Christopher Blazina, PhD Editor The University of Houston David White, CAE Executive Director WINTER 2001
Robert McPherson, PhD Director of Professional Affairs Lynda Keen Executive Director’s Assistant Sherry Reisman Director of Membership Lila Holmes Membership Assistant
TPA BOARD OF TRUSTEES
President-Elect Designate Deanna F. Yates, PhD Past-President Richard M. McGraw, PhD
BOARD MEMBERS Gary Brooks, PhD Ray Brown, PhD Mary Connell, EdD Patrick J. Ellis, PhD C. Alan Hopewell, PhD Sheila Jenkins, PhD Joseph C. Kobos, PhD Alaire Lowry, PhD Elizabeth L. Richeson, PhD Jose Luis Torres, PhD Jarvis A. Wright Jr., PhD
Trends in Patient Requests: Lessons from PsychSelect William C. Whitehead, PhD
Powerful Partners, Belong to Both Michael Sullivan, PhD
Roots of Terror: Psychology Responds to Terrorism Ronald F. Levant, EdD, ABPP
Practitioner Report Ronald F. Levant, EdD, ABPP, APA Recording Secretary
Division of Trauma Psychology is Coming to APA Gail Brothers Braun, PhD
A Developmental Model of Supervision of Therapists Working with Sexually Traumatized Children Laura Palmer, PhD Robert McPherson, PhD Anne R. Farrar, MA Heather Wallrath, MA
EX-OFFICIO BOARD MEMBERS Foundation President Robbie N. Sharp, PhD PSY-PAC President Ron Cohorn, PhD
Screening for DSM Disorders Michael B. Frisch, PhD
President Sam Buser, PhD President-Elect Walter Cubberly, PhD
VOLUME 52, ISSUE 4
Council of Representatives, American Psychological Association Joseph C. Kobos, PhD, ABPP
Corporation President Rick McGraw, PhD Federal Advocacy Coordinator Thomas A. Van Hoose, PhD
Federal Advocacy Coordinator Paul Burney, PhD
PRESIDENT’S MESSAGE: Remember the Alamo! Sam J. Buser, PhD, TPA President
PUBLISHER Rector Duncan & Associates P.O. Box 14667 Austin, Texas 78761 512-454-5262 Kim Scheberle Managing Editor Matt Stillwell Advertising Sales
David White, CAE, TPA Executive Director
LAW: What is Your Duty to Report? Sam A. Houston & Merritt McReynolds Marinelli
Scott B. Williams Art Director The Texas Psychological Association is located at 1011 Meredith Drive, Suite 4, Austin, Texas 78748. Texas Psychologist (ISSN 0749-3185) is the official publication of TPA and is published quarterly.
FROM TPA HEADQUARTERS: America’s United ... It is our Time
Psychologists in Non-Traditional Settings Christopher Blazina, PhD
2001 PSY-PAC Contributors
www.texaspsyc.org WINTER 2001
me that many other physicians (e.g., family practitioners and gynecologists) actually prefer collaborating with psychologists, valuing our skills and approach to people. Nonetheless, whenever psychiatry opposes us, the heavily endowed Texas Medical Association lines up with the Texas Society By Sam J. Buser, PhD of Psychiatric Physicians like distant cousins from Arkansas (“We ain’t close, but we are As a native Texan, I have always considered the Alamo a kin.”). The money and political clout of psychiatry, especially when combined with shrine to heroism. A few brave defenders sacrificing everything TMA, makes them a formidable foe, particfor a cause they believed in deeply. Yes, I know the history is ularly when we seek to pass bills, such as a bit more complicated than that, but their courageous stand prescription authority, that have an impact still inspires us. I hope it will inspire you. on them. On the other side of our little mission building are the forces of the master’s level pens to your ability to practice, research, or ad News. There are only around 1,000 professionals. Like the Texicans at the teach without a voice for psychology in the psychologists who are full members of Alamo, we are outnumbered! Most of the legislature. Who will look out for your proTPA. Yet there are 3,560 licensed psycholotime our interests dovetail, and there is no fession if TPA is not there? Like the defendgists in Texas. Why so few members? conflict. But like the defenders of the ers of the Alamo, we are surrounded on all Nonmembers and, sometimes, even memAlamo, if we take a stand independent of sides by forces that are not our friends. bers say to me, “Sam, it’s too expensive. them, they can On one side is psychiWhy should I join? What does TPA do for descend in hordes on atry. It is no secret to us me?” As a member of the TPA Board for the the state capitol and that organized psychiatry past six years and on us. Again, it is no is not our friend. If psyespecially as your TPA exists to secret that many maschiatry had had their president this year, ter’s level professionals way, psychologists would I know the answer want to call themnever have been able to to that question. as political selves psychologists. practice in Texas or, for TPA represents These persons don’t that matter, in any other the interests of believe it is necessary state. Psychiatry opposed psychologists to representation to to get a doctorate to be bills to authorize the the Texas Legislature. In my opinion, that is qualified as a psycholpractice of psychology at our most essential role. Sure, we provide every juncture, and we the good CE workshops, but there are dozens Legislature. ogist. They don’t see the value of our much only obtained the ability of other CE workshops you can attend. Yes, longer training, our to practice in Texas in we have member benefits like discounts for emphasis on research 1969. As Don Corleone services, but they are not enough to make a and science, or our extended pre- and postin the “Godfather” said as he bumped off a person want to join. (Sam’s Club offers disdoctoral internships. They would argue that former family friend, “This is not personal. counts, too!) You can stay in contact with a master’s degree of two years is sufficient to It’s business.” colleagues through TPA, but there are other practice psychology. What’s the big deal Like you, I have good relationships with ways to make friends and to associate with about a doctorate they ask? many psychiatrists. We are friends and suppeers. Nope, our major reason for existence In every legislative session, including the port each other’s work through referrals and is to serve as political representation to the most recent session, there has been an effort sharing of clients; however, organized psylegislature. by master’s level persons to obtain indepenchiatry is not the same as individual psychiYou may object to this role definition. dent practice of psychology. Ask yourself atrists. Organized psychiatry would like to Many psychologists dislike the taste of polhow long would psychology be a doctoral see psychologists lose the ability to practice itics. Psychologists frequently feel that polilevel profession if there were no TPA? independently, and they have much more tics is a dirty or unfamiliar business, and Without TPA’s voice talking to legislators money to influence legislators than does most of us would just prefer to help clients, about our profession and its rigorous stanpsychology. Psychologists often point out to do research, or teach. But picture what hapFROM THE PRESIDENT
Remember the Alamo!
dards there would be no doctoral standard. The master’s level groups are well organized, but, more importantly, they vastly outnumber us. In 2005 TPA faces a major battle with the “sunset” of our state board and our licensing act. We must persuade the legislature to renew our charter in order for us to continue practicing psychology in Texas. Without that bill, every psychic and personal advisor in Texas, much less master’s level professionals, could advertise that they are providing psychological services. Already, our opponents are gathering their forces to make another effort to diminish our profession and assault our territory. TPA has begun its own preparations for sunset, and you will be hearing more about this in the next year. As part of our efforts, we will ask all psychologists to contribute an additional $25 each year when they renew their membership. This money is vital for us to support our efforts legislatively and in other ways to maintain the doctoral standard for the practice of psychology in Texas. TPA is defending the ramparts of our profession, but like Colonel William B. Travis, commander of the Alamo, we need reinforcements. If you are a member of TPA, please renew promptly and support your organization so that you can continue your ability to practice tomorrow. Ask your associates to join so that we have the resources to represent you and the profession well. When someone asks you, “What has TPA done for me?” tell them that TPA obtained the ability to practice psychology in Texas and defends that ability each year. Tell them that TPA battles successfully to curb the excesses of managed care. Tell them that TPA opposes efforts to make psychology a master’s level profession. In addition, tell them that TPA seeks to expand opportunities by obtaining prescription authority for appropriately trained psychologists. If you are reading this and you are not yet a member, go to our Web site (www.texaspsyc.org) and fill out the application. Defend the profession. Remember the Alamo! ✯ WINTER 2001
FROM TPA HEADQUARTERS
America’s United ... It is our Time By David White, CAE, TPA Executive Director
he events of September 11 are forever etched into our collective and individual memories. Our lives will never be the same. The way we approach life will be dramatically different. In a matter of minutes, the world we live in changed. Routine daily events that we did without a second thought now become very obvious in our minds. We look at our neighbors differently and we wonder when the news will give us another “breaking story.” We are all dealing with this in our own personal way, but we are all very aware of one thing—we have lived through a historic moment in the world. This event will be talked about for hundreds of years. So with only 60 days having passed since this tragedy, what have we learned? The most important lesson I notice is UNITY. This country is ONE. We are not divided; 4
we do not talk about racism, party affiliation, or competition. We act by giving blood, money, clothes, food, and our time. We have come together to support and comfort one another. Our leaders have shown their unity by their actions; the federal government helping a state, a state helping a city, and a city looking at the brave and fearless individuals that make up a community. We applaud this action by proudly displaying our American flags on our homes and cars. We attend sporting events where 80,000 people wear red, white, and blue shirts. We sing “God Bless America” instead of “Take me out to the Ballgame” at baseball games and honor the professionals who make our community safe and secure. So is a tragic event the only thing that will bring unity to a group? NO. What
brings unity is a group all believing in the same cause. That is what you and your colleagues did 54 years ago when they created TPA. They came together because they believed that a unified group could accomplish feats that individuals could not. They came together because there was a need. Well, TPA has its own unifying event that is about to take place. In short, it is the future of YOUR profession. The future is uncertain. The demise of the psychological profession could be the next “breaking story.” In 2005, the state of Texas will review the profession and determine whether there still should be regulated psychological services in this state. Your profession has been around a quarter of a century in Texas so you might feel secure in the role you play in the medical community. Please do not assume anything. The dentists are a great example of the “definition” of assumption. You might have disagreed with TPA on several issues over the last several years—the creation of the LSSP, the creation of the PAAC (Psychological Associates Advisory Committee), the by-law revision that made all voting members doctoral level psychologists or most recently, the movement to gain prescription privileges for psychologists. Whatever your disagreement is with the association, it is time to put that behind you. We all must be unified when we prepare for the review of the psychological profession in Texas. We will all have to stand as ONE and share the tremendous service that each of you provide daily to your clients. In so much, we are asking EVERY psychologist in the state to contribute $25 per year for the next three years so that we can build a legislative team to deal with this specific issue. We will build a team of highly respected lobbyists to assure that every legislator knows the role psychologists play in the community. We are preparing for this task today. I realize that by reading this article you are a current member. We need your help in sharing this information with your non-member colleagues. We must have 100 percent unity. This is YOUR time—please act today. ✯ WINTER 2001
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What is Your Duty to Report?
How to Respond to Elderly Abuse, Neglect and/or Exploitation Occurring in Nursing Home Facilities
Sam A. Houston & Merritt McReynolds Marinelli
s practicing psychologists, you are no doubt already aware that the Rules of Practice require you to comply with all applicable state and federal laws affecting the practice of psychology. This month’s article focuses on when a psychologist practicing in a nursing home facility setting has a duty to report elderly abuse, neglect, and/or exploitation to the Texas Department of Human Services (TDHS). Generally, the law requires that any person who has reasonable cause to believe that a resident is in a state of abuse, neglect, or exploitation must report it to TDHS’ State Office and must follow the facilities’ internal policies regarding abuse, neglect, or exploitation. Accordingly, this duty extends to psychologists and their staff working in nursing home facilities. It is important to note at the outset that this duty to report is an affirmative, non-delegable duty that cannot be discharged simply by reporting to one’s superiors or to the authorities at the nursing home. Rather, the specific individual made aware of the abuse, neglect, or exploitation must independently report the matter to the proper authorities. Well, what is reasonable cause to believe that a resident is in a state of abuse, neglect, or exploitation? For that matter, what is the legal definition of abuse, neglect, and exploitation? While Texas law does define abuse, neglect, and exploitation, it does not provide a specific meaning for reasonable cause to believe. However, a review of other statutes and relevant definitions provides a 6
good general sense of what the phrase means: when the facts and circumstances within a person’s own knowledge, and other reasonably trustworthy information, are sufficient in themselves to justify a person of average caution to believe that a resident is in a state of abuse, neglect, or exploita-
You have a
duty to report elderly abuse,
neglect, and/or exploitation to the Texas Department of Human Services (TDHS)
tion, then that individual must report the same to the TDHS and proper nursing home authorities. Conversely, if the person does not believe he or she has sufficient information to meet the threshold set forth above, there is no duty to report the matter to the TDHS.
Nevertheless, out of an abundance of caution, the individual should still make a brief written report of the matter to the proper authorities at the nursing home facility, so that they may take whatever appropriate steps they deem necessary to address the situation. If the individual is not satisfied with the response of the facility, he or she may still elect to file a report with the TDHS regarding the incident, even though he or she did not feel the incident at first impression triggered the reporting requirement. The definitions of abuse, neglect, and exploitation, are as follows: Abuse: Any act, failure to act, or incitement to act done willfully, knowingly, or recklessly through words or physical action which causes or could cause mental or physical injury or harm or death to a resident. This includes verbal, sexual, mental/psychological, or physical abuse, including corporal punishment, involuntary seclusion, or any other actions within this definition. Neglect: A deprivation of life’s necessities of food, water, or shelter, or a failure of an individual to provide services, treatment, or care to a resident which causes or could cause mental or physical injury or harm or death to the resident. Exploitation: The illegal or improper act or process of a caretaker using the resources of an elderly or disabled person for monetary or personal benefit, profit, or gain. In conclusion, if while working at a nursing home, you witness or hear of possible allegations of abuse, neglect, or exploitation, ask yourself whether, based on what you personally know and what you know from other reasonably trustworthy information, a person of average caution would believe that a resident is or had been in a state of abuse, neglect, or exploitation? If yes, then you have a duty to report to TDHS and to notify the appropriate authorities at the nursing home. The procedure for making a report to TDHS is set forth on page 8. WINTER 2001
PMA-2000 Practice Management Software for Mental Health The easiest to use practice management software for your billing, scheduling and client notes. Tracks managed care and computes amounts due from insurance. Prints the HCFA-1500 claim form, client statements (with many options) and numerous reports. PMA-2000 requires Windows 95/98/2000 or NT. The program gives you the ability to send all of your claims electronically through the Texas Health Information Network at no monthly or per claim charge. This is a great savings, both in time and money! Prices range from $205 for the Solo Starter version (limited to one provider and 100 clients) to $1,000 for a Large Group version with electronic billing. Network support is included at no extra charge and there is no charge for technical support. Free demos can be downloaded from our website, www.pma2000.com, or call us and weâ€™ll send you one ($10 s/h).
