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VOLUME 38 NO. 2 SUMMER 2003
BULLETIN
PsychotherapyOFFIC IAL PUBL ICAT ION OF D IV IS ION 29 OF THE
AMERICAN PSYCHOLOGICAL ASSOCIAT ION
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In This Issue
Could the Titanic Disaster Have Been Prevented?
Medical School Training, Patient Safety,and Prescriptive Authority for Psychologists
Reactions to Segal, Williams & Teasdale’sMindfulness-Based Cognitive Therapy
for Depression
Division 29 • 2003 APA Convention Program
PresidentPatricia M. Bricklin, Ph.D. 2002-2004470 Gen. Washington RoadWayne, PA 19087Ofc: 610-499-1212 Fax: [email protected]
President-electLinda F. Campbell, Ph.D., 2001-2003University of Georgia402 Aderhold HallAthens, GA 30602-7142Ofc: 706-542-8508 Fax:[email protected]
SecretaryAbraham W. Wolf, Ph.D., 2002-2004Metro Health Medical Center2500 Metro Health DriveCleveland, OH 44109-1998Ofc: 216-778-4637 Fax: [email protected]
TreasurerLeon VandeCreek, Ph.D., 2001-2003The Ellis Institute9 N. Edwin G. Moses Blvd.Dayton, OH 45407Ofc: 937-775-4334 Fax: [email protected]
Past PresidentRobert J. Resnick, Ph.D., 2002-2003Department of PsychologyRandolph Macon CollegeAshland, VA 23005Ofc: 804-752-3734 Fax:[email protected]
Board of Directors Members-at-LargeNorman Abeles, Ph.D. , 2003-2005Michigan State Univ.Dept. of PsychologyE. Lansing, MI 48824-1117Ofc: 517-355-9564 Fax: [email protected]
Mathilda B. Canter, Ph.D., 2002-20044035 E. McDonald DrivePhoenix, AZ 85018Ofc/Home: 602-840-2834 Fax: 602-840-3648E-Mail: [email protected]
Patricia Hannigan-Farley, Ph.D. 2003Office: 440- 250-4302 Fax: 440-250-4301Email:[email protected]
Jon Perez, Ph.D., 2003-2005Washington, D.C. [email protected]
Alice Rubenstein, Ed.D., 2001-2003Monroe Psychotherapy Center20 Office Park WayPittsford, New York 14534Ofc: 585-586-0410 Fax [email protected]
Sylvia Shellenberger, Ph.D., 2002-20043780 Eisenhower ParkwayMacon, Georgia 31206Ofc: 478-784-3580 Fax: [email protected]
APA Council RepresentativesJohn C. Norcross, Ph.D., 2002-2004Department of PsychologyUniversity of ScrantonScranton, PA 18510-4596Ofc:570-941-7638 Fax:[email protected]
Jack Wiggins, Jr., Ph.D., 2002-200415817 East Echo Hills Dr.Fountain Hills, AZ 85268Ofc: 480-816-4214 Fax: [email protected]
Alice F. Chang, Ph.D., 2003-20056616 E. Carondelet Dr.Tucson, AZ 85710Ofc: 520-722-4581 Fax: [email protected]
STANDING COMMITTEES
FellowsChair: Roberta Nutt, Ph.D.
MembershipChair: Craig N. Shealy, Ph.D.James Madison UniversitySchool of PsychologyHarrisonburg, VA 22807-7401Ofc: (540) 568-6835 Fax: 540-568-3322 [email protected]
Student Representative to APAGS:Anna McCarthy2400 Westheimer #306-WHouston, TX [email protected]
Nominations and ElectionsChair: Linda F. Campbell, Ph.D.
Professional AwardsChair: Robert J. Resnick, Ph.D.
FinanceChair: Leon VandeCreek, Ph.D.
Education & TrainingChair: Jeffrey A. Hayes, Ph.D.Associate Professor and Director ofTraining Counseling Psychology ProgramPennsylvania State University312 Cedar BuildingUniversity Park, PA 16802Ofc: (814) [email protected]
Continuing EducationChair: Jon Perez, Ph.D.
Student DevelopmentChair: Open
Psychotherapy ResearchChair: Clara Hill, Ph.D.Dept. of PsychologyUniversity of MarylandCollege Park, MD 20742Ofc: (301) [email protected]
ProgramChair: Alex Siegel, Ph.D., J.D.915 Montgomery Ave. #300Narbeth, PA 19072Ofc: 610-668-4240 Fax: [email protected]
TASK FORCES
Task Force on Policies & ProceduresChair: Mathilda B. Canter, Ph.D.
Diversity Chair: Dan Williams, Ph.D., FAClinP,ABPP185 Central Ave- Suite 615East Orange, New Jersey 07018Ofc: 973-675-9200 Fax: [email protected] - 1-888-269-3807
Interdivisional Task Force on HealthCare PolicyChair: Jeffrey A. Younggren, [email protected]
Task Force on Children, Adolescents& FamiliesChair: Sheila Eyberg, Ph.D.Professor of Clinical & HealthPsychologyBox 100165University of FloridaGainesville, FL 32610FEDERAL EXPRESS ADDRESS1600 SW Archer [email protected] 352-265-0468Co-Chair: Beverly Funderburk, Ph.D.
Division of Psychotherapy ! 2003 Governance StructureELECTED BOARD MEMBERS
COMMITTEES AND TASK FORCES
Chair: John C. Norcross, Ph.D., 2002-2008Department of PsychologyUniversity of ScrantonScranton, PA 18510-4596Ofc:570-941-7638 Fax:[email protected]
Publications Board Members:Jean Carter, Ph.D., 1999-20053 Washington Circle, #205Washington, D.C. 20032Ofc: [email protected]
Lillian Comas-Dias, Ph.D., 2001-2007Transcultural Mental Health Institute908 New Hampshire Ave. N.W., #700Washington, D.C. [email protected]
Raymond A. DiGiuseppe , Ph.D., 2003-2009 Psychology Dept St John’s University 8000 Utopia Pkwy Jamaica , NY 11439 Ofc: 718-990-1955 [email protected]
Alice Rubenstein, Ed.D. , 2002-2003Monroe Psychotherapy Center20 Office Park WayPittsford, New York 14534Ofc: 585-586-0410 Fax 585-586-2029Email: [email protected]
Publications Board Members, continuedGeorge Stricker, Ph.D., 2003-2009 Institute for Advanced Psychol Studies Adelphi University Garden City , NY 11530 Ofc: 516-877-4803 Fax: 516-877-4805 [email protected]
Psychotherapy Journal EditorWade H. Silverman, Ph.D. 1998–20031390 S. Dixie Hwy, Suite 1305Coral Gables, FL 33145Ofc: 305-669-3605 Fax: [email protected]
Psychotherapy Bulletin EditorLinda F. Campbell, Ph.D., 2001-2003University of Georgia402 Aderhold HallAthens, GA 30602-7142Ofc: 706-542-8508 Fax:[email protected]
Internet EditorAbraham W. Wolf, Ph.D., 2002-2004Metro Health Medical Center2500 Metro Health DriveCleveland, OH 44109-1998Ofc: 216-778-4637 Fax: [email protected]
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EDITORLinda Campbell, Ph.D.
CONTRIBUTING EDITORS
Washington ScenePatrick DeLeon, Ph.D.
Practitioner ReportRonald F. Levant, Ed.D.
Education and Training CornerJeffrey A. Hayes, Ph.D.
Professional LiabilityLeon VandeCreek, Ph.D.
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Psychotherapy ResearchClara E. Hill, Ph.D.
Student CornerAnna McCarthy
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PSYCHOTHERAPY BULLETINOfficial Publication of Division 29 of the
American Psychological Association
Volume 38, Number 2 Summer 2003
CONTENTSResearch Corner ......................................................2
Student Column ......................................................7
Call for Nominations ..............................................8
Feature: Could the Titanic Disaster Have Been Prevented? ........................................9
Practitioner Report ................................................13
Division 29 Program – 2003 APA Convention ..15
Feature: Medical School Training, PatientSafety, and Prescriptive Authority forPsychologists ......................................................20
Washington Scene ..................................................26
Feature: Reactions to Segal, Williams & Teasdale’s Mindfulness-Based CognitiveTherapy for Depression ....................................27
Mark Your Calendars ............................................29
Tenth Annual Rosalee G. Weiss Lecture ............30
APA Membership Application ............................56
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Sarah Knox, Ph.D., is an Assistant Professor inthe Department of Counseling and EducationalPsychology at Marquette University. Shereceived her doctorate in CounselingPsychology from the University of Maryland in1999. Her research focuses on the therapy rela-tionship. Correspondence concerning this arti-cle should be sent to Sarah Knox, Ph.D.,Department of Counseling and EducationalPsychology, School of Education, MarquetteUniversity, Milwaukee, WI, 53201. Electronicmail may be sent to [email protected].
“You know, I was spending time with my fam-ily the other day, and we were all getting backinto our old nasty patterns, but instead of feel-ing upset and responding bitterly as I usuallydo, I heard your calming voice and felt you withme, and I was able to get through the situationwithout getting hurt.”
It is not uncommon for therapists to hearsuch words from clients. Therapists may,in fact, consider such statements an indica-tion that therapy is succeeding and thatclients are learning to translate what theyexperience and learn in therapy to theirlives outside the therapist’s office. Suchstatements reflect a phenomenon referredto as an internal representation, defined asclients bringing to awareness the internal-ized “image” (occurring in visual, audito-ry, felt presence, or combined forms) oftheir therapists when not actually withthem in sessions, and thereby evoking theliving presence of the therapist as a person(Knox, Goldberg, Woodhouse, & Hill,1999). Through their internalizations,clients continue the work of therapybetween, and perhaps more importantly,beyond therapy sessions.
In this short article, I will briefly mentionexisting theory and research regardingclients’ internal representations of theirtherapists, include some clinical examplesto try to bring the phenomenon to life onthe written page, and finally offer somethoughts about how these representationsmay be used in the service of therapy.
Theorists assert that clients’ internal repre-sentations are critical to the healingprocesses of therapy, and that clients’improvement may be related to the extentto which they are able to evoke representa-tions of the benignly influential compo-nents of the therapy relationship(Rosenzweig, Farber, & Geller, 1996), suchas the therapist her-/himself. Some writ-ers further posit that many of the mostimportant experiences that occur in thera-py are those that foster the creation of thesebenevolently influential and enduring rep-resentations of the therapist (Dorpat, 1974;Edelson, 1963; Geller, 1984; Horwitz, 1974;Kohut, 1971, Loewald, 1960; Schafer, 1968;Strupp, 1978). Once created, clients’ inter-nal representations may function as theunassigned “homework” of therapy, aswell as the psychological connective tissuebetween successive sessions (Orlinsky,Geller, Tarragona, & Farber, 1993), whereinclients continue between sessions to workon what they address in sessions. Just asathletes or musicians may improve by con-tinuing to work on their activities betweenpractices or lessons, so, too, might clients’growth and healing be enhanced by suchbetween-session processes. Clients’ inter-nal representations of their therapists maythus serve important functions outside ofthe therapy office.
