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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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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27 Jun 2017

Cultural Competence is Key

Cultural Competence is Key

When working with refugees or asylum-seekers, something as seemingly straightforward as greeting new patients with a handshake can compromise trust, says psychologist Rehman Abdulrehman, PhD, co-author of an online guide called "Working with Refugees from Syria and Surrounding Middle Eastern Countries," published by the Public Mental Health Initiative he directs.

"Some Muslims believe that any kind of cross-gender contact is disrespectful," says Abdulrehman, an assistant professor of clinical health psychology at the University of Manitoba and a member of APA's Committee on International Relations in Psychology. Let Muslim patients make the first move, he suggests. If they don't offer their hands, you could put your hand over your heart and nod instead.

Noting that most psychologists don't get training in working with refugees, asylum-seekers and asylees, Abdulrehman and others offer several tips for working with those who have fled their homelands:

Learn about patients' contexts. You'll need to learn about your patients' culture, religion and other factors, says Abdulrehman. Without that insight, it can be easy to mistake normal activities for pathologies, such as mistaking Muslims' pre-prayer washing ritual for obsessive-compulsive disorder. Build competence by reaching out to members of the particular community, he suggests. In addition, be sure to understand the sociopolitical context of the country people have fled as well as the country where they've resettled, says Rita Chi-Ying Chung, PhD, a professor of counseling and development at George Mason University who has worked with nongovernmental organizations to serve refugees. Also, find out about laws affecting refugees, the asylum process, family reunification policies and how to connect patients to medical, legal and social services, she says.

Emphasize trust building. Seeking help from a psychologist is not something many refugees and asylum-seekers are comfortable with. "The notion of coming to a stranger you've never met and spilling out your most embarrassing, shameful secrets is very foreign," says Adeyinka Akinsulure-Smith, PhD, a senior supervising psychologist at the Bellevue/New York University Program for Survivors of Torture. Chung agrees. When she goes into a refugee community, she doesn't want to be seen as an expert. Many refugees come from countries where psychologists could be seen as part of the government and intake questions seen as disturbingly intrusive. "They might perceive it as, ‘Oh, my gosh, I might suddenly disappear the next day,'" says Chung. Instead, she asks community leaders how she can help, then engages in active listening while working with people on everyday tasks. "I might be working with women in the kitchen, with difficult topics coming up," she says.

Focus on symptoms. Some refugees and asylum-seekers, especially Muslims, come from countries where talking about feelings isn't as accepted as it is here, says Abdulrehman. That's why he uses cognitive-behavioral therapy with his Muslim clients. In addition to focusing on symptoms, cognitive-behavioral therapy also has a practical, solutions-oriented approach that helps restore clients' sense of control over their lives, he says.

Build strong relationships with professional interpreters. Bringing another person into the therapy session introduces potential new complications, says Akinsulure-Smith. The patient may worry about confidentiality; an interpreter from the same country may have their own issues when hearing about the patient's experiences. Spend some time with the interpreter before the session, be clear that you expect word-for-word translation and debrief afterward, she suggests.

By Rebecca Clay


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

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27 Jun 2017

Work-life Balance Still a Struggle for Most Psychologists

Work-life Balance Still a Struggle for Most Psychologists

When Pamela Hays, PhD, began her psychology career, she tried to do it all: clinical work, writing, research and teaching. But she couldn't sustain it. After a decade of going full tilt, she developed neck problems and carpal tunnel syndrome so severe she had to start using a voice-activated computer system.

"I was driven," she says. "But I drove myself into health problems I couldn't ignore anymore."

Hays, now a clinical psychologist practicing in Soldotna, Alaska, might be an extreme case. Or maybe not. Work-life balance is something that many psychologists struggle with.

The unfortunate irony is that psychologists know better than anyone the importance of making time for self-care. "We talk about it a lot with patients, but we don't practice what we preach," says Chelsi Day, PsyD, a behavioral health provider at Windrose Health Network in Indianapolis.

Psychologists might even have a false sense of invulnerability, says John F. Christensen, PhD, a psychologist in Corbett, Oregon, and past co-chair of the APA Advisory Committee on Colleague Assistance (ACCA). "We study burnout and think that applies to the people we're trying to help," he says. "In fact, health is on a continuum, with well-being at one end and burnout at the other. And most of us, during a professional career, slide back and forth on that continuum depending on what's going on in our lives."

