NJ Psychologist Winter 2021

Winter 2021 | Volume 71 | Number 1

NJ Psychologist

Special Section: Forensic Psychology The Impact of the Coronavirus Pandemic on the Online Sexual Solicitation & Grooming of Minors: Guidelines For Prevention A Perspective on the Coronavirus Pandemic in Correctional Facilities: Recommendations For Mental Health Practitioners Juvenile Interrogation Law For Psychologists: The New Jersey Case Law

CE Article

Burnout Compassion Fatigue, Secondary Traumatic Stress, Vital Exhaustion: Effects, Treatment, & Implications For COVID-19 (1 CE)

Ethical Concerns Questioning Motives & Biases in Forensic Matters

Early Career Psychological Flexibility: Different Perspectives From Students and Early Career Psychologists For Stressful Times

Diversity The Unspoken Truth: Working With Survivors of the Sri Lankan Civil War

NJ Psychologist

Table of Contents 3 4 6

2019 -2021 Continuing Education Cycle President's Message

35 Welcome New Members!

Executive Director Role, Goals, and Room to Grow

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36 Diversity Matters

Who's Who

The Unspoken Truth: Working With Survivors of the Sri Lankan Civil War

Ethical Concerns: Questioning Motives & Biases in Forensic Matters

10 Burnout Compassion Fatigue, Secondary Traumatic Stress, Vital Exhaustion: Effects, Treatment, & Implications for COVID-19 (1 CE Credit)

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Special Section: An Introduction to Forensic Psychology

19 The Impact of the Coronavirus Pandemic on the Online Sexual Solicitation & Grooming of Minors: Guidelines For Prevention

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Book Review: Clinical Psychology in the Mental Health Inpatient Setting: International Perspectives

23 A Perspective on the Coronavirus

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Pandemic in Correctional Facilities: Recommendations for Mental Health Practitioners

Member News

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Psychological Flexibility: Different Perspectives From Students & Early Career Professional For Stressful Times

29 Juvenile Interrogation Law for Psychologists: The New Jersey Case Law

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Psychological Flexibility in Theory & Practice for Clients, Graduate Students, & Clinical Supervisors During COVID-19

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Thank you Foundation Donors!

Thank you Political Action Committee Supporters!

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Your 2019 - 2021 continuing education cycle ends June, 30 2021!

Every biennial license renewal period, licensees shall attest that they have completed courses of continuing education. Each applicant for biennial license renewal shall be required to complete during the preceding biennial period 40 credits of continuing education related to the practice of psychology.

For New Jersey Continuing Education Requirements (see Section 13:42-10.19 of the BoPE Regulations for details) Live-In Person Requirements The BoPE Regulations state that licensees must earn 10 CE credits through live in-person programming. Any live, online webinar that offers live interaction with the presenter qualifies toward the live in-person requirement for mandatory continuing education. All NJPA live webinars meet this criterion. On April 13, 2020, The State Of New Jersey Department of Law And Public Safety Division of Consumer Affairs issued a Notice of Rule Waiver pursuant to Executive Order No.103 (Murphy) COVID-19 State Of Emergency DCA-W-2020-04 – All Continuing Education Credits Earned During The Public Health Emergency, Including But Not Limited To Credits Earned Prior To The Date Of This Rule Waiver, Will Be Counted As In-Person Credits.

EARN CE AT HOME! Utilize NJPA’s Homestudy Continuing Education Library!

ON-DEMAND WEBINARS & HOMESTUDY ARTICLES Visit www.psychologynj.org | Under the Learn Tab NJPA Publication Disclaimers Errors and Omissions: The NJPA Central Office staff is responsible for the layout and formatting of the NJPA journal publication, the NJ 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 NJ 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 NJ Psychologist. NJPA makes no warranties or guaranties concerning the accuracy or reliability of the content contained in the NJ 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 NJ Psychologist articles posted on the NJPA website or their 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 NJ 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 NJ Psychologist.

Any opinions that appear in material contributed by others are not necessarily those of the Editors, Advisors, or NJPA, nor of the particular organization with which an author is affiliated.

Manuscripts should be sent to: NJPA Central Office E-Mail: NJPA@PsychologyNJ.org Published by: New Jersey Psychological Association | 354 Eisenhower Parkway, Suite 1150 | Livingston, NJ 07039 973-243-9800 • FAX: 973-243-9818 | Web: www.PsychologyNJ.org

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

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Welcome to 2021!

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e made it! I don’t have to tell you how challenging, tumultuous, and uncertain 2020 was, but as I write to you today, I am encouraged, excited, and hopeful. One of our members, Dr. Kelly Moore, was quoted in an article about parenting in the age of COVID-19 and one of my takeaways from her comments was the idea that managing uncertainty is a skill that can be learned, and I would extend that one can actually thrive during times of uncertainty.

As I think about my experience in leadership, I reflect on Past-President, Morgan Murray’s pre-COVID-19 experience, Past-President, Lucy Sant’Anna Takagi’s leadership response during the onset of the pandemic, and how my time, as a NJPA leader, is emerging during a continued period of uncertainty around us. The pandemic is still raging, vaccines are being distributed, all the while as mental health, stress, and wellness are becoming regular talking points in the media and in our everyday lives. All of us are functioning dually as wellness professionals, but also as individuals who are susceptible to the multiple impacts of the pandemic. I wonder, how many of us are leading or participating in mindfulness activities prior to beginning meetings? In this moment, I am reminded what I do well. One of the reasons I chose to be a psychologist is my skill in creating structure in ambiguous situations. As a consulting psychologist, when I work with systems or when working with a client or writing an assessment for someone seeking clarity about their mental health status, my ability to create clarity and operationalize a focused vision has been greatly beneficial for all involved. So, I want to lean in on this strength during my term as your president.

First, I want to institutionalize our shared leadership model, communication plan, and culture of transparency, which was elevated under Lucy’s term. Leadership will continue to be proactive and work to communicate with membership about relevant issues and decisions that impact our association and our work in the field. Additionally, I want to continue to de-centralize the leadership model and engage board members and members-at-large to become more active in association business in order to accomplish more and cover more ground during this season. NJPA needs to make sure our roles as psychologists are not only secure, but available for opportunities to expand our practice in the future.

Second, I want to help members understand the association and how we can collectively support one another from the view of our executive director, Keira Boertzel-Smith. Keira has frequently described the four pillars of the association as membership, advocacy, continuing education, and communication. These are the essential activities that make NJPA

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The Five Pillars of the Association Membership: • • •

Support our plan to recruit 300 new NJPA members Support our plan to grow NJPA Affiliate membership Support our plan to cultivate a culture that honors and celebrates our current members

Advocacy: • • •

Support our plan to reformulate the insurance committee as an advocacy tool Support our plan to secure the role of psychologists in the integrated care arena Support our plan to continue the conversation about RxP

Continuing Education: • • •

Support our plan to increase the number of training offerings we provide to NJ Psychologists Support our plan to develop a pain management training project Support our plan to create continuing education home study video library for members

Communication: • • • •

Support our plan to create and share relevant articles in our journals Support our plan to market our Mental Health Awareness Events Support our plan to promote social justice and racial equity as resources for change Support our plan to re-invigorate our listserv community

Association Administrative Business: •

Support our Strategic Planning Process

vital and relevant to the field. These areas need our attention and collectively, our active support. Recently, in our conversations, a fifth pillar was added, association administrative business. This was a focal point last year because we had to maintain the financial health of the organization, but has now evolved into revisiting our strategic plan, which sunsets in December 2022. Again, I want to stress that these five pillars need our collective attention and I want to ask for your support as NJPA embarks on the following tasks and activities this year.

Lastly, please be on the lookout for announcements to join the Pain Management Training Task Force, and your invitation to join committees that you expressed interest in. You may also want to join a call to participate in one of our leadership development projects or the Parliamentarian Bench that was formulated under Morgan’s term.

Let’s stay active and involved!

In closing, I hope you have received the central point of this message…simply stated, we are stronger together and are a force for good when we collectively support each other, our association, and our communities.

I am excited and optimistic about our future. Please join me in spreading that hope!

NJPA President Daniel Lee, PsyD

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communicate with the organization, leadership and members, the association’s goals and the actions needed to achieve those goals. The past reflection and forward planning work starts in 2021. The executive director should be a valuable resource in assisting the association with articulating our current reality, where are we going, and how we are going to get there. I want to stress the need for membership, committees, and Central Office acceptance of, and willingness to, actively support and participate in the process, ensure that the plan is written in clear and simple language, and that the implementation steps are manageable. Lastly, I will work to make the strategic plan work visible with continuous and effective Central Office marketing.

Executive Director Role, Goals, and Room to Grow

by Keira Boertzel-Smith

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e are all going through something during this ongoing pandemic, even if it is not the same thing as each other. We all have degrees of fears, gratitude, and a new perspective on life. This ongoing pandemic demands that we look inward and ask ourselves and each other, “How are you?” This January, I decided to focus on an inward reflection, as it pertains to the NJPA executive director role and NJPA association business. I see that there is room to grow, which is exciting.

Community Relations and Advocacy The COVID-19 pandemic provided a much needed spotlight on mental health. This year, we have the potential to build and grow our favorable relationships within the state, and nationally, to address psychology. NJPA can inform, engage, inspire community action, and make alliances to leverage influence. I look forward to being available to the calls for conversation with APA, our state legislators, NJPA affiliates, BoPE, and outside organizations to address, promote, protect, and enhance the science and profession of psychology. I look forward to assisting with facilitating the review and discussion of, and decision-making for, the expected increase in mental health legislation.

Running a successful association takes an active executive board and a dedicated staff led by a capable executive director. While the role of the board is to provide oversight and guidance, and ensure that the organization stays aligned with its mission and values in addition to complying with all federal and state laws, the board hires a key staff person, the executive director, to execute those policies, programs, and initiatives. The executive director is charged with the day-to-day operations of the organization, managing staff and the consultants, keeping the board informed on what the organization is doing, attending key meetings, and maintaining open lines of communication with the board, members, and the public.

The board and executive director also work together on broader projects that are important to the well-being of the organization. This work provides the executive director with a unique view of the executive director role, association, and of the potential for growth.

Operational Effectiveness COVID-19 required NJPA to ask more of our apps and technology. In 2021, we will continue to gather through video and in group communication chains to check in, provide continuing education, and get our work done.

NJPA has the opportunity to take advantage of the virtual footprint that members and the public leave on the NJPA website, through attendance at our meetings and continuing education programs, and while accessing our resources and publications. NJPA can make 2021 a time to use this newly captured data to better understand ongoing needs and trends to ensure that NJPA blossoms.

My two favorite pieces of advice that I have received as executive director are: 1. An executive director can have goals and visions, as long as they are firmly within the association’s mission and strategic plan.

2. The key to a good working relationship between president, board, and executive director is no secrets, no surprises.

Fundraising and Resource Development NJPA President, Dr. Daniel Lee, asked NJPA and the NJPA Foundation to think outside the box when considering income. There is no question about rising operating expenses, but what about income sources? How can we reconsider new ways to increase the money coming into the association to help fulfill our individual missions? For example, NJPA can ensure that outside organizations are contacted about continuing education sponsorship opportunities for all of our live and recorded programs.

The NJPA Foundation can consider outside grants and partnerships to complement our members’ donations. I am open to exploring new revenue sources with our boards, chairs, and staff. It is prime time for resource exploration.

With these two pieces of wisdom, I have come to view the below six areas, as key areas to ask “How are you doing?” and areas to consider the potential for growth.

Strategic Leadership and Planning The current NJPA strategic plan will sunset in December 2022. This strategic plan is the document used to

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Organizational Management The COVID-19 pandemic abruptly changed the NJPA Central Office physical work dynamics, including our communications with each other, members, and the public. NJPA will lean into this new remote human power management frontier, and embrace technology and remote work benefits. We are learning to better control our distractions, and improve creation of goals and boundaries to most effectively and efficiently perform our association duties and take care of ourselves.

a spreadsheet, and it provides a detailed, organized, and easily understood breakdown of how much money NJPA anticipates coming in and how much NJPA anticipates spending each year. It’s an invaluable tool to help NJPA prioritize its spending and managing money. Planning and monitoring the NJPA budget will help NJPA identify wasteful expenditures, adapt quickly as our financial situation changes, and achieve our financial goals. In the summer of each year, the executive director and bookkeeper work on a first draft of the following year’s budget. In 2021, we are still under the cloud of the pandemic and must be fiscally conservative. It is imperative that we continue to watch our expenses and grow our income. However, it does behoove NJPA to consider how to best use our operating savings and investment accounts. The NJPA fiscal management must be built into our new strategic plan.

Fiscal Management The NJPA board has the responsibility to ensure that NJPA’s financial matters are properly managed. NJPA approves the following year’s budget in December. The budget is an itemized summary of anticipated income/ revenue and expenses for the upcoming calendar year: January through December. It is created using

2021 NJPA EXECUTIVE BOARD (serve through year indicated)

(1YR) NJPAGS CHAIR: Jared Hammond

NJPA OFFICERS (1YR) PRESIDENT: Daniel Lee, PsyD

p.bolling@att.net

danielleepsyd@msn.com

(1YR) PRESIDENT-ELECT: Peter DeNigris, PsyD

pdenigris@somersetpsych.com

(1YR) PAST PRESIDENT: Lucy Sant’Anna Takagi, PsyD

lucytakagi@yahoo.com

(3YR) (2019-21) SECRETARY: Mary Blakeslee, PhD

maryblakeslee99@comcast.net

jhammond@kean.edu

AFFILIATE CAUCUS CHAIR: Phyllis Bolling, PhD (1YR) CODI CO-CHAIRS: Phyllis Bolling, PhD; p.bolling@att.net Susan Herschman, PsyD; susanherschman@gmail.com EXECUTIVE DIRECTOR: Keira Boertzel-Smith, JD

NJPAkbs@PsychologyNJ.org

(3YR) (2021-23) TREASURER: Marc Gironda, PhD

DIRECTOR OF PROFESSIONAL AFFAIRS: Susan C. McGroarty, PhD; NJPAdpa@psychologynj.org

PRESIDENT’S APPOINTMENT (1 YR) (2020) PARLIAMENTARIAN: Joseph Coyne, PhD

Northeast Counties Assn. of Psychologists: Nansie Ross, PsyD; nansie@verizon.net

MEMBERS-AT-LARGE (3YR) (A=Affiliate generated; N=NJPA generated) (A-2019-21): Phyllis Bolling, PhD

Essex/Union County Assn. of Psychologists: Sara Tedrick Parikh, PhD; sjtparikh@gmail.com (Alternate representative - Dina Cagliostro, PhD dinacag@gmail.com)

mgironda@bartkyhealth.com drjcoyne@aol.com

p.bolling@att.net

(A-2020-22): Aida Ismael-Lennon, PsyD

alennon07@me.com

(A-2018-23): Elio Arrechea, PhD

elioarrechea@gmail.com

(N-2019-21): Nicole J. Rafanello, PhD

nicole@drrafanello.com

(N-2020-22): Aileen Torres, PhD

Mercer County Psychological Association: Loraine Washton, PhD; lwashton@thewashtongroup.com Middlesex County Assn. of Psychologists: Tammy Dorff, PsyD; tdorff@stridesinpsych.com Rosalie DiSimone-Weiss, PhD

aileentorres.phd@gmail.com

DrRosalieDiSimoneWeiss@gmail.com

Dr.Dan.DaSilva@gmail.com

Monmouth/Ocean County Psychological Assn.: Deirdre Waters, PsyD; deirdremwaters@gmail.com

(N-2018-23): Dan DaSilva, PhD

(3YR) (2019 -21) APA COUNCIL REPRESENTATIVE: Rhonda Allen, PhD, rhondaall@hotmail.com SPECIAL REPRESENTATIVES (1YR) ECP CHAIR: Melany Rivera Maldonado, PhD

melanym.rivera@gmail.com

Morris County Psychological Association: TBD Somerset/Hunterdon/Warren County Psychological Association: Janie Feldman, PsyD; drjanie@yahoo.com South Jersey Psychological Association: TBD

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Ethical Concerns Questioning Motives and Biases in Forensic Matters by, Jonathan Wall, PsyD

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y forensic work demands that I continually challenge myself and question my motives. We all have blind spots, and my colleagues’ objective advice is a necessary part of avoiding ethical pitfalls.

Colleagues can point out ethical concerns, biases, and other tripping hazards.

humbly share their mistakes while mentoring others on how best to avoid them.

Unfortunately, some evaluators cut corners even highly qualified individuals who should know better. For example, I recall discreetly telling a psychologist to rethink his habit of cutting and pasting snippets of canned Rorschach reports into his parental fitness evaluations.

Then there was a senior psychologist I once advised to stop calling a section of his report a neuropsychological assessment for “organicity” because he misapplied the Bender Gestalt perceptual-motor skills test as an attention and projective test. And finally, I worked with a patient in therapy who once shared that their custody evaluator offered to complete the MMPI-2 for them: “He was so nice. He said I looked tired. He told me to leave, and he would finish it for me!” In this matter, if the patient’s report was accurate, I doubt discussing my concerns with the evaluator would change his behavior.

For example, an attorney once asked me to prepare a parenting time evaluation. Despite my preference to serve as a joint expert for both parents, I sent off my retainer agreement. After interviewing and assessing both parents, I became increasingly convinced that the parent who did not retain me for my services should be the residential parent.

I found myself in a predicament. I figured the zealous attorney deserved to know my stance before I exhausted his client’s funds to write the report. However, I still needed to gather more information for his client before sharing my inchoate recommendations. When should I pull the plug? Should I continue to speak to all the collateral contacts and engage in home observations by the slight chance that I might decide otherwise? Given the client’s humble circumstances, should I lower my fee, not charge for my time, close down the process?

Beyond blatant plagiarism, lack of competence, and (alleged) connivances noted above; all forensic evaluators are prone to unconscious bias. While we might surmise that another evaluator skewed their recommendations given their “adversarial allegiance” to the attorney’s position who referred them the case, we may not perceive ourselves as biased. Our unconscious blind spots can skew our perception. Daniel Murrie, PhD’s research on unconscious bias, reveals that even the best of us may “select and interpret data in a manner that favors the party that retains them.” An attorney may then choose me to prepare an evaluation because I have consistently argued for the same positions they wish me to support. Murrie finds that “savvy attorneys may have a good sense of how evaluators tend to lean and pick them accordingly. We call that selection effects.” (Daniel Murrie, 2020, p. 72)

I consulted with a colleague who reminded me that the client’s financial straits are not my problem: my job was to write a thorough report not serve as an unqualified financial or legal strategist. The failure to do so could legitimately result in a board complaint. In this case, unsettling collateral information could sway my recommendation. I solved this dilemma by listing all of the remaining tasks with estimates of the costs. I shared this list with the client and attorney in order to give them the opportunity to make an informed decision about whether they wished for me to finalize the evaluation.

Whether deliberate or inadvertent, ethical missteps or, at least, the perception of questionable ethical lapses occur with some frequency in forensic psychology. What should you do when you come across an apparent ethical violation in another expert’s work?

This problem speaks to the complicated nature of forensic work and the need for consultation. Forensic evaluations often deal with murky matters, and providing a proper recommendation requires an extensive effort to interview and assess those we evaluate.

Bush, Connell, and Denney’s book Ethical Practice in Forensic Psychology: A Systematic Model for Decision Making provide a framework for addressing questionable and unethical conduct by a forensic evaluator. Bush et al. first ask us to identify the specific issue that runs afoul of the APA ethical guidelines. Then, they ask us to reach out

Notwithstanding the ethical challenges of forensic work, most forensic psychologists I’ve met are ethical, “good enough” professionals. We err at times, but we seek consultation. The exceptional few who stand above all in their intellectual rigor, and decency, when asked, often

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to our colleagues to address our concerns. If we are still unsatisfied and fear that substantial harm may arise from inaction, then we may have no choice but to contact the court and the state licensing board during the trial.

Making a diligent effort to get objective feedback beforehand may help clarify, you should contact the judge during a trial.

To recap this structured approach, Bush, Connell, and Denny ask you to analyze and identify the problem; consider the relevant issue(s); review the laws and regulations that the evaluator may have transgressed, and anticipate how this revelation may impact the legal process. After reviewing your findings with colleagues, you may be able to discern whether you ought to raise your concern during the trial or with the State Board of Psychological Examiners. If in doubt, contacting your malpractice insurance for their advice, reaching out to an attorney specializing in representing psychologists, and

Even then, Ethical Standard 1.05 Reporting Ethical Violations require us to be careful. Should the court find our concern not “egregious” enough, but, instead, determines that your complaint “specious,” we may have run afoul of APA ethics Standard 1.07, which involves making an “Improper Complaint.”

