20 Jun 2017

Care and Legal Help for Patients in Need

Care and Legal Help for Patients in Need

Medical-legal partnerships are bringing lawyers and paralegals to health-care teams to improve the health and well-being of underserved populations

When Jack Tsai, PhD, treats veterans at the VA Connecticut Healthcare System, they often have problems that go beyond the scope of his work as a psychologist. Many have post-traumatic stress disorder or cognitive disabilities and are fighting for disability benefits. Others are embroiled in housing disputes, are facing eviction or have already become homeless.

While psychologists can treat their mental health concerns, these veterans need legal help, too. "A lot of these patients have never had anyone advocate for them in court," says Tsai, who has dual appointments at the VA and the Yale School of Medicine.

Enter the medical-legal partnership, or MLP, a model that embeds lawyers and paralegals into health-care teams to detect, address and prevent social conditions that harm health. Those legal experts typically work on-site in health-care settings, either part time or full time, where they can access patients' medical records and even sit in on clinical meetings. The legal services are offered at no charge to the patient. Programs are typically funded through a combination of philanthropy, law schools and civil legal aid agencies, with a handful of contributions from health-care partners.

Psychologists are obvious candidates for getting involved in MLPs, Tsai says. They already have long-term relationships with their clients and understand how their legal problems might be interfering with their mental health and well-being. Plus, psychologists are often accustomed to working on interdisciplinary teams.

Unlike sending patients to a legal aid clinic, Tsai adds, the process is streamlined when the legal team is located inside the hospital. "We can walk patients down the hall and do a warm handoff," he says.

Helping underserved populations

The current MLP model was developed at the Boston Medical Center in 1993 but didn't begin to catch on until the late 2000s when it was embraced by the American Medical Association and the American Academy of Pediatrics. To date, nearly 300 hospitals and health centers nationwide have developed MLPs, according to the National Center for Medical-Legal Partnership.

Adding a legal expert to the team helps underserved populations in a variety of ways: They can help patients apply for food stamps and disability benefits; press landlords to improve substandard housing; help tenants avoid eviction; advocate for special education services; fight employment discrimination; and assist with issues related to immigration, child custody and domestic violence—just some of the many factors that can undermine a patient's health.

"I can't imagine what things would be like without having the MLP, because they do so much," says Britt Nielsen, PsyD, an associate professor at Case Western Reserve University and clinical psychologist at MetroHealth Medical Center in Cleveland. In 2015, the MetroHealth MLP provided assistance to 839 people. Of those, 43 percent had mental health disorders.

MetroHealth began its MLP program 14 years ago in the pediatrics department, Nielsen says. Though it has since expanded to assist adult patients as well, advocating for kids is still a focus. "We do a lot of advocacy as psychologists, talking to teachers or writing letters to a patient's school," Nielsen says. "But MLPs have a great working knowledge of the law, and the things they're able to do go beyond what I can do in a phone call or a letter."

Often, families in underserved populations don't understand what rights they have when it comes to education, living arrangements or Supplemental Security Income, she adds. In addition to helping families directly with legal issues, she says, the MLP has also made physicians more aware of patients' rights, helping to ensure more patients get the services and support they need.

In some cases, MLPs highlight a bigger need that goes beyond a single patient. Nielsen points to a case where a local school district wasn't providing students with the special education services required by law. "The MLP was able to take the district to court and get restitution for those families," she says.

Need for data

While anecdotal evidence suggests MLPs are valuable, few studies have assessed their effectiveness. The National Center for Medical-Legal Partnership is developing metrics to systematically measure the effects of MLPs on patient well-being and health-care costs. Meanwhile, some smaller studies have found the partnerships provide benefits.

A study by Mary M. O'Sullivan, MD, at St. Luke's-Roosevelt Hospital Center in New York City, and colleagues found asthma patients had reductions in asthma medications and their hospital admissions and emergency room visits declined after an MLP was put into place (Journal of Asthma, 2012). And a pilot study of a Tucson-based MLP by Anne M. Ryan, JD, and colleagues at the University of Arizona found patients' perceived stress levels decreased and overall well-being increased after receiving help from an MLP (Journal of Health Care for the Poor and Underserved, 2012).

Evidence also suggests that MLPs make economic sense. In one example, Kerry J. Rodabaugh, MD, at the University of Nebraska Medical Center, and colleagues studied the benefits of an MLP for cancer patients and their health-care institution. Between April 2004 and December 2007, the program assisted terminal patients with legal issues such as guardianship, estate planning and benefits advocacy. During that period, the MLP helped overturn denials of insurance benefits for 17 patients, preventing economic hardship for patients while recovering $923,188 in reimbursements to the hospital (Journal of Palliative Medicine, 2010).

Tsai and his colleagues recently received a grant from the Bristol-Myers Squibb Foundation to evaluate whether the MLP model improves mental health and quality of life for patients at four VA sites in Connecticut and New York over the next two years. Aside from his study, however, little research has been done focusing on the mental health benefits of such programs, he says.

Those data are sorely needed, says Tsai, especially as many MLPs are struggling to find funding through grants and donations. "There's huge potential for mental health researchers to help these legal clinics collect data and evaluate outcomes," he says. "It's an area ripe for psychologists."

For more information on medical-legal partnerships, visit the National Center for Medical-Legal Partnership http://medical-legalpartnership.org.

To watch a video on how medical-legal partnerships work, go to www.youtube.com/watch?v=NdvE5wbumYw.

When Jack Tsai, PhD, treats veterans at the VA Connecticut Healthcare System, they often have problems that go beyond the scope of his work as a psychologist. Many have post-traumatic stress disorder or cognitive disabilities and are fighting for disability benefits. Others are embroiled in housing disputes, are facing eviction or have already become homeless.

While psychologists can treat their mental health concerns, these veterans need legal help, too. "A lot of these patients have never had anyone advocate for them in court," says Tsai, who has dual appointments at the VA and the Yale School of Medicine.

Enter the medical-legal partnership, or MLP, a model that embeds lawyers and paralegals into health-care teams to detect, address and prevent social conditions that harm health. Those legal experts typically work on-site in health-care settings, either part time or full time, where they can access patients' medical records and even sit in on clinical meetings. The legal services are offered at no charge to the patient. Programs are typically funded through a combination of philanthropy, law schools and civil legal aid agencies, with a handful of contributions from health-care partners.

Psychologists are obvious candidates for getting involved in MLPs, Tsai says. They already have long-term relationships with their clients and understand how their legal problems might be interfering with their mental health and well-being. Plus, psychologists are often accustomed to working on interdisciplinary teams.

Unlike sending patients to a legal aid clinic, Tsai adds, the process is streamlined when the legal team is located inside the hospital. "We can walk patients down the hall and do a warm handoff," he says.

Helping underserved populations

The current MLP model was developed at the Boston Medical Center in 1993 but didn't begin to catch on until the late 2000s when it was embraced by the American Medical Association and the American Academy of Pediatrics. To date, nearly 300 hospitals and health centers nationwide have developed MLPs, according to the National Center for Medical-Legal Partnership.

Adding a legal expert to the team helps underserved populations in a variety of ways: They can help patients apply for food stamps and disability benefits; press landlords to improve substandard housing; help tenants avoid eviction; advocate for special education services; fight employment discrimination; and assist with issues related to immigration, child custody and domestic violence—just some of the many factors that can undermine a patient's health.

"I can't imagine what things would be like without having the MLP, because they do so much," says Britt Nielsen, PsyD, an associate professor at Case Western Reserve University and clinical psychologist at MetroHealth Medical Center in Cleveland. In 2015, the MetroHealth MLP provided assistance to 839 people. Of those, 43 percent had mental health disorders.

MetroHealth began its MLP program 14 years ago in the pediatrics department, Nielsen says. Though it has since expanded to assist adult patients as well, advocating for kids is still a focus. "We do a lot of advocacy as psychologists, talking to teachers or writing letters to a patient's school," Nielsen says. "But MLPs have a great working knowledge of the law, and the things they're able to do go beyond what I can do in a phone call or a letter."

Often, families in underserved populations don't understand what rights they have when it comes to education, living arrangements or Supplemental Security Income, she adds. In addition to helping families directly with legal issues, she says, the MLP has also made physicians more aware of patients' rights, helping to ensure more patients get the services and support they need.