RESEARCH CORNER
I Sensed You With Me the Other Day: A Review of theTheoretical and Empirical Literature on Clients’ InternalRepresentations of Therapists
Sarah KnoxMarquette University
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Extant empirical research supports thesetheoretical positions, indicating that inter-nal representations may indeed be helpfulto clients. In the Knox et al. (1999) study,for example, the majority of the partici-pants (i.e., 13 adults in individual psy-chotherapy who were interviewed using asemi-structured qualitative protocol) indi-cated that they felt positive emotions (i.e.,calm, comfort, focus, grounding) whenexperiencing their internal representationsof their therapists. In addition, theserespondents reported that their representa-tions largely had salutary effects on thetherapy (i.e., the experience of the repre-sentations benefited or accelerated therapyand/or the therapy relationship). Further-more, most of the participants stated thatthey used their representations for intro-spection, and also as “between sessionmini-sessions.” Similarly, Wzontek, Geller,& Farber (1995) found that self-perceivedimprovement in therapy was positivelyrelated to the participants’ tendency to usetheir representations to continue the thera-peutic dialogue outside of sessions, as wellas post-termination. With respect to wheninternal representations may occur, Gellerand Farber (1993) found that clients’ repre-sentations were most likely to be evokedoutside of therapy when painful emotionswere experienced (e.g., sadness, anxiety,depression, guilt, fear, stress, self-hate).Calling upon these benign internal repre-sentations of the therapist in such circum-stances may, then, help clients get throughdifficult events.
To bring this phenomenon more clearly intofocus, what follows are some examples ofinternal representation experiences thatactual clients have reported. Rosen (1982)described two powerful examples of theinternal representations experienced bypatients of Milton H. Erikson. In the firstcase, a patient felt too embarrassed to tellErikson of a problem in a face-to-faceencounter. Instead, she drove to his house,parked in his driveway, and evoked hispresence with her in the car. This enabledthe patient to think her way through herproblem. In the second example, a patient
wished to take the therapist and zip her upinside of the client’s body, certainly apoignant means of holding on to the pres-ence of the therapist. Reflecting the functionthese representations may serve betweensessions, Kantrowitz, Katz, and Paolitto(1990) reported the words of one client asfollows: “It [the client’s internal representa-tion of the therapist] was like a continuationof the [therapy]. I mean that was part of theway I would think about myself—sort ofimagine myself being [in the consultationroom], and what would happen there, andhow I would think” (p. 643).
As additional examples, Knox et al. (1999)reported a variety of client internal repre-sentational experiences. In one example, aclient saw her therapist’s “penetratingeyes” pulling the client to do what shefeared, and saw the therapist’s smile whenthe client succeeded in facing her fears.Another client reported imagining her ther-apist extending her arms to the client,pleading with her to come for help whenthe client considered self-mutilation. Athird client described his internal represen-tations as more dream-like, as non-literalimages of the therapist in which the clientexperienced his therapist, similar to aDisney cartoon or medieval paintingdepicting angels and devils, sitting on theclient’s shoulder. Finally, Knox et al. (1999)reported the case of a client who, when hehad what felt like a breakthrough at workwith a challenging colleague, immediatelyfound himself, through his internal repre-sentation, envisioning himself talking tohis therapist to reinforce what had beendiscussed in therapy.
As these examples demonstrate, clients dofind internal representations of their thera-pists helpful, and use them to continue theprocesses of therapy outside of sessions.How, then, can therapists attend to clients’internal representations in the service oftherapy? One idea is simply for therapiststo broach the topic of internal representa-tions with clients. In the Knox et al. (1999)study, several clients indicated during theirinterviews that although their internal rep-
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resentations were ultimately helpful, theclients were nevertheless uncomfortableabout having such experiences, fearing thattheir presence indicated abnormality,dependency, or pathology. As a result, theshame and embarrassment many reportedfeeling were alleviated simply by recogniz-ing, via their participation in the study, thatsuch experiences are not inherently patho-logical, but instead are relatively commonoccurrences in the psychotherapy process.Because the clients themselves were notcomfortable discussing their representa-tions with their therapists (few in this studyreported having such discussions with theirtherapists), it may well be the therapists’responsibility to open this up as a topic ofdiscussion. Such discussions may thus nor-malize the presence of the representations,thereby allaying clients’ shame, embarrass-ment, and fear. Given the strong positiveuse and impact of their internal representa-tions that clients have reported, even in thepresence of some shame or embarrassment,might not even more beneficial effects arisewithout such fears?
Once clients’ qualms about having internalrepresentations of their therapists arereduced, it may also be beneficial to engagein a full discussion of the representationsthemselves: What form do they take (i.e.,auditory, visual, felt presence, combined)?What triggers them? How often they occurand how long do they last? How do clientsuse them and what effect do they have onclients? What affect is associated withthem? How do they change over time?Through such discussions, therapists andclients may come to understand the func-tion the representations hold for clients,functions that may yield clues for enhanc-ing the therapy itself. If, for example, aclient’s representations are primarily visu-al, yet traditional talk therapy relies on ver-bal exchanges of information, therapistsmay want to think about alternative inter-ventions they may use to better attend to aclient’s visual way of processing his/herexperiences (e.g., visual imagery). If therepresentations seem to occur only at par-ticular times, or in particular situations,
this may give clues as to when clients maybe most in distress. Likewise, if the fre-quency of internal representations sudden-ly increases or decreases, these changesmay signal some alteration in the client’swell being and/or in the therapy relation-ship. Or if the reasons clients invoke theirrepresentations change over time, suchchanges may indicate that clients haveresolved some issues but may still be strug-gling with other, as yet unresolved, issues.These are but a few of the many importantquestions therapists may wish to askregarding clients’ internal representationsof therapists.
It may be that therapists occasionally wishto proceed even further with regard toclients’ internal representations. As foundin the Knox et al. (1999) study, most thera-pists took no deliberate role in suggestingto their clients that they use internal repre-sentations. It is possible, though, that somecircumstances might call for a therapist’smore active invocation of such representa-tions. A client in the Knox et al. (1999)study, for instance, expressed a wish thather therapist would provide her with par-ticular statements that she could use tocalm herself. One of my colleagues tooksuch an action with a client, with reported-ly positive effect: Her client was experi-encing significant distress, having difficul-ty even grounding herself to present reali-ty. The colleague literally wrapped herarms around the client and held her for afew seconds. She then told the client toremember that feeling when the client feltthat she was losing her grasp on reality.
Thus, in the same way that a transitionalphysical object may prove comforting to aclient in distress, being able to evoke spe-cific therapist words, images, or presencemay likewise be helpful when clients faceparticularly troubling situations. Imagine,for example, clients who are prone to panicattacks when in crowds. Might it be help-ful for the therapist to provide specificwords clients could say to calm themselvesat such times? Or might clients find ithelpful to be invited to recall the therapist’s
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comforting face when the former faces dis-tressing events? Or as in the case citedabove, to recall the therapists’ physicalpresence as a source of grounding and sup-port? Important discussions of clients’internal representations of therapists may,then, have several functions: to normalizethe experience of representations, toexplore their phenomenology and mean-ing, and to deliberately invite clients to usesuch representations in times of need.
There also exist ample opportunities for fur-ther research of this phenomenon. As acomplement to our present knowledge, forinstance, it would be helpful to know thera-pists’ perspectives on clients’ internal repre-sentations. Secondly, is there any connectionbetween client diagnoses and internal repre-sentations? Or between attachment styleand internal representations? In addition,tracking the evolution of clients’ representa-tions over the course of therapy may yielduseful information about change processes:Are such changes, for example, associatedwith any parallel changes in psychologicalfunctioning? These are only a few of themany provocative questions that could bepursued in our efforts to understand, andthus better serve, our clients.
REFERENCES
Dorpat, T. L., (1974). Internalization of thepatient-analyst relationship in patientswith narcissistic disorders. InternationalJournal of Psycho-Analysis, 55, 183-188.
Edelson, M. (1963). The termination of inten-sive psychotherapy. Springfield: CharlesC. Thomas.
Geller, J. D. (1984). Moods, feelings, andthe process of affect formation. In C. VanDyke, L. Temoshok, & L. S. Zegans(Eds.), Emotions in health and illness:Applications to clinical practice. Orlando,FL: Grune and Stratton.
Geller, J. D., & Farber, B. A. (1993). Factorsinfluencing the process of internaliza-tion in psychotherapy. PsychotherapyResearch, 3, 166-180.
Horwitz, L. (1974). Clinical prediction inpsychotherapy. New York: Jason Aronson.
Kantrowitz, J. L., Katz, A. L., & Paolitto, F.(1990). Follow-up of psychoanalysis fiveto ten years after termination: II.Development of the self-analytic func-tion. Journal of the American Psycho-analytic Association, 38, 637-654.
Knox, S., Goldberg, J. L., Woodhouse, S., &Hill, C. E. (1999). Clients’ internal rep-resentations of their therapists. Journalof Counseling Psychology, 46, 244-256.
Kohut, H. (1971). The analysis of the self.New York: International Universities Press.
Loewald, H. W. (1960). On the therapeuticaction of psychoanalysis. InternationalJournal of Psycho-Analysis, 41, 16-33.
Orlinsky, D. E., Geller, J. D., Tarragona, M.,& Farber, B. A. (1993). Patients’ repre-sentations of psychotherapy: A newfocus for psychodynamic research.Journal of Consulting and ClinicalPsychology, 61, 596-610.
Rosen, S. (1982). My voice will go with you:The teaching tales of Milton H. Erikson.New York: Norton.
Rosenzweig, D. L., Farber, B. A., & Geller, J. D.(1996). Clients’ representations of theirtherapists over the course of psycho-therapy. Journal of Clinical Psychology, 52,197-207.
Schafer, R. (1968). Aspects of internalization.New York: International Universities Press.
Strupp, H. H. (1978). The therapist’s theo-retical orientation: An overrated variable.Psychotherapy: Theory, Research andPractice, 15, 314-317.
Wzontek, N., Geller, J. D., & Farber, B. A.(1995). Patients’ posttermination repre-sentations of their psychotherapists.Journal of the American Academy ofPsychoanalysis, 23, 395-410.
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Durriya received her Doctorate in Psychologyfrom Wright State University, Ohio. Beforestarting her doctoral program, she worked as alecturer at North South University where sheestablished the first counseling center in thehistory of the country. Her clinical work hasfocused on issues of diversity and violenceagainst women (especially South Asianwomen), multicultural issues, and providingservices to communities of color andinternational students for which she has wonawards. Originally from the state of Gujarat(India), Durriya grew up in Bangladesh andhas spent almost 10 years of her life in the USAand Canada. She is fluent in Gujarati, Bengali(Bangla), and Hindi; and speaks French andUrdu as well.
ABSTRACT
Acid violence, in which nitric or sulfuricacid is thrown at the victim at very closerange, causes the skin to melt and fusetogether, leaving the bones exposed. Thescarring and disfigurement are permanent,often resulting in a loss of basic functions,such as vision, hearing, use of limbs, etc.Females are the primary targets, for refus-ing the advances of a predatory male, fam-ily disputes, vengeance, or dowrydemands. Acid violence has received widescale recognition only in the past few yearsbecause it has generally been considered tobe a “third-world” country problem. Acidattacks against women have been docu-mented in several countries around theworld. However, such attacks have seen analarming rise in Bangladesh over the pastfew years. One reason for such an increaseis the easy availability of acid. A secondreason is the corrupt legal, judicial andpolitical systems that allow such violence
to go unchecked. Like other forms of vio-lence against women, acid violence cannotbe treated as separate from the global con-text within which violence against womenoccurs. That there is interplay betweengender and violence in most cultures isindisputable and therefore, an understand-ing of the historical context of a female’sstatus within that culture is critical.