From the board’s perspective, examples of an egregious or outrageous action may include being intimate with a patient, releasing confidential information without consent, filing false insurance claims, or extorting money from a client. In contrast, is it “outrageous” to carelessly misquote collaterals, misinterpret or inaccurately report an inventory result or make a recommendation that overly favors the retaining party? Contacting the board to report a vague impression as biased or unprofessional may do more harm than good. It’s essential to be as specific as possible when outlining your concern and confirming your position with colleagues or the court.

raising your concerns with the ethics and forensic committees in your association are all good options.

REFERENCES APA. (2017, 01 01). Ethical Principles of Psychologists and Code of Conduct. Retrieved from APA.org: http://www.apa.org/ethics/code/#102 Bush, S., Connell, M., & Denney, R. (2006). Ethical Practice in Forensic Psychology: A Systematic Model for Decision Making. Washington, DC: APA.

What should you do, then, when you read a biased report replete with errors and unfounded recommendations in what appears to be a brazen attempt to deceive the court?

The last thing you will want to do is make an improper complaint only to be accused of having tampered with a witness. As such, Bush et al. refer to the American Academy of Neuropsychology’s recommendation to contact the court only after the trial ends. Be mindful that if the court deems your complaint frivolous, you may receive a counter-complaint for slandering another professional.

Daniel Murrie, P. (2020). How Reliable and Objective are Forensic Mental Health Evaluations. The University of Virginia, Institute of Law, Psychiatry and Public Policy. The University of New Mexico Health Sciences.

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Burnout Compassion Fatigue, Secondary Traumatic Stress, & Vital Exhaustion: Effects, Treatment, and Implications for COVID-19 (1 CE Credit)

Introduction By, Aaron Gubi, PhD

What is Burnout?

“As a metaphor for the draining of energy, burnout refers to the smothering of a fire or the extinguishing of a candle.

It implies that once a fire was burning but the fire cannot continue burning brightly unless there are sufficient resources that keep being replenished.”

(Schaufeli et al. 2009)

The special section this issue is intended to disseminate information regarding burnout as it pertains to psychologists, related health care workers, parents, and clients. In particular, the implications of COVID-19, as it pertains to compassion fatigue, secondary traumatic stress, and vital exhaustion and how they challenge healthy coping is assessed. The article concludes by examining psychological interventions and evidence-based practices that psychologists can utilize in their work with clients to prevent burnout and promote well-being. We thank Lorraine Gahles-Kildow, PhD, for her comprehensive examination of this topic in her article Burnout, Compassion Fatigue, Secondary Traumatic Stress, and Vital Exhaustion: Effects, Treatment, and Implications for COVID-19.

Burnout as a concept has been around for several decades. In an overview of the concept of burnout, Schaufeli et al. 2009 trace the early history of this phenomenon.

It was originally borrowed from a term used by drug addicts in the 1970s (Freudenberger, 1974) and was made more prominent when Maslach (1996) identified three distinct factors that comprised burnout. These factors were: 1) emotional exhaustion, 2) depersonalization, and 3) a reduced sense of personal accomplishment or efficacy (Maslach and Jackson, 1981; Maslach et al., 2008).

Aaron Gubi, PhD is a licensed psychologist and certified school psychologist. He is an assistant professor and serves as Clinic Director of Kean Psychological Services, the community training clinic for the Doctoral Program (PsyD) in Combined School-Clinical Psychology at Kean University. He also holds part-time positions with a private practice and an adolescent residential treatment facility, and currently serves as the editor of the NJ Psychologist.

At first, burnout was considered to occur only when working with people, especially in healthcare and human service occupations.

Later, people began to realize that these three factors could occur in other occupations and research in organizations began to explore the concept that chronic stress on the job could result in burnout. The persistence of burnout as a phenomena was explained by Maslach et al. in

Earn 1 CE credit when you read this article and complete the CE evaluation. Instructions for obtaining CE credit: Visit www.psychologynj. org and find the CE Homestudy Library link under the Learn Tab.

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2009 as resulting from two prime factors. One, the progressive imbalance between work demands and the collateral lack of resources to meet the demands. The depletion of resources can occur at the external level, for example, lack of equipment, space, and or funding, and at an internal level, such as reduced opportunities to rest and replenish one’s energy and reserves. Another influencing factor suggested by Schaufeli et al. 2009, for the maintained experience of burnout, was a motivational one. As service fields became more corporate, a mismatch began to occur between provider ideals for themselves and their recipients and corporate values for the organization and its bottom line.

Maslach and Leiter (2016) cite industrial psychology’s conceptualization as a form of job stress and use the term dimensions to explain the burnout experience. The exhaustion dimension produces behaviors like fatigue, lack of energy, and feeling debilitated. The cynicism dimension, originally called depersonalization, results in inappropriate behavior toward clients such as irritability, withdrawal, and negative attitude and loss of idealism. The inefficacy dimension replaces reduced sense of personal accomplishment and is measured by negative morale, an inability to cope, and low productivity. An additional aspect of this dimension seen in the healthcare field is medical error and malpractice lawsuits.

One of the first measures of burnout, and one that is considered the standard assessment today, is the Maslach Burnout Inventory (MBI).

It measures the three dimensions discussed above. A relatively recent development in the burnout area has been to design measures that capture the opposite experience of burnout, termed engagement.

As stated by Maslach and Leiter (2016), engagement dimensions are reflected by high energy, involvement, and a sense of efficacy.

Another measure, the Utrecht Work Engagement Scale assesses vigor, dedication, and absorption as a separate, positive experience at work.

Work Related Quality and Safety Cost in Healthcare Burnout In a discussion paper by Dyrbye et al. (2017), they cite cross sectional studies done with US surgeons where error and malpractice claims were independently related to burnout. They further suggest that burnout and medical errors have a bidirectional, cyclical relationship. As burnout levels increase, the likelihood that errors are reported also increase. Additionally, when errors are reported, burnout tends to become worse. The level of burnout in nurses has been associated with more infections in patients especially in the ICU environment and both doctors’ and nurses’ burnout levels are associated with mortality ratios and teamwork reductions. Job dissatisfaction, turnover rates, and reduced work effort are all other aspects of the efficacy dimension that have been impacted by the burnout experience in healthcare workers.

The Personal Cost of Burnout The personal cost of burnout is that it produces “real suffering among people dedicated to preventing and relieving the suffering of others” (Dyrbye et al., 2017).

Studies have shown a 25% increased risk of alcohol abuse and a 200% increased risk of suicidal ideation in physicians compared to the general US population.

Specifically, the suicide rate is 40% higher for male physicians and 130% higher for female physicians in the US compared to other workers.

Gender and Racial Diversity Issues Templeton et al., 2019 found that there were genderbased differences in burnout, for example, female physicians reported more emotional exhaustion while men reported more depersonalization. Some of the gender-based issues faced by women included lack of role models, challenges of dual career couples, a finite number of years to bear a child, lack of parity in salaries, lower number of promotions, conscious and unconscious biases, and higher rates of experienced sexual harassment. Women physicians earned less money consistently throughout their careers and across specialties. In addition, women who became mothers experienced discrimination when pregnant and during breastfeeding resulting in limited opportunities for advancement and higher self-reported burnout. This study cites that 70% of women reported experiencing gender discrimination and they postulate that women in racial and ethnic minority groups may experience additional discrimination leading to feeling marginalized with a consequential decrease in self-confidence (inefficacy).

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The prevalence of racial/ethnic differences in physician burnout has not been investigated as widely. Garcia, Shanafelt, West et al., 2020, sought to investigate this in a second analysis of a cross sectional study of US physicians from 2017 to 2018. Burnout was seen in 44.7% of Non-Hispanic White physicians, 41.7% in NonHispanic Asian physicians, 38.5% in Non-Hispanic Black physicians and 37.4% in Hispanic/Latinx physicians as compared to general workers in the population. The minority racial/ethnic groups of physicians were less likely to experience burnout as compared to the White physicians.

This pattern seemed to be associated with less reporting of emotional exhaustion for the minority racial/ethnic groups. There were no reported differences with the depersonalization dimension of burnout. In addition, Black physicians reported more work life integration than White physicians.

Depression and career satisfaction showed no significant differences along race or ethnic dimensions. Possible explanations suggested by these authors were: 1) stigma attached to selfdisclosure of burnout for minority/racial/ethnic groups, 2) inability to retain medical students from minority racial/ethnic groups, 3) a difference in resilience factors associated with being from a minority racial/ethnic group and a selection bias that favors those with resilience from these groups.

One multi-institutional study reported that minority students showed resilience and recovered from burnout more than their White contemporaries.

The authors suggest that there is a dearth of information about minority racial/ethnic differences and that further research will help to elucidate these possible explanations.

Cultural Diversity When resources fail to keep pace with demands and when workers do not have the opportunity to rest and replenish depleted energy, organizational values create a conflict with individual values and one sees a motivational depletion in the individual in addition to energy depletion or exhaustion (Shanafelt et al., 2009). Even though work environments and national values differ across different countries and cultures, studies show that burnout occurs in Western and Eastern Europe, Asia, the Middle East, Latin America, Australia, New Zealand, Africa, China, and the Indian subcontinent. It seems that as countries develop with increasing work, productivity, and time pressure demands, burnout increases accordingly. Often, the term exhaustion is used

and in some European countries, like Sweden and the Netherlands, burnout has become an “established medical diagnosis” (Shanafelt et al., 2009).

Burnout and its Relation to Secondary Traumatic Stress, Compassion Fatigue, and Vital Exhaustion Much research has focused on the exhaustion dimension of burnout. Schaufeli et al. (2009) and Cieslak et al. (2014) note the overlapping definitions and measurement of the burnout experience as well as the evolving conceptualizations of exhaustion.

Researchers have included physical exhaustion and mental and emotional exhaustion. Others add physical and psychological fatigue to exhaustion.

Melamed et al., (2006) added vital exhaustion and cognitive exhaustion to the conceptual framework.

These authors consider burnout the “depletion of individual energetic resources as represented by feelings of physical fatigue, emotional exhaustion, and cognitive weariness. This depletes coping resources and can result in physical illnesses, especially cardiovascular events. They propose that vital exhaustion is like burnout in that it is associated with work stress and it influences many other detrimental outcomes, such as increased irritability, sleep disturbances, and health impairments and disorders such as inflammation, immune, and metabolic disorders. They reason that chronic stress activates the hypothalamic pituitary adrenal (HPA) axis on an excessive basis. This then causes dysregulation of the HPA and therefore a dysregulated allostatic response which affects glucocorticoids (mainly cortisol) that has a regulatory role in whole body homeostasis, basal activity, and termination of the stress response. A dysregulated HPA tends to influence hypocortisolism (lack of cortisol availability) that can result in increased risk for autoimmune disorders, inflammation, chronic pain, asthma, and allergies (Heim et al., 2000 and Raison and Miller, 2003 as cited by Melamed et al. 2006). Thus, stress influences burnout and vital exhaustion that influences health disorders that serve as risk factors for cardiovascular events. Segerstrom and Miller, 2004 as cited by Melamed et al. 2006, found that chronic stressors were associated with suppression of cellular and humoral immunity, thus exhausted people were more at risk for reduced immunocompetence and prone to infectious diseases, such as upper respiratory and viral infections.

Hobfoll (2000,) as cited by Melamed et al., (2006), suggests that in the early stages of burnout when active coping is still being used to replenish loss of energetic resources, anxiety often accompanies burnout, whereas, in later stages of burnout

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depression is noted. This is based on the notion that one’s energetic resources like vitality and vigor can be used rapidly and are difficult to replenish. The authors suggest that organizational and individual psychological interventions are best in the early stages of burnout and vital exhaustion before physical health impairments set in.

Within the context of direct and indirect exposure to trauma, the burnout construct is related to compassion fatigue and secondary traumatic stress.

An overlapping conceptual framework allows one to address exhaustion and other factors related. Compassion fatigue is considered a type of burnout associated with caregiving.

of resources theory (COR) (Hobfoll,1989, Shoji, 2015) that posits we only have a limited amount of resources to cope with ongoing stress and continual exposure to stressors lowers our reserve, resulting in secondary traumatic stress symptoms.

It captures the emotional components of caring, empathy, and emotional investment, which are beneficial to those who provide care, but can also have a cost (Figley, 2002). In particular, according to Figley (2002), compassion fatigue can limit our desire to care about and “bear the suffering of others.” Figley states that compassion fatigue is a “secondary traumatic stress reaction” that results in symptoms similar to Post Traumatic Stress Disorder: re-experiencing the trauma material, avoidance of trauma triggers or numbing of emotions, and heightened arousal such as anxiety.

Burnout in parents “The fact is that child rearing is a long, hard job, the rewards are not always immediately obvious, the work is undervalued, and parents are just as human and almost as vulnerable as their children.

---Benjamin Spock (2011, p. 5)” (Spock, 2011 as cited by Mikolajczak et al. 2019) Parental burnout has the same features of burnout, but the three dimensions are related to the parenting role. Parents can feel overwhelming stress about their parenting role and feel that they lack the resources to deal with it (Mikolajczak et al. 2019).

This outcome coincides with the job-demand resources theory of stress (JD-R model) originally proposed by Demerouti, Bakker, Nachreiner, & Schaufeli, 2001, as cited by Schaufeli and Taris, (2014). The JD-R model suggests that high job demands with low resources leads to burnout and its consequent health impairments. The revised version of the JD-R by Schaufeli and Baker in 2004, added work engagement and vigor, dedication, and absorption as the positive counterparts to burnout (Schaufeli and Taris, 2014).

Cieslak et al. (2014), in a meta-analysis, found that there was a strong correlation between burnout and secondary traumatic stress with indirect trauma exposure, especially when it was measured within the framework of compassion fatigue.

Other researchers questioned whether burnout led to secondary traumatic stress or vice versa (Shoji et al., 2015). These authors used a longitudinal design across two countries, the United States and Poland. They found that job burnout may predict secondary traumatic stress, but secondary traumatic stress does not predict burnout. The pattern was in one direction and thus burnout may be considered a “gateway” outcome that makes the risk of developing secondary traumatic stress more likely. These findings are related to conservation

In a study with French-speaking parents from Belgium, Europe, and outside of Europe, with at least one child at home, data showed that there are

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three types of stressors that parents may experience: daily hassles, acute stressors, and chronic stressors.

Daily hassles included things like homework, work schedules, school, and after school activity schedules. Acute stressors were family conflicts, angry reactions, and sudden emergencies. Chronic stressors were any emotional, physical, and learning disabilities in children (Mikolajczak et al. 2018). It is when the demand placed by risk factors outweighs the resources, parents have to cope with them, that parents are more likely to experience burnout.

According to Mikolajezak et al. 2019, when this imbalance occurs, one sees extreme exhaustion and detachment (emotional and possibly physical) from one’s children and an insecurity (inefficacy) about whether one is able to be a good parent or not. Just the fact that you are experiencing stress does not mean that you are experiencing burnout. It is chronic, overwhelming stress that influences the definition of parent burnout (Mikolajezak et al. 2018, Mikolajezak et al. 2019). Parental burnout and job burnout can be separate experiences. One can be burned out from the job, but not have burnout with their children (Mikolajczak et al. 2019).

being a single parent, having very young children, being in an inadequate living space, or having financial difficulties, did not show any significant correlations in their preliminary studies. The upside of this finding is that the significant correlations found were with variables that can be changed through psychological intervention. The authors suggest that intervention studies should focus on “improving emotional competencies, improving adult attachment, improving marital satisfaction, enhancing coparenting agreement, and promoting positive parenting practices.”

Mikolajczak et al. 2019 investigated “escape ideation (ideas of running away or committing suicide), child neglect, and parental violence” as consequences of parental burnout. They used two cross-lagged longitudinal studies, one in a French cultural context and the other in an English cultural context to determine a relationship. The results showed that parental burnout had strong associations with escape ideations, neglect, and violence at all the times measured and across the two cultures. The authors suggest that more research is needed and that parental burnout may be a risk factor for child abuse and neglect. Identifying parent factors may pave the way for early intervention so that these adverse outcomes can be prevented.

Mikolajezak et al. (2018) found that there were three important risk factors that correlated with burnout. These were: 1) stable traits of the parent, 2) parenting, and 3) family “(dys)functioning.” The authors obtained weighted estimates associated with each risk factor. In the stable trait of the parent, they found a strong negative correlation between burnout and emotional intelligence (-.79) suggesting that as emotional intelligence increases parental burnout may decrease. Neuroticism (a personality trait measure) showed a positive correlation with burnout (.53) while an avoidant attachment pattern also showed a strong positive correlation (.42). One’s parenting style also has an effect. Positive parenting and self-efficacy beliefs showed a strong negative correlation -.62 and -.82, respectively. This suggests that interventions in self efficacy and promoting positive parenting styles may protect against parent burnout. In the family functioning factor, four variables were measured: exposure to conflict (.56), co-parental agreement (-.59), marital satisfaction (-.73), and family disorganization (.87). These correlations show that treatment targeting families in reducing conflict and disorganization while increasing agreement between parents on parenting practices may help in mitigating against parent burnout.

With regard to parent factor characteristics, a study was done by Hubert and Aujoulat (2018) investigating parent exhaustion from five different mothers in five different cities in Belgium. Although the method was phenomenological interpretative analysis, it is included here to provide some additional insight into the parenting risk factor for burnout along the exhaustion dimension.

Two in-depth interviews were performed at two separate times for each subject and the following themes emerged: overinvestment with perfectionistic standards and self-pressure, along with a fear that they were not good parents. They also reported a fear that everything they did now would affect their child’s future (projection).

These overarching fears led to exhaustion that seemed to lead to emotional distancing and were described as robotic like behavior towards their children. They then began to lose control with their children verbally but, in this group, they did not physically hit their children. This led to a change in their self-identity comprised of selfhate, shame, guilt, and loneliness. These mothers did not ask for help, but, once they were able to identify, express, and manage their emotions, they had a better

understanding of the burnout experience and were more open to talk about it. The authors suggest that interventions that facilitate emotional competence and emotional intelligence may help mitigate against this type of inefficacy dimension of parental burnout.

An interesting original finding about their research in risk factors was that sociodemographics, for example,

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depressed and anxious. (Kannampallil, T.G. et al., 2020) Despite being a vulnerable group, very few trainees took advantage of the mental health support services that were available to them at the workplace.

Implications of COVID-19 COVID-19 has certainly taken a toll on healthcare workers, and, presumably their levels of burnout, compassion fatigue, secondary traumatic stress and vital exhaustion have been affected.

A brief article by Liang, Zhu, and Fang (2020) gives us some information about the post-traumatic stress response and COVID-19 that may inform us about the possible secondary traumatic stress responses. The authors from Wuxi and Shanghai, China, hypothesize that there is a circular relationship between PTSD from the stress of COVID-19 influencing immunosuppression that, in turn, influences one’s susceptibility to COVID-19. They suggest that PTSD shows two phases with regard to the stress response. In its early stages, there is acute stress and a subsequent increase in the immune response, however, when the stress becomes chronic, one sees a suppression of the immune response that then can lead to increased susceptibility to infections, particularly respiratory viral infections, like influenza and pneumonia (Song H, Fang F, Tomasson et al. 2018; Yang et al. 2020 as cited by Liang, Zhu and Fang 2020). This research corroborates with the physical pathways and outcomes stated in the Melamed et al. (2006) study.

Previous research on burnout suggests that US physicians were already experiencing burnout before COVID-19. Shanafelt et al. 2015 found that more than half of US physicians compared to US workers in general reported experiencing at least one burnout symptom and dissatisfaction with their work life balance. This was an increase seen from their research in 2011 that showed that less than half of the US physicians reported burnout. A significant percentage (about 46%) reported high emotional exhaustion, while about 34% had high depersonalization, and 16% showed low personal accomplishment scores on the Maslach Burnout Inventory (MBI). The rates of depression 39% in 2014 vs. 38 % in 2011 and suicidal ideation 6.4 % in

2014 vs. 6.4% in 2011 stayed the same. Physician specialties reported different percentages of burnout with the highest burnout occurring in the Emergency Medicine field.

Parents also have been impacted by the quarantine that made them take on multiple roles all at once, making sure their children were attending Internet-based classes, doing their school work plus homework, all the while performing their own full-time work at home, along with their usual parenting duties. The American Psychological Association’s Stress in America Report pertaining to stress in the time of Coronavirus states that “American parents are, on average, feeling significantly higher levels of stress than adults without children.” About 71% of American parents say that managing online learning for their children is a major stressor, while 67% of American parents state that the government’s response to COVID-19 is a source of stress (Mental Health Weekly, 2020). Additionally, parents also labeled inadequate access to healthcare, change in routines, food and housing access, and self-isolation as significant stressors. People of color have also reported that they feel “constant” stress about “getting the virus,” as well as “getting their basic needs met and having adequate access to healthcare.”

