16 Oct 2017

Access to Care for All Veterans

Access to Care for All Veterans

The Department of Veterans Affairs and APA are working to improve treatment for veterans in new ways

Hiring 1,000 more mental health professionals and increasing the number of private-sector mental health providers who are culturally competent in military issues are among the new priorities at the Department of Veterans Affairs (VA), according to VA Secretary David J. Shulkin, MD, who testified in March to the House Veterans Affairs Committee.

Shulkin also emphasized the need to strengthen suicide-prevention programs and announced his intention to open up access to treatment to veterans with other-than-honorable discharges.

APA is helping to ensure that the secretary's goals become a reality by pushing Congress to expand resources for VA mental health care and research. "We are thrilled that Dr. Shulkin was named VA secretary," says Heather O'Beirne Kelly, PhD, who in March was named APA's first-ever director of veterans and military health policy. "And we applaud all his newly announced priorities."

Saving lives

The number of veterans committing suicide has dropped to roughly 20 a day, the secretary told Congress. But when it comes to suicide prevention, he said, "What we are doing now—and we are doing a lot—is not enough." The VA is seeking new approaches, he said. "We are reaching out to the very best and brightest from the academic world and the community to come in and tell us what else we can do."

As part of Shulkin's suicide-prevention effort, he plans to make emergency mental health care accessible to the 500,000-plus veterans who have other-than-honorable discharges, which render them ineligible for VA care. "Our goal is simple: to save lives," said Shulkin, explaining that the suicide rate among veterans who don't use VA facilities is increasing at a greater rate than that of veterans receiving care within the VA.

Shulkin's proposal would give veterans with other-than-honorable discharges access to VA emergency departments, vet centers and the Veterans Crisis Line at (800) 273-8255. The secretary plans to meet with members of Congress, Department of Defense officials and representatives of veterans service organizations before finalizing his proposal this summer.

Veteran Thomas Burke, who received an other-than-honorable discharge after being booted from the Marines for smoking hashish to manage post-traumatic stress disorder (PTSD) in Afghanistan, supports the proposal. "When people think of ‘less-than-honorable' discharge, they think of dishonorable; to get a dishonorable discharge, you have to rape or murder someone," says Burke, now treasurer of High Ground Veterans Advocacy and a master's degree candidate at Yale Divinity School. But, he says, other-than-honorable discharges are often the result of behavior related to PTSD, traumatic brain injury, military sexual assault and other mental health problems. Of course, says Burke, the secretary's proposal is just a proposal. That's why he and other veterans in High Ground support the Honor Our Commitment Act, which seeks to transform the proposal into legislation requiring the VA to provide mental and behavioral health services to veterans with other-than-honorable discharges.

APA outreach

APA supports the secretary's proposals, says Kelly. APA generally supports the proposed legislation, too, although Kelly wants to keep a close eye on implementation details. There have been calls to retroactively assess veterans' discharge statuses, for example, and it would be critical to understand how and by whom those assessments would be performed and interpreted and how they would be used by the VA for health-care decision-making, Kelly says.

Of course, the secretary will also need resources to fulfill his vision for the VA. APA called for that increased funding along with other requests in testimony to the House Appropriations Committee's Subcommittee on Military Construction, Veterans Affairs and Related Agencies in March:

  • Suicide prevention. APA supports Shulkin's commitment to enhanced suicide prevention efforts. In terms of other clinical priorities, Kelly urged Congress to support the hiring of more psychologists, increase support for integrated care and hold community providers to the VA's high standards.
  • Prescriptive authority. Kelly also urged Congress to grant prescriptive authority to appropriately trained psychologists in the VA.
  • Research funding. As part of the Friends of VA Medical Care and Health Research, APA asked for $713 million in fiscal year 2018 for VA research. "A strong VA psychological research program provides the scientific foundation for high-quality care within the VA system," Kelly told Congress.

One concern is the VA's push toward privatization, with more care being provided outside of VA facilities, adds Kelly. While many veterans groups were happy to hear the secretary talk of eliminating the rule requiring veterans who live close to VA facilities to get their care there, she says, APA is concerned that community providers may lack the preparation and capacity to handle the increased demand. Plus, says Kelly, having psychologists embedded into primary-care settings is vital to ensuring high-quality care for veterans.

"We will continue to work with Secretary Shulkin and the VA about what they mean by community care to ensure that the VA is strengthened as an integrated-care provider for veterans and not just as a funder of outside care," Kelly says.

To read Dr. Heather Kelly's full testimony to the House Subcommittee on Military Construction, Veterans Affairs and Related Agencies, go to www.apa.org/about/gr/issues/military/testimony_va_research.pdf.

By Rebecca A. Clay


This article was originally published in the June 2017 Monitor on Psychology

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11 Oct 2017

How Much Do Today’s Psychologists Earn?

How Much Do Today’s Psychologists Earn?

The latest salary report from APA finds that psychologists in the middle of the country outearn their peers

In May, APA's Center for Workforce Studies (CWS) released its most comprehensive salary report to date. The report finds that the median annual salary for U.S. psychologists in 2015 was $85,000, but that salaries varied widely by subfield and geographic region.

Most psychologists (57.4 percent) earned between $60,000 and $120,000, 20 percent earned less than $60,000, and 22.7 percent earned more than $120,000. Those in industrial/organizational psychology were at the top of that range—the median annual salary for I/O psychologists was $125,000. Those with a degree in educational psychology, at the other end of the spectrum, earned a median salary of $75,000.