In the traditional, conservative cultures ofmost South Asian countries (for the pur-pose of this paper only India, Pakistan andBangladesh have been considered becauseof their shared sociopolitical, cultural andreligious histories), women today are atbest secondary citizens or at worst, non-cit-izens. This is in contrast to the contentionthat many historians make about the highstatus that women occupied in SouthAsian, specifically Indian, society ofancient times. It is asserted that a multi-tude of factors, including politicalupheavals and shifts in religious domi-nance, eventually led to the decline in thestatus of the South Asian female to theposition that she occupies today.Moreover, the dominance and acceptanceof a single religion as a way of life, whetherit is Hinduism or Islam, means that manyforms of violence may be believed to becondoned by the religion itself. A compre-hensive understanding of this form of vio-lence requires that it be examined withinthe realm of cultural, religious, social, andgender norms. Case studies of survivors ofacid attacks in Bangladesh highlight theemotional and psychological consequenceson the victim and her family. Lack of ade-quate medical facilities has resulted inmany survivors being sent abroad for treat-ment, sponsored by international organiza-
STUDENT PAPER DIVERSITY AWARD
Twentieth Century Barbarism: Culture, Gender and Acid ViolenceDurriya Meir
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tions such as the United Nations. However,once abroad, survivors are faced withadjusting to a new culture with little or nosupport. Moreover, social isolation due tolanguage barriers and the prospect of pro-longed medical treatment in a foreign coun-try intensify the emotional and psychologi-cal trauma. Survivors are often faced with adouble bind — if they seek political asylum,they risk negatively affecting other sur-vivors’ chances of being sent abroad fortreatment; on the other hand, if they return,they risk being re-victimized. Moreover, thelack of systematic and well-established psy-
chological services means that there are lit-tle or no resources to help survivors re-adjust to the society. Their only sources ofsupport are their families and informal net-works of non-governmental and/orwomen’s organizations. Implications fortherapy, which is often considered a neces-sary part of survivors’ psychosocial andemotional rehabilitation, are addressed inlight of the lack of awareness about thisform of violence, including the social andpolitical context within which they takeplace. Cultural considerations in treatingvictims are discussed.
CALL FOR NOMINATIONS
DIVISION 29 FELLOWS
Deadline for nominations:September 15, 2003.
Deadline for receipt of all application materials:October 15, 2003.
Letters of nomination and requests for application materialsshould be sent to:
Roberta L. Nutt, Ph.D.Division 29 Fellows Chair
Department of Psychology & PhilosophyP. O. Box 425470
Texas Woman’s UniversityDenton, TX 76204-5470
(940) [email protected]
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On April 14, 1912, 1,503 passengers andcrew members on the HMS Titanic died inthe most publicized maritime disaster of alltime. However, on at least four crucialpoints the disaster could have been avertedor at least greatly ameliorated. Three ofthese four points were characterized by alack of communication.
First, ships of that era traditionally hadseveral water tight compartments at theirbottoms. In the event of a puncture belowthe water level, one compartment could fillup with water, but the others would be freeof water and keep the ship afloat.However, the Harland and Wolff companydid not build such traditional water tightcompartments in the Titanic and when theiceberg punctured the Titanic below thewaterline its entire bottom filled withwater and it sank.
Second, the White Star Line, which ownedthe Titanic, put on life boats for only one-third of the passengers. The owner of theline, J. Bruce Ismay, was so confident of theimpregnability of the Titanic that hethought lifeboats were unnecessary. Thecrew was not even trained in the use of thelifeboats that they did have; otherwise routine drills with lifeboats never occurred.
Third, the Titanic’s wireless operators hadbeen instructed to give priority to the socialmessages of its wealthy passengers.Consequently, the wireless operators wereso busy sending outgoing social messagesthat they did not receive all of the incomingtelegraph messages warning of icebergsightings in the vicinity. Unaware of the ice-berg danger, Captain Edward Smith orderedthe Titanic to go full speed through icebergterritory in hopes of breaking the world’s
record for crossing the Atlantic. If the Titanichad been going more slowly, the pilotsmight have seen the iceberg in time andmissed it entirely (as it was, the iceberg bare-ly scraped the Titanic, but enough to leave agash along its side below the water level).
Finally, the USS California, which was with-in only a few miles of the Titanic when itstruck the iceberg, could have saved every-one if it had responded promptly to theTitanic’s distress flares. However, one hourbefore the Titanic struck the iceberg, theCalifornia’s authoritarian Captain StanleyLord had ordered his crew to shut downthe telegraph post and to not disturb himfor any reason. When his sailors saw theflares from the Titanic, they chose to inter-pret them as routine communicationsbetween ships and dared not wake CaptainLord to solicit his opinion (Lord, 1955).
Who is to blame for the disaster? Was it theHarland and Wolff Company, J. BruceIsmay and the White Star Line, CaptainEdward Smith and the telegraph operatorson the Titanic, or Captain Stanley Lord ofthe USS California? In reality each of themshares some portion of the responsibilityfor the loss of life.
However, it could be asked why systemswere not in place to ensure adequate pre-cautions? Why weren’t Harland and Wolffrequired to build their ships appropriately?Why wasn’t the White Star Line requiredto place a sufficient number of life boats onits ships? Why wasn’t the crew trained inusing them? Why was the Titanic allowedto sail in iceberg-infested water withoutthe ability to receive communicationsthrough the telegraph? Why was CaptainStanley Lord allowed to give orders that
FEATURE
Could the Titanic Disaster Have Been Prevented?The Relevance of Patient Safety to Psychological Practice1
Samuel Knapp, Ed.D.Leon VandeCreek, Ph.D.
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prevented his crew from notifying him ofthe distress signals?
A systems perspective has been used toinvestigate and understand other disasterssuch as Three Mile Island, Chernobyl, andairplane crashes. Recently this perspectivealso has been used to evaluate seriouserrors in the treatment or management ofhospital patients, especially in regard tomedication errors. This article reviews thebasic principles of the systems-basedpatient-safety movement and identifies itsrelevance to the practice of psychology,especially in outpatient settings.
MEDICAL ERRORS
According to the Institute of Medicine(1999), between 44,000 and 98,000 patientsdie each year because of medical errors,including a substantial number from med-ication errors. According to some statistics,medical errors are the eighth leading causeof death in the United States. Althoughsome believed that the Institute of Medicinereport overestimated the amount of harmdone by medical errors, general consensusexists that efforts should be taken to reducethe frequency of those errors.
A medical error is defined as any mistakethat substantially harms or creates a realis-tic threat of harming the safety of a patient.Many medical errors involve medicationsand include prescribing or delivering thewrong medication or the wrong dose ofmedication. Other errors include mistakesby laboratories (e.g., the wrong name issubmitted with a blood vial), a patientbeing given an improper diet, surgery con-ducted on the wrong body part, infantabduction or the discharge of an infant tothe wrong family, and failure to provideadequate monitoring to a patient who issuicidal or homicidal.
Some medical errors are the result of inten-tional acts that involve patient abuse ortreatment of a patient by a practitionerwho is under the influence of alcohol oranother drug. However, most of the errors
are related to systematic communicationfailures. For example, a nurse or pharma-cist may misinterpret the medicationabbreviation used by the physician; a resi-dent may be afraid to express her doubts orconcerns to the attending physician; andpatients are not given the opportunity toexpress their distress or symptoms clearlyto their caregivers.
State governments and the JCAHO are tak-ing actions to reduce medical errors.JCAHO has developed the “sentinel” pro-gram by which they will require agenciesthat they accredit to report medical errors.A sentinel event “is an unexpected occur-rence involving death or serious physicalor psychological injury, or the risk thereof”(Sentinel Event Policy and Procedures,2000, p. 1).
States have varied in how they haveresponded to the problem of medicalerrors; some states have developed man-dated reporting systems for medical errors.The federal Agency for HealthcareResearch and Quality (AHRQ) has beenawarding research grants directed atstudying ways to prevent medical errors.Congress has been considering federal leg-islation to address the problem of medicalerrors; however, no legislation has beenenacted yet.
Research about medical errors is on-going,but many recommendations have beenmade, many of them dealing with enhanc-ing the communication that occurs amonghospital staff. For example, JCAHO hasmade several recommendations concern-ing patient safety such as requiring stan-dardized abbreviations, acronyms, andsymbols throughout the organization(including a list of abbreviations, acronymsand symbols not to be used).Organizations that fail to follow these rec-ommendations could be sited for a viola-tion in their accreditation report.
RELEVANCE TO PSYCHOLOGY
What relevance does the patient safety lit-erature have for the practice of psychology?
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Obviously it applies to psychologists whowork in hospitals or other institutions, butthe basic principles of patient safety applyto outpatient psychologists as well.
The optimal manner by which to reduceerrors is to develop a “culture of safety” inwhich the welfare of patients becomeseveryone’s business. According to an edi-torial in the Journal of the American MedicalAssociation, the prevention of medicalerrors requires a “culture of trust, honesty,integrity and open communications amongpatients and providers in the health caresystem” (Lenape et al., 1996, p. 1445). Wesuggest that psychologists can foster theculture of safety by striving for enhancedcommunications not only with the patientbut with others involved in the welfare ofthe patient (such as other health careproviders or family members), and theiroffice staff, and that they embed them-selves in a protective network of trustedcolleagues.
Of course, it is essential to develop a trust-ing relationship with patients (or whenclinically indicated, the patients’ families)who will share information essential fortreatment. However, patient welfare alsorequires that psychologists work closelyand share information with physicians andother health care professionals who areworking with the patient. For example,medical errors can occur when physiciansdo not receive accurate information frompsychologists about their mutual patients.Physicians need to know how the patient isresponding to medications or if the patientis taking other medications, over-the-counter drugs, or alternative herbal reme-dies that could compromise the effective-ness of a prescription drug, or otherwisejeopardize patient safety. Unfortunately,many patients do not tell their physiciansabout their use of alternative medicalremedies (Defino, 2000).
Second, psychologists need to keep chan-nels of communications open with mem-bers of their office staff and supervisees.Staff members and supervisees need to feel
free to bring issues to the attention of theirsupervisors/psychologists. Busy psycholo-gists can sometimes give a “CaptainStanley Lord” impression that they do notwant to be bothered.
Finally, psychologists can embed them-selves in a protected network where theyreceive regular feedback from colleaguesand associates concerning their perfor-mance. They can receive on-going consul-tation on cases where knowledgeable asso-ciates can give them feedback on their gen-eral style of therapy. They can learn aboutemerging techniques in the field.Sometimes these are called “peer supervi-sion” groups (this is probably a misnomer;peer consultation is a better term).Sometimes they are called journal clubs.