In a review done by Balasubramanian et al.

(2020), they found that workers in the healthcare field in Wuhan, China, were overwhelmed by being thrust into an unfamiliar situation with high risk. This resulted in high levels of distress and depression. Research done on healthcare workers on the frontlines in Wuhan, reported anxiety, stress disorders, and depression. Further, mental health impairments were prevalent across all participants, but in different degrees, for example “subthreshold 36%, mild 34% moderate 22% and severe 6%.”

These healthcare workers used different coping strategies “perusing psychological resources (36.3%), accessing digital psychological recommendations (50.4%), and participating in therapeutic support (17.5%).” It was hypothesized that workers who were severely distressed were less likely to obtain resources to cope. Of note here is that the largest percentage of use of coping resources were from digital psychological recommendations as opposed to therapeutic support.

Fontanesi et al. (2020) examined the effects of the lockdown of COVID-19 on parents in Italy. The outcomes they describe may be generalized to US parents. The lockdown has increased parent stressors, such as managing frequency, duration, and outcomes of children’s schooling, financial worries, anxiety about social isolation of themselves and their children due to lack of peer and teacher support, and concerns about physical health and how to present accurate information of COVID-19

In a recent study of frontline healthcare workers in the United States, it was found that physician trainees who were exposed to COVID-19 patients reported more stress and burnout than a non-exposed group.

In addition, they reported moderate to extreme stress with regard to childcare and a lower work life family balance. Females were more likely to be stressed while unmarried trainees were more likely to be

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in an age-appropriate manner. Loss of security, predictability of the lockdown and disease course, and immobility are all factors that can contributed to detachment and distancing by parents. For those with pre-existing mental health problems, these conditions can be exacerbated. Not all parents are able to address their children’s educational needs, especially for those children with disabilities. Research has shown associations between parents’ mental health and their parenting practices, for example, parents’ “lack of confidence in their parental role, high stress, too much or too little discipline, more frequent use of punishments, and verbal hostility.” The authors suggest family interventions should address certain key issues: safety, distress, dysfunctional coping strategies, and negative parenting behaviors. In addition, therapists should promote and enhance hope, social connectedness, self-efficacy, and psychological well-being.

therapy delivered via telehealth was equally as effective as in-person therapy. Cognitive processing therapy is a subtype of cognitive behavior therapy where one uses psychoeducation about trauma, focusing on one’s “stuck point” in cognitions or “problematic beliefs,” and examining the impact of their view of the world, themselves, and others as a result of the trauma. Cognitive strategies are then

Possible Interventions for Burnout, Compassion Fatigue, Secondary Traumatic Stress, and Vital Exhaustion Positive Lifestyle Balasubramanian et al. (2020) suggest that coping strategies can include positive lifestyle interventions, such as regular quality sleep patterns, eating healthy meals, and getting physical exercise. Research has shown that having a positive attitude and seeking family and peer support are healthy coping mechanisms.

Mindfulness A before and after design study by Krasner et al.

2009 provided an intensive education program to primary care physicians that included mindfulness, communication, and self-awareness training for eight weeks with 10 months of maintenance.

They found that improved mindfulness decreased emotional exhaustion and depersonalization, but increased personal accomplishment. They also saw an increase in empathy, conscientiousness, and emotional stability.

Luken and Sammons (2016), in a systematic review of mindfulness practice and job burnout, found that job burnout was decreased in six of the eight studies investigated following mindfulness training.

Cognitive Processing Therapy For PTSD An article by Moring et al. (2020) cites practical applications of delivering cognitive processing therapy through telehealth modalities. Previous research had established that cognitive processing

used with common themes related to trauma, such as “safety, trust, power and control, esteem, and intimacy” (Moring et al. 2020).

Progressive Muscle Relaxation Research conducted by Liu et al. 2020 in patients with COVID-19 in social isolation in Haikou, China, showed that practicing progressive muscle relaxation 30 minutes a day reduced anxiety and improved sleep quality. This was a randomized controlled clinical trial. It was performed as an alternative to using benzodiazepine-type drugs for sleep and anxiety reduction that have the potential to create respiratory depression in already compromised patients.

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Possible Positive Psychology Interventions for Vital Exhaustion Cardiac Events, Immune System Issues and to Increase Vigor, Vitality, and Engagement Fredrickson et al. (2000) showed experimentally that inducing positive emotions following a stressful event can bring cardiac reactivity back to normal faster than if one experiences a negative emotion or a neutral emotion. The authors called this the “undoing effect” of positive emotions.

Another positive effect of inducing positive emotions for mental, emotional, and physical health is that positive emotions serve a “broaden and build” function in providing cognitive, psychological, and biological resources to us. Specifically, positive emotions can broaden our cognitions so that we can perceive in an expanded way, seeing broader and more divergent alternatives “pathways thinking” thus being able to problem-solve and cope more effectively “broad minded coping.” The build aspect of positive emotions results in gaining more ego resilience and having more social connections “bonding” that enhances more “purpose” in living. Finally, we also build biological resources by increasing cardiac vagal tone that increases the regulation of the cardiovascular system, and positive emotions have shown decreases in inflammatory cytokines involved in inflammation (Fredrickson, 1998; Kok et al. 2013; Fredrickson et al. 2008; Stellar et al. 2015).

In a comprehensive review article done by Fredrickson (2018) called the Biological Underpinnings of Positive Emotions and Purpose, she cites research studies that show that negative conditions or stressors can increase the expression of genes involved with inflammation and decrease gene expression of antiviral responses and IgG synthesis. Positive emotions and a sense of purpose can create an inverse to that gene expression profile, that is: lower inflammation and increase antiviral response possibilities. Similarly, in a study done using a lovingkindness meditation (LKM) group versus wait list controls, the LKM group showed increases in cardiac vagal tone (CVT) a prognostic indicator of good heart health. Oxytocin (produced by such positive emotions as love) has been associated with reduced inflammation, increased pro-inflammatory cytokines, increased CVT, and decreased hypertension. Fredrickson calls this a “vantage resource” because it enhances the emotional rewards of meditation and makes us more responsive with positive emotions to social connections. Intranasal oxytocin vs placebo

showed an increase in reports of spirituality (same day and 1 week later) and a boost in positive emotions when engaged in LKM and mindfulness meditation. This was pronounced especially with awe, gratitude, inspiration, and love.

Positive well-being that incorporates positive emotion, positive affect, and optimism, has beneficial effects on mental health and flourishing and physical health. There are two types of positive well-being: hedonia, a pleasure in attainment of happiness or satisfaction, and eudaimonia, a deeper well-being due to meaning & purpose in life. In a review on well-being and its relations to physical health, Sin (2018) found that positive well-being was protective against incident cardiovascular disease, secondary cardiac events, and mortality. These were partially mediated by better health behaviors such as physical activity, medication adherence, sleep, diet, and non-smoking. However, positive well-being was also associated with better immune, neuroendocrine, and cardiovascular functioning, in addition to less stress reactivity and healthier coping skills. Sin concludes that “Interventions to enhance positive well-being or to sustain well-being in the face of stress may have the potential to promote favorable physiological functioning, optimal health behaviors, and downstream cardiovascular outcomes.”

In conclusion, burnout, compassion fatigue, secondary traumatic stress, and vital exhaustion share overlapping effects on our mental, emotional, and physical well-being. COVID-19 has tested us in many ways and has exacerbated the above conditions, especially healthcare worker burnout and parent burnout. It is important to recognize these conditions and realize that there are interventions that can help us overcome these adversities and even enhance our ability to flourish in these trying times. ** some of the original sources used were presented with Dr. Nancy Gahles at the Integrated Healthcare Symposium in NYC February 2018 “Burnout Syndrome” and in 2019 “Compassion Fatigue Vital Exhaustion: a matter of the heart.”

References Furnished Upon Request About the Author Lorraine Gahles-Kildow, PhD, is a licensed psychologist in NJ, in private practice for 21 years as a cognitive behavior therapist treating adults, teens, and children with issues related to Trauma, PTSD, Compassion Fatigue, Burnout, Anxiety, OCD, Depression and other disorders. Former adjunct professor and adjunct instructor at Raritan Valley Community College and Union County College and former Instructor at Princeton Center for Teacher Education for 20 years.

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Special Section: Forensic Psychology Introduction

by David Brandwein, PsyD It is my genuine privilege to be able to write the introduction to this special section on forensic psychology. The practice of forensic psychology has been a passion of mine for many years, and is the focus of my private practice, my teaching at Kean University, and my research agenda. My practice is focused on the family court system, involving matters of child custody/parenting time and child abuse and neglect, and the nuances and complexities of this work require ongoing education and dialogue with peers.

It is with those insights in mind that I read the three articles in this special section. While they were focused on subspecialties within forensic psychology outside my scope of practice, I resonated with the contents of these articles. I specifically noted that the authors of all three articles focused on client welfare, including in the context of the COVID-19 pandemic, and offered guidance and best practice recommendations for service providers.

Although some forensic evaluations involve work that can be considered adversarial, client welfare must always be

paramount. The guidance and best practice suggestions were also helpful, and I found that the guidance and suggestions had applications to my own forensic practice. I am grateful for the work of the authors of these articles and want to thank them for their important contributions to the practice of forensic psychology.

I certainly hope that the articles contained within this special section provide opportunities for enrichment for my colleagues in forensic psychology and also provide some helpful insights to NJPA members unfamiliar with the practice of forensic psychology. I also want to wish everyone safety and good health in these challenging times.

About the Author David Brandwein, PsyD, is a licensed psychologist in NY and NJ. His private practice is located in Freehold, New Jersey. Dr. Brandwein is also an associate professor at Kean University and is the Associate Director of Clinical Training in the University’s Doctoral Program (PsyD) in Combined School-Clinical Psychology. Dr. Brandwein also enjoys reading books about history and practicing the mixed marital arts.

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The Impact of the Coronavirus Pandemic on the Online Sexual Solicitation and Grooming of Minors: Guidelines for Prevention by, Georgia Winters, PhD; Leah Kaylor, PhD; Elizabeth L. Jeglic, PhD; & Caitlin E. Krause

T

he global spread of the coronavirus (COVID-19) has been coined the “once-in-a-century pandemic” (Gates, 2020) and has resulted in governments around the world closing schools in an effort to prevent spread (UNESCO, 2020). As many schools globally have moved education to a partially or fully online format for the 2020-2021 school year, the Internet has become a vital learning resource for children and adolescents. Many minors are also turning to social media and online gaming to overcome the loneliness and isolation of quarantine (Onion, 2020). Notably, however, while the Internet has proved to be a necessary resource during these challenging times, the increase in online engagement by children and adolescents can, in turn, leave children more vulnerable to online sexual solicitation and grooming (Jeglic, 2020). The National Center for Missing and Exploited Children (NCMEC), Interpol, and may other agencies have reported an increase in online child sexual abuse due to the pandemic (Alfonso, 2020).

Thus, the present article aims to address concerns regarding online solicitation and grooming in the context of the recent coronavirus pandemic, as well as provide recommendations to children, their parents, and treatment providers to improve Internet safety for youth.

high rates of unwanted online sexual contact (20%) and solicitation (11%) among minors (Madigan et al., 2018).

Although predators often initiate contact with children online, these communications may not remain exclusively on the Internet. Research has found online offenders also contacted victims via text message and telephone calls, some with the intention of arranging an in-person meeting with the child (Tener et al., 2015).

Online Sexual Grooming

Online Sexual Solicitation

Online sexual solicitation of minors may involve the perpetrator using sexual grooming behaviors to prepare the child or adolescent for sexual abuse (Beech et al., 2008). While there is no universal definition of online sexual grooming, it generally describes the process whereby an offender emotionally manipulates the child into some form of sexually inappropriate behavior (e.g., exchanging photographs, cyber sexual activity, arranging an in-person meeting to engage in sexual contact; Ybarra et al., 2007). The Internet has the unique potential to accelerate the grooming process, likely due to the private nature of online chatting and the ability to quickly retreat if the risk of detection becomes too high (Black et al., 2015) This is concerning, since sexual grooming can have distressing consequences for the victim, such as feeling upset, fearful, unsafe, humiliated, shameful, vulnerable, threatened, or suicidal (Bowles & Keller, 2019; Mitchell et al., 2001).

The use of the Internet to target victims for child sexual abuse is a relatively new phenomenon, but an approach that has a wide reach (DeHart, et al., 2017).

The anonymity of the Internet allows predators of all ages and backgrounds to target victims online (Egan et al., 2011). Moreover, the Internet may be a preferred method for predators as it allows for communication with several potential victims at one time (Alexy et al., 2005). Sexual solicitation involves an adult inviting a minor to engage in sexual conversations or activities over the Internet (e.g., sending or receiving sexually explicit photographs, using webcams; Child Exploitation Online Protection Centre [CEOPC], 2010). A recent meta-analysis confirmed there are

In general, the process of online grooming involves selecting a victim, developing a trusting relationship with the child, and introducing sexual content (O’Connell, 2003). Online perpetrators tend to select victims based on the child’s perceived vulnerabilities, access, and opportunity (Malesky, 2007). Staksrud (2013) suggested the offender begins the grooming process by observing chat room communications without participating and viewing a minor’s profile to decide who to target. The age of the child, young-sounding usernames, and the perceived neediness, submissiveness, or loneliness of the child were found to be indicative of the victim being selected for unwanted online sexual contact (Malesky, 2007; Winters et al., 2017).

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2016).

After a potential victim has been selected, the predator engages the minor in a private conversation where grooming can commence. O’Connell (2003) describes two stages in the process of online sexual grooming in which the offender forms a friendship and then subsequently a more intimate relationship with the minor in an effort to gather information, determine vulnerabilities, and relate to the child. Early on, offenders often express having similar hobbies, interests, likes, and dislikes (Williams et al., 2013). The offender may seek to assess the risk of being detected by inquiring about the secretiveness of the conversation with the child (O’Connell, 2003). Some researchers have suggested that online predators may skip the friendship and relationship forming stages described previously and introduce sexual content early into the conversation, possibly to determine if the child will respond or if they need to find a new victim (Staksrud, 2013). After sexual content is introduced, online offenders frequently used compliments and flattery to facilitate the online sexual grooming process (Black et al., 2015;). While in-person grooming can take months or even years, online predators move quickly (often within just three days) from sexual conversation to participating in sending and receiving photographs, cyber sexual activity, or teaching the victim to masturbate (Briggs et al., 2011; Winters et al., 2017).

Online Gaming A more recent phenomenon has been the online solicitation of minors through online multiplayer video games (Bowles & Keller, 2019; Interpol 2020) that can give predators access to younger children (8 to 13 years) who may not yet be allowed to use social media (Threadgall & Horsman, 2019).

According to the Pew Research Center, 97% of teenage boys and 83% of teenage girls play video games (Perrin, 2018). Many games played by younger children, like Minecraft, Roblox, Among Us, have a built-in chat function, which normalizes interacting with strangers (Bowles & Keller, 2019). This permits opportunities for online predators to gain access to children and adolescents in the gaming environment and then attempt to move communications from the gaming platform to another social media platform, such as Skype or Kik, to allow for more privacy (Threadgall & Horsman, 2019). For children streaming their game play, they can have people subscribe and donate to their page.

Online offenders accessing children in gaming platforms may send money, gifts, or game credit, such as V-Bucks in the video game Fortnite, in an effort to build a relationship with the child and encourage sharing of sexually explicit images or videos. Once obtained, these images and videos may be used as blackmail to garner increasingly more graphic or violent sexually explicit materials (Bowles & Keller, 2019).

Vulnerable Online Platforms

The Impact of the Coronavirus on Online Sexual Solicitation and Grooming

Social Media and Chatrooms It is estimated that 90% of adolescents between the ages of 13-17 have used social media, and 75% of those have at least one active social media account (American Academy of Child and Adolescent Psychiatry, 2018).

Instagram is one of the most popular social media sites for young people (Tran, 2020), and recently the NSPCC has found that it was the most common application used for child sexual grooming in the United Kingdom (UK).

Over a period of six months, police recorded 1,317 cases of online sexual grooming, and of those, Instagram was used in 32% of cases, Facebook in 23%, and Snapchat in 14% (British Broadcasting Corporation [BBC], 2019).

Previous research has shown some online offenders choose to pose as minors, which gives them the ability to create one or more fake social media profiles, oftentimes using a stolen profile photo (Charles, 2017). Within the chatroom or anonymous chat applications, predators are able to use a host of manipulative techniques to sexually extort and blackmail victims (e.g., dares, polls, competitions; Tribune News Service, 2018). If a minor shares sexually explicit materials of themselves, the offender may threaten to share or disseminate these materials if the child does not comply with further requests from the offender (Stolberg & Pérez-Peña,

Since the onset of the global coronavirus pandemic in the spring of 2020, organizations like the Federal Bureau of Investigation (FBI) and the United Nations International Children’s Emergency Fund (UNICEF) have issued warnings that online offenders may be multiplying (Jeglic, 2020). NCMEC has seen an exponential rise in cybertips for online child sexual abuse; for example, in April 2019, NCMEC received one million reports on its CyberTipline compared to 4.1 million in April 2020 (Alfonso, 2020).

There are several factors associated with the coronavirus pandemic that will likely increase the risk for victimization of minors online, including: 1) increased Internet usage by minors; 2) inadequate supervision; and 3) increased loneliness and heightened desire for interpersonal interactions.

A consequence of the stay-at-home orders during the coronavirus pandemic has been a surge in Internet usage amongst children and adolescents because they are using the Internet for schooling and socializing. A survey of more than 3,000 parents released at the end of April 2020 by ParentsTogether, a national parent-led organization, found that almost 50% of the parents surveyed reported that their children were spending more than six hours per day online

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(aside from school) – a 500% increase from before the onset of the pandemic. As many students are now required to participate in online education, schools are providing students who previously may not have had Internetenabled devices at home with personal laptop computers in order to permit at-home learning via online forums and Zoom (Bourne, 2020). Therefore, it can be surmised that the general increase in Internet use by youth during the pandemic will produce higher levels of online contact with potentially predatory individuals.

solicitation due to their increased online presence and decreased parental supervision. A quote from Staksrud (2013) that is particularly salient to the current social climate is that “the Internet does not make children more vulnerable, but might make already vulnerable children more accessible” (p. 163) highlighting the need for improved child and parental education and support from mental health providers, as well as treatment recommendations, on how to keep children safe on the Internet, particularly during this period of increased risk.

Second, given that many parents are maintaining full-time employment from home while also juggling childcare and home schooling, it is likely that these circumstances could result in inadequate online supervision and loosened screen time restrictions (Joyce, 2020). Further, lower income families, whose children may already be at an increased risk for child abuse (Runarsdottir et al., 2019), may have parents that are more likely to have jobs that are deemed essential during the pandemic, meaning that they may be required to leave children at home alone while they work (Valentino-DeVries et al., 2020). This is concerning since prior research suggests that minors engaging in conversations with adult strangers most often do so during times when supervision is lacking. Specifically, GreeneColozzi (2017) found that minors were at increased risk for online victimization over summer vacation and winter breaks and during evening or late-night hours (when parents are unlikely to be monitoring the child’s activity).

With this combination of heightened Internet use and decreased supervision during the pandemic, minors may be more vulnerable to online solicitation now more than ever.

Children Experts recommend that children should be educated about how sharing information or photographs/videos with strangers via online chatrooms, social media websites, and gaming platforms can be dangerous (Jeglic, 2020).

Organizations such as Commonsense.org have created lessons plans for children of all ages for Internet safety that can be viewed and discussed (Oh, 2020). Other similar resources can be found through the NCA and the National Center for Missing & Exploited Children (NCMEC) that also include resources for parents. Children should be educated about what information is appropriate to post or share online. Studies have shown that many minors opt to share intimate personal details with adult strangers online, including name, age, interests, hobbies, and photographs; many of whom even included this content in public profiles, which are easily accessible to any observer (Greene-Colozzi, 2017). This information can in turn be used to sexually groom potential victims by allowing predators to profess similar interests in order to build a trusting relationship (Williams et al., 2013).

Moreover, since there are circumstances where the perpetrator may actually be known to the child (such as a friend of a friend), parents should discuss how sharing inappropriate content (e.g., sexual images via texting) could have negative consequences.

Lastly, children and teens may also be at increased risk for online solicitation during the quarantine as psychological vulnerabilities, such as loneliness and a heightened need for interpersonal communication stemming from social distancing, may make them more likely to engage in online conversations with strangers (Wolak et al., 2010). Indeed, a recent survey of 2,000 youth ages 11 to 17 revealed that 4% of respondents had received or been asked to send a sexual message to an adult, but this number nearly doubled (9%) for children who described feeling lonely, unhappy, or extraverted (NSPCC, 2020). This underscores the risk the current pandemic poses for predatory offenders to find children and teens who are likely experiencing these negative emotional states (Centers for Disease Control and Prevention, 2020); in fact, it is possible that an offender may even use these emotions to bond with the child, such as validating the child’s feelings of loneliness or boredom.

