2015 - Western State Hospital Internship Program

November 11 2015

Friday Factoid (Catch-Up): Rural Psychologists Face Additional Ethical Challenges

Many psychologists choosing to work in a rural setting need to negotiate a delicate balance between their specialty setting and the APA ethics code, which was written within an urban context. The APA ethics code is not only important in directing professional behavior, it provides psychologists with a unified professional identity. While there has been some call to write a rural-specific ethics code, creating separate ethics codes tailored to each specialty practice within psychology has the potential to harm the profession as a whole. As such, rural psychologists must find creative ways to maintain adherence to the code of ethics, especially in most likely areas of difficulty: managing potential unavoidable dual relationships, navigating community contacts, and protecting confidentiality related to incidental exposure/contacts (such as visibility of practitioner’s office),

Part of the informed consent processes in a rural community might include discussions about how to handle unavoidable dual roles and likely community contacts. For example, it’s more likely the psychologist’s and patient’s children attend school together at the only elementary school in the area. When the psychologist is the only resource for hundreds of miles referring to another clinician may not be feasible. Patients should be aware of predictable/obvious situations in which they may encounter therapists, and some discussion of how boundaries will be managed in those situations may be necessary.

Additionally, a frank discussion about how the patient prefers community contacts to be handled would be advisable. The patient may prefer that the psychologist not interact with them in order to preserve confidentiality. Conversely, some patients may not understand that a boundary exists during community contact and therapeutic issues cannot be discussed outside of therapy. Without a proactive discussion, these issues can become ethically and therapeutically problematic.

Rural psychologists have many considerations when it comes to protecting patient confidentiality. The location of the psychologist’s office must be considered in towns where many people know one another. Patients may become leery of obtaining treatment if the office is in an easily visible area. When patients know one another, the psychologist may have to manage their own reactions when a patient discloses information about someone else the psychologist is treating, or people the psychologist knows personally and socially. This information, while confidential to the original patient most certainly could affect the psychologist’s work with additional patients, and place some burden on personal interactions as well.

There are of course many other dilemmas that may affect rural psychologists and their practices. Above all, the well-being of the patient and psychologist should guide decisions. Psychologists may consider patients first, but it is crucial they also weigh how handling ethical problems could affect their quality of life in a small community. Having a patient you know is angry with you and has an unpaid bill attending your church is certainly a possibility in a small rural town! Creativity and proactive management are likely to be the best options for management of these issues.

References

American Psychological Association. (2010). Ethical principles of psychologists and code of conduct. Retrieved from http://apa.org/ethics/code/index.aspx

Smalley, K. B., Rainer, J., & Warren, J. (2012). Rural Mental Health : Issues, Policies, and Best Practices. New York: Springer Publishing Company.

Rain Blohm, MS
WKPIC Doctoral Intern

November 11 2015

Friday Factoid Catch-Up: Self-Care for Psychologists–Ethical and Necessary

Self-Care seems to be a topic frequently addressed with graduate students and psychologists. We often hear these messages, but at the same time mentally run down a list of things we need to do in our head. Often, these mental lists include assignments, research, clients, family commitments and other professional duties and personal obligations. Many conferences and other gatherings of clinicians offer informative talks about self-care, even stressing that it is an ethical imperative and a duty for clinicians to engage in self-care on a routine basis—and yet, those to-do lists still rise up to defeat our attempts to look after our own needs.

Why do psychologists fair so poorly in caring for themselves? Ironically, many of our life experiences, such as trauma or family dysfunction, which may strengthen our work with patients, simultaneously impair our ability to care for ourselves.

I have heard the same suggestions for self-care over and over: exercise, diet, sleep, vacations, etc. I am not always in agreement on suggesting “standard” self-care because I think each psychologist’s life is unique, and so the self-care strategies will be equally unique. I think it may be important for psychologists to develop five or more main self-care activities, and this list probably should evolve over time. Aspects of this list might include insuring that basic physiological needs are attended to as well as personal therapeutic goals. I have yet to see a standard self-care list state a recent addition to my own list, like “learning to accept your mistakes.” It may be that it is easier for a room full of wounded healers to accept a prescription for physically running versus sitting and thinking about accepting imperfection. A lack of exercise and perfectionism both carry a significant cardiovascular disease burden.

The list we make for our self-care should be portable. What I mean by that is, it should be something we can take with us each day. A vacation to Tahiti every day isn’t feasible, but five minutes of visualization practice certainly is. I may not be able to start a fabulous new diet overhaul today but I can try to abide by a general guideline like asking myself if I would feed the meal I’m about to eat to someone I love.

I do believe that self-care is a vital clinical skill, but it is critically important to look at why it is so difficult for psychologists to consistently achieve. The argument of lack of time is simply not valid—or not the only factor. People filling schedules caring for others without investment in themselves have unaddressed issues of one form or another. These issues are unique for each of us, and a deeper exploration of the reasons for self-neglect may prove to be a worthwhile personal and professional endeavor.