Want to earn more? Move to the Middle Atlantic region, where psychologists earned, on average, $108,000 per year. Psychologists in the East South Central region, in contrast, earned $59,000 per year.Psychologist salaries

Meanwhile, women continued to earn less than men ($80,000 compared with $91,000), white psychologists earned more ($88,000) than racial/ethnic minority psychologists ($71,000), and those with a PhD earned more ($85,000) than those with a PsyD ($75,000). (To read more about the gender pay gap, see the article "Women Outnumber Men in Psychology, But Not in the Field's Top Echelons" in the July/August Monitor.)

The new salary report is APA's most representative look yet at psychologists' earning power, according to Luona Lin, a CWS research associate. In previous reports, the association's salary data came from member surveys, but APA members skew older and less racially and ethnically diverse than the profession as a whole.

The new report instead analyzes data from the 2015 National Survey of College Graduates, a nationally representative survey conducted every two years by the U.S. Census Bureau on behalf of the National Science Foundation's National Center for Science and Engineering Statistics. The CWS report pulls the survey's data on full-time working psychologists—those with a doctorate or professional degree in psychology who work at least 35 hours per week.

The NSF survey was revised with a new sample design in 2010, adding a fresh level of detail for CWS to examine.

"Because this is a new data set to look at salaries in psychology, we have a lot of variables that weren't available before," Lin says. For example, for professional service positions, she and her colleagues were able to analyze salaries by employment sector (public, private, nonprofit) and employer size. For psychologists in management, they could break out salaries by a person's number of direct reports. And for researchers, they could examine salaries by type of institution and research activity.

There were a few surprises in the data. For example, salaries were highest in the Middle ­Atlantic region, which includes cities with a high cost of living, such as New York and Philadelphia. But salaries were also relatively high in the Midwest—$92,000 in the West North Central area (which stretches from Kansas to Minnesota), and $91,000 in the West South Central area (which includes Texas, Arkansas, Oklahoma and Louisiana).

"That was kind of surprising at first glance," Lin says.

But, she adds, the explanation might lie in a 2014 CWS report on job ads, which found a high concentration of open positions in the center of the country.

"We haven't done a causal analysis for this, but we think it might be highly relevant—the salaries [in the Midwest] could be driven higher by demand."

Lin says that interest in the report has been high, and that CWS staff plan to produce new salary reports biannually when NSF releases new survey data.

To read the full report and access the underlying data, go to www.apa.org/workforce/publications/2015-salaries/index.aspx.

By Lea Winerman


This article was originally published in the September 2017 Monitor on Psychology

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04 Oct 2017

Boosting Productivity

Boosting Productivity

Research identifies small changes that lead to big improvements in performance

When Larry Rosen, PhD, talks to people who want to improve their productivity, he zeroes in on the importance of minimizing interruptions. Rosen, professor emeritus of psychology at California State University, Dominguez Hills, goes as far as to suggest that people put up a "do not disturb" sign when they need to focus on a task.

While this may not be plausible for everyone, Rosen's studies have shown how being distracted can become a bad habit that ultimately decreases our effectiveness at work or in school.

Fortunately, he and other psychology researchers have identified new ways to help people overcome the hurdles that stand in the way of their productivity, whether they are personal habits or environmental challenges. Here are some of those findings.

Grow your attention span

Even though technology can empower us to accomplish things faster, Rosen has found that those benefits can disappear when digital distractions are so readily available.

In one study, Rosen asked 260 middle school, high school and university students to study for 15 minutes in their homes. He found that participants averaged less than 6 minutes of studying before switching tasks, most often due to technology distractions—phones vibrating, new email alerts or instant message notifications, as well as students' "self-interruptions" to check electronic devices (Computers in Human Behavior, Vol. 29, No. 3, 2013).

While it can be tempting to think that dealing with these messages is productive, Rosen says this is a false sense of effectiveness. "We may think we are multitasking, but we are really task-switching," he says. "These interruptions take us away from the task at hand." The original task becomes less salient in our brains, and when we return, we waste time trying to remember what we were thinking when we left, Rosen explains.

To increase attention span and productivity, one of Rosen's solutions is the "technology break." He encourages students and workers to give themselves a couple of minutes to check alerts, texts and other messages after 15 minutes of undistracted work. The best way to stay focused is silencing the phone, turning it face down to avoid seeing visual notifications, turning off email alerts and closing distracting websites, Rosen says.

"Once you learn how to work for 15 minutes, start increasing the time before taking a technology break," Rosen says.

Taking short breaks not only satisfies the technology fix, but it also allows us to maintain focus, according to a study conducted by Alejandro Lleras, PhD, a psychology professor at the University of Illinois at Urbana–Champaign. He found that participants who took a short break while focusing on a visual task maintained the same level of performance for 40 minutes, but performance declined for those who didn't take any breaks (Cognition, Vol. 118, No. 3, 2010).

"We know that after about 30 minutes, concentration starts to decrease, so it's important to take small breaks to stay focused on your main task."

The results also showed that the breaks can be surprisingly short—only a couple of seconds for some tasks—to achieve this effect.

Write out your goals

Many people who work are familiar with the idea of setting goals for themselves, but achieving those goals can be elusive. Research is showing that establishing a habit of writing about goals can boost performance.

Cheryl Travers, PhD, a professor at the School of Business and Economics at Loughborough University in Leicestershire, England, asked students to identify areas where they needed to improve, such as raising a grade in a class or increasing concentration while studying. The students were asked to visualize desired outcomes and outline how they could put their goals into practice.

Then the students kept diaries for three months to reflect on their goal progress. For example, students could write down what happened as they attempted to make a change in a particular situation, what worked well or not well, what could have been done better and actions they could take going forward. Travers found that the reflective goal-related writing had a significant impact on their ability to perform better academically (British Journal of Educational Psychology, Vol. 85, No. 2, 2015).

