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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28 Jun 2017

Psychologists Work to Help Communities Adopt, Sustain Evidence-based Treatments

Psychologists Work to Help Communities Adopt, Sustain Evidence-based Treatments
Ten years ago, as a clinical psychology graduate student working at an academic clinic for children with anxiety disorders, Rinad Beidas, PhD, planned to pursue a career running her own lab and identifying treatments that could really help these kids.

"But then I kept seeing kids come to our clinic having already seen lots of different community providers, without getting any better"—most likely, she says, because they weren't receiving evidence-based interventions. What the community had in its toolbox just wasn't working.

But her hope was renewed when children at the clinic participated in an evidence-based treatment for anxiety called Coping Cat, and nearly all of them were able to improve the quality of their lives. That's when Beidas became convinced about the effectiveness of evidence-based practices and the need for them to be more widely available.

"Evidence-based practices need to be available in the community so that kids have access to them and can benefit from them, as a matter of social justice," says Beidas, now an assistant professor of psychiatry at the University of Pennsylvania.

Today, she is one of many psychologists working at the state, county and city levels to make sure evidence-based treatment is available beyond academic medical centers, which aren't accessible to most people. As part of that effort, she sought to find out why more evidence-based practices aren't in wider use. In a study she conducted with clinical psychologist Arthur C. Evans Jr., PhD, commissioner of the city of Philadelphia's Department of Behavioral Health and Intellectual disAbility Services, she found some answers: When it comes to treating children and adolescents with psychiatric disorders, organizational factors—such as the support therapists get from others on the health-care team—are better predictors of the use of evidence-based practices than an individual therapist's knowledge and attitude about therapy techniques (JAMA Pediatrics, 2015).

"Implementation happens at multiple levels," says Beidas, who also directs implementation research at Penn's Center for Mental Health Policy and Services Research. "Even though a provider might be the one in the room with a patient, it's not just about that provider deciding to do an evidence-based practice. It's also about their organization and their supervisor supporting them, and the larger system supporting that process."

Focus on accountability

Serene Olin, PhD, a professor of child and adolescent psychiatry at New York University, is fostering the use of evidence-based treatments in another way: She is exploring how the use of evidence-based practices can help health-care systems establish greater accountability for patient care.

"Care in the real world is so much driven by who pays for what and what you're being held accountable for," she says.

In line with this shift toward more accountability, New York's state mental health department is focusing on what works—and how to train providers in these evidence-based treatments as efficiently and effectively as possible, says Olin, deputy director of New York University's Center for Implementation-Dissemination of Evidence-Based Practices Among States, known as the IDEAS Center. In 2011, the center began training clinical staff to implement evidence-based practices such as the "4 Rs and 2 Ss for Strengthening Families Program," at nearly 350 child-serving outpatient clinics in the state. The trainings vary in intensity, from one-hour webinars to yearlong collaborative learning experiences. The goal is to help clinics develop strong business and financial models, informed by empirical evidence, to ensure sustainability.

The IDEAS research team is using state administrative data to predict who will adopt these business-improvement and evidence-based clinical practices to help the state target its funding. They found that state clinical trainings were more likely to be adopted by clinics with more staff, likely because they're more easily able to release health-care providers for training compared with agencies with smaller staffs. In addition, clinics affiliated with smaller health-care systems were more likely to attend and implement business-practice trainings compared with clinics associated with larger, more efficiently run agencies (Psychiatric Services, 2015). These findings suggest that policymakers should understand the factors that influence the type and amount of training clinics are willing or able to adopt.

Sustaining evidence-based practice

In another effort to understand the use of evidence-based practices in community settings, Anna Lau, PhD, a psychology professor at the University of California, Los Angeles, and Laura Brookman-Frazee, PhD, a University of California, San Diego, psychiatry professor, are working to understand what happens when community therapists are required to deliver these interventions.

