General Information - Western State Hospital Internship Program

October 10 2014

Summary of Giving Courts the Information Necessary to Implement Limited Guardianships: Are We There Yet?

Purpose
Gibson (2011) provided a retrospective analysis of adult guardianship cases in two Kentucky counties. The goal of the analysis was to determine if the information provided to the courts during these cases was comprehensive, if least restrictive intervention alternatives were considered, and if the limited guardianship option was utilized. Gibson (2011) concluded with recommendations for improvements in these areas of guardianship cases with particular attention to the role social workers could play.

Background
The article reported an estimate from 2006 that 1.5 million people were under private or public guardianships. However, the article also noted that the US Government Accountability Office stated that neither state governments nor federal governments keep track of how many elderly individuals have guardians or the incidences of abuse of those individuals with guardians. While Gibson (2011) highlighted many intended benefits of guardianships such as protecting people from abuse, neglect, and exploitation, the article also highlighted potential pitfalls of guardianships and the current system.

Autonomy appeared to be the biggest concern once an individual was determined to need a guardian. Gibson (2011) discussed a case from 1966, Lake v. Cameron, which highlighted the importance of the least restrictive intervention. In the case, a 60-year-old woman was reported to wander the streets and was involuntarily hospitalized. She was diagnosed with dementia, but not deemed to be a danger to herself or others. The court found that the woman could not be indefinitely hospitalized without considering less restrictive forms of treatment. Gibson (2011) mentioned a previous study of guardianship cases noting that 94% of petitions were granted and only 13% of those granted were limited guardianships. Gibson (2011) also cited a review of court practices that concluded that reports with more thorough testimony were more likely to result in limited guardianships being awarded.

Methodology
The article examined 40 randomly selected disability cases of 813 disability cases in two Kentucky counties from a three-year period (2004, 2005, 2006). The study used a modified Guardianship Evaluation Recording Instrument (GERI Mod) to examine information for the cases and collected demographics, social workers’ reports, psychologists’ reports, physicians’ reports, and the audio recording of court testimony, if available. The analysis looked at over 300 items and determined whether the item was present or not. The items looked at information that included, but was not limited to, clinical examination procedures, medical history, cognitive symptoms, functional abilities, social functioning, consideration of least restrictive interventions, diagnoses, and final recommendations.

Results
Gibson (2011) found that 97% of the guardianship cases examined were granted, 82% of those were awarded full guardianships and 18% were limited guardianships (partially disabled in Kentucky). The study utilized seventeen of the items that were consistent with Kentucky law as well as current best practice and provided a score of adherence to these seventeen items. Gibson (2011) found that psychologists scored a mean of 11.98 with a standard deviation of 3.21, social workers scored a mean of 11.45 with a standard deviation of 1.62, and physicians scored a mean of 8.35 with a standard deviation of 2.65. Based on these findings, Gibson (2011) determined that there was a significant difference between the adherence score of the physicians and the other two disciplines. Although the mean score of psychologists was slightly higher than that of the social workers, the smaller standard deviation indicates that the social workers were more consistently adhering to the items. Gibson (2011) determined that medical history, effect of medications on behaviors, adaptive behaviors, and strengths were frequently lacking from the reports of psychologists, social workers, and physicians alike.

Discussion
Gibson concluded with a discussion of how social workers could be useful in providing more information to courts in guardianship cases. The suggestion was to have a court visitor, a social worker who would come in to ensure that all areas were being address properly, that the least restrictive alternative was being considered, and that clients were empowered to seek clarification and ask questions. Even though social workers provided similar amounts of information in the cases examined for this article, Gibson (2011) expressed that social workers are uniquely primed for this role, given that they have a history of advocacy, are familiar with other professional disciplines, and have the opportunity to educate clients and their families. Gibson (2011) concluded that more thorough information from social workers and other professionals would better help the courts make decisions about guardianships and may prepare a court to award limited guardianships when the individual is still capable of maintaining some of their basic rights and autonomy.

Reference
Gibson, L. (2011). Giving courts the information necessary to implement limited guardianships: Are we there yet?. Journal of Gerontological Social Work, 54(8) 803-818. doi: 10.1080/01634372.2011.604668

Brittany Best, BA
WKPIC Doctoral Intern

September 09 2014

Alert for Psychology Internship Applicants: Beware of Scams Claiming to Help You Match!