"The act of writing something down seems to make us accountable to a goal," Travers says. "It also helps people to write their way through a problem when they encounter barriers."

By writing about successes and failures and thinking about strategies to overcome difficulties, students gained confidence in themselves and developed academic self-efficacy, Travers says. What was particularly interesting was the evidence showing that academic performance improved even for students who set nonacademic, "softer" goals, such as "increase my assertiveness" or "decrease stress."

Travers is now collecting diaries for managers in organizations, and she will be studying whether this reflective goal setting improves their effectiveness as leaders. "This process allows people to essentially become self-coaches because they are continually evaluating goal outcomes and becoming more self-aware about leader behaviors."

Get together

The idea of fitting in another meeting may seem counter-productive for people working in group settings, but research suggests that taking time to debrief as a team can improve productivity in the long run.

Michaela Schippers, PhD, a professor of behavior and performance management at the Rotterdam School of Management at Erasmus University, studied teams working in a health-care environment. She found that the groups that met regularly to evaluate work processes were much more likely to come up with innovative solutions to problems than groups that did not meet regularly. Her work has shown how this team reflexivity (reflecting on team functioning) can significantly improve work performance levels (Journal of Management, Vol.41, No. 3, 2015; Journal of Organizational Behavior, Vol. 34, No. 1, 2013).

"Workers should have regular debriefings, like in the military, but the purpose is not to point out what people are doing wrong," Schippers says. "Instead, the group can brainstorm how to improve as a team, ideally with a facilitator who is leading the meeting."

In the study, the reflexive teams talked about issues such as decreasing waiting times for patients, improving patient record systems and developing a more effective appointment system.

"Our work showed that it was very important for teams that are particularly busy to meet regularly to debrief, because these teams benefited most from the innovative improvements," Schippers says. "The meetings gave them space to think collectively about what could be changed."

Get out of the chair

Researchers are finding that employees with stand-­capable workstations may be more productive than their seated counterparts. Mark Benden, PhD, a professor in the department of environmental and occupational health at Texas A&M School of Public Health, studied two groups of call center employees over six months. One group sat at traditional desks and the other group at stations that enabled workers to elevate their tables whenever they wanted to stand. Benden found that those with stand-capable workstations stood about 1.5 hours longer per day and were 42 percent more productive than those who worked at seated desks. Productivity was measured by how many successful calls the workers completed per hour (IIE Transaction on Occupational Ergonomics and Human Factors, Vol. 4, No. 2-3, 2016).

"By being up more of the time, we improve blood flow to the brain and circulation to the body, and these things combine to make the brain more active and engaged," Benden says.

Research also suggests that it is important for people to avoid "static standing" in one place, he says. The best stand-­capable workstations have foot rails that allow workers to take weight off of one side of the body. If it's not possible to get this type of workstation, workers should take breaks to walk around and get out of the chair, Benden says.

Further reading

The Distracted Mind: Ancient Brains in a High-Tech World 
Gazzaley, A., & Rosen, L., 2016

Managing Motivation: A Manager's Guide to Diagnosing and Improving Motivation 
Pritchard R.D., & Ashwood, E.L., 2008

Evidence-Based Productivity Improvement: A Practical Guide to the Productivity Measurement and Enhancement System 
Pritchard, R.D., Weaver, S.J., & Ashwood, E.L., 2012

Future Time Perspective and Promotion Focus as Determinants of Intraindividual Change in Work Motivation 
Kooij, D.T., Bal, P.M., & Kanfer, R., Psychology and Aging, 2014

By Heather Stringer


This article was originally published in the September 2017 Monitor on Psychology

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02 Oct 2017

Using Objective Data to Improve Performance

Using Objective Data to Improve Performance

Psychologists are using biofeedback to help clients identify and change their physical responses to stress and more

When Denver sport and performance psychologist Steve Portenga, PhD, first started providing therapy to athletes, he taught them breathing and relaxation exercises to practice at home. But he often doubted whether the athletes were doing their homework correctly, if at all.

"I'd ask them how their relaxation went over the past week and was getting answers like, ‘Oh, yeah...right.'" he says. The replies left him thinking, "You didn't do it, did you?"

Then Portenga learned about biofeedback—a tool that provides empirical evidence of physiological activity, such as heart rate, breathing rate, muscle tension, skin temperature and brain wave patterns. Using sensors connected to displays, he and his clients could see how their bodies reacted to stress and to stress-reduction exercises. Athletes can also train with biofeedback apps at home and these sessions can be tracked, to see not only that they do their homework, but how well it works.

Portenga says he appreciates not just biofeedback's ability to provide accountability, but the way it has helped his athletes learn to handle competitive pressure. He has used the technique with athletes in every major professional sport, including at Super Bowls, world championships and the Olympics.

Biofeedback is an umbrella term covering several types of therapies. Common ones include heart-rate variability (HRV) biofeedback, which looks at the interval between heartbeats; electroencephalograph (EEG) biofeedback, also called neurofeedback, which focuses on brain wave activity; and electromyography biofeedback, which concentrates on muscle activity.

During biofeedback training, clients can see the response that's being measured while under simulated stress—such as by viewing a competition video or playing a challenging computer game. Biofeedback therapy holds that as people practice different responses to stress (slower breathing, for example), they can see how effective these are and adjust accordingly, which helps them learn how to better manage stress.

