiatric diagnoses (Myrbakk & von Tetzchner, 2008). Individuals with comorbid psychiatric diagnoses and IDD require a higher level of care than typical psychiatric patients due to the degree of medical complexity and need for supportive community care. Unfortunately many dually diagnosed individuals are misdiagnosed, receive ill-informed care, or no care at all. Accurate diagnosis is often impacted due to atypical symptoms of mental illness in individuals with intellectual disabilities, lack of providers with specialized training, diagnostic overshadowing and provider stigma. Diagnostic overshadowing occurs when certain behaviors, such as actions (i.e., agitation, aggression, low motivation) resulting from mental illness is attributed to the IDD (Robinson et al., 2012). Stigmatizing attitudes towards people with IDD appear to be present among mainstream health professionals due to lack of knowledge and exposure, stereotypic perceptions, and fear and anxiety (Pelleboer-Gunnink et al., 2017). Additionally, many psychotherapists doubt the ability of people with IDD to benefit from psychological treatment (Shankland & Dagnan, 2015). Along the same lines, antidepressants and anxiolytics are under-prescribed and antipsychotics are typically over-prescribed. For individuals with IDD, psychiatric disorders are classified by the DSM-5 and supplemented by DM-ID-2 (Fletcher et al., 2017) published by National Association for the Dually Diagnosed (NADD), an association for persons with developmental disabilities and mental health needs. NADD was established in 1983 for professionals, care providers, and families to promote the understanding of and services for individuals who have IDD and mental health needs. NADD collaborated with the American Psychiatric Association on the publication of Diagnostic Manual-Intellectual Disability (DM-ID) in 2007, and developed updated guidance in conjunction with DSM-5 by releasing DM-ID-2, a text guiding diagnosis of mental disorders in persons with intellectual disabilities. Vulnerability to Trauma People with IDD are at a significantly higher risk than neurotypical individuals to experience trauma due to their need for higher level of assistance from caregivers, higher level of stress on family or caregivers, Fall 2020

vulnerability to being taken advantage of, difficulty expressing themselves with words, and a lifetime of being trained to be compliant (Charlton et al., 2004). Statistically, people with IDD are 2.5 to 10 times more likely to experience abuse (Petersilia et al., 2001), and are more likely to be repeatedly abused with estimates that 49% of people with IDD will experience 10 or more incidences of abuse, and are abused for a longer period of time (Sobsey & Doe, 1991). Children with disabilities are almost two times more likely to be physically or sexually abused or neglected than children without disabilities (Abuse and Exploitation of People with Developmental Disabilities, 2020). It’s estimated that more than 90% of people with intellectual disabilities will experience some form of sexual abuse at some time in their lives (Balderian et al., 2013; Sobsey & Doe, 1991). Individuals with IDD may be at higher risk of developing PTSD compared to the general population (Breslau et al., 2005) secondary to a potentially reduced capacity to process information, including traumatic memories. A limited ability to communicate the trauma or limited social skills can lead to difficulty integrating the traumatic event and their emotional response that can result in aggression or behavioral dysregulation (Keesler, 2016). However, people with IDD typically have the same response to trauma as people in the general population (Charlton et al., 2004) including sleep disturbance, startle response, numbing, emotional constriction, disrupted sense of safety, etc. Trauma responses generally represent a change from the person’s normal level of functioning. People with developmental disabilities are less likely to recover spontaneously from trauma without treatment. Vulnerability to COVID-19 Although individuals with developmental disabilities experience significant healthcare disparities throughout their lifetime, they have a lower incidence of health promotion behaviors than the average population, due to many barriers to care (CDC, 2013). This vulnerability becomes more pronounced in the wake of the COVID-19 pandemic. The risk to this group is twofold: Physical health (increased risk of mortality and morbidity due to COVID-19) and mental health (increased risk of worsening mental health symptoms, increased risk of mental illness relapses, and increased challenging behaviors).

Physical Health: Early information on coronavirus disease 2019 (COVID-19) suggests that older adults and people with health conditions have a heightened risk of getting very sick. Researchers sought to determine the effects of COVID-19 on patients with intellectual and developmental disabilities as compared to patients without IDD and found that both groups had the highest percentage of cases between the ages of 18-74. However, when it came to children, those with IDD made up over 25% of all cases as compared to just 8% of children without IDD, and the case-fatality rate was 1.6% among those with IDD as compared to less than 0.1% of children without IDD (Turk et al., 2020). They found that individuals with IDD had a higher prevalence of comorbid circulatory, respiratory, metabolic and endocrine diseases across all age groups that may explain the higher fatality rate. For those living in a congregate setting, such as a group home, they are four times more likely to contract COVID-19 and almost twice as likely to die as compared to the general population (Turk, et al., 2020). While nursing homes have come under the spotlight, little attention has been paid to group homes. On March 13, 2020, the New Jersey Division of Developmental Disabilities (DDD, 2020) closed all Divisionfunded, facility-based day program settings, discontinued community outings, and withheld visitors from residential group homes. DDD has been compiling biweekly statistics on positive COVID cases on approximately 24,000 IDD adults in NJ. As of 8/9/20, there were 946 positive cases and 148 deaths (DHS, 2020). While the rest of us have been coping with sheltering in place, direct support professionals have been providing care in place as underpaid essential workers. Testing and safety protocols can be difficult for people with IDD: they may have difficulty reporting their symptoms and may not meet criteria for testing, transportation to a test site can be difficult due to limited staffing, and some individuals may be resistant to the nasal swabbing that is required, further impeding testing. There may also be behaviors that put them at higher risk for transmission such as touching one’s face, difficulty wearing a mask that is both a sensory and social challenge, and hearing or speech impairments making it harder to understand or be understood when wearing a mask. 13

Mental Health: During previous disasters the need for behavioral health services peak around six months after the event. The COVID-19 pandemic is a prolonged event that is still in the disaster phase and it’s difficult to predict what recovery will look like. The experience of stress negatively impacts the psychological well-being of adults with IDD, and this in combination with the likelihood of previous trauma results in higher vulnerability to mental health sequelae secondary to this pandemic. People with IDD may dramatically decompensate under stress, and stress level has been found predictive of current and future symptoms of psychopathology among adults with mild IDD (Hartley & MacLean, 2005; Hastings et al., 2004). Many individuals with IDD have limited verbal communication skills, difficulties understanding situational trauma with unfamiliar settings, low stress thresholds, and anxiety due to separation from known family members, friends, or staff. Similar to the impact of school closure on children with special needs, day programs in NJ have been shuttered since midMarch leading to social isolation, boredom, and changes in routine. Changes in routine can lead to increased anxiety, agitation, and acting out behaviors. There can be disruption in key staff changes or access to usual care providers. When there is a need for hospitalization, ‘No Visitors’ policies may result in detrimental outcomes due to vital medical and social information not being available to medical staff because the individual needs a historian and advocate present. Additionally, fear and anxiety may lead to non-compliance with medical procedures or increased use of sedatives. Many adults with IDD are being cared for in the community by aging parents who are vulnerable to severe complications from COVID-19 infection and many are coping with loss and grief. Families struggle to care for individuals with dual diagnosis and many report they are unable to find providers who will treat their family member with IDD. Caregivers are also suffering from lack of respite, stress over no visit policies, and concerns over what would happen if they get sick or die and who would care for their child. Mental Health Intervention and Resources Until the 1990s, people with IDD were treated almost exclusively by medication, behavioral modalities (ABA), and hospitalization. People with IDD can participate in and 14

benefit from therapy (Mansell et al., 1998), in fact many different types of therapy have been found to be effective in treating people with developmental disabilities including mindfulness, CBT, and Dialectical Behavior Therapy (DBT), requiring only minor adaptations (Flynn, 2012; Robertson 2011; Jahoda et al., 2017; Crossland et al., 2017; Charlton & Dykstra, 2011; McNair, et al., 2017). Approximately one third of adults with IDD have emotion dysregulation difficulties. When autism spectrum disorder is also present with IDD, mood dysregulation may be exacerbated by communication difficulties, hypersensitivity to sensory stimulation, and cognitive inflexibility (Bakken et al., 2016). People with intellectual disability may be prone to difficulties with mood regulation due to poorly developed socialization and coping skills. Clinicians should carefully examine environmental, medical, and/or pharmacologic causes for mood outbursts, as well as other triggers for dysregulated mood, such as interpersonal conflicts, unwanted task demands, and physical pain and discomfort. Behavioral dysregulation is an important target for effective intervention, as well as providing trauma informed care and understanding that behavior is a form of communication. DBT (Linehan, 1993) holds particular promise in effectively reducing emotional dysregulation. The Skills System (Brown, 2011) is a modified emotion regulation skills curriculum designed for individuals with IDD including strategies to build mindfulness, interpersonal effectiveness, emotional regulation, and distress tolerance capacities. Additionally, active coping and problem-focused coping during stressful situations has been found helpful to decrease psychological distress for adults with mild ID (Hartley & MacLean, 2005). Unfortunately, there are few psychologists treating this population in NJ. Few graduate programs offer any courses or specializations in working with those with intellectual disability and, although many professionals deny stigma toward those with IDD, they continue to believe that people with IDD don’t have mental illness or can benefit from counseling. The best treatment plans are derived from a comprehensive multidisciplinary diagnosis and assessment including biological, psychological, and social factors. Medical conditions and dental pain are often underdiagnosed and can mask as behavioral problems.