According to the American Medical Informatics Association, it can take 17 years for evidence-based practices to trickle down to practice in community-based settings. In a system-driven reform that cuts short that lag time, the Los Angeles County Department of Mental Health is reimbursing contracted agencies for delivering evidence-based practices through a countywide prevention and early intervention initiative. Lau and Brookman-Frazee are investigating how those practices are sustained. The Knowledge Exchange on Evidence-based Practices Study (4KEEPS) examines how community therapists work with evidence-based practices for youth and identifies barriers and facilitators to their implementation with ethnically diverse and disadvantaged communities.

Through the study, Lau and Brookman-Frazee are collecting data from agency leaders and frontline therapists about their experiences implementing six evidence-based interventions for child mental health problems. The pair is studying whether and how these treatments are still being used up to eight years following their adoption.

"We hear a lot about people's concerns that these evidence-based practices aren't equally applicable or equally accessible across different cultural or socioeconomic groups, so we're trying to see if there's evidence of that," she says.

As of September, more than 800 therapists and nearly 200 program managers from 68 agencies have participated in the study with an additional two years of data still to be gathered, says Brookman-Frazee.

"There are huge benefits in learning from what therapists are doing that might inform the intervention development process and allow for a more bi-directional communication process between research and practice," she says.

 

By Amy Novotney


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

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27 Jun 2017

Coaching Adults, Students and Young Kids with ADHD

Coaching helps clients cope with attention-deficit/hyperactivity disorder while helping psychologists flourish without relying on insurers

Children, adolescents and adults with attention-deficit/hyperactivity disorder (ADHD) don't necessarily need psychotherapy, says psychologist Abigail Levrini, PhD. What they often do need is help getting themselves organized and reaching their goals—coaching, in short.

To fill that niche, Levrini founded an ADHD coaching business called Psych Ed Connections in 2008. Demand for her services has been so great that the company now has three offices in two states. And what's good for consumers with ADHD has also been good for Levrini by allowing her to fulfill her dream of building a practice independent of insurance companies.

"I had heard many unfortunate horror stories about psychologists not getting reimbursed for the clients they had seen and worked with," says Levrini. "Fortunately, I have never had to go that route and have been able to make it without it."

Whether ADHD coaching is a full-time business or just a small supplemental income stream, it's a real growth area, says Frances Prevatt, PhD, the Florida State University psychology professor who developed the evidence-based ADHD coaching intervention that forms the basis of former student Levrini's coaching practice. "More and more people are being diagnosed," says Prevatt. "And there aren't that many people who specialize in treating those with ADHD."

A specialized business

Prevatt developed the coaching intervention 14 years ago when she realized she had no place to send students she was diagnosing with ADHD as director of Florida State's Adult Learning and Evaluation Center. "Other than recommending medication and accommodations, we didn't really have anything good to offer them," says Prevatt.

Grounded in cognitive-­behavioral therapy principles, the intervention she developed is an eight-week program that matches clients with doctoral psychology students who serve as coaches as a practicum experience. Working one-on-one, the coaches and their clients identify two or three goals to tackle, such as improving time-­management strategies, managing long-term projects, passing a specific class or even learning to do laundry. Each week, the pair identifies intermediate steps and brainstorms how to overcome obstacles, with rewards and consequences built in to boost motivation. "We're not telling them what to do," says Prevatt. "We're teaching them the problem-solving process."

Levrini was one of Prevatt's coaches at Florida State and studied the intervention for her dissertation. Once she graduated and launched her own practice, she took that model, tweaked it and established it in Ponte Vedra, Florida; Alexandria, Virginia; and Ashburn, Virginia. One key difference is that the coaches are all licensed psychologists and other mental health professionals. Because the Florida office is located in an underserved area, it offers services beyond coaching, but coaching represents at least half its business.

Educating children and adults about the difference between coaching and therapy is a crucial first step, says Levrini, who often compares being an ADHD coach to being an athletic coach for kids. "You'd never expect to be able to just put on a uniform and go out onto a sports field and play effectively on your own, so why should people with ADHD expect that they should just be able to figure out ways to stay organized or manage their lives effectively without help?" she says. "A coach can help you learn the rules of the game, see where your strengths and weaknesses are and help you 'play' more effectively, in sports or in life."