In some cases, MLPs highlight a bigger need that goes beyond a single patient. Nielsen points to a case where a local school district wasn't providing students with the special education services required by law. "The MLP was able to take the district to court and get restitution for those families," she says.

Need for data

While anecdotal evidence suggests MLPs are valuable, few studies have assessed their effectiveness. The National Center for Medical-Legal Partnership is developing metrics to systematically measure the effects of MLPs on patient well-being and health-care costs. Meanwhile, some smaller studies have found the partnerships provide benefits.

A study by Mary M. O'Sullivan, MD, at St. Luke's-Roosevelt Hospital Center in New York City, and colleagues found asthma patients had reductions in asthma medications and their hospital admissions and emergency room visits declined after an MLP was put into place (Journal of Asthma, 2012). And a pilot study of a Tucson-based MLP by Anne M. Ryan, JD, and colleagues at the University of Arizona found patients' perceived stress levels decreased and overall well-being increased after receiving help from an MLP (Journal of Health Care for the Poor and Underserved, 2012).

Evidence also suggests that MLPs make economic sense. In one example, Kerry J. Rodabaugh, MD, at the University of Nebraska Medical Center, and colleagues studied the benefits of an MLP for cancer patients and their health-care institution. Between April 2004 and December 2007, the program assisted terminal patients with legal issues such as guardianship, estate planning and benefits advocacy. During that period, the MLP helped overturn denials of insurance benefits for 17 patients, preventing economic hardship for patients while recovering $923,188 in reimbursements to the hospital (Journal of Palliative Medicine, 2010).

Tsai and his colleagues recently received a grant from the Bristol-Myers Squibb Foundation to evaluate whether the MLP model improves mental health and quality of life for patients at four VA sites in Connecticut and New York over the next two years. Aside from his study, however, little research has been done focusing on the mental health benefits of such programs, he says.

Those data are sorely needed, says Tsai, especially as many MLPs are struggling to find funding through grants and donations. "There's huge potential for mental health researchers to help these legal clinics collect data and evaluate outcomes," he says. "It's an area ripe for psychologists."

For more information on medical-legal partnerships, visit the National Center for Medical-Legal Partnership http://medical-legalpartnership.org.

To watch a video on how medical-legal partnerships work, go to www.youtube.com/watch?v=NdvE5wbumYw.

Additional reading

  • Medical-Legal Partnerships: Transforming Primary Care by Addressing the Legal Needs of Vulnerable Populations, Sandel, M., Hansen, M., Kahn, R., Lawton, E., Paul, E., Parker, V., Morton, S., and Zuckerman, B. Health Affairs, 2010
  • The State of the Medical-Legal Partnership Field: Findings from the 2015 National Center for Medical-Legal Partnership Surveys, Regenstein, M., Sharac, J., and Trott, J.

By Kirsten Weir 


This article was originally published in the November 2016 Monitor on Psychology

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20 Jun 2017

NIH Toolbox Offers Easier Data Collection

NIH Toolbox Offers Easier Data Collection

The set of measures is useful for both researchers and clinicians alike—and can save money and time over traditional tools

For years, neurobehavioral researchers often couldn't compare data across studies or even within the same longitudinal study because they lacked a "common currency" for collecting data on various aspects of research participants' functioning.

"People used all sorts of different measures and assessments," says Molly V. Wagster, PhD, a psychologist who heads the behavioral and systems neuroscience branch in the National Institute on Aging's neuroscience division. And because there were different tests for different age groups, she says, "people had to resort to all sorts of different measures to follow someone over a period of time." Plus, she adds, researchers looking for quick-and-easy assessments sometimes resorted to tools designed for diagnosing disorders, not assessing function.

Now all that has changed, thanks to the National Institutes of Health's creation of the NIH Toolbox® for Assessment of Neurological and Behavioral Function. Developed by more than 250 scientists, many of them psychologists, the toolbox offers brief measures—some already existing and some created especially for the project—for assessing cognitive, emotional, sensory and motor functioning in research participants ages 3 to 85.

Introduced in 2012 and adapted for the iPad in 2015, the NIH Toolbox offers researchers a comprehensive set of tools for collecting data that can be compared across existing and future studies, says Wagster, the lead federal project officer for the toolbox.

The NIH Toolbox saves researchers time, says psychologist Richard C. Gershon, PhD, the NIH Toolbox's principal investigator and a professor at Northwestern University's Feinberg School of Medicine. "You can administer the equivalent of a one- or two-day neuropsych battery in two hours," says Gershon. The complete cognition battery can be administered in about 30 minutes.

The toolbox can also save money, says Gershon. Take the test used to assess people's sense of balance, which could be used to gauge older people's risk of falling. "Our test arguably replaces between $10,000 and $100,000 worth of equipment with a $160 iPad," he says.

Clinical psychologists could find the NIH Toolbox useful, too, says Abigail B. Sivan, PhD, an associate professor of clinical psychiatry and behavioral sciences at Northwestern, who helped develop it. In the future, a clinical psychologist might use the toolbox's assessments to help distinguish between attention-deficit/hyperactivity disorder and anxiety, for example, or between Alzheimer's disease and normal age-related changes in memory, she says. Clinicians could also use the NIH Toolbox to track patients' progress over time, she says.

Available as an app at iTunes, the NIH Toolbox can be downloaded on up to 10 iPads for an annual subscription fee of $500. Users can try it out for free for 60 days.

For more information, visit www.nihtoolbox.org.

By Rebecca  A. Clay


This article was originally published in the December 2016 Monitor on Psychology

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20 Jun 2017

New Licensure Test on the Horizon

New Licensure Test on the Horizon

A new licensure test is on the horizon. What is it and why is it necessary?

The Association of State and Provincial Psychology Boards (ASPPB) announced in March that its board of directors had approved a plan to develop an additional licensure exam that would complement the existing test. The new exam, called the EPPP (Examination of Professional Practice in Psychology) Step 2, would focus on assessing skills, while the existing EPPP would continue to test knowledge.

The announcement about the EPPP-2, which may become a requirement as early as January 2019, is evoking mixed responses in the psychology community.  

"I can definitely support the idea that there is a need to test skills because there are inconsistencies in training, but I'm worried that it will be expensive and yet another hoop that students are going to have to deal with," says Christine Jehu, PhD, chair of the American Psychological Association of Graduate Students (APAGS).

For others, the announcement was primarily welcome and perhaps long overdue news. "The competency movement has been going on for 30 years in psychology, and this new test is very consistent with a number of initiatives APA has been involved with," says Catherine Grus, PhD, deputy director of APA's Education Directorate.

In 2004, for example, APA formed a task force that studied then-current practices in competency assessment within psychology and other health professions. Two years later, the group released a report recommending that psychology develop a mechanism to test knowledge, skills and attitudes. The EPPP tests knowledge, but not skills and attitudes, Grus says.

"There are hundreds of different psychology training programs and practicum and internship sites, all with different supervisors and no common standard," says ASPPB CEO Stephen DeMers, EdD. "We have to find a way to keep the process of education credible and the profession relevant."

While APA accreditation holds schools to a certain standard of education, relatively few states have licensing laws that require psychologists to graduate from an accredited school. Even if all states required graduation from an accredited program, the field still needs to develop a method of screening candidates for licensure, DeMers says. "Accreditation evaluates an entire program, but licensure depends on competency of an individual," he says.

A test of skills is also in line with competency testing models used for other medical professionals such as MDs, says Eddy Ameen, PhD, director of APA's Office on Early Career Psychologists. "Proper competency assessment is an important part of what it means to be a psychologist. It ensures that all who treat the public have a minimum universal skill set."  

DeMers hopes that the EPPP Step 2 ultimately will help psychologists increase their clout when lobbying third-party payers for reimbursement coverage and government agencies for federal programs. "I think we lose opportunities in these areas when we are not demonstrating a maintenance of competence," he says. "For that reason, I think this change is exciting and also necessary." 

The path to a new test

The ASPPB initially explored the idea of developing a skill-based exam in the 1990s when it investigated an approach called latent image testing that was touted as a method of evaluating an applicant's decision-making process during a practice scenario. It was a paper-and-pencil version of today's electronic adaptive testing, which tracks the number of correct responses and how efficiently people move through a test. ASPPB abandoned the idea because it was cumbersome and did not seem to adequately assess the complex decision-making involved in psychology treatment scenarios, DeMers says.