Psychotherapy requires adaptation and flexibility from the therapist. A psychologist helps to interpret behavior by listening and putting words to what is said non-verbally. Some general guidelines for therapy include assessing the person’s language skills and adapting your language, scheduling brief and more frequent sessions to help with attention challenges and allow for a relationship to develop, longer treatment length to allow for repetition and generalizing skills, utilizing a direct approach and modifying interventions to the person’s abilities, asking permission to communicate with collaterals, and being supportive. Developing rapport and trust is very important due to history of trauma or being treated badly. Be aware of acquiescence – many individuals with IDD like to please and will nod as if they agree when they may not understand your vocabulary. Most importantly, always talk to the individual, not about them to others without permission, and treat them with the respect of any other adult within your care. Further information and training can be found on the NADD website (www.theNADD.org) and through the Boggs Center on Developmental Disabilities; New Jersey’s University Center of Excellence in Developmental Disabilities, Education, Research and Service (https:// rwjms.rutgers.edu/boggscenter/). Specific to the current pandemic there are several immediate needs for intervention. Coping with stress during a pandemic is difficult for everyone, and those with IDD are particularly vulnerable to this stress. Fear and anxiety about a new disease and public safety precautions can be overwhelming and cause strong emotions. Changes in routine and social distancing can make people feel isolated and lonely and can increase stress and anxiety. Encourage the person with IDD to cope with this stress by controlling what they can, staying away from media reports, staying connected through social media, and maintaining a consistent routine. Specific examples and assistance may be necessary. There is a COVID-19 Self-help Booklet Series for people with intellectual disabilities and can be used with the support of family members, friends, staff, and health care professionals. They can be found at <https://www.camh.ca/covid19booklets>. Grief counseling for COVID-19 related losses may also be necessary. Adults with IDD may be particularly vulnerable to maladaptive grief reactions due to previous traumatic losses, such as being placed outside the home, early separation from caregivers, New Jersey Psychologist

loss of staff due to frequent turnover, and loss of personal freedoms (Gaus et al., 1999; Whitehouse et al., 2006). Additionally, many social stories are available that explain changes related to COVID-19, need for wearing a mask, COVID-19 testing, and social distancing. Social stories are narratives made to illustrate certain situations and problems and how people deal with them. They are used to share information, educate, prepare, and reduce stress for individuals with Autism or other IDD. Several can be found at <https://www.covid19.autism-society.org/>. Finally, many individuals with IDD have difficulty wearing required masks due to sensory issues, discomfort, or even

fear of seeing others wearing a mask. Most research on treating medical fears among people who have IDD have utilized in vivo exposure paired with other behavioral techniques, such as stimulus shaping, positive reinforcement, and modeling (Conyers et al., 2004; Shabani & Fisher, 2006; Gillis et al., 2009; Cuvo, Reagan, Ackerlund, Huckfeldt, & Kelly, 2010). These same strategies, combined with Occupation Therapy exercises to introduce the uncomfortable sensation and provide proprioceptive input can make mask wearing more tolerable. ❖

the Rowan Integrated Special Needs (RISN) Center in Sewell, NJ, as well as clinic coordinator for the Rowan Center of Excellence for Fragile X Treatment and Research. She is an Assistant Professor in the Department of Psychiatry at Rowan School of Osteopathic Medicine and the Department of Psychology at Rowan University. Her specialization is treating individuals with disabilities and their caregivers, and conducting research into trauma and techniques for improving access to medical procedures. References Furnished Upon Request.

About the Author Dr. Wendy Aita is a licensed psychologist, and co-director and Behavioral Health Lead at

Autism Spectrum Disorder (ASD) in Schools: Challenges Faced During COVID-19 and Preparing for the Return to School

Elisabeth Endrikat, PsyD Lack of Services Pre-COVID-19 ew Jersey has the highest rate of children with Autism Spectrum Disorder (ASD) in the United States. In New Jersey, 1 in 32, or 3.1%, of children are diagnosed with ASD compared to the national average percentage of 1.85% (Maenner et al., 2020). Additionally, Caucasian children are 1.3 times more likely to be diagnosed with ASD than African American children and males are four times more likely to be diagnosed than females (Maenner et al., 2020). Among children diagnosed with ASD, 24.6% were diagnosed as also having an Intellectual Disability (ID; Maenner et al., 2020). Parents of children with ASD faced unique challenges daily. Seltzer et al. (2010) found mothers of children with ASD experience similar chronic stress levels to parents of children with cancer, combat soldiers, Holocaust survivors, and individuals suffer-

Fall 2020

ing from PTSD. They also experience high levels of depressive symptoms (Abbeduto et al., 2004). In New Jersey, children attend school a minimum of 180 days for five and a half to seven hours per day, excluding additional time for extracurricular activities and sports (New Jersey Department of Education, n.d.). The New Jersey Department of Education (2018) reported 241,047 children receive special education making up 17.66% of the school-age population. Among students receiving special education, 22,251 or 1.63% were classified as “Autistic” and 5,393 or 0.40% were classified as “Intellectually Disabled” (New Jersey Department of Education, 2018). School psychologists have specialized training in education, behavior, and mental health models, research, and evidence-based interventions making them the ideal service provider to meet the needs of children with ASD in schools (National Association of School Psychologists, 2015). School psychologists are also familiar with family systems theory that assists them in facilitating collaboration between families, schools, and community agencies (National Association of School Psychologists, 2020a). Behavioral and mental health services provided in

school eliminate barriers, such as transportation to private providers and insurance or out-of-pocket fees (Eklund et al., 2015). Schools are the main source of behavioral and mental health services for many children, but barriers exist limiting access (Villarreal, 2018). The National Association of School Psychologists (NASP) recommends a ratio of 500 students per school psychologist, and an even lower ratio for school psychologists working primarily with populations that have more significant special needs, such as children with ASD (National Association of School Psychologists, 2020a). An average ratio of 731 students to one psychologist has been reported in New Jersey (United States Department of Education, 2018). There is a shortage of school psychologists in New Jersey because of a deficit in the number of positions, as well as an insufficient quantity of qualified school psychologists (American Association for Employment in Education, 2016; National Association of School Psychologists, 2016). School psychologists also experience a lack of time to provide behavioral and mental health services due to special education mandates, monitoring student academic performance, and perceived lack of support from school 15

administration (Eklund et al., 2017). The increasing school psychologist to student ratio and school psychologist shortages pose significant threats to children’s ability to access behavioral and mental health services in schools (National Association of School Psychologists, 2017b). Challenges Presented by COVID-19 On March 9, 2020, Governor Phil Murphy (2020d) declared a State of Emergency and a Public Health Emergency in New Jersey. The State of Emergency remains until the governor rescinds, but the Public Health Emergency expires after 30 days unless renewed. Governor Phil Murphy (2020e) extended the Public Health Emergency on April 7, 2020; May 6, 2020; June 4, 2020; and July 2, 2020. Governor Phil Murphy (2020c) ordered statewide school closures beginning March 18, 2020 and to remain closed as long as the Order remains in effect. On May 5, 2020, Governor Phil Murphy (2020b) extended statewide school closures through the end of the 2019-2020 academic year. School closures have added additional challenges, stress, and responsibilities for parents of children with ASD. The State of Emergency, Public Health Emergency, and school closures in New Jersey have caused disruptions in daily routines. This inconvenience for typically developing individuals can cause significant anxiety and distress for children with ASD due to their unique personality characteristics. One of the core diagnostic criteria for ASD in the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5) is “restricted, repetitive patterns of behavior, interests, or activities” (American Psychiatric Association, 2013, p. 50). This can be manifested by “insistence on sameness, inflexible adherence to routines, or ritualized patterns of verbal or nonverbal behavior” (American Psychiatric Association, 2013, p. 50). For example, individuals with ASD may experience “extreme distress at small changes, difficulties with transition, rigid thinking patterns, greeting rituals, need to take the same route, or eat the same food every day” (American Psychiatric Association, 2013, p. 50). Such personality characteristics make it difficult for children with ASD to adapt to the new norm. As a result, many parents reported anxiety and aggressive behaviors (SPARK). Parents also reported increased difficulties in managing their children’s daily activities, both structured and unstructured (Colizzi et al., 2020). 16

The State of Emergency, Public Health Emergency, and school closures in New Jersey have also resulted in social isolation for many individuals and children with ASD are at greater risk due to predisposed traits. Another core diagnostic criterion for ASD in the DSM-5 is persistent deficits in social communication and social interaction manifested by deficits in social-emotional reciprocity, nonverbal communication behavior used for social interaction, and developing and maintaining relationships (American Psychiatric Association, 2013, p. 50). For example, children with ASD experience great difficulties appropriately initiating and maintaining a conversation that can result in a lack of friends (American Psychiatric Association, 2013, p. 50). Children with ASD also experience great difficulties understanding and using body language (American Psychiatric Association, 2013, p. 50). Face coverings and the requirement to physical distance can make this even more difficult for children with ASD. Schools are filled with natural settings that encourage peer communication and socialization, such as the classroom, cafeteria, and playground. They also contain the necessary providers to implement social skills interventions: school psychologists, speech language pathologists, teachers, and same-aged peers. School-based social skills interventions have been found to increase the frequency and duration in which students with ASD communicate with peers (Sutton et al., 2019). They can be provided individually or in a group. Social skills groups are the most widely used approach (McMahon et al., 2013). They are also found to be effective (Rose & Anketell, 2009). Remote learning, face coverings, and physical distancing has cost children with ASD these natural opportunities to improve social and communication skills. Virtual services can help maintain a routine and encourage socialization. On April 1, 2020, the State Board of Education adopted temporary modifications to the New Jersey Administrative Code for Special Education, Title 6A, Chapter 14-Special Education that governs the provision of special education and related services to students with disabilities (McDonald, 2020). Temporary regulations allowed schools to utilize telehealth, telemedicine, electronic communications, remote, virtual, or other online platforms to deliver special education and related services to students with disabilities (McDonald, 2020). Prior

to the board’s actions, schools were not allowed to provide related services to students with disabilities using telehealth, telemedicine, electronic, online, or virtual platforms (McDonald, 2020). As a result, between March 18, 2020 and April 1, 2020, at minimum, children with disabilities lost access to special education and related services including, but not limited to, counseling, occupational therapy, physical therapy, medical services, and speech-language services as a result of school closures in New Jersey. This will undoubtedly result in regression and recoupment for children with disabilities as parents report most support services are delivered in schools (Colizzi et al., 2020). Extended School Year (ESY) provides special education and related services beyond the regular school year for students with disabilities, such as ASD and ID, who experience significant regression and recoupment when there is an interruption in educational programming (Special Education, N.J.A.C. 6A:14., 2016). On June 12, 2020, Governor Phil Murphy (2020a) announced that modified in-person, or a combination of remote and in-person, ESY could, but were not mandated to, begin on or after July 6. This announcement came too late for schools to appropriately plan for the health and safety of students, especially those with significant special needs. As a result, the majority of ESY special education and related services were provided remotely and children with disabilities continued missing out on the in-person services they desperately needed. Regardless, our children, families, and colleagues need help, and because we are unable to provide one-on-one services inperson, we need to do our best to provide them within the limitations imposed by COVID-19 (National Association of School Psychologists, 2020b). Telehealth allows services, such as counseling, to be provided virtually by phone call, email, and video platform. Consultation through telehealth also provides greatly needed assistance to parents and teachers and its effectiveness has been supported (Fischer et al., 2017). Although telehealth dates back to the early 1900s, minimal research on its effectiveness in providing direct services to children with ASD exists (National Association of School Psychologists, 2020c). In the majority of studies, telehealth recipients are parents and teachers (Sutherland et al., 2018). Only one, single subject case study New Jersey Psychologist