Parents Many children and adolescents have access to computers or laptops, tablets, smart phones, and gaming devices.

Children and teenagers who had caregivers who habitually monitored their online activity were far less likely to chat with adult strangers or experience online sexual solicitation (Greene-Colozzi, 2017) and thus, it is necessary for parents to monitor all of these devices. The parent should take special care to supervise who the child is communicating with and the type of content shared.

Guidelines should also be established about family rules about online device usage and how these guidelines will be modified/enforced during quarantine. For example, children should be only using Internet-enabled devices in common areas, and caregivers should consider placing limits on the time children can spend on Internet-enabled

Recommendations The coronavirus pandemic has created a situation where children and teens may be at greater risk for online

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devices. In the context of online grooming, some predators groomed their victims over numerous conversations across a lengthy period of time (Winters et al., 2017).

Therefore, limiting the excessive use of Internet sites can reduce the extent to which children can engage with potentially predatory individuals online. In addition to supervision, the majority of apps and games offer optional parental controls that can limit the user’s ability to chat with strangers, as well as block offensive and inappropriate contact and content. Further, there are more omnibus protection systems, such as Bark, FamiSafe, or Qustodio, which parents can purchase and install on their children’s devices to monitor texts, e-mails, YouTube, and over 30 social networks for safety concerns (Staples, 2020).

created a comprehensive website with resources ranging from anonymous counseling, confidential helplines, online self-help courses, referrals, and consultations. Additionally, researchers from the Karolinska Institute in Sweden created an innovative way for people to seek treatment online. The program, “Prevent It”, offers anonymous online cognitive behavioral therapy intervention for individuals who use child sexual abuse materials (CSAM) on the darknet. Advertisements for this treatment are placed on darknet CSAM websites, where participant’s privacy will be protected. By offering this intervention through the darknet, participants have the freedom to seek care without fear of legal actions based on engaging in CSAM. The intervention creators believe participants will be more open and honest compared to alternative in-person treatment methods. Blind randomized clinical trials are currently underway to determine its effectiveness for decreasing the consumption of child sexual abuse materials, but regardless, it is a step toward a solution for online offending (Parks et al., 2020).

It should be acknowledged that part of the attraction of these platforms is the ability for children and teenagers to play and talk with their friends, especially in these extremely isolating times. Therefore, if caregivers decide to permit their child to use the chat and voice functions, experts recommend that it is integral for parents and children to maintain open communication (Jeglic & Calkins, 2018). Setting aside a regular time for family discussions during the quarantine, such as dinner time or family meetings, can be helpful to establish a forum where such issues can be discussed. Regular conversations can help children feel comfortable discussing these issues with their parents, which consequently can facilitate their reporting of any predatory incidences online. As outlined by NSPCC (2020), parents should reassure their children they care and are interested in their life, inquire about what the child enjoys about their online activity, and ask about whether the child has any worries or concerns. Moreover, parents should ensure that they react carefully should their child disclose encounters with online predators, as punishing the children (e.g., restricting video game or social media use) could result in increased secrecy or engagement in risky online behaviors. Finally, if the parent notices or is informed of any suspicious or predatory online behaviors, they can consult the FBI’s website to learn how to report (FBI, 2020).

Conclusion The coronavirus pandemic and resulting stay-at-home orders has likely placed children and teenagers at a greater risk for online solicitation and grooming than ever before. Increased Internet use by minors, coupled with heighted psychological distress and potentially inadequate parental supervision, may result in conditions that make youth vulnerable to online exploitation. Ultimately, in the face of the numerous challenges ignited by the pandemic, the risk to youth online can likely be reduced with increased education, vigilance, and communication across various stakeholders.

About the Authors Georgia M. Winters, PhD, is an assistant professor at Fairleigh Dickinson University’s School of Psychology and Counseling. Her research focuses on sexual grooming, paraphilias, and sexual violence prevention.

Leah Kaylor, PhD, is a licensed clinical psychologist.

Her research focuses on child sexual abuse and sexual paraphilias.

Treatment

Elizabeth L. Jeglic, PhD, is a professor of psychology at the John Jay College of Criminal Justice and a NJ licensed clinical psychologist. Her research focuses on sexual grooming, sexual violence prevention, and evidence-based public policy.

There is a growing need for mental health resources for individuals who have sexual thoughts or behaviors involving children. Due to stay-at-home orders, there has been an increase in online offending (Parks et al., 2020). Researchers believe this increase is caused by a few factors: individuals have more time to spend online, new users are exploring the darknet for more extreme material, and individuals who have tried to quit previously have returned (Parks et al., 2020). In response, Johns Hopkins Bloomberg School of Public Health (2020)

Caitlin E. Krause is currently a graduate student in Fairleigh Dickinson University’s Forensic Psychology MA program. Her research interests include paraphilic disorders, sexual trauma, and online sexual behavior.

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A Perspective on the Coronavirus Pandemic in Correctional Facilities: Recommendations for Mental Health Practitioners By, Sharron Spriggs, Caitlin E. Krause, and Georgia M. Winters, PhD Department of Psychology and Counseling, Fairleigh Dickinson University

S

ince the start of the global coronavirus (COVID-19) pandemic, it is estimated that over 14 million individuals have tested positive for COVID-19, and over 600,000 individuals have died across 213 countries and territories (Worldometer, 2020). As a result, COVID-19 has been deemed a “once-in-a-century pandemic” (Gates, 2020). Government officials around the world have implemented numerous regulations to slow the spread of COVID-19, such as stay-at-home orders, school closures, and social distancing mandates (Harvard Medical School, 2020; Wamsley, 2020). For correctional settings, the spread of the coronavirus presents unique challenges due to a constellation of factors, including: 1) the overcrowding of prisons and jails, 2) the lack of resources at correctional facilities to decrease community spread, and 3) many inmates have a myriad of pre-existing health conditions that leave them especially vulnerable (Equal Justice Initiative, 2020; Vance, 2020). Ultimately, these unique conditions have produced unprecedented challenges for health care providers, including psychologists, working in jails and prisons. Therefore, the present article aims to provide an overview of the impact of COVID-19 on correctional facilities, followed by recommendations for psychologists working in these settings.

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The Impact of the Coronavirus on Correctional Populations According to the Marshall Project (2020), over 64,000 prisoners in the US have been diagnosed with COVID-19 and over 650 prisoners have died. In fact, correctional facilities represent 7 out of the 10 largest outbreaks across the US based on the percentage of the population infected (Equal Justice Initiative, 2020). For example, 15.7% of COVID-19 cases in Illinois can be traced back to the Cook County Jail (Health Affairs, 2020). COVID-19 is disproportionately impacting incarcerated individuals compared to the general public, with the known infection rate for COVID-19 in the prison population being 2.5 times higher than that of the general population (Equal Justice Initiative, 2020). In April 2020, there was an estimate of 696 positive coronavirus cases per 100,000 prisoners, compared to 250 positive cases per 100,000 people in the general population (Park et al., 2020). Moreover, data from June 2020 indicated that the number of positive cases in correctional facilities has continued to increase even as the number of positive cases decreases in the general population. While it is possible this could be attributed to increased testing among prison populations, especially amongst the hardest-hit states (e.g., Ohio, Michigan, Tennessee, and Texas), prisoners are nonetheless facing increased risk for infection (The Marshall Project, 2020). Of those states that do mass testing (e.g., Ohio), up to 85% of the prisoners tested positive for COVID-19 (Sawyer, 2020). As a result, media outlets and health advisors have deemed prisons as “clusters” of the coronavirus outbreak, a phrase that has also been attributed to nursing homes and food processing plants, two other highrisk settings (The New York Times, 2020).

Factors that Increase Risk in Correctional Settings As described above, with the emergence of COVID-19, issues were raised about prisons being incubators of infectious diseases, highlighting that “prison health is public health” (Kinner et al., 2020). The World Health Organization’s (WHO; 2020) guidelines on responding to COVID-19 in prisons recommended “urgently” addressing risk management, prevention, control, and treatment in such facilities. However, there was no consensus on how to implement such action, leaving correctional facilities vulnerable to outbreaks. Several factors may increase prisoners’ risk of contracting the coronavirus, including (1) overcrowding, (2) limited access to resources (e.g., hand soap and hand sanitizer), and (3) the vulnerable prison population.

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Overcrowding has been described as “one of the key contributors to poor prison conditions” (Penal Reform International, 2020), which is particularly relevant during the coronavirus pandemic. The Centers for Disease Control and Prevention (CDC; 2020a) recommends keeping six feet between individuals (i.e., social distancing) to prevent the spread of the coronavirus; however, correctional facilities may not be able to appropriately implement these recommendations. In the US, half of the states and federal prisons have met or exceeded their number of available beds, meaning that they are at capacity or over-capacity (Equal Justice Initiative, 2020). In overcrowded prisons, beds may be spaced as close as three feet apart (Kajstura & Landon, 2020), and prisoners can be confined to their shared cells for up to 22 hours a day that could result in near constant exposure to the coronavirus (Eisler et al., 2020). Due to these practices, prisoners are estimated to live in closer-contact conditions than even those on cruise ships (Kajstura & Landon, 2020). The number of prisoners living in close contact with each other makes it difficult to clean surfaces and lavatories between usages, which is especially concerning considering that many individuals infected with COVID-19 are asymptomatic and may be unknowingly spreading the coronavirus to other prisoners (Edwards, 2020). The close living conditions also make it hard to fully separate symptomatic individuals from healthy individuals.

Ultimately, overcrowding in prisons results in an inability to social distance, properly sanitize, and separate those that test positive for COVID-19 from those who are healthy.

In the national race to procure materials to combat the coronavirus, prisons are often left without proper resources to protect the prisoners and staff. For example, prisons have struggled to get enough test kits for inmates, resulting in only those showing symptoms being tested (Eisler et al., 2020). However, as noted above, there may be asymptomatic individuals among the prisoners who can spread the coronavirus to other prisoners undetected. This is why some states have made an effort to test every inmate to detect the spread of the coronavirus (Aspinwall & Neff, 2020), although this process has not been widely implemented. In addition to the shortage of tests, prisons struggle to get personalprotective equipment, such as N-95 or surgical masks, for their staff and inmates (Eisler et al., 2020).

Other preventative measures, such as hand washing and using hand sanitizer, are difficult to implement in prisons. Most prisons have banned prisoners from having hand sanitizer due to its alcohol content, though some have rescinded that ban due to the

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if they contract COVID-19. Prisoners have worse health than those in the general population; specifically, there is a higher prevalence of hypertension, diabetes, heart problems, asthma, kidney problems, and stroke amongst incarcerated individuals (Nowotny et al., 2017). These health problems may stem from factors external to the prison, such as poverty and genetics, but also the prison environment, such as limited ability to exercise and nutritional deficits (Equal Justice Initiative, 2020). The vulnerable prison population, combined with overcrowding and inadequate resources, places prisons in high risk categories for the spread of COVID-19.

Psychological Implications of the Coronavirus The American Psychological Association (APA; 2020c) named the coronavirus pandemic a psychological crisis, given the associated social isolation, changes in daily activities, job loss, financial stress, and grief. These mental health concerns can be prevalent for both inmates and correctional psychologists alike. Even before the pandemic, research has consistently shown that prisoners have higher rates of psychiatric disorders in comparison to the general public. In fact, in some states there are more people with severe mental illness in prisons than psychiatric hospitals. Suicide and self-harm are also more common in prisoners than in the general community when compared to persons of similar age and gender (Torrey et al., 2010). The risk of suicide in inmates is approximately 50% more likely for males and 60% more likely for females when compared to the general population. Environmental factors, including overcrowding, close quarters, and periods of isolation (i.e., solitary confinement) further exacerbate these poor mental health outcomes. Then, with the added stress of this mysterious immunocompromising virus that requires isolation (i.e., via social distancing), it is expected that prisoners are suffering from immense stress, depression, fear, and other psychiatric issues (Montoya-Barthelemy et al., 2020; The New York Times, 2020).

pandemic (Tolan, 2020). Another concern is that prisons have finite resources for respiratory support, such as oxygen (Widra & Wagner, 2020). If the prison exhausts its supply of oxygen, they need to transfer the affected prisoner to the hospital, a procedure that could jeopardize the prisoner’s medical condition and potentially expose others to the coronavirus. Indeed, the lack of sanitization and healthcare equipment are unique factors that contribute to exceptional rise and spread of COVID-19 in prison settings.

The population in prisons tend to be older, male, and people in poorer health, all factors that make them more vulnerable to COVID-19 (Montoya-Barthelemy et al., 2020; Nowotny et al., 2017; Williams, 2012).

Due to various criminal legislation enforcing harsher punishments (e.g., the “three-strikes law” implements a mandatory life sentence for an individual who has been convicted of a felony three times; Caulkins, 2001), prisoners are receiving longer sentences, resulting in prisoners older than 55 comprising the majority of prison population (Williams, 2012). Indeed, the percentage of people in state prisons that are aged 55 or older has more than tripled from 2000 to 2016 (Equal Justice Initiative, 2020). Given that research has shown that the coronavirus is more lethal for those over the age of 55, with the risk of death increasing with age, these elder prisoners represent a vulnerable group (CDC, 2020b). Research also indicates that men are more likely to have complications due to COVID-19 and die from it compared to women (Jin et al., 2020). The Federal Bureau of Prisons (2020) reports that 93.2% of incarcerated individuals are male, resulting in a majority of prisoners falling in the high-risk category. Furthermore, the CDC (2020a) warns that those with underlying health conditions, such as diabetes, heart problems, and asthma have a higher risk of severe complications

Psychologists and other mental health workers play a vital role in correctional settings by providing services to treat minor and severe mental illnesses. State and federal government designated psychologists as essential workers (i.e., the only employees allowed to work inperson during the governor’s stay-at-home orders), with the stipulation that psychologists do not have to provide their in-person services and should instead provide services through telehealth (i.e., therapy via zoom or doxy.me; APA, 2020b). During the pandemic, insurance providers, at exceptional rates, covered telehealth for community psychologists and these services have been widely implemented (APA, 2020b). However, this

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poses issues for providing psychological treatment to prison populations, as many facilities do not have adequate electronic systems needed for telehealth.

Furthermore, even if the facility has adequate electronic systems, prisoners might not have access to personal electronic devices or there may not be enough personal devices available.

As such, during the pandemic, when prisoners were in need of mental health treatment more than ever, it is expected these psychological services were limited, if not nonexistent. The expected high rates of mental distress in correction settings, combined with restrictions on available services, poses unique challenges for mental health professionals in jails and prisons. As correctional psychologists continue to utilize telehealth and transition back to in-person therapy upon return to the facilities, it is important to have guidance on ways in which practitioners can best provide services during the coronavirus pandemic.

provide individuals the opportunity to voice their concerns and ask questions to ensure the respect for human dignity. The use of open forums, that comprise both inmates and correctional staff, could be considered in order to promote an integrated and collaborative response. Mental health practitioners can assist in this endeavor by helping create and disseminate pertinent information, as well as facilitate group discussions on the subject.

2) Assessment for Suicide and Psychiatric Issues

Recommendations for Mental Health Practitioners in Correctional Settings Based on the above information, it is clear that mental health practitioners in jails and prisons serve an important role during the pandemic. The following suggestions have been made to increase the wellbeing of both incarcerated prisoners and those who have been, or will be, released because of the COVID-19 pandemic, as well as staff working with correctional population.

1) Psychoeducation Prisoners and correctional staff alike would benefit from opportunities for education about COVID-19 (i.e., the infection rates in the facility; how to prevent spread) and ways of coping (e.g., involvement in enjoyed activities, relaxation techniques), with the aim of reducing anxiety and improving morale (Larsson et al., 2003). These educational services should be provided to inmates and staff on a regular basis and as any changes occur in the facility and could be administered via written (e.g., pamphlets; handouts) and/or verbal (e.g., community meetings) formats. Ideally, these educational services would

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As noted previously, there were concerning rates of suicide in incarcerated settings before the pandemic and thus, screening for suicidality and psychological distress is especially pertinent during this time.

Ideally, suicide risk assessments should have been conducted on all inmates upon entering the correctional facility or, if there were limited resources, on those individuals who would likely pose a higher risk (Winters, Greene-Colozzi, & Jeglic, 2017). These assessments typically cover relevant risk (e.g., history of suicidal behavior, medical illness, familial history of suicide, life stressors, hopelessness, psychiatric issues) and protective (e.g., quality social supports, religiosity, reasons for living) factors. During the pandemic, it would be beneficial to utilize targeted suicide risk assessments based on those who fell in the moderate or higher risk categories based on these initial assessments. This updated assessment would include the evaluation of notable changes in clinical presentation or recent suicidal ideation, intent, or presence of a plan, as well as other factors relevant to suicidal risk for that individual. This could be facilitated through the use of a thorough clinical interview based on evidence-based factors, and/ or more standardized screening measures, such as

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the Columbia-Suicide Severity Rating Scale (Posner et al., 2008) and the Suicide Assessment Five-Step Evaluation and Triage (Jacobs, 2007).

Not only should there be screening for suicide specifically, but there should be increased attention to the development of psychological symptoms, such as depression, anxiety, and fear, in incarcerated individuals (Montoya-Barthelemy et al., 2020; The New York Times, 2020). It is recommended that mental health providers screen potentially higherrisk prisoners for mental health symptoms and make appropriate referrals (e.g., psychiatric or psychological treatment) as needed. For example, these targeted assessments could be done based on inmates who have documented psychiatric issues or individuals who have displayed recent changes in their clinical presentation (e.g., social isolation, self-harming behavior, panic attacks).

Another potentially vulnerable population at this time Includes the pre-trial defendants being housed in correctional facilities. Most courts closed during the height of the pandemic, with many continuing to remain closed or with limited services (United States Courts, 2020), which means that court dates have been pushed back. This understandably could lead to hopelessness, frustration, and other negative emotions for these pre-trial defendants; therefore, increased attention should be paid to these individuals to ensure they are properly assessed and treated, if needed.

Lastly, given that psychological staff is likely limited at this time (either working remotely or reduced contact services), it may be beneficial to provide education for front-line staff (e.g., correctional officers) on signs of suicidality and psychological distress, as well as the proper mental health referral channels. A combined effort to recognize and further assess suicidality and psychological distress is highly recommended during the pandemic.

psychological distress (Morgan et al., 2006). Given that resources ARE likely limited, especially during the pandemic, the identification and selection of services to higher risk groups will be important. That is, higher-risk inmates (e.g., those with serious and persistent mental illness or suicidality) should be provided opportunities for individual and/or group therapy, as these needs require a higher level of care.

4) Early Release It should be noted that in order to combat the spread of COVID-19, the federal and state governments have attempted to release offenders early or send them to home confinement (Simpson & Butler, 2020).

However, there are concerns that those who are released are spreading COVID-19 to the community and, most applicable to mental health professionals, that the prisoners might not be prepared to reintegrate into the community (Westervelt, 2020).

To address reintegration, prisoners should be offered pre-release services, such as psychoeducation or therapy, regarding what to expect upon release, how to cope with the barriers and challenges of release, and what services are available in the community.

Likewise, prisoners who will be released during this time should be given information regarding the current rates of positive cases in their districts and legislative rules in that area. Providing additional attention and care to those who are being release early can help ensure smoother transitions back to the community.

5) Psychologist Competence The APA, consistent with ethical guidelines, provided recommendations during the COVID-19 crisis to ensure that psychologists are remaining competent.

These recommendations included: competence in telemedicine (i.e., education on rules and regulations regarding HIPAA compliance) before beginning to see patients remotely; boundary setting (i.e., maintaining professionalism in the online setting); and confidentiality (i.e., recommending sessions be conducted in private settings, sending information via secure systems). The APA’s website provides numerous resources related to maintaining ethical and effective practices during the pandemic that all psychologists should become familiar with (APA, 2020a)

3) Treatment In addition to providing psychoeducational information to inmates as described above, some prisoners may also benefit from a more targeted treatment regarding COVID-19 concerns. For example, clinicians could organize and implement mental health groups dedicated to discussing and addressing mental health issues as they relate to the coronavirus pandemic. These groups would likely be beneficial, as supportive-expressive therapy has been shown to help those experiencing collective trauma (Gishoma et al., 2014). These groups should also target coping strategies that can be utilized in reducing

6) Psychologist Self-Care It is important that psychologists practice self-care to avoid burn-out and other issues experienced by essential workers during the COVID-19 crisis, especially those in high risk areas such as

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correctional facilities (Clay, 2020). Health care workers report growing concerns about personal safety and lack of personal protective equipment (PPE), transmitting the virus to family and friends, and higher burnout rates (Sasangohar, et al., 2020). It has been noted that mental health professionals may develop anxiety, depression, and post-traumatic stress disorder (PTSD) during these stressful times (Nurse & Ormsby, 2003). As such, the APA has stressed that it is more important now than ever to engage in self-care (Clay, 2020). APA has provided suggestions such as creating a standard daily routine, maintaining health (e.g., healthy eating, exercise, adequate sleep), facilitating socially distanced activities with friends or family, and engaging in mindfulness or relaxation techniques. Psychologists should all work towards identifying and implementing an individualized self-care routine during the pandemic to maintain professional competence and enhance their psychological well-being.