ASPPB revisited the concept of competency testing about eight years ago, and in 2010, appointed a task force to review the literature on the topic. The group started gathering information from other professions (such as medicine, nursing and pharmacy) that were already involved in skill-based assessments and surveyed licensed psychologists to determine the criteria for the skills testing.

The task force suggested that ASPPB move forward with developing a skill-based test that would assess competency in the following areas: scientific orientation, professional practice, relational competence, professionalism, ethical practice and systems thinking.

Who, when and how much?

While there may be advantages to updating the licensing process, ASPPB recognizes another expensive test may seem daunting to new graduates. Many new graduates already carry considerable debt and are paying multiple fees for state boards where they are applying to practice, Jehu says.

ASPPB's goal is to keep the cost of Step 2 comparable to the EPPP, which is about $700, DeMers says. This will be challenging because the new test will likely use more expensive technology than Step 1, such as computer-based simulation, taped scenarios and possibly avatars.

"There will be a lot of upfront costs, but this has to happen and it's our job to make it as low-cost as possible," DeMers says.

In addition to cost concerns, some early career psychologists question whether it is wise to wait until the conclusion of training to weed out potentially incompetent psychologists. "If the goal is to be consistent with other degree programs, then why would we wait until so much later than medical programs, which test individuals throughout their training program as a uniform national standard?" says Samantha Rafie, PhD, an early career psychologist at Bay Area Pain and Wellness Center in California.

DeMers says that once the EPPP-2 is available, it may be possible to begin offering Step 1 before internship. This would mean the first test could be given immediately following coursework when knowledge is easier to recall. This could potentially reduce the need for people to spend money on expensive test preparation materials, he says.

"Moving the first test earlier could also allow students to use loan money to help cover the cost of the test," Jehu says. "There would also be more peer support when studying for the test if students are still at school."

Another question within the psychology community is who will be required to take the test. Rafie is already licensed, and she is concerned that she would have to take EPPP-2 if she wanted to move outside of California to practice. ASPPB will recommend that its member jurisdictions not require Step 2 for previously licensed psychologists with no record of complaints or discipline, DeMers says. For those who will be seeking a license after Step 2 is required, ASPPB will recommend to its member groups that psychologists only take it once to work in any state or Canadian province.

What's next

Before ASPPB will be ready to start offering the test, the organization needs to develop a blueprint for the exam, train psychologists to write the questions and conduct beta testing. They welcome help from psychologists who are interested in writing questions for the test or beta testing it. People interested in helping can email ASPPB Chief Operating Officer Carol Webb at cwebb@asppb.org.

Although the Step 2 is a costly and time-consuming endeavor for both ASPPB and graduates of the future, Grus is optimistic that advantages of updating the testing process will be felt throughout the psychology community.

"ASPPB has to be responsive to a society that trusts psychology to be a profession that is populated by individuals who are well trained," Grus says. "I think Step 2 will establish that psychologists are holding themselves accountable and we value our profession."

By Heather Stringer


This article was originally published in the July/August 2016 Monitor on Psychology

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19 Jun 2017

Managing Staff and Organizations in Support of Practice Excellence

Whether you have one part-time clinical or administrative staff member, or you are an owner of a large inter-disciplinary group, you are an employer. Having employees (or independent contractors) adds complexity and responsibility. This webinar focuses on addressing these demands to promote excellence in service delivery via employment contracts, policies and procedures, and mentoring to promote staff development. During this presentation you will learn the following:

• Your practice as an employer
• Are you a "family"? - The importance of contracts, policies and procedures
• Integrating your vision into management decisions
• Hiring staff (challenges, 1099 or W-2, compensation and benefits)
• Ethical and regulatory compliance (HIPAA, 1099, interviewing, sexual harassment, etc.)
• Mentorship and staff development (administrative and clinical)

Learning Objectives 1
List the advantages of having contracts as well as policies and procedures as part of the administrative structure of their practice.

Learning Objective 2
Describe the intersection of running a practice with professional ethics and regulatory obligations.

Learning Objective 3
Discuss the importance of effectively mentoring staff and promoting staff development.

*This program does not offer CE credit.

ZimmermanPresenter
Dr. Jeff Zimmerman has been in independent practice for over 35 years in solo practice and as founding and managing partner of an inter-disciplinary multi-site group. Dr. Zimmerman is a founding partner of The Practice Institute, LLC. He is President of the Society for the Advancement of Psychotherapy, Division 29. Dr. Zimmerman is co-author of The Ethics of Private Practice: A Guide for Mental Health Clinicians. He is co-editor of a soon to be released book entitled the Handbook of Private Practice: Keys to Success for Mental Health Practitioners and is Editor of Practice Innovations, the journal of Division 42.

 

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06 Jun 2017

Protecting Patient Privacy When the Court Calls

Protecting Patient Privacy When the Court Calls

Psychologists are obligated to protect their clients' records. So what do they do when they are presented with a subpoena or asked to testify?

Over the course of their careers, many psychologists will receive subpoenas directing them to disclose or testify about a client's records or test data. Such requests can put psychologists in a quandary: As practitioners, they are well versed in the ethical, professional and legal obligations related to maintaining patient confidentiality, so how can they release such records?

In an effort to guide psychologists in this area, APA's Committee on Legal Issues recently updated its article on understanding subpoenas, seeking to offer strategies that psychologists may use to respond to subpoenas or compelled court testimony. While this article is not intended to establish standards of care or conduct for practitioners, it seeks to address several common questions psychologists have when responding to such legal requests. It is important to note that this article does not provide legal advice, nor is it intended to be or substitute for the advice of an attorney.

Psychologists who receive a subpoena or other legal process that requires or is likely to require production of client/patient records or test data, manuals, protocols, or other test information are encouraged to consult legal counsel who can review the pertinent law and facts and provide appropriate legal assistance.

Understanding subpoenas

From the legal system's perspective, the more relevant information that a judge or jury considers in a court case, the fairer the decision. To obtain this material, the court may issue subpoenas (legal commands to appear to provide testimony) or subpoenas duces tecum (legal commands to appear and bring along specific documents). A court may also issue a court order requiring a party to provide testimony or produce documents.

Unless the issuing attorney or court excuses the psychologist, the psychologist must respond to a subpoena — that is, to be at a particular place at a particular time. Responding to the subpoena, however, does not necessarily mean that the psychologist must disclose confidential information requested in the subpoena. Before a psychologist does so, he or she should ensure that the subpoena is valid and that the conditions for disclosing confidential information are met — such as with a client's consent, a protective order or other legal mandate. In contrast to a subpoena, when a court order for testimony or documents is issued and any attempt to have the court vacate or modify its order has been unsuccessful, a psychologist may be held in contempt of court if he or she fails to comply with the court order.

Unfortunately, the demands of the legal system may conflict with psychologists' responsibility to maintain client confidentiality. This responsibility arises from tenets of good clinical practice, ethical standards, professional licensing laws, and other applicable statutes and legal precedent. In many contexts, client information may also fall under an evidentiary privilege, which protects the client information from being considered as evidence by the legal fact-finder in the case.

Most state and federal jurisdictions allow a client to prevent confidential material that he or she has conveyed to a psychologist from being communicated to others in legal settings, but there are some variations from state to state and between some state and federal courts, and there are significant exceptions (such as cases where the client herself has put her mental health at issue in the litigation). In general, the psychologist has a responsibility to maintain confidentiality and to assert the psychotherapist–patient privilege on behalf of the client unless the client has explicitly waived privilege or signed a valid release, a legally recognized exception to privilege exists, or the court orders the psychologist to turn over the client's information.

The clinical record, any separately kept psychotherapy notes, client information forms, billing records and other such information usually may be turned over to the court with appropriate authorization by the client or with a court order. Psychologists required to comply with provisions of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) would need a HIPAA-compliant authorization form to release such information, and a separate authorization for release of psychotherapy notes if those notes are developed in strict compliance with the HIPAA definition of psychotherapy notes.