An underlying principle in quality treat-ment is for psychologists to place them-selves in an environment that reinforcesdesired behaviors that promote patientwelfare. “Make your environment work foryou, not against you” (Norcross, 2000, p.711). The environment should provide aconsistent feedback loop whereby the out-comes and procedures are consistentlybeing reviewed and modified. The variousforms of external feedback include, but arenot limited to, consulting with peers, gath-ering systematic data on patient outcomesor satisfaction, receiving reviews of profes-sional notes, engaging in informal conver-sations with colleagues, and participatingin continuing education programs.
CONCLUSION
If they could have done it over again,Harland and Wolff would have built theTitanic differently, the White Star Linewould have had a sufficient number of lifeboats aboard, the crew would have knownhow to operate the lifeboats, CaptainEdward Smith would have ordered theTitanic to slow down and to keep its tele-graph post open to receiving iceberg warn-ings, and Captain Stanley Lord wouldhave sent the California to the rescue. Eachone of these participants could point thefigure of blame at someone else. In reality,
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however, each one of them could have pre-vented or ameliorated the disaster.
Just like the participants in the Titanic dis-aster, all health care professionals have aresponsibility to anticipate and preventtragedies. We need to promote a “cultureof safety” characterized by open communi-cation and cooperation with the patient,other health care providers, and membersof our staff. We also need to promote a“culture of safety” when we embed our-selves in a protective social network.Patient welfare requires nothing less.
REFERENCES
Defino, T. (2000, February 24). Use amongcancer patients high: But physicians often aren’t told. WebMD Medical News.
Institute of Medicine. (1999). To err ishuman: Building a safer health system.Washington, DC: National AcademyPress.
Lenape, L., Woods, D., Hatlie, M., Kizer, K.,Schroeder, S., & Lundberg, G. (1998).Promoting patient safety by preventingmedical error. Journal of the AmericanMedical Association, 280, 1444-1447.
Lord, W. (1955). A night to remember. NewYork: Henry Holt.
Norcross, J. (2000). Psychotherapist self-care:Practitioner-tested, research-informedstrategies. Professional Psychology: Theory,Research, and Practice, 31, 710-713.
1 A portion of this article has been adapted,with permission of the PennsylvaniaPsychological Association, from a previousarticle published in the PennsylvaniaPsychologist.
Find Division 29 on the Internet. Visit our site atwww.divisionofpsychotherapy.org
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Ronald F. Levant, Ed.D., A.B.P.P., is a candi-date for APA President. He is in his secondterm as Recording Secretary of the AmericanPsychological Association. He was the Chair ofthe APA Committee for the Advancement ofProfessional Practice (CAPP) from 1993-95 , amember of the Board of Directors of Division 29(1991-94), a member at large of the APA Boardof Directors (1995-97), and APA RecordingSecretary (1998-2000). He is Dean, Center forPsychological Studies, Nova SoutheasternUniversity, Fort Lauderdale, FL.
From my current vantage point as both adean of a graduate school of psychologyand an officer of the AmericanPsychological Association, I have a uniqueopportunity to reflect on the evolution ofprofessional psychology. The scope of psy-chological practice is expanding and diver-sifying into new areas—areas where thedistinction between applied scientist andprofessional practitioner begins to blur—such as health psychology (and its relatedaspects such as psychology in primarycare, psychoneuroimmunolgy, and appliedpsychophysiology), neuropsychology,rehabilitation psychology, forensic psy-chology, child and family psychology, mul-ticultural psychology, geropsychology,business and industry consultation, andpsychopharmacology. It cannot be empha-sized enough that the future evolution ofprofessional psychology will entail thedevelopment of roles that do not nowexist—in health care, public sector care, thecourts, the correctional system, schools,businesses, etc.—in the numbers that psy-chologists entered the role of outpatienttherapists in the 1970s and 80s.
In this column I want to highlight the newopportunities for expanding the roles ofprofessional psychologists in psychologi-cal health care. I will first discuss the rede-finition of psychology from specialty men-tal health care to primary health care andthen take up the psychological manage-ment of disease and health.
REDEFINITION: FROM SPECIALTYMENTAL HEALTH CARE TO PRIMARYHEALTH CARE
One of the most important aspects of theevolving nature of professional practice: isthe redefinition of psychology from spe-cialty mental health care to primary healthcare. As a specialty profession of mentalhealth care, we deal primarily with thepeople who self-identify as having psycho-logical problems and who have access to amental health specialist, which is just afraction of those who need psychologicalservices. As a primary health care profes-sion we would be able to serve the muchlarger group of people who do not haveaccess to mental health care or who do notidentify their problem as psychological. Tograsp this potential, please consider a fewfacts about health care: (1) The U.S.Department of Health and Human serviceshas pointed out the seven top health riskfactors—tobacco use, diet, alcohol, unin-tentional injuries, suicide, violence, andunsafe sex—are behavioral; (2) Seven outof the nine leading causes of death havesignificant behavioral components; (3) Atleast 50% (and maybe as much as 75%) ofall visits to primary care medical personnelare for problems with a psychological ori-gin (including those who present withfrank mental health problems and thosewho somaticize) or psychological compo-nent (including those with unhealthy
PRACTITIONER REPORT
Psychological Health Care1
Ronald F. Levant, Ed.D., MBA, ABPPNova Southeastern UniversityAPA Recording Secretary
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lifestyle habits such as smoking, those withchronic illnesses, and those with medicalcompliance issues); (4) .Moreover, there is agrowing body of empirical evidence sup-porting the effectiveness of psychologicalinterventions in ameliorating a wide rangeof physical health problems, includingboth acute and chronic disease affecting lit-erally every organ system and encompass-ing pediatric, adult and geriatric popula-tions. In addition to being clinically effec-tive, these interventions are dramaticallyless expensive than alternative somaticinterventions across a wide variety of ill-nesses and disorders, including cardiovas-cular disease, diabetes, traumatic braininjury, etc. (5) The vast majority of peoplereceiving mental health treatment arecared for by medical professionals withminimal specific training in mental health.
The Cartesian world view, which separatesmental health from physical health, isbreaking down, and as a result psychologyhas a tremendous opportunity to evolveinto a premier primary health care profes-sion. At the very least this would put psy-chologists on the front lines of health care,working collaboratively with physiciansand nurses. The more visionary perspec-tive is that health care should be reorga-nized so that psychologists serve as prima-ry caregivers at the gateway to the healthcare system, functioning to diagnose andtreat the more prevalent psychologicalproblems, and referring to medical physi-cians when indicated.
PSYCHOLOGICAL MANAGEMENT OFDISEASE AND HEALTH
Over the past several years, it has been aconsistently predicted that psychology’spotential contribution to the prevention,assessment, treatment, and management ofacute and chronic illnesses will play animportant role in the future developmentof the profession. Much of the work inhealth psychology—and a significantopportunity for the field of psychology ingeneral—focuses on behavioral contribu-tors to health and disease.
Moreover, as noted, psychological inter-ventions are effective and cost-effective inameliorating a wide range of physicalhealth problems. For example, data regard-ing the efficacy and cost-effectiveness ofpsychological interventions for chronicpain are so compelling that the NationalInstitutes of Health (NIH) published a con-sensus statement calling for wider accep-tance and use of behavioral treatments inconjunction with typical medical care(NIH, 1995). In primary care settings, med-ical utilization can be substantially reducedthrough the availability of behavioral inter-ventions. Total ambulatory care visits havebeen shown to decrease an average of 17percent, with even greater reductionswhen visits for specific illnesses such asasthma (49 percent) and arthritis (40 per-cent) are tracked (Sobel, 1994).
All of this suggests a huge potential marketfor psychological services in health caresystems. In order to access these opportu-nities, however, psychology must defineitself as a health profession rather than as amental health profession. In fact, the APABoard of Professional Affairs Work Groupon Expanding the Role of Psychology inthe Health Care Delivery System hasrecently called for a “figure-ground rever-sal” in professional psychology (APA,2000). That is, rather than viewing itself asa mental health profession with health psy-chology representing a subset of its exper-tise, the group advocated a view of psy-chology as a health profession, with mentalhealth as a subset of its expertise.