exists limiting generalizability (Boisvert et al., 2012). Boisvert et al. (2012) provide support for telehealth as an effective method of service delivery for children with ASD as measured by Individualized Education Program (IEP) goals and objectives. Overall, major concerns regarding confidentiality and privacy exist (National Association of School Psychologists, 2017a). While telehealth to provide related services has been encouraged, it has been discouraged in administering standardized assessments. Common assessments, such as the Wechsler intelligence scales and the Woodcock-Johnson IV (WJ IV) system, have not been standardized for telehealth administration questioning the reliability and validity of results. Q-interactive is an in-person virtual administration and scoring program, but should not be confused with virtual delivery through telehealth (Pearson, n.d.). Although interviews and rating scales could be conducted through telehealth, children’s behavior during crises do not provide a true representation of typical functioning. The decision to evaluate should always be based on the best interest of the child and their individual needs. Regardless of the ability to provide services via telehealth and the research available, 63% of parents with children with ASD reported severe disruptions in related services due to COVID-19, reporting speech therapy to be the most disrupted (Chung, 2020). Of related services disrupted, 84% were provided in schools (Chung, 2020). These disruptions in related services negatively impacted 95% of children with ASD’s behavior and 82% of their mental and emotional health (Chung, 2020). Some parents felt responsible for tasks that a team of providers normally assisted their child with (Chung, 2020). This has resulted in 97% of parents reporting feeling stressed or overwhelmed due to disruptions in their child with ASD’s services and 95% of parents reporting that COVID-19 has negatively impacted their mental health (Chung, 2020). Overall, only 35% of parents reported receiving telehealth and, of these families, only 43% report benefitting moderately well to significantly (Chung, 2020). As we prepare to begin school this fall, whether it be full-time remote, full-time in-person, or hybrid, these statistics are alarming. Preparing for the Returning to School Transitioning back to school will be a difficult task as the majority of children Fall 2020

have been out of school since early March, 2020. This is approximately six months in comparison to the usual two-month summer break. Numerous organizations have proposed school re-entry guidelines. Such documents focus on the physical health and safety, education, behavioral and emotional support, staff needs, and family communication of children, in general, but have failed to address special needs populations, such as children with ASD. The following are additional considerations and recommendations for school re-entry of children with ASD. The earlier and more intense the application of interventions, the better the outcome (Lovaas, 1987). Upon return to school, meetings will need to be held with parents and IEP teams to review and revise IEPs. Compensatory education and related services may be necessary. Educational and related service goals and objectives that were in place prior to school closures and during remote learning may no longer be relevant. For example, coping strategies may be more crucial than previous academic difficulties (National Association of School Psychologists, 2020b). To meet health and safety standards, in-person evaluations will require the use of PPE (personal protective equipment) and other modifications, depending on the measure being administered. This threatens reliability and validity and increases measurement error as instruments were not standardized this way (Allen, 2020). When evaluating children with ASD, reports should include this information. Other factors that may impact results of standardized achievement and cognitive measures include additional social and emotional factors caused by COVID-19, such as level of distress and current circumstances, as well as regression and recoupment (Allen, 2020). Most importantly, service providers need to be flexible as guidance from district, state, and US Department of Education guidelines continue to change almost daily. Behavioral interventions for children with ASD has been long supported in the research. Many employ the use of operant conditioning that increase behaviors through reinforcement and decrease them through punishments (Kazdin, 2000). Positive reinforcement interventions involve the addition of a desired stimulus following a behavior while negative reinforcement interventions involve the removal of an unpleasant stimulus following a behavior both with the intention of increasing that

behavior. However, positive reinforcement has proven to be more effective than negative reinforcement that often achieve the same behavioral goals (Zager, 2004). Positive reinforcement interventions are highly individualized and typically include tangible reinforcers (e.g., desired objects or activities) or token economy systems (Zager, 2004). Chaining can then be used to reinforce behaviors occurring in a sequence to form a more complex behavior. Parents and providers can use social stories to teach appropriate behaviors. Social stories are short, individualized stories of specific situations, skills, or concepts (Gray, 2010). By answering “wh” questions, the goal of social stories are to share accurate information and help children understand the expectations of specific situations, skills, or concepts and their expectations (Gray, 2010). For the child to relate, they must be tailored to the individual’s preferences, talents, and interests (Gray, 2010). Social stories are one of the primary interventions to assist children with ASD in understanding what is going on around them, transitions, coping with anxiety, and sensory sensitivities (Aldabas, 2019). There are not any negative side effects associated with social stories and they also demonstrate long-term effects (Aldabas, 2019). Social stories and operant conditioning can be useful in the transition back to school. Only 42% of families report their child with ASD understands information related to COVID-19 moderately well to completely (Chung, 2020). Social stories can be used by parents and service providers to share information regarding COVID-19 and help children understand the health and safety guidelines for returning to school. Operant conditioning and chaining can also be used to assist with face coverings as they are required in New Jersey when indoor public places, such as schools, and outdoors when social distancing is not possible. Children with ASD can experience hyper- or hyporeactivity to sensory input (DSM-5). Children can first be rewarded for holding the mask, then for touching the mask to their face, then for placing the straps over their ears, and then for keeping the mask on for a specified amount of time. Students in New Jersey are eligible for full-time remote learning when schools reopen in the fall opposed to the in-person or hybrid options schools offer (New Jersey Department of Education, 2020). Some 17

parents of children with ASD may choose this option as some found remote learning to be beneficial reporting their child experienced less anxiety and that it allowed for a slower pace of instruction (Chung, 2020). Regardless of family decisions, as we navigate this “new normal,” children with ASD, their parents, and service providers will need additional support throughout the transition. It is inevitable that we will encounter many situations that will not have

solutions. Parents and service providers will need to collaborate to monitor, problemsolve, and modify interventions to help children with ASD be successful. These lessons we learn from COVID-19 will better prepare us for future State of Emergencies and Public Health Emergencies. It also highlights the importance of maintaining contact with school during emergencies as parents receive most support services from schools (Colizzi et al., 2020).❖

About the Author Elisabeth Endrikat, PsyD currently assumes the role of school psychologist and Child Study Team (CST) leader at the Freehold Township High School. She is also a New Jersey licensed psychologist. References Furnished Upon Request.

Supporting Students with Special Needs and Their Families During Remote Learning Christina Galese, MS, Kristen Parente, BS, Keri Giordano, PsyD, Adrienne Garro, PhD Kean University Abstract Among the sweeping societal changes brought on by the COVID-19 pandemic was the unprecedented change to the way children receive education, with remote learning turning homes into classrooms for an estimated 55 million children. Children with disabilities are at increased risk for educational deficits resulting from onlinebased learning platforms. Psychologists play multifaceted roles in facilitating appropriate educational services for children with special needs. This article focuses on ways that psychologists can support elementary student populations with learning disabilities, attention deficit hyperactivity disorder, anxiety disorders, and autism spectrum disorders and their families during times of remote learning. The impact of the novel coronavirus (COVID-19) has pervaded almost every aspect of living on a global scale: healthcare systems have seen tremendous overload, family dynamics have shifted, and activities of daily living (e.g. food shopping, employment) have been thoroughly disrupted. In addition, this unprecedented event has had a tremendous effect on schools, as an estimated 55 million students and their teachers experienced historic upheaval from their educational settings and were required to transition to remote learning (Coronavirus and School Closures, 2020). Given the unprecedented nature of nationwide remote learning, the direct impact of COVID-19 on students’ acquisition of academic skills is not yet fully understood; yet, the National Association of School 18

Psychologists (NASP, 2020) suggests it can be assumed that students lost approximately 25% of content from their prior grade’s curriculum. Students with special needs, such as neurodevelopmental challenges, learning disabilities, and anxiety-related issues, are at a greater risk of falling behind their peers academically, missing out on special education and related services, and struggling with social and emotional functioning (Camera, 2020). The lack of individual support and school-based management strategies, combined with the challenge of implementing accommodations included in Individualized Education Plans (IEPs) likely hindered academic progress even more so for students with special needs. Although many educational systems adapted admirably to the seemingly insurmountable challenges inflicted by COVID-19 and were able to educate students through the end of the school year, it is imperative to acknowledge the effects on children as a result of the unanticipated deviation from typical school settings and routines. Moreover, these effects need ongoing consideration as students enter a new school year, particularly among students with special needs who require academic and/or social-emotional support. With respect to prevalence of these students, it is estimated that 5-8.4% of children have attention-deficit hyperactivity disorder (ADHD; American Psychological Association [APA], 2013; Danielson et al., 2018a), and, of these students, over 80% have received school-based educational support (Danielson et al., 2018b). Likewise, specific

learning disorders (SLDs) impact roughly 5-15% of all students (APA, 2013), and approximately 33% of students receiving accommodations under IDEA in the 2019 academic year had a SLD (Students with Disabilities, 2020). Recent research on the prevalence of autism spectrum disorder (ASD) among school aged children suggests that one in 54 children meet criteria for diagnosis based on the Diagnostic and Statistical Manual--Fifth Edition (DSM-5), with a rate that is 4.3 times higher in boys than girls (Maenner et al. 2020). Additionally, although prevalence rates of anxiety disorders vary, they are considered the most common class of psychological difficulties for children (Cartwright-Hatton et al., 2006). Early research has focused on supporting the post-secondary general education population in adjusting to remote learning during COVID-19 (Institute of Education Sciences, 2020) and some preliminary recommendations to facilitate online learning have been distributed by the APA (McEntarffer, 2020); however, less information has been directed at elementary students and children with special needs. As such, this paper aims to provide recommendations as to how psychologists can help families and school systems support young students with special needs as they continue their education during the uncertainty of COVID-19. Implications of Remote Learning As the school year approaches, school districts are tasked with developing plans for continuing education while also proNew Jersey Psychologist