Otherwise, notes of psychotherapy sessions are treated in the same manner as the remainder of the clinical record or file. In cases in which clients do not authorize release of their records, HIPAA details procedures that a psychologist may follow upon receiving a subpoena not accompanied by a court order to disclose those materials. These issues emphasize an important practice tip: At the beginning of treatment, psychologists should inform their clients in the informed consent document and first session discussions of the risk that their confidential information may be disclosed in response to a subpoena or court order.

A request for psychological test data and test materials present other concerns. Although a client's test data (including raw and scaled scores and client responses to test questions or stimuli) may be released in response to a proper subpoena, the disclosure of test materials (including manuals, instruments, protocols and test questions) may require the safeguard of a protective order from the court. The APA Ethics Code requires psychologists to "make reasonable efforts to maintain the integrity and security of test materials and other assessment techniques consistent with law . . ." in order to not threaten the validity of psychological tests and their value as a measurement tools (APA Ethics Code, Standards 9.04, 9.11).

Psychologists have numerous ethical, professional and legal obligations related to the release of client records, test data and other information in the legal context. Many of these obligations may favor disclosure, including, in particular, the general obligation of all citizens to give truthful and complete testimony when required to do so. But there are often conflicting duties and principles that favor withholding such information. These may include obligations to:

  • Clients or other individuals who receive treatment and/or are given psychological tests.
  • The public (to avoid public dissemination of test items, questions, protocols or other test information that could adversely affect the integrity and continued validity of tests).
  • Test publishers, including contractual obligations between the psychologist and test publishers not to disclose test information and obligations under the copyright laws.
  • Other third parties, such as employers.

A special type of third-party obligation may arise in forensic contexts if, for example, a psychologist performed work with a litigant for an attorney. In such cases, the key concern is whether records from that work with the litigant is protected from disclosure under the attorney work product privilege.

Strategies for dealing with subpoenas

Psychologists, in consultation with an attorney if needed, should consider six strategies when issued a subpoena:

1. Determine whether the request for information carries the force of law

The psychologist must establish whether he or she has received a legally valid demand for disclosing test data and client records. For example, to be valid, a subpoena should generally allow sufficient time to respond to the demand for materials and provide for some time for the opposing side to quash such a demand if appropriate. If a demand is not legally enforceable for any reason, then the psychologist has no legal obligation to comply with it and may have no legal obligation to respond.

Even a demand that claims to be legally enforceable may not be. For example, the court issuing the subpoena may not have jurisdiction over the psychologist or his or her records: A subpoena issued in one state, for example, may not be legally binding on a psychologist who lives and works in another state. Or, the subpoena may not have been properly served to the psychologist — some states may require service in person or by certified mail. A psychologist should consult with an attorney in making such a determination.

If the psychologist concludes that the demand is legally valid, then a formal response to the attorney or court is required, whether it is compliance with or opposition to the demand, in whole or in part. A psychologist's obligation to respond to the subpoena is not necessarily the same as those under a court order (see below under "File a motion to quash the subpoena or file a protective order").

2. Contact the client

Clients may have a legally protected interest in preserving the confidentiality of their records. So, if a psychologist receives a subpoena or notice requiring that he or she divulge a client's records or test data, the psychologist may discuss the implications of the demand with the client (or his or her legal guardian). The psychologist may also consult with the client's attorney when appropriate and with the client's valid consent.

When talking with the client, the psychologist should explain which information has been demanded, the purpose of the demand, the entities or individuals to whom the information is to be provided, and the possible scope of further disclosure by those entities or individuals. After that discussion, a legally competent client or the client's legal guardian may consent to allow the psychologist to produce the data. Generally, such consent is required to be in writing, which helps to avoid future conflicts or legal entanglements with the client over the release of confidential tests or other records. The client's consent may not, however, resolve the potential confidentiality claims of third parties (such as test publishers).

The psychologist may want to emphasize to the client that when he or she agrees to release information requested, he or she cannot specify or limit which information is released. Rather, the entire record — including psychotherapy notes, billing records, administrative notes and more — will be available. The scope of the release may be the subject of negotiation among attorneys, however, so if the psychologist believes that a release would harm the client, he or she should voice his or her concerns and object to the release on that basis.

3. Negotiate with the requester

If a client does not consent to release the requested information, the psychologist — often through counsel — may seek to prevent disclosure through discussions with legal counsel for the requesting party. The psychologist's position in such discussions may be bolstered by legal arguments against disclosure, including the psychologist's duties under evidence rules regarding psychotherapist–patient privilege. These rules often allow the psychologist to assert privilege on behalf of the client in the absence of a specific release or court order. (Some possible arguments are outlined in the section below, "Consider possible grounds for opposing or limiting production of client records or test data.") Such negotiations may explore whether there are ways to achieve the requesting party's objectives without divulging confidential information, perhaps by disclosing nonconfidential materials instead. Psychologists may also be able to negotiate to avoid compelled testimony.

4. File a motion to quash the subpoena or file a protective order

If negotiation is not successful, it may be necessary to file a motion for relief from the obligations imposed by the demand for confidential records.

motion to quash is a formal application made to a court or judge to have a subpoena vacated or declared invalid. There may be grounds for asserting that the subpoena or request for testimony should be quashed, in whole or in part. For example, the information sought may be protected by the psychotherapist–client privilege and therefore may not be subject to discovery, or it may not be relevant to the issues before the court (see below in the section "Consider possible grounds for opposing or limiting production of client records or test data"). This strategy may be used alone or in combination with a motion for a protective order.

A motion for a protective order assumes that the psychologist will produce the information asked for by the subpoena but asks that the court protect it from the untoward consequences of disclosing information. The primary focus of this strategy is to prevent or limit the number of people who see sensitive client and test information. A motion for protective order can establish procedures to note the materials as confidential and have them placed under seal, which prevents their disclosure to the public.

Generally, the motion may state that the psychologist is ethically obligated not to produce the confidential records or test data or to testify, unless compelled by the court or with the consent of the client. It may include a request that the court consider the psychologist's obligations to adhere to federal requirements (such as HIPAA) and to protect the interests of the client, the interests of third parties (such as test publishers), and the public's interest in preserving the integrity and continued validity of the tests themselves. The motion might also attempt to suggest ways to minimize the adverse consequences of a disclosure. For example, the psychologist may suggest that the court:

  • Direct the psychologist to provide test data only to another appropriately qualified professional designated by the court or by the party seeking the information.
  • Limit the use of client records or test data to prevent wide dissemination. For example, the court might order that the information be delivered to the court, be kept under seal, and be used solely for the purposes of the litigation and that all copies of the data be returned to the psychologist after the litigation is terminated.
  • Limit the categories of information that must be produced. For example, client records may contain confidential information about a third party, such as a spouse, who may have independent interests in maintaining confidentiality, and such data may be of minimal or no relevance to the issues before the court.
  • Determine for itself, through a nonpublic hearing or a review by the judge in chambers, whether the use of the client records or test data is relevant to the issues before the court or whether they might be insulated from disclosure, in whole or in part, by the therapist–client privilege or another privilege (such as attorney–client privilege).
  • Deny or limit the demand because it is unduly burdensome on the psychologist (see, e.g., Federal Rule of Civil Procedure 45(c)).
  • Shield "psychotherapy notes" if the psychologist keeps separate psychotherapy notes as defined by the Privacy Rule (see Security and Privacy, 2015).
5. Determine whether to testify

If a psychologist is asked to disclose confidential information during questioning at a deposition, he or she may refuse to answer the question only if the information is privileged. If there is a reasonable basis for asserting a privilege, the psychologist may refuse to provide test data or client records until ordered to by the court.

A psychologist who refuses to answer questions without a reasonable basis may be penalized by the court, which may include requiring the psychologist to pay the requesting parties' costs and fees in obtaining court enforcement of the subpoena. For these reasons, it is advisable that a psychologist be represented by his or her own counsel at the deposition.