Coaches and clients then meet each week to outline "baby step" actions and track progress on two to four overall goals. These goals must be specific, measurable, action-driven, realistic and time-sensitive, says Levrini. They should also focus on the process of achieving them as well as the outcomes, she adds. "A student with ADHD might procrastinate, stay up until 3 in the morning to work on a project and still get a good grade," she points out. "But doing so generates a lot of stress and anxiety in the process, so it's important not to encourage positive outcomes that are not a result of healthy processes." As in the Florida State program, Levrini's coaches also use external rewards and consequences to help clients who need an extra dose of motivation.

Another twist on the original program is that coaches and clients don't necessarily meet face to face, thanks to Psych Ed Connections's online coaching option. That expands the potential client base to include the entire country or even the whole world, says Levrini.

A helpful sideline

For psychologist Peter C. Thomas, PhD, of Atlanta, a small ADHD coaching sideline represents a way to help his clients while bringing in a little extra income.

In his practice, Thomas focuses on evaluating children for ADHD and learning disabilities and providing psychotherapy to children, adolescents and families. About 20 years ago, he realized his clients needed something more: ADHD coaching.

What people with ADHD need most is help structuring their time, says Thomas. "Having someone to check in with helps them stay focused on what they want to accomplish," he says, adding that his clients tend to be disorganized college students and adults. "Coaching can help them learn to develop the habits that they're having trouble developing on their own."

To get the training he needed to launch his coaching business, Thomas attended a three-day workshop conducted by child psychiatrist and ADHD expert Edward Hallowell, MD, EdD, founder of the Hallowell Centers, which offer ADHD treatment in Boston MetroWest, New York, San Francisco and Seattle. Conducted by Hallowell and other coaches, the workshop focused on the intervention as well as the business aspects of coaching.

As a result of that training, Thomas developed a simple coaching intervention he dubbed FOCUS (From Organized Coaching Ultimate Success). The process begins with coaches interviewing new clients—who come to the service via referrals from other psychologists, psychiatrists, word of mouth and Thomas's own practice—about their problems and goals.

Clients then call their coaches each morning during the work week to discuss the three main goals they want to accomplish that day. Together clients and their coaches discuss how to accomplish those goals and make a plan. The process takes from five to 10 minutes. Clients renew their contracts and prepay with credit cards every two weeks as long as they need, which may be several months or even years. As clients internalize these problem-­solving skills, the calls taper off. To help keep the service affordable, Thomas doesn't provide coaching himself. Instead, he trains psychology graduate students to offer coaching services and monitors their work on an ongoing basis. He then splits the proceeds from the coaching with his coaches.

"It's not a big money maker, but it's slow and steady," says Thomas, who estimates that ADHD coaching represents 1 percent of his income. "It brings a little extra into the revenue stream."

Additional reading

ADHD Coaching: A Guide for Mental Health Professionals
Prevatt, F., & Levrini, A. APA, 2015

ADHD Coaching With College Students: Exploring the Processes Involved in Motivation and Goal Completion
Prevatt, F., et al. Journal of College Student Psychotherapy, 2017

By Rebecca A. Clay


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

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27 Jun 2017

The Men America Left Behind

The Men America Left Behind

They suffer from the the largest shortfall of jobs. Their mortality rate has been rising. What are psychologists doing to help?

For as long as America has been a country, the straight white American man has been king of the hill. But as society changes and culture evolves, the ground beneath that hill is growing shaky. Economically, physically and emotionally, many American men are fighting to maintain a foothold.

"What it means to be a man today is different than what it meant 20 years ago," says James O'Neil, PhD, a psychologist at the University of Connecticut who studies gender role conflict. "There's a paradigm shift occurring in our country regarding what it means to be masculine, and many men have had difficulty adjusting to that transition."

That shift might have been a factor in the 2016 presidential race. President Donald J. Trump's vow to "make America great again" seemed to resonate with the nation's male voters: Exit polls showed the widest gender gap among voters since exit polling began in the 1970s, with men favoring Trump over Hillary Clinton by 12 percentage points and women favoring Clinton over Trump by the same margin—for a total gender gap of 24 percentage points.