tecting the health of students and staff. As part of these plans, many students will be participating in remote learning, either full or part time. As such, it is imperative that the needs of students with disabilities or behavioral and/or academic challenges are addressed in this context. Emerging literature suggests that during remote learning, students with ADHD struggled to keep themselves and their materials organized, plan for long-term assignments, sustain their attention during virtual classes, minimize errors, and turn in assignments in a timely manner (Cortese et al., 2020). Further, students with anxiety-related disorders may have exhibited an increase in symptoms. For instance, literature suggests students with contamination-related pediatric obsessive-compulsive disorder (OCD) may show increases in obsessive thinking due to concerns about contracting the coronavirus and, thus, exhibit increased hand-washing compulsions (Tanir et al., 2020). It is important to note that the impact of remote learning has not been all negative, as children with social anxiety may have experienced less distress due to the reduced social stimulation present in online learning environments. For children with ASD and their families, the abrupt, unexpected transition to online learning may have been extremely difficult, as students with ASD often demonstrate resistance to change, intolerance of uncertainty, changes in sleep patterns, and difficulties with communication and peer relationships (Nuske et al., 2018; Veatch et al., 2017). What Role Do Psychologists Play? Given the wide range of changes and challenges described above, there are a number of ways for psychologists to facilitate positive outcomes for students as they continue to navigate the educational transitions associated with COVID-19. Psychologists can consult with teachers and families, emphasizing preventionbased strategies and providing guidance for addressing unique challenges posed by remote learning. Universal design is key, as strategies designed to support one student will also likely have a positive impact on others. One example of this type of universal strategy is to help teachers and parents use brief antecedent writing exercises (Park et al., 2013) Such exercises involve verbally validating the stress and anxiety students may be experiencing while having the students write about their feelings that can Fall 2020

help students counter anxiety about remote learning, online classwork, and the inherent uncertainty related to the pandemic. Psychologists can help parents and teachers organize some general healthy strategies that will reduce stress and promote better learning. As an example, because students with ADHD, Autism, and other disabilities often benefit from breaks in classroom instruction, this principle can also be applied in the online environment. Breaks can be active, for example 5, 4, 3, 2, 1 energizers (e.g., five jumping jacks, four pushups, etc.) or more quiet, such as mandala coloring. Movement activities can be beneficial for children with autism or ADHD, since they help increase focus (Mahar et al., 2012), and mindful coloring activities have been shown to reduce anxiety (Carsley et al., 2015). Having several activity options available and allowing children to pick out of a hat can also be motivating. Psychologists can provide information to families about maintaining routine, especially surrounding sleep and wake cycles, as children transition back into school schedules. Opportunities for healthy eating and snacking can also be incorporated into online learning routines, and psychologists can recommend creative strategies in this area, such as using cookie cutters to make lunch sandwiches or building dessert skewers with fruit and yogurt or chocolate dip. Healthy snacks can help replenish students’ cognitive energies, as decreases in memory and attention have been found two-to-three hours post-breakfast (Wesnes et al., 2003). Psychologists can also assist parents and teachers with the implementation of mindfulness practices that help students pause, reflect, and engage in self-regulatory behaviors. Research suggests that mindfulness strategies are beneficial to students with anxiety, ASD, and ADHD and their families, as helping parents to learn and lead brief mindfulness practices may be beneficial to both their own well-being and the child’s, reducing stress and anxiety and providing an increase in self-compassion (Benn et al., 2012; Fuchs et al., 2017; Jones et al., 2018). Mindfulness exercises for younger children should focus on tangible experience in the moment, with body scans and sensory exploration as examples. Age appropriate and brief practices like dance breaks, yoga, sign language or other movements can be simple, short interventions to increase focus and decrease feelings of stress

(Mulvahill, 2020). Parents can also partake in these breaks, allowing for bonding and enjoyment of the process. Psychologists can be particularly helpful in supporting teachers and parents in modifying behavior during times of remote learning. During this time, disruption of learning routines, inconsistency in schedules (especially for students attending school on a hybrid schedule), and lack of individualized attention and support can cause an increase in undesired behaviors. Positive reinforcement strategies are known to be an effective tool in working with students who have ADHD, autism, and other disabilities. Under the circumstances of COVID-19, such strategies need to be adapted to include online modifications. For example, teachers can write individualized, private messages to students via their platform’s chat feature to reinforce desired behavior (e.g. keeping focused on the screen, staying in their seat, etc.; Kern & Clemens, 2007). Alternatively, parents can provide a token in a jar for every 5-10 minutes that students stay seated, focused on the content, and actively engaged in learning activities. Praise should be specific, and focus should be on effort (Hawkins & Heflin, 2011) rather than accomplishment (Burnett, 2001). Students may then receive a tangible reward at home for exhibiting a certain level of desired behavior consistently. Families should also develop and stick to a structured routine. Having the student plan out their upcoming day the night before and develop a schedule may help them anticipate what is expected of them, facilitate transitions, and encourage independence; students benefit from self-management practices that allow them to plan out their work, evaluate and reflect on their work, and determine adjustments (Martin et al., 2003). In addition to behavior modification, psychologists can suggest educational interventions to help support student learning. Psychologists should encourage families to review their child’s IEP or 504 plan, and ask school personnel how the plan will be modified for the online learning environment. Instructional adaptations, such as having time built into classes for reflection on class material, rephrasing of information, and thought-provoking discussion, can help keep students engaged and reinforce newly learned material (McEntarffer, 2020). Downloadable/printable graphic organizers should be provided for written work, with 19

free downloads available through popular sites such as Pinterest, or dedicated sites such as Understood.org or Studenthandouts.com. Students should be encouraged to complete assignments via cloud-based platforms such as Google Docs, as doing so allows the teacher to enter the document, track progress, and answer any questions students may have in real time. For parents concerned about supplementing education, they can incorporate educational opportunities into their daily routines. For instance, baking with a child reinforces reading and math, going on walks can factor in science, social studies, and engagement with their community, and creating a bedtime routine that includes 15 minutes of reading can promote better sleep by disengaging with technological devices. Parents can have children help solve daily problems around the home (e.g. “we have three cookies and six people in our family. What do we do?” or ask children to rearrange dishes in the dishwasher to fit the most dishes inside). Other creative and engaging ways to promote organization and sequencing, as well as conceptual story-telling, could be by creating a comic book, where the student can draw frames of the story, include thought or speech bubbles, and then tell the story to parents, siblings, or friends. Children participating in remote learning are essentially working from home. In accordance with this, psychologists can help parents establish productive working environments for their students. Similar to adults working from home, students should maintain their routines, including getting dressed in the morning and work in a consistent, clutter-free space. Boundaries must be drawn between when children are in school and when they are not; this can be done by setting aside a specific place that is only used during school hours or hanging large signs indicating that it is “school” or “home” time. Parents working from home can model behavior, explaining how they are navigating the changes to their routine, adapting to their use of technology, and managing their stress (Dragnić-Cindrić & Greene, 2020). Parents and children can generate a list of activities that must be completed that allows children autonomy and choice, while maintaining enough structure so children can focus on school tasks for extended stretches of time (Korb, 2020). Recognition of positive choices and praise will help to reinforce these behaviors. During this time of physical distancing, 20

finding ways to promote social relationships is especially important. Social-emotional learning is imperative to student success, as development in these areas relates to students’ attitudes and behavior; specifically, social-emotional development has demonstrated reductions in externalizing behavior and conduct problems, decreases in internalizing behaviors, and improved academic performance (Durlak et al., 2011). Encouraging students to maintain social relationships through letter writing, email, or text contributes to developing written expression skills and also reinforces positive social interactions. Group projects can be adapted to the online format that encourages students to work together and gives students opportunities to exercise their social-emotional skills (Corso, 2007). Parents can set up virtual or outdoor, distanced playdates to help children maintain their friendships. Structured activities with planned opportunities for interaction, such as an online cooperative game, an outdoor karate or yoga class, or Lego building where each child creates a piece of a larger creation (without sharing materials), can help keep children calm and distanced. Psychologists can also assist parents with determining boundaries in terms of their role as a parent versus teacher, as this is imperative for parental well-being and student progress. Parents may feel pressure to teach their children concepts and become frustrated, increasing the potential of completing their child’s assignments to lessen the burden of online schooling. However, this is ultimately a detriment to the student, as the teacher will be unable to evaluate the student’s progress and make determinations around appropriate support. If children do not understand concepts, parents should communicate this to the teacher, or, if the child is old enough, teach the child how to do so. Psychologists can also remind parents of the value of self-care, especially during these times of uncertainty and stress. Some quick suggestions for self-care include meditation breaks (Headspace is a good app for this), getting outside daily, making time for hobbies, by either introducing children to these hobbies or helping children try new hobbies during this time, taking a time out by setting a timer for 5-10 minutes during which children can only interrupt if there is an emergency, this should be followed by a favorite activity for the child, and maintain social contact, through virtual happy hours, online group

texts, or go for a walk while Facetiming a friend (Connery, 2020). Finally, as long as basic needs are met, parents should be encouraged to lower some expectations. For example, a parent who formerly had strict rules regarding the amount of screen time for their child may now find that by loosening these rules a little, they are able to find a few minutes to engage in self-care activities. Ultimately, adults cannot be expected to fully meet the needs of children if their own needs are being neglected. Conclusion In conclusion, although there are many unknowns regarding what schooling will look like this school year, it is clear that many children will receive at least part of their education in virtual learning environments. Psychologists play a vital role in helping ensure that schools and families are adequately supporting children with special needs, regardless of the teaching format. As is often the case, planning ahead and being proactive can contribute to better outcomes for all. While we may be facing unprecedented times, psychologists have the skills needed to help support children and families as they navigate the complexities of meeting learning and psychological needs in a virtual environment. About the Authors Christina Galese is a doctoral student in Combined School and Clinical Psychology at Kean University. Her research interests include the efficacy of mindfulness-based practices for elementary and adolescent students. Kristen Parente is a doctoral student in Kean University Combined School/Clinical PsyD program. Her research explores risk and resilience factors, and health outcomes in marginalized child and adolescent populations. Dr. Keri Giordano is an assistant professor in the Advanced Studies in Psychology department at Kean University. She specializes in supporting the mental health needs of infants and young children. Dr. Adrienne Garro is an associate professor in the Department of Advanced Studies in Psychology at Kean University and is the program coordinator for the School Psychology Professional Diploma Program in this department. She is also a licensed psychologist in New Jersey and Pennsylvania. References Furnished Upon Request. New Jersey Psychologist

Challenges, Changes, and Recommendations in Providing Neuropsychological Assessment and In-Patient Evaluations During the COVID-19 Pandemic