6. Consider possible grounds for opposing or limiting production of client records or test data

There are several options for resisting a demand to produce confidential client information. They include that:

  • The court does not have jurisdiction over the psychologist, the client records, or the test data or the psychologist did not receive a legally sufficient demand asking him or her to produce the information.
  • The psychologist does not have custody or control of the records or test data that are sought — for example, they may belong to the psychologist's employer, not to the psychologist.
  • The therapist–client privilege insulates the records or test data from disclosure. The rationale for the privilege, recognized in many states, is that the openness necessary for effective therapy requires clients to expect that all records of therapy, contents of therapeutic disclosures and test data will remain confidential. Disclosure would be a serious invasion of the client's privacy. The psychologist is under an ethical obligation to protect the client's reasonable expectations of confidentiality (APA Ethics Code, Ethical Standards, Section 4). There are important exceptions to this protection that negate the privilege. For example, if a client or former client is a party to the litigation and has raised his or her mental state as an issue in the proceeding, the client may have waived the psychotherapist-patient privilege. This varies by jurisdiction, with most jurisdictions holding a broad patient-litigant exception to privilege, with a few construing the patient-litigant exception much more narrowly. It is important that the psychologist be aware of the law in the relevant jurisdiction since this may ultimately control the issue about release of (otherwise) confidential client information. In this circumstance, the fact that a client who is a party to a legal case does not want to consent to release of information may not ultimately be dispositive on the issue. In such a case, the psychologist should discuss the issue of potential patient-litigant exception with the client's attorney, to determine if the records will need to be turned over due to the exception and to obtain any needed authorizations from the client.
  • The information sought is not relevant to the issues before the court.
  • Public dissemination of test information, such as manuals or protocols, may harm the public interest because it may affect responses of future test populations.
  • Test publishers have an interest in the protection of test information, and the psychologist may have a contractual or other legal obligation (e.g., copyright laws) not to disclose such information.
  • Psychologists have an ethical obligation to protect the integrity and security of test information and data, including protecting the intellectual property and unauthorized test disclosure, and to avoid misuse of assessment techniques and data. Psychologists are also ethically obligated to take reasonable steps to prevent others from misusing such information.
  • Some court rules allow the party receiving the subpoena to object to the subpoena's demand or ask that the demand be limited on the basis that it imposes an undue burden on the recipient (see, e.g., Rule 45(c) of the Federal Rules of Civil Procedure, 2014).

Ultimately, the judge's ruling controls in a court. Psychologists who are not violating human rights and who take reasonable steps to follow Standard 1.02 of the Ethics Code and inform the court of their requirements under the Ethics Code will not be subject to disciplinary procedures for complying with a court order directing them to produce information. Protecting patient privacy when the court calls can be complicated. To respond appropriately, psychologists should weigh ethical responsibilities and legal demands. Psychologists who have questions should consult legal counsel.

By APA’s Committee on Legal Issues


This article is condensed from "Strategies for Private Practitioners Coping With Subpoenas or Compelled Testimony for Client Records or Test Data or Test Materials," which appeared in Professional Psychology: Research and Practice, Vol. 47(1), Feb 2016, 1–11. To read the full article, which includes all citations and appendices, go to www.apa.org/about/offices/ogc/private-practitioners.pdf (PDF, 260KB).

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06 Jun 2017

Reimbursing Interns, Increasing Care

Reimbursing Interns, Increasing Care

When Medicaid pays for psychology interns' services, more people get care

It is already hard for many psychology graduate students to find high-quality internships. The fact that training programs in 34 states cannot be reimbursed by Medicaid—the government insurance program for those with low incomes and limited resources—for the work of their highly skilled interns makes it even harder. The result? Less access to care for vulnerable patients who are already among the most underserved in the nation.

At least one North Carolina internship site, for example, has already closed partly because it couldn't get Medicaid reimbursement for the services its interns provided. In states that allow Medicaid reimbursement for interns, internship sites use that money to help finance their internship programs.

"My concern is that as there is more and more pressure on internship programs to support themselves, we could be in danger of losing more," says Sally Cameron, executive director of the North Carolina Psychological Association. Traditionally, she says, clinicians did not have to worry about billing enough services to cover their salaries. But with health-care institutions facing mounting financial pressures, that has changed—in a way that could be bad news for internship programs and Medicaid patients alike.

"Not being able to bill for a qualified service by a highly trained, supervised intern could result in further losses," says Cameron.

The lack of reimbursement for interns is also bad for consumers, because fewer internship slots mean fewer providers and thus gaps in mental health care for people who rely on Medicaid, Cameron points out. The 60 or so North Carolina internship slots at sites that now see Medicaid patients—the state's 20 other internship slots are in the federal prison system, where Medicaid reimbursement is not an issue—may not be allowed to see Medicaid patients because they cannot be reimbursed for their services. There is also a quality of care issue, adds Cameron, noting that the interns who see Medicaid patients are better equipped to serve Medicaid patients well once they become full-fledged psychologists.

The North Carolina Psychological Association is just one of many state, provincial and territorial psychological associations (SPTAs) working alongside APA to push for new legislation or regulatory fixes. "Our goal is full reimbursement for interns' services, without any strings attached," says Cameron. "We want interns to be full partners in providing services under supervision."

What is at stake is access to high-quality psychological services for the more than one in five Americans who rely on Medicaid for their health care. And with the Medicaid expansion in many states as a result of the Affordable Care Act, the demand for psychological services will only grow. "In some places, clients are already waiting weeks or months to be seen," says Eddy Ameen, PhD, who directs APA's Office on Early Career Psychologists.

Meeting a growing need

Because Medicaid is a joint federal/state program, each state runs its own program, within broad parameters set by the federal government. "Programs vary tremendously from state to state," says Shirley Ann Higuchi, JD, associate executive director for legal and regulatory affairs in APA's Practice Directorate. The managed-care companies that run many state Medicaid programs—and provide services to 80 percent of Medicaid beneficiaries—may also have their own reimbursement rules.

Only 16 states currently allow reimbursement for interns in some capacity; Nevada and Texas have rule changes pending that would allow for intern reimbursement. Of those 16 states, some limit intern reimbursement to certain settings or services. In Oregon, for instance, interns can be reimbursed only for services provided in coordinated care organizations. In Colorado, interns can bill for Medicaid services provided in residential facilities and a few other settings.

APA's Practice and Education Directorates are working to increase the number of states that allow Medicaid reimbursement for interns. APA is researching state programs to determine how they function and to identify barriers, investigating possible legislative or regulatory fixes and trying to come up with a national strategy that could be used as a template for advising state Medicaid agencies considering changes. APA is also tackling the problem of the six states, plus the District of Columbia, that don't even reimburse independently practicing psychologists for services provided to Medicaid patients—a situation that also limits patients' access to mental health care.

One significant barrier that has to be overcome is the concern among some state Medicaid agencies that interns aren't competent to provide services because they aren't yet licensed. "People outside the psychology training community assume that because doctoral psychology students take their licensing exams after their internship years, these unlicensed practitioners aren't as qualified as their licensed supervisors," says Caroline Bergner, JD, a policy and advocacy fellow in APA's Education Directorate. "But interns have so much experience by the time they start their internships—between 1,500 and 2,000 hours of patient care—that they're very well-equipped to provide psychotherapy and a host of other services."

Bergner and others encourage psychologists and trainees to reach out to APA for help if they're interested in fixing the intern reimbursement problem in their states. They should also collaborate with their SPTAs, training directors, state psychology licensing boards, students and others as they begin exploring legislative or regulatory possibilities. In states that have already won the fight, the psychology community should share that story and help those in other states achieve success, too. Says Ameen, "We need champions in more states."

For more information about Medicaid reimbursement, tips on how you can help and resources, check out the Advocacy Toolkit at www.apa.org/ed/graduate/about/reimbursement/index.aspx.

By Rebecca A. Clay


This article was originally published in the September 2016 Monitor on Psychology

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06 Jun 2017

Improving Care for Children with Cancer

Improving Care for Children with Cancer

New standards outline the psychosocial supports that all pediatric oncology sites should offer.

When 6-year-old Mattie Brown complained that his arm hurt, his parents assumed that he had injured himself at tennis camp. Then a routine trip to his pediatrician — plus X-rays and other diagnostic testing — revealed he had bone cancer.

For more than a year, Mattie endured chemotherapy and surgeries that left him in a wheelchair and fitted with prostheses. But his problems weren't just physical. Despite the efforts of his mother, who has a doctorate in counseling, he was also diagnosed with depression, anxiety and medical post-traumatic stress disorder. Just over a year after his initial diagnosis, he died.

Determined to keep the memory of their only child alive, Victoria Sardi-Brown, PhD, and her husband, Peter, created the Arlington, Virginia-based Mattie Miracle Cancer Foundation to push for improved psychosocial care for children like Mattie. Now the foundation has achieved a major goal: the publication of the first national standards for the psychosocial care of children with cancer and their families.