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Oral Telephone Report When reporting an incident by telephone, the following information is needed: facility name, vendor number, resident name(s), time and date of incident, what occurred, condition of resident(s), person(s) involved (other than resident), and action taken by facility authority to date. Written Report Within five working days of making the oral report, send the written investigation report, with statement and other relevant documentation to TDHS using the attached form. Always include your Medicaid of TDHS-assigned vendor number on the report. Mail to: Texas Department of Human Services Long Term Care- Regulatory Customer Service Section, E-349 ATTN: Intake coordinator P.O. Box 149030 Austin, Texas 78714-9030 However, if your answer is no, then you need not make a report to TDHS, but you should still make a brief written report to the appropriate authorities at the nursing home, so that they may take the appropriate steps they deem necessary to address the situation. If after reporting the matter to the nursing home authorities you are not satisfied with their response, then you may report the suspected abuse, neglect, or exploitation to TDHS. While as a practical matter it may be desirable to make a report to TDHS in unison with the nursing home, it is not required or necessary. Remember, the affirmative duty to report abuse, neglect, and exploitation of the elderly is a non-delegable duty that cannot simply be discharged by reporting complaints to the nursing home. If deciding not to report a matter to TDHS, it is important to prepare a brief written report for your files and to be submitted to the nursing home, that sets forth the facts and circumstances known to you at that time and why you do not believe reasonable cause exists so as to require a report to TDHS. Thereby simultaneously creating 8
a record that alerts the nursing home to your concerns, but also explains why given what you currently know, you find there is insufficient information to require a report to TDHS. If after making such a report to the nursing home, you later become aware
of additional information that corroborates and/or bolsters your previous concerns, rising them to the level of reasonable cause, then you have an affirmative, non-delegable duty to report the abuse, neglect or exploitation to the TDHS. âœŻ
NEW MEMBERS The following individuals joined TPA between Aug. 2, 2001 and Oct. 1, 2001. TPA welcomes all of our new members.
Doctoral Carlos Antoline, PhD Karin Curtiss, PhD Ronald Davis, PhD Sheree Gallagher, PsyD Elizabeth Hamilton, PhD Gerald Harris, PhD Scott Hickey, PhD Marc King, PhD Doreen Lerner, PhD Roberta L. Nutt, PhD Diana Quintana, PhD John Sell, PhD Alan H. Silverblatt, PhD Anne E. Smith, PhD Michael Walker, EdD Don Wolff, EdD Associate Gloria Beckham, MA John Douglas Burns, MS Deborah Hammond, MA Ellen Irons, MEd Lakshmy Parameswaran, MA Adrienne Sportsman, MA Student Mark Arcuri, MA Joan Belcher Edna Brinkley, PhD Sara Buckley, MSCP Jeanne Bulgin, EdM Susan Carter Bai-Yin Chen, MA
Allison Cloth, EdM Angela Cool, MS Brandon Davis, MA Julia Deal, MA James DePetro, PhD Gloria Gonzalez Tammy Grahmann Lynne Havsy, MA Rosemary Hernandez Tonya Inman Joseph Kenneally, MS Yuko Kishimoto Angela Larery Lesley Locker, MS James Long, MS Ehrin Lovria Jeffrey Martindale Reina Martinez Elena Mikalsen, MA Michelle Nuttall Lynette Page Beth Peters, MA Melissa Praysner Jennifer Schroeder, MS Sandy Simmons Ann Smith, MA Tiffany Stafford Flor Tokoph, MA Russell Van Dyke, MEd Pamela Way Carl Williams, MA Sandra Winans, MS Emily Young, MS
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MEMBERSHIP RENEWAL Membership renewal time is October/November! If you have an e-mail
Daniel Macias, PhD, started at the San Antonio State Hospital as a Staff Psychologist on Acute Care on May 15, 2000. Effective Sept. 1, 2001, he was promoted to Unit Director of the Adolescent Unit at SASH. In his new position, he has both clinical and administrative responsibilities. On Sept. 14, 2001, at Bexar County Psychological Association’s Fall Social, two local psychologists were awarded the “Fellow” designation for their outstanding contributions to the Bexar County Psychological Association and Psychology: Drs. Bonnie L. Blankmeyer, UTHSCSA, and Dixie Lee Cody Van Eynde, UTSA. They were honored at Trinity University’s Holt Center. Diane N. Roche, PhD, Clinical Psychologist, is proud to announce that she is now in the position to begin accepting clients into a parttime private practice. Therapy services to adults, children, adolescents, and families are provided. Particular interests include adult survivors of sexual abuse, women’s issues, gay and lesbian teens, child and adolescent victims of sexual abuse, and children and adolescents experiencing divorce or other family transitions. She is located at 3418 Mercer Street, Suite 100, Houston, TX, 77027.
address on file with TPA, you should have received a renewal reminder. Soon, you will be able to pay your renewal online via TPA's website. If you haven't been receiving announcements via e-mail, send your e-mail address to firstname.lastname@example.org.
In a CE Jam? Are you near your license renewal date and still one, two or three hours short on continuing education hours? TPA can help you through its home study articles. You can earn up to three hours of CE by reading these articles and completing a test for each. Home Study Articles Include: • Testing Hispanic Populations • Overview of Multicultural Psychotherapy • Ethical Principles That Need Consideration When Providing Services Electronically If you are in a CE jam and would like more information on the articles, contact Sherry Reisman at 888-872-3435 or 512-280-4099.
texaspsyc.org www.texaspsyc.org 10
University of Houston - Clear Lake Visiting Lecturer in Clinical Psychology University of Houston-Clear Lake (UHCL) invites applications for a one-year Visiting Lecturer position in the master's program in Clinical Psychology beginning August 2002. Doctorate in Clinical Psychology or closely related discipline required. Responsibilities include teaching four courses per semester (fall and spring). Summer teaching with additional compensation possible. Successful candidate must be prepared to teach at least two of the following master's level courses: Behavioral/Cognitive Therapies, Personality Assessment, Psychopathology, and/or Psychotherapy: Theory and Research. Additional teaching assignments might include graduate courses such as Basic Psychotherapy Skills, Behavioral Medicine, and Stress Management and/or undergraduate courses such as Abnormal Psychology and Theories of Personality. Competitive salary with excellent benefits. UHCL is an upper-level university (juniors, seniors, and master's level students) adjacent to NASA-Johnson Space Center. Proof of eligibility to work in US required. UHCL is an Affirmative Action/Equal Opportunity Employer supporting workplace diversity. The program seeks candidates who can enhance campus diversity. Review of candidates begins immediately and continues until position is filled. We reserve the right to extend search or not fill position. Send application letter, curriculum vitae, transcripts, and three current letters of references (with telephone contact information) to Chair, Clinical Psychology Lecturer Search Committee, UHCL Box 167, 2700 Bay Area Blvd., Houston, TX 77058-1098.
TPA Member Benefits www.texaspsyc.org • Are you in the market for professional
• Director of Professional Affairs.
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Call TPA’s preferred vendor, American Professional
member questions and requests for information
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limited to, ethics, insurance/managed care, and practice management (512) 280-4099. • Subscription to the Texas Psychologist.
ten by Conseco Medical Insurance Company, spe-
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cializing in health insurance plans for small employ-
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SCREENING FOR DSM DISORDERS A Quick Screen for DSM Disorders: The Essential Symptom Approach and the FESS
Michael B. Frisch, PhD Baylor University
Professional psychologists need efficient ways to screen clients for some 345 DSM-IV disorders. A quick screening can be achieved when clients are queried about the “essential” or required symptoms of disorders and general categories of disorders. The initial validation and clinical application of the first general purpose, self-report measure of DSM-IV essential symptoms, the Frisch Essential Symptom Scale or FESS, is discussed. Readers are encouraged to develop their own essential symptom scales or interviews for more particular purposes and settings by using the model of validation illustrated here with the FESS.
“How can a psychologist quickly screen clients for some 345 DSM-IV disorders?” Some would answer this question by saying, “It can’t be done and don’t bother trying.” Others—including many scholars and ethicists (Frisch, 1992, 1998, 1999, 2000a; Kazdin, 1993; Maruish, 1999; Rabkin, Wagner, & Griffin, 2000; Strupp, 1996)— would answer this question by saying, “It must be done” to: 1. Answer the ubiquitous referral question, “Does this client suffer from a major psychological disturbance—and if yes— what is it?” 2. Allow for a complete, accurate, and comprehensive assessment/evaluation that is ethically desirable and that reduces the risk of malpractice liability for missing important symptoms, diagnoses, and problems, allow for a more accurate and effective case conceptualization, treatment plan, and treatment per se. Essential Symptom Interviews and Scales One way to efficiently screen a client for diagnoses and symptoms of psychological 12
disturbance is to query clients about “essential” or required symptoms of DSM-IV disorders. Essential symptoms or “features” are defined as symptoms that must be present in order for a diagnosis to be given (American Psychiatric Association, 1994). If a client denies the essential symptoms of a disorder or class of disorders, a psychologist can stop questioning about diagnostic criteria and say with confidence “the client does not meet the criteria for ‘Disorder X’ (that is, the disorder or class of disorders in question).” For example, a person must admit to either depressed mood or anhedonia in order to merit the diagnosis of “Major Depressive Disorder (see Table 1).” Therefore, if a client denies both of these symptoms, it can be said that this client does not meet the criteria for “Major Depressive Disorder.” In this way, major diagnoses and even classes of major diagnoses can be excluded from consideration without laborious questioning about specific criteria for a disorder or class of disorders. On the other hand, further interviewing based on DSM criteria may be required when clients admit to essential symptoms of
a disorder (Ogles, Masters, and Lambert, 1996). Thus, a client admitting to either depressed mood or anhedonia must be asked about all of the diagnostic criteria for Major Depression to unequivocally establish that the client is “clinically depressed” or is suffering from for “Major Depressive Disorder.” Entire classes of disorders can be disposed of using this essential symptom approach. For example, clients who deny “physical problems that no doctor has been able to explain” (Frisch, 2000), may be spared further questioning about the eight or so Somatoform and Factitious Disorders listed in DSM-IV. Similarly, clients who deny hallucinations or delusions may be spared further questioning about the nine or so Psychotic Disorders listed in DSM-IV. Essential symptom interviews—whether structured (e.g., Othmer et al., 1989) or unstructured (e.g., Othmer & Othmer, 1994)—are not the most efficient way to screen for DSM disorders. Clients can complete brief, written questionnaires of essential symptoms before the first or second session of an evaluation so that precious interview WINTER 2001
time is saved. The remainder of this article will describe the validation and clinical application of the FESS, a self-report questionnaire of DSM-IV essential symptoms. The FESS or Frisch Essential Symptom Scale The FESS is a 76-item self-report questionnaire of DSM-IV essential symptoms designed to screen for most DSM-IV disorders. It is the first and only general purpose self-report measure of DSM-IV essential symptoms (for related measures see American Psychiatric Association, 2000). Table 1 lists representative items from the FESS concerned with the essential symptoms of Major Depressive Disorder (American Psychiatric Association, 1994). While designed as a paper-and-pencil test, the FESS may be administered via interview or audiotape. Testing orally is most appropriate for those who cannot read at or above a sixth grade level. Once a FESS is completed, a clinician usually needs to inquire further about a subject’s responses. In every case where a patient responds “YES” to an item, the clinician is encouraged to follow up on the answer to the item with a DSM-IV-based clinical interview. That is, the clinician can ask about the specific diagnostic criteria for the disorder that has been flagged by the affirmative answer to the FESS item. In those cases in which a clinician does not have time to conduct a DSM-IV-based interview as a follow-up to an affirmative answer to the FESS, the test examiner may report “the patient admits to a major symptom of ‘Disorder X’.” As can be seen in Table 1, the name of the particular mental disorder that is being assessed by a particular FESS item is abbreviated at the end of the item in parentheses. This abbreviation is followed by a dash, which is followed by a page number from the DSM-IV on which the clinician can find the specific criteria for a disorder that may be examined more fully in order to conclusively assign a diagnosis. In cases where patients deny essential symptoms of a particular disorder, it may be said that “the patient does not suffer from WINTER 2001
‘Disorder X’ or does not meet the diagnostic criteria for ‘Disorder X.’ For a client who answers “No” to all of the items of the FESS, it may be said that “this patient denies having any major psychiatric symptoms or disorders such as depression or schizophrenia” While the FESS is vulnerable to distortion in patients who over report or under report symptoms, the same is true of DSMIV clinical interviews, the most recognized and reliable method of establishing the presence or absence of a psychiatric disorder (Ogles, Masters, and Lambert, 1996;
Does this client suf fer from a
psychological disturbance— and if
what is it?
Othmer & Othmer, 1994). There may be no way to force or trick a patient into admitting psychiatric symptoms (American Psychiatric Association, 2000). Of course, cases in which a patient may gain advantage by either under or over reporting symptoms should be documented as such. In order to improve the efficiency of the FESS, it does not slavishly ask about every possible DSM disorder. In terms of Somatoform Disorders, for example, the FESS emphasizes disorders in which somatic complaints have not been associated in any way with a bona fide general medical condition. Thus, the FESS inquires about physical complaints that have not been explained by any known physical disease or medication. Medication-induced movement disorders are not addressed in the
FESS. Other modifications are described in the FESS manual (Frisch, 2000c). Non-essential Symptom Questions In addition to essential symptom questions, the FESS includes items that, while not symptoms per se, are “red flags” for, or are highly indicative of, particular DSM disorders. For example, patients who recall being treated for manic-depression or bipolar disorder in the past (item #10), merit further evaluation for Bipolar Disorder even if they deny the “essential” manic symptoms delineated in DSM-IV. Similarly, personality disordered patients may deny symptoms and yet admit that “other people” have noticed these symptoms (items 27 and 29). Items 73 and 74 ask clients to list medications and physical illnesses/disabilities that are important to consider in the process of DSM-IV differential diagnosis. Item 76 asks clients to explain any arrests or convictions for criminal offenses that can be relevant to such diagnoses such as substance abuse, personality disorders, or bipolar disorder. The last portion of the FESS focuses on mental health emergencies such as suicidal thoughts and sexual or physical abuse, which are essential to ask about even though they may not have a mental disorder designation in the DSM-IV. How to validate essential symptom measures. According to both Ogles, Lambert, and Masters (1996) and Othmer and Othmer (1994), a clinical interview based on the specific DSM-IV criteria for disorders is the “gold standard,” which is the most efficient, reliable, and accurate way to make a DSM-IV diagnosis in everyday clinical practice. Lengthy structured interviews such as the SCID-1 are seen as not worth the effort for everyday clinical practice. Essential symptom scales like the FESS are designed to reduce the length of DSM-IVbased clinical interviews by screening patients for key symptoms with a paperand-pencil test before the clinical interview takes place. With scales, essential symptom criteria are presented to clients in written form rather than orally via a clinical interview. Thus, essential symptom scales are Texas Psychologist
Table 1. Sample items from the FESS1 FESS™ NAME _______________________________
INSTRUCTIONS: Please answer the following questions as quickly and honestly as you can. Your answers will be kept strictly confidential except for any exceptions which the test examiner can explain to you. Check Yes or No to each item.