Psychologists’ core skills in assessmentand treatment can be integrated with rolesin supervision, administration, programdesign, program evaluation, and research.As a consequence, psychologists areuniquely positioned to assume a greaterrole in the management of both health anddisease. Potential functions include coor-dinating complex interventions, assistingpatients to evaluate and select among treat-ment options, helping people to make nec-essary lifestyle changes and to complywith complex and difficult treatment regi-mens, and providing treatment for coexist-
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Symposium: Current Perspectives andFuture Directions for Treating PersonalityDisorders8/07 Thu: 11:00 AM – 12:50 PMMetro Toronto Convention Centre,Constitution Hall 105ChairJeffrey J. Magnavita, PhD, University ofHartfordParticipant/1stAuthorJudith S. Beck, PhD, University ofPennsylvaniaTheodore Millon, PhD, Institute for theAdvanced Studies of Personology andPsychopathology, Coral Gables, FLFrancine Shapiro, PhD, Mental ResearchInstitute, Palo Alto, CALorna S. Benjamin, PhD, University ofUtah
Conversation Hour: Getting It Right—Legends Albert Ellis (90) and Aaron T.Beck (82) in Conversation With FrankFarley8/07 Thu: 1:00 PM – 1:50 PMMetro Toronto Convention Centre,Constitution Hall 105ChairFrank Farley, PhD, Temple UniversityParticipant/1stAuthorAlbert Ellis, PhD, Albert Ellis Institute, NewYork, NYAaron T. Beck, MD, University ofPennsylvania
Workshop: Enhancing PsychotherapyTraining and Supervision With Computer Technology8/07 Thu: 1:00 PM – 2:50 PMMetro Toronto Convention Centre, MeetingRoom 203BCo-chairsKenneth L. Miller, PhD, Youngstown StateUniversityDon Martin, PhD, Youngstown StateUniversity
Participant/1stAuthorJoLynn V. Carney, PhD, Youngstown StateUniversityJan Gill-Wigal, PhD, Youngstown StateUniversityVictoria E. White, PhD, Youngstown StateUniversitySherry A. Gallagher-Warden, PhD,Youngstown State UniversityStephanie J. Ford, PhD, Youngstown StateUniversity
Symposium: Role of Emotional Processesin Dysfunctional Behaviors8/07 Thu: 3:00 PM - 3:50 PMMetro Toronto Convention Centre, MeetingRoom 714AChairJeanne C. Watson, PhD, University ofToronto, NONE, ON, CanadaParticipant/1stAuthorGoldie M. Millar, PhD, University ofToronto, NONE, ON, CanadaTitle: Portrayal of Emotion WithinSubstance Dependence: Arguing forChangeFiona Downie, MEd, University of Toronto,NONE, ON, CanadaTitle: Disordered Eating and EmotionalExpression: Self-Silencing ConsideredLisa A. Berger, MEd, University of Toronto,NONE, ON, CanadaTitle: Role of Emotional Processing in Self-Harm Behavior
Symposium: EMDR (1989—2002)—-Update of Sociopolitical, Research, andClinical Implications8/08 Fri: 8:00 AM - 9:50 AMMetro Toronto Convention Centre,Constitution Hall 105ChairByron R. Perkins, PsyD, NONEParticipant/1stAuthorByron R. Perkins, PsyD, NONETitle: EMDR: An Overview
DIVISION 29 PROGRAM - 2003 APA CONVENTION
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Nancy J. Smyth, PhD, State University ofNew York at BuffaloTitle: Role of Exposure in EMDR Treatmentof PTSDSusan Rogers, PhD, VA Medical Center,Coatsville, PATitle: Latest Findings in EMDR ProcessResearch and Component AnalysisJohn C. Norcross, PhD, University ofScrantonTitle: Sociopolitical and PsychohistoricalFactors in Acknowledging the Effectivenessof EMDRDiscussantFrancine Shapiro, PhD, Mental ResearchInstitute, Palo Alto, CALarry E. Beutler, PhD, Pacific GraduateSchool of Psychology
Conversation Hour: Albert Ellis at 90—-AConversation With Frank Farley8/08 Fri: 2:00 PM - 2:50 PMMetro Toronto Convention Centre,Constitution Hall 106ChairFrank Farley, PhD, Temple UniversityParticipant/1stAuthorAlbert Ellis, PhD, Albert Ellis Institute, NewYork, NY
Symposium: Dual Perspectives on DualRelationships—-Critical Incidents inNonsexual Boundaries8/08 Fri: 3:00 PM - 4:50 PMMetro Toronto Convention Centre,Constitution Hall 105ChairJohn C. Norcross, PhD, University ofScrantonParticipant/1stAuthorArnold A. Lazarus, PhD, Rutgers the StateUniversity of New Jersey, Princeton, ZZGerald P. Koocher, PhD, Simmons CollegeOfer Zur, PhD, Independent Practice,Sonoma, CAEric Harris, EdD, JD, APA Insurance Trust,Lincoln, MDPLEASE NOTE: THIS SYMPOSIUM HAS BEENCANCELLED
Social Hour 8/08 Fri: 6:00 PM - 7:50 PMCrowne Plaza Toronto Centre Hotel,Ontario Room
Symposium: Real Relationship inPsychotherapy—-Theoretical Foundationsand Measurement8/09 Sat: 8:00 AM - 8:50 AMMetro Toronto Convention Centre, MeetingRoom 715AChairCheri L. Marmarosh, PhD, CatholicUniversity of AmericaParticipant/1stAuthorCharles J. Gelso, PhD, University ofMaryland College ParkJairo Fuertes, PhD, Fordham UniversityTitle: Measuring the Real Relationship inPsychotherapy: Real Relationship InventoryTherapist FormCo-Author: Frances A. Kelley, PhD, GeorgiaState UniversityDiscussantBruce E. Wampold, PhD, University ofWisconsin—Madison
Invited Address: Update onPharmacological Interventions for ADHDAcross the Life Span 8/09 Sat: 9:00 AM - 10:50 AMMetro Toronto Convention Centre,Constitution Hall 106ChairAlice K. Rubenstein, EdD, MonroePsychotherapy Center, Pittsford, NYParticipant/1stAuthorRobert J. Resnick, PhD, Randolph—MaconCollege
Symposium: Positive Strategies to PreventEthical Problems in PsychotherapyPractice8/10 Sun: 8:00 AM - 9:50 AMMetro Toronto Convention Centre,Reception Hall 104CChairAlan C. Tjeltveit, PhD, Muhlenberg College
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Participant/1stAuthorSamuel Knapp, EdD, PennsylvaniaPsychological Association, Harrisburg, ZZTitle: Preventing Ethical Problems: AnOverview of Existing and ProposedStrategiesMichael C. Gottlieb, PhD, University ofTexas Health Science Center at DallasTitle: Primary Prevention Approach toEthical PracticeMelba J.T. Vasquez, PhD, Vasquez &Associates Mental Health Services, Austin, TXTitle: Development of Character, Virtue,and MoralityCaren C. Cooper, PhD, ConcordiaUniversity at AustinTitle: Ethical Issues in Emerging Areas ofPractice
Symposium: Legal and Ethical Challengesin the Supervision of Psychotherapy8/10 Sun: 10:00 AM - 11:50 AMMetro Toronto Convention Centre, MeetingRooms 205A/BChairJanet T. Thomas, PsyD, IndependentPractice, St. Paul, MNParticipant/1stAuthorThomas F. Nagy, PhD, NONETitle: Supervision and Ethical StandardsGary R. Schoener, BA, Walk-In Counseling,Minneapolis, MNTitle: Psychotherapy Supervision: Trainingin Maintaining Boundaries and EffectiveClinical PracticesLinda M. Jorgenson, JD, Spero andJorgenson, Cambridge, MATitle: Psychotherapy Supervision: LegalIssues, Risk Management, and PracticeStandardsJanet T. Thomas, PsyD, NONETitle: Supervisees at Various DevelopmentalStages: Ethical Challenges for SupervisorsEric Harris, EdD, JD, APA Insurance Trust,Lincoln, MD
Symposium: Using Outcome Measures toImprove Psychotherapy8/10 Sun: 12:00 PM - 1:50 PMMetro Toronto Convention Centre, MeetingRoom 717AChairDavid W. Smart, PhD, Brigham YoungUniversityParticipant/1stAuthorCory Harmon, MS, Brigham YoungUniversityTitle: Enhancing Psychotherapy Outcome:Using Client Feedback and ClinicalSupport ToolsCo-Author: Michael J. Lambert, PhD,Brigham Young UniversityCo-Author: Eric J. Hawkins, BA, BrighamYoung UniversityCo-Author: Karstin L. Slade, BA, BrighamYoung UniversityCo-Author: Michael Campbell, BA,Brigham Young UniversityCo-Author: Jeffrey Case, MA, BrighamYoung UniversityCo-Author: John C. Okiishi, PhD, BrighamYoung UniversityCo-Author: David W. Smart, PhD, BrighamYoung UniversityCo-Author: Stevan L. Nielsen, PhD,Brigham Young UniversityWade Lueck, MA, Brigham YoungUniversityTitle: Differential Response to Treatment asa Function of Diagnostic ClassificationCo-Author: Michael J. Lambert, PhD,Brigham Young UniversityCo-Author: David A. Vermeersch, PhD,Brigham Young UniversityStevan L. Nielsen, PhD, Brigham YoungUniversityTitle: Continuing Patterns of TreatmentResponse at Follow-UpCo-Author: Jacob Hess, BA, Brigham YoungUniversityCo-Author: Melissa Goates, BA, BrighamYoung UniversityCo-Author: Michael Campbell, BA,Brigham Young UniversityMichael J. Lambert, PhD, NONE
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Title: Ethnic Background and TherapyOutcomeCo-Author: Michael Campbell, BA, NONECo-Author: Karstin L. Slade, BA, NONECo-Author: Eric J. Hawkins, BA, NONERichard Isakson, PhD, Brigham YoungUniversityTitle: Assessing Couple Therapy as aTreatment for Individual DistressCo-Author: Eric J. Hawkins, BA, BrighamYoung UniversityCo-Author: Jennifer Martinez, MA,Brigham Young UniversityCo-Author: Richard Moody, PhD, BrighamYoung UniversityDiscussantCharles J. Gelso, PhD, University ofMaryland College Park
Workshop: Cognitive—BehavioralApproaches to Treating Suicidal Behavior8/10 Sun: 1:00 PM - 2:50 PMMetro Toronto Convention Centre,Meeting Room 101
ChairMichele S. Berk, PhD, University ofPennsylvaniaParticipant/1stAuthorMichele S. Berk, PhD, NONETitle: Cognitive Therapy Intervention forTreating Suicide AttemptersGregg R. Henriques, PhD, University ofPennsylvaniaTitle: Complex Issues in the Treatment ofSuicide AttemptersM. David Rudd, PhD, Baylor UniversityTitle: Cognitive Therapy for SuicidalityAlec L. Miller, PsyD, Montefiore MedicalCenter, Bronx, NYTitle: Dialectical Behavior Therapy forSuicidal Multiproblem Adolescents
Business Meeting8/10 Sun: 1:00 PM - 3:50 PMFairmont Royal York Hotel, AlgonquinRoom
JACK D. KRASNER EARLY CAREER AWARD
Congratulations to Craig Shealy, Ph.D., who is the recipi-ent of the Jack D. Krasner Early Career Award. Please jointhe Division in recognizing Dr. Shealy at the Division 29Awards Ceremony/Social Hour on Friday, August 8, at6:00 pm at the Crowne Plaza Toronto Centre Hotel,Ontario Room
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ing psychological problems as well as thepsychological and emotional reactions ofpatients, their families, and other healthcare providers. Further, our strong researchbackground—a unique qualification ofpsychologists among health care profes-sionals—prepares us to play key roles inthe design, implementation, and evalua-tion of prevention, and intervention pro-grams at the individual, system, and com-munity level.
A serious limitation on psychologists’ abil-ity to participate in integrated care hasbeen the absence of payment mechanismsto reimburse psychological services withingeneral health care settings. Psychologistshave not been permitted to bill under pro-cedure codes such as evaluation and man-agement of medical disorders, patient edu-cation, and preventative services. As aconsequence, they were forced to billunder mental health codes, which are ofteninappropriate, or to make arrangementswith systems to bundle their services (e.g.,using DRG or per diem methodologies).Moreover, psychologists frequently do nothave access to reimbursement for servicesprovided to patients related to non-psychi-atric diagnoses, even when these servicesare well accepted clinically and are strong-ly supported by the empirical literature.However, the recent approval of the Healthand Behavior codes for psychologists willbegin to address these problems.
Some of the more specific trends in healthcare also have implications for psychology.For example, information about geneticfactors in a variety of diseases and disor-ders is rapidly becoming available, largelyas a result of the Human Genome Project,and genetic testing is becoming increasing-ly common. Genetic testing will confrontpeople with profound choices and deci-sions. Assisting people to evaluate theavailable information, make appropriatechoices, and implement preventative pro-grams are roles that psychologists may ful-fill in the future (see Shiloh, 1996). Theaging of our society will also present sig-nificant opportunities for psychologists toenter health and disease management inthe geriatric area (see Haley, Salzberg, &Barrett, 1993; Qualls, 1998; Takamura,1998). As a part of a large and growinginterest in complementary or alternativemedicine (see Eisenberg et al., 1998),Americans are increasingly consumingherbal and nutritional remedies for a vari-ety of prevention and treatment purposes.As an aspect of their practice, psycholo-gists can play a key role in helping con-sumers to evaluate the available empiricaldata about the effects and the effectivenessof these remedies.
As always, I welcome your thoughts onthis column. You can most easily contactme via email: [email protected].
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In a previous article I wrote of the addedvalue that I believe derives from training inpsychopharmacology. I pointed out thatincreased patient safety was one importantvalue that one can expect to after complet-ing training in psychopharmacology. Someopponents to prescriptive authority (Hayes& Heigby, 1996; Sechrist, 2002; Bush, 2002)for psychologists argue that medical schooltraining is the only way that psychologistscan be trained to safely prescribe medica-tions because of the complexities of thephysiological response to psychotropicmedications, which they believe are dan-gerous drugs. Their arguments, however,remain in the realm of opinion becausethere is no large scale data on psycholo-gists performance prescribing medications.One study, performed by the AmericanCollege of Neuropsychopharmacology,looking at the performance of militarytrained psychologists who prescribe med-ications, does not support the concerns ofRxP opponents (ACNP, 1998).