Finding balance, however, is easier said than done. "The sin of the early 21st century is being nonproductive," Christensen says. "We're conditioned by our culture to equate value with productivity."

Of course, as psychologists well know, no one is as productive as they can be when they are exhausted and overworked. Burnout is a legitimate phenomenon, marked by feelings of emotional exhaustion, depersonalization and a diminished sense of accomplishment. "When we move into burnout, we get impatient, we treat others as objects, and we start treating ourselves as task-processing machines," Christensen says. "Our empathy tank has run dry."

For psychologists in clinical practice, neglecting well-being can even impair professional competence, making the matter an ethical concern. As Erica H. Wise, PhD, a psychologist at the University of North Carolina at Chapel Hill and current co-chair of the ACCA, argues in a recent article, it's much harder to stay competent when you're burned out. "Competence … is an essential ethical obligation and provides a critical link between ethics and self-care," Wise and her colleagues conclude (Professional Psychology: Research and Practice, 2012).

Practical balance

Unfortunately, there's no one-size-fits-all strategy for achieving personal-professional equilibrium. Stressors and obligations are different for everyone, and they also change over the course of an individual's life. "It is important for psychologists to stay attuned to these issues throughout their professional life span, since personal and work-related stressors tend to shift over time," Wise says. "Work-life balance isn't a once-and-done thing."

Some people start by establishing a career with some balance built in. Day, a sport psychologist, recently decided not to pursue an opportunity that she described as a dream job — building a counseling and sport psychology center at a Big 10 school. Although the opportunity thrilled her, after she factored in the long commute, the fact that she'd be on call 24 hours a day and her desire for personal and family time, the job didn't sound quite so dreamy. "Work-life balance is important to me," she says. "I don't want to burn out in 10 years."

After working herself into physical health problems, Hays left academia and moved back to her home state of Alaska to start a clinical practice. She joined a yoga class and a book group, started spending more time with family, and wrote the 2014 book "Creating Well-Being: Four Steps to a Happier, Healthier Life."

But finding balance doesn't necessarily mean you have to change jobs (or move to Alaska). You can start by taking a critical look at your commitments.

Wise recommends doing either formal or informal self-care assessments, which can remind you of your goals and help you figure out which daily activities energize you — and which feel like a slog. "From that, you have critical information that you can factor into your choices about your personal and professional activities," she says.

Jim Davies, PhD, a faculty member at Carleton University in Ottawa, says that for him and many of his colleagues, a lot of work commitments are self-imposed. "They are projects we are passionate about and take on whether we have the time to commit to them or not," he says. "We're too busy because we're overcommitted, not because our jobs are too onerous."

Davies uses a rigid strategy to balance personal and professional time. Every morning, he fills in a detailed spreadsheet with activities for each half hour of his waking day. "Crucially, I also schedule in my breaks," he says — including lunch, coffee breaks and even daily naps. "For me, prioritizing life means putting it in the schedule like all the other important things."

Still, for many people, time management isn't really the problem, says Sandra Lewis, PsyD, a clinical psychologist at Montclair State University in New Jersey and founder of The Living Source, a company that helps clients improve well-being and achieve their goals. "People focus a lot on time management, but I think in terms of personal energy management. If you have enough energy, you make better use of your time," Lewis says. "In the same way we charge our cellphones, we need to charge ourselves."

Yet when we're overextended, even activities that energize us can feel like one more item on an endless to-do list. So Wise suggests taking advantage of smaller moments. You might not have an hour to go to the gym, but you could take a 10-minute lunchtime walk. If you can't fit in a yoga class, take five minutes between appointments to breathe or stretch or meditate. "Find self-care strategies that you can integrate in rather than add on," she says. "Honor the smaller things."

While such strategies are helpful, more needs to be done to change the culture of workplaces from the top down, says Christensen. Too many organizations value busyness and productivity at the expense of their employees' well-being, he says. "Often in this kind of professional workplace, when you're working with other smart, committed people, the way to excel is to overwork."