While large-scale research covering biofeedback's efficacy remains scant, studies have indicated biofeedback's potential in treating a variety of physical and psychological conditions. Research led by Poppy Schoenberg, PhD, now at the Vanderbilt University Osher Center for Integrative Medicine, examined 63 studies on various types of biofeedback used to treat psychiatric disorders. She found that about 81 percent of participants showed some level of improvement, with 65 percent demonstrating "statistically significant" symptom reduction (Applied Psychophysiology and Biofeedback, 2014). A meta-analysis by Richard Gevitz, PhD, a health psychology professor at Alliant International University, examined HRV biofeedback's effectiveness in treating both psychological and physical disorders. Gevitz's review of more than 55 studies found that it shows promise in treating many disorders, including asthma, cardiovascular conditions, hypertension, depression, anxiety and insomnia, and has potential for improving performance (Biofeedback, 2013).

Today, Portenga, a founding member of APA's Coalition for the Psychology of High Performance, focuses his practice on adolescent athletes and nonathletes who may be faced with stressful situations that involve being judged or evaluated, including sports competitions and school tests. A session typically includes a mix of biofeedback and psychotherapy. As such, he says, he doesn't bill separately for biofeedback, in the same way a therapist wouldn't bill separately for mindfulness training. Portenga provides detailed invoices to clients to use for insurance filing, and is paid out-of-pocket by clients.

Portenga recommends clients use biofeedback apps at home—such as Respiroguide Pro—to help them visualize their breathing, like with an image of a ball rising with each inhalation and dropping with each exhalation. This helps clients adopt slower, synchronized breathing and heart rates to evoke a calmer state of mind, which is part of HRV biofeedback training. Over time, clients become accustomed to breathing at the slower rate and have less need to use apps, Portenga says. "To be able to track this to see what's going on, to see when things are progressing and when they're not, has just been fantastic."

Beyond stress management

Leah Lagos, PsyD, a performance psychologist in private practice in New York City, has been using biofeedback in her practice for about 10 years. She has used HRV biofeedback to help post-concussion syndrome patients alleviate headache, problems concentrating and other symptoms. She is working with New York University on a study exploring the use of HRV biofeedback with this syndrome, which she explains is linked to an injury to the autonomic nervous system. "I've treated over 100 athletes [with post-concussion syndrome] and they have very similar trajectories of experience: At week four their headaches dissipate, by week seven they can focus again," says Lagos.

She's also used biofeedback to help a patient end persistent vomiting after other medical interventions didn't work, and reduced incidence of migraines in other patients.

In addition, Lagos provides biofeedback to PGA tour golfers, dancers, Olympic rowers, soccer players, track athletes, basketball players and others. She typically meets patients once a week for about 10 weeks, with sessions lasting 45 minutes to an hour, during which time she uses biofeedback as well as cognitive-behavioral skills such as mindfulness training. She also insists clients do homework: two 20-minute sessions where they practice heart-rate variability using apps, such as Heartmath and Breath Pacer.

Biofeedback can also foster other benefits, says Lagos, including improved mood, reduced anxiety, lower muscle tension and improved attention.

While she doesn't accept insurance, she has had patients tell her that sometimes they are able to get insurance coverage for their biofeedback, particularly if they are being treated for headaches, she says. One of the aspects of this training that she most treasures, she says, "is seeing how it develops the patient's confidence."

Helping Olympians master their nerves

Lindsay Thornton, EdD, is a sport psychologist and a senior sport psychophysiologist at the U.S. Olympic Committee in Colorado Springs, Colorado, working with Olympic-bound athletes in sports such as track and field and swimming. "What I'm mainly working on is managing pressure, anxiety and stress around performance," Thornton says.

Thornton counsels athletes when needed, but the bulk of her work is helping athletes prepare to compete, which often entails using biofeedback. She claims that biofeedback can provide a "faster learning curve" for athletes to learn pressure-management skills.

"Sometimes in talk therapy, we can talk, talk, talk" without being able to change behaviors, she says. "But for me, using psychophysiology as a tool has been really powerful to teach athletes skills" in ways that would be difficult to do using words alone—with a sensor on the muscle, the client can visualize what's happening and see the impact of various exercises.

Thornton primarily uses HRV biofeedback and EEG biofeedback, also called neurofeedback, which focuses on brain waves. When Thornton first sees athletes, she does a "full-cap" assessment with 19 sensors on an athlete's head to allow her to see brain-wave patterns under different conditions. For example, she'll have athletes work on virtual tasks, which enables her to see their physiological responses to stress.

With neurofeedback, clients are able to see their brainwaves displayed and to differentiate between those that occur when they are stressed or losing concentration and those that happen when they are calm and focused. Through neurofeedback training, athletes learn to modify their brainwaves and states of mind, which helps improve performance, says Thornton.

"The goal of neurofeedback training is to create an awareness over what certain mental states feel like and then to develop strategies to recreate that state under pressure or in the face of distraction," she says.

Thornton creates routines for each athlete that are rehearsed repeatedly under simulated stress conditions. Athletes may practice pre-performance rituals, for instance, that can include visualizations of their performance, breathing exercises and use of code words associated with what they expect to do (an archer may say, "smooth, shoulder, through" to reinforce upcoming actions to take).

Thornton became attracted to biofeedback during her training in sport psychology. "I wasn't sure I was always doing the right things with athletes," she says. "We were talking about muscle relaxation and visualization. The athlete might believe they were doing it correctly and I might think they were doing it correctly, but I wanted some type of assurance that we were achieving our goal." Biofeedback helps provide that objective evidence, she says.

Olympic-level athletes are fascinated by peering inside their bodies—by seeing the responses her sensors display. "They enjoy that type of feedback," she says.