7) Facility Safety Precautions For treatment providers and evaluators seeing inmates in person, proper safety precautions should be utilized. Treatment rooms should develop safety precautions for groups and individual therapy, such as spaced seating, protective face covering, and other recommended precautions (American Society of Addiction Medicine, 2020). Typically, incarcerated individuals are not allowed access to technology; however, during the pandemic, many mental health services were moved from in-person to telecommunication. Given that the use of personal technology devices is prohibited at most correctional facilities, there is an added barrier to inmates receiving psychiatric treatment.

Thus, it is recommended that psychologists work with their facilities to increase the availability of these types of services to inmates, such as offering video sessions on communal computers in private locations. As psychologists begin to return to work in-person, there can be the continued use of this type of telecommunication for mental health services to protect against spreading should an inmate exhibit symptoms but still require psychological treatment.

Similarly, for pre-trial defendants who need to be evaluated for various reasons (e.g., sentencing mitigation, competency to stand trial, criminal responsibility), they should be provided needed electronic services (e.g., video conferencing) or safe meeting spaces (e.g., socially distanced interviewing rooms with protective gear).

be noted that increased attention must be paid to implement proper safety precautions facility-wide. For example, there should be efforts towards checking temperature and inquiring about relevant symptoms before anyone (staff, inmates, and visitors) enters the facility. Additional safety precautions within the facility could include mandatory mask wearing, increased sanitation services (especially in common areas, such as restrooms or cafeterias), and environmental changes (e.g., installing plexiglass in meeting rooms). There could also be efforts to arrange single-celled rooms and separate living pods, and isolative environments for those who are sick or were knowingly exposed. Regarding visitations (for both professional and personal reasons), there should be established safe meeting rooms, as well as increased access to alternate forms of communication (e.g., video conferencing, telephone).

Conclusion Currently, in the face of the global pandemic, the correctional settings in the US are facing unprecedented challenges. These settings are disproportionately impacted by COVID-19 due to overcrowding, lack of resources, and an already existing vulnerable population. As such, attention must be paid to the mental health of inmates in the context of the pandemic, a responsibility that largely falls on mental health practitioners in correctional settings who provide necessary psychological screening and treatment. Mental health workers in correction facilities can make an important impact through providing prisoner and staff education, increasing assessment and treatment efforts for psychological distress and suicidality, maintaining competence and self-care, and adhering to safety precautions in facilities.

References Furnished Upon Request About the Authors Sharron Spriggs is a third year doctoral student at Fairleigh Dickinson University studying clinical psychology. Sharron’s interests include public safety assessment. Her dissertation is on investigating the influence of viewing police brutality videos on social media and perceptions of police officers.

Caitlin E. Krause is currently a graduate student in Fairleigh Dickinson University’s Forensic Psychology MA program. Her research interests include paraphilic disorders, sexual trauma, and online sexual behavior.

Georgia M. Winters, PhD, is an assistant professor at Fairleigh Dickinson University’s School of Psychology and Counseling. Her research focuses on sexual grooming, paraphilias, and sexual violence prevention.

While largely beyond the scope of this article and the responsibilities of mental health providers, it should

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Juvenile Interrogation Law for Psychologists: The New Jersey Case Law By, Matthew B. Johnson, PhD, Erica R. Young, & Kimberly Echevarria

“A thirteen-year-old cannot be expected to assert his right to remain silent when the detective is repeatedly exhorting that he has to speak.” New Jersey Supreme Court Justice, Barry T. Albin’s dissent in State ex rel.

A.W. (2012).

T

he interrogation of juveniles has been a central issue in forensic psychology for several decades (Grisso, 1981). There is also renewed interest related to the popular film coverage of the Central Park Five exonerees (DuVernay, 2019; Burns, 2012) and the controversial conviction of Brendan Dassey from Wisconsin (Padilla, 2019; Ricciardo & Demos, 2015). In many ways, the US Supreme Court invited psychological research and consultation with the remark, “… the modern practice of in-custody interrogation is psychologically rather than physically oriented” (Miranda v Arizona, 1966, p. 708).

Grisso’s early research underlined the vulnerability of youth during criminal interrogation and introduced empirical assessment methods (Grisso, 1998). The legal framework governing the interrogation of juveniles is largely state specific. Johnson (2002) reviewed the New Jersey juvenile ‘Miranda’ case law and identified factors the state high courts recognized as relevant in determining the admissibility of incriminating statements elicited from juveniles. The review provided guidance to psychologists conducting forensic examinations (Johnson & Hunt, 2000). The review also advocated the mandatory recording of all custodial questioning (Johnson, 2005; Johnson, 2000) that was subsequently adopted by the New Jersey Supreme Court and Legislature (Rabner, 2006).

Juvenile Miranda Case Law in New Jersey, 1966 - 2001 Johnson (2002) cited nine New Jersey high court rulings on juvenile interrogation since the right-to-counsel and privilege against self- incrimination were extended to juvenile suspects (In Re Gault, 1966). In these opinions, the courts sought to balance the need to maintain adequate due process protections for juvenile suspects while also protecting the public from juvenile offending.

The nine decisions are summarized in Table 1.

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The ‘Reasoning’ Column in Table 1, identifies various factors the courts have noted in ruling incriminating statements (‘confessions’) were not admissible (the juvenile’s age, prolonged interrogation, parental exclusion, insufficient documentation, mental limitations, evidence of suggestion, insufficient corroboration, inadequate Mirandizing, parental presence during initial Mirandizing, fairness, and voluntariness). Psychological examination can be critical in the assessment of these factors. Psychologists have unique skills and knowledge (clinical interviewing, testing and assessment, knowledge of child and adolescent development, and research informed literature regarding Miranda comprehension and risks of false confession) that can be applied to consultation and testimony regarding juvenile interrogation.

It is essential to recognize how courts typically weigh and consider these factors. The US Supreme Court (Fare v. Michael C., 1979) and the New Jersey Supreme Court (State v. Presha, 2000) hold the admissibility of statements from custodial interrogation is determined through analysis of the ‘totality of circumstances’ (TOC).

In this regard, psychologists (Kassin, Drizin, Grisso, Gudjonsson et al, 2010) have differentiated situational/ contextual and dispositional/personal factors associated with increased risk of unreliable ‘confession’ evidence (see Table 2). With the ‘TOC’ approach to analysis, the existence of any one or two (or more) of the factors does not determine the ruling on admissibility. Rather, the court weighs the various factors. For instance, a court might rule a prolonged or deceptive interrogation would render the incriminating statement from a 14-year-old to be inadmissible while the same methods used to interrogate a 17-year-old juvenile suspect, with a history of multiple arrests, may be acceptable [1].

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Table 2. Situational and Dispositional Risks During Custodial Interrogation* Categories

Examples

Situational/ contextual factors

Isolation, prolonged interrogation, false incriminating evidence, minimization (themes)

Dispositional/personal factors

Youth and immaturity, cognitive limitations, mental illness, suggestibility, compliance

*From Kassin et al, 2010

Comprehensive psychological examination including review of relevant records (discovery, educational, mental health, and medical), interviews with the juvenile and informants (such a parent/guardian), psychological test data, and assessment of possible malingering, are invaluable in presenting to the court a host of factors that warrant consideration in the TOC inquiry (Goldstein & Goldstein, 2010; Rodgers, Sharf, & Henry et al, 2018; Zelle, Romaine, & Goldstein, 2015).

Juvenile Miranda Case Law in New Jersey, 2002 – present Since the prior review (Johnson, 2002), the New Jersey Appellate and Supreme Courts have published seven additional case law rulings which further elaborate the state specific law regarding the interrogation of juveniles (see Table 3).

As noted above, the state has adopted a rule requiring law enforcement to electronically record the entire custodial interrogation of criminal suspects, juveniles as well as adults. The resultant objective record of interrogations only enhances the understanding of criminal interrogation, the risks encountered for suspects, as well as the risks to the integrity of criminal investigation.

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Before review of New Jersey high court rulings since 2002, a comment is warranted on State v. Presha (2000) that is frequently cited as the guiding New Jersey State Supreme Court decision on juvenile interrogation (State in the Interest of AA, 2018; State ex rel. AW, 2012; State in the Interest of AS, 2010).

Among other things, the Presha ruling delineated a ‘bright line rule,’ “When the juvenile is under the age of fourteen, the adult’s absence will render the young offender’s statement inadmissible as a matter of law--unless the adult is truly unavailable [or unwilling to be present] (Presha p. 13).” In such cases, the questioning should be conducted with, “utmost fairness and in accordance with the highest standards of due process and fundamental fairness.” (p. 12). While this assertion in Presha affirms special protection to juvenile suspects below age 14, the only prior case where such statements were ruled admissible by the high courts was State in the Interest of RW (1971), where it was the juvenile who undermined the efforts of the police to involve the parent (Johnson, 2002).

sexual assault, was inadmissible due to several factors (the suspect’s age, deficit reading level, lack of prior exposure to Miranda, and irregularities in the Mirandizing process). In addition, the court noted the juvenile’s (adoptive) mother had an apparent conflict of interest because the victim of the reported assault was her four-year-old biological grandson.

The adoptive mother was markedly accusatory toward the juvenile during the police interrogation and the defense argued the record verified the minor was “badgered to confess by the mother” (p. 8) [2].

Interestingly, the court noted the juvenile testified at the suppression hearing that she sought to exercise her right to silence, “[w]hen I would remain silent they kept on asking me the same questions over and over again for me to answer. They never said that I had to say, no, I don’t want to talk no more. It says remain silent and that’s what I had did.” (p. 7). The appellate court ruled the incriminating statements were not admissible, but the juvenile was still adjudicated delinquent based on other evidence, principally the testimony of the four-year-old. Also, the appellate court stated that in future cases, where the parent/ guardian has a conflict with respect to the juvenile suspect and the identified offense victim, an attorney should be appointed to represent the juvenile. As a result, the prosecution appealed to the State Supreme Court and the defense cross-appealed.

In State in the interest of JDH (2002), the New Jersey Supreme Court reversed the appellate ruling that had excluded incriminating statements by a 16-year-old suspect who had been surreptitiously recorded by a sexual assault complainant under the direction of a prosecutor. The court held the state did not have to prove the statement was voluntary because the juvenile was not in custody.

On appeal, the New Jersey Supreme Court (State in the Interest of AS, 2010) affirmed the exclusion of the juvenile’s incriminating statement. In addition, the court reversed the delinquency adjudication and remanded the case for a new trial, noting the admission of the incriminating statements at trial was not harmless. The court stated it was unlikely that even a highly capable judge can compartmentalize evidence of such magnitude as the involuntary incriminating statements that were presented at trial (see Wallace & Kassin, 2012). The Supreme Court also ruled that where a parent had conflicting loyalties, the police can secure another adult to act as advisor during interrogation rather than requiring the appointment of a lawyer.

In State in the interest of QN (2004) a 12-year-old juvenile was charged with the sexual assault of “young girls.” Considering the TOC, the New Jersey Supreme Court ruled the juvenile’s incriminating statements were admissible even though he was under age 14 and the parent was absent during part of the interrogation. The court determined the parental absence was voluntary, not the result of exclusion by the interrogating officer, and the interrogation proceeded with ‘utmost fairness.’ In the published dissent, Justice Wallace (joined by Justice Long) held that because the law enforcement officer initiated the request to question the minor alone, and the minor did not have an opportunity for a private consultation with the mother, and the child and mother were not informed that either could refuse to allow the child to be questioned alone, the state had not met it’s burden of proving the interrogation was consistent with the “… highest standards of due process…” as required in State v. Presha (2000).

In State ex rel. P.M.P. (2009), the prosecutor’s office filed a delinquency complaint and obtained an arrest warrant naming 20-year-old PMP. It was alleged PMP committed sexual acts when he was a juvenile.

However, the complainant was unsure whether the acts occurred during the summer of 2001 or 2002.

The following day PMP was arrested, mirandized, and reportedly admitted wrongdoing. PMP filed a motion to suppress the statements, arguing the filing of the delinquency complaint was the equivalent

In State in the Interest of AS (2009) a New Jersey Appellate Court ruled the incriminating statement of a 14-year-old female, charged with aggravated

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of an indictment and thus his right to counsel was automatically operative. The New Jersey State Supreme Court held PMP could only waive his right to counsel in the presence of, and after consultation with, counsel (N.J.S.A. 2A:4A-39, 2014), and thus the statement was inadmissible.

State ex rel. AW (2012) resulted in a complex record involving multiple considerations such as the Presha ‘bright line’ rule regarding juveniles under age 14, bilingual interrogation, parental exclusion, fidelity to Miranda, Reid interrogation methods, and related social science research. It was alleged 13-year-old, AW committed sexual acts upon a five-year-old victim (his cousin). There was no medical evidence of abuse, but none would result from the acts alleged.

Writing for the majority, Supreme Court Justice Hoens summarized the disputes as involving two basic considerations; a) whether the interrogating officer impermissibly suggested the parent leave the interrogation where he was supporting his son, and b) whether the interrogation techniques were unduly coercive and inappropriate for a juvenile. The majority determined the juvenile’s confession “was made knowingly, intelligently, and voluntarily” (p. 14), and the questioning was consistent with the “highest standards of fundamental fairness and due process” (p.15), consistent with State v. Presha (2000). It was noted the interrogation was brief (45 minutes), conducted by a female detective, in civilian clothing, at a Child Advocacy Center (rather than a precinct).

The detective was described as calm and even toned in her voice, and the father agreed to leave the interrogation at his son’s request.

The AW case also produced a dissenting opinion by Justice Albin that cited relevant psychological and social science research (such as Kassin et al, 2010; Drizin & Leo, 2004; and the ACLU of New Jersey amicus brief State of New Jersey in the Interest of AW, 2011) related to juvenile interrogation. Albin advanced five points to support his opinion the incriminating statements should be suppressed and the case should be remanded for re-trial. 1) The juvenile’s request his father leave the interrogation was the product of suggestions by the interrogator, and portions of the interrogation occurred in English that effectively excluded the father. 2) The ‘Reid’ method trained interrogator presented apparently false incriminating evidence to the juvenile. 3) The interrogator refused to accept the juvenile’s denials of the allegations. 4) The interrogator minimized the seriousness of the alleged offense, suggesting the juvenile merely made a ‘mistake’ or was ‘experimenting’. 5) And finally, the interrogator provided assurances of leniency if the juvenile

confessed, suggesting he would get therapy and not be jailed. Albin held the combination of these factors had the capacity not only to overbear the will of a 13-year-old, but also to induce a false confession.

In State in the Interest of AA (2018), Appellate Court Judge Manahan addressed an issue without precedent in New Jersey. A juvenile, AA (age not reported), was adjudicated delinquent for aggravated assault and firearms possession. AA was allegedly among a group of three African-American males who rode their bicycles in unison, while one of them fired a handgun striking two individuals producing nonlife-threatening injuries. Just prior to the shooting, AA had been seen in the vicinity on a bicycle by a police officer who had arrested AA in the past.

Available video surveillance was not adequate to confirm identifications. No handgun was recovered.

The trial judge admitted into evidence statements AA made to his mother while he was held at the juvenile detention center. That is, a detective testified he informed the mother of the allegations against AA. The mother became emotional, questioned AA, and the juvenile responded, “Because they jumped us last week”. The detective reported he stood 10 – 12 feet away when he heard the exchange. The trial judge reasoned the statements were not the product of police interrogation and thus Miranda warnings were not necessary. The Appellate Court disagreed noting since AA was in custody, and he experienced the “functional equivalent of police interrogation” (p. 9), Miranda warnings were required and thus the statement should have been suppressed.

The adjudication was reversed and the case was remanded to the lower court. In addition, the Appellate Court noted the juvenile and parent were not provided a private consultation to which they were entitled to effectively serve the purpose of parental advice and guidance consistent with Presha.

Summary and Discussion: Review of the recent New Jersey case law reveals several factors the courts have relied upon in determining the admissibility of statements obtained during the interrogation of juveniles. Identified factors include whether the juvenile was in fact in custody, the circumstances of parental absence, the fairness of the interrogation, the juvenile’s age, intelligence, and experience with interrogation, parental support during interrogation, presentation of the Miranda warnings, the impact of improperly admitted incriminating statements, use of language to exclude a parent in a bilingual interrogation, implied leniency, and provision of a private consultation.

Psychological assessment skills, coupled with

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research informed knowledge of child and adolescent development, can provide the basis for expert witness examination and testimony.

an observer (Inbau et al, 2013). Also, a related question, apparent in the above review is, what are the elements of a meaningful private consultation between the juvenile and the parent in the context of juvenile interrogation?

The TOC framework suggests examination should not be limited to delineating deficits such as age or cognitive impairments but must outline the suspect’s vulnerabilities in the context of how the interrogation was conducted (Johnson & Hunt, 2000). For example, as noted by Justice Albin (State ex rel. AW, 2012), how is a 13-year-old to understand his right to silence if he is continually told by the detective he has to speak. Similarly, suggestions or offers of help during interrogation may nullify the Miranda warning that statements will be used against the suspect in court.

Notes 1. Even where the incriminating statement is ruled admissible, psychological testimony challenging the reliability of the statement can be presented at trial (Crane v. Kentucky, 1986).

2. AS was the first New Jersey juvenile Miranda case law decision to be informed by an electronic recording of the full interrogation.

About the Authors

Psychologists can also contribute by conducting research to further explore processes in juvenile interrogation. For instance, does research support the assertion that a 12 or 13-year-old can make a knowing, intelligent, and voluntary surrender of constitutional rights, as the courts asserted in QN (2004) and AW (2012)? Might there be a better way to frame and evaluate the circumstances of such a youthful suspect? Another question, is whether parental presence is sufficient or effective protection for juveniles during custodial interrogation (see Cleary & Warner, 2017; Woolard et al 2008)? The case law review suggests while some parents are capable of advising youths on the exercise of their rights, other parents (for any number of reasons) are punitive and align with police interrogators. In some circumstances, parents may be simply uninformed and incapable of providing effective assistance.

It is relevant to note that a leading interrogation training manual instructs officers to discourage the parent from talking and confine their role to that of

Matthew Barry Johnson, PhD is an associate professor of psychology at John Jay College of Criminal Justice-CUNY. He recently authored ‘Wrongful Conviction in Sexual Assault: Stranger Rape, Acquaintance Rape, and Intra-familial Child Sexual Assault’ for Oxford University Press.

Erica R. Young is a graduate student in Forensic Psychology at Kean University. Her interests are in interrogation policy and research regarding Miranda rights.

Kimberly Echevarria is a senior undergraduate student majoring in forensic psychology and minoring in law at John Jay College of Criminal Justice (CUNY). Her research interests include juvenile interrogation, as well as factors involved in wrongful convictions (i.e. false confessions, eyewitness misidentification, official misconduct, etc).

References Furnished Upon Request

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Diversity Matters The Unspoken Truth: Working with Survivors of the Sri Lankan Civil War By, A. Keshani Perera & Aileen Torres, PhD Introduction

B

eautiful sandy beaches, breathtaking views from the mountains, friendly smiles, and great hospitality are some of the million things that make Sri Lanka the “pearl of the Indian ocean.” Located southwest of the Bay of Bengal and separated from the Indian peninsular by the Gulf of Manner and the Palk Strait, this beautiful island has been identified to be one of the friendliest countries in the world. Known by other names previously, such as Ceylon, Thambapanni, Taprobane, and Serendib, the country currently known as the Democratic Socialist Republic of Sri Lanka and is home to a multiethnic population of 21 million individuals. The country is very diverse, with the Sinhalese, Sri Lankan Tamil, Indian Tamil, and Sri Lankan Moors comprising the largest specific cultural and ethnic groups. The Sinhalese comprise the majority population and largely speak in Sinhala, which is the native tongue. Sinhala and Tamil languages are recognized as national languages and English is identified as a second language.

Lankan, Indian, Pakistani, and Bangladeshi immigrants as the largest growing population (57.2%) in the state of New Jersey between 2000-2010. The US Census (2017) indicates that there are approximately 49,116 Sri Lankans in the US. This paper will explore the cultural beliefs and values, personal experiences, pre-, during, and post-war attitudes, and the struggles of the Sri Lankan diaspora in the United States.