Jared B. Hammond, MA

Kelly A. Kearns, PsyD Acknowledgement: The authors would like to express gratitude for the support and guidance of Dr. Jon DeLuca in the development of this manuscript. Introduction Neuropsychology is a complex and specialized discipline within the field of psychology that focuses primarily on brainbehavior relationships. It is grounded upon multiple foundations of neuroanatomy, neuropathology, neuroscience, behavioral neurology, cognitive psychology, developmental psychology, and neurodiagnostic techniques (APA, 2010; Stebbins, 2007). Neuropsychology, the first specialty recognized by the American Psychological Association (APA), is distinct from other disciplines of psychology given the advanced training, understanding, and utilization of psychometric constructs and assessment measures in order to facilitate diagnostic discrimination, advise treatment, and provide recommendations (Bowler & Lezak, 2015; Hammond & Brooks, 2018). Given that neuropsychologists receive such advanced training in psychometrics, assessment, and diagnostic discrimination, this makes them exceptional candidates to treat individuals with complex medical and psychological issues. This has made neuropsychologists indispensable in the medical and rehabilitation systems. Within the brain injury unit of an acute inpatient physical medical rehabilitation center on the East Coast, neuropsycholoFall 2020

gists are often consulted for neurological conditions with various cognitive sequela. General conditions for evaluation often include, but are not limited to, anoxia, dementia, stroke, traumatic brain injury, brain tumor, encephalopathy, and patients with severe disorders of consciousness. However, all this changed in mid-March of 2020, when the COVID-19 pandemic struck the US with full force. The novel coronavirus quickly presented challenges and changes to the field of neuropsychology. The purpose of this manuscript is to reflect how we were able to overcome these challenges, begin neuropsychological evaluation days after the world came to a stop, and share implications for the future, particularly within the adult in-patient rehabilitation setting. Challenges and Changes The immediate challenges of providing neuropsychological assessment to the inpatient population became evident quickly. With the news of the novel coronavirus having made its way to both California and New York, things changed overnight. The next day, temperature checks and quick screens were conducted at all entrances; however, we would quickly learn this was not effective enough. Given that the nature of transmission was not clearly understood (Coetzer & Bichard, 2020) students, externs, interns, fellows, residents, and all non-essential personnel were instructed to self-isolate and work remotely. Although now it is known that transmission is correlated to viral load and aerosol contact versus surface transmission (WHO, 2020), that was not a risk that could be afforded. Notwithstanding, quick action needed to be taken. This institution, like many others, was beginning to receive referrals for COVID-19. Almost instantaneously, this institution began restructuring to care for a primary COVID-19 population. Another challenge that became evident, other than the clear issue of physically getting into the office, was designing a neuropsychological battery that would help provide differential diagnosis between the impacts of COVID-19 and other neuro-

psychological sequelae. When we considered this novel infectious disease and the problems it created in understanding the neuropsychological sequelae, we decided to utilize a multidimensional approach. Since information and research in midMarch was limited regarding COVID-19, we first considered historical accounts of neuropsychological sequelae of viral infection. Reasoning for this was supported by research suggesting the influenza pandemic of 1918-1919 that infected nearly a third of the global population, has viral and epidemiological ties to the more recent H1N1 pandemic, and thus provided guidance when dealing with the “swine flu” pandemic (Manjunatha et al., 2011). A meta-analytic review of all neurologic, neuropsychiatric, and neuropsychological articles covering over twelve different pandemics during the 20th and 21st centuries yielded data describing neurological impacts as far back as 1510 (Henry et al., 2010). We also considered more recent research on HIV/AIDS. There has been literature to suggest that the mechanism by which this novel coronavirus, as well as other coronaviruses (Zhang & Yap, 2004), infect cellular structures is very similar to retroviral mechanisms often described in HIV (Zhang et al., 2020), providing hope that treatments targeting these mechanisms will be successful (Mussarat et al., 2020). Based on the research above, as well as neuropsychological assessment protocol for other neurologic conditions (e.g., TBI, MS, dementia), we were able to develop a flexible battery approach that covered multiple areas of cognitive and neuropsychological functioning through a digital platform. It is important to note that despite how quickly we were able to put this teleneuropsychological (TNP) battery into practice, we immediately began to describe our non-standard administration and why such practices were necessary for the well-being of the patient, especially given the impacts of non-standard administration (Jones et al., 2020). Furthermore, our efforts were aided by being able to provide the majority of our assessments using iPad/ tablet administration and screen sharing 21

platforms. We had already been using digital neuropsychology platforms given its utility in bedside assessment. The literature has demonstrated that TNP has reliable normative data since 2014 (Marra et al., 2020). More recent research conducted in this area has demonstrated that performance across traditional neuropsychological assessment, or assessment as usual (AAU), and TNP was largely commensurate with the exception of processing speed that was noted to be faster for children when using Q-Interactive. Since our institution primarily treats adults, this was not considered to be a concern. In our TNP battery, we followed traditional practices and utilized measures of word reading to assess premorbid intellectual functioning. Although the shortcomings of using word reading paradigms are well documented (Lezak et al., 2012; Strauss et al., 2006), this provided the most appropriate and safest way to estimate such functioning, especially with newer algorithmic systems, such as the Test of Premorbid Functioning (TOPF), that combines word reading performance with relevant biopsychosocial information. For individuals who were educated in the US, we also conducted a measure of general fund of knowledge, commonly assessed using the Information subtest from the Wechsler Adult Intelligence Scale, 4th Edition (WAIS-IV). This measure is often discounted within the neuropsychological community given its lack of a specific/ focal brain region (as opposed to a network process); however, it is often considered a measure of crystallized intelligence, suggesting that it should be least susceptible to the impacts of brain injury. For individuals who may have not been educated in the US, we utilized the Comprehension supplemental task from the WAIS-IV to estimate understanding of social constructs and pragmatics. Perceptual reasoning was a more difficult construct to assess, not only because neuropsychological assessments are less sensitive to perceptual challenges, but also the heavy reliance on paper and pencil measures. When psychomotor issues were not a challenge, we had patients copy the complex figure from the Rey Complex Figure and Recognition Test (RCFT); however, this required a facilitator, and given the pronounced psychomotor difficulties and extreme muscle fatigue seen in this population, it was not always a reliable 22

measure of right hemispheric functioning. We were, however, able to use the screen sharing function, as permitted by Pearson, to show stimulus items from WAIS-IV subtests, such as Matrix Reasoning, Visual Puzzles, and Picture Concepts. Working memory and attention were assessed using the Digit Span subtest from the WAIS-IV, while learning and memory were assessed using the California Verbal Learning Test, 3rd Edition (CVLT-3). The advantages of using the CVLT-3 versus other list learning tasks, at least with this population, are the advanced psychometric analysis and the demographically adjusted norms. Given that most other list learning tasks only account for education, the CVLT-3 provided more accurate assessment for individuals from ethnically and culturally diverse backgrounds. This is important given the historical nature of psychological and neuropsychological assessment over-pathologizing behavior and functioning of Black persons and other people of color (BIPOC). Aside from the clinical and psychometric utility of the CVLT-3, the three paradigms from the Digit Span subtest provided helpful neuropsychological information. Notwithstanding, this task was perhaps most susceptible to problems within the TNP battery. Specifically, any glitches with technology, including the Internet or volume, could impact performance. As such, we deemphasized the findings from this test and often compared it to the Letter-Number Sequencing subtest from the WAIS-IV. Though it is often considered more a process of executive functioning that attention, the comparison of performance between the two subtests helped understand what was a functioning of the testing environment versus cognitive performance. Language and communication was often assessed using measures of phonemic and semantic fluency. These tasks are usually assessed using the Controlled Oral Word Association Test (COWAT) or the Verbal Fluency subtest from the D-KEFS. However, we often used the COWAT versus the D-KEFS given that semantic fluency from the D-KEFS incorporates names of boys that has been considered biased culturally and sexually. Instead, we used the traditional F-A-S paradigm for phonemic fluency, and the Animals-Fruits-Vegetables paradigm for semantic fluency. While the Animals paradigm often sufficed as an estimate of semantic fluency,

providing other measures of semantic fluency allowed us to use the MOANS normative information when appropriate. This is important to consider given that COVID-19 has disproportionately impacted BIPOC. Depending on the specific nature of the referral question, additional measures of language and communication were included. Specific measures from the Boston Diagnostic Aphasia Examination, 3rd Edition (BDAE-3), such as the Complex Sentence Ideation Test, Boston Naming Test, 2nd Edition (BNT-2), and Cookie Theft, were included to help with receptive and expressive language. Social pragmatics and comprehension were often assessed using the Comprehension subtest from the WAIS-IV and the Verbal Reasoning subtest from the Cognitive Competency Test (CCT), as well as select subtests from the Independent Living Scales (ILS). Repetition was often assessed informally, though if a standardized measure was required, Sentence Repetition subtest from the Weschler Individual Achievement Test, 3rd Edition (WIAT-III) was sufficient. Perhaps the most difficult domain to assess with the TNP battery is processing speed. Although this dimension of functioning is least correlated with global intelligence, it is still a critical aspect of the neuropsychological evaluation. To assess this, we estimated performance in this area with oral measures of processing speed, such as the Symbol-Digit Modality Test (SDMT). This has been especially helpful in the rehabilitation setting in which many of the patients have physical and/or motor limitations preventing them from many the traditional graphomotor paradigms (e.g., WAIS-IV Coding or Symbol Search). This was also a consideration for the patients recovering from COVID-19, who often complained of severe motor fatigue. Although the SDMT was standardized on a population who first completed the paper and pencil version prior to the oral version, this provided a fair estimate of processing speed in conjunction with other measures of processing speed, such as reading and naming fluency paradigms, such as the Stroop Test or the Color-Word Interference Test from the D-KEFS (Sisco et al., 2016). Executive functioning was assessed using Similarities, Matrix Reasoning, Visual Puzzles, and Letter-Number Sequencing subtests from the WAIS-IV, as well as selected tasks from the D-KEFS (Lezak et al., 2012). Clock command was also utilized New Jersey Psychologist

for individuals who did not have psychomotor impairment. Mood and personality were often assessed in the clinical interview, along with the Beck Inventories (BAI; BDI-2), the Patient Health Questionnaire (PHQ-2; PHQ-9), and the Geriatric Depression Scale (GDS-15; GDS-30). In rare instances, the Personality Assessment Inventory (PAI) was utilized given the additional scales for substance abuse and negative/positive impression management. Performance validity was assessed with imbedded measures (e.g., Reliable Digit Span from the WAIS-IV; CVLT-3 Forced Choice Recognition Trial) compared to overt or standalone measures. Recommendations and Conclusions After multiple months, it is becoming more and more likely that the problem of the novel coronavirus is not going to disappear any time soon. As such, it is more prudent for neuropsychologists to consider assessment procedures that will be clinically useful and reliable in the coming years. After reviewing the challenges we faced in these endeavors, here are some of our recommendations for the field. First, it is clear that neuropsychology as a field, given its heavy reliance on paper and pencil measures, must consider moving into the age of digital assessment through TNP. While many neuropsychologists would argue that paper and pencil measures are the “gold standard” of our field, this clearly is an artifact of a world before COVID-19. Without question, the ability to give multiple assessments that are both reliable and sensitive in measuring cognitive dysfunction with only a piece of paper and a pencil is extraordinary. But given that another lockdown or quarantine could occur at any time, neuropsychologists need to be prepared to continue providing their essential services in a digital world. That weakens the utility of the paper-pencil model. Furthermore, given that many of the individuals we assessed who were recovering from COVID-19 had hypoactive delirium and pronounced psychomotor impairments, paper and pencil measures likely would not accurately capture the cognitive abilities of these individuals. Toward that end, we found that the Q-Interactive system, while requiring Internet connection, an iPad and a laptop, was integral for providing acceptable non-standardized assessment procedures early in the process. There were only a few instances in which Fall 2020