❐ YES ❐ NO 1. For two weeks, I have felt sad, blue, depressed, or down in the dumps for most of the time. (MDD-344) ❐ YES ❐ NO 3. I don’t do the things that used to give me pleasure or enjoyment. (MDD-344) 1
©2000, Michael B. Frisch.
meant to be a written substitute for a clinical interviewer’s questions based on the specific, essential symptom criteria of DSM-IV. If a DSM-based clinical interview is seen as the gold standard for diagnostic accuracy, then the validity of an essential symptom scale is determined by the extent of correspondence between patients’ responses to the scale and their responses to a clinical interview that asks about the same diagnostic criteria (According to this view, the ability of essential symptom scales to identify patients with specific diagnoses is really a question of the DSM-IV’s validity and not that of essential symptom scales per se.). In this vein, the DSM itself can be seen as an interview measure, that is, a measure intended for use in the context of a clinical interview. A self-report essential symptom scale is valid if it yields the same results as a DSM-based clinical interview. Initial Validation of the FESS The comparability of responses to DSM-based interviews and the FESS was examined in a sample of 17 male psychiatric outpatients who were referred for psychotherapy by their probation officers for the following difficulties: substance abuse, pedophilia, depression, anxiety, and anger 14
management. Of the sample, 12% were African-American, 12% were MexicanAmerican, and 76% were white EuropeanAmericans. Participants were not well educated; all but two had a high school education or less, Mean for years of school completed=10.41, S.D.=2.58. The age of participants ranged from 21 to 55 years old, Mean=39.41, S.D.=11.24. Of participants, 88% were employed with 47% divorced, 29% married, and 24% single. Essential symptom criteria and their definitions in the DSM-IV were underlined and collated so that the experimenter could formulate yes-or-no interview questions based on the DSM material that directly corresponded to items on the FESS. The experimenter, a third year student enrolled in a clinical psychology doctoral program who had transferred with a master’s degree from another clinical program and who had received specialized training and supervision in diagnosis and the DSM, administered both the DSM-IV clinical interview and the FESS to participants in random order. The correlation coefficients for those items on the FESS that directly correspond to specific DSM-IV criteria are presented in Table 2. The correlation for each item rep-
resents the relatedness between a participant’s written response to a FESS item and his or her oral response to the corresponding DSM-IV interview question. There were insufficient values to justify computing correlations for FESS items 6-9, which are elaborations of item 5 on manic episodes. The results in Table 2 support the validity of the FESS in so far as 44 of 46 FESS items that directly correspond to DSM-IV criteria were found to significantly correlate with these DSM-IV criteria when they were presented via a clinical interview as recommended by Ogles, Lambert, & Masters (1996) and Othmer and Othmer (1994). The magnitude of the significant correlations was large with a range of .60 to 1.00. These results are impressive given the low educational level of participants, which may have suppressed the magnitude of the correlations obtained. Limitations While encouraging, these preliminary results should be extended to larger and differing clinical samples. The sample size here was very small and results with respect to the probation setting should be extended to other clinical settings such as hospitals, CMHCs, and private practices. Clinical Usefulness of the FESS: Initial Feedback Does the FESS achieve its stated aims of streamlining assessment and facilitating treatment? Is the FESS clinically useful in practice? To answer these questions, one must first define terms. The concept of the clinical usefulness or utility of a measure consists of both assessment and treatment utility. The treatment utility of a measure refers to its contribution to a positive treatment outcome, usually by facilitating the ease, efficiency, or accuracy of assessment, treatment planning, and/or treatment per se (Frisch, 1992; Hayes, Nelson, & Jarrett, 1987). The assessment or evaluation utility of a measure refers to its contribution to a full and accurate assessment of clients’ psychiatric symptoms and disorders, problems WINTER 2001
in living or quality of life issues (Frisch, 1992,1998,1999), personality, and assets or strengths (Frisch, 2000). Preliminary evidence in support of the FESS’ clinical usefulness, that is, both assessment and treatment utility, comes from feedback from clinicians who use the FESS in their practice. Currently, the FESS is used for a multitude of purposes: psychological evaluations and intake screening; high risk/relapse risk assessment; treatment planning (especially in clarifying treatment goals); progress monitoring for the individual patient; and outcomes assessment. Clinicians report using it successfully in a variety of settings, including outpatient private practices, managed care settings, community mental health centers, residential substance abuse agencies, psychiatric hospitals, medical centers, university counseling centers, prisons and probation departments, and homeless shelters. Several themes have been independently repeated by clinicians who have used the FESS, lending support to the hypothesis that it is at least somewhat clinically useful and is capable of meeting its stated goals: 1. Validity. Clinicians consistently report that FESS responses are comparable to responses obtained from lengthy interviews like the SCID. Such reports corroborate the formal study reported here, suggesting that the FESS may save valuable time by yielding the same responses as those elicited by a lengthy diagnostic interview. 2. Assessment or Evaluation Utility. In keeping with the feedback on the FESS’ validity, clinicians consistently report that it dramatically reduces the time needed to conduct a psychological evaluation whenever a DSM diagnosis is part of the referral question. According to them, the FESS routinely revealed problems, symptoms, and diagnoses that were not revealed in clinical interviews. When it comes to diagnosis alone, some clinicians view the FESS as preferable to more lengthy instruments such as the MMPI-2 or Rorschach or those whose items do not correspond directly to
DSM-IV criteria such as SCL-90-R or BSI. Clinicians appreciate the fact that clear statements about diagnoses could be made on the basis of the FESS. For example, FESS responses allow for such unequivocal statements as “the patient denies any major (essential) symptoms of depression, anxiety, or psychosis.” Unlike the FESS, the SCL and BSI were seen as lacking any items about the essential symptoms of bipolar disorder and mania, PTSD, substance abuse or dependence, somatoform disorders, ADHD, personality disorders, impulse control, eating disorders, and pedophilia. Clinicians also reported that the FESS was generally “easy” to use and for clients to understand. The FESS appears to make some clinicians more confident that their evaluations are complete and accurate. In addition, some believe that it reduces their malpractice liability by screening for all major DSM disorders. 3. Treatment Utility. Clinicians in treatment-orientated settings claim that the FESS contributed to positive treatment outcomes in clients by revealing heretofore unknown problems or symptoms and by providing a more complete picture of clients’ mental status. For example, a VA psychologist reports that the FESS revealed a Bipolar I Disorder in a patient diagnosed with “merely” Major Depression. Needless to say, this information drastically altered the patient’s treatment plan and prognosis. 4. False Positives with the FESS. In terms of problems with the FESS, some clinicians felt that it shares a liability with other screening instruments, that is, it can result in false positives whenever clients claim to have a symptom when they really do not. For example, a university counseling center psychologist reports the case of a client who claimed to have periods of feeling “fantastically good, high, and ‘on top of the world’.” (item 5 about manic episodes) Further interviewing revealed that the client had never really been manic, although she did feel “terrific” whenever she was involved in a love relationship. Indeed, discussion of this item and one concerning Dependent
Table 21 Correlations Between FESS Items and Corresponding DSM-IV-based Interview Questions Correlation FESS with DSM-IV Item Interview Question 1 .87 2 .78 3 .67 4 1.00 5 .86 11 .60 12 1.00 13 .85 14 .88 15 1.00 16 1.00 17 .68 18 .71 20 1.00 23 1.00 24 1.00 25 1.00 28 1.00 30 1.00 31 .66 33a .69 33b .89 33c .87 33d .87 33e .68 33f .88 33g .87 33h .19 36 .60 38 .71 39 .69 42 .86 44 .68 46 1.00 48 .87 52 -0.09 53 1.00 54 .76 55 1.00 56 1.00 57 1.00 58 1.00 60 .88 61 .68 62 .68 63 .79 1
All Pearson r’s (df = 15) significant at .001 level for one-tailed tests except for items 33h and 52, using the Bonferroni adjustment for multiple correlations.
Personality Disorder, revealed a serious problem with dependency in romantic relationships.
5. Modifying the FESS or Creating New Scales For Special Purposes and Settings. The general-purpose FESS can be modified or tailored to focus on only those disorders and problems of interest for a particular program, purpose, or setting. For example, FESS items about eating disorder complaints that are so common in university counseling centers, have been omitted from versions of the FESS used in a nursing home with a low incidence of such problems. The approach illustrated here—in which the validity of an essential symptom scale is determined by the extent of correspondence between patients’ responses to the scale and their responses to a clinical interview that asks about the same diagnostic criteria— can be used to develop new essential scales for particular purposes. For example, an essential symptom scale for the newly proposed “Anger Disorders” could be validated against a comparable essential symptom interview using the procedure outlined and illustrated here with the FESS (Eckhardt & Deffenbacher, 1995). Using the example of the FESS presented here, readers are encouraged to develop their own essential symptom scales and interviews to suit their own particular needs whether by modifying the FESS or creating a new scale or interview entirely. ✯
American Psychiatric Association (1994).
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Hillsdale, NJ: Lawrence Erlbaum.
Diener and D.R. Rahtz (Eds.).
Advances in Quality of Life Theory and Research. New York: Kluwer Academic. Frisch, M.B. (2000b). Frisch Essential
Ogles, B.M., Lambert, M., & Masters, K. (1996). Assessing outcome in clinical
practice. Boston: Allyn & Bacon. Othmer, E., & Othmer, S. C. (1994). The
Symptom Scale (FESS): A screening
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tool for DSM-IV disorders. Waco, TX:
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Author. Frisch, M.B. (2000c). Manual for the
Association. Othmer, E., Penick, E.C., Powell, B.J.,
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Rabkin, J., Wagner, G., & Griffin, K.W.
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Author’s Note This work was supported, in part, through a sabbatical grant awarded to the author. An electronic copy of the FESS and the FESS Test Manual can be obtained free of charge from the author by e-mailing him at email@example.com. Other correspondence may be addressed to Michael B. Frisch, PhD, Professor, Department of Psychology and Neuroscience, Baylor University, P. O. Box 97334, Waco, Texas 76798-7334.
ment planning and outcome assess-
and assessment in health care.
Washington, D.C.: Author. Strupp, H.H. (1996). The tripartite model and the Consumer Reports study.
American Psychologist, 51, 10171024.
Clinical Psychology: Science and Practice, 5, 19-40. Frisch, M.B. (1992). Use of the Quality of Life Inventory in problem assessment and treatment planning for cognitive therapy of depression. In A. Freeman & F.M. Dattilio (Eds). Comprehensive
Casebook of Cognitive Therapy (pp. 27-52). New York: Plenum. Frisch, M.B., Cornell, J., Villanueva, M., & Retzlaff, P.J. (1992). Clinical validation of the Quality of Life Inventory: A mea-
ARTICLE REPRINTS Call Matt Stillwell at (512) 454-5262 for rates and information.
sure of life satisfaction for use in treat16
Trends in Patient Requests: Lessons from PsychSelect William C. Whitehead, PhD
PsychSelect is an online referral system developed to assist potential clients in locating a psychologist well suited to their needs. Over the past three and one half years, 4,831 requests for referrals have been logged by the system. This article summarizes the psychologist characteristics that are most often requested by the clients (including psychologist age, gender, specialty areas, and insurance accepted) and compares these to the actual characteristics of psychologists participating in PsychSelect.
PsychSelect was initially developed for the Dallas Psychological Association as an adjunct to their existing telephone referral system. Since then, the Collin County Psychological Association and the Fort Worth Area Psychological Association have joined the network. It is hoped that in the future all Texas local area societies will participate in this low-cost system. To view the system at work, visit www.psychselect.com. Patients wanting an online referral enter information about desired psychologist characteristics: location, age, gender, specialties, and managed care plans accepted. The PsychSelect software scans its own database of psychologists (members of the local area society) and, using weighted scoring techniques, suggests the three psychologists who most closely match the patient’s requests. They are then able to view additional information about the psychologists and are referred to the psychologist’s web page, if one exists. A summary of information about these referral requests is presented below. The information provides an interesting glimpse at the current marketplace for psychological services. However, a limitation to the data should be discussed. Because this is an online referral system, only persons with a home computer, Internet access, and comfort with using the Internet are represented in the data pool. This implies that younger, more affluent, and more technical individuals are over represented here. First, we examine the battle of the sexes. When patients were asked their preference for psychologist gender, 24.8% requested a male, 41.6% requested a female, and 33.6% expressed no preference. When a gender preference was expressed, 19.3% rated therapist gender as “slightly important” to their selection process, 49.1% rated it as “somewhat important,” and 31.6%
chose “very important.” This is interesting in light of the gender makeup of our current community. Of the 115 psychologists registered with PsychSelect, 45% are male and 55% are female. It would seem that more female psychologists are needed in the future to keep up with market demands. Since recent graduates in clinical psychology are predominately female, it appears that future needs in this area are already being accommodated. Is it possible to broach a more sensitive topic than preferred gender? Yes, for we will now examine preferences for psychologist’s age. When asked about age preferences, 36.2% of the patients expressed no such preference. However, 15.4% wanted their psychologist to be “about 30,” 32.6% said “about 40,” 14.0% selected “about 50,” and only 1.6% wanted the psychologist to be “about 60.” So much for my visions of a late career on Easy Street! It is somewhat encouraging to note that only 13% of those with an age preference listed age as a “very important” factor. (62% said “somewhat important” and 25% said “slightly important.”) I suspect (and certainly hope) that the relative youth of Internet users is a factor in these expressed preferences. The data on specialty areas requested by patients is presented in graphical form. It is no surprise that depression/grief, the “common cold of mental illness,” is the most requested specialty area. The frequent requests for help with anxiety are also expected. Somewhat more surprising is the volume of requests for either “marriage/relationship” specialists or “family problems” specialists. Perhaps graduate programs in psychology should give more emphasis on family therapy training in the future. A graph of the participating psycholoWINTER 2001
gists’ specialty areas is also presented. By a quick visual scan, a comparison is possible between these community resources and the patients’ expressed community needs. In general, it appears that the news is good: where there are high community needs, there is also a wealth of psychologists who consider themselves able to meet those needs. It is very surprising to see one exception to this trend. Although 52% of psychologists specialize in sexual issues, only .1% of patients requested a specialist in this area. Perhaps our modern culture is a bit different than that of 19th century Vienna. To paraphrase Yogi Berra, “if Freud were alive today, he’d turn over in his grave!” Patients are given the opportunity to write in a specialty area that is not listed on the checklist, on the off chance that a psychologist has listed that “splinter” specialty. Few patients do so, but some of the most frequent specialty requests are interesting. These include “geriatric,” “Christian,” “sexual abuse,” “social phobia,” and “sports psychology.” It is noteworthy that a substantial number of patients who checked “OCD” as a problem area also wrote out “OCD” in this space—just to be sure! Patients are given the opportunity to specify their participation in any managed care insurance plan. It is encouraging to note that exactly 50% of patients leave this blank. The plans most often requested are, in order: Aetna (8%), BCBS (8%), United (7.8%), Cigna (6.5%), PHCS (3.4%), and Unicare (1.5%). The remaining 41 listed (and 60 writein) plans are requested less than 1% of the time. It would appear that participation in these six plans would capture 70% of local patients who want PPO or HMO coverage. PsychSelect has been quite successful in providing a low-cost, 24-hour, confidential referral system to the growing Internet community. Please contact me (972-818-3993 or firstname.lastname@example.org) if you would like to discuss adding your local area society to the system. ✯ WINTER 2001
Sliding Scale Fees
Post Traumatic Stress
Dissociative Disorder/MPD Depression/Grief
Neuropsychology/Brain Injur y
Powerful Partners, Belong to Both Michael Sullivan, PhD Assistant Executive Director, State Advocacy APA Practice Directorate
This is the story behind a new “ad” that is appearing in the pages of the APA Monitor on Psychology. A variation of this ad has also begun to appear in state and provincial psychological association (SPPA) newsletters. It features a logo with the acronyms of APA and the SPPA, and it reads “Powerful Partners, Belong to Both.”