Because there were so few psychologistsinvolved in that study, opponents do notsee it as predictive and one that can be gen-eralized to a larger population of psychol-ogists. One possible way to shed somelight on the relationship of training to per-formance is to look at adverse drug events(ADEs), which are preventable errors com-mitted by physicians who presently pre-scribe the bulk of medications. Also, onecan look at a comparison between theinjury rates of psychotropics and otherclasses of medications. Dr. Jack Wigginsand myself have done this and that analy-sis presently is in review. Some results ofour findings may help answer many of theconcerns of some that believe patient safe-ty would be jeopardized if psychologistswere allowed to prescribe without com-
pleting a medical school education andtraining program.
THE RELATIVE SAFETY OFPSYCHOTROPIC MEDICATIONS
During the calendar year ending 2001 overthree billion prescriptions for medicationswere written in the United States at a costwell over $132 billion dollars (AHRQ, 2001;Woodcock, J., 2000). Psychotropic compriseabout 15% of the total but are the fastestgrowing drugs of all medication classes.Generally, the risks of ADEs associated withpsychotropic medications are less than thoseof drugs for other disorders (Chakos, M., etal., 2001; Breier, AF, et al., 1999; Khaled, S. &Kaplowitz, N, 1999; Volavka, J., et al., 2002).But, psychotropic medications are also usedto treat other than their approved uses forsymptoms of psychological disorders.Increasingly, psychotropics are used forconditions that they are not designed orapproved for and with populations neverintended. Often their use is seen by some asa less costly substitute for psychotherapy.Off label uses can increase ADEs.
Estimates of the annual cost due toincreased harm from ADEs ranges from alow of $72 billion to a high of $172 billiondollars (AHRQ, 2000; Classen, D., et al.,1997; Wachter, R., 1997). The fact that theincreased harm and costs from medicationsmay actually exceed the total annual cost ofthe medication themselves begs for furtherstudy. Fatalities from adverse drug events(ADE) in the US are estimated to exceed100,000 people on a yearly basis (IOM,2000). Non-fatal injuries from ADEs are esti-mated to be about 650,000, yearly (Gebhart,2000; IOM, 2000; Schenkle, S., 2001).
The Institute of Medicine of the NationalAcademies of Sciences did a comprehen-
FEATURE
Medical School Training, Patient Safety, and Prescriptive Authority for PsychologistsJohn L. Caccavale, Ph.D., M.S. PsychoPharm
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sive investigation of medication errors byphysicians and published this landmarkstudy as To Err Is Human (2000). A majorfindings of that study was that annualfatalities from medication errors surpasseddeaths from motor vehicle accidents(43,458), breast cancer (42,297), and AIDS(16,516). Fatalities and injuries from poli-cies in the use of restraints and other nonmedications procedures in nursing homesettings far exceed those associated withpsychotropic medications (Bourdel-Marchasson, I., et al., 1997; Castle, NG,Fogel, B & Mor, V, 1997; Evans, LK, et al.,1997; Lackner, TE & Battis, GN, 1995;Mitchell, SL, Kiely, DK, & Lipsitz, LA,1997). Opiate and cardiac medications con-tribute the greater share of all ADEs andfatalities (Khaled, S. & Kaplowitz, N, 1999;Love, JN, et al., 2000; Tabboulet, P., et al.,1993; Thomas, EJ & Brennan, TA, 2000).These classes of medications are not beingpursued by psychologists seeking RxP.
Yet, even though the incidence rates ofinjury and fatalities from non-psychotropicdrugs vastly exceeds those related to psy-chotropic medications, there is a miscon-ception by many that psychotropic drugsare more dangerous than other classes ofmedications. The data, however, does notsupport this claim. For example, in the yearending 2000, over 16,000 deaths from gas-trointestinal complications were attributedto non-steroidal anti-inflammatory drugs(Singh, G., 1998). Further, several thousandmore deaths involving cardiovascularcomplications also were attributed to thissame class of medication, which are usedto treat common inflammation (Page, H. &Henry, D., 2000).
One cannot find any statistics that mortali-ty from psychotropic medicationsapproach the level of NSAIDS, which nowcan be obtained over-the-counter. In com-parison, since its introduction several yearsago, the anti-psychotic medication Clozaril,a drug used to treat schizophrenia in a pop-ulation of treatment resistant patients, reg-isters about 10-15 fatalities for every 10,000patient years ( Glassman, AH, & Bigger, JT,
2001). This is a very low incidence rate incomparison to fatalities from opiates, car-diac and NSAID medications. Moreover, ingeneral, the causative relationship betweenClozaril and fatality have not been clearlyestablished because patients using thismedication typically have a very compro-mised physical state, suffering from a hostof non-psychiatric ailments. Most psy-chopharmacologists, I believe, would agreethat Clozaril, despite it being one of themost potentially harmful of all psychotrop-ic medications, represents less potential forharm than the majority of cardiac medica-tions. Thus, any objective analysis showsthat prescribing psychotropic medications,which are being pursued by psychologists,are much safer than other classes of med-ications, which RxP psychologists have nointention to prescribe.
MEDICAL SCHOOL TRAINING ANDPRESCRIBING ERRORS AND PROFICIENCY
What types of prescribing errors are madeby physicians? Type A ADEs are harmsresulting from prescription medicationerrors and other avoidable errors. Harmscan range from a simple rash to death.Type B ADEs are harms not so much relat-ed to errors but to the unique response ofthe patient to the drug, e.g., anaphylacticshock. An undetected hypersensitivity orunknown inherited response to a medica-tion comprise this category of ADE. Mostof the studies relating to ADEs show thatthe errors made by physicians when pre-scribing are largely due to errors in dosingor ordering the wrong medication (Dean,B., 2001; Kenneth, EB, et al., 2002). Theymay even give the wrong dose or thewrong medication even when known aller-gies to a medication exist. Gebhart (2000),in an article published in Drug Topicsreported that “overdosing is a major prob-lem. He believes that many ADEs are aresult of physicians using higher doses ofmedications than are needed to treat theproblem. Despite the inaccurate claims bythe medical profession that physicians arewell trained in pharmacology and pre-scribing, these errors persist.
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In testimony before a FDA hearing onADE’s, Dr. Robert Califf, a cardiologist rep-resenting the American Heart Association,testified that a major problem in under-standing ADE’s is that the medical educa-tion of physicians is deficient when itcomes to training them to prescribe med-ications . In his testimony, Dr. Califf added:“Inadequate knowledge is a problem.And I believe here we must point theblame at the academic medical communi-ty, my own group. Medical schools....aredoing very little to teach practitionersabout the system and how it works interms of where to get information, howthe information is actually derived.”(FDA Hearing On Risk Management ofMedication Errors. May 22, 2002)
On the subject of ADEs related to a pro-longed QT interval, a serious and poten-tially fatal event so frequently connected tosome medications, Dr. Califf, at that sameFDA hearing, testified: “At the AmericanHeart Association, we’re finding that lessthan 50 percent of physicians can accu-rately measure a QT interval.” Some psy-chotropic medications can affect the QTinterval, as do other classes of medications,psychologists who have completed train-ing in clinical psychopharmacology receivespecific training on these drugs and theirrelationship to QT prolongation.
A factor to consider in prescribing medica-tions is to have a good assessment of thefunctioning of a patient’s renal system andkidney functioning. If the kidneys areimpaired then this will affect the concen-tration of the drugs in the system afterbeing absorbed and metabolized. In dis-cussing physicians prescribing for elderlypatients, Dr. Califf remarked: “Elderlypeople by normal physiology haveimpaired creatinine clearance. As we’renow beginning to look at the outpatientclinic, it seems that most doctors justdon’t remember that you have to adjustthe doses of renally excreted drugs forcreatinine clearance, and this is a hugenational problem that I think really doesneed to be specifically addressed and
soon.” Here, too, clinical psychopharma-cology programs differ from medicalschool programs in that they provide spe-cific training on the differential response tomedications by the elderly, polymorphismamong different racial and ethnic groups,children and women. When one considersthat medications are a routine practice ofmedicine, Dr. Califf’s statements shouldsound a major alarm.
Yasuda (2002), surveyed a number of med-ical school programs and found that themajority of medical schools did not offertraining to third or fourth-year students inclinical pharmacology or adverse drugreactions. Those schools that did offer suchtraining, only eight percent made itmandatory. Well over 60 percent of theinternal medicine residency programsoffered only lectures in adverse drug reac-tions. The authors opined that there isinsufficient incentive to include this topicbecause the subjects is not included as anindependent topic in the United StatesMedical Licensing Examinations.
The Institute of Medicine identified impor-tant deficiencies in medical school educa-tion and training as a major causative factorin ADEs. The authors of the IOM studymade several recommendations focusing onthe roles that medical societies and organi-zations and state medical boards can play inreducing ADEs. Most prominently was thatstate medical boards should consider peri-odic physician certification in pharmacolo-gy and licensing. My feeling is that anyoneadvocating for medical school training forpsychologists needs to consider that suchtraining appears to be inversely related tolearning safe prescribing skills.
Concluding RemarksThe Institute of Medicine identified defi-ciencies in medical school education andtraining as a major cause of ADEs. Theyrecommend certification in pharmacologyfor physicians. Organized Medicine contin-ues to oppose those recommendations. TheAmerican Psychological Association’sModel Training Program In Psycho-
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pharmacology is an example of specializedpost doctoral training that would clearlymeet the IOM recommendation. The pro-gram is built upon specialized education,training, testing, and supervision. Whilethese may not guarantee the competence ofany one prescriber, it is far better than any-thing presently available in general andspecialty medicine. Very few psychiatristshave completed proficiency certification inpsychopharmacology according to theAmerican Society of Clinical Psycho-pharmacology. Psychologists are in theunique position of becoming a positive fac-tor in reducing ADEs while at the sametime providing mental health serviceseffectively and efficiently. General practi-tioners and other non-psychiatric physi-cians are neither mental health specialistsor psychopharmacologists. Collaborationbetween the psychological and medicalprofessions can result in more effective andsafer treatment for mental health patientsby reducing ADEs. Prescriptive authorityfor psychologists is expected to promotehigher quality mental health care, increaseaccess to services, and promote better effi-ciency while reducing overall health carecosts.(ACNP, 1998; Caccavale, JL., 2002;Norfleet, MA., 2002).
In light of the overwhelming evidence thatinappropriately trained physicians areassociated with the greatest harm topatients, opponents of prescriptive author-ity for psychologists need to look inwardwhen insisting that psychologists whowant to prescribe go to medical school.Pre-residency medical training is focusedon acquiring diagnostic skills. Learninghow to prescribe comes much later, if at all.Practicing clinical psychologists alreadyhave very good diagnostic skills. Thus ask-ing psychologists to go to medical schoolmay not be in the best interest of patientsor the best environment to acquire goodprescribing skills. Prescribing is a profi-ciency and skill that is achieved throughtraining, experience, testing, and practice.Thus, these skills are best acquired as apost doctoral proficiency.