Thornton has her athletes practice outside her lab with apps such as Stress Doctor, which reinforces their heart-rate variability training. But she doesn't want her clients to rely on technology, pointing out that "they can't pull out their phone on the field." So, she gradually weans them from visual and auditory feedback to just audio to no feedback at all, using only their own now-heightened body awareness.

The payoff, she says, is seeing athletes master these strategies and witnessing "the pride and comfort and confidence they have." And when the hard work she and her athletes have put in results in Olympic medals, as happened in the 2016 Rio Olympics? "It's really exciting," says Thornton.

"No Insurance Required" is a Monitor series that explores practice niches that require no reimbursement from insurance companies. To read previous installments, go to www.apa.org/monitor/digital and search for "No Insurance Required."

For a more extensive look at the research on biofeedback, visit our digital edition at www.apa.org/monitor/digital and search for "Positive Feedback" in the March 2016 issue.

Resources

Biofeedback Certification International Alliance 
BCIA.org

The Association for Applied Psychophysiology and Biofeedback Inc. 
AAPB.org

By Lorna Collier


This article was originally published in the June 2017 Monitor on Psychology

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29 Sep 2017

How Did You Get That Job? A Q&A with Sports Psychologist Dr. Nyaka NiiLampti

The knowledge, skills and experience gained through your psychology training can transfer successfully to a variety of jobs. Dr. Nyaka NiiLampti is the director of player wellness for the NFL Players Association (NFLPA), the union for professional football players. In her role, NiiLampti ensures that players are educated about the NFL’s policies for substance abuse, and provides education, resources and guidance to players in multiple areas of wellness, including mental health support.

Learn how you can apply your psychology education in a similar career path.

Nyaka NiiLamptiSpeaker:
Dr. Nyaka NiiLampti is a sports psychologist with over 15 years of experience in the field. A collegiate athlete, her senior thesis explored the psychological impacts of sports on women. She holds an M.A. in exercise and sport science (sport psychology) and a Ph.D. in counseling psychology. Before joining the NFLPA, NiiLampti worked in college counseling centers and a large group private practice, and was an assistant professor of psychology at Queens University of Charlotte in North Carolina.


Garth Fowler, PhDHost:
Garth A. Fowler, PhD, is an Associate Executive Director for Education, and the Director of the Office for Graduate and Postgraduate Education and Training at APA. He leads the Directorate’s efforts to develop resources, guidelines, and policies that promote and enhance disciplinary education and training in psychology at the graduate and postdoctoral level.

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27 Sep 2017

Coping with Challenging Clients

Coping with Challenging Clients

What to do with clients who yell at you, question your competence or just sit silently seething

Even though Seattle-area private practitioner Kirk Honda, PsyD, had been a psychotherapist for 15 years, it only took a hostile client a few minutes to make him question his own competence.

He was working with two parents and their daughter, when the father started attacking Honda, making hostile comments about his abilities as a therapist. The daughter soon joined in. "Within 15 minutes, they had completely torn apart my self-esteem," says Honda, who chairs the couple and family therapy program at Antioch University in Seattle. "I started having a mini anxiety attack. I started to sweat. I couldn't think straight. I almost ran out of the office."

Although the mother stepped in to defend Honda and they eventually repaired their therapeutic relationship, the experience left him shaken. He's not alone. Psychologists sometimes face clients who have personality disorders that prompt them to lash out, for example. Other clients may just be rude. Some — whether they're in court-mandated treatment or pushed into therapy by spouses or parents — just don't want to be in therapy. Challenging clients aren't just a problem for clinical and counseling psychologists, either. Forensic psychologists, such as those working as postdivorce parenting coordinators, can also face hostility.

Responding the wrong way — whether by pushing back at the client or withdrawing — can derail the client's progress, say Honda and others. But, they add, there are ways to use uncomfortable interactions to actually improve treatment.

How can psychologists respond effectively to challenging clients? Here's advice from practitioners who have eased stressful encounters with their clients:

Calm yourself. When faced with a challenging client or situation, you don't want to escalate the situation by reacting to it in kind, says Honda. Instead of fighting back, be aware of your emotional and physical state, such as a racing heart, surging adrenaline, confusion and dread, he says. When the father and daughter started yelling at him, for example, Honda put his head in his hands and asked them to stop talking for a few minutes so he could calm down. Without that time out, he says, "I knew I wasn't going to be able to be constructive."

Mindfulness meditation can help psychologists prepare for the anxiety, frustration and anger that challenging clients provoke, says psychologist Mitch Abblett, PhD, executive director of the Institute for Meditation and Psychotherapy in Boston. Through daily practice of mindfulness, clinicians can learn to notice sensations arising in the body and thoughts arising in the mind without judgment. They can also keep in mind the core values that undergird therapy. "If you connect with those values, it can pull you through some of these charged moments," says Abblett.

Express empathy. Don't argue or make excuses, says Honda. Instead, validate the client's feelings by saying, "You're angry with me because …." and asking "Am I hearing you right?" And even if it doesn't feel fair, says Honda, apologize, telling the client you're sorry that something you did has made them angry or that they feel you're not competent to provide the services they need. "That can not only help de-escalate the situation, but can also further the ultimate goal of providing therapy," he says.

But keep in mind that expressing empathy has to be done right or challenging clients may see it as phony, says Stanley L. Brodsky, PhD, a professor emeritus of psychology at the University of Alabama in Tuscaloosa, who also has a private practice. "Difficult, suspicious clients may be put off by expressions of empathy," he says. "One has to earn the right to be empathic with such clients and to avoid clichéd expressions."

Compassion for the client should also be accompanied by consequences, adds Abblett. "This is not a rainbows-and-unicorns passive approach," he says. Acknowledge the emotion that is driving the client's behavior, then emphasize that it's not acceptable for him or her to make threats or swear, refuse to pay for services or simply not show up, he says.