The Sri Lankan Culture, Beliefs, and Values The documented history of Sri Lanka dates over 3000 years. With a rich history and cultural heritage, the island nation is known to be dominantly a Theravada Buddhist country. The Sri Lankan community was once highly based on a caste system, some of which still exist to date among the majority and minority communities.

Following colonization by the Portuguese, Dutch, and the British, the class and caste systems changed and shifted to its current representation of lower to the upper class. The collectivistic value systems of the country emphasize family relationships, familial responsibility, the importance of the collective, resiliency, and growth through adversity, the importance of culture and history, as well as self-control, including the suppression of affect and maintaining a strong and stable stance. It is important to explore how some of their values, cultural aspects, and beliefs may have contributed to the resilience of the Sri Lankan community across multiple traumatic events. While some literature is present on this topic, most literature explores one side of the story.

A civil war erupted in 1983, lasting for approximately 25 years (1983-2009) and resulting in refugees spread out all over the world and the loss of over 100,000 lives. Many Sri Lankans sought refuge in other countries such as the United States, Canada, United Kingdom, Australia, and India, while many others survived in refugee camps in Tamil borderlands of India. New York City, Long Island, Staten Island, and Central New Jersey are home to the largest Sri Lankan communities in the United States. The New York City Metropolitan Area contains the largest Sri Lankan community in the United States, primarily in the Tompkinsville neighborhood of Staten Island.

New Jersey identifies South Asians, including Sri

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Therefore, this article attempts to capture the experiences, attitudes, and beliefs of both minority and majority perspectives pre-, during, and post-war. All the information in the following section were collected via individual interviews and contain subjective experiences of individuals.

188 Sinhalese children in the South were affected by the war, compared to 59.2% of the Tamil children who were located in the North and Northeast areas of the island.

Therefore, it is important to explore the experiences of each ethnic/regional, and age group (Catani et al., 2010).

The personal experiences of several individuals who lived during the civil war were interviewed and this article describes the narrative themes. The interviewees are two local Sinhala and Tamil individuals who are currently based in Sri Lanka and two Sinhala and Tamil individuals who have relocated and currently live in the United States. These narratives describe some of the lifestyle’s differences that many majority and minority individuals from different parts of Sri Lanka have experienced.

These cases illustrate the psychological and societal pressures that these individuals encountered and how these may have impacted their post-war attitudes. While it is important to note that varying levels of impact and experiences are inevitable, these accounts set a solid foundation to understanding the everyday lives of Sri Lankan citizens who lived through the civil war, allowing psychologists who work with these populations to gain some basic knowledge of the scope of the experiences and providing a trauma-informed lens to employ when working with this immigrant population.

Growing Up During a Civil War Sri Lankan historical literature identifies two crucial incidents that significantly contributed towards the start of the ethnic conflict and nationalism between the Sinhala government and the rebel group, the Tigers of the Tamil Eelam (LTTE). The first is the burning of the Jaffna Public library in 1981 that housed priceless and irreplaceable ancient manuscripts and cultural literature. The library was the center of the Tamil culture and learning and the destruction of the building was an attack on the Sri Lankan Tamils at the core of their cultural identity (Jayasuriya, 2016). The second incident can be identified as the July 1983 riots, also known as “Black July.” The riots were eruptions of anger by the Sinhalese in response to the murders of 13 Sinhalese soldiers in the North by the LTTE. The Tamil guerrillas were rated as the most dangerous guerrilla army in the world (Jayasuriya, 2016). The riots led to looting and destruction of Tamil homes, businesses, and lives.

Tamils sought refuge in the homes of their Sinhalese neighbors, while some of their family members were burned alive in their own homes (Jayasuriya, 2016).

The Beginning of the Dark Times Noeline (pseudonym) is a woman in her 50s. She is a homemaker and a businesswoman. Her experiences capture the start of the civil war and the aspects that are usually not talked about or addressed. Her accounts may be similar to those who lived in Sri Lanka during her generation and immigrated to the United States shortly after the war began.

Noeline is a descendant of the Colombo Chetty’s (a district Tamil ethnic group that descends from a trading caste in India). Noelene’s family was brought up as Sinhalese.

She attended a high tier catholic school in Colombo and described the fear and clear visual details of the event.

She was only 16 years old when the riots broke out in Colombo in 1983. Noeline described that the riots began when the Sinhala majority burnt down the Jaffna library.

"It was 9:30 am when the school closed, the principal sent everyone home in private school vans. My friends and I decided to take the train home. We got to the train station and saw the whole sky covered with black smoke. We saw fires break out in the next town and felt scared for our lives, we did not know what was happening."

“I remember hearing Kafeer jets fly above our school and I would close my eyes and pray to God it wasn’t a bomb.”

Many Sri Lankans lived years constantly scared for their lives not knowing if they would return home safely from school. While the whole island was affected by the civil war, it is important to consider the rates of trauma exposure varied based on ethnicity and location. One study showed that only 4.7% of

She recounted the events that took place when they finally arrived at the main station to catch their connecting train:

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were taught how to save themselves during a bomb blast, frequent bomb drills were conducted in schools, and children were taught to be mindful of their surroundings.

She recalled that unattended parcels triggered anxiety, and family members did not travel together.

"Sinhala people were breaking the Tamil shops in the city, they were looting all their belongings and distributing it to the Sinhala public. When we finally got into the connecting train, the train stopped in every single station. Sinhala people were shouting at the passengers, looking for Tamil individuals. They were looking for them to kill them, we had to hide our friends. It was a very scary situation. When we eventually got home, we heard multiple blasts.

Sinhala people had burnt multiple factories. We had a gas factory that was close to our house and they had set fire to it. The blasts were all the gas tanks catching fire, we couldn’t stay inside the house as the house was shaking. All of us were outside the house and my mother had packed up all our jewelry, money, and medicine; we were ready to run."

“Every person in the family would take different modes of transport. Parents would never travel together because if something happens to one parent at least the children have one parent left.

We would always listen to the radio, to make sure that we are aware of whatever is going on.

Becoming a parent during this time was quite challenging. When I sent my child to school, I had memorized the license plate of her school van. The radio would announce the vans that would be caught at a bomb blast or whatever, you never knew if your child would come home from school. To this date, I don’t know where some of my friends are, they are Tamils and they left the country during this time. I have no idea if they are alive or dead.”

Noeline also recalled that after a while of ongoing riots and continuous curfews, families were struggling to meet their daily needs and put food on the table, and many rationed the little food they had. What followed these events left many families afraid of their lives.

Born into the War Dilushi (pseudonym) a Sinhala, 29-year-old teacher, was born and raised in the city of Colombo and has immigrated to the United States in her early 20s. While she did not report any experiences before the start of the war, as she was born during the war, she did recount what life was like living through and growing up during the war.

“People were going house to house with machetes and swords looking for Tamil people. We had some relatives who were living at our house during this time. A group of people was banging on our gate asking us to send the Tamils out. My relatives had dark skin and they thought they were Tamils; they were Sinhala. The truth is, we had a servant at home who was Tamil, we hid him in the house and didn’t let him out at all.

We were scared of what would happen. We saw Tamils being burned alive; I can still see it in my mind so vividly.”

“When we were sent to school, our parents didn’t know what would happen to us, life was so uncertain. There were multiple bomb blasts around the area I lived in. My school was also located in a high-security zone, which meant that higher-ranked individuals in the forces either lived or worked around the area. Our school van had to drop us about half a mile from school because vehicles were not allowed in, so we had to walk. When we finally got to the school, we have to go through a metal detector and a thorough bag check. I remember praying every day to get the opportunity to come back home safely. During this time many school events were canceled, and we lost out on a lot of things. Parents couldn’t even come to pick us up from school without special permission."

This statement exhibits the vivid memories and fear that many citizens experienced. Another important theme that arose throughout the conversation with Noeline is the collectivistic desire to protect their servant and member of the household. Noeline recalled that the schools eventually opened, but the reality was that nothing was ever the same. She noted that many bomb blasts occurred across the island following the riots. Children

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Dilushi reflected further on her experience in attending a school that was situated in a high-security zone where many government officials and military officials worked and lived.

belongings with them, and if they didn’t, you had to act quickly. That’s what they showed on TV. It was like we were living in constant uncertainty and anxiety."

The aftereffects of traumatic events are long-lasting and can sometimes be very consuming. Being born during a time of the war, you don’t often realize the different aspects of life you have missed out. Life during the war becomes your “normal.” Many changes took place immediately after the war ended in Sri Lanka. Dilushi recalls her experiences as such:

“Because the school was located in a highsecurity zone, where many high-ranking officials spent time, there was more possibility that an attack would take place. So, every time an official was going on the road, everyone had to freeze, turn away from the road and face a wall. These experiences made my school life very chaotic. I know some people in the community found these procedures very annoying because it bothered their daily routine, but the fact was that we didn’t know what could happen."

“I remember having a huge lifestyle change when the war ended. Shortly after the war ended, the movie theaters opened, stores opened until late, roads were not closed, we were able to stay out until later in the night and got to go to dinner and enjoy it. I think before that people really avoided these places, it was a scary thing to think that a suicide bomber could be anywhere and could be anyone. Living in fear makes you adopt certain biases towards others in society."

Dilushi recalled the feelings of uncertainty about individuals they face on a day to day basis. She recalled that the possibility of anyone being a suicide bomber was a constant thought as she walked through half a mile to get to her school. She also noted that while this experience made her life chaotic, she believes that life was likely worse for individuals who lived in the war zones. In fact, research supports that 92% of children in north-eastern Sri Lanka have experienced severely traumatizing events during the war, such as combat, shelling, bombing, and witnessing the death of loved ones. It is reported that at least 25% of the northern Sri Lankan children meet criteria for PTSD (Elbert et al, 2009). These rates are much higher when compared to children who lived in the southern part of the island.

Speaking further on her experience being raised during a civil war, Dilushi recalled the effects these experiences have had on her mental health.

These statements suggest the importance of engaging in the therapeutic exploration of the aftereffects and post-war attitudes and biases some may hold post-war. Furthermore, the concept of growing through adversity and the gratitude for a return to normalcy should also be explored.

The Other Side of the Story Yoga (pseudonym) is a 25-year-old Tamil student from Northern Sri Lanka, who immigrated to the United States in his late teens. He was born and raised in a neighboring town where the terrorist leader was from and therefore lived in the epicenter of the war before he eventually moved to Colombo and later to the United States. His family had ties to the Sri Lankan government as his grandfather was the chief of the village. According to Yoga, the rebel terrorist group initially started with a good motive, to fight the discrimination and fight for the representation of the Tamil people.

“I remember hearing the tune for breaking news on the TV, that itself triggered my anxiety. Every time you hear that its breaking news, you hold your breath for a second, hoping that everything is okay. It was like we associated breaking news with something extreme. These feelings resurfaced when the Easer attacks happened.

I felt that it took my memory back to the bad times. I do believe that this is one of the reasons people don’t like to or want to talk about the dark times. It shows how powerful those times were and how it affected us. It may not have created many negative effects, not everyone has lost a person during the war, but it did affect all of us psychologically. I also remember taking public transport and we couldn’t keep our personal belongings on the top shelf of the bus. You also had to be very vigilant and suspicious about the person who was sitting next to you. You had to make sure that they took their personal

“Their purpose was to have the minority voice be heard, unfortunately shortly after the terrorist group lost their purpose and started attacking their own people.”

He recalled that the Sinhala and Indian armies were attacking the Tamil residents in the north and the terrorist group aimed to fight against these unfair acts. However, shortly after, the LTTE lost sight on their initial goal and stood against anyone who stood against them, including their own people. The interviewee recalled that during these times, many personal belongings, lands, houses, and even children were snatched from their families and recruited into the LTTE terrorist group.

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of affect and are engaged in fact-based processing. As a widely seen characteristic among any trauma population, specific consideration should be given to processing the affective experience and labeling these experiences within a safe, therapeutic space.

“Many locals who were able to flee the country, fled during these times to save their children and loved ones. The rebel group started to portray the government in a negative light to receive the support of locals. All the support the locals were receiving from the government such as dry rations, kerosene oil for lamps, etc., had to go through the LTTE and were stolen by them for the most part. During this time many other international sources also funded the LTTE with money, weapons, and intelligence, including support from individuals who fled the country. You had to do whatever to stay safe, we even had a bunker in our house.”

Post War Attitudes A consistent theme across all interviewees, when asked about their post-war attitudes, was the prevention of another civil unrest. All of the interviewees spoke about how their lives had changed following the civil war. They emphasized increased feelings of safety and the reduced levels of anxiety and uncertainty they were feeling.

“During the riots, the Sinhalese burned the Jaffna Library, we lost a lot of our history books and record, they were burnt to the ground. Some people still hold on to that anger, the others are trying to move on and find their origins. I just know for sure, that I would do anything to the country going into another war again.”

Yoga recalled that he was privileged enough to move to Colombo with his family. Unfortunately, this was not an option for many families.

“Even though we came to Colombo, we had to leave some of our family members behind.

Therefore, traveling to the north was a monthly occurrence. Trips to Jaffna took at least 13 hours, we had to drive through 3-4 checkpoints. The checkpoints did not open till 9 am and when they did there would be a big queue so people would get to the checkpoints by around 4 am. There were 2 army checkpoints and 2 LTTE checkpoints.

Getting to a checkpoint was very nerve-wracking, especially when you are Tamil. The officers at the checkpoint would be nervous too. When they see you are Tamil, they become all serious and start searching for everything. Because my father worked for the government, he had a special ID, he would show that, and they would be nice to us. Then we will get to the LTTE checkpoint, the moment they see the government ID, they turn our car upside down. You have to wear all the jewelry you have, if they are in your bags, they will just take it.”

“We did not go through it alone; we went through it as a community. When that happens, you share the trauma with many other people, you share similar emotions and it is a helpful opportunity to talk with people who are going through similar experiences.

Adverse events make you stronger. I think all the common experiences that people have, were amplified by the Easter attacks. That definitely brought a lot of that anxiety back. That really made me think of the idea of peace, what life was like during the war, and what life has been like since the war ended.

This statement amplifies the importance of cultural practices and the paradigm of posttraumatic growth.

Emerging trauma literature supports that individuals are capable of processing and exploring traumatic events by systematically examining the positive aspects individuals experience as a part of their traumatic exposure. This allows individuals to render new, helpful meanings out of unpleasant and difficult events and moves them towards post-traumatic growth (Calhoun & Tedeschi, 2006; Satkunanayagam, Tunariu & Tribe, 2010). The psychosocial reactions that become accepted within the community following a widespread traumatizing event, aka “collective trauma” should be addressed using culturally sensitive, integrative, and holistic methods of treatment.

Research that explores western treatments that have been conducted in Sri Lanka following the Tsunami suggests that these measures were largely unsuccessful within this community. Therefore, significant measures should be taken on the part of the clinician to open doors towards discussing cultural experiences, cultural attitudes, and practices and to adapt and integrate culturally sensitive, holistic methods of treatments when working

In 2005, the government closed all the roads that led to Jaffna, limiting individuals who had families in the north from visiting them at all.

“The terrorist group also disconnected phone lines and we couldn’t really stay in touch with them. We had to send them packages with batteries for lamps etc., they had no electricity to study or work. We did not even know if the packages would get delivered or would be stolen by the LTTE. We didn’t even know if they were alive.”

The lack of affect and fact-based statements were a common theme across all the interviews. Considering the cultural values of suppression of affect to appear resilient and strong, it is likely that many citizens may be diffused

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with this population.

to bringing shame to the family, growth through adversity becomes a norm and emotional suppression becomes a frequently used coping tool. Understanding the role that emotional suppression may play in the patient’s symptom presentation will aid clinicians in paying attention to clinical nuances such as somatic symptoms (Torres et al., 2019).

Treatment Implications While the trauma exposures range based on the origin country, research has identified South Asian refugees to be a particularly high-risk group for trauma and PTSD (Sue et al., 2012), with significantly higher exposure to war trauma ((Roberts, Gilman, Breslau, Breslau, & Koenen, 2011). Regardless of these higher rates of exposure, only 28% of those with diagnosable conditions seek out mental health services, with many of them terminating treatment prematurely (Le Meyer, Zane, Cho, & Takeuchi, 2009). Sue et al., (2016) suggests that premature termination can be directly linked to the lack of culturally informed treatment.

Therefore, the cultural implication of trauma exposure and treatment should be considered.

Finally, previous research have suggested using a community, valued based model when working with Asian immigrants for their effectiveness within this population.

Further research also supports that the treatment of Asian populations depend on a clinician’s willingness to work within the cultural and values framework of their patients (Torres et al., 2019). Therefore, a culturally sensitive, open, and curious approach should be employed when exploring their culture (Torres et al., 2019). Furthermore, other effective strategies such as enlisting family support (Sue & Morishima, 1982), proceeding slowly with the affective experience (Lorenzo & Adler, 1984; Nishio & Blimes, 1978), using directive, problem-focused techniques (Kim, 1985), and incorporating the patient’s interpretations of their symptoms (Tanaka-Matsumi, Sieden, & Lam, 1996) have been found to be effective within this population.

Research suggests that many Asian trauma survivors may exhibit and report significant somatic symptoms.

These somatic presentations have been linked to other factors such as cultural stigma, shame, saving the family name, and protecting the family integrity (Torres, Raghavan & Perera, 2019). These rates are also tied to lower levels of treatment-seeking and lower levels of symptom disclosure. Furthermore, the mind-body connection is emphasized in many Asian cultures and in their religious and cultural traditions. Therefore, when working with south Asian populations such as Sri Lankans, it is important to consider the mind-body connection.

Conclusion The migration and diasporic journey of many of Sri Lankans is both inspiring and fraught with potential traumatic exposure. The cumulative effects of the civil war and the Easter terrorist attacks, the Tsunami that hit the island in 2004, and related exposures to many other natural disasters have left the Sri Lankan people vulnerable to higher levels of stress and psychopathology than other communities. While many of these individuals have attempted to put the challenging past behind them, the psychological, emotional, and physical effects of the wartime and related traumatic experiences still torment many people. It is important to consider both their close knit and supportive culture alongside these challenging factors arising out of modern day Sri Lanka when providing clinical care to members of this cultural community.

Another important factor to consider when working with a Sri Lankan population is the collectivistic values that are held within their culture. The western traditions of psychotherapy are built on the individualistic values of the western cultures often requiring the patient to place a significant focus on themselves. Sue (1977) suggests that this practice directly conflicts with Asian values, which are highly collectivistic. Furthermore, the practice of speaking about one’s family in therapy can be viewed as “airing dirty laundry” that is seen as bringing shame to the family. Other themes that were seen across interviewees were the importance of the collective and the importance of history and culture, growth through adversity, and repression of affect or flat affect.

Furthermore, for members of a community who have lived in constant uncertainty, it is typical to hold on to something that does not vary, such as one’s culture and history. Sri Lankans derive pride from their rich history and culture and therefore clinicians who work this population should explore how these factors may affect their patients. Another element to keep in mind is the rate of emotional suppression that is often influenced by cultural stigma. For individuals who descend from a culture where speaking about one’s distress is tied

About the Authors A. Keshani Perera is a doctoral candidate in the PsyD program in Clinical Psychology at William Paterson University. Her clinical interest are in torture, trauma, abuse, and racial/ethnic minority issues. Her research focuses on immigration, psychopathology, and cultural issues.

Aileen Torres, PhD is a licensed psychologist, who teaches at William Paterson University and has her own clinical practice. Her research focuses on immigrant cultural adjustment, ethnic identity development, developmental psychopathology, and childhood abuse.

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Book Review: Clinical Psychology in the Mental Health Inpatient Setting: International Perspectives Turel, M., Siglag, M. & Grinshpoon, A. (Eds.) (2020). New York, NY: Routledge. by, Anthony F. Tasso, PhD Fairleigh Dickinson University

I

npatient psychiatric hospitals have experienced some of the more pronounced booms and busts within the mental health field. From the early and oft-inhumane days of Bedlam, to the more clinically rich and compassionate ethos of Harry Stack Sullivan and his devotees, the nature of inpatient clinics in this country and abroad have been anything but static. Indepth psychotherapeutic work, the hallmark of clinical psychology and psychiatry, has not always been the status quo within the walls of psychiatric hospitals. All too often, the nature of residential psychiatric hospitals, where the most severely disturbed are located, has consisted of medicating, managing, and, at times, ‘warehousing’ such patients – much of which consists of (at best) minimal personalized psychotherapeutic endeavors.

being designed and delivered.

Although recent decades have witnessed greater attempts to individualize inpatient care, the prevailing contemporary image is that comprehensive psychotherapy in inpatient units is rather antediluvian.