The primary causes of ADEs result fromavoidable errors such as writing the wrongdose for a medication or prescribing thewrong medication. Less often, ADEs resultfrom incorrect diagnoses or the interactionof a medication with an underlying med-ical disorder. The key issue here is avoid-able error due to insufficient training orprescribing medications with effects withwhich the prescriber is unfamiliar. If com-plex medical knowledge were a significantdeterminant for the reduction of ADEsthen perhaps there would be a correlationwith prescribing and medical training.Moreover, although some physicians maynot be able to prescribe safely with medicaltraining at an acceptable level of compe-tence, it does not follow that others, such aspsychologists, would also prescribe poorlybecause they are not trained in the mannerof physicians. In fact, the converse is apt tobe more correct. By providing specialtytraining in psychopharmacology to psy-chologists who already have diagnosticand treatment expertise, will insure betteroutcomes can be expected. Experienceshows that one can learn much from theerrors of others.
Lastly, psychotropic medications are muchsafer than other classes of medications.They are typically administered on an out-patient basis. The vast majority of knownADEs occur in hospital settings. When try-ing to assess safety issues one must look athow mental health patients are presentlytreated. Most are first seen by a generalpractitioner who, according to the data,may be the least able to appropriately diag-nose and then prescribe an appropriatemedication, if needed. If the patient is seenby a psychiatric physician, they may farebetter with respect to diagnosis and gettingthe correct medication. However, they willlikely be seen every five to six weeks afteran initial consult This is significant becauseside effects and drug reactions are likely tooccur between appointments. This time lagcan significantly increase risks. If thepatient were being seen by a prescribingpsychologist, the scenario is greatly
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changed and risks from ambulatory ADEsare significantly reduced because psychol-ogists see patients regularly. Psychologistsare not psychiatric physicians and we donot aspire to that treatment model. Thus,all factors considered, psychologiststrained in psychopharmacology increasepatient safety. Our training programs inclinical psychopharmacology remain thebest insurance for our patient’s safety.
REFERENCES
Agency for Healthcare Research andQuality.(2001). Reducing and prevent-ing adverse drug events to decrease hos-pital costs. Research in Action, Issue 1.Number 01-0020, March, Agency forHealthcare Research and Quality,Rockville, MD.
American College of Neuropsycho-pharmacology (1998). DoD prescribingpsychologists: External analysis, moni-toring, and evaluation of the programand its participants. Final Report, May,1998.
Breier, AF., Malhotra, TP., Su, DA., Pinals,I., Elman, CM., Adler, RT., & Pikar, D.(1999). American Journal of Psychiatry,156, 2, 294-298.
Bourdel-Marchasson I, Dumas F,Pinganaud G. (1997). Audit of percuta-neous endoscopic gastrostomy in long-term enteral feeding in a nursing home.International Journal of Quality HealthCare, 9,4,297-302.
Bush, JW.(2002). Prescribing privileges:Grail for some practitioners, potentialcalamity for interpersonal collaborationin mental health. Journal of ClinicalPsychology, 58, 6, 681-696.
Caccavale, J. (2002). Opposition to pre-scriptive authority: Is this the case of thetail wagging the dog? Journal of ClinicalPsychology, 58, 6, 623-633.
Califf, R.(2002). FDA Hearing On RiskManagement of Medication Errors. May22, 2002)
Castle NG, Fogel B, Mor V.(1997). Risk fac-tors for physical restraint use in nursinghomes: Pre-and post-implementation of
the Nursing Home Reform. Act.Gerontologist, 37, 6, 737-747
Chakos, M., Lieberman, J., Hoffman, E.,Bradford, D., & Sheitman, B. (2001).Effectiveness of second generationantipsychotics in patients with treat-ment resistant schizophrenia: A reviewand meta-analysis of randomized trials.American Journal of Psychiatry, 158, 4,518-526.
Classen, DC., Pestonik, SL., Evans, RS.,Lloyd, JF, & Burke, JP. (1997). Adversedrug events in hospitalized patients.Excess length of stay, extra costs, andattributable mortaility. Journal of theAmerican Medical Association, 277, 4, 301-306
Committee on Quality of Health care inAmerica: Institute of Medicine.(2000).To Err Is Human: Building a safer healthsystem. Washington, D.C., NationalAcademy Press.
Dean, B. (2001). Learning from prescribingerrors .CMAJ, 164, 4, 126-131.
Evans, LK., Strumpf, NE., & Allen-Taylor,SL. (1997). A clinical trial to reducerestraints in nursing homes. Journal ofthe American Geriatric Society, 45, 6, 675-681.
Gebhart, F.(2002). Is standard dosing toblame for adverse drug reactions? DrugTopics, January Issue.
Glassman, AH & Bigger, JT.(2001).Antipsychotic drugs: Prolonged QTcinterval, torsade de pointes, and suddendeath. American Journal of Psychiatry,158, 1774-1782.
Hayes, S C. & Heigby, E. (1996).Psychology’s drug problem: Do weneed a fix or should we say no?American Psychologist, 51, 198-206.
Honigfield, G. (1996). Effects of the clozap-ine national registry system on incidenceof deaths related to agranulocytosis.General Psychiatric Service, 47, 1, 52-56.
Kenneth, EB., Beckley, B., McDade, M.,Adams, A., Zechnich, A., & Hedges,J.(2001). The effect of computer assistedprescription writing on emergencydepartment prscription errors. AcademicEmergemcy Medicine, 8, 499.
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Khaled, S. & Kaplowitz, N. (1999).Hepatotoxicity of psychotropic drugs.Hepatology, 29, 5, 1347-1351.
Lackner TE, Battis GN.(1995). Use of war-farin for nonvalvular atrial fibrillation innursing home patients. Archives ofFamily Medicine, 4,12, 1017-1026.
Love JN, Howell JM, Litovitz TL, Klein-Schwartz W. (2000). Acute beta blockeroverdose: Factors associated with thedevelopment of cardiovascular morbid-ity. Journal of Toxicological ClinicalToxicology, 38, 3, 275-281.
Mitchell SL, Kiely DK, Lipsitz LA.(1997).The risk factors and impact on survivalof feeding tube placement in nursinghome residents with severe cognitiveimpairment. Archives of InternalMedicine,157, 3, 327-332.
Norfleet, MA (2002). Responding to soci-eties needs: Prescription privileges forpsychologists. Journal of ClinicalPsychology, 58, 6, 599-610.
Page, J., & Henry, D.(2000). Consumptionof NSAIDs and the development of con-gestive heart failure in elderly patients:An underrecognized public health prob-lem. Archives of Internal Medicine, 160, 6,777-784.
Sechrist, L. & Coan, JA.(2002). Preparingpsychologists to prscribe.
Journal of Clinical Psychology, 58, 6, 649-658.
Schenkel, S. (2001). Promoting patient safe-ty and preventing medical error inemergency departments. AcademicEmergency Medicine, 7, 204-1222
Singh, G. 1998). Recent considerations innonsteroidal anti-inflammatory druggastropathy. American Journal ofMedicine, 105, 31S- 38S.
Taboulet P, Cariou A, Berdeaux A, BismuthC. (1993). Pathophysiology and man-agement of self-poisoning with beta-blockers. Journal of Toxicological ClinicalToxicology, 31, 4, 531-551
Thomas, EJ & Brennan, TA. (2000). Incidenceand types of preventable adverse eventsin elderly patients: Population basedreview of medical records. British MedicalJournal, 320, 741-744.
Volvavka, J., Czobor, B., Sheitman, JP,Lindenmayer, L., Citrome, J., &Lieberman, JA. (2002). Clozapine, olan-zapine, risperidone, and haloperidol inthe treatment of patients with chronicschizophrenia and schizoaffective disor-der. American Journal ofPsychiatry,159,2,255-262.
Wachter, RM. (1997). Making health caresafer: A critical analysis of patient safetypractices. Univerrsity of California atsan Francisco-Stanford UniversityEvidence-Based Practice Center, AHRQContract No. 290-0013.
Woodcock, J. (2000). Testimony on medicalerrors: Understanding adverse drugevents.Before the senate Committee onHealth, Education, Labor, and Pensions.February 1, 2000
Yasuda, S.( 2002). Adverse drug reactioncurriculum missing at many medicalschools. Psychopharmacology Update,April, 2002.
DIVISION 29 DISTINGUISHED PSYCHOLOGISTS
Clara Hill, Ph.D.Charles Gelso, Ph.D.
Congratulations to both Dr. Hill and Dr. Gelso for their outstanding contributions toDivision 29 and to the field of psychology.
Please join the Division in recognizing Dr. Hill and Dr. Gelso at the Division 29Awards Ceremony/Social Hour on Friday, August 8 at 6:00 pm at the Crowne PlazaToronto Centre Hotel, Ontario Room.
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One of the rewards of personal involve-ment in the public policy process is theopportunity to experience, on a first handbasis, concerned citizens laying the foun-dation for substantive changes in the statusquo. When I arrived on Capitol Hill onleave from the State of Hawaii Departmentof Health, it was the first day of the infa-mous Watergate hearings. At that time,there were also ongoing (admittedly lessvisual) discussions regarding the need forthe Congress to enact National HealthInsurance in order to ensure that allAmericans would have access to qualityhealth care. There was a perceived short-age of health care professionals of all disci-plines and community health centers,established during the Great Society era ofPresident Johnson, and health maintenanceorganizations were viewed very positive-ly. Few today realize that the then-CarterWhite House gave serious consideration tosignificantly expanding its mental healthfocus to include insuring access to a broadrange of primary care services. That wasnearly three decades ago.
The Senate Appropriations Committee, onwhich Senator Inouye serves, has recentlybegun a series of public hearings highlight-ing the related issues of health care accessand affordability. Interestingly, this time itis the business community (i.e., the ulti-mate payers of the bill) that have becomeparticularly concerned. Health insurancepremiums are “out of control,” havingmore than doubled for a family with twochildren from 1999-2003; premiums foremployers rose 14.7 percent last year.Some businesses report 30 percent increas-es in annual premiums; school districts areexperiencing premium increases of over 50percent. Access to quality health care
appears to have once again become a majorpublic policy concern.
Our nation currently spends nearly doubleper person on health care, compared toother countries, with many of them havinghigher life expectancies and healthier pop-ulations. The Commonwealth Fund testi-fied: “It is long past time to simply pay forservices rendered without establishing ascientific-basis for effectiveness not just fornew drugs but for consultations, proce-dures, and tests.” Today, the lag betweenthe discovery of more efficient forms oftreatment and their incorporation into rou-tine patient care is, on average, 17 years.Surveys have shown that an estimated 20to 50 percent of primary care practitionersare not aware of, or not using, new evi-dence related to common current prac-tices. This simply is not acceptable.
In my judgment, HPA’s impressive foraythis past legislative session into the pre-scriptive authority (RxP-) arena, in con-junction with our State’s community healthcenters, goes directly to the underlyingissues of ensuring the highest quality ofsychopharmacological care for those citi-zens who are most in need and deliveringservices in a cost-effective manner. This iswhat psychologists, as highly educatedprofessionals, must do. My sincerestappreciation to Don Kopf and his col-leagues. Fundamental change in the statusquo takes time. However, it is importantand it is our societal responsibility to pro-vide proactive vision and effective leader-ship. Mahalo,
Pat DeLeon, former APA President HawaiiPsychological Association June, 2003
WASHINGTON SCENE
DEJA VU, ALL OVER AGAIN
Pat DeLeon, Ph.D.