Christensen has been collaborating with health-care systems in Oregon to measure well-being among clinicians, including physicians and psychologists. He's optimistic that many such organizations are starting to realize that helping employees avoid burnout is not only good for employees, but also for patients and the financial bottom line. That kind of sea change is crucial for making work-life balance more attainable, he says. "The things we as individuals can do will take us only so far."

Meanwhile, Wise argues that instead of focusing only on reducing stress, the field of psychology should do more to promote and maintain well-being broadly. "We need a more positive vision," she says. "As a profession, whether we practice or do research, whether we're being mentors or treating patients, we need to be aware that keeping ourselves healthy is important."

Further reading

  • Hays, P. H. (2014). Creating well-being: Four steps to a happier, healthier life. Washington, DC: American Psychological Association.
  • Walsh, R. (2011). Lifestyle and mental health. American Psychologist, 66(7), 579–592. DOI: 10.1037/a0021769
  • Wise, E. H., Hersh, M. A., & Gibson, C. M. (2012). Ethics, self-care and well-being for psychologists: Reenvisioning the stress-distress continuum. Professional Psychology: Research and Practice, 43(5), 487–494. DOI: 10.1037/a0029446

By Kirsten Weir


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26 Jun 2017

Charlotte Patterson, at the Forefront of LGBTQ Family Studies

Charlotte Patterson, at the Forefront of LGBTQ Family Studies
Charlotte Patterson
APA Fellow Charlotte Patterson has done groundbreaking research on child development, most notably on the topic of children of lesbian and gay parents.

It was her career on the line. Could the publication of one paper “taint” a reputation built on 20 years of child development research? It was the question Charlotte Patterson asked herself when she went to work at her University of Virginia (UVA) office one morning in the 1980s.

“I can still remember walking up to this building, looking up and thinking, well, who else is going to do it if not me?” says Patterson, PhD, APA Fellow, Stanford grad, noted developmental psychology researcher. And lesbian.

The paper in question was her landmark work, “Children of Lesbian and Gay Parents.” It was among the first research that debunked then-prevalent beliefs that children with lesbian or gay parents showed compromised psychosocial development relative to children from heterosexual parents.

Published as the lead article in Child Development in 1992, it blew open doors for mainstream lesbian and gay studies and became a crucible for public and legal discourse about LGBTQ family issues for decades to come.

“In those days, and still today, if you write something on a LGBTQ topic as a professional research psychologist people will assume you have some connection to the topic,” Patterson says. “I was frankly worried that . . . it would be a real problem for my career. Would people let me work with their children?

“A lot of people were shocked that I wrote it,” she continues. “People saw that article as a kind of professional coming out. That won me some friends and lost me some, as you can imagine.”

Since then, Patterson has been at the forefront of LGBTQ family studies, worked as an expert witness on landmark child custody cases involving lesbian parents, and been party to changes in state recognition of gay marriage that paved the way for Obergefell v. Hodges (same-sex marriage ruling by the U.S. Supreme Court).

A major challenge for Patterson and other early LGBTQ researchers was the dearth of available data on lesbian and gay families. In statistics, as in life, these families remained hidden. To amass a review of the scant literature that existed in the 1980s, Patterson literally drove from campus to campus in search of doctoral dissertations.

“Information was strewn across many fields—some in social work, psychology, psychiatry—a few people here and there who didn’t seem to know one another. It wasn’t a coherent field at that point in time. I realized there were lots and lots of interesting things that nobody had studied, to put it mildly.”

As if to emphasize this, Patterson glances at a bookshelf full of gender studies texts at her UVA office, where she has spent her entire academic career. (“I arrived here at 25, when I didn’t even own a couch!” she laughs.) An entire row of publications are her own, including Handbook of Psychology and Sexual Orientation, the 2013 APA Division 44 Book of the Year. “In those days, it was this sense of seeing an open frontier in front of you and wondering where to begin.”

Patterson started by studying what she knew: the relatively large group of lesbians raising children in the San Francisco Bay area in the 1980s, where she was then living on sabbatical.