Insurance limitations, insufficient mental health funding, and the shuttering of far too many psychiatric hospitals all share culpability. However, it would be wrong to place the blame exclusively on external factors. Clinical psychology’s training zeitgeist shies away from concerted attention to intensive training with the seriously mentally ill. Clinical programs, explicitly or not, intimate that the role of practicing psychologists is to work with higher functioning patient populations, whereas the treatment of more severely psychopathological patients is left to our psychiatry counterparts. This ‘in house’ variable is just as responsible for perpetrating the notion that psychotherapy has no place in mental health hospitals as budget constraints or other external factors.

Despite this public and professional perception, Clinical Psychology in the Mental Health Inpatient Setting: International Perspectives (Routledge) demonstrates that ‘real’ psychotherapy is currently happening in psychiatric hospitals, and is happening at a high level. Editors Meidan Turel, Michael Siglag, and Alexander Grinshpoon bring together a group of 29 clinicians from the United States and abroad to explore the various ways that inpatient clinical psychotherapeutic services are currently

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The book opens with a discussion about the varied roles of the inpatient psychotherapist (e.g., individual therapist, group facilitator, clinical researcher), underscoring the multitude of ways a psychologist contributes to the sustainability of a mental health hospital. This section describes a psychoanalytically informed psychiatric center in which four-times-a-week psychotherapy is the standard, adhering to the psychoanalytic ethos that making meaning of symptoms, even with the severe mentally ill, is a vehicle to facilitating a more authentic way of living. Two authors describe the landscape of inpatient work in Australia, with its multidisciplinary team approach (similar to many US hospitals where teams consist of psychologists, psychiatrists, and case workers) along with the inherent challenges that accompany limited financial resources. Clinical Psychology in the Mental Health Inpatient Setting also covers the treatment and administrative ethical dilemmas confronting those working within a psychiatric hospital. The effectiveness of behavioral interventions is reviewed in a stand-alone chapter, followed by a discussion about the various ways in which psychologists in a psychiatric center attend to patient as well as the organizational and cultural needs of the hospital. This section touches on inpatient substance abuse work (with the aim of instilling hope, healing, empowerment, and connections with others) while another chapter addresses the importance of professional self-care. This section of Clinical Psychology in the Mental Health Inpatient Setting concludes with one of the editors reflecting on his lengthy career as a clinical psychologist in an inpatient psychiatric unit – from his days as a clinical trainee to his position as training director of an APA-accredited internship at the same psychiatric hospital, charged with the essential task of training the next generations of inpatient clinicians.

Part II moves to a discussion about the different types of inpatient interventions with separate chapters devoted to CBT, psychoanalytic, and mentalization-based treatment perspectives. The book then parses supportive treatment techniques (which aim to shore-up patient strengths) from intensive treatment techniques (which aim to foster

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insight). The chapter concludes by underscoring how most treatments consists of an integration of the two.

The bridge between the inpatient unit and community care is examined, with procedural information on how a psychiatric hospital treatment team facilitates outpatient mental health connections. A chapter also delves into inpatient psychotherapeutic interventions that directly target violence and those convicted of crimes. This discussion provides nuanced material on the role of forensic work within a mental health hospital.

versus biopsychosocial perspectives to the challenges of cultivating empathy with patients so disconnected from reality to the difficulties of working with those with severely compromised psychological structure. The book provides grounding information for those currently, or considering, patient work in such settings. The editors conclude by asserting that, despite the tremendous challenges for the practicing psychologist working in an inpatient psychiatric hospital, the professional and personal rewards are enduring.

Clinical Psychology in the Mental Health Inpatient Setting is a welcomed text for practicing clinicians, regardless of their professional setting or experience with inpatient populations. In other words, one doesn’t need to be an inpatient psychologist to benefit from the insights provided by inpatient psychologists, which allow the practicing therapist to peer in to the meaningful clinical work occurring in the inpatient units. This, I argue, allows an outpatient therapist to have greater confidence in referring patients to a higher to a highly level of care based on a deeper understanding of the procedural aspects of hospitalized treatment. The illustrative clinical vignettes bring these processes to life for those who may have never stepped foot on a psychiatric hospital floor.

Assessment and diagnosis are the focus of Part III, which profiles the Austen Riggs and Menninger hospitals, two premiere American psychoanalytic treatment centers. The authors emphasize how these psychiatric hospitals incorporate comprehensive psychological testing (i.e., objective, projective, and cognitive assessments) as a means of illuminating symptomatologies and character structure. This section of Clinical Psychology in the Mental Health Inpatient Setting also discusses the ways in which mentalizating abilities – a person’s capacity to attend to the thoughts, feelings, and behaviors of self and others – are identified and supported by certain psychiatric hospitals. Key to this section is how some inpatient assessment measures go beyond mere symptoms or observable behaviors by aspiring to attend to the entire person. Put otherwise, there are indeed inpatient centers that still aim to treat the person rather than their symptoms alone.

Of course, those psychologists working, or planning to work, in a psychiatric hospital stand to benefit the most from reading this book. The clinical psychology trainee will gain powerful insights into such work from the wealth of information provided by these authors, who are working professionally both stateside and abroad.

The mid-career and seasoned clinician will further develop their skills by tapping into the collective wisdom of inpatient therapists from around the globe, who bring their varied experiences to address a range of patient populations through different theoretical modalities. This book will surely enhance the reader’s clinical acumen as well as interventional and supervisory skillsets. An ancillary benefit of this book is the overall ‘support’ provided across the pages, with many of the authors admirably opening up about the exasperation and stress that comes from working in such an environment.

Turel, Siglag, and Grinshpoon bring together a group of exemplary clinical scholars, each of whom makes a meaningful contribution to the text, just as they have to the lives of the most severely ill amongst us. As such, Clinical Psychology in the Inpatient Mental Health Setting is a worthwhile read.

The next section focuses on inpatient clinical training.

The book accentuates the inevitable excitement and anxieties idiomatic of trainees working in a psychiatric hospital. This section further delves into the doctoral internship experience of working as part of a multidisciplinary clinical team (e.g., psychologists, psychiatrists, nurses). The author underscores how such intensive training in the inpatient psychiatric unit provides a solid professional identity fostering a sense of autonomy and independence as well as building the neophyte’s confidence in assessing and treating the breadth and depth of psychiatric disorders and behavioral control struggles. Clinical Psychology in the Mental Health Inpatient Setting also examines patient suicide. Difficult at any professional stage, the book taps into the oft-severe impact a patient’s suicide can have on an early career professional. The summation of this erudite section nicely highlights the personal and professional growth associated with such meaningful inpatient training.

Anthony F. Tasso, PhD, ABPP is Professor of Psychology and Deputy Director of the School of Psychology & Counseling, Fairleigh Dickinson University. He also maintains a private practice in Whippany (Hanover Township), Morris County, NJ.

The last section of Clinical Psychology in the Mental Health Inpatient Setting contains the editors’ final reflections, consisting of musings on topics ranging from the omnipresent tensions between biomedical

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Member News Monica Carsky, PhD has a new publication: Carsky, M. (2020). How Treatment Arrangements Enhance Transference Analysis in Transference-Focused Psychotherapy. Psychoanalytic Psychology, 37(4):335343.

Peter Economou, PhD announces the release of his new book Mindfulness Workbook for Beginners, which went on sale 2/9/21. Online reviews are very important to a successful book launch and he hopes you share your thoughts with an honest review on the book’s Amazon product page once reviews open on 1/26/21. You can use this promo code at checkout: CALLISTO29.

Matthew Johnson, PhD has a new book out entitled Wrongful Conviction in Sexual Assault. Here is a link to the book: https://global.oup.com/academic/product/wrongful-conviction-in-sexual-assault9780190653057?cc=us&lang=en&

Chris Kotsen, PsyD has recent publications: Kotsen, C, one of 176 authors. United States Department of

Health and Human Services. Smoking Cessation. A Report of the Surgeon General. Centers for Disease Control and Prevention. National Center for Chronic Disease Prevention and Health Promotion; Office on Smoking and Health. Atlanta, GA. 2020; Kotsen C, Dilip D, Carter-Harris L, O’Brien M, Whitlock CW, de Leon-Sanchez S, Ostroff JS. Rapid Scaling Up of Telehealth Treatment for Tobacco-Dependent Cancer Patients During the COVID-19 Outbreak in New York City. Telemed J E Health. 2020 Jul 9:1-10. doi: 10.1089/tmj.2020.0194. Epub ahead of print. PMID: 32649266; Kotsen C, Ostroff J, Carter-Harris L. e-Health Interventions for Tobacco Cessation. In: Psycho-Oncology, 4th edition. Breitbart WS, Butow PN, Jacobsen PB, Lam W, Lazenby M, and Loscalzo MJ (Eds). Oxford University Press, New York, NY, (in press); Banerjee, S. C., Staley, J. M., Howell, F., Malling, C., Moreno, A., Kotsen, C., Parikh, D., & Parker, P. A. (in press). Communicating effectively via tele-oncology (Comskil TeleOnc): A guide for best practices for communication skills in virtual cancer care. Journal of Cancer Education Ruth Lijtmaer, PhD presented the paper: My name is nobody. I do not know what is my true self: Trauma of refugees in the 21st Century at APCS Association for the Psychoanalysis of Culture and Society).

Conference theme: Truth & Dare: Complexities in the Psychosocial Space. 10-16-20 Conference: 1016-20 to 10-17-20 and 24-25, 2020. ONLINE. She also had the following published: Destruction and survival in a dangerous journey. Library of Social Sciences Newsletter, August 2020, newsletter@ libraryofsocialscience.com:iMusic beyond sounds and its magic in the clinical process in the American Journal of Psychoanalysis, (2020),80(4),435-457 DOI: 10.1057/s11231-020-09271-x https://rdcu.be/ ca6Cf , and a book chapter: The Routledge International Handbook of Race, Culture and Mental Health (2021) (Eds.) Eunjung Lee and Roy Moodley. Chapter 7: Culture and Psychoanalysis. Routledge, Taylor and Francis Group: London and New York. ISBN: 967-1-138-27999-5 hbk); ISBN: 967-1-138-27999-7 (pbk); 967-1-138-27999-8 (ebk) Rosemarie Scolaro Moser, PhD received the 2020 Alfred M. Wellner Lifetime Achievement Award for Clinical Excellence from the National Register of Health Service Psychologists. This award is named in honor of the National Register’s first Executive Officer, Alfred M. Wellner, PhD, and is the highest honor bestowed on a Registrant by the National Register to commemorate numerous, significant contributions to psychology during a distinguished career. Dr. Moser is the Director of the RSM Psychology Center and the Sports Concussion Center of New Jersey. She received her PhD in Professional Psychology, from the University of Pennsylvania and is a board-certified neuropsychologist and rehabilitation psychologist and certified school psychologist.

Peggy Rothbaum, PhD published an article about private equity firms purchasing medical practices. https://www.kevinmd.com/blog/2020/12/yet-another-injury-to-our-doctors-and-our-health-caresystem.html. She is honored that artwork was featured on the holiday card of the Elizabeth Coalition to House the Homeless.

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Psychological Flexibility: Different Perspectives From Students and Early Career Professionals for Stressful Times

Dominique Reminick

Keryn Kleinman

Aaron A. Gubi, PhD

Mary Toolan, PsyD

NJPA ECP Committee

Combined Doctoral Program in Clinical and School Psychology, Kean University

For my own part, the second in this collection, I add that I have found the dialectical world view taught in Dialectical Behavior Therapy (Linehan, 1993; 2015; King, n.d.), i.e., the acknowledgement and ongoing synthesis of competing truths from moment to moment, to be an invaluable way of going about psychological flexibility in my professional and personal life. My clients, trainees, colleagues, friends, and family would certainly attest to my enthusiasm for the approach. As they all frequently hear my replies of “There’s actually a dialectic here;” “Well, on the one hand, . . . and on the other hand, . . . ;” “Both truths can be valid;” “It’s all about synthesizing those two truths;” and “It’s not just taking the average, but using your wise mind to come up with something greater or creative to synthesize the dialectic.” I summarize some selfcare strategies (Norcross & Guy, 2007; Norcross & VandenBos, 2018) that seem to me to emanate from this perspective (King, n.d.).

Christopher King, JD, PhD NJPA ECP Committee Past-Chair

Editor’s Note

I

am very pleased to have the opportunity to introduce an article about psychological flexibility that was co-authored

by Drs. Aaron Gubi and Mary Toolan, members of the NJPA ECP Committee, and two of Dr. Gubi’s students at Kean University, Dominique Reminick and Keryn Kleinman. The NJPA ECP Committee felt that this topic was particularly important and timely in light of all that is going on in New Jersey, across the country, and throughout the world, and we were glad to be able to include two of our junior colleagues at co-authors on this column. The first part of the entry, penned by Ms. Reminick, Ms. Kleinman, and Dr. Gubi, reviews the approaches used in acceptance and commitment therapy to increase psychological flexibility, and evidence supporting the role of increased psychological flexibility in positive ACT outcomes. The third part, contributed by Dr. Toolan, offers a conversational account of psychological flexibility during the pandemic, applicable to both clinical work and our personal lives under present circumstances.

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sychological flexibility has been defined as “the process of contacting the present moment fully as a conscious human being and persisting or changing behavior in the service of chosen values” (Hayes et al., 2006, p. 9).

Conceptualized in its current form in the 1990s, it is considered the core therapeutic process within Acceptance and Commitment Therapy (ACT), a third-wave cognitive behavioral therapy (CBT) that incorporates mindfulness and acceptance into the traditional CBT framework (Hayes et al., 1999; Zettle, 2011). Born from the union of Relational Frame Theory (RFT), Applied Behavior Analysis

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(ABA), and Functional Contextualism (FC), ACT views psychological inflexibility as a maladaptive process originating from the nature of human language, in which the dominance of language processes contributes to reduced sensitivity to contexts and contingencies, and leads to rigid, rule-governed behavior (Hayes et al., 2006; Torneke, 2010). Such inflexibility can result in psychological distress and impaired functioning; thus, the ultimate goal of ACT is to increase psychological flexibility in the service of one living a more meaningful life (Hayes et al., 2006).

Unlike traditional CBT that seeks to directly modify maladaptive cognitions, ACT endeavors to help people change their relationship to their thoughts, rather than the thoughts themselves (Hayes et al., 2006).

The model that ACT employs to this end is the ACT hexaflex, that is comprised of six core processes that work in conjunction to increase psychological flexibility (Ciarrochi et al., 2010). The ACT hexaflex consists of (1) cognitive defusion, in which one sees thoughts as merely thoughts rather than edicts of reality; (2) self as context, i.e., the “I” that notices having thoughts and experiences that fosters a perspective of self as an observer of life’s content; (3) acceptance, i.e., not avoiding unpleasant sensations that may arise; awareness, or noticing and non-judgmentally describing psychological and environment events as they occur; values, the “whos” and “whats” that are chosen as personally important; and committed action, rededication to making more moves toward one’s values (Ciarrochi et al., 2010). It is through exploring and embodying these mindfulness and acceptance processes, and their corresponding commitment and behavior change processes, that overall psychological flexibility can be developed and strengthened.

resistant” participants with various diagnoses found both interventions to relieve depressive symptoms, reduce stress, and improve quality of life by the end of treatment; however, only those in the ACT condition maintained improvements in depression at six month follow up (Clarke et al., 2014). Another multi-site RCT found that participants in the ACT intervention group showed significantly greater psychological flexibility posttreatment, as well as greater well-being and fewer stress, anxiety, and depression symptoms relative to waitlist controls (Grégoire et al., 2018). Overall, the research that has investigated psychological flexibility as a mechanism of change for improved psychological functioning and decreased distress has been quite promising.

Psychology Practice Dialectics for Synthesis Toward Self-Care

The literature on psychological flexibility increasingly supports its role as a transdiagnostic process underlying psychological well-being (Ciarrochi et al., 2010; Stockton et al., 2018). Multiple studies have observed a relationship among psychological flexibility, psychological distress, and symptom severity that suggests that interventions that increase psychological flexibility decrease distress and improve both mental health and overall functioning (Fledderus et al., 2013; Levin et al., 2014; Lin et al., 2018).

Further, psychological flexibility has been found to be associated with overall positive mental health and may serve as a protective factor for myriad psychological disorders, including depression and anxiety (Kashdan, 2011; Ramaci et al., 2019). Psychological flexibility has also been studied in randomized control trials (RCT), the gold standard for assessing treatment effectiveness. An RCT investigating the effectiveness of group ACT vs CBT treatment-as-usual for “treatment

In a prior NJPA member-only resource, I reconceptualized self-care strategies recommended by Norcross and Guy (2007) and updated by Norcross and VandenBos (2018) in Dialectical Behavior Therapy (DBT) skills terms. I explained that thinking dialectically is thinking flexibly. It is being open-minded to there always being two or more “truths” in any situation; entering into these paradoxes and shifting effectively between polar truths toward creative gestalts; and participating in this process over and over again. I also highlighted some common dialectics for synthesis: acceptance vs. change, emotion mind vs. rational mind, being vs. doing, and self-denial vs. selfindulgence.

Finally, I referred to a variety of more specific dialectical issues pertaining to psychology practice. These dialectics included:

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• periods of discomfort (prompts for change) vs. refreshment (“easies” to accept);

happen, albeit changing daily, it can be unsettling, confusing, and scary. Due to the worldwide pandemic crisis, significant changes have occurred that have impacted and altered everything entirely.

• the cons vs. pros of the profession; • being employed vs. being an independent contractor (in one sense or another);

The current pandemic crisis has quickly forced many people into situations never before experienced.

Absolute changes, such as job security and health, have shifted quickly, as well as less tangible changes in thought and emotions. Prior schedules are set aside and even abandoned when such crisis occurs. Family responsibilities are rearranged.

Basic needs change and in this case, something as normal and typical as running an errand is restricted and may even be wholly impossible. Choices, once large in number, are suddenly severely limited.

Many changes are obvious and readily discerned, but subtler and shifting emotional dimensions may be less obvious. Changes in feelings of safety and security, comfort, fear, anxiety, and loss may occur daily if not hourly. When maintaining what was and going on “as normal” becomes no longer possible, what are your options? One notion includes being flexible; being open minded to the idea that something different may need to happen.

• professional strengths vs. professional limitations; • professional failures vs. professional successes; • monetary professional wealth vs. wealth in terms of professional enjoyment; • expected or needed workaholism, professional perfection and celebrityism, and Olympian selfcare vs. good enough; • practicing therapy vs. practicing what you preach by seeking your own therapy; • being a psychologist among your colleagues vs. being a non-psychologist among your family and friends; •

dedication to your clients vs. protecting your personal time;

•

a high number of clients and risky clients vs. a low number of clients and “safe” clients;

•

you and your client impacting one another as people vs. your unilateral obligation to meet your client’s needs;

•

clients’ transferences toward you vs. management of your countertransferences;

•

caring vs. challenging;

•

empathy and connection vs. healthy boundaries;

•

utilizing metaphors, paradoxes, and irony;

•

utilizing irreverence, including humor and absurdity;

•

the possibility that you caused client events vs. other potential causes;

•

success as a dichotomous outcome vs. success as a continuous process; and

•

personal failures vs. failed cases.

Flexibility is to consider options and adapt to a new manner of things. What is controllable and what can rationally and literally be accomplished? Is being capable of adapting to a new, different, and changing requirement possible? Can needs be met on an “as needed” basis? Much is still unknown; therefore, remaining flexible about possibilities and unknown circumstances becomes a necessary adjustment to be realized. As the world, and our own microcosms navigate the struggles, adopting an attitude of flexibility may help us tolerate our stressors. Shifting your thought to acknowledging change can absolutely encourage feelings of preparedness and empowerment.

As a therapist and a clinician, allowing yourself the space to do things differently and perhaps even on an “as needed” basis may become the “new normal.”

Flexibility in thought may mean that when fixated on things being a certain way and consistent, new options are introduced including ideas of varying degrees. Understand the need to permit (both yourself and your clients) time to react and resettle as the crisis did not permit for prior preparation.

Understanding our own needs will provide greater understanding of client needs. Accepting or even embracing flexibility is increasingly important as unknown circumstances surrounding this crisis are still occurring. So much is still unknown. Being flexible with clients may not only mean meeting

I believe syntheses of these dialectics facilitate psychologist self-care, among other DBT skills that can support self-care.

Flexibility in Therapy During the Pandemic: A Therapist’s Perspective An absolute that the pandemic continues to remind us of is that the truly unexpected can happen at any time. When the unexpected happens and continues to

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via phone or video conferencing, but also may require responding to a crisis call, or altered hours of availability and manners of payment. Topics typically discussed by a client may shift as other subject matter becomes more prominent, thus requiring flexibility in treatment.

then, flexibility requires being flexible to what might need to be adjusted or changed the next moment or day when the situation requires just that!