Led by social worker Lori Wiener, PhD, of the National Cancer Institute, plus psychologists Mary Jo Kupst, PhD, Andrea Farkas Patenaude, PhD, Robert B. Noll, PhD, and Anne E. Kazak, PhD — all five of them fellows of APA's Div. 54 (Society of Pediatric Psychology) — a multidisciplinary group of experts drew on the research to establish standards of care for psychosocial support in pediatric oncology (see sidebar).

The standards could do more than just improve care at hospitals around the country. They could also help convince Medicaid and other insurers of the need to reimburse psychologists and other licensed mental health professionals for the psychosocial care the standards recommend, according to Sardi-Brown.

"Unless psychosocial issues are dealt with, medical care can't be as effective as it should be," she says. "We're clearly behind the need for medical research and drug development, but that's going to take years. Psychosocial support is something that can be implemented today."

Compiling the evidence

Although extensive research documents the psychosocial risks children and their families face during and after cancer treatment, that research hasn't necessarily been incorporated into pediatric cancer care. As a result, whether patients and families receive adequate support often depends on what pediatric cancer facility they end up in or what insurance they have.

Sardi-Brown and her husband began working to solve that problem in 2012, when their foundation sponsored a congressional briefing. Five experts — Kazak, Noll, Patenaude, Wiener and psychologist Kenneth Tercyak, PhD — joined childhood cancer survivors and parents in stressing the need for support. But that wasn't enough, says Kupst, an emerita professor of pediatrics at the Medical College of Wisconsin and one of the lead authors of the standards.

"At the briefing, people were very nice as always but said, ‘We need more evidence,'" says Kupst. "That was the impetus for doing this in a way that hadn't been done before — to do a very rigorous evaluation of the research in this area and develop standards."

Kupst and a multidisciplinary group of more than seven dozen other health-care professionals — most of them psychologists — spent the last three years doing just that, with support from Mattie Miracle. After reviewing more than 1,200 studies, the group produced 15 evidence- and consensus-based standards for services that are essential for all children with cancer and their families.

The standards call for systematically assessing children's psychosocial needs, preparing them for invasive procedures, monitoring adherence to treatment and ensuring access to support and interventions throughout the disease's trajectory, for example. Children with brain tumors should receive monitoring for neuropsychological problems, the standards state, while long-term survivors should receive yearly screening for educational, social and psychological problems. There are also standards focused on family members, which call for ongoing monitoring of their mental health needs, supporting siblings and assessing families' risk of financial hardship.

The emotional aspects of dealing with cancer can fall through the cracks, says Patenaude, another lead author of the standards.

"Families are immediately quite overwhelmed just taking physical care of their children," says Patenaude, a psychologist at the Dana-Farber Cancer Center and an associate professor of psychology at Harvard Medical School. "And it's not just the child who's having the hard time. Parents, siblings, grandparents and other family members are all struggling with emotions they might not have encountered before."

Psychologists and other mental health professionals help families overcome trauma and increase resilience during what is typically the multiyear — even lifetime — process of dealing with cancer, says Patenaude. They also help families communicate effectively with medical staff. "When there's not much psychosocial support, a lot of emotion can get funneled toward staff, which makes relationships between families and staff challenging in ways they don't have to be," she says.

Psychosocial care shouldn't stop after a child's death, according to the standards. One standard calls for contacting families to assess their needs, check for problems and offer bereavement resources.

The experts behind the standards also hope that they will spur research. "My hope is that the standards not only improve clinical service but that people will look at the standards, see holes in the literature and decide, ‘This is a place where I could really move my career and answer some questions,'" says Noll, a professor of pediatrics, psychiatry and psychology at the University of Pittsburgh and another of the lead authors.

For example, says Noll, there is little research in the important area of how to help school-aged children with cancer ease back into school after their diagnosis and treatment. "People just haven't researched it," he says.

Putting recommendations into practice

The publication of the standards is only a first step. One next step will be to seek endorsements from key organizations in the pediatric oncology field. The Society of Pediatric Psychology has already given its endorsement.

The group will also be assessing what services pediatric cancer sites are already offering. "As a baseline, we want to find out what the psychosocial teams look like in all the centers, what they're doing and how close they are coming to the standards," says Kazak, co-director of the Nemours Center for Healthcare Delivery Science at the Nemours Children's Health System in Wilmington, Delaware, and another of the lead authors.

Once it's clear what people are already doing, the standards group could help sites put the recommendations into practice. The standards are intentionally non-specific, adds Kazak. "We didn't want them to be prescriptive, to say, ‘You must give measure x within y number of days,'" she says. Because there are many ways to meet each standard, she says, the group hopes to eventually help sites comply with the standards.

The project's ultimate goal is to improve care for children with cancer and their families through the provision of services that embody these standards, says Kupst. "We want to increase access by having some ‘teeth,'" she says. "If it's the standard of care, then [insurance companies] really need to provide reimbursement for it."

The group hopes the standards will convince Medicaid and private insurers to cover the services outlined in the standards. Another tactic could be to make achieving the standards a requirement for hospital accreditation.

For Mattie's parents, the effort is a way to find meaning in the loss of their child and to keep his memory alive.

"We always reflect on Mattie's experiences and use them as a guide and driving force to help other children and families in the future," says Sardi-Brown. "We feel strongly that the way we can do that is through psychosocial support."

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By Rebecca Clay


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05 Jun 2017

Research-Based Strategies for Better Balance

Research-Based Strategies for Better Balance

1. Practice mindfulness. Numerous studies have demonstrated that mindfulness has benefits for body and mind, reducing stress and depression and even boosting immune function. It can also be instrumental in maintaining work-life balance. In a study of working parents, psychologist Tammy D. Allen, PhD, found people with greater mindfulness reported better work-family balance, better sleep quality and greater vitality (Journal of Vocational Behavior, 2012). "Cultivating a habit of self-awareness is vital," says John Christensen, PhD, past co-chair of the APA Advisory Committee on Colleague Assistance. "One of the best things we can do is to develop a reflective habit of checking in with ourselves at least a couple times a day, taking note of the emotional ‘weather' without judgment."

2. Look for silver linings. H. Shellae Versey, PhD, a psychologist at Wesleyan University, found that when working adults looked for benefit in negative situations, they experienced fewer negative psychological effects from work-family conflict. The finding was especially strong for women. During stressful periods, for instance, it can help to think of work-family conflict as a temporary strain, and to focus on the payoffs, such as higher salaries and better opportunities. But lowering expectations and downgrading one's goals did not have that protective effect, she found (Developmental Psychology, 2015). The difference, she believes, is that positive reappraisal is a way of taking control, while downgrading goals can feel like giving up. "Lowering aspirations without having another goal or Plan B in mind could be detrimental," she says.

3. Draw from positive psychology. The principles of positive psychology can aid in psychologists' self-care, as Erica Wise, PhD, and colleagues described in an article on psychologist well-being (Professional Psychology: Research and Practice, 2012). Positive emotions can broaden cognitive, attentional and behavioral repertoires, she explains, which boosts resilience and facilitates well-being. One evidence-based way to boost positive emotions is to practice expressing gratitude on a regular basis.

4. Take advantage of social support. Seeking support from other people is critical to well-being. Geertje van Daalen, PhD, at Tilburg University in the Netherlands, and colleagues found that social support from spouses and colleagues can be especially important for reducing conflict from family obligations spilling over into the workday (Journal of Vocational Behavior, 2006). Connecting with professional colleagues can be especially important for psychologists, Christensen adds. "Many psychologists work in their own silos and have little contact with professional peers," he says. "That isolation can be a risk factor for burnout."

5. Seek out good supervisors. Unsurprisingly, sympathetic bosses can also be helpful — something to keep in mind if you're on the hunt for a new job. David Almeida, PhD, at Penn State University, and colleagues found people had more negative emotions and greater stress on days when work obligations interfered with family responsibilities. But those negative effects were buffered by supportive supervisors (Journal of Marriage and Family, 2016).

6. Get moving. A robust body of research has shown that exercise can boost mood in the short term, and in the long term can improve symptoms of depression, anxiety, addictive disorders and cognitive decline.