the Internet or the quality of the technology was inadequate, usually on the Digit Span subtest; however, the benefits of assessment procedures standardized on technology outweigh the potential risks. This may also help with training programs during the fallout of the pandemic. Second, it is important for neuropsychologists to recognize our field has certainly been altered by the development of technology. Neuropsychological assessment was originally the mechanism for localization of brain dysfunction prior to neuroimaging. Now that neuropsychological assessment is often considered a functional confirmation of neuroimaging findings, many wonder why they should refer their patients for neuropsychological assessment that can be both time consuming and financially expensive. With the possibility of a blood test for dementia, this concerned many neuropsychologists about the utility of the field. Notwithstanding, neuroimaging for individuals with COVID-19 is inconclusive, with new research of atypical findings coming out each month (Rogg, Baker, & Tung, 2020). For multiple individuals we assessed impacted by COVID-19, we observed diffuse cognitive dysfunction comparable with hypoxic/anoxic brain injury. Given the limited ability of affordable neuroimaging scans to assess for these injuries, it becomes imperative for neuropsychologists to bridge the gap between neurology, neuroimaging, and neurorehabilitation. Toward this end, clinicians and researchers in the field of neuropsychology need to continue collaborative efforts so that we may anticipate these challenges before they arise so that there are fewer gaps in medical and psychological services. Finally, we believe that neuropsychology must continue to make commitments to multiculturalism, diversity, and intersectionality. Too often in the past has there been public misperception about the function of psychologists, and neuropsychology is no exception. With roots in phrenology, we must accept that the localization of function can be reductionistic and has been misused in the past for more nefarious purposes. With this in mind, there may be a pull in the medical setting to shorten reports for the purpose of efficiency and billable hours; however, this must be balanced with justice for the client. This comes not only in the form of a good clinical interview, but also growth outside of the clinical setting. To address this, we must

expand such training in doctoral programs and incorporate more concepts in inform conceptualization and formulation, such as White fragility and anti-racism. This has been integral on the in-patient rehabilitation setting, and it can certainly benefit the field of neuropsychology as a whole. Many of the challenges we encountered during the past few months could have been easily avoided had we prepared for this situation. While Q-Interactive was that plan initially, it became clear that, while TNP normative data exists, is not as prominent as traditional paper-pencil norms. With globalization, another pandemic is likely to occur in the future. We must be prepared for the event with more research and inclusion of technology. Furthermore, with the recent events following the murder of George Floyd and a renewed civil rights movement, we as neuropsychologists must examine how we will handle the construct of race and diversity in our practices. All of this must be accomplished before we as a field can move forward. About the Authors Jared B. Hammond, MA is a fourth year doctoral student at Kean University’s Combined School and Clinical Doctoral Program (PsyD) and aspires to become board certified in clinical neuropsychology. He has completed externships previously in clinical neuropsychology at Kessler Institute for Rehabilitation and Lenox Hill Hospital. In addition, he currently works for Head to Head Consultants, a private clinical neuropsychology practice specializing in neurodevelopment disorders and concussion. Dr. Kearns works as a neuropsychologist at Kessler Institute for Rehabilitation on the acute inpatient brain injury unit. She provides neuropsychological assessments and psychological interventions to patients that have sustained a traumatic brain injury, stroke, or other acquired neurological condition. References Furnished Upon Request.

Keeping The Old Man Out

Kenneth Herman, EdD

am 93 and still see myself as an active and vital person. I exercise at the gym seven days a week (when not in the middle of a pandemic) and hope to continue staying in shape and productive. In 2007, after 50 years of practice as a clinician, launching and directing The Psychological Service Center in Teaneck, New Jersey, I retired to promote my self-help book Secrets from the Sofa: A Psychologist’s Guide to Achieving Personal Peace. Throughout my very satisfying professional life, along with a busy clinical practice, I taught at three universities, supervised psychologists, published numerous articles, conducted research, lectured extensively, appeared on television and radio shows, and served on many professional boards. But, I knew it was time to move on.

Simultaneously, I was actively looking for an all-consuming volunteer project of monumental dimensions. I still had the need to be a helping person. When I heard of a group that was interested in launching a free medical service for the working poor who had no insurance, I immediately got involved. The volunteer program I chose to help launch and support was The Bergen Volunteer Medical Initiative (BVMI), a free primary care medical facility in Hackensack, New Jersey. It took many altruistic people working arduously for five years before the facility became operative. We are currently in our tenth year. I served on the original board of trustees and presently serve on the advisory board. The center is committed to improving the overall health of the community through a “Culture of Caring,” respecting the dignity and individuality of the patients and staff. My involvement with BVMI has made my retirement years, indeed, special. Fundraising and public relations are my ongoing tasks. Particularly satisfying to me is the enormous number of patients, who have been receiving life-saving care and whose

numbers keep growing. I am proud to be associated with such a wonderful cause and the great professional and volunteer staff at BVMI. So colleagues, you can keep the old man out by discovering your own BVMI, an important project that you can’t wait to get to tomorrow morning. It will be a place where you can utilize your human relations skills and where your passion will be ignited and will be indispensable for your new venture. It’s probably right around the corner. About the Author Dr. Kenneth Herman served in World War 2 in General Patton’s Third Army as a sergeant and communication chief. After a poor academic high school record and being told by his high school guidance counselor to “quit school and go to work: school is not for you,” he received a master’s degree from Boston University and a doctorate from Columbia University. He is a Diplomate in Clinical Psychology. He and his wife Benita have been married 60 years and have four married children and nine grandchildren. He can be reached at: drherman@optonline.net

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Fall 2020

Existential Therapy as a Tool for Combatting the Deleterious Psychological Effects of Racism During COVID-19

Simone Robinson, MA

Marianne Dunn, PhD Abstract his article evaluates the sociopolitical effects of racism on the African-American population, especially as it relates to current reactions to People of Color in light of the current pandemics: coronavirus (COVID-19) and racism. The increase in negative reactions to the African-American population calls for the application of appropriate counseling interventions to improve the mental health of those affected by racism. Existential therapy provides therapists with culturally appropriate interventions that may be effective in decreasing anxiety, depression, and trauma perpetuated by individual, cultural, and institutional racism and xenophobic attitudes among People of Color. The tenets of freedom, choice, and self-responsibility will therefore be underscored as it relates to counseling People of Color using the existential approach.

Assessing the Two Pandemics: Impact of Racism and COVID-19 on AfricanAmericans The COVID-19 pandemic has led to an upsurge in racist attitudes towards several minority groups, namely African-Americans. Though COVID-19 is a new pandemic, it highlights old, deep-rooted racist attitudes that have been a part of the history of America for a long time. As posited by Constantine and Sue (2006), though the Civil Rights Act was passed several decades 26

ago, in 1964, to ensure fair treatment of every race, the historical legacy of racism and discrimination continue to take precedence in the American society. Apropos of that, there are three main racisms that plague the African-American and other People of Color: individual, cultural, and institutional racism. Individual racism comes in the form of both intentional and unintentional acts of discrimination meted out by the White, majority group on individuals who belong to a Black, minority racial group due to the majority’s belief that their group holds the greatest superiority (Constantine & Sue, 2006). Additionally, cultural racism is also a pervasive paradigm that adversely affects the lives of African-Americans and People of Color in that it seeks to favor the European cultural phenomenon and shuns the cultural practices and values of People of Color. As such, any values that People of Color hold are minimized and dismissed or in

Keywords: Racism, stereotype threat, micro-aggressions, People of Color, AfricanAmericans, coronavirus (COVID-19), pandemic, existential therapy some cases pathologized as being uncivilized or unnatural (Constantine & Sue, 2006). The stereotype that African-Americans and other People of Color are uncivilized and have innate criminal characteristics continues to fuel police brutality meted out to African-Americans. In fact, the assumed criminal character of African-Americans by some law enforcement officers often ends in death (Sausdal, 2018). As such, the names of George Floyd, Breonna Taylor, Sandra Bland, Eric Garner, and many others ring with much familiarity as the list lengthens with each fatal encounter with law enforcement. A direct response to this is seen in the many anti-racist marches that have been carried out in the US and other parts of the world. Recently, Kendi (2019) compared racism to cancer in a profound personal

manner, and framed racism in terms of racist and anti-racist policies and actions. In this light, racism must be eradicated by challenging racist policies that directly and indirectly affect People of Color. Centuries of racism and discrimination has led to what scholars know as institutional racism, but what African-Americans and other People of Color recognize as an oppressive experience due to the organized network that enact normative practices that work to keep the aforementioned minorities at a disadvantage in systems such as healthcare, education, and business (Constantine & Sue, 2006). A direct result of institutional racism, as highlighted by Eligon et al. (2020), can be seen in public health statistics that indicated the coronavirus has been killing African-Americans at a disproportionate rate. Nationwide, Black people are dying at 2.5 times the rate of Whites (COVID Racial Tracker, 2020). In New Jersey; Black or African-Americans constitute 13% of the population, but 18% of COVID-19 deaths. Here, the COVID Racial Tracker (2020) works to highlight discrimination, and social determinations of health (e.g., unequal healthcare access and utilization, higher likelihood of being an essential worker, educational, income and wealth gaps, and housing factors) may contribute to the increased risks that minorities experience related to COVID-19 morbidity and mortality. Early misinformation about COVID-19 led to the formation of rumors that indicated that African-Americans might be immune to the virus. This rumor further exacerbated the spreading of COVID-19 as the confusing messages left some states and cities behind in taking precautionary measures. Here, it is evident that the effects of the redlining policies of the 1930s still lingers. Segregation of African-Americans in urban areas often results in a lower life expectancy. However, segregation has not been proven to have any effect on Caucasians in suburban communities (Eligon et al., 2020). According to the CDC (2020), the objective conclusion with regards to the African-American community’s susceptiNew Jersey Psychologist