any of you have already done what the ad is asking, namely, to support both the American Psychological Association and your state psychological association by your membership dues. So what’s the point of the joint membership ad? As long as there are societal needs going unmet, and as long as there are fellow citizens lacking quality health care, we can be doing more. More than half of APA members do not belong to their SPPA, and onequarter of SPPA members do not belong to APA. If they did, psychology would unquestionably be in a position to increase and expand its contributions to the psychological health of our country. Investing In Your Passions Joint membership takes a small bite out of disposable income but paradoxically makes financial sense. “Investing in professional organizations is investing not only in your future, but also the future of your profession,” observed Lorryn Wahler, an executive director of a state psychological association (New Jersey) and member of APA’s Committee for the Advancement of Professional Practice (CAPP). “Please remember that being a psychologist is about more than maintaining a license, providing psychotherapy and conducting research, it is also about making an investment in your livelihood and your passions,” noted Daniel Abrahamson, PhD, director of professional affairs for the Connecticut Psychological Association and former chair of APA’s Board of Professional Affairs. 20
Abrahamson and Wahler are both members of a working group convened by CAPP to promote joint membership in APA and SPPAs. As Abrahamson pointed out, “belonging to both” amounts to the cost of a medium-size cup of coffee a day from Dunkin’ Donuts. Compared to other doctors, psychology’s dues are low. No one minimizes the hardship that several hundred dollars a year in dues represents in the managed care era. As an out-of-pocket expense, it is steep. But looked at as a business investment, it is a bargain. Psychologists can belong to both their national and state associations for less than what other doctors pay to belong to their national association alone. Expanding Our Civil Rights A long list of effective partnerships between APA and state psychological associations can be cited as examples of what you get in return, such as the satisfaction of knowing that your profession is suing against managed care abuses, and that you have new opportunities for community entree and visibility through the youth antiviolence campaign and the Psychologically Healthy Workplace Award initiative. But perhaps the best illustration of the synergy created by state and national partnerships is mental health parity, for which APA and the state associations have been leaders of mental health coalitions. The civil rights laws of the mental health field, parity laws have been passed in 37 states and at the federal level. The story of the gradual and steadily growing elimina-
tion of insurance discrimination against mental disorders serves as a classic example of how state and federal issues are interdependent and mutually reinforcing. Five states served as precedent-setting pioneers in passing parity laws before the Congress enacted the Mental Health Parity Act of 1996. The federal parity law was a limited but symbolically important breakthrough in the nation’s health policy, and helped propel 32 additional states to pass parity laws going into the 2001 sunset of the federal law. In turn, the fact that so many states have enacted parity of varying degrees has greatly increased the likelihood that Congress will pass true across-theboard parity this year. Because of the widespread implementation of state parity, and parity in the Federal Employees Health Benefit Plan (FEHBP), the cost increase of implementing true national parity is projected at only 1 percent, according to actuarial estimates of Ron Bachman of PriceWaterhouseCoopers. This type of breakthrough in enlightened health policy, ending decades of insurance discrimination against mental conditions, will create more incentives for people to access psychological services when discriminatory co-pays and deductibles are finally eliminated. Doing Your Part So if you are not already doing so, please do your part. “Belong to both”, and take satisfaction from knowing that you are advancing the cause of the profession most needed in the 21st century information age. ✯ WINTER 2001
ROOTS OF TERROR: Psychology Responds to Terrorism Ronald F. Levant, EdD, ABPP APA Recording Secretary
I have long argued for psychology’s involvement in informing the public policy process on the grounds that we have much science-based expertise to offer to the formulation of public policy on a range of matters. In this spirit, I want to take up the matter of terrorism.
would like to start by quoting sections from an article titled “Osama Bin Laden: Man or Meme?” by Robert Wright, that appeared on September 27 in the Internet publication “Earthling,” (http://slate.msn. com/code/story/actions/print.asp?strURL= /XML/Earthling/01-09-27/Earthling). I am quoting these sections with the permission of the author. I also want to clarify at the outset that I am quoting these sections to stimulate discussion. I am not suggesting that APA endorse these views, or any other views for that matter. The article begins: “On Sept. 12, Colin Powell framed America’s impending military response to the previous day’s attack as part of a campaign to ‘go after terrorism and get it by its branch and its root.’ Here is an alternative horticultural metaphor that I came across a few days ago: ‘Military action to destroy terror ... will be like hitting a fully mature dandelion with a golf club.’ ... The ‘branch and root’ model speaks of centralization. You trace the plant’s branches downward until you find the underground headquarters. If you’re strong enough, you can rip out the whole thing and end the trouble once and for all.Terrorism has long resisted this kind of description. Terrorist ‘cells’—semi-autonomous and self-sufficient groups—are given little knowledge about one another, precisely so the whole structure can’t be easily uprooted. ... Terrorism also has a second annoying property: Reprisals spawn hatred, increasing the number of terrorists. (Note the contrast with true “war,” in which the enemy state’s resources are from the outset wholly com22
mitted to your destruction, so upping the hatred doesn’t have much downside.)” “A big problem America faces right now is that both properties of terrorism—decentralization and contagiousness—have been intensified by technology. The Internet, cell phones, and so on, mean that any resourceful terrorist can organize a terrorist assault from almost any piece of turf. You can kill Bin Laden and carpet-bomb Afghanistan, but his movement will still have great orga-
to destroy terror will be
a fully mature
dandelion with a golf club. nizational power. Deputy Secretary of Defense Paul Wolfowitz said America’s goal is “ending states who sponsor terrorism”—a message the administration later amended to “ending state-sponsored terrorism.” Either way, how relevant is state sponsorship to what happened on Sept. 11? It now looks as if the attack may have been organized largely in Germany—and, of course, in the United States. ... Terrorism, now more than ever, is a movable feast. To pull off something like the Sept. 11 attack, all you need is $200,000, computer literacy,
the organizational skills of a mid-level manager, and intense hatred.” “The spread of that hatred is itself technologically abetted. The first videotaped Muslim casualties in Afghanistan will be not just broadcast on CNN, but put on the World Wide Web and probably played ad nauseam at the fundamentalist schools in Pakistan and elsewhere that mold both tomorrow’s suicide bombers and tomorrow’s Osama Bin Ladens. And, once Bin Laden himself has been promoted from terrorist mastermind to martyr, his preachings will spread more profusely than ever, available in audio or video to anyone with a good Internet connection or a VCR. These packets of information are the dandelion’s seeds.” “A currently fashionable term for packets of information is ‘memes.’ A meme can be an image, a song, a belief, an attitude—anything that can hop from one brain to another. Some types of memes are called ‘mind viruses’ because they’re not good for the brains they inhabit; they thrive by parasitizing their ‘hosts.’ The hijackers’ brains, for example, no longer exist, but the meme that killed them—the meme of fundamentalist hatred—is doing quite well. Similarly, Osama Bin Laden may not be long for this world, but Osama Bin Laden’s memes have a longer life expectancy. And killing the man may be the best thing America could do for the memes.” For the record I do think we need to deal with Bin Laden the man and with states that support terrorism. However, I do think Robert Wright has performed a valuable WINTER 2001
service in drawing our attention to the “dandelion seeds.” On Sept. 19, 2001, the APA Board of Directors held a conference call. One of the items for discussion was the terrorist attack on September 11. We noted with appreciation the tremendous efforts of the APA Practice Directorate’s Disaster Response Network, which has been working hand-inglove with the American Red Cross in responding to the needs of both victims and rescue workers at the World Trade Center and the Pentagon. We also expressed appreciation to the staff for all of the wonderful materials on coping with trauma, stress, and grief that were recently added to APA’s website. In tune with the idea that psychologists need to contribute their expertise to matters of public policy, the board then turned to the question of what more psychology could contribute to this national crisis. Noting, as was made clear in Robert Wright’s article quoted above, that terrorism is fundamentally a psychological process, and, further, that psychology played significant roles in the war efforts during both World Wars of the last century, we began to take stock of what psychology might contribute to the goal of ending terrorism. We looked at foundational areas such as social psychology and its work on malignant attitude formation, such as prejudice and fanaticism. We also looked at more applied areas such as international psychology, peace psychology, conflict resolution, multicultural psychology, the psychology of religion, military psychology, and the psychology of criminal justice. We have began to assemble lists of potential contributors and have written to the presidents of APA’s divisions asking them to help identify their members who might be conducting research that has relevance to the anti-terrorism effort. But we also decided that before we go off and write white papers, it would be appropriate to learn what might be of genuine assistance to key policy- and decision-makers. Hence we are now attempting to network with psychologists working in mission critical governmental departments such as Defense, WINTER 2001
State, the CIA, etc. To monitor and shepherd this burgeoning effort, the board established a new Subcommittee on Psychology’s Response to Terrorism, with Ron Levant as chair, Laura Barbanel and Nate Perry as members, and with staffing from the Science, Education and Practice Directorates (with the Science Directorate taking the lead). This subcommittee held a conference call afterwards and took stock of recent activities in the three directorates to assemble resources and reach out to individuals and organizations. This promises to be a very significant effort with many ramifications. If you have suggestions or resources to contribute please send an email to Kurt Salzinger at the APA Science Directorate (email@example.com). We are at the proverbial fork in the road as a society in dealing with this problem.
There are many ways that psychologists can help, and I have sketched just a few of them. The stakes are high. If we can help, we must. As always, I welcome your thoughts on this column. You can most easily contact me via email: firstname.lastname@example.org. ✯ Ronald F. Levant, EdD, ABPP, is in his second term as Recording Secretary of the American Psychological Association. He was the Chair of the APA Committee for the Advancement of Professional Practice (CAPP) from 1993-95, a member of the Board of Directors of Division 42 (1991-94), a member at large of the APA Board of Directors (1995-97), and APA Recording Secretary (1998-2000). He is dean of the Center for Psychological Studies at Nova Southeastern University in Fort Lauderdale, Fla.
PRACTITIONER REPORT Ronald F. Levant, EdD, ABPP APA Recording Secretary
Psychology is definitely on the move. I have reported in recent columns that I have observed signs of a new spirit of optimism, perhaps even a renaissance in psychology.
he Annual Convention in San Francisco was no exception. This very high-spirited event was distinguished by the decision of United States Surgeon General David Satcher, MD, to use the occasion of our convention to present his most recent report on mental health, a report that focused on mental health care for ethnic minorities. One of the most important lessons that I have learned over the years is how vital it is for psychologists to participate in the public policy process—to be at the table where important policy decisions are made and to speak to policy makers at every available opportunity. This lesson was perhaps most strongly reinforced by my participation in the White House Summit Meeting on Children’s Mental Health hosted by former First Lady Hillary Rodham Clinton and in the resulting Surgeon General’s conference on Children’s Mental Health, public policy events in which psychology’s voice was clearly heard. Opportunities for psychologists to interact with such high-level officials seem to be increasing. For example, this is not the first time that the Surgeon General has come to APA meetings. Further, during Pat DeLeon’s presidency, we were honored with the presence of both Health and Human Services Secretary Donna Shalala and Education Secretary Richard Riley at APA meetings during the year. And this year the Association of Veteran’s Administration Psychology Leaders brought Anthony Principi, Secretary of the Veterans Administration, to their meeting as the keynote speaker. The importance of such events lies not only in the fact that psychol24
ogy becomes more visible to the high level public official, but also in the opportunities to build a relationship in which we are increasingly called upon for information and expertise deemed helpful to that official. The convention offered a wonderful array of choices of programs and social events, plus all of the attractions of that beautiful city by the bay—San Francisco. I had the honor of chairing one of the new experimental programs for President Norine Johnson’s mini-convention on
in the public
“Pioneering and Reinventing: Innovative Practices for the 21st Century from a Diversity of Perspectives and Backgrounds.” This program used a new model called the “pod,” which is sort of a hybrid between a poster session and a symposium. It is an interactive group, in which presenters post the highlights of their work on poster boards, give five minute overviews and then engage in a very rich dialogue with the audience for over an hour. There are some issues that need to be resolved, such as noise
from adjacent pods, but overall this format offered a much higher level of group interaction than other models, and will likely be continued when the convention changes next year. The meeting of the Council of Representatives was quite lively and resulted in a number of significant actions. One action that I would like to highlight was the passage by Council of the modified Wildcard Plan, which (if approved by the membership) will result in the seating of all affiliated state, provincial and territorial psychological associations (SPPAs) and APA divisions. For 50 years (Since APA was reorganized in the late 1940s) SPPAs have been poorly represented on Council. This is unfortunate because even the smallest jurisdiction can have a major precedent-setting impact on professional psychology (witness Guam’s passage of prescriptive authority legislation). Hence, many leaders in the practitioner community have been working for over a decade to find a way to seat all SPPAs. Several years ago we developed the Wildcard Plan through a process of interest-based bargaining among all major APA constituencies (using the expertise of APA Past President Ron Fox and CEO Ray Fowler), which resulted in the seating of all divisions and most SPPAs (Peterson & Levant, 2000). During his presidency, spurred on by such advocates as Ruth Paige, Pat DeLeon started an initiative to seat all remaining SPPAs. This resulted in the establishment of the Task Force on Council Representation 2 (TFCR2), co-chaired by Ron Levant and Ruth Paige, with representatives from all of the major constituencies in APA and with Ron Fox reprising his role as the interestWINTER 2001
based bargaining consultant and APA CEO Ray Fowler acting again as a resource to develop the mechanics of the plan. TFCR2 developed the modified Wildcard plan, which will cap Council at 162 seats and preserve the one-person one-vote (actually, one person, ten votes) principle of the apportionment ballot (developed by the Albee Commission in the 1960s). It will create two pools of seats, one for divisions, and one for states, based on the proportion of the apportionment vote that each group gets. Then, each unit will get one seat. Remaining seats in each pool will be distributed in two steps. First, units that qualify for a second, third, etc. seat based on the percent of the apportionment vote that they got will get those seats. Second, any remaining seats will be assigned to those units that came closest to getting a next seat, based on the percent of the apportionment vote that they received. This is admittedly a complicated process, which resulted in quite a bit of discussion on Council. Fortunately, Dr. Leona Aiken, representing the Division of
Evaluation, Measurement, and Statistics, came to our aid and developed an understandable step-by-step algorithm for explaining how seats are allocated. As always, I welcome your thoughts on this column. You can most easily contact me via email: Rlevant@aol.com âœŻ Reference Peterson, M. & Levant, R (2000). Resolving conflict in the American Psychological Association: A historical note on the use of mediation methods.