“This was the perfect place to try to do that work,” recalls Patterson, who later had children with her own partner-then-wife. “It was the only place in the world at that time with a large concentration of lesbian families who had kids together. So it was my great good luck to begin research there . . . to meet families and to interview them.”

Much of the early work highlighted data on similarities between same-sex and opposite-sex parented households.

“The first findings of primary importance to policy issues were that [same-sex] parents in general were pretty well-adjusted people. That doesn’t seem surprising to people today but it did then. A second conclusion was, in general, that the children were also well adjusted, pretty much like their neighbors and peers in school.”

One study that gained wide media attention presented data suggesting that same-sex parents have a more equal division of household labor than their heterosexual counterparts do, findings corroborated by other studies internationally.

“The division of labor was the first big difference we saw,” recalls Patterson. “It’s so dramatic. A lot of people have taken up the finding and said, ‘Look! This is same-sex couples leading the way into a less gendered world!’”

But that was just the beginning of the story as far as she was concerned. Patterson wanted to understand the nuances of family systems—the distinctive qualities of experiences in families of lesbian and gay parents—and the differences among them.

She embarked on wide-reaching research that yielded significant findings: sex-role identity among children of same-sex headed families; adoption issues among gays and lesbians; division of household labor among gay and lesbian parents; and LGBTQ family issues within the context of changing legal and social policy environments.

Interestingly, it was the cross-examination by a prosecutor in her first of many appearances as an expert witness in lesbian-gay family legal battles that prompted Patterson to take her research to the next level.

“There was a 1993 trial that took place in Henrico Co., Va., not far from here,” recalls Patterson. “It involved a lesbian mom being sued for custody of her little boy by her own mother. It was a dramatic case, a sordid tale.

“Testifying as an expert, I was asked by the opposing attorney, ‘This research you’ve done, isn’t it about some crazy people in Berkeley?’ And of course, the research was about people who lived in Berkeley, not people who lived in Henrico. I thought his point was well taken actually, and it led me to want to know more about other groups and more carefully selected samples. It really made a huge impact on me.”

To obtain a more objective sample, Patterson teamed up with a sperm bank that had extensive records of all clients seeking help in getting pregnant. “It made a wonderful sample—singles, couples, straight, gay. We were able to invite every single woman who had come to this clinic to participate.”

A resulting paper in Child Development in 1998, “Psychosocial Adjustment Among Children Conceived via Donor Insemination by Lesbian and Heterosexual Mothers,” showed that these children were developing normally, and that their adjustment was unrelated to parental sexual orientation or the number of parents in the household.

Later, Patterson was able to tap into a large national data set—the National Longitudinal Study of Adolescent Health—to develop a methodological innovation in the study of child development in households headed by same-sex couples. The study didn’t ask parents if they were lesbian or gay. But by teasing out details among their answers—Are you in a marriage-like relationship? What is the gender of your partner?—Patterson was able to identify families with same-sex parents.

“It was very challenging to do that,” she recalls. “There were lots of technical challenges; we were trying to discern the signal from the noise.”

Importantly, this work confirmed her earlier findings.

Patterson takes satisfaction in the role of her work in expanding knowledge and public policy about what determines a family, but expresses something more personal about its effects on her own community: “I sometimes see that my research has made an impact when people tell me that they used the work in many ways when they were considering having children.

“Most people my age in the gay community grew up assuming they wouldn’t have kids. A lot of us were affected with what I would call internalized homophobia,” she explains. “If you’ve heard people around you forever telling you that you’d be a terrible parent you wonder, maybe I shouldn’t have children. A lot of people told me they read my articles and said, ‘Hey, maybe I could be a good parent!’ Or they used the findings to reassure worried grandparents-to-be.”

She looks at a photo of her grinning children on her desk, reflecting on the wonderful adults each has become.

“There are so many stories!” she marvels. “This work on families continues to rivet my attention. I think families are the most interesting thing in the world.”

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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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06 Jun 2017

Predatory Publishers Increasingly Targeting Psychologists, Social Scientists

Predatory Publishers Increasingly Targeting Psychologists, Social Scientists

Publishing in peer-reviewed journals can be rewarding — it allows us to share our research with peers and can advance academic careers. However, it can also be difficult and frustrating. Journals on average reject 75 percent of submissions, according to an APA report (American Psychologist, 2014). Peer review can take months and often requires authors to make significant changes to articles prior to publication.