Reframe resistance. "Some clients say they really want to change, then fight every inch of the way to make sure they don't," says Fred J. Hanna, PhD, who directs the counselor education and supervision program at Adler University in Chicago and is also a faculty associate at Johns Hopkins University. But don't resist resistance, says Hanna. "When the client is resisting the therapist and the therapist starts getting irritated with the client, then you have two people resisting each other," he says. "That's not therapy; that's called war." Instead, suggests Hanna, praise the client's resistance. "I say, 'If you worked as hard to make your life better as you do to make sure nothing changes, you could be extraordinarily successful,'" he says. If a client curses at him, Hanna expresses his admiration for the client standing up for him- or herself. Doing so, he says, helps clients see that their therapists understand them.

At least rudeness gives you something to work with, adds Brodsky. Say a client attacks the way a psychologist looks. Don't react negatively, Brodsky says. Instead, encourage the client to say more about why you're so unattractive. "Once you do that, you're actually talking," says Brodsky. Plus, if clients are rude with therapists, they're often rude with others in their lives. "It lets you explore what they've done to put off other people," says Brodsky.

Cultivate patience. Psychologists should strive to be patient not only with challenging clients, but also with themselves, says Sarah A. Schnitker, PhD, an associate professor of psychology at Fuller Theological Seminary in Pasadena, California. Her research has uncovered two strategies that can help psychologists cultivate more patience. One is loving-kindness meditation, in which practitioners direct well wishes to themselves, friends and family, even their enemies. The other strategy is re-appraisal, or thinking about situations in new ways. If a client is frustrating you, remember the bigger picture — that therapy is helping to bear the burden of another person's pain, says Schnitker. "You might think, 'This is helping to test me as a clinician' or 'This is helping me develop patience, a virtue I can use in my own life.'"

Seek support from your peers. Psychologists can feel a lot of shame when they're having trouble with clients, says Honda. "A big reason for that is because people don't talk enough about their difficulties," he says. "They think they're the only ones." Sharing tales of challenging clients with other mental health professionals — while respecting confidentiality — can not only help end that isolation but also lead to constructive suggestions about how to deal with such challenges.

It can also be helpful to get a second opinion by consulting on specific cases with colleagues who are "outside the fray," says Matthew J. Sullivan, PhD, a private practitioner in Palo Alto, California. "You can touch base with them when you're feeling rattled or insecure about something you've done," he says. Even a quick phone call with a colleague can help.

Consider terminating the relationship. Clients who think a psychologist is terrible at his or her job have every right to question credentials, challenge therapeutic decisions or even decide to end the relationship, says Honda. Sometimes, he says, "it just isn't a good match."

It's also OK for a psychologist to end the relationship, says Abblett. "I talk about how it seems like we're not on the same page about our expectations of the work and our mutual responsibilities," he says. Abblett outlines what he believes his own responsibilities are toward a client, then asks the client if he's meeting them. He then tells the client what he needs from him or her. "If that can't happen, we may need to talk about a referral to someone else," says Abblett.

Additional reading

Patience and Self-Renewal 
Schnitker, S.A., Blews, A.E., & Foss, J.A. 
In the book: Clinician's Guide to Self-renewal: Essential Advice from the Field, 2014

Strategies for Working with Difficult Clients 
Sullivan, M.J. In the book: Parenting Coordination in Post-Separation Disputes: A Comprehensive Guide for Practitioners, 2014

The Heat of the Moment in Treatment: Mindful Management of Difficult Clients 
Abblett, M., 2013

Treating Reluctant and Involuntary Clients 
Brodsky, S.L., &, Titcomb, C.R. In Psychologist's Desk Reference: Third Edition, 2013

By Rebecca A. Clay


This article was originally published in the July/August 2017  Monitor on Psychology

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22 Sep 2017

Women Outnumber Men in Psychology, but Not in the Field’s Top Echelons

Women Outnumber Men in Psychology, but Not in the Field’s Top Echelons

A new APA report recommends ways to boost women's status and pay

Even as women have come to dominate psychology in terms of numbers within the educational pipeline, workforce and APA, they continue to lack equity with their male colleagues when it comes to money, power and status, according to a new report from APA's Committee on Women in Psychology (CWP).

"The Changing Gender Composition of Psychology: Update and Expansion of the 1995 Task Force Report" reviews the data and offers recommendations in such areas as education and training, employment and professional activities.

What's most surprising about the findings is how little has changed in the more than two decades since the first report, says lead author Ruth Fassinger, PhD.

While female psychologists have made gains in some areas, they have seen increasing disparities in other areas, such as salaries (see chart), which the report suggests could be partly due to the influx of young women joining the workforce for the first time.

"Women [in psychology] are still experiencing inequity," says Fassinger, a professor emerita at the University of Maryland's College of Education. "You see it everywhere: in training, in the jobs that women have and the patterns of workforce participation, and in APA itself."

Pervasive inequities

Drawing on data from APA's Center for Workforce Studies (CWS) and a literature review and analysis Fassinger conducted as a visiting scholar at APA, the report notes the dramatic growth of women's representation within psychology that began in the 1970s and 1980s. Take psychology education. Of the 70,311 students enrolled in psychology graduate programs in 2014, according to CWS data, 75 percent were women. And up to 80 percent of students in training programs focused on health service provision are women. But by the time they finish their training, the report notes, female doctoral students are already at a disadvantage, with significantly higher debt levels than their male peers, according to a CWS analysis of pooled data from 1997 to 2009.