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“I went to University of California SantaBarbara where I received my B.A. in psychology.There I studied the behavioral effects of psycho-stimulant drug exposure on brain reward circuitry in rats. In the clinical PhD programat the University of Houston, my researchinterests involve studying hedonic processes in depression and the association betweendepression, mood, and goal formation.”
Mindfulness-Based Cognitive Therapy(MBCT) is a psychosocial treatment program designed to prevent relapse inindividuals who have recovered fromdepression. The therapy capitalizes bothon Eastern meditative practices andWestern cognitive approaches. Zindel V.Segal, J. Mark G. Williams, and John D.Teasdale, the creators of MBCT, spentmuch of the 1980s and 1990s researchingthe link between thought and emotion.Their effort helped lay the groundwork forthe development of this treatment. Theyargue that depression is maintained by theprocess of rumination, which is defined asthe act of trying to reduce discrepanciesbetween actual and desired states throughexcessive, unproductive thought. Tounderstand and solve their problems rumi-nators incorporate new thoughts of thesame evaluative nature which takes hold ofthem and only makes matters worse. Segal,Williams, and Teasdale present an interest-ing hypothesis as why people who haveexperienced more episodes of depressionare at greater risk for future relapse. Theybelieve that those who have recoveredfrom depression tend to use old habits ofreacting to negative emotion or negativethoughts in this ruminative style, whichonly intensifies negative moods. Once a
stressful event or painful emotion is present,previous depressive mental patterns areactivated which may lead to relapse.MBCT is intended to help clients disengagefrom ruminative response patterns. Thetreatment borrows heavily from Jon Kabat-Zinn’s mindfulness-based stress reductionprogram that helps individuals deal withmedical conditions, sleep disorders, anxiety,and panic.
During the program, individuals learn toapply a new mode of thought, termedmindfulness, to everyday activities. Thuswhen a “relapse signature” arises, clientscan be mindful of their emotions andthoughts rather than responding withautomatic ruminative thought. Duringstates of mindfulness one does not thinkabout the future, past, or any abstract ideabut rather focuses on exactly what is occur-ring in the here and now. Because all atten-tion is directed towards what is occurring,thinking capacity is exhausted leaving nospace for rumination. There are twoaspects of MBCT that causes change: learn-ing mindfulness and using it. In addition,the authors believe that being mindful notonly changes ruminative tendencies butalso alters one’s whole being. In that theymean that a person can become more per-ceptive, enjoy the richness of life, and learnto “let go” and accept painful states.
Most of the techniques have never beenformally applied to treat depression before.The strategy of the therapist is to teachmindfulness in all situations or better yetto empower clients so that they can becomemindful. Mindfulness techniques involvethe raisin exercise, the body scan, breathingspace, listening to meditative tapes, read-ing related poems, mindful stretching,
FEATURE
Reactions to Segal, Williams, & Teasdale’s Mindfulness-BasedCognitive Therapy for Depression1
Adam Leventhal
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mindful walking, seeing and hearing exer-cises, and taking a wider view of thoughts(for a description these techniques consultthe guidebook). The raisin exercise is thefirst task introduced in MBCT and is a sim-ple example of mindful thought. In thistask, clients spend a few minutes slowlyseeing, touching, smelling, and tasting araisin with strong attention paid to the sen-sations involved. This exercise introducesthe extreme difference between automaticexperience and mindful experience. Afterthe exercise some clients will say that theywere able to see the raisin with more clari-ty or that they never noticed how juicyraisins are. These activities are intended toteach clients to pay attention to all things inthe present as if watching a movie. Later inthe program, a sense of perspective isgained that allows individuals to take astep back and attend to external stimuli,thoughts, feelings, and sensations. Duringmindful states individuals are not sweptaway with internal events, but are focusedon the present.
The first half of the program is dedicated toteaching mindfulness. This is probably themost challenging part because these ses-sions require intense concentration anddiligence. For example, the sitting medita-tion exercise that is introduced in sessionthree requires that clients spend up to fortyminutes in mindful states, intensely con-centrating on their internal sensations andsurroundings. Clients who struggle tryingto suffocate wandering thoughts arereminded to gently bring back the mindand to be aware of their thoughts and notreact to them. It seems that dealing withfrustrated client may be one of the mostchallenging parts of MBCT. The second halfof the program teaches clients to apply mind-fulness to deal with negative affectivestates. Once clients can get comfortable withmindfulness practice the program I assumethat it becomes much less challenging.
The manual outlines everything session bysession. It is an eight week program com-prised of one two hour session per week
and four follow-up classes in the year fol-lowing the program. Class size should bearound twelve. It is noted that the therapistis more like an instructor in MBCT.Included in the handbook are transcripts ofclient-therapist interactions, word for wordinstructions to give clients, and handoutsand session agendas that can be copied foruse. In addition, the introductory chaptersprovide fascinating insight as to why theauthors decided to pursue mindfulness asa treatment for depression relapse preven-tion. The manual is useful, but I would rec-ommend that if you wish to disseminateMBCT, you should practice mindfulnessyourself before even reading the manual.It’s hard to understand mindfulness with-out having experienced it, which is whythe creators insist that therapists should bemindful or have experience with medita-tion before they can instruct a MBCTgroup. There is no formal class to teachtherapists mindfulness. The authors’ bestsuggestion is to learn it firsthand fromsomeone with experience. To get a betterperspective I tried doing some of the exer-cises and found them very difficult. I canunderstand why some clients may get dis-couraged at first because it is challengingto focus your attention so intensely formore than a few minutes. Segal, Williams,and Teasdale emphasize that practicing inand out of therapy six days a week areessential to client and instructor progress.They remind potential disseminators thatMBCT is stressful for the client and instruc-tor, but after this new mode of mind islearned and applied, life becomes richerand fuller.
At first there seems to be no resemblance inits techniques, the authors compare mind-fulness to traditional cognitive therapy.They state that both involve distancing andtreating thoughts just as thoughts and notthe truth. Some cognitive-behavioral tech-niques are brought in towards the tail endof therapy. For example, clients are taughtto evaluate mastery and pleasure of situa-tions and to recognize that automaticthoughts are attached to depressed mood
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and have no validity in non-depressedstates. An important practice is taughttowards the end of the program. Clientslearn that when a negative thought or feel-ing occurs, to first be mindful and welcomeit, and then if you wish you may act on itby doing something that creates a sensemastery or pleasure.
MBCT’s empirical support is in a three siterandomized controlled trial was completedwith 145 subjects comparing MBCT totreatment as usual in its one-year relapserate. It was significantly better, but thereare many further questions as to its efficacy.For example, the results suggest that theprogram is more effective for those withthree or more past depressive episodesthan those with two. The study uses a sam-ple of individuals who have recoveredfrom depression. In the manual it is explic-itly stated that MBCT is designed to pre-vent relapse in recovered individuals.Although the treatment hasn’t beenapplied to acutely depressed populations,the creators believe that intense negativestates would prevent them from learningmindfulness in the earlier stages of treat-ment. In the manual, the client base ofMBCT is described as those formerly treat-
ed with antidepressants and then pulledoff of them before therapy. It would beinteresting to see how those treated withcognitive-behavioral therapy respond tomindfulness approaches in preventingrelapse. Also, could mindfulness be added tothe cognitive therapy package as relapse pre-vention? We’ll have to wait and see as newliterature is published on this treatment.
To summarize, MBCT is an interesting newmethod in the prevention of depressionrelapse. It is the first American psychoso-cial program designed explicitly for thispurpose. It really is an Eastern approachthat incorporates some Western cognitiveprinciples. MBCT may be an appropriateavenue for clinicians who have the time,dedication, and interest to provide aunique empirically supported psychosocialtreatment for this population.
REFERENCES1Segal, Williams, & Teasdale (2002).Mindfulness-based cognitive therapy fordepression: A new approach to preventingrelapse. New York: Guilford Press.
Mark Your Calendars
Don’t miss these important Division 29 events at the APA Convention in Toronto,Ontario Canada
Presidential AddressUpdate on Pharmacological Interventions for ADHD Across the Life SpanRobert Resnick, Ph.D., presentingSaturday, August 9 9:00-10:50 amMetro Toronto Convention Center, Constitution Hall 106This address will provide FREE CE to attendees at the convention.
Social and Awards HourFriday, August 8 6:00-7:50 pmCrowne Plaza Toronto Centre Hotel, Ontario Room
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Dr. Raymond A. Weiss established the Rosalee G. Weiss Lecture Series to honor his wifein 1994. Annual gifts support the series, and a bequest will perpetuate it. Divisions 29and 42, upon approval by the APA Board of Trustees, select an annual lecturer to speakat the APA Convention. The individual must be an outstanding leader in the arts or sci-ences whose career is not directly in the spheres encompassed by psychology, or an out-standing leader in any of the special areas within the spheres of psychology.
About John C. Norcross, Ph.D. John C. Norcross, Ph.D., is professor and former chair of psychology at the Universityof Scranton, a clinical psychologist in part-time practice, and an internationally rec-ognized authority on behavior change and psychotherapy. Author of more than 150scholarly publications, Dr. Norcross has co-written or edited 12 books, includingPsychotherapy Relationships that Work (Oxford University Press), the AuthoritativeGuide to Self-Help Resources in Mental Health (Guilford Press), Changing for Good (Avon;with Prochaska and DiClemente), the Handbook of Psychotherapy Integration (Basic;with Goldfried), and Systems of Psychotherapy: A Transtheoretical Analysis(Brooks/Cole; with Prochaska). He is the past-president of the APA Division ofPsychotherapy, president-elect of the International Society of Clinical Psychology, edi-tor of In Session: Journal of Clinical Psychology, and has served on the editorial boardsof a dozen journals. Dr. Norcross has received many professional awards, such asPennsylvania Professor of the Year from the Carnegie Foundation, fellowship statusin professional organizations, and election to the National Academies of Practice. Hiswork has been featured in hundreds of media interviews, and he has appeared onmany national shows, such as the Today Show, the Early Show, CBS This Morning, andGood Morning America. An engaging teacher and clinician, John has conducted work-shops and lectures in 20 countries.
THE AMERICAN PSYCHOLOGICAL FOUNDATIONand
APA Division 29 PsychotherapyPresent the
Tenth Annual Rosalee G. Weiss LectureIntegrating Self-help into Psychotherapy:A Revolution in Mental Health Practice
Delivered by John C. Norcross, Ph.D.
Presenters:Dorothy W. Cantor, Psy.D., APF President
Patricia M. Bricklin, Ph.D., APA Division 29 President
Saturday, August 9, 20032:00 to 2:50 p.m.
Metro Toronto Convention Centre • Reception Hall 104C
DIVISION OF PSYCHOTHERAPY ! MEMBERSHIP APPLICATION
Please return the completed application along with payment of $40 (or $29 for Student membership) by credit card or check (Payable to: APA Division 29) to:
Division 29 Central Office6557 E. RiverdaleMesa, AZ 85215
Code _____ FD _____
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