bility to COVID-19 is clear; segregated communities are a breeding ground for diseases. However, the prevalence of African-American cases and fatality is not biological, rather, it is a result of racial and structural inequalities that are exacerbated due to COVID-19. African-Americans have been victims of racism for centuries which is a known stressor and, as a result, African-Americans have undergone weathering; stress-induced wear and tear. Stressors are scientifically known to favor exposure to toxins, thus suggesting an operationalization for African-Americans being a susceptible group (CDC, 2020). According to Sausdal (2018), it is also very common in present-day society where law enforcement officers hold racist attitudes towards People of Color. This notion is also disguised in the deep political and cultural rationalization that every AfricanAmerican’s intention is to break the law. This is also due to the presence of stereotypes that can be exhibited in the form of micro-aggressions. As posited by Sue et al. (2007), micro-aggressions are “brief and commonplace daily verbal, behavioral, and environmental indignities, whether intentional or unintentional, that communicate hostile, derogatory, or negative racial slights and insults to the target person or group.” It is also seen where micro-aggression can exist in the form of overt behaviors, covert behaviors, as well as environmental conditions. To further operationalize micro-aggressions, Sue et al. (2007) created three typologies, micro-insults (negative insinuation about ability or character), micro-assaults (discriminatory acts), and micro-invalidations (denial of racialized experiences). In today’s society, micro-aggressions towards immigrants of color come in the form of questions, behaviors, and the social, economic, and political climate of the society. Questions such as “Where are you from?”; or statements like “You are a credit to your race.” More commonly, it is noted where immigrants of color are made to feel unintelligent, exposed to stereotypic rhetoric about their group, presumed to be criminal and dangerous, are subjected to hypervigilance by law enforcement (Sausdal, 2018). Notably, Kendi (2019) challenged this conceptualization, and argued that the concept of “micro-aggressions” is better understood as racist abuse. Regardless, a host of evidence has indicated that hypervigilance has been brought on by implicit biases fueled by stereotype Fall 2020

threat. As posited by Steele (2003), stereotype threat is, “the threat of being viewed through the lens of a negative stereotype, or the fear of doing something that would inadvertently confirm that stereotype.” In Chapter 14, In the Air Between Us: Stereotypes, Identity and Achievement, Steele (2003), carried out a study to further operationalize the influence of stereotype threat in the lives of minority students. In 1995, Steele, Aronson, and Spencer sought to assess the stereotype that Black students experience when taking a standardized test. In the study, White and Black sophomore students at Stanford were given an English Literature GRE exam designed for seniors. The results of this study highlighted the significance of negative stereotypes on the intellectual ability of African-American students. When the students were primed to believe that the exam was designed to favor White students, the Black students performed significantly lower than their white counterparts. However, when the African-American students were led to believe that they had a high chance of doing well, rid of the stereotype threat, they performed better than their White peers (Steele, 2003). Here, stereotype threat effect functions to lower the self-efficacy of marginalized groups. Existential Approach to Counseling Victims of Racism Assessing Freedom, Choice, Self-Determination, Responsibility The humanistic nature of existential therapy allows for applicability among the African-American population. This approach is relative to all ethnic backgrounds because it accounts for different cultures as it relates to viewing the individual as a blank canvas “tabula rasa.” This theory also allows the individual to be able to freely develop based on the cultural variables essential to their personal growth. Essentially, the existential approach holds promise for treating clients who suffer from anxiety, depression, or PTSD from trauma-inducing experiences in the US. For centuries, African-Americans have endured structural racism that has led to the oppression of People of Color that inevitably resulted in anxiety, depression, and trauma (Solomon & Koska, 2019). That is, People of Color who have experienced fear, grief, isolation, or feel like their life has no meaning due to structural oppression in the US will be given renewed hope and purpose. Here,

existential therapy will allow People of Color acquire competencies that will aid their ability to devise healthy coping strategies that will help them to move past their traumatic experiences and existential anxiety, ultimately fueling their personal self-actualization (Corey, 2015). As a result, the tenets of existentialism (i.e., freedom, choice, self-determination, and responsibility) meets each individual where they are at, allowing for personal self-actualization. Existentialism allows one to “become” without being restricted to a deterministic view. Rather, one is able to employ freedom, choice, and self-determination and responsibility to shape their personal evolution (Halbur & Halbur, 2015). For People of Color, anxiety is a normal part of their existence. This anxiety may be as a result of intrapsychic conflicts that are fueled by their negative experiences in the US due to their second class status (Solomon and Koska, 2019). These intrapersonal conflicts may come in the form of questions, such as: “Who am I?”; “How do I create meaning for my life?”; “Do I have the freedom to do as I wish?”; “Am I responsible for my actions?”; and “How do I remain true to myself?” These questions are commonplace for People of Color who are victims of racism. It is also seen where intrapsychic conflicts have been exacerbated during the COVID-19 pandemic. Not only are People of Color burdened with oppression caused by racism, they now also have to combat these conflicts doubly, due to the increase in racism from COVID-19. In seeking to answer these questions, existential interventions will promote awareness, freedom, choice, responsibility, purpose, positive attitude and self-actualization (Halbur & Halbur, 2015). The process of gaining awareness may help People of Color to choose to do things that will boost their understanding of the foundational issue they face, and engage in self-advocacy. People of Color may be able to reframe their experiences through existential therapy, and transcend into a more positive space, mentally. The core of the existential therapy is our ability to choose our actions. Therefore, the goal of therapy would be to guide People of Color to a better understanding and acceptance of their own personal freedom. This new insight will allow People of Color to realize that their personal freedom and power is shaping their destiny (Corey, 2015). In instances where oppression, caused by racism 27

and COVID-19 decreases People of Colors’ sense of freedom, Existential therapy may aid in the reconstruction of their freedom as it emphasizes individuals’ capacity to react emotionally and intellectually to their situations as we see fit. Thus, People of Color may be able to choose from their alternatives, i.e., employing resilience and fighting the urge to succumb to oppression. Rather, they should employ discernment and consider the outcome of succumbing to inequalities, versus choosing alternatively to fight their intrapsychic conflicts caused by racism, particularly as evidenced during COVID-19, ultimately fueling personal freedom. This type of self-advocacy may involve anti-racist work as an outcome. To share an existential case study, Paula, a 51-year-old female, has been suffering from depression and anxiety. The existential approach was used for 25 months to help her regain personal freedom by choosing to alter her perspective of her current experiences. Paula felt disappointed with her life, she expressed feeling like a failed artist. In therapy, the first intervention was asking Paula to chronicle her becoming a “hero” in her own life, as opposed to seeing herself as damaged goods. This gradually gave Paula renewed hope and she began her portfolio as an artist. She soon began to realize that much of her depression was caused by her view that she isn’t good enough, as opposed to an alternative view that she is a good artist who is just lacking motivation (Lipari, 2008). Another intervention prompted her to explore her ability to be the author of her life and renew her identity as an artist. She was then prompted to use her existential anxiety to incite actions that will help her develop her skills as an artist, such as attending art workshops. Paula gradually became more confident and she gained insight that allowed her to understand that she can choose to have a different perspective of her experiences, one that allows her to use her freedom to choose her purpose and work towards self-actualization (Lipari, 2008). In the context of the current twin pandemics of racism and COVID-19, consider that Paula is an African-American woman, the process and outcome of existential therapy might involve “Paula” engaging in anti-racist work, self-care, and mobilization of social-support, and participating as an advocate to combat racist policies and behaviors that marginalize and denigrate People of Color. As evidenced in this vignette, one has the ability to use their 28

personal freedom to compartmentalize their experiences using existential interventions. Thus, in light of the twin pandemics, existential interventions might involve oppressed individuals’ identity management and purpose formation. Here, in seeking to personally combat racism, People of Color can seek to develop their own identity and purpose and work to optimize and selfactualize despite oppression. Naturally, with freedom comes great responsibility. Thus, existential therapy can help People of Color to understand their personal responsibilities as a result of their freedom. Thus, People of Color can learn how to accept responsibility for shaping a positive trajectory for their lives without being deterred by an overwhelming sense of burden (Halbur & Halbur, 2015). At first glance, the existential therapy may appear serious and complex. However, in actuality, it is one that has the ability to help People of Color feel a greater sense of freedom, purpose, and happiness when they achieve personal goals. As such, through existential therapy, People of Color will work to create a balance between the structural racism and oppression they face, allowing them to see the brighter side of existence and work towards self-actualization (Halbur & Halbur, 2015) and anti-racism. About the Authors Simone Robinson, MA is a recent graduate (May, 2020) of Saint Elizabeth University’s MA in Counseling Psychology Program and is currently working as a Behavioral Case Manager with schizophrenic clients at an outpatient psychological facility. As an existentialist, her main areas of focus in research are Social Justice, racism/xenophobia and constructs of positive psychology relative to the academic success of 1st generation college students. Marianne Dunn, PhD is currently the director of the PsyD program and assistant professor at Saint Elizabeth University. She is a licensed psychologist in NJ and NY and operates a small private practice. She is skilled in crisis intervention, psychotherapy, clinical supervision, and psychological assessment. Overall, a strong community and social services professional with a PhD focused in Counseling Psychology from University of Maryland College Park.