American Psychologist, 55, 957-959.
Ronald F. Levant, EdD, ABPP, is Recording Secretary of the American Psychological Association. He was the Chair of the APA Committee for the Advancement of Professional Practice (CAPP) from 199395, a member of the APA Board of Directors (1995-97), and APA Recording Secretary (1998-2000). He is dean of the Center for Psychological Studies at Nova Southeastern University in Fort Lauderdale, Fla.
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APA UPDATE Division of Trauma Psychology is Coming to APA Gail Brothers Braun, PhD Texas Representative to the APA Trauma Interest Group
In the aftermath of the terrorist attacks that occurred against the United States on September 11, 2001, a timely event is occurring within American psychology: Psychologists are forming a new division within the American Psychological Association to promote the psychological study of trauma and disaster.
he proposed Division of Trauma Psychology will focus on research, public policy, education, and clinical practice in the area of trauma psychology. The intent is to advance scientific inquiry, training, and professional practice in the area of trauma treatment as a means of furthering health and human welfare. There has been interest in organizing such a group within the APA for several years. Although the APA administration, many APA divisions, and some state psychological associations were involved in trauma-related activities, there was no structure to coordinate or disseminate such information. Consequently, many psychologists involved in traumatic stress found their professional “home” in organizations other than psychological ones. In August, 1999, this issue was raised before the APA Council of Representatives, and a trauma interest group was initiated within the APA. Representatives to the group were sought from APA divisions and state psychological associations. Approximately 100 representatives and interested persons gathered at the trauma group’s inaugural meeting on August 6, 2000, during the annual APA convention. Led by organizers Judith Alpert, Terrance Keane, and Laura Brown, those who were present decided overwhelmingly to work toward creating an organized voice for trauma psychology within the APA. The proposed new division was to include diverse areas that share an interest in the psychological effects of trauma, including research, 26
treatment, education, and public policy. A steering committee was selected to begin the process of establishing a division (Judith Alpert, Terrance Keane, Laura Brown, Dean Kilpatrick, Laurie Pearlman, Kay Saakvitne, Christine Courtois, Peter Sheras, Katherine Kendall-Tacket, Shilpa Taufique, Harry Wexler, Jon Perez, and Robert Geffner) and an Internet list serve was established to facilitate communications. During the group’s second meeting on August 26, 2001, at the APA convention, a flurry of organizational activity occurred. By-laws were approved (available on the website) and officers were elected: President Judith Alpert, President-Elect Robert Geffner, Secretary Kathleen KendallTackett, and Treasurer Harry Wexler. To date, a Web site has been launched by web maven Laura Brown, http://www.geocities.com/traumainterestgroup, an electronic newsletter is in the works by editor Jon Perez, and membership efforts are underway by co-chairs Catherine Hansen and myself. The importance of this proposed division became keenly evident following the September 11 terrorist assaults. The trauma interest group’s list serve and Web site have been disseminating information regarding trauma response to help psychologists respond to the terrorist assaults and ensuing tragedies. Psychology has much to offer in the wake of disasters and traumatic events. We know from research that there is a connection between experiencing traumatic events such as the terrorist assaults and later psychological difficulties. Research has also
shown a difference in response depending on the nature of the trauma, with deliberate, violent actions having a greater association with later psychological problems than random natural events (e.g., hurricanes). These associations are especially strong for persons who are directly exposed, such as the thousands of survivors, witnesses, rescue workers, and persons who lost a loved one in New York, Washington, D.C., or Pennsylvania. However, the connection exists even when the exposure is indirect, such as the hundreds of thousands across the nation who watched television reports of the attacks. Therefore, there is a great need for psychologists to help the nation recover. Not all persons who were exposed to these events will require psychological treatment, but there will be many needing help with post-traumatic stress reactions, anxiety, depression, anger, and other trauma-related problems. For information and assistance, please go to the trauma interest group Web site. Links to other related sites are also provided. If you are a voting member of the APA and are interested in supporting the development of a Division of Trauma Psychology, you can help. Signed petitions are needed from 796 APA members, fellows, or voting associates for the establishment of a new APA division. Please log on to the trauma interest group’s website, download a copy of the petition, sign and mail to the indicated address. Share copies of the petition with other voting members of APA who may be interested. ✯ WINTER 2001
Psychologists in Non-Traditional Settings
The Role of the Psychologist in Training Family Practitioner Medical Students
Christopher Blazina, PhD University of Houston Community Clinic Houston, Texas
Psychologists can play an active role in training medical students who are in the process of becoming family practitioners. Because there is a special emphasis upon sustained relationships with patients, psychologists can train medical students about relational dynamics and the needed accompanying skills. This article focuses upon a training program that uses a psychoanalytic foundation as a way of teaching future family practitioners about these dynamics.
pann (2001) has recently highlighted the changing nature of family medicine, which includes shifts in reimbursement, increased patient load, and a move away from the gatekeeper model imposed by managed care. Added to this is the growing trend of patients’ desiring more involvement in decision-making, better information about health care, and an increased movement toward consumerism. Spann concluded that a rethinking and subsequent redesign of family practice needs to occur. Morrison (2000) suggests that the new medical care system will have the physician playing six key roles including: shaman, health advisor, wellness coach, knowledge navigator, proceduralist, and diagnostician. Even with the changing role of family practitioner, Spann suggests that “The physician-patient relationship that is the cornerstone of the family practice will continue to be our most powerful therapeutic tool” (p.585). In a similar vein, Ewigman (2001) suggest that in the new family medicine paradigm the physician-patient relationship WINTER 2001
will still be central but expressed in different ways. In reinventing family medicine, Ewigman suggests adding information mastery to the repertoire of skills and the need to interface with colleagues from other disciplines. This article builds upon these suggestions made by Spann and Ewigman in considering the role of the psychologist in the changing face of family medical practice, in particular, teaching medical students about the importance of the relationship enhancement with patients. It is argued here that there can be a successful interface between the mental health professional with that of the family practitioner on multiple levels, including in their training as medical students. The work of Houston psychologist James Brae (Brae & Rogers, 1997) has pioneered psychology’s influence on training physicians in America. In other countries, such as Great Britain, there are also trends toward psychologists working collaboratively with physicians in the treatment of patients. With that said, there are still few
programs, here or abroad, that offer a direct interface between a psychologist and the training of family practice medical students. This article will briefly describe the philosophy and structure of one such programs at the Community Clinic, which is a nonprofit outpatient facility servicing mostly indigent patients in Houston. Behavioral Health Program The behavioral health program at the Community Clinic has been in existence for approximately two years, training third and fourth year medical students on a 2-4 month family practice rotation. The classes are usually small, consisting of three to five medical students who meet weekly with a licensed psychologist who, in turn, works collaboratively with the onsite licensed family practitioner. The end result is a collaborative interface of family medicine with a special emphasis upon relationship building and enhancement. This program is not geared toward making medical students psychologists; rather, it strives to make them more effective practitioners of the medical arts through attending to the relationship with their patients. During the course of the rotation, weekly meetings are held between the psychologist and medical students. These meetings are structured in a simple format consisting of the two interrelated functions: case consultation/didactic and direct supervision of medical students as they treat patients. In terms of the first, medical students bring cases to discuss with the psychologist and their fellow medical students. This includes discussing demographics, presenting problem (medical), and then the treatment dynamics that are present. In the early meetings, there is often a misconception that the medical student needs to bring an exemplary case of psychopathology. That is not the purpose; rather, there is an emphasis on taking any case situation and forming a more comprehensive view of the dynamics that influence the patient’s life and health. The actual case presentation itself is often used as a starting point for a discussion that may lead to Texas Psychologist
potential offshoot issues and didactic interaction, which include psychiatric diagnosis, developmental issues, how to deal with difficult situations, skill building, etc. Part of this process includes an exercise in patient dynamic brainstorming in order to get medical students out of the frame of mind of seeing only a medical presenting problem before them instead of the whole person. In this way, medical students are asked to consider the patient from multiple angles, including: What is their presentation? Is the patient’s mood congruent with their presenting problems? What is their personal and family history? Do they have a previous psychiatric history? What developmental life stage is the patient in and how might this affect their health? If there are multiple people accompanying the patient, what is the role of the patient in the family? And, what are the family dynamics? The answers to these questions all lead to specific impressions that form an overall gestalt of the individual and a better appreciation of what is the present condition of the patient and the forces that have shaped them. The purpose of this type of exercise is to not only encourage medical students to think outside the box in terms of only organic causes, but also to foster empathy for patients and use this understanding of the patient’s inner-world in an attempt to provide good care that is both efficient and matches the patients needs. While the primary focus of these case consultations is on understanding what is going on medically, emotionally, and psychologically with the patient, oftentimes more advanced medical students can concentrate, as well, on their own reactions, which both facilitate and hinder the relationship building process. For instance, in one group case consultation the notion of countertransference reactions to difficult patients was brought up. With some reflection, each of the medical students was able to identify their own signature way in which they expressed their own displeasure or annoyance and how they distanced themselves from their patients. This might include a change in tone of voice, avoiding 28
the affect of the patient, feeling impatient or afraid, not asking the questions they know they should in the psychosocial history to shorten the time spent with a difficult situation or person, and physically distancing themselves, perhaps, to the other side of the examination room. This type of discussion is helpful in that it proves countertransference reactions are normal and that by more willingly accepting them, it prevents the temptation to act out the countertransference reactions in ways that prevent good patient care. That is, by being knowledgeable of idiosyncratic reactions to difficult patients, medical students can be trained to be aware of their feelings and take steps to counteract those inclinations. The second part of the training is following the medical students as they see patients. Patients are informed that the clinic is a training facility for medical students and that part of that includes direct supervision by the licensed family practitioner and a licensed psychologist. Medical students perform routine psychosocial history and cursory medical exams with patients while the psychologist is in the examination room. This, in itself, can be a fruitful opportunity for the psychologist to observe the medical student’s relationship building skills. The psychologist can then provide specific feedback after the examination is complete. This may include help in finetuning skills of the more advanced students or providing feedback to beginning students who may negatively impact building the relationship. Providing post-examination feedback can also be an opportunity to raise medical students’ awareness of the dynamics that impact the relationship with their patients. In seeing the student work with a range of patients in one day, there is an opportunity to observe them interact across multiple settings with different types of people. The students are encouraged to develop a “constant approach” to patients where they are the same caregiver who is equally as open, equally as present, and equally able to provide a good balance of support and challenge. This is parallel to the psychoanalytic
notion of being a constant object with and across patients. As medical students learn to find this constant way of being, they are taught to recognize when they deviate from their normal course of relating to patients. That is, when they do not feel equally as open, equally as present, some dynamic is compelling this to be so, which in turn effects the relationship with the patient. By doing this consciousness raising, medical students can monitor their own reactions and self-correct when they feel countertransference reactions. Seeing the patients with the medical students is also an opportunity for psychologists to directly interact with patients as a model in terms of information gathering, how to connect with patients, and when appropriate, do brief psychosocial interventions. In terms of the later, these interventions may include psychoeducation about target behaviors the patient identifies as wishing to change. It is important to help patients understand the mind-body connection in some of their health concerns. This includes helping reveal the more underlying psychological/emotional dynamics that keep the patient stuck in poor self-care. For instance, patients who have uncontrolled diabetes, hypertension, or the like, are often in potentially life-threatening situations. When repeated pleas by others (e.g., family, friends, and other healthcare providers) have not lead to behavioral change in terms of better self-care, the medical student is often fooled into thinking that by instructing the non-compliant patient on what to do that they will come around. This often leads to the patient acknowledging in some perfunctory fashion, that yes, indeed, they need to change and then usually doing nothing about it. Or even worse, the medical student gets into a tug-of-war with the patient about behaviors the student believes need to be changed. Oftentimes, both parties walk away with even more defended positions and no change. In the behavioral health program, the medical students are instead trained to recognize where the patient is in the process of WINTER 2001
change based upon Prochaskia and DeClementes’ transtheoretical model of behavior change (Prochaskia & DeClementes, 1994). This model recognizes the importance of matching the right type of interventions with where the patient is in the stage of change. The transtheoretical model outlines five stages of change ranging from Precontemplative (no or little awareness of problem), Contemplative (has just gained awareness but has taken no steps toward change), Preparation (possible avenues of change are explored), Action (attempts are made to change target behavior), and Maintenance (the behavioral plan has been placed into effect and there is finetuning and problem solving in regard to possible pitfalls for sustaining change). An example of how this theory can be out in place is as follows. Patients in the Precontemplative stage of change have little or no level of awareness that there is a problem. It is often external factors such as medical tests or feedback from others that reveal there is a problem. The matched types of interventions for these people are the Rogerian skills of listening, reflecting, and empathy to raise the awareness of the patient on these previously unconscious matters. To do more advanced interventions such as the prescription of some type of behavioral change may lead to the empathic failure by the medical student, pushing the patient to a place the patient is not ready for. This type of process can also be seen in the Contemplative stage of change, where the patient recognizes there is a problem and is considering doing something about it. The failure on the part of the health care provider can be again to misunderstand the patient as being ready to take action when there may be issues of fear of the unknown, a sense of security with known maladaptive ways of being, recollections of prior failure to change, may all hinder the patient’s readiness for behavioral change. Training medical students to probe for the real reason patients are contemplating change but presently doing nothing can free patients to move forward. By learning to WINTER 2001
recognize where patients are in the process of change and then matching that with the appropriate invention, patients feel heard, understand, and may even quickly move to being ready to make more advanced steps toward change. Further, with the continuing trend toward consumerism, gone are the days where the medical student can use their professional clout such as “Listen to me. I am a doctor,” to achieve patient compliance.
Chris Blazina, PhD, is an assistant professor at the University of Houston and the Director of the Behavioral Health program at the Community Clinic, 5808 Airline, Houston, TX, 77076. You can email Dr. Blazina at firstname.lastname@example.org. References Brae, J.H., & Rogers, J.C. (1995). Linking psychologists and family physicians for collaborative practice, Professional
Psychology: Research and Practice,
Conclusion Psychologists are trained to be authorities in the field of relationships, including the subtle nuances that accompany good relational connection. The family practitioners’ philosophy is based on the notion that the relationship with patients is the foundation upon which their specialty rests. In seems that the interface between these two disciplines would be a natural extension of interdisciplinary healthcare. This type of interface seems to have much potential in considering a more holistic view and treatment of the medical patient. ✯
26, 132-138. Ewigman, B. (2001). Reinventing family practice again. The Journal of Family
Practice, 50, 586-587. Morrison, I. (2000). Health care in the
new millennium. San Francisco, CA: Jossey-Bass. Prochaska, J.O., & Diclemente, C.C. (1994).