In red states and blue states alike, many men are struggling to figure out their place in 21st century America, says Ronald F. Levant, EdD, a former APA president who studies men and masculinity as a professor of psychology at the University of Akron.

"With globalization, automation, the evolution of manufacturing, the increase in disparity of both income and wealth, there are all kinds of things going on that have had a devastating impact on white working-class men," he says.

Distress and disconnection

Several recent analyses highlight the modern challenges for white, working-class men in America. In a working paper released in October, Princeton economist Alan Krueger, PhD, reported that more than 11 percent of men age 25 to 54 were unemployed and not seeking work (Boston Federal Reserve Bank, 2016). That figure has been trudging upward for decades, but particularly during the last 20 years. Survey data suggest that nearly half of those men sitting on the sidelines of the workforce take pain medication on a daily basis, Krueger reported.

Indeed, the United States is in the midst of what the U.S. Centers for Disease Control and Prevention (CDC) has described as an "opioid epidemic." Between 1999 and 2014, the number of opioid prescriptions in the United States nearly quadrupled, according to the CDC—and deaths related to opioid overdose, including prescription painkillers as well as illicit drugs such as heroin, also quadrupled during that period.

Other data suggest many of the nation's white men—as well as women—are struggling with both physical and mental health problems. While other ethnic and racial groups have seen their health improve over the years, death rates have increased for middle-aged white Americans with no college education. Princeton economists Angus Deaton, PhD, and Anne Case, PhD, analyzed health data and found that increase can be explained by an epidemic of deaths related to alcoholism, substance abuse and suicide, a category sometimes referred to as "despair deaths" (PNAS, 2015).

While the latter data apply to both men and women, experts say that some cultural changes appear to be affecting men in uniquely troubling ways. "Society is changing, but we don't talk to white men and ask them what they are struggling with," says William Liu, PhD, a professor of counseling psychology at the University of Iowa who studies masculinity. "There's a tendency to minimize it, yet the distress and disconnection are very real."

Over the last several decades, working-class men have seen jobs in manufacturing and mining grow scarcer. Meanwhile, the economic disparity between the haves and have-nots has only gotten wider. "Working-class men look into the future and see that their options are limited. They're not sure what their role in society is," says Liu.

Many men feel their masculinity ideology is under attack, Levant adds. That ideology is built on a set of gender norms that endorses features such as toughness, dominance, self-reliance, heterosexual behaviors, restriction of emotional expression and the avoidance of traditionally feminine attitudes and behaviors. "These gender roles come through our parents, male relatives, teachers and peers, and we're socialized into these roles starting in infancy," Levant says.

Men who strive to meet these masculine "ideals" might feel threatened, consciously or otherwise, by societal shifts, including the increasingly powerful role of women in the workplace or the growing acceptance of same-sex relationships. "The culture is changing, and it no longer privileges [the stereotypical male] point of view," says Liu.

Unfortunately, that viewpoint can be self-defeating, say experts who study gender role conformity. In a new meta-analysis, Y. Joel Wong, PhD, a professor of counseling psychology at Indiana University Bloomington, and colleagues found that overall, men who conformed to traditional masculine norms had higher rates of mental health problems such as depression, anxiety and stress, and lower rates of positive mental health outcomes, such as life satisfaction, self-esteem and psychological well-being (Journal of Counseling Psychology, 2016).

In particular, Wong found conformity to three masculine norms—playboy behavior, power over women and self-reliance—were significantly linked to psychological maladjustment. That suggests that sexist attitudes might have detrimental effects on men's mental health, Wong says. And men who assign a great deal of value to self-reliance are less likely to seek help when they need it, he explains. "Self-reliance may have been helpful in the past, but it is becoming increasingly outdated in our interdependent world," Wong says.

The traditionally male trait of "restrictive emotionality" also works against men's well-being, adds O'Neil. Many men haven't been given the tools to discuss their feelings in healthy ways. "Men are experiencing the loss of [traditional male] stereotypes but they don't have the capacity to process the loss emotionally. Men don't know what to put in place of what they're giving up," he says.