References
Barnette, J.E. (n.d.). Psychological wellness and self-care as ethical imperative. Retrieved from http://www.apa.org/careers/early-career/psychological-wellness.pdf

Rain Blohm, MS
WKPIC Doctoral Intern

November 11 2015

Article Review: Posttraumatic Stress Disorder in DSM-5: New Criteria and Controversies

As our knowledge of mental health issues continues to increase, The Diagnostic and Statistical Manual for Mental Disorders (DSM) must consistently update its analytic and disorder-specific criteria. It is essential to do so to ensure not only its relevance, but also its championing of the most current and accurate diagnostic information available. Each update or manual revision has the potential to create controversy or difficulties with implementation in practice. Miller, Wolfe and Keane (2014) recognized that the fifth and latest revision of the DSM (DSM-5) was no exception, especially with respect to the diagnosis of Posttraumatic Stress Disorder (PTSD). Additionally, new controversy has erupted related to the upcoming International Classification of Diseases, Edition 11 (ICD-11) (Miller, Wolf & Keane 2014).

Moving PTSD
Miller, Wolfe and Keane identified the removal of PTSD from the Anxiety Disorders chapter and into a new one titled “Trauma- and Stressor-related Disorders” as the most substantial and potentially controversial move made in the new revision. PTSD had previously been included with anxiety disorders, since its introduction in the DSM-III, even though some were apprehensive with the placement. The newly created chapter in the DSM-5, that now houses PTSD, was formulated to better reflect the heterogeneity of psychological distress found in samples of individuals exposed to serious adverse life events (Miller, Wolfe & Keane, 2014).

The researchers found that in the beginning, most developments related to PTSD came about because of its close association with anxiety disorders. They then noticed that as studies progressed, symptomology, as well as the backgrounds of those diagnosed with PTSD, revealed that re-experiencing the event was the key symptom. The majority of research they reviewed clearly identified fear and anxiety as being present and essential to varying degrees in the development of PTSD, but further noted that reliving the event was the principal complaint. (Miller, Wolfe & Keane, 2014).

The arguments against the move note that effective treatment for PTSD focuses on fear and anxiety. Therefore, many still believe that PTSD should be included under the meta-structured chapter of Anxiety Disorders. Our researchers disagree and explain that the DSM-5 even notes that anxiety and fear are more prominent for some patients than others, but are required symptomatology for all who are diagnosed with PTSD. (Miller, Wolfe & Keane, 2014).

Criterion A Changes
Miller et al (2014) listed several changes that were made to the definition of trauma (Criterion A). First, the types of involvements considered to be traumatic have been more specifically identified as sexual violence, serious injury or exposure actual or threatened death. “Exposure” can be in the form of direct contact, being a witness to the event, hearing about the event if it happened to those close to the person, and/or repeated exposure, such as what a trauma counselor would experience. The change in this information is to better clarify and differentiate from events that are life-altering but not traumatic.

A second change to Criterion A was the elimination of A2. It was a list of emotional responses that the person must have felt regarding the event. Study data revealed that the list was irrelevant to diagnosis because many persons do not experience those emotions at the time of the event. Therefore, since it was not purposeful to diagnosis, it was not needed as criteria for the disorder.

The third and final change to Criterion A was the wording of the language. With the change of traumatic “event” to “event(s)”, PTSD symptoms related to more than one trauma can now be diagnosed. It also made a diagnosis possible for those individuals who would not have met the criteria through one single event. Additionally, patients who have endured multiple traumas can include the events and symptoms as a collective instead of linking them to one isolated event.

Revision to the Specific Symptoms that Define PTSD
Miller et al. (2014) noted that adding three new symptoms to PTSD criteria, four symptom clusters instead of three, and adding a new diagnostic algorithm was the most palpable change. The first of the three new symptoms to be added was having “distorted cognitions about the cause or consequences of the traumatic event(s) that lead the individual to blame himself/herself or others.” The second is a “persistent emotional state.” Both of these symptoms can be found in Criterion D. The final symptom added to the DSM-5 was “reckless or self-destructive behavior” and it is in Criterion E. (DSM-5)

In mentioning the above symptoms, it is easy to note that Criterion E is the newly added symptom cluster. In addition to this cluster, the previous ones received modifications as well. Cluster B was only minimally effected with the change in wording from “re-experienced” to “intrusion.” Criterion C was aptly named “persistent avoidance of a stimuli associated with the traumatic event(s) and was derived from a combination from C1 and C2 from the previous DSM version. “Negative alterations in cognitions and mood that are associated with the traumatic event” was the term given to Criterion D. The new Criterion E was actually the hyperarousal cluster from the previous DSM-IV. It received a new title known as “alterations in arousal and reactivity that are associated with the traumatic event(s).” (Miller, Wolfe, & Keane, 2014).

The new diagnostic algorithm was one of the last changes noted by Miller et al. (2014). This algorithm indicates that to meet a PTSD diagnosis, an individual has to experience at least one symptom in both Criterions B and C as well as two symptoms in each Criterions D and E.