The transtheoretical approach: Crossing traditional boundaries of therapy. New York: Krieger Publishing Company. Spann, S.J. (2001). The future of family medicine: Clinical practice. The Journal
of Family Practice, 50, 584-585.
A Developmental Model of Supervision of Therapists Working with Sexually Traumatized Children Laura Palmer, PhD Robert McPherson, PhD Anne R. Farrar, MA Heather Wallrath, MA
This paper provides a conceptual model of supervision for therapists who work with children with a history of sexual trauma. The model is based on the revised Integrated Developmental Model (IDM) of supervision delineated by Stoltenberg, McNeill, and Delworth (1998). The dynamics of the treatment relationship between the therapist in training and sexually abused children are reviewed, providing the context for a developmental conceptualization of clinical supervision. Supervision is encouraged for all therapists working with sexually traumatized children, because the dynamics and intense countertransference that often occurs pose an ever-present threat to the integrity and efficacy of the treatment process. A brief review of factors related to this specific population is provided, beginning with an overview of the prevalence of child sexual abuse.
etermining the actual prevalence of child sexual abuse is difficult due to the lack of standard definitions (Finkelhor, 1986; National Center on Child Abuse and Neglect, 1983; Russell, 1983). For the purpose of this article, the following definition by Matsakis (1996) will be used: an individual has been a victim of child sexual abuse â€œif they have been fondled, penetrated, made to engage in oral sex or other sexual acts by an elder person before they were the age of 18â€? (p. 292). She includes exposure to genitals even if no stimulation or penetration occurred. In addition to the problem of definition, the prevalence of child sexual abuse is difficult to accurately document, because many victims never disclose for various reasons (Finkelhor, 1978; Russell, 1983; Schultz, 1973). Overall, approximately one-third of women and one-sixth of men in this country have experienced some form of sexual contact with someone older than themselves by the age of 16 (Finkelhor, 1978; Russell, 1986). In 1995 alone, an estimated 126,095 children were victims of substanti30
ated or indicated child sexual abuse in 48 reporting states (U.S. Department of Health and Human Services, 1997). Psychological Consequences The documented incidence of sexual victimization of children is not sufficient in representing the issues that will possibly present across the treatment process. A brief review of the range of possible psychological consequences resulting from trauma is helpful in anticipating clinical impasses and emotional challenges for the developing clinician. This topic has been addressed by many studies that indicate early life trauma, including incest, can result in various psychological consequences such as delayed development in physically abused children (Oates, 1985), post traumatic stress disorders (Terr, 1985), maternal deprivation, and attachment disturbances (Bowlby, 1984). Some research indicates that some types of childhood maltreatment may be related to the development of certain mental disorders. Herman, Russell, and Trocki (1986) found that half of a survey popula-
tion of women who were sexually abused as children perceived the incest as having lasting effects including anxiety, distrust, and difficulty in forming and maintaining intimate relationships. Blake-White and Kline (1985) also suggest that sexual abuse can interrupt psychosocial development, and depending on the childâ€™s age at onset of incest and its duration, the victim will experience unsatisfactory development task resolution. Several authors (Eth & Pynoos, 1985; McCann & Pearlman, 1990; Pearlman & Saakvitne, 1995; Terr, 1985; Wolfe, Gentile, & Wolfe, 1989) suggest the effects of child sexual abuse result in psychological consequences similar to Post Traumatic Stress Syndrome diagnosed in war veterans. Van der Kolk (1987) has identified this phenomenon in children and suggests that abuse interrupts cognitive and psychosocial development. Beverly James (1989) extended the traumatic factors identified by Finkelhor and Browne (1986) to include the following possible consequences, some specific to childhood sexual abuse: stigmatiWINTER 2001
zation, betrayal and loss, self-blame, powerlessness, erotization, destructive rage, dissociation, and attachment disorders. This review of the psychological consequences of child sexual abuse is significantly abbreviated. However, it elucidates the intensity of impact on the child’s psychological and emotional processes and outlines the possible range of clinical manifestation. A more thorough review of the impact of child sexual abuse can be found in Kendall-Tackett, Williams, and Finkelhor (1993), and a summary of the effects of treatment with this population can be found in Finkelhor and Berliner (1995). Further, a conceptual framework by Carlson and Dalenberg (2000) provides a more detailed understanding of the impact of a variety of traumatic experiences on a person. Many of these children have experienced repeated and chronic trauma, along with secondary trauma incurred through intervention (i.e., intrusive medical examination, removal from their home, separation from family and peers, multiple foster care placements, etc.). The emotional sequelae (e.g., mistrust, misperception, emotional dysregulation) can present significant challenges to the therapeutic relationship, generally understood to be the critical factor in recovery, that can go unrecognized or misinterpreted by the therapist. This represents a potential therapeutic impasse and can often result in a negative countertransference that has the potential to further diminish the child’s willingness to risk emotional attachment in any form. Countertransference Given this concern, this paper reviews the emotional experience of the therapist and the subject of countertransference related to working with this population. Webb (1990) defines countertransference as the “therapist’s feeling about a patient (client) which emerge from the therapist’s unconscious or preconscious conflicts or anxieties” (p. 63). More recently, Pearlman and Saakvitne (1995) define countertransference as including two components “(1) the affective, ideational, and physical responses WINTER 2001
a therapist has to her client, his clinical material, transference, and reenactments, and (2) the therapist’s conscious and unconscious defenses against the affects, intrapsychic conflicts, and associations aroused by the former” (p. 23). They further assert that the client’s and therapist’s responses arise in the context of the therapist’s professional identity, the therapeutic relationship, and the therapist’s own personal history. Although the historical origins of the concept of countertransference date back to Freud’s work, there has been little written regarding countertransference issues related to children and even less research related to countertransference with sexually traumatized children. Marshall (1979) provides a typology of countertransference specific to therapeutic work with children and adolescents. In this work, countertransference is defined across two broad dimensions - the source of the countertransference and the degree of consciousness. Marshall (1979) refers to Type I (therapist-induced, unconscious) as the “major and most feared type of countertransference and is a true transferential response to the patient” (p. 416), and suggests the resolution is achieved through analysis or analytic supervision. The major danger lies in the therapist’s lack of conscious awareness. Marshall cites multiple clues to Type I countertransference which can include excessive play with avoidance of discussion; quickly yielding to request for gratification, such as gifts and food; strong emotional reactions toward the child, especially when accompanied by anxiety or guilt; tuning out during repetitive or traumatic play; and/or allowing the parents to utilize the child’s therapy time for consultation. Type II countertransference (therapistinduced, conscious) is less destructive, but can still be problematic. In this situation, the therapist is aware of the countertransference, but cannot seem to overcome it. Marshall (1979) recommends analytically oriented supervision. Type III (patientinduced, unconscious) can “stagnate or obscure the therapy ... no real movement occurs because the patient is in control of
the therapy. ... progress can resume when the therapist recognizes the problem” (p. 417). Marshall suggests that any form of supervision can assist in correcting this problem. Type IV countertransference is understood as occurring when the client is the primary source of inducing “thoughts and feelings (but no action) in the therapist which are fully within the therapist’s awareness. The therapist’s main task is to study the interactional field and devise proper interventions.” (p. 417). Marshall would argue that this type of countertransference is “not only unavoidable, but is a prerequisite for successful therapy, especially with those patients who function primarily at a preverbal level” (p. 417). The range of countertransference reactions cited by Marshall (1979) includes the following: sleepiness, inadequacy, futility, boredom, anger, incompetence, sexuality, seductiveness, helplessness, disinterest, devotion to cure, immobilization, and hopelessness. Webb (1990) would add the following possible reactions: overzealous rescue fantasy, joining with the parents’ feelings of helplessness and panic about their situation, or joining with the parents’ aggression, hostility, and rejection or passivity towards the child. Another possibility might be for the therapist to react with negative feelings toward the parents due to unresolved conflict with authority figures, or to strive to displace the position of the parents, so the therapist can be considered the “good parent.” If one accepts that countertransference issues are inherent to the process of child psychotherapy, then it is reasonable to anticipate that they are intensified when working with traumatized children. Reynolds-Mejia and Levitan (1990) address the countertransference issues experienced by therapists working with child sexual abuse survivors. They describe the following therapist reactions as specific to this area of treatment: psychologically isolating the perpetrator; expressing feelings for the victim instead of facilitating the victim’s own expression of feelings; substituting sympathy for empathy; forfeiting emphatic tolerTexas Psychologist
ance as a self-protective device; imposition their own feelings upon the victim and family; and resisting acknowledging ambivalence, guilt, a sense of complicity, or exploitation of power. Pearlman and Saakvitne (1995) expand on countertransference issues by identifying types of countertransference typically associated with working with survivors of child sexual abuse. They identify positive and negative aspects of all types of countertransference in the therapeutic setting. The types of countertransference include the following: (a) Parental: wishing to repair the damage done, feeling of protectiveness and fear for the client; (b) Love: feelings of love for the client. “It is not unusual for the therapist and client to feel deep love and caring for one another” (p. 86). For example, a love for their strength to survive; (c) Denial: the need not to know or believe the abuse occurred; (d) Sexual and Voyeuristic: feeling of curiosity about the abuse. Sometimes excitability and arousal; and (e) Body Centered: the unconscious display of affect through the therapist’s body language. Reynolds and Mejia (1990) suggest that over-identification can occur more often in working with child abuse victims when the therapist has their own unresolved childhood unresolved childhood traumas. A more universal risk for overidentification occurs from the desire to be of assistance to a vulnerable population, a core feature of the therapist’s dedication to healing. This overidentification can impede the therapeutic process if it “involves a denial of the child’s introjected destructive potential” (Reynolds & Mejia, p. 56). This process of denial renders the therapist unable to recognize the child victim’s potential to re-enact the trauma against self or others. Additional citations that support the position of these authors include Henning’s (1987) investigation of countertransference encountered by clergy treating child abuse and Pollak and Levy’s (1989) exploration of the involvement of countertransference in the failure to report child abuse. These investigators identified fear, guilt, shame, and sympathy as a basis for therapists’ reluc32
tance to report. Carr (1989) describes five countertransference reactions that may be experienced by workers on child abuse management teams, which include rescuing the child, rescuing the parents, rescuing the mother and child, while persecuting the father, rescuing the father, and persecuting the family. Given the similarity of psychological consequences of children who are traumatized and develop Post Traumatic Stress Disorder (PTSD) in combat veterans. Wilson (1989) provides an extensive review of countertransference themes in posttraumatic therapy. Wilson categorizes the therapist’s potential reactions in two areas: emotional countertransference issues and cognitive countertransference and interpersonal strategies. This review of countertransference issues gives credibility to the concept of secondary trauma, or vicarious traumatization, of the clinician who works with traumatized individuals. Pearlman and Saakvitne (1995) emphasize the need for the therapist to be aware of vicarious traumatization and its impact on the therapist. “Vicarious traumatization is the process through which the therapist’s inner experience is negatively transformed through empathic engagement with clients’ trauma material” (p. 279). For example, a therapist may experience nightmares related to sexual abuse, may experience fear, may have safety issues, or may feel compelled to question own childhood experiences or their own vulnerability to abuse, after hearing the stories of child sexual abuse survivors. As noted earlier, countertransference can become an integral factor in facilitating effective therapy, and it presents significant danger when unrecognized and unchecked. This paper describes the significance of clinical supervision as an essential aspect of treatment of psychological trauma resulting from child sexual abuse. Thus, it seems imperative to briefly review how clinical supervision has been conceptualized in the literature and review several relevant models before describing an appropriate model for therapists working with this population.