Reprinted with permission of Dr. Keilin:

Each year, the APPIC Board receives feedback about the increasing number of enterprising individuals who have established businesses that focus on assisting applicants in obtaining an internship. Furthermore, the APPIC Board has heard comments and complaints about the claims that some of these individuals are making, the ways in which certain individuals are advertising their businesses and recruiting students, and the rates being charged to students (e.g., $100 or more per hour) for these services.

While there may in fact be some legitimate and helpful services that are being offered, the Board remains very concerned about the potential for exploitation — i.e., that some of these businesses may be taking advantage of the imbalance between applicants and positions by exploiting students’ fears and worries about not getting matched.

We encourage students to be cautious and informed consumers when it comes to decisions about using any of these services. Please know that there are a number of no-cost and low-cost ways of obtaining advice and information about the internship application process, such as the workbook published by APAGS (as well as books written by other authors), the free information available on the APPIC and NMS web sites, discussion lists sponsored by APPIC, APAGS, and others, and the support and advice provided by the faculty of many doctoral programs.

Jason Williams, Psy.D.
Chair, APPIC Board of Directors

Greg Keilin, Ph.D.
APPIC Match Coordinator

********

To add to what Dr. Keilin and Dr. Williams have to say, WKPIC wants you, our prospective applicants, to know that you are enough, in and of yourself, for our application process. Services such as these are absolutely not necessary for you to be competitive in applying for our site. We are interested in the quality of your educational and clinical experiences, and in you, the person and potential intern. “Glossy” applications or photos–not needed. We look forward to the chance to meet you, and for you to meet us.

As you will hear from us many times over, the issues in our system’s current Match system relate to many variables, but though these issues affect you, they are not because of you, or deficiencies in your application or interviewing. There are simply not enough slots to meet your needs, and APA, training programs, and internship sites are working hard to correct this problem. Feel free to read through some of our Match posts, where interns have shared their experiences in surviving this stressful period. If you have a story of your own, email it to me, and we’ll talk about posting it here. We support you, and your fellow interns, current and past, support you, too.

Susan R. Vaught, Ph.D.
WKPIC Training Director

August 08 2014

Summary of Gianoli, Jane, O’Brien, & Ralevski (2012): Treatment for Comorbid Borderline Personality Disorder and Alcohol Use Disorders

Gianoli, Jane, O’Brien, & Ralevski (2012) explain that there is a high degree of comorbidity between borderline personality disorder (BPD) and alcohol use disorders (AUDs). Research has demonstrated that this pattern of comorbidity may be associated with poorer prognosis for these individuals. Three psychotherapies have been specifically developed for patients with borderline personality disorder and substance use disorders (SUDs), but only one of these (Dynamic Deconstructive Psychotherapy) has been tested among patients with dual diagnoses of BPD and AUDs. Of all substance-use disorders, alcohol use disorders (AUDs) including both alcohol abuse and alcohol dependence are the most common among individuals with borderline personality disorder.

Borderline personality disorder is present in approximately 1% to 1.6% of the general population and in about 20% of the psychiatric population. Borderline personality disorder is thought to be about three times more common among females than males but this gender difference has not always been proven in community-based studies. Data from the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) suggest that among patients with a lifetime diagnosis of borderline personality disorder, 58.3% also had lifetime diagnoses of alcohol use disorders. Rates of co-occurrence of lifetime borderline personality disorder among patients with alcohol use disorders ranged from 9.8% to 14.7% in this same study. A study found that among individuals with borderline personality disorder, the prevalence rate of alcohol use disorders was 48.8% and among patients with alcohol use disorders, the prevalence rate of borderline personality disorder was 14.3%. Comorbidity rates are even higher among female psychiatric patients, with 59% of women with borderline personality disorder also carrying a lifetime diagnosis of either alcohol abuse or dependence. Individuals diagnosed with both borderline personality disorder and alcohol use disorder have worse outcomes compared to those with either borderline personality disorder or alcohol use disorder alone. Borderline personality disorder traits are significantly predictive of future problems associated with alcohol use, even after controlling for other Axis I disorders (including other current substance use disorders) and nonborderline personality disorders.