Gender role conflict doesn't just damage the way a man sees himself, Liu adds. It can also strain the relationships a man has with male family members and friends. If a man starts to challenge traditional "locker-room talk," for example, he might find he doesn't know how to connect with his father or his brother as easily as he once did. "A lot of men are socialized into messages and mottos and identities that have been passed down. That allows them to relate to important people in their lives," he says. "As society changes, individual narratives start to change, and that puts stress on the intergenerational connections men have."

Masculinity gets in the way

Endorsement of traditional gender role norms can be a challenging issue to address, says Levant. "In many ways, masculinity is the problem—and it also gets in the way of the solutions."

One traditional male norm, for example, is to avoid all things feminine. Yet some of the fastest-growing occupations in the United States are in fields traditionally embraced by women, such as child care, health care, education and food preparation, Levant says. "Men who strongly endorse these masculine norms probably wouldn't consider a 'pink-collar' occupation," he says—a catch-22 for men who are unemployed and struggling to find a place in modern society.

The men America left behindBut while traditional gender roles are deeply entrenched, they aren't immutable. One of the best ways to chip away at old-fashioned gender norms, Levant says, is with education. "Working-class, less-educated men tend to believe it's very important for men to meet these standards. More educated men have more occasions to challenge these ideas," Levant says.

He proposes targeted campaigns to challenge gender roles, such as public service announcements that encourage men to pursue careers traditionally thought of as feminine. He points to projects such as the Man Up Campaign, which engages youth to promote gender equality and end violence against women.

Levant also encourages men in positions of power to violate outdated male norms. A politician crying during a press conference, or a popular pro athlete talking openly about his depression, can go a long way toward breaking down those barriers, he says.

In addition, the psychology field has to get creative to reach the men who are struggling. One example is "Boys Don't Cry," a YouTube video produced by APA's Public Interest Directorate, which was designed to let boys know it's OK to show emotions.

"Therapy should always be there, and we should always advocate for it. But we know masculine norms that are correlated with mental health problems also prevent men from seeking psychological help," Wong says. "We need to look beyond therapy to find other ways to reach men."

Liu agrees, and says psychologists must be proactive in reaching out to men through channels such as blogs, TED talks or social media. While academics often talk in nuances and approximations, he says, the public responds best to language that is direct and discrete. "We have to make our message more easily digested," he says.

It's especially crucial to give psychology a new public face, he adds, since so much of the information on the internet reinforces toxic male stereotypes. "Instead of the positive masculine scripts we could be putting out there, we're competing against YouTube channels that talk about how to be alpha men. When you type in 'masculinity,' that's what you get," he says.

But creating a digital presence is only one place to start, Liu adds. Psychologists also need to make themselves more visible in the real world, offering talks, discussions and workshops for the lay public. That might mean partnering with local agencies or workplaces to start getting positive messages of masculinity into the minds of men who might be struggling.

Wong acknowledges that men who are most in need of outreach are the least likely to attend workshops or talks. Instead, he's been pondering the idea of reaching them through their friends. He suggests providing training in schools and community centers to teach progressive men how to talk about and model gender-egalitarian behavior to their traditional male friends, and how to challenge toxic masculine norms in everyday conversation.

"These men can serve as a bridge to traditional men," he says. "As psychologists, we have to be more publicly engaged and visible," Liu adds. "That's the way we can disseminate our science."

Additional reading

Measurement of Masculinity Ideologies: A (Critical) Review
Thompson Jr., E.H., & Bennett, K.M. Psychology of Men & Masculinity, 2015

Men's Gender Role Conflict: Psychological Costs, Consequences, and an Agenda for Change
O'Neil, J.M., American Psychological Association, 2015

Meta-Analyses of the Relationship Between Conformity to Masculine Norms and Mental Health-Related Outcomes
Wong, Y.J., Ho, M.R., Wang, S., & Miller, I.S.K., Journal of Counseling Psychology, 2016

The Psychology of Men and Masculinities
Levant, R.F., & Wong, Y.J., 2017

By Kirsten Weir


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

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