Attributes of Effective Supervisors Black (1987) investigated the components of effective and ineffective supervision as perceived by supervisees with different levels of clinical experience. She refers to a previous study by Hutt, Scott, and King (1983) that “reported that effective supervision is characterized by an integration of both task-oriented and positive person-oriented behaviors” (as cited in Black, p. 35). Another study cited by Black is Kinder’s (1981) study of the elements of supervision that influenced supervisee’s perceptions of supervision as unhelpful or helpful. These elements were identified as the learning alliance or the working relationship between supervisor and trainee, content or topics dealt with in supervision, the structural aspects or environment of the training setting, and the working relationship developed between the trainee-therapist and the patient. Understanding core attributes of effective supervisors is not sufficient. A great supervisor without an adequate theoretical conceptualization of supervision is the equivalent of a great therapist without any guiding theoretical orientation. The next section provides a general overview of leading models of supervision. Models of Supervision Bromberg (1982) describes the role of the supervisor as an educator whose primary purpose is to facilitate the supervisee’s capacity to function more effectively with their clients in order to facilitate their ability to live their lives more effectively. Of particular significance is the concept of parallel process, defined by Bromberg (1982) as “something, which occurs when the supervisee is unconsciously enmeshed in an unresolved treatment difficulty, resistance or impasse with his patient,” (p. 103). Another concept relevant to both the treatment process and to supervision is projective identification, in which the client projects some quality onto the therapist, who indeed may actually have these traits, or who may begin to respond, after a potential is “activated by a continuous and powerful transWINTER 2001
ferential stimulation. When that situation becomes fixated over a period of time, we have the basic ingredient for the development of transference neurosis, and at times, its counterpart, countertransference neurosis” (Arlow, 1963, as cited in Bromberg, p. 106). These aspects contribute to Pearlman and Saakvitne’s (1995) view of supervision as having a focus on the therapy relationship, not the client. One study reviewed indicated that only half of analytically trained supervisors addressed obvious countertransferential issues during the course of supervision. Goin and Kline (1976) reviewed supervision tapes of 24 psychodynamically oriented supervisors and psychiatric residents. Their findings indicated that 12 of the supervisors actively avoided discussion of the countertransference, while only eight directly addressed it, and four indirectly addressed it. Reasons cited by the supervisors for avoiding the subject included fear of becoming involved in therapeutic issues, concerns about confusion between roles of therapist and educator, and concern about arousing the therapists’ anxiety. Although Goin and Kline elucidate areas for possible misuse of supervisee’s countertransference, they feel that addressing these issues in supervision allows the therapist to develop an awareness of how his or her reactions affect the therapy and to develop a “curiosity about one’s reactions and feelings toward patients, with the goal of promoting rational therapeutic interactions” (p. 44). Doehrman (1976) describes effective supervision as dependent upon “active insight into the interplay of forces in the parallel process of therapy and supervision” (p.17). Doehrman (1976) believed that the resolution of supervisee-supervisor conflict often serves facilitate the therapist’s capacity for clarity and insight into the dynamics of the therapeutic relationship. Doehrman (1976) identifies supervision as “the teaching of psychotherapeutic skills, whereas the goal of therapy is to alter the characteristic modes of reacting in order to function more effectively in all areas of life” (p. 79). Doehrman asserts that supervision WINTER 2001
should focus on the impact of the therapist’s activity on his relationships with his patients. The therapist’s personal meaning and defenses are considered a secondary focus. Pearlman and Saakvitne (1995) report that regular weekly supervision should be upheld by the therapist. They identify a minimum of an hour weekly for experienced therapists and more for beginning therapists. The process of development of clinicians occurs across clients, across stages, and across years. The process can be made more deliberate and informed if there is a guiding, prescriptive model. The experience of therapists working with sexually abused children will vary according to a number of identifiable variables (i.e., experience levels, novelty of issues or degree of trauma, knowledge and skills, personal history of trauma, current life circumstances, etc.). All of these factors will effect the process and outcome of therapy, and can be incorporated effectively into the treatment process if expressed, processed, and contextualized within the course of supervision. For supervision to be effective, it must mirror the therapist’s particular level of professional development. Hess (1987) reviewed the literature and “determined the various stage theories seem to have four psychological eras in common” (p. 251). Hess proposed that the professional counselor “can recycle, in an ascending spiral fashion, through these stages” (p. 251). He identifies the four stages as: 1. Inception: Involves a role induction for the therapist and demystification of therapy. Various fears and fantasies are activated as sudden changes occur. 2. Skill development: Involves an increasingly better fit between one’s clients and the didactic and experiential material being mastered. One can sense the supervisee beginning to identify with a system of therapy and a philosophy of human nature. An apprentice role and some sense of autonomy are featured in this stage. 3. Consolidation stage: Involves integrating the building blocks acquired previously. The therapist considers that their identity is defined in part by their skills. The role of a
therapist’s personality emerges, and skill refinement competencies are featured. 4. Mutuality stage: Involves the therapist in a different light, as an autonomous professional who can create solutions to problems and share this insight with others. Hess suggests the supervisee continues to face learning problems in this stage, although other theorists disagree. He cites burnout and stagnation as examples of difficulties encountered by therapists in this stage. Hess (1987) suggests that therapists are “confronted with a wealth of material, often tragic and stress inducing, from each client session. The search for meaning and for indications as to how best to conduct therapy can reach crisis proportions” (p. 256). Taylor (1983, as cited in Hess) reported on the process by which people confront tragedy. “First people try to find meaning in the event and its implication. Second, they gain a sense of mastery or control. Third, after catastrophe, there occurs a strong need to restore self-esteem” (p. 256). This confrontation of traumatic experience and its impact on the therapist can be revisited across multiple child clients over the course of a single day in the treatment of child sexual abuse. A conceptual framework that is prescriptive across the various developmental stages and that monitors the therapists’ progress can mediate the impact of traumatic material, protecting both the therapist and client. A developmentally informed model of supervision directs supervision across multiple stages of therapist development, allowing for instruction, support and challenge appropriate to increasing skills, knowledge, and self-development. Developmental paradigms are descriptive of the type of supervisory relationships necessary to facilitate supervisee growth. Relative to working with a steady diet of traumatic material and vulnerable populations, a developmental model should anticipate the novice therapist’s reactions and provide guidelines for teaching, support, monitoring, and confrontation. It is equally important to attend to the process of establishing and maintaining a supervisory working alliance. A review of the literature of developTexas Psychologist
mental models of supervision can be found in Stoltenberg and Delworth’s (1987) text on supervising counselors. The revised Integrated Developmental Model (IDM) was published by Stoltenberg, McNeill, & Delworth in 1998; it is more contemporary and it integrates both Stoltenberg’s Counselor Complexity Model (1981) and Loganbill, Hardy, and Delworth’s (1982) model based on the eight domains of psychosocial development. In Stoltenberg and Delworth’s (1987) model, the trainee progresses across three basic structures—self and other awareness, motivation, and autonomy—in a continuous manner through Levels 1 to 3. This process is understood to occur progressively through eight domains relevant to professional activities in counseling and psychotherapy. The eight specific domains are intervention skill competence, assessment techniques, interpersonal assessment, client conceptualization, individual differences, theoretical orientation, treatment goals and plans, and professional ethics. After the aforementioned review of the purpose and various models of supervision, the authors present Stoltenberg, McNeill, and Delworth’s (1998) IDM stages of counselor development, as the preferred model for supervision of therapists working with sexually traumatized children. The IDM model has been used by the senior author for the past 10 years as it provides clear direction in facilitation of therapists’ skills and conceptual growth. The primary features of the revised IDM model are specifically articulated by Stoltenberg, McNeill and Delworth (1998). The revised model is modified by the authors of this article, adapting the process to make it more specific to supervisors who supervise therapists who work with traumatized children. Based on the experience with the model, and twenty years of experience in treating sexually abused children, specific recommendations for developmentally informed supervision are provided. Level 1 Therapist In service to children and families, it is 34
critical to have a solid foundation in the areas of child development, multicultural competencies, systems theories, a working knowledge of experiential and expressive therapies, treatment issues involved with this particular population, state and federal laws, and an understanding of the local child protective services and judicial system. Specific to child sexual abuse, therapists will need to develop a conceptual framework for understanding the developmental impact of traumatic experience (Carlson & Dalenberg, 2000). This knowledge is not necessarily present and should be an integral part of supervisory activities for the Level 1 therapist. The Level 1 therapist operates at a pivotal point in their development. Level 1 supervision should anticipate possible countertransferential experiences, grief due to a loss of naivetÈ, a possible profound sense of inadequacy, and a generally high level of anxiety. An effective supervisor empowers the Level 1 therapist through provision of resources and clinical examples, possibly joining in as a co-therapist when appropriate, and exposing them to relevant professional literature and networks. The Level 1 therapist’s experience is on some level similar to the client’s experience of feeling alone and overwhelmed. Essential elements in the relationship with the supervisee are trust, empathy, and availability. It is therefore important that rapport be established quickly, with a predictable schedule set for supervisory meetings and provisions made for “emergency” consultations. Frequent appraisals and feedback are needed, with specific provisions for improvement and/or redirection. It is equally important to validate the supervisee’s competency and to train them in selfevaluation. Some tools that assist in this aspect of professional development are professional journals; professional self-inventories, which can be reviewed periodically in supervision; review of supervisee’s process notes with specific feedback from the supervisor; peer consultation; and support groups. The last tool can be especially effec-
tive if there are several Level 1 therapists practicing at the same program. The supervisor may want to encourage case presentations and facilitate peer consultation and problem formulation. These meetings are also a less threatening forum for Level 1 therapists to share common and unique experiences with peers who can provide validation and empathy, along with alternative solutions and interventions. An additional benefit is the formation of professional alliances that may continue throughout one’s professional career, providing a rich source for consultation, acknowledgment, history, and support. It is also critical that the supervisor completely orients the supervisee to the agency, organization, or practice environment. Structure, orientation, and environment should be clear, comfortable, and accommodating for the Level 1 therapist. Their energy should be directed to skill and knowledge development. Involving them as a team member with other staff is a critical aspect of orientation, seemingly fundamental but frequently an afterthought in many treatment programs serving children and adolescents, and utilizing students. Initial caseloads should be small and selectively assigned so as to maximize entry-level skills and enthusiasm. Care should be given to create assignments that approximate optimal treatment conditions, such as not assigning a therapist to both an individual and the family, so as to avoid dual relationships and to provide a necessity for interprofessional communication. If the ideal cannot be attained due to various “real life” limitations, these issues should be explored candidly in supervision. Finally, careful attention should be paid to teaching the Level 1 therapist about the experience of countertransference. Level 1 supervisees typically lack the self-awareness and experience necessary to recognize and address countertransference. While countertransference is understood to be an important consideration in any dynamically oriented therapeutic relationship, the complications presented by the emotional and relational sequelae of child sexual abuse WINTER 2001
make it a paramount supervisory concern. The complicated relationship dynamics involved in child sexual abuse cases make this a priority. Initial reactions may include, but are not limited to, confrontation of personal history of trauma, doubt regarding prevalence and psychological impact, demonizing the perpetrators, and a prevailing sense of despair. Initially, it is the responsibility of the supervisor to inquire about the therapist’s feelings, thoughts, and behaviors toward their clients, the therapeutic material, and the overall dynamics of child sexual abuse. Novice therapists are frequently ashamed or frightened by their intense feelings toward clients. If left unattended, these feelings can result in a myriad of risks to the efficacy of the therapy, as well as to developing a sense of competency. Bernard and Goodyear (1998) describe the supervisory relationship as “at least a three-person system comprised of client, therapist-supervisee, and supervisor, and they note the importance of two dynamic forces, described in more traditional psychoanalytic and family therapy training literature, to complement and facilitate the address of countertransference in a developmental supervision framework. Analysts often refer to parallel process as the circumstance in which various aspects of the client-therapist interaction are subsequently manifested or replicated in the therapistsupervisor relationship. For example, oftentimes an eager Level I therapist or a naively overconfident Level II therapist will engage in an advice-giving mode of interaction with a client who initially agrees with the therapist’s suggestions, but then immediately dismisses or minimizes the advice offered. This “yes, but” behavioral pattern is then replicated in the therapist’s supervisory session when the trainee describes their difficult, reluctant, or resistant client, and then solicits advice from the supervisor for dealing with such a challenging case. The trainee then completes the parallel process by telling the supervisor, “Yes, I agree, but here is how my client responds.” While it has been the experience of the authors of WINTER 2001
this paper that the more advanced therapist may readily and productively engage in reflective consideration of this dynamic when it is brought to the therapist’s attention by their supervisor, the Level I and Level II therapists are less able to process the affective parallels between the duality of their experience as therapist and trainee. As previously discussed, the supervisor is encouraged to allow more supervisory time for discussion with the trainee and must be prepared to provide concrete suggestions and clear direction regarding intervention during this teachable moment in supervision with the Level I therapist. The strivings for autonomy in the Level II therapist have to be understood and responded to with insight and patience on the part of the supervisor, always maintaining focus on the needs of the client. The notion of isomorphism, a concept embraced by family therapists such as Jay Haley (Bernard & Goodyear, 1998), suggests that the dynamics of the supervisory relationship will be replicated in the clienttherapist relationship. In such cases, the therapist will simply repeat with their client the intervention(s) utilized by the supervisor during supervision. Again, it has been the clinical experience of the authors of this paper addressing these dynamics with beginning therapists is not always productive or immediately understood by the trainee. Remember, the Level I therapist is highly motivated and very eager to please the supervisor, in addition to having only a narrow range of therapeutic skills. The supervisor should simply embrace the dynamic of isomorphism as a skill-building pedagogical strategy with novice therapists, while utilizing a more interpretative address of these dynamic with Level II therapists, who seek to establish a more independent relationship with the supervisor. Level 2 Therapist As the therapist develops a stronger sense of competency and increases self-knowledge, as well as increases knowledge specific to treatment of traumatized children, the supervisor may experience some subtle or
not-so-subtle nudges for autonomous decision-making. The supervisee’s need for autonomy may supercede the supervisor’s readiness to relinquish direct control over their clinical work. Supervisors may find a Socratic method of supervision more useful at this point, asking probing questions that direct the supervisee to explore clinical issues or decisions they have made. It is critical to recognize the therapist’s professional growth and insure that they are adequately challenged. Based on the mastery of supervisee’s clinical skills, a supervisor may consider increasing their caseload or adding an additional modality if there is any sense that the supervisee is not being challenged. This should be addressed directly in supervision, and if the supervisee requests additional responsibility or new challenges, this request should be accommodated to an appropriate level. Case presentation at internal conferences or meetings can be very effective in building the supervisee’s sense of competence. Additionally, encouraging the supervisee to seek literature support and peer consultation for difficult cases is effective in addressing resistance to supervisory input sometimes encountered with the Level 2 supervisee. However, in most instances, given an adequate supervisory relationship built on trust and mutual respect, the desire for autonomy should not be viewed as resistance, but considered as a natural and desirable indicator of professional development. The structure should be clear, with support predictably available when the supervisee experiences distress or concern regarding their ability to make autonomous and effective therapeutic decisions and interventions. Situations should be created that facilitate this period of development as mentioned in some of the recommended activities. Level 2 supervisees may experience countertransference reactions more specifically related to an individual client rather than to the overall issue and dynamics involved in child sexual abuse. Specifically, as the Level 2 supervisee shifts from selffocus to more of a client focus, they will experience countertransference in relation to Texas Psychologist
particular client traits, attributes, and levels of responsiveness. The strivings of the Level 2 therapist for autonomy may present as a tendency to restrict sharing of pertinent case material with the supervisor. It is incumbent upon the supervisor to assist the supervisee in realizing that their emotional reactions to their clients are integral to the therapeutic process and tend to enhance rather than impede the process. Finally, it needs to be restated that the supervisor’s responsibility is to explore the countertransference, as it reflects what the child is either consciously or unconsciously evoking in the therapist. If personal issues arise for the supervisee during the exploration of countertransference, this should be understood to be productive and facilitative of both the therapy and the therapist’s professional and personal development. Unexplored reactive personal issues present significant risks to the integrity of the therapeutic relationship. While it is not uncommon for this to occur, it is important to for the supervisor to distinguish what is relevant to the therapeutic relationship and what is better addressed in the supervisee’s personal therapy. It is not acceptable or ethical for the supervisor to engage in the therapeutic work with a supervisee. Level 3 and Level 3i Therapists The Level 3 counselor is approaching mastery, and the supervisory meetings should shift from a directive nature to a naturally consultative nature. An autonomous individual is emerging as a professional. The nature of the supervisory meetings might shift to discussion of professional identity issues, affiliations with professional organizations, concern with the multifaceted issues that impinge upon provision of services, and clinical issues related to serving child sexual abuse victims. These are appropriate considerations as the highly aware and involved therapist potentially becomes a more effective clinician and develops a pool of resources that can serve the related needs of their clients. This level of awareness and professional involvement is sometimes overwhelming for beginning therapists and can actually divert energy 36
that may be needed for learning effective assessment and therapy techniques. Countertransference is more easily recognized by the Level 3i supervisee, and it becomes an anticipated experience of the therapeutic relationship. The Level 3i supervisee can both introduce and discuss the countertransference in supervision with less defensiveness. The supervisee is better able to not only acknowledge the countertransference, but to use it as course correction feedback. Insights gleaned from exploring the countertransference allow for improved clinical clarity resulting in deeper empathy with the child sexual abuse client. The Level 3i therapist has gained a level of mastery that shifts the supervisory relationship with the therapist becoming a colleague. The frequency of sessions may be maintained or reduced, but sessions are often used to exchange ideas, to monitor burnout, to share encouragement for continued professional development, or to exchange resources. Other vital roles for this relationship are the review of ethical practices and problem-solving for potentially volatile cases. Therapists who choose to specialize in child sexual abuse cases will inevitably have to confront potentially violent perpetrators, report additional abuse, face possible litigation, face brilliant defense attorneys charged with discrediting their work, and many other difficult situations. These issues are best approached by consulting colleagues who have knowledge of one’s abilities and have some previous experience in similar circumstances. Too often, supervision is terminated prematurely, in the early stages of professional development. This can result in inadequately revealing, addressing, and/or resolving Level 3 and 3i developmental tasks. McNeill, Stoltenberg, and Romans (1992) caution supervisors to not assume a counselor’s competencies when they are presented with unfamiliar clinical situations. Summary and Discussion Awareness of developmental progression
in therapist training is a critical feature of the “good enough” supervisor. It has been demonstrated that the process of effective clinical intervention for traumatized children requires an informed approach to clinical supervision. The attuned supervisor is aware that counselor development occurs across predictable and fluid stages. This process of development is affected by the interpersonal qualities of the supervisor and the therapist’s personal history, and is often mediated by complex countertransference. Supervision informed by this complex of factors will more accurately contribute to the training process and the efficacious treatment of traumatized children. ✯ Laura Palmer, PhD, is an assistant professor and co-director of training for the Counseling Psychology PhD Program at Seton Hall University in South Orange, NJ. Robert McPherson, PhD, is chair and associate professor of the Department of Educational Psychology at the University of Houston in Houston. Anne R. Farrar, MA, is a doctoral candidate at Seton Hall University. Heather Wallrath, MA, is a doctoral candidate at the University of Houston. All correspondence should be addressed to Laura Palmer, PhD, at email@example.com or mailed to Seton Hall University, 317 Kozlowski Hall, 400 South Orange Avenue, South Orange, NJ 07079. References Bernard, J.M., & Goodyear, R.K. (1998). The fundamentals of clinical supervision. Allyn & Bacon: Boston. Black, B.K. (1987). Components of effective and ineffective psychotherapy supervision as perceived by supervisees with different levels of clinical experience. Unpublished doctoral dissertation, Teachers College Columbia University, New York. Blake-White, J., & Kline, C. (1985). Treating the dissociative process in adult victims of childhood incest. The Journal of Contemporary Social Work, 9, 394-402. Bowlby, J. (1984). Violence in the family as a disorder of the attachment and caregiving systems. American Journal
of Psychoanalysts, 44, 9-27. Bromberg, P.M. (1982). The supervisory process and parallel process in psychoanalysis. Contemporary Psychoanalysis, 18, 92-111. Carlson, E.B., & Dalenberg, C.J. (2000). A conceptual framework for the impact of traumatic experiences. Trauma, Violence, & Abuse, 1, 4-28. Carr, A. (1989). Countertransference to families where child abuse has occurred. Journal of Family Therapy, 11, 87-97. Doehrman, M.J. (1976). Parallel processes in supervision and psychotherapy. Bulletin of the Menninger Clinic, 40, 1-100. Ekstein, R., & Wallerstein, R.S. (1958). The teaching and learning of psychotherapy. New York: Basic Books. Eth, S., & Pynoos, R. (1985). Post-traumatic stress disorder in children. Washington, D.C.: American Psychiatric Press. Finkelhor, D. (1978). Psychological, cultural and family factors in incest and family sexual abuse. Journal of Marriage and Family Counseling, 4, 41-49. Finkelhor, D. (1986). A sourcebook on child sexual abuse. Newbury Park, CA: Sage. Finkelhor, D., & Berliner, L. (1995). Research on the treatment of sexually abused children: A review and recommendations. Journal of the American Academy of Child & Adolescent Psychiatry, 34(11), 1408-1423. Finkelhor, D., & Browne, A. (1986). Initial and long-term effects: A conceptual framework. In D. Finkelhor (Ed.), A source book on child sexual abuse. Newbury Park, CA: Sage. Goin, M.K., & Kline, F. (1976). Countertransference: A neglected subject in clinical supervision. American Journal of Psychiatry, 133, 41-44. Henning, L.H. (1987). The emotional impact of treating child abuse. Journal of Religion and Health, 26, 37-42. Herman, J., Russell, D., & Trocki, K. (1986). Long-term effects of incestuous abuse in childhood. American Journal of Psychiatry, 143, 12931296. Hess, A.K. (1987). Psychotherapy supervision: Stages, Buber, and a theory of relationship. Professional Psychology: Research and Practice, 18, 251-259.