There are surprisingly few treatments that have been developed or tested for concurrently treating borderline personality disorder and alcohol use disorders. Several randomized studies have found that targeting personality traits in brief coping skills interventions is effective in reducing alcohol and illicit substance use. An approach called, Personality-Guided Treatment for Alcohol Dependence (PETAD), was created that integrates cognitive therapy for addictive behaviors with strategic interventions for maladaptive personality features. Compared to those receiving standard cognitive therapy, those in the PETAD condition were more likely to stay in treatment, and had significantly more days of alcohol abstinence at their six-month follow-up visit. In another study, Linehan et al. (1999) examined the efficacy of Dialectical Behavior Therapy (DBT) with patients with borderline personality disorder and substance use disorders. In this particular study, patients were randomized to one year of either DBT-S or treatments as usual (TAU). At the 16-month follow-up, DBT-S patients reported better social and global adjustment compared to the TAU group.

Another psychotherapy has been developed for the concurrent treatment of personality disorders and substance use disorders called Dual Focus Schema Therapy (DFST). Unlike DBT-S, DFST was developed for the treatment of a broader range of personality disorders that are often comorbid with SUDs and AUDs. DFST includes a 24-week, manual-guided, individual cognitive-behavioral therapy integrating relapse prevention techniques while addressing chronic, maladaptive personality functioning and coping styles. The efficacy of DFST for specifically treating patients with borderline personality disorder and alcohol use disorder is unknown, but there are some encouraging findings regarding its efficacy among patients with dual diagnoses of personality disorders and SUDs. Both DBT-S and DFST appear to be promising approaches for the concurrent treatment of borderline personality disorder and substance use disorders.

The only form of psychotherapy that has been specifically tested for the concurrent treatment of borderline personality disorder and alcohol use disorders is Dynamic Deconstructive Psychotherapy (DDP), a time-limited, manual-based treatment based on object-relations theory, deconstructive philosophy and neurocognitive research. Analyses from a study comparing DDP and TAU found no significant differences between groups during the course of the study, however, there were statistically significant improvements found over time on measures of parasuicide behavior, alcohol misuse, and proportion of patients needing institutional care for those receiving DDP but not for those receiving TAU.

In summary, DBT-S and DFST appear to have only modest effects on drinking behavior. Further research is clearly needed for all three psychotherapies. It will be important for future studies to explore the effectiveness of these psychotherapies not only in bigger samples, but also in samples of patients with dual diagnoses specifically of borderline personality disorder and alcohol use disorders.

In treating individuals with alcohol use disorders, the main objective is relapse prevention. Thus, pharmacological strategies usually involve medications that deter alcohol use by moderating craving and/or producing adverse reactions when alcohol is consumed. The FDA approved medications for alcohol relapse prevention are disulfiram [acetaldehyde dehydrogenase (ALDH-1 and -2 inhibitor)], oral and injectable naltrexone (mu-opioid antagonist), and acamprosate (NMDA receptor modulator). Differentially, there are no FDA approved medications for the treatment of borderline personality disorder. Nevertheless, psychotropic medications, namely antidepressants, anticonvulsants, and antipsychotics, are often used to manage the anger, impulsivity and mood lability that are characteristic of borderline personality disorder. Of these medications, anticonvulsants, namely topiramate and lamotrigine, and second-generation antipsychotics, specifically aripiprazole and olanzapine, appear to be the most helpful. Antidepressants, although most commonly prescribed for patients with borderline personality disorder are only modestly effective in managing symptoms of borderline personality disorder. There are no published studies that have explored medication options to concurrently manage symptoms of borderline personality disorder and decrease alcohol consumption. A study was conducted utilizing disulfiram with individuals with borderline personality disorder and alcohol disorder. Two of the eight patients remained completely abstinent under supervised disulfiram therapy over their respective treatment period (4.5 and 14 months). These studies provided evidence that relapse prevention medications may be similarly effective in reducing alcohol consumption for individuals with and without comorbid borderline personality disorder. However, neither study reported on changes in borderline personality disorder symptoms. Therefore, while relapse prevention medications may help to control alcohol use, there is no evidence that they effectively manage borderline personality disorder symptoms. There is also emerging evidence that anticonvulsants and second-generation antipsychotics are most effective in the management of borderline personality disorder symptoms. Interestingly, the very same medications may be helpful in the treatment of alcohol use disorders. Of these classes of medications, most support has been found for topiramate and aripiprazole, however, encouraging findings have also been reported for lamotrigine and olanzapine.