Unequal Pay Continues

As women psychologists enter the workforce, they encounter lower salaries than men regardless of subfield. The average wage gap in starting salaries for recent doctoral grads is almost $20,000, the report points out, citing National Science Foundation (NSF) data from 2010.

One bright spot is jobs at government agencies, where women psychologists predominate and the wage gap is much smaller than in other settings. According to the NSF data, women with psychology PhDs who were working in government in 2010 made almost 92 percent of what their male counterparts made. But even that sector has seen a drop in equity along with other sectors; in 1993, women's government salaries were 94 percent of men's.

"The fact that women are accruing greater debt yet are being paid less is alarming," says Alette Coble-Temple, PsyD, chair of APA's CWP and a professor of clinical psychology at John F. Kennedy University in Pleasant Hill, California. Women who are ethnic and racial minorities and women with disabilities can face even greater disparities, she adds. Minority students finish their doctoral training with significantly more debt than white students, for example. The difference is especially pronounced among PsyD students, the report notes, citing data from 1997 to 2009 that show an average $95,000 debt for minority PsyD recipients versus $84,000 for white PsyD recipients.

Women in academia face particular challenges, the report emphasizes. It typically takes women a year longer to achieve tenure than men, for example. And even though women are flooding into the discipline, they are still underrepresented as associate professors, full professors and institutional leaders.

According to CWS data, 46 percent of all male psychology faculty in the academic year 2013–14 were full professors compared with 28 percent of female faculty, for instance. Just 16 percent of male academics were assistant professors compared with almost 28 percent of female academics. Women were also overrepresented among adjunct, nontenure-track lecturer and other temporary positions, with almost 17 percent of female faculty in these roles compared with 11 percent of male faculty. These patterns have held steady over the last two decades despite the influx of women into psychology departments.

The inequities play out within APA itself. Women now make up 58 percent of APA's membership and hold more than half of governance positions. Yet women are underrepresented when it comes to the association's top honors, participation in divisions and editorial roles. While 40 percent of those involved in the review process of APA journals are women, for instance, most are ad hoc reviewers. Just 18 percent of editors of APA journals are women.

The report acknowledges that women's choices account for some of the disparities. Women are more likely to seek PsyDs, for instance, and graduates of these programs accumulate almost twice as much debt as those of PhD programs. In addition, women practitioners are more likely to work part time, limiting their income. But, says Fassinger, these choices must be viewed within a sociocultural context that constrains women's options. "It's almost impossible to talk about things as free choice when you have all this socialization that propels people into certain directions," she says, noting that women may choose part-time work because of child-rearing obligations.

To address the disparity, the Committee on Women in Psychology recommends in the report that APA work to raise awareness and advocate for equity, pushing policies that encourage salary transparency and monitoring progress.

The report also calls for researching students' decision-making processes and interventions that could influence their decisions, such as making students at all levels aware of the wide range of meaningful careers beyond health service provision so that they can take advantage of other employment sectors where there are opportunities. Other recommendations include continuing to advocate for federal funding for trainees and early career psychologists, creating a task force to identify barriers to advancement within academia, and facilitating more mentorship for women.

The report should spur research exploring the factors that make psychology careers less attractive to men, says Paola Michelle Contreras, PsyD, of APA's CWP and an assistant professor of counseling at William James College in Newton, Massachusetts. "This is a good take-off point to get more data and learn more about the nuances," she says.

To read the full report, visit www.apa.org/women/programs/gender-composition/index.aspx.

By Rebecca A. Clay


This article was originally published in the July/August 2017 Monitor on Psychology

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21 Jul 2017

Leadership: A Three-Part Series

Leadership: A Three-Part Series

In this 3-part web series, you'll learn the fundamentals of servant leadership, a leader or an organization that seeks first to serve others. The presentations cover effective communication, managing people and processes and positively transforming people and organizations. *This series is eligible for CE credit. Earn 1 CE credit for each session.

Each program runs about 1 hour:

Leadership and Communication

No communication skill is more important than listening. Knowing the basic barriers and shortfalls of communication and doing something about them is a big step in improving our ability to communicate effectively.

Leading and Managing People and Processes

In order to accomplish a mission, establishing a process is important. However, people complete the processes and ensure the mission is accomplished. Learn the importance of maintaining a dual focus on people and processes.

Leaders Implementing Positive Change

It takes strong leadership to help people and an organization transition in order to make a change. Change is the event, transition is the means of getting there. Learn what it takes to implement positive change by focusing on the transition process.

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11 Jul 2017

Nancy Sidun Wants Psychology to Help Prevent Human Trafficking

Nancy Sidun Wants Psychology to Help Prevent Human Trafficking
Nancy Sidun
APA Fellow Nancy Sidun's clinical work has covered international relations and women's issues as well as working with the military.

What Nancy Sidun, PsyD, loves about being a psychologist is that she gets to help people attain a better life than they might otherwise have—her patients, her colleagues and the subjects of her research.

"It's hokey but true," Sidun says. As a girl, "I saw that movie, The Miracle Worker, and I was so taken by the fact that Annie Sullivan didn't give up on Helen Keller. I wanted to be like Annie Sullivan. I wanted to spend my life investing in people others thought were disposable. That's the great thing about clinical psychology. Your job is trying to empower people to be the best they can be." 

 In her own career, Sidun has followed that goal into some tough areas. In 2014, she co-chaired the APA's Task Force on Trafficking of Women and Girls after chairing a similar investigation for Division 52. "They were the ones who gave me voice" for pursuing the issue, Sidun says of the  APA’s Division of International Psychology, but "it became clear that we needed the support of the full APA" to effect any real change. She first got involved with the issue a decade ago, in part because she had adopted a daughter from China. "My God, what if her life had taken a different path?" Sidun says.