So just imagine the joy psychologists might experience upon receiving an email from a journal (with a name very similar to a respectable APA journal) that invites them personally to submit a paper for a forthcoming issue. The journal promises peer review within one week and publication within two weeks. Imagine further that the journal claims to have a high impact factor, partly due to the fact that its content is freely available worldwide.

As the old adage goes: If it sounds too good to be true, it probably is. Unfortunately, there is a high likelihood that such an invitation has been sent by a "predatory publisher." While these publishers initially focused on biomedical sciences, a growing number now target psychologists and social scientists.

What are predatory publishers?

Predatory publishers are counterfeit scholarly publishers that aim to trick honest researchers into thinking they are legitimate. They use spam email to solicit research manuscripts, which they quickly accept and publish in their many online open-access journals. Though they claim to peer review articles, many conduct no peer review at all or carry out a minimalist or pro forma review, accepting and publishing flawed manuscripts that most legitimate journals would reject.

Predatory journals are supported by fees charged to authors upon acceptance of their manuscripts, and their goal is profit. The journals want to accept and publish as many manuscripts as possible to increase their revenue. This income strategy conflicts with peer review, which, when done properly, often results in manuscripts being denied publication.

Predatory publishers have fooled many honest scholars into believing that they are legitimate. Experts at mimicking respected publishing houses, they use sophisticated spam techniques, pandering to researchers through personalized spam that praises a researcher's earlier work while inviting a new submission. Other spam emails appeal to authors needing to publish in journals that have earned an impact factor. Companies now exist that supply fake impact factors to questionable journals, metrics they then display in their spam email advertising.

Problems caused by predatory publishing

Predatory publishing harms the scientific community in numerous ways. First, authors may be misled into investing their money and intellectual capital in a journal that they think is high impact and stable when it is neither. Some predatory online publications exist for very short periods of time and are rarely cited in journals that are indexed by reputable databases.

Second, predatory publishing has created a substantial body of published literature that is branded as science, but has not passed through adequate peer review, which is a primary form of quality control. For many readers, reporters and the public, the distinction between authentic and junk science is not readily discernable, yet these publications are readily accessible by anyone.

Compounding the problem, comprehensive academic indexes such as Google Scholar routinely index the junk science, mingling it with authentic research in search results. How are learners, such as high school and college students, supposed to tell them apart? Moreover, new research builds on already-published research, as anyone who has ever compiled a literature review knows. Writing such reviews now requires additional skill and more effort, for the author now must filter out unvetted research.

What can be done?

Researchers and academic disciplines benefit from open access to well-managed, high-quality journals. So what can be done to protect the integrity of open-access publishing?

First, researchers need to develop a "scholarly publishing literacy" skillset to recognize and avoid predatory publishers. Researchers can no longer assume that all scholarly journals are trustworthy and must be on guard against the perils of predatory publishers. Educating graduate students, fellows and junior faculty about predatory publishing should become a routine part of mentoring. (See sidebar for tips from APA staff on how to avoid predatory publishers.)

Second, scholars can refuse to serve on the editorial boards of predatory publishers, which seek to enhance their reputations by creating affiliations with scholars at reputable academic institutions.

Finally, the process of scholarly evaluation must adjust to reflect the new reality of scholarly publishing. Tenure and promotion committees must more carefully scrutinize candidates' publishing records. A quick scan of a CV is no longer sufficient, for journal titles that look authentic may not be. To be fair to those seeking promotion and tenure, this recommendation needs to be combined with the first — educating scholars about appropriate venues for scholarly publishing.

The world of publishing is quickly evolving. Electronic media are increasingly supplanting print media; journals are increasingly accessed through subscription packages rather than subscriptions to individual journals; and funding agencies and professional associations are increasingly pushing for free public access to scientific publications. The challenge before us is to protect the integrity of scholarly publishing even as we adapt to new technologies, circumstances and demands.

By Jeffrey Beall, DSc, a librarian at the University of Colorado Denver & James M. Dubois, PhD, the director of the Center for Clinical Research Ethics at Washington University in St. Louis.


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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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