Initial Studies Examining the Impacts of these Changes
Miller et al. (2014) reviewed data from numerous empirical studies comparing and contrasting the occurrence of PTSD in the general population, veterans, college students and earthquake survivors. They found that in the initial studies that compared event exposure in the general population for prevalence estimates for a lifetime (L) and past six months (6M) were somewhat lower when defined in by the DSM-5 (L=8.3, 6M=3.8) when compared to the defined criteria in the DSM-IV (L=9.8, 6M=4.7). However, additional research and studies demonstrated that the DSM-5 was providing minutely higher approximations than the DSM-IV. Once study noted by our authors indicated that the when 185 volunteers were administered a revised version of the PTSD Scale, 50% met criteria for PTSD when assessed using the criteria in the DSM-IV and 52% met the criteria when using the DSM-5 (Calhoun, et al, 2012). The last study mentioned in the article utilized the college student population. It measured for students who would actually be clinically diagnosed with moderate functional impairment due to PTSD symptoms. Using the DSM-5 criteria, the prevalence estimate was 4.8% and 4.3% using the DSM-IV. Statistically, there was less than a one percent difference and deemed that DSM-5 had “no substantial” effect on prevalence when compared to the DSM-IV (Miller, Wolfe, & Keane, 2014).

Additionally, Miller et al. (2014) studied the configuration of factor loadings in the DSM-5 model. They found that the “amnesia” symptom and “new/reckless/self-destructive behavior” symptoms resulted in “weaker loadings on their respective factors in CFA (Miller, Wolfe & Keane, 2014). In further exploration, they identified a link between those who endorsed these symptoms and increased levels of PTSD.

Rater reliability was also analyzed. The findings were quite favorable. They suggested that even those professionals with moderate experience using the DSM-5 diagnostic criteria for PTSD were producing reliable diagnoses (Miller, Wolfe, & Keane, 2014).

The Dissociative Subtype of PTSD
A new dissociative subtype was added to the DSM-5 that included the features of derealization and/or depersonalization. The addition of this subtype is deemed controversial by some because there is still a debate of sorts as to whether or not the symptoms are basic features of PTSD or those that are experienced by a subset of individuals only. Miller et al. (2013) were the first to conduct a study utilizing latent profile analysis with the subtype and its correlation to PTSD. Using CAPS (Blake et.al., 1995), they assessed a sample group of veterans and their partners. Three distinct groups emerged from their data: 1) low PSTD severity and no derealization/ depersonalization 2) high PTSD severity and no derealization/depersonalization 3) high PTSD severity (equal to group 2) and discernible symptoms of derealization and/or depersonalization. The third group is now titled as the dissociative subtype group (Miller, Wolfe, & Keane, 2014).

Patients who meet the criteria for the dissociative subtype experience more recurrent and forceful flashbacks, are more likely to have a history of sexual abuse, suffer psychogenic amnesia, psychiatric comorbidity, suicidal ideation and functional impairment (Miller, Wolfe, & Keane, 2014). Additionally, those linked with this subtype were found to experience an over-modulated reaction to trauma cues so much so that the frontal brain regions dynamically inhibit the limbic brain regions that are profoundly associated in emotional responsivity. Fear was found to be the emotion most responsible for this reaction (Lanius et al., 2012). Miller et al. (2014) noted that the inclusion of this subtype into the DSM-5 provided a greater reliability in the conceptualization of dissociation across PTSD studies and diagnosis.

Conclusion
The diagnosis of PTSD continues to be surrounded by controversy. The new changes made in the DSM-5 have only worked to lengthen the debate for some. However, preliminary studies indicate that the modifications have not had a considerable effect on the approximations of PTSD prevalence. Likewise, the reliability of diagnosis using a clinical assessment has not experienced a significant effect due the changes, either.

References
Lanius, R. A., Brand, B., Vermetten, E., Frewen, P. A., & Spiegel, D. (2012). The dissociative subtype of posttraumatic stress disorder: Rationale, clinical and neurobiological evidence, and implications. Depression and Anxiety, 29, 701–708. doi:10.1002/da.21889

Miller, M., Wolf, E.J., & Keane, T. (2014). Posttraumatic Stress Disorder in DSM-5: New Criteria and Controversies. Clinical Psychology: Science and Practice, 21(N3), 208-220. doi:10.1111/cpsp.12070

Miller, M. W., Wolf, E. J., Kilpatrick, D., Resnick, H., Marx, B. P., Holowka, D. W., Friedman, M. J. (2013). The prevalence and latent structure of proposed DSM-5 posttraumatic stress disorder symptoms in U.S. national and veteran samples. Psychological Trauma: Theory, Research, Practice, and Policy, 5, 501–512. doi:10.1037/a0029730

Trauma and Stressor Related Disorders. (2013). In Diagnostic and statistical manual of mental disorders: DSM-5. (5th ed.). Washington, D.C.: American Psychiatric Association.

Crystal Bray, BS
WKPIC Doctoral Intern