Inherent in flexibility and gaining the ability to adapt is to be in the space of waiting, while knowing that there may not be an “answer” or resolution in the near future.

However, there is support to facilitate coping with the newer circumstances. Adopting a flexible mindset may provide ourselves and our clients with the comfort of knowing that although there is still much that is unknown within this crisis, we are capable of coping and even adjusting our outlook. Knowing that within the unknown, there is space to remain and to be. Perhaps “embracing” the unknown is a big ask, but simply being is often what is left. We are left with our thoughts, emotions and actions that will benefit from flexibility. Trust is gained by knowing and experiencing, tolerating and being resilient.

Additional trust is gained by knowing that after the initial “fight or flight” response, we can take deep breaths, speak aloud “I don’t know what is going to happen, but that’s ok.” All the while, focusing on what you can do in the present to activate the brain to plan, organize thoughts, and create options thus allowing the parasympathetic nervous system a chance to realize that the danger, however real, is not necessarily imminent.

Dominique Reminick, MA is a third-year doctoral student in the Combined Clinical and School Psychology PsyD program at Kean University in Union, NJ, where she manages Kean’s Center for Autism Assessment and Research Services (CAARS). In 2020, she served as a board member for the New Jersey Psychological Association for Graduate Students (NJPAGS), and held the Member-at-Large position for the Committee on Diversity and Inclusion. Her recent research focuses on traumainformed care in school settings, with an emphasis on supporting diverse student populations.

Just as in the therapeutic situation, one approach, one methodology, one technique is not at all suited for each and every person. Each client necessitates essential flexibility: a new therapeutic relationship, a new strategy, a new and remodeled collection of ideas, an individualized case conceptualization, and more before the therapeutic alliance is established and therapy can be accomplished. Just as in life, we need to find the level of flexibility that feels comfortable. Even

References Furnished upon request About the Authors

Keryn Kleiman is a third-year doctoral student at Kean University’s Combined Clinical and School psychology PsyD program. She is currently a doctoral extern at the Center for Anxiety and also serves as a doctoral assistant at Kean, where she manages clinic-related research efforts, including designing and implementing a study evaluating a compassion-focused acceptance-based therapy for anxiety, mood, and trauma-related difficulties. Previously, Keryn served as a doctoral extern in the Ridgefield Park School District. Prior to entering graduate school, Keryn worked as a research assistant at the Regulation of Emotion in Anxiety and Depression lab at Columbia University and a junior research scientist at the Family Translational Research Group at New York University.

Mary Toolan, EdS, PsyD is in private practice in Springfield, NJ. As a former practicing school psychologist, Dr. Toolan often conducts complete psycho-educational evaluations and consults with area schools, and families. Dr. Toolan enjoys providing individual and couples therapy specializing in supporting children, adolescents, adults, and couples manage their anxiety, depression, relationship difficulties, conflicts, life changes and stressors, and grief.

Aaron Gubi, PhD is a licensed psychologist and certified school psychologist. He is an assistant professor and serves as Clinic Director of Kean Psychological Services, the community training clinic for the Doctoral Program (PsyD) in Combined School-Clinical Psychology at Kean University.

His clinical interests include conducting psychological assessments and providing therapy with children, adolescents, and young adults, with particular interests in trauma, autism spectrum disorders, and disabilities. He also holds part-time positions with a private practice and an adolescent residential treatment facility, and currently serves as the interim editor of the NJ Psychologist.

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Psychological Flexibility in Theory and Practice for Clients, Graduate Students, and Clinical Supervisors During COVID-19

By Deirdre Waters, PsyD and Paulina Calcaterra, BA (l to r)

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s quickly as COVID-19 impacted the state of New Jersey, the transfer to remote learning, telehealth services, and digital clinical supervision occurred for doctoral students in clinical psychology. Paulina Calcaterra, BA, is a rising 2nd year doctoral student in clinical psychology at the Rutgers University GSAPP program and Deirdre Waters, PsyD is a NJ licensed psychologist and part-time lecturer at GSAPP. Here is an account of their experience of transitioning to remote learning and therapy services.

As a beginning clinician, Paulina found the clinical supervision seminar helpful. This was her first exposure to clinical work as the therapist in the room and application of theory into practice. Past experiences of therapy as the client and the role reversal was impactful. Paulina appreciated ACT’s humanistic idiosyncratic approach and learning how it applies to treatment goals. Additionally, watching the flexibility and attunement of her supervisor and fellow trainees helped her to develop clinical instincts and provided the opportunity to practice empirically supported techniques.

Clinical Supervision

Five months into our weekly CBT group supervision, which met weekly on campus at the Rutgers University Center for Psychological Services, our last on-site group supervision occurred. It was March 11, 2020. Spring break was scheduled for the next week. Prior to each student’s case presentation, we discussed the news of the partial university shut down that had just been announced due to COVID-19. The identified plan was to continue therapeutic services for individual therapy and to continue meeting for supervision in our small group.

We discussed spring break plans in relation to accessibility for client care and identified personal concerns about COVID-19. This supervision session progressed in the usual format, clinical cases were presented, videos of therapy sessions reviewed, supervisory feedback provided, and specific CBT/ ACT techniques recommended.

Doctoral programs in clinical psychology provide theoretical and applied practice of psychology throughout the course of the program. In the first year of training at GSAPP, students are assigned therapy cases that correspond with foundational course work. The clinical work is supervised in small groups and facilitated by licensed psychologists on the faculty and in the community.

The learning process is accelerated by formulating case conceptualizations and presenting videotaped sessions, receiving feedback from one’s supervisor and cohort, and participating in the other group members’ clinical growth and case presentation.

Our supervision seminar was Cognitive Behavioral Therapy (CBT), with an emphasis on Acceptance and Commitment Therapy (ACT). ACT highlights psychological flexibility and teaches acceptance strategies, mindfulness, and valued driven actions as ways to promote psychological well bring (Hayes, Strosahl, & Wilson, 2016).

Four months now into the pandemic, this normalcy in our supervision seems remarkable to reflect on.

Through the years, many supervised students have

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experienced personal tragedies, family changes, and lived through national and world tragedies.

Monitoring emotional regulation skills, utilization of coping mechanisms, and reinforcing self-care is an accepted part of the supervision process as we help prepare students for a career in psychology.

When our supervision group unsuspectingly met for the last time on campus, Dr. Waters did not anticipate the severity of the pandemic nor the associated personal and professional losses for our clients and our supervision group.

Psychological Association, 2020).

It is important to note that a smooth transition to telehealth is likely indicative of privilege. For example, a private space for therapy, reliable Internet connection at home, and technology with the capacity to support video calls, is required.

Similarly, the economic privilege of being a graduate student is exclusionary and further promotes class inequality. These dynamics are also true for clients accessing mental health treatment and the ability to adapt to telehealth may reflect the economic privilege in the field of psychology. Despite the relative ease with which many practitioners transitioned to telehealth, the field should continue to have critical conversations about inclusivity and accessibility of services. It is important to listen to the voices of clinicians and clients for whom the current system is not working and learn how we can adapt. Clients who have the most complex and pressing mental health needs in this pandemic may not have the ability to engage in telehealth. Furthermore, given the treatment barriers that have been well documented in our field, it is likely that access issues have been exacerbated in this time (Cook, Hou, Lee-Tauler, Progovac, Samson, & Sanchez, 2019; Cook, Trinh, Li, Hou, & Progovac, 2016; Kohn, Saxena, Levav, & Saraceno, 2004). As we experience a moment of reckoning with systemic racism and experience two pandemics, COVID-19, and systemic racism, we must also acknowledge how intersecting identities and multiple systems of oppression create disproportionate barriers to mental healthcare among marginalized groups.

Impact of COVID 19 and Transition to Telehealth Within the next week, the university campus closed, and the graduate students left the New Brunswick area to be closer to family and friends.

Clients were contacted and advised of the clinic closing and telehealth services, including phone and video options, were offered. Psychologists, therapists, and graduate students across the country report a similarly quick transition to telehealth. In fact, according a recent American Psychological Association survey (APA, 2020), 75% of psychologists closed their physical offices and began providing remote services via phone or a HIPAA compliant video session. The graduate students appeared to adjust well to the virtual platform for both supervision and for presenting their cases for clients who continued with treatment.

Paulina hosted the secure Zoom meetings from her university account and kindly assisted Dr. Waters with any technological challenges. When connections were lost or rebooted, the group responded with ease and flexibility. The digital platform continues to be functional as our work remains remote.

As we made our transition to telehealth, the group observed how the pandemic produced a range of clinical implications. Some of our clients quickly transitioned to virtual sessions, missing only one scheduled meeting; therapy sessions were held over the telephone and then transitioned to a secure video platform. Other clients terminated therapy abruptly. Each scenario posed challenges and opportunities: clinicians had to develop new skills for communicating support and attunement remotely for the first time. Transitioning to phone or video sessions also provided an opportunity to learn more about clients as we see them in their intimate environments. That has led to insights that Paulina wonders if she and her clients could have ever arrived at in a neutral therapy room. For instance, a moment during which a family member interrupted a client during a session,Paulina saw an enactment of difficult family dynamics and her client’s response in real-time. For those whose clients discontinued treatment unexpectedly, there were self-doubt and

The literature has supported clients reporting favorable results for telehealth when it is available (Bischoff, Hollist, Smith, & Flack, 2004; Chen et al, 2019). Clinicians have noted the same challenges as those noted in our supervision process (troubleshooting technology issues, connection disruptions, and a level of required mental focus).

Individually and in groups, we attended telehealth trainings, CEU workshops, and reviewed the written material provided to assist in our quick transition to the telehealth platform. Cognitive beliefs about telehealth being suited only for targeted populations (remote areas, housebound clients) and the practice as less effective than in person therapy were no longer held. Emergency legislation (A3860) was quickly passed that increased access to insurance reimbursement of telehealth services and home residence accepted as place seen (American

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present, and ability to help our clients do the same.

Additionally, when therapists have multiple privileged identities, it is important to explore and unpack how these privileges enter the therapy room during the supervision hour.

reinforcement of internal events around inadequacy to manage. Our group was encouraged to practice the same techniques they were introducing to their clients, observing the accompanying internal events (thoughts/feelings) without becoming stuck to them, honoring the frustration and uncertainty, and quickly adapt to the changes that were outside of our control.

ACT also encourages clinicians to de-emphasize the idea that therapists are experts on their client’s experiences, which Paulina has experienced as comforting during this difficult time. Harris (2006) describes how in ACT treatments, therapists “are in the same boat as their clients—so they don’t need to be enlightened beings or to ‘have it all together.”’ He uses the following metaphor to outline the therapist stance: a therapist might explain to a client that it’s “as if you’re climbing your mountain over there and I’m climbing my mountain over here. It’s not as if I’ve reached the top and I’m having a rest. It’s just that from where I am on my mountain, I can see obstacles on your mountain that you can’t see. So I can point those out to you, and maybe show you some alternative routes around them”’ (Harris, 2006, p. 8).

The mountain metaphor has been especially helpful and necessary during this pandemic. No amount of training or wisdom that the clinician holds can make this situation less difficult. Whether it is a technical difficulty or any other kind of interruption in the ideal therapeutic situation, clinicians can demonstrate a willingness to accept the limitations of the present moment while remaining engaged and authentic despite not having perfection or control. Both the client and clinician are practicing their abilities to adapt to the chaotic environments of the pandemic, and telehealth, practicing flexibility in the moment together and learning experientially.

These techniques echo many of the six core processes of ACT, specifically acceptance, cognitive diffusion, being present, and self as context (Hayes, Strosahl, & Wilson, 2016). ACT explains that maladaptive responses develop when we are inflexible, avoid experiencing the present moment, entangle with our cognitions, attach to our narratives about ourselves and the world, and act in ways that do not align with our values (Hayes et al, 2016). As clinicians, it was important to tap into the core processes of ACT to transcend those pitfalls and stay in a helpful state of mind during this challenging pandemic.

Adaptation, Flexibility, and Rewards As we began to conduct psychotherapy remotely and manage these various clinical demands, it became clear that therapists’ own experiences of the pandemic were impacting their work. Weighing the horrors of COVID, the disproportionate impact on Black, Indigenous, Asian and other communities of color, and all of the injustices that it highlights are overwhelming thoughts to hold. We are all impacted by the pandemic, clinicians and clients alike, to varying degrees and with access to different resources. Learning how to the balance of providing therapeutic care and managing personal painful experiences is a necessary career long skill. In the literature on providing psychological first aid and responding to traumatic crises, it is acknowledged that containment is a core skill for therapists to utilize to stabilize and support those who are suffering (Kraybill, 2018). ACT’s emphasis on mindfulness, authenticity, and acceptance provided tools for sitting in the present moment with clinical concerns and our own processes. Practicing techniques in supervision allows for mastery and induced calmness that could be brought into the therapy sessions. An important element of our supervision group was a consistently held value and practice of incorporating our own humanity into our work. We checked in with each other in meaningful ways and with intention. It was clear that this process was necessary to make our work sustainable. Clinicians’ self-care and capacity for mindfulness allows an increased connection to the

Furthermore, expanding our mental filters and making room to recognize the joy and positive elements of training and life outside of COVID-19 was another practice in supervision that became very important. Questions Dr. Waters asked included “What is one thing you learned this week?” and students were encouraged to think outside of our clinical training. We shared recipes, community involvement and other fun facts. There was a balance from checking in and expressing shared grief and anxiety with expressing gratitude and hope. This action allowed us to practice concepts that we teach our clients: holding many different truths and aspects of reality at once (even those that are oppositional) and challenging our negative attentional biases by reminding ourselves of things that bring happiness and healthy distraction.

We believe that the fundamentals of psychological flexibility have helped us to all navigate this novel

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situation. Practicing acceptance strategies on events outside our control, promoting present moment awareness and utilizing defusion to become unstuck as we provide therapeutic care for others. Treatment objectives and goals are being met. Graduate students, clients, and supervisors are adapting to the chaotic environments of the pandemic, and telehealth. Although mental health challenges have been exacerbated by this global crisis, the ability to push forward or stay still inspires hope.

About the Authors Deirdre Waters, PsyD is a licensed psychologist who has a private practice in Monmouth County. She is also the director of the non-profit the Behavioral Health Institute of Monmouth County, maintains consulting privileges at Jersey Shore University Medical Center and Riverview Medical Center, and teaches as an adjunct at Montclair State University and for Rutgers GSAPP. Paulina Calcaterra is a 2nd-year student at the Rutgers Graduate School of Applied and Professional Psychology Clinical PsyD program. At this point in her training, she is interested in specializing in trauma, gender-based violence, and body acceptance from a psychodynamic and ACT framework.

Works Cited American Psychological Association, 2020. Psychologists embrace telehealth to prevent the spread of COVID-19.

Retrieved from https://www.apaservices.org/practice/legal/technology/psychologists-embrace-telehealth Bischoff, R.J., Hollist, C.S., Smith, C.W., & Flack P (2004). Addressing the mental health needs of the rural underserved: Findings from a multiple case study of a behavioral telehealth project. Contemporary Family Therapy, 26(2), 179–198.

Chen, C. K., Palfrey, A., Shreck, E., Silvestri, B., Wash, L., Nehrig, N., Baer, A. L., Schneider, J. A.,Ashkenazi, S., Sherman, S. E., & Chodosh, J. (2019, February 11). Implementation of TelementalHealth (TMH) Psychological Services for Rural Veterans at the VA New York Harbor Healthcare System. Psychological Services. Advanced online publication.

Cook, B. L., Hou, S. S.-Y., Lee-Tauler, S. Y., Progovac, A. M., Samson, F., & Sanchez, M. J. (2019). A Review of Mental Health and Mental Health Care Disparities Research: 2011-2014. Medical Care Research and Review, 76(6), 683–710. https://doi.org/10.1177/1077558718780592 Cook, B. L., Trinh, N., Li, Z., Hou, S. S., Progovac, A. M. (2016). Trends in racial-ethnic disparities in access to mental health care, 2004-2012. Psychiatric Services, 68, 1-16.

Cooper, L. D., Murphy, H. G., Delk, L. A., Fraire, M. G., Van Kirk, N., Sullivan, C. P., Waldron, J. C., Halliburton, A. E., Schiefelbein, F., & Gatto, A. (2019). Implementing routine outcome monitoring in a psychology training clinic: A case study of a process model. Training and Education in Professional Psychology, Advance online publication. https://doi. org/10.1037/tep0000298 Harris, R. (2006). Embracing Your Demons: an Overview of Acceptance and Commitment Therapy. Psychotherapy in Australia, 12(4), pp. 2-8.

Hayes, S., Strosahl, K., Wilson, K. (2016). Acceptance and Commitment Therapy, Second Edition: The Process and Practice of Mindful Change. New York: The Guilford Press.

Kohn, R., Saxena, S., Levav, I., Saraceno, B. (2004). The treatment gap in mental health care. Bulletin of the World Health Organization, 82(11), pp. 858-866.

Kraybill, O. (2018). When Is Therapy Inappropriate After Trauma? Do’s and don’ts when responding to trauma. Psychology Today, accessed at https://www.psychologytoday.com/us/blog/expressive-trauma-integration/201805/when-is-therapyinappropriate-after-trauma Luxton, D. D., Pruitt, L. D., & Osenbach, J. E. (2014). Best practices for remote psychological assessment via telehealth technologies. Professional Psychology: Research and Practice, 45(1), 27–35.

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ur Mission: In addition to supporting the New Jersey Psychological Association (NJPA) mission, the mission of the Foundation is promoting the psychological health of the diverse people of New Jersey.

JPA Foundation is the heart of NJPA. The NJPA Foundation administers and raises money to support the training of psychology graduate students as clinicians and researchers with an emphasis on treating underserved populations. The NJPA Foundation supports the mission of NJPA especially in its commitment to diversity, public health, underserved populations and the training of graduate students in psychology.

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Francesca Peckman, PsyD Katherine Rhoades, PhD Michael Richardson, PsyD Bart Rossi, PhD Elissa Rozov, PhD Anne Rybowski, PhD Debra Salzman, PhD Luciene Sant’Anna Takagi, PsyD Komal Saraf, PhD Louis Schlesinger, PhD Gail Schrimmer, PhD Richard Schwartz, PsyD Nancie Senet, PhD William Shinefield, PsyD

Laura Eisdorfer, PsyD Renan Erkut-Petermann, PhD Joan Fiorello, PhD Antonia Fried, PsyD Lorraine Gahles-Kildow, PhD Marie Geron, PhD Gary Goldberg, PhD Sandra Grundfest, EdD Angela Hall, PsyD Steven Hartman, PhD Frances Hecker, PhD Susan Herman, PhD Doris Hiatt, PhD Tamar Kahane, PsyD

Copper (up to $99) Alexander Alperin, PsyD Benjamin Alterman, PhD Amy Becker-Mattes, PhD Leslie Becker-Phelps, PhD Karen Bekker, PhD Jeffrey Bessey, PhD Phillip Bisco, PsyD Phyllis Bolling, PhD Dorothy A Borresen, PhD Charles Buchbauer, PhD Monica Carsky, PhD Marvin Chartoff, EdD Karen Cohen, PsyD Jamila Dakhari, PsyD Deborah Dawson, PsyD Promila Dhillon, PhD Nancy Distel, PhD

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Paula Kaplan-Reiss, PhD Lisa Kestler, PhD Eileen Kohutis, PhD Peter Krakoff, PhD Dennis La Scala, PhD Phyllis Lakin, PhD Ilana Lev-El, PsyD Katharine Loeb, PhD Mark Lowenthal, PsyD Konstantin Lukin, PhD Heather MacLeod, EdD Margery Manheim, PhD Thomas Massarelli, PhD Susan McGroarty, PhD Gail McVey, PsyD Tracy Menzie, PhD Jacqueline Mesnik, PhD Alexandra Miller, PsyD Norine Mohle, PhD Lynn Mollick, PhD Marsha Morris, PhD Alice Nadelman, PhD Elizabeth Nadle, PsyD Susan Neigher, PhD Cathy Novaky, PhD Susan Orshan, PsyD Mark Pesner, PhD Vincenza Piscitelli, PsyD Jeffrey Pusar, PsyD Gina Rayfield, PhD Lori Rayner-Grossi, EdD Louis Richmond, PhD Debra Roelke, PhD Amelia Romanowsky, PsyD Barbara Rosenberg, PhD Gianine Rosenblum, PhD George Sanders, PhD Arline Shaffer, PhD Jeffrey Singer, PhD Tamara Sofair-Fisch, PhD Lois Steinberg, PhD Andrew Thomas, PsyD William Walsh, PhD Jennifer Weberman, PsyD Richard Zakreski, PhD Michael Zito, PhD