Hutt, C.H., Scott, J., & King, M. (1983). A phenomenological study of superviseesâ€™ positive and negative experiences in supervision. Psychotherapy: Theory, Research, and Practice, 20, 118-123. James, B. (1989). Treating traumatized children: New insights and creative interventions. Lexington, MA: Lexington. Kendall-Tackett, K.A., Williams, L.M., & Finkelhor, D. (1993). Impact of sexual abuse on children: A review and synthesis of recent empirical studies. Psychological Bulletin, 113(1), 164-180. Loganbill, C., Hardy T.J., & Delworth, V. (1982). Supervision: A conceptual model. The Counseling Psychologist, 10, 3-34. Marshall, R.J. (1979). Countertransference with children and adolescents. In L. Spetein & A. Feiner (Eds.), Countertransference. New York: Aronson. Matsakis, A. (1996). I canâ€™t get over It: A handbook for trauma survivors (2nd ed.). Oakland, CA: New Harbinger. McCann, I.L., & Pearlman, L.A. (1990). Vicarious traumatization: A framework for understanding the psychological effects of working with victims. Journal of Traumatic Stress, 3, 131-149. McNeill, B.W., Stoltenberg, C.D., & Romans, J.S.C. (1992). The integrated developmental model of supervision scale development and validation procedures. Professional Psychology: Research and Practice, 23, 504-508. National Center of Child Abuse and Neglect. (1983). Child protection: A guide for state legislation. Washington D.C.: U.S. Department of Health and Human Services. Oates, K. (1985). Self-esteem and early background of abusive mothers. Child Abuse and Neglect, 9, 89-93. Pearlman, L.A., & Saakvitne, K.W. (1995). Trauma and the therapist: Countertransference and vicarious traumatization in psychotherapy with incest survivors. New York: W.W. Norton. Pollak, J., & Levy, S. (1989). Countertransference and failure to report child abuse and neglect. Child
Abuse and Neglect, 13, 515-22. Reynolds-Mejia, P., & Levitan, S. (1990). Countertransference issues in the inhome treatment of child sexual abuse. Child Welfare, 69, 53-60. Russell, D. (1983). The incidence and prevalence of intrafamilial and extrafamilial sexual abuse of female children. Child Abuse and Neglect, 7, 133-149. Russell, D. (1986). The secret trauma: Incest in the lives of girls and women. New York: Basic Books. Rycroft, C. (1973). A critical dictionary of psychoanalysis. Totawa, NJ: Littlefield, Adams & Co. Schultz, L.G. (1973). The child sex victim: Social, psychological and legal perspectives. Child Welfare, 52, 147-148. Stoltenberg, C. (1981). Approaching supervision from a developmental perspective: The counselor complexity model. Journal of Counseling Psychology, 28, 59-65. Stoltenberg, C., & Delworth, U. (1987). Supervising counselors and therapists: A developmental approach. San Francisco: Jossey-Bass. Stoltenberg, C.D., McNeill, B., & Delworth, B. (1998). IDM supervision: An integrated developmental model for supervising counselors and therapists. San Francisco: Jossey-Bass. Terr, L. (1985). Psychic trauma in children and adolescents. Psychiatric Clinics of North America, 8, 815-835. U.S. Department of Health and Human Services (1997). Child maltreatment: 1995: Reports from the states to the national child abuse and neglect data system. Washington, D.C.: U.S. Government Printing Office. Van der Kolk, B. (1987). Psychological trauma. Washington, D.C.: American Psychiatric Press. Webb, N.B. (1990). Supervision of child therapy: Analyzing therapeutic impasses and monitoring countertransference. The Clinical Supervisor, 7, 61-76. Wilson, J.P. (1989). Trauma, transformation and healing. New York: BrunnerMazel. Wolfe, V., Gentile, C., & Wolfe, D. (1989). The impact of sexual abuse on children: A PTSD formulation. Behavior Therapy, 20, 215-228.
Council of Representatives American Psychological Association August 19, 2001 San Francisco, California Joseph C. Kobos, PhD, ABPP
ou will be reading this report after the tragedy of September 11. All of our perspectives have changed since that time. And while we all have a different sense of our values and priorities, I know that I continue my commitment to our profession. Our profession has much to offer in this time of crisis, whether in crisis counseling, facilitating negotiations, or helping understand the individual and group behaviors that contribute to evil and joy in our lives. We shall move on each of us using our skills to cope with the present and to develop a better place in which to live. I know TPA and our local associations will foster these efforts. And now my summary report. APA continues to face the issue of membership retention and recruitment. A task force has been established and proposals made to encourage our growth. Membership numbers have been flat for the past year. It is essential that we urge new professionals to make a commitment to APA. Houston psychologist Dr. Ray Molinari was elected to initial Fellow status. Congratulations! APA took a big step forward in ensuring that all states have representation at Council. Adopting an approach known as the “wild card” plan, Council modified the rules regarding the minimal number of apportionment votes needed for representation. Each state and Division will now have a seat on Council and additional seats will be allocated according to a new formula. It is essential that Texas TPA members continue to vote Ten for Texas. Of the large population states, we are the only one with one representative. We need the visibility and input that increased representation would provide. Council voted to establish a two-year college Teacher Affiliate category and a committee of Psychology Teachers at 38
Community College. This will foster more interchange with this large group of teachers and students. Council heard recommendations from the Committee on Recognition of Specialties and Proficiencies in Professional Psychology. Earning recognition are Forensic Psychology, Psychopharmacology and Alcohol Treatment. Council passed a very small deficit budget for the coming year. Council has taken a very cautious stance in approving new projects and ventures. In August we learned that some of our investments were not doing well and would be reevaluated. Since that time, we have been informed that our market holdings, like those of many, have experienced a downturn. Our human capital, that is our fine staff, continues in place and intact. We have experienced a more stable staff over the past year with much less turnover. The most emotional debate on Council centered on a proposal for APA to reimburse Council meeting expenses to any
Division or state that sent an ethnic minority representative. The goal of the proposal is to offer incentives to recruit, nominate, and elect ethnic minority representatives. The proposal passed. Another issue that stimulated strong debate was a proposal to establish a seat on the Board of Directors and Council for a member of APAGS (APA Graduate Students). The major concern expressed was that the Board of Directors is the Executive Committee of Council. The Board is elected by Council and to establish a seat that has a different entry to the Board creates problems. The recommendation was sent back for further review. Norrine Johnson, current APA president is having a very successful year in bringing psychology as a “health” profession into a variety of policy making venues. Ray Fowler reviewed the successes of the past year. Our two buildings are fully occupied and are becoming a financial resource. The Publication Manual has been revised and produces a steady revenue stream. The Encyclopedia of Psychology is completed and has been well received. The APA Foundation is becoming a real resource. In the past 10 years, the Foundation has attracted major donors and will produce an endowment to support a variety of projects. Council meets again in February 2002. ✯
Special Thanks to the 2001 Convention Program Committee No event the magnitude of the TPA Annual Convention can be possible without the dedicated, and often unappreciated, work of volunteer members. They are committed to insuring that your Annual Convention is the best educational experience possible. Their loyalty and dedication to this endeavor are vital contributions that add value to membership in TPA. Convention Program Committee: Gary Brooks, PhD—Chair (Waco) Cindy Carlson, PhD (Austin) Collie Conoley, PhD (College Station) Robbie Sharp, PhD (Houston) Jose Luis Torres, PhD (Dallas)
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can perform testing, as well as therapy.
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C L A S S I FI ED S
2001 PSY-PAC Contributors January 1 - October 1 Ron Cohorn, PhD, PSY-PAC President
hank you for your year 2001 contribution(s) to PSY-PAC, the Texas Psychological Associationâ€™s Political Action Committee. As a supporter of PSY-PAC, you are among the special group of individuals who make the sacrifice to protect and enhance the practice of psychology in Texas. Thanks to your donation(s), psychology is still a doctoral level profession and we have initiated the process of obtaining prescription privileges. However, PSY-PAC is not limited to these issues. Our lobbyist and central office staff are constantly monitoring all legislation and responding appropriately. Without your contribution(s), psychologists would have no voice in the Texas political process. Please make a personal commitment to contribute regularly to PSY-PAC. Again, thank you for your support. YOU ARE APPRECIATED. $2,500 and above Paul Burney, PhD Deanna Yates, PhD
$1,000-$2,499 Judith Norwood Andrews, PhD King Buchanan, PhD Ron Cohorn, PhD Cary Conaway, PhD Edward Davidson, PhD Mark Foster, PhD Cheryl L. Hall, PhD Ethel W. Hetrick, PhD James B. Quinn, PhD Elizabeth L. Richeson, PhD Kevin G. Smith, PhD Thomas A. Van Hoose, PhD
$500-$999 Richard Fulbright, PhD Angela Ladogana, PhD
$250-$499 Maria Concepcion Cruz, PhD El Paso County Psychological Society C. Elizabeth Salmeron, PhD Kenneth D. Huff, PhD
$100-$249 Lisa Balick, PhD Tim Branaman, PhD Robin Burks, PhD Sam Buser, PhD Sean Connolly, PhD Jim Cox, PhD Walter Cubberly, PhD Michael Duffy, PhD Thomas H. Edwards, PhD Patrick J. Ellis, PhD Charles F. Gray, PhD Sophia K. Havasy, PhD Lynette Heslet, PhD David Hopkinson, PhD Ronald J. Jereb, PhD Kevin T. Jones, PhD William Lucker, PhD Jerry Mabli, PhD Suzanne Mouton-Odum, PhD Matthew Nessetti, PhD Barbara S. Peavey, PhD Michael C. Pelfrey, PhD John Pinkerman, PhD Robbie N. Sharp, PhD Bryan E. Smith, PhD Alan Stephenson, PhD Daniel J. Thompson, PhD Joan Weltzien, EdD M. Wright Williams, PhD John W. Worsham Jr., PhD
Under $100 Walter Ray Allberg, PhD Bruce Allen, PhD Bonnie Brookshire, PhD Elaine Calaway, PhD C. Munro Cullum, PhD Dana Davies, PhD Ronald Davis, PhD Sally Davis, PhD Philip Davis, PhD Alan B. Frol, PhD Marsha T. Gabriel, PhD Ronald Garber, PhD Sylvia Gearing, PhD Judy W. Halla, EdD JoBeth Hawkins, PhD A. S. Helge, PhD Annette Helmcamp, PhD Cliff Jones, PhD Nancy A. Leslie, PhD Raul Martinez, PhD Joseph McCoy, PhD Jacqueline Miekka, PhD Frank D. Ohler, PhD Esther Polland, PhD Harriet T. Schultz, PhD Shannon E. Scott, PhD James P. Thompson, PhD Niki Valentine Vick, PhD Alisha Wagner, MA Debbi S. Wagner-Johnson Lee T. Wallace, PhD Colleen A. Walter, PhD Patricia D. Weger, PhD Jack Wiggins, PhD WINTER 2001
Associaton for Advanced Training in the Behavior Full 1c New - Film Inside Back Cover
Academic Review Full 1c New - Film Back Cover
Official publication of Texas Psychological Association.