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

Practice Health Metrics

Practices of any size need to be viable (whether for- or not for-profit) to serve the community. It is essential to track and understand basic metrics to make day-to-day decisions about the practice and to facilitate strategic planning. Assuring the overall health of the practice enables you to provide innovative patient care and service delivery. During this presentation you will learn about:

• Types of measures (accounts receivables, referral patterns, productivity, etc.)
• Keeping it simple, pertinent and doable
• Using a dashboard
• Loss prevention
• Improving patient care
• Strategic planning

Learning Objective 1
Participants will be able to describe different types of practice metrics.

Learning Objective 2
Participants will be able to analyze basic practice metrics.

Learning Objective 3
Participants will be able create or modify a strategic plan based on practice metrics.

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

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30 Jun 2017

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

Communities have unique needs (e.g., serving veterans, the underserved, disaster relief, health challenges, etc.) which may change over time. Positioning to meet these needs can better serve the community and make your practice relevant. Learn how to address these needs and make them available to your community. During this presentation you will learn the following:

• Incorporating your vision into niche development
• Using research to build a niche
• Niches and managed care
• Ethics and scope of practice (training and mentorship)
• Marketing a niche practice

Learning Objective 1
List practice niches outside of managed care.

Learning Objective 2
Describe how research can be used to build and market a niche practice.

Learning Objective 3
Describe key ethical considerations that need to be addressed when building a niche practice.

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

 

 

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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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20 Jun 2017

NIH Toolbox Offers Easier Data Collection

NIH Toolbox Offers Easier Data Collection

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

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

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

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

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

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

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

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

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

For more information, visit www.nihtoolbox.org.

By Rebecca  A. Clay


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

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20 Jun 2017

New Licensure Test on the Horizon

New Licensure Test on the Horizon

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

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

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

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

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

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

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

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

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

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

The path to a new test

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

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

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

Who, when and how much?

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

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

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

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

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

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

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

What's next

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

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

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

By Heather Stringer


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

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19 Jun 2017

Managing Staff and Organizations in Support of Practice Excellence

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

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

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

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

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

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

 

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06 Jun 2017

Protecting Patient Privacy When the Court Calls

Protecting Patient Privacy When the Court Calls

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

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

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

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

Understanding subpoenas

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

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

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

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

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

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

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

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

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

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

Strategies for dealing with subpoenas

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

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

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

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

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

2. Contact the client

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

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

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

3. Negotiate with the requester

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

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

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

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

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

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

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

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

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

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

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

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

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

By APA’s Committee on Legal Issues


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

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06 Jun 2017

Reimbursing Interns, Increasing Care

Reimbursing Interns, Increasing Care

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

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

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

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

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

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

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

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

Meeting a growing need

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

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

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

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

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

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

By Rebecca A. Clay


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

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