Borderline personality disorder and alcohol use disorders are highly comorbid and this type of comorbidity has been associated with particularly negative prognosis. Yet, there are very few treatments that concurrently treat symptoms of both borderline personality disorder and alcohol use disorders. There have been three psychotherapies that have been designed to concurrently treat borderline personality disorder and substance use disorders. However, only one (Dynamic Deconstructive Psychotherapy) has been specifically evaluated for the concurrent treatment of borderline personality disorder and alcohol use disorders, and although it may be effective in reducing symptoms of borderline personality disorder, its efficacy in reducing alcohol consumption over time may be comparable to treatment as usual. There is evidence that some anticonvulsants and antipsychotics may significantly reduce anger (one core symptom of borderline personality disorder), and some like lamotrigine have been shown to reduce other core symptoms of borderline personality disorder including impulsivity and mood lability. Other studies have suggested that the same medications may also reduce alcohol craving and consumption in patients with alcohol use disorders/problems alone. Considering these results, further study of the role of anticonvulsants and second-generation antipsychotics is warranted, and further studies aimed at exploring other treatments that simultaneously treat both symptoms of borderline personality disorder and alcohol disorder are recommended. (Gianoli, Jane, O’Brien, & Ralevski, 2012)

Gianoli, M. O., Jane, J.S., O’Brien, E., & Ralevski (2012). Treatment for comorbid borderline personality disorder and alcohol use disorders: A review of the evidence and future recommendations. Experimental and Clinical Psychopharmacology, 12 (4). 333-344.

Cindy A. Geil, M.A.
WKPIC Doctoral Intern

August 08 2014

Friday Factoids: Good Resource for Treatment Planning

Developing specific and detailed treatment plans can be challenging when you are a new clinician. The Complete Adult Psychotherapy Treatment Planner, Fifth Edition (Jongsma, 2014) is a great resource that incorporates evidence-based interventions for 43 presenting problems.

This is a good place to start when wanting to tailor treatment plans for each individual client. The Practice Planners series has other adult treatment resources, The Adult Psychotherapy Progress Notes Planner (Jongsma, 2014) and Adult Psychotherapy Homework Planner (Jongsma, 2014), and similar resources for other populations including Child, Adolescent, Older Adult, Severe and Persisting Mental Illness, Personality Disorder, Co-Occurring Disorders, Addiction, Couples, Family, Group, Suicidal and Homicidal Risk, and Crisis Counseling and Traumatic Events.

Danielle McNeill, M.S., M.A.
WKPIC Doctoral Intern

July 07 2014

Article Summary: Operationalzing the Assessment and Management of Violence (Doyle & Logan, 2012)

In their article, Doyle and Logan (2012) suggest a system, Short-Term Assessment of Risk and Treatability (START), for assessing violence risk that addresses shortcomings of current methods. Studies have estimated between one in 10 and one in three admissions are preceded by violence toward others. Although assessing violence risk has been widely studied, there are far fewer studies related to managing and reducing risk once identified.

Risk judgments made based on total scores of risk factors is only loosely related to risk management. The structured professional judgment (SPJ) approach to risk assessment considers not only the presence or absence of specific risk factors, but also specific individual and contextual factors. There are six stages of SPJ:

Gather information from a variety of sources.
Consider the presence and relevance of risk factors – historical, current, contextual, protective.
Develop a risk formulation – motivators (drivers), (dis)inhibitors, destabilizers. Here the clinician discusses whether or not these risk factors are relevant to the individual’s potential to be violent in the future.
Consider risk scenarios, e.g. repeat, escalation, twist. This step directly links risk assessment to risk management by formulating a judgment about risk and protective factors, and how these factors impact potential for violence in the future.
Develop risk management strategies derived from the most relevant risk and
protective factors.
Summary of judgment including judgments of the urgency of action, risk in other areas, any immediate action required, and when the next review should occur.