References CDC. (2020). Health Equity Considerations and Racial and Ethnic Minority Groups. Retrieved July 31, 2020, from https://www.cdc.gov/coronavirus/2019ncov/community/health-equity/raceethnicity.html Constantine, M. G., & Sue, D. W. (2006). Addressing racism: Facilitating cultural competence in mental health and educational settings. Hoboken, NJ: Wiley. Corey, G. (2015). Theory and practice of counseling and psychotherapy. Boston, MA: Cengage Learning. COVID Racial Tracker (2020). Racial Data Dashboard. Retrieved July 31, 2020, from https://covidtracking.com/race/ dashboard Eligon, J., Burch, A., Searcy, D., & Oppel, R. (2020, April 7). Black Americans Face Alarming Rates of Coronavirus Infection in Some States. Retrieved from https://www.nytimes.com/2020/04/07/ us/coronavirus-race.html Halbur, D., & Halbur, K. V. (2015). Developing your theoretical orientation in counseling and psychotherapy. Boston: Pearson. Kendi, I. X. (2019). How to be an antiracist. First Edition. New York: One World. Lipari, J. (2008). The Case of “Paula”: An Existentially Based Treatment Approach to Chronic Depression. International Journal of Existential Positive Psychology, 2(1). Sausdal, D. (2018). Pleasures of policing: An additional analysis of xenophobia. Theoretical Criminology, 22(2), 226–242. https://doi-org.cse.idm.oclc. org/10.1177/1362480617707947 Solomon, H., & Kosaka, H. (2019). Xenophobia in South Africa: Reflections, narratives and recommendations. 1-26. Retrieved March 3, 2019, from http:// www.saccps.org/pdf/2-2/SAPSS 2(2) Solomon & Kosaka.pdf Steele, C. (2003). Stereotype Threat and African-American Student Achievement. Inequality in the 21st Century,315-318. doi:10.4324/9780429499821-55 Sue, D. W., Capodilupo, C. M., Torino, G. C., Bucceri, J. M., Holder, A. M. B., Nadal, K. L., & Esquilin, M. (2007). Racial micro-aggressions in everyday life: Implications for clinical practice. American Psychologist, 62, 271-286. doi: 10.1037/0003066x.62.4.271 New Jersey Psychologist

Book Review: The Multiple Self-States Drawing Technique: Creative Assessment and Treatment with Children and Adolescents Anthony F. Tasso, PhD Fairleigh Dickinson University Chair, Department of Psychology & Counseling

he use of project assessment methods and psychological testing in general hold a place of prominence in the annuals of clinical psychology. Whereas there once was a time when a practicing psychologist not incorporating psychological testing into a patient’s comprehensive treatment was an anomaly, the professional environment today is quite different. The pendulum has swung to the point where the implementation of formal assessment measures within patient work is the decided exception. Put otherwise, psychological assessment and related treatment methods are only a small dot on today’s psychotherapeutic landscape. Figure drawings, a subset of projective testing, exemplify an even more unique piece of the psychological testing puzzle. The reasons their use has become so rare range from the complexities associated with the administrative and interpretative process, to how to present the test to patients, to the fact that – unlike other assessment measures (e.g., MMPI, Rorschach, TAT) – there is no unified figure drawing test. As such, figure drawings, even during the heyday of assessment, have always experienced challenges sitting at the psychological testing table. What this means for today’s inhospitable assessment environment is that, unfortunately, fewer clinical training paradigms incorporate their use, and fewer clinicians appreciate the therapeutic value of utilizing figure drawings in their daily work. Looking beyond the current professional climate, New Jersey psychologist Susan Parente thankfully developed a sophisticated child and adolescent assessment and treatment in which figure drawings are the centerpiece. The Multiple Self-States Drawing Technique: Creative Assessment and Treatment with Children and Fall 2020

Parente, S.C. (2019). New York, NY: Routledge.

Adolescents (hereinafter, the titular assessment will be referred to as the MSSDT) outlines Parente’s inspirational clinical method. The author provides a convincing rationale for the MSSDT approach along with easy-to-follow procedural information. In her book, Parente beautifully coalesces long-standing theories and techniques with contemporary basic and applied research, which she augments with anecdotal clinical observations to educate the reader on her clinical approach to treating children and adolescents. The book opens by describing the MSSDT’s rather organic genesis -- Parente’s experiences during her lengthy career working as a psychologist in the trenches of the school system. Specifically, the author describes the emergence of significant data from the comprehensive psychological test batteries, including particularly fruitful findings gleaned from her child subjects’ figure drawings. Parente highlights how the overall testing findings, set alongside the individualized aspects of each child’s drawings, converge to form a lucid picture of the individual. She further notes how, compared to other formal tests or even clinical interviews, figure drawings proved a user-friendly, non-threatening means by which a clinician can engage a disengaged, apprehensive, or even hostile child. These two ideas (i.e., rich patient information and alliance building) intersect to form the foundation of the Multiple Self-States Drawing Technique. Parente presents a historical overview of the clinical use of figure drawings. To start, the book describes Florence Goodenough’s use of figure drawings as a nonverbal assessment of maturity and intelligence, later methodologically refined by Harris, resulting in the Goodenough-Harris Drawing Test (1963). This led to multiple figure

drawing approaches (e.g., Kinetic Family Drawing, House-Tree-Person), all of which featured unique and overlapping properties. More so, these early figure drawing pioneers prompted more contemporary clinicians (e.g., Fischer, Finn) to eliminate the distinction between assessment and treatment and rightly explicate that they are one and the same. Parente nicely summarizes how these clinical theorists facilitated powerful insights into their subjects’ intrapsychic and interpersonal functioning. The author also explains that phenomenology is the bedrock of the MSSDT. Parente illustrates, both through theories and vignettes, how her unique treatment approach serves as an avenue by which the clinician can apprehend a patient’s subjective thoughts, feelings, experiences, and possible impetuses for behaviors, and does so in a nimble and individualized manner. Here, we witness her humanistic influences. The MSSDT is decidedly collaborative in nature – the clinician and patient approach the process together, with the therapist asking follow-up questions in an interactive, open-ended fashion. The book delves into the construct of self. Leaning on the historical works of John Jackson and William James, to more contemporary neuroscientific research of Damasio, Schore, Fosha, and Siegel, this section thoroughly plumbs the self, which is broadly viewed as a conglomerate of neurocognitive networks born out of constitutional and environmental factors that converge to create an ever-changing character that encompasses somatic, affective, ideational, and behavioral phenomena. The book further touches on the self vis-àvis psychiatric conditions (e.g., depression, anxiety) and the bidirectional relationship of psychophysiological experiences and one’s self-perception and interpersonal in29

teractions. The text reports on evidence debunking the notion of a unitary, static self; our sense of self varies based on contextual factors as well as intrapsychic experiences. Parente provides cogent examples how the self changes as a function of the setting, people present, and the psychobiological state of the person. The author identifies the healthy fluctuations and shifting of self-states, describing how an individual with an integrated sense of self possesses the oft-seamless ability to adapt fluidly to time, place, and circumstances – and do so while securely anchored in a stable self. The psychologically healthy person, Parente explains, develops such abilities through early parental attunement. The author explains how parents who are able to help their infant make sense of their fluctuating disparate experiences of fear, sadness, euphoria, and frustration facilitate an integrated self, affect regulation, and establish the interpersonal skillset to anticipate and understand the inner world of the self and of others (contemporaneously referred to as mentalization). This person ultimately develops the capacity to tolerate strong affects and exhibit good behavioral control. Underscored is the fact that affect regulation (i.e., the experience of one’s self as cohesive, continuous, and connected along with a clear yet flexible idea of one’s emotional and behavioral propensities) is the sine non qua of healthy self-states. The author leans on recent research demonstrating how affect regulation is governed by the autonomic nervous system; it is created out of parental attunement, which allows the individual to experience and withstand the full range of emotionally evocative memories and even intense interpersonal experiences without psychological decompensation. Parante juxtaposes this healthy self with that of an inchoate and fragmented sense-of-self. Born out of early trauma or traumas that result in dissociative processes, create such a self and lead to the developing child – and later adult’s – failure to integrate and categorize varied and intense emotional experiences. The book explains how this can lead to breakdowns in cognitive functioning during heighted emotional arousal as well as a propensity for emotional dysregulation and aggressivity (either towards the self or others). Furthermore, such a person resides in an interpersonal world wrought with struggles, pitfalls, and disappointments. 30

With the goal of attending to all facets of the self (and specific attention to dissociated elements, affect regulation and integration, and interpersonal abilities), the author spells out the easy-to-follow procedural information by outlining the four phases of the MSSDT (initial interviews, presenting the structure, feedback, and implementation of treatment). Parente discusses how to best address disintegrated self-states, guiding the clinician to ask the young patient to draw a picture of themselves depicting their disparate moods and experiences, including both illustrative drawings and identifying words (e.g., “angry,” “happy,” “scared”). She further explains how this opens a therapeutic window into the self and subsequent accessibility to these varied states. The clear yet flexible protocol encourages the patient to describe regulated and dysregulated experiences, and, in autobiographical fashion, present when and why they experienced such affects. The clinician asks set questions to attend therapeutically to the developing child’s diverse self-states and follows explicit instructions to address both proactive regulative experiences as well as dysregulative experiences. The latter part of the book consists of three detail-rich chapters of MSSDT-based treatment of a child with OCD, a patient burdened with relational trauma, and one who experiences social anxiety. It is at these points the reader is able to fully grasp the breadth and depth of this treatment. Parente demonstrates the savvy ways in which her technique is woven into preexisting treatment approaches, yet remains transtheoretical in nature. With these clinically rich chapters, The Multiple Self-States Drawing Technique illuminates how this innovative approach offers a sound springboard for therapy, facilitation of deeper patient work, and tangible treatment progression markers. Key to the MSSDT is that it is not a stand-alone treatment but a solid technique incorporated into a range of treatment modalities, capable of addressing a broad range of disorders and concerns. Implementation of the MSSDT rests on tried-and-true tenets of sound clinical work. Parente underscores the need for the therapist to be present in the here and now, cultivating the child or adolescent’s ability to attend to one’s self and other’s mental states, and remaining ever mindful of the therapeutic relationship. This book demonstrates the clear value of including

the MSSDT in child and adolescent treatment. Parente accentuates its experiential value (i.e., innocuous introduction to exploring distressing complex experiences, alliance enhancement), assessment abilities (i.e., presenting problems, range of affect states, self-awareness, aspects of cognitive functioning), and treatment progression markers (i.e., mentalizing, reflective functioning, articulation of struggles, richness of autobiographical narratives). Quite the clinical impact. The Multiple-Self-States Drawing Technique represents a powerful tool for clinicians in the throes of child and adolescent psychotherapy. Parente provides brief yet rich information on the history of figure drawings along with contemporary research to illustrate the capabilities of the MSSDT. Far from boilerplate, this practical ethos lays the groundwork for a unique, contemporary, and customized clinical approach of the multiple self-states drawing intervention. Armed with illustrative clinical vignettes, the author outlines the utility of this technique while refraining from hyperbole. The fact that Parente packed so much information into less than 150 pages is perhaps as impressive as her clinical acumen. Susan Parente’s extensively researched book leans heavily on the classics (Goodenough, Beck, Hammer) and is buttressed with contemporary research-based perspectives (Damasio, Fongangy, Stern, Schore, Siegel). In doing so, it beautifully brings the early ideas of figure drawings up to today’s speed, which is not easily accomplished, but here it is masterfully done. It also makes for good pedagogy. Parente’s book, like her assessment and clinical approach, is clinically rich yet easily understood and applied. With its ability to be incorporated into virtually any theoretical modality, the MSSDT will appeal to clinicians of all theoretical persuasions. Erudite and comprehensive, the Multiple Self-States Drawing Technique is a book as useful to the neophyte therapist as it is the seasoned. About the Author Anthony F. Tasso, PhD, ABPP is professor of psychology and Deputy Director of the School of Psychology and Counseling, Fairleigh Dickinson University. He also maintains a private practice in Whippany (Hanover Township), Morris County, New Jersey.

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