She's excited about the influence organized psychology may eventually bring to bear on human trafficking, which the task force report defines as the "economic exploitation of an individual through force, fraud or coercion."

The International Labor Organization has estimated that 12.3 million people worldwide are now living in some kind of forced servitude. Far and away, most victims are women. While many are forced into agricultural work and urban industries like sweat shops, nail salons and domestic service, the overwhelming majority are exploited sexually. In the United States, when women are trafficked for sex, the coercion is most likely psychological, a "grooming" process whereby a woman is lured into a seemingly caring relationship with a man who will put her to work for his benefit in the commercial sex trade, Sidun says.

"Psychology can do so much to help, but we're very late to the table. Every other discipline has been attending to trafficking," Sidun says.

Psychologists can help prevent trafficking by backing empowerment programs for vulnerable women, working to change the public's perceptions about the commercial sex trade to reduce demand, championing the rights of victimized women and identifying at-risk individuals in schools and other settings. Psychologists can also develop effective therapeutic interventions that will address the "extensive and complex" needs of women for whom the very concept of trust has been shredded, and evaluate governmental and nonprofit programs that have been set up to intervene.

One of the most important roles for psychologists is to educate the public and officials in the criminal justice system. People need to know how to recognize trafficking when they see it, and how to follow up with appropriate action that will lead to freeing the women and prosecuting the traffickers. When coercion is psychological, it's not always easy to understand the dynamic without some familiarity with research that has been done on the topic, which psychologists can make available and digestible. They can also testify in court.

U.S. citizens are among both the victims and the perpetrators in the trade, and American Indian women are the most disproportionately trafficked of any U.S. group, Sidun says.

Research on trafficking can be "challenging" to conduct, as there is "no typical case," according to the task force report. What traffickers have in common is their utter willingness to exploit the vulnerable. Any instability creates an opportunity for them, notably poverty, natural disasters and political conflict. Orphans are at particular risk. Only about 6 percent of individuals trafficked into the commercial sex trade in the United States are male.

Sidun says trafficking "runs the gamut from mom and pop operations to organized crime," from sophisticated international enterprises to teenaged boys pimping out their girlfriends. One study that looked at 25 pimps in Chicago found that they often have been "born and raised in an environment where people were exploited. Trafficking is safer and more lucrative than the drug trade, and [pimps] are less likely to get arrested. They often think of themselves as the good guys, protecting the girls. It's quite disturbing," Sidun says.

A New Jersey native, Sidun spent most of her adult life in Chicago, but 17 years ago moved to Hawaii. In Chicago, Sidun taught at a number of colleges, but Hawaii didn't offer the same opportunities. She worked for several years in administration and direct service with Kaiser Permanente, and then went into "telehealth." In a state with a large military presence, Sidun now treats "100 percent" of her clients remotely, via secure clinical video-teleconferencing (VTC) systems. "Most of my clients are in Korea," others are in Japan, Guam, American Samoa, Alaska, and the far-flung islands of Hawaii. Virtually all are military dependents or personnel on active duty she treats through the Pacific Regional Tele-Behavioral Health Hub at Tripler Army Medical Center in Honolulu, Sidun says.     

"For the younger generation, it's the normal way of communicating," she says. "And some of the service members are not as comfortable with emotions, so they don't mind being in an office by themselves during a session. In some ways, for them, that [remote aspect] can enhance treatments. I don't get to read the full body language, but I really like working this way."

She finds the "military culture fascinating. You have to be aware of the culture to be effective [with military clients], and I've enjoyed getting to know about that. I'll say one thing: If I give my military clients homework, it's going to get done!" she says.

In the past, some active-duty personnel may have been concerned their careers might stall if they sought help for such work-related conditions as post-traumatic stress disorder (PTSD), but Sidun thinks that now, "the military is trying to change that mindset. There are good treatments for PTSD," including prolonged exposure, cognitive processing therapy, and eye movement desensitization and reprocessing (EMDR). "They can help people," she says, adding that military officials definitely are beginning to recognize and encourage active-duty personnel to get the help they need.

Sidun is a past president of the Hawaii Psychological Association. She thinks activity in associations is "critical in protecting psychologists' interests. We watch bills in the legislature very closely, and advocate if we think we need to," she says.

Sidun also trains psychologists in self-care, and she's returning to using her early training in art therapy in this sideline. "We psychologists are bad at self-care," she says. "We take care of our patients, not so much of ourselves."

You could say Sidun is pursuing the role that led her into psychology, that of the dauntless teacher.

"I love supervision. I love training. It's my favorite thing," she says. "I think I'm a good clinician, but I have an opportunity to touch more people if I'm teaching."     

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06 Jul 2017

Improving Practice Delivery Series

Improving Practice Delivery Series

From the solo practice to the large group practice, whether for profit or not-for-profit, the concepts presented in this series can help strengthen the organization in which services are delivered. *This series is eligible for CE credit. Earn 1 CE credit for each session.

The four 90-minute programs focus on:

How to Create and Implement a Vision for Your Practice

Learn about creating an over-arching vision for your practice and how to use it to guide both clinical and practice/administrative decisions.

Managing Staff and Organizations in Support of Practice Excellence

Learn how to promote excellence in service delivery via employment contracts, policies and procedures, and mentoring to advance staff development.

Expanding the Scope of Your Practice to Address the Needs of the Community

Keep your practice relevant by positioning it to meet the changing needs of the community you serve.

Practice Health Metrics

Keep your practice thriving and growing by tracking your basic metrics (accounts receivables, referral patterns, productivity, etc.), thus assuring the overall health of the practice for the future.

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