7. Go outside. Spending time in nature has been linked to improved cognition, attention, mood and subjective well-being. It also appears to reduce symptoms of stress and depression, as Roger Walsh, PhD, a psychologist at the University of California, Irvine, described in a review of lifestyle changes and mental health (American Psychologist, 2011).

8. Make your life meaningful. In his American Psychologist article, Walsh also described the benefits of seeking meaning — whether through religion, spirituality or volunteer service. "We do our best work and live our best lives when we have a sense of meaning — a feeling that what we do extends beyond us and brings good to others," says clinical psychologist Sandra Lewis, PsyD.


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05 Jun 2017

Expanding Opportunities in Women’s Specialty Care

Meet three practitioners who work hand-in-hand with medical professionals to keep new mothers, military veterans and other women healthy

The expectant mothers at Denver's Presbyterian/St. Luke's Hospital—a regional center for high-risk pregnancies—often have such high blood pressure that both they and their babies are at risk of complications or even death. On bed rest at the hospital for weeks or even months, they have little to do but worry—which can send their blood pressure soaring even higher.

That's where consulting psychologist Jennifer Harned Adams, PhD, comes in. She teaches the women visualization, breathing exercises, progressive muscle relaxation and other strategies they can use while they're stuck in bed. She'll also help them find relaxation apps on their cellphones or tablets so they can use the techniques whenever they need them.

"These moms are facing all these potentially scary outcomes for themselves and their babies, but can't do a whole lot physically to manage that anxiety," says Adams. "Being a part of the team is great so we can think about these moms in a more holistic fashion."

Adams's work with pregnant women is just one example of how psychologists are working with physicians and other medical providers to improve women's overall health. Adams and other psychologists are helping women transition to motherhood, overcome chronic pain, heal from sexual assault and explore their gender identities.

The Monitor spoke to Adams and two other psychologists working in integrated settings focused on women's health.

Jennifer Harned Adams is assisting new mothers

Dr. Jennifer Harned Adams specializes in treating pregnant women on hospital bed rest. Presbyterian/St. Luke's and the affiliated Rocky Mountain Hospital for Children brought Adams on two years ago, and she spends a quarter of her time consulting with patients at the hospitals. "They were seeing the need for greater support for families," says Adams, who spends the rest of her work week at her private practice. "They saw how having a psychologist would help improve the quality of the hospital stay and the transition into parenthood."

Her training prepared her well. After earning her doctorate in clinical psychology from the University of Houston in 2003 and doing an internship at the University of Texas-Houston Health Sciences Center, she had three years of postdoctoral training in reproductive health and psychosocial oncology at The University of Texas-MD Anderson Cancer Center.

On the antenatal side, Adams now spends most of her time helping women cope with extended bed rest. In addition to boredom, they're facing worries about their babies, the work they're missing and their families back home. They may be mourning past miscarriages or—in the case of multiple babies—the death of a twin or triplet. "Of course, they're also bringing in whatever was going on with their lives to begin with—relationship or financial difficulties or previous histories of depression, anxiety or substance abuse," says Adams.

And since patients come from as far away as Wyoming and Nebraska, many are also isolated. Adams helps the women problem-solve and helps prepare them and their families for potentially bad outcomes. If their stay is long enough, she might even delve into more traditional psychotherapy.

Adams also works with mothers and other family members in the neonatal intensive care unit. For many patients, ending up in the unit is a traumatic surprise following an unexpectedly premature birth or delivery complication. "Women and families can be overwhelmed," says Adams. "It can be very unsettling to feel out of control." Adams helps them find a sense of control where they can, settle into a routine and work through the trauma.

The work is fluid and fast-paced, says Adams. "I love being able to walk down a hall and have a nurse tell me she's feeling worried about a mom and being able to troubleshoot or help make a plan," she says, adding that rounds and case planning meetings offer more formal collaboration opportunities.

Adams also helps educate nurses and other health-care professionals, offering trainings on understanding grief and loss in their patients and themselves and on preventing compassion fatigue and burnout in their professional roles. "I urge them to look for opportunities for self-care for themselves and others just in the course of their day and also to make aggressive self-care—exercise, massage or other practices—a regular part of their lives," says Adams, who has also worked with the Wishbone Foundation to train more than 300 nurses in nine hospital systems how to support families who've lost their babies.

The training also helps nurses work more effectively with patients, adds Adams. Often, she says, there are communication problems because patients and their families are interacting angrily with nurses and other providers. "I help providers reframe that anger as fear, which helps them respond differently," she says.

Kelly Huffman is helping patients overcome pelvic pain

Dr. Kelly Huffman specializes in treating pelvic painKelly Huffman, PhD, specializes in another type of care for women: treating pelvic pain. "Women are overrepresented in chronic pain populations," says Huffman, a psychologist at a pelvic pain clinic "by and for women" within the Cleveland Clinic's Center for Neurological Restoration.

Pelvic pain can have many causes. No matter what the etiology, it can leave women depressed or anxious about what's wrong with them. Pelvic pain can also cause sexual dysfunction and thus relationship problems.

And psychological distress can make pain worse, says Huffman, who did a postdoctoral fellowship in psychology and pain medicine at the Cleveland Clinic after earning her doctorate from the University of Wisconsin–Madison in 2008.

"If you have a lot of stress, depression, anxiety and other things going on in your life, it can amplify pain perception," she says. The opposite is true, too. "If you don't have a lot going on in your life, pain can become front and center in your life because you have nothing else to focus on."

When patients with pelvic pain come to the clinic, they consult with Huffman, plus a physician, physical therapist, occupational therapist and other team members who create individualized treatment plans. For some, that might mean surgery; for others, pelvic floor therapy, a type of physical therapy designed to rehabilitate pelvic floor muscles. The clinic also weans patients off opioid analgesics, if necessary. For patients who need more help, the clinic runs a three-week, full-time rehabilitation program.

Huffman's role on the team is to address any psychological issues. She might counsel couples on relaxation techniques they can use to enhance sexual functioning, for instance. Or she might help a sexual assault survivor work through the trauma that's contributing to her pain.

Working collaboratively can prevent unnecessary medical interventions, says Huffman. One patient, for example, had such severe pain with intercourse that she was scheduled for a vestibulectomy—surgical removal of some flesh at the vagina's opening. When Huffman talked with the patient, however, it turned out that it wasn't a physical problem that was holding her back but instead uncertainty about her sexual orientation. "If you don't have a partner you're attracted to, of course it would make intercourse difficult," says Huffman. The surgery was canceled.

Because many patients are convinced they need opioids to manage their pain, Huffman also provides psycho-education. "The common perception is, ‘If I have pain, the answer is to take opioid analgesics,'" says Huffman. Addiction isn't the only danger of opioid use: Opioids can also make pain worse. "Most patients don't know about acute versus chronic pain," says Huffman. "Opioids are actually contraindicated for chronic pain."

This kind of integrated approach works, Huffman and her colleagues have found. In a study of 36 patients with pelvic pain, Huffman and co-authors found that interdisciplinary treatment including medication management, occupational and physical therapy, and individual, group and family therapy significantly improved pain severity, disability, depression, anxiety and "catastrophizing" (Journal of Pain, 2016).

And word is getting out, says Huffman. "The pelvic pain clinic has only been open for about a year," she says. "At this time, we have more volume than we can handle."

Rosalie C. Diaz is helping veterans heal

Dr. Rosalie C. Diaz treats female veterans in a women’s healthcare clinicIn the military, seeking mental health care can be especially stigmatizing. That's one reason why psychologist Rosalie C. Diaz, PsyD, is happy to be treating female veterans in a stand-alone women's clinic at the Louis Stokes Cleveland Veterans Affairs (VA) Medical Center. "Having a psychologist be part of their primary-care team isn't seen as stigmatizing by our veterans," says Diaz. "I'm just part of the team."

The VA began emphasizing coordinated, co-located care in 2010 as a way of decreasing stigma and improving access to care, says Diaz, who did her predoctoral internship at Louis Stokes in 2003 and started her current position in 2013. "It's also seen as cost-effective because you're being more preventive," she says. A physician or other provider might be worried about a patient's depression, substance use or cognitive capacity, for example, so Diaz meets with the patient, screens for the problem and works with the provider on treatment recommendations. Other patients may have mood disorders, insomnia or difficulties with medical compliance. Infertility, pregnancy loss and post-traumatic stress disorder are also common.

Military sexual trauma—and the wide range of psychological emotions that often accompany it—is another big issue. "If you review their records before they see you, they'll sometimes deny to a provider that there has been any assault," says Diaz. "Then you're seeing them for therapy, and they'll share something that they've never confided before."

On an individual level, a veteran might also need Diaz to accompany her to gynecological exams to help her cope and avoid panic, for example. More broadly, Diaz and others are also working to raise awareness of military sexual trauma among patients and providers alike with an annual monthlong education campaign. For the veterans, she says, the campaign emphasizes that they're not alone and that there's an advocate for them. For providers, the message is that trauma is often hidden. "The provider might see anger in the forefront, but underneath there's fear or vulnerability," says Diaz. By working alongside the physician or other provider, Diaz can help ensure the patient gets the care she needs.

Diaz also works with the center's transgender clinic, which addresses physical, social and mental health issues. As part of that interdisciplinary team, she helps patients manage their transitions and explore their gender identity. She also helps screen patients to see if they're candidates for hormone therapy. Many of these patients have experienced bullying and harassment and may feel depressed, anxious or just uncertain. "We're looking at stability, support and their use of coping skills," says Diaz, who works alongside a primary-care physician, a psychiatrist, nurses, a social worker and another psychologist.

The biggest challenge with providing collaborative, multidisciplinary care that involves so many specialty providers in the same place at the same time is that it requires a good amount of time and space for them to collaborate on the best plans of care for their patients, says Diaz. "We have a lot of providers ready and willing to see veterans, but sometimes it's hard to coordinate with all the different disciplines and find rooms because we're growing," she says. "That's probably a good problem to have."

More on integrated care

Every 2016 issue of the Monitor features a profile of a psychologist on an integrated-care team. To access the full series, visit our digital edition at www.apa.org/monitor/digital.

By Rebecca Clay


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05 Jun 2017

Brighter Horizons for Rural Psychology

Brighter Horizons for Rural Psychology

APA's focus on rural communities continues to improve access for underserved populations.

Rural clients face barriers that can make accessing behavioral health services particularly challenging — not just tangible ones like physical distance and lack of time, transportation and insurance, but a stoical culture that emphasizes self-reliance and a related stigma about using mental health care. 

"Their personal needs tend to get put on the back burner," says Emily Selby-Nelson, PsyD, a clinical psychologist who works at Cabin Creek Health Systems, a federally qualified health center with several locations in rural West Virginia.

Thanks to her rural psychology training, though, Selby-Nelson is well versed in the nature of these problems — and the system she works in helps to effectively address them.

Cabin Creek Health Systems uses integrated primary-care services, a patient-centered approach, integrated electronic medical records and an understanding that behavioral factors can play a major role in health outcomes. As a consequence, patients see Selby-Nelson as a health-care professional who can help them sort out their problems in a brief chat after a visit with their primary care physician, rather than as a stranger intent on analyzing their mental health issues.

What's more, because the system receives federal funds and grants to serve underserved populations, Selby-Nelson's clients aren't as worried about payment or billing concerns. And thanks to technology's ability to connect people and resources, she participates in a full range of professional activities — conducting research, training future rural integrated-care psychologists, and serving in professional leadership roles.

Selby-Nelson's practice is a striking example of how far rural psychology has come in the last few decades. While rural practitioners still face challenges like professional isolation and navigating multiple relationships, mental and behavioral health are becoming a more vital and embedded part of rural health care, thanks in part to psychologists' efforts (see sidebar for a short history).

In fact, rural practice has sometimes led the charge toward more progressive forms of health care, says Paul L. Craig, PhD, a neuropsychologist in Anchorage, Alaska, and longstanding advocate for improved mental health care in rural areas.

"Rural settings have been in the vanguard of demonstrating the viability and efficacy of integrated care," he says.

Expanding care 

Perhaps the greatest boon to rural health care has been the National Health Service Corps, or NHSC, the federal program that repays the student loans of health-care providers who work in underserved areas. Since 2002, 263 psychologists have completed the program.

Today, there are 3,277 NHSC mental health providers in service nationwide. A 2012 survey found that 82 percent of all health-care providers stayed on for at least a year after completing their service commitment, while 61 percent of mental health providers continued to work at the site four years after service completion.

"The program gives people access to mental health services and help they would otherwise not have received," says Darryl Salvador, PsyD, a former chair of the APA Committee on Rural Health who now serves on the national advisory committee for the NHSC. "The presence of these providers has probably saved lives and prevented the higher use of services, like hospitalizations." Such services can be especially costly, he adds, if people have to be flown to external facilities because their own community lacks such services.

Salvador worked as an NHSC loan repayment clinician for a federally qualified health center in rural Hawaii from 2007 to 2011, treating depression, anxiety, substance abuse and post-traumatic stress related to familial abuse. Before coming to the center and learning that a behavioral health clinician was available to treat them, many of these clients had never been treated or had been treated inadequately for such conditions, he says.

"I felt like I was really making a difference," says Salvador.

Innovative programs 

Rural psychologists also have been responsible for adding behavioral components into rural health efforts. Salvador, for example, helped his rural clients learn behavioral strategies to better manage their diabetes and to stop smoking. Diana L. Prescott, PhD, of Hamden, Maine, also a former chair of the APA rural health committee, developed the integrated behavioral health portion of the pediatric obesity program The Way to Optimal Weight, or WOW. Preliminary data show it has helped obese children lose weight and improve their quality of life.

At the Southcentral Health Foundation in Anchorage, Alaska, psychologists have taken an even broader view of helping the community. The facility offers a combination of integrated health and social services to improve family and community well-being, including programs on domestic violence, abuse and neglect, among other issues. The foundation reports that its outreach has helped to reduce emergency room visits by 53 percent and specialty care visits by 65 percent — all while earning a 90 percent consumer satisfaction rating.

Rural psychologists are also leading the way in the use of technology to expand care. In a 2015 article in Training and Education in Professional Psychology, for example, Matt J. Gray, PhD, of the University of Wyoming, and colleagues reported that providing videoconferencing sessions to victims of sexual assault or domestic violence was just as effective as providing in-person sessions. The intervention led to about a 60 percent drop in post-traumatic stress symptoms and a 50 percent drop in depressive symptoms from before to after treatment, as well as consistently high treatment satisfaction, the team found.

The technology helped all of the parties involved, Gray says, adding, "It's a really symbiotic relationship." His students who provide the teleconferencing sessions have a chance to use their treatment skills with more people; off-site clients receive free expert interventions they otherwise wouldn't have gotten; and the staff at crisis centers — who are often overextended and underfunded and whose first expertise is practical rather than psychological help — can link their clients with needed services, he says.

Rural psychologists were also the lead authors of another recent study that supports telehealth's ability to expand access to quality care. A 2015 pilot project found that children in rural Kentucky whose parents participated in an evidence-based group parenting program via videoconference and telephone improved to the same extent as kids whose parents received the program in person. The children improved on measures of internalizing symptoms, such as depression and withdrawal, and externalizing ones, such as aggression and hyperactivity (Psychological Services, 2015).

"The technology does not seem to alter or disrupt the factors or processes that make any psychological intervention helpful," says the study's lead author, Robert J. Reese, PhD, of the University of Kentucky.

Forward thinking 

Psychologists also are weighing in on new challenges in rural areas. One example is hydrofracking: APA's Committee on Rural Health is starting to examine the psychological toll industry practices may be having on small, underserved communities. Anecdotal reports suggest that a variety of ills can accompany the financial gains of fracking, including contaminating water and overcrowding schools and other infrastructures that are unable to properly accommodate new arrivals, says Iva GreyWolf, PhD, a member of APA's rural committee who is spearheading the group's hydrofracking effort.

"When you have people with high poverty and you're offering them an oil lease, it's hard for them to say no," despite the unknown consequences, she says.

Similarly, new drug problems are cropping up in rural areas, with heroin a dangerous and increasingly ubiquitous arrival, and psychologists are working to determine the best treatments (see the February Monitor).

Working to address such problems and improve care for underserved people is "a beautiful opportunity for psychologists," says Prescott.

By Tori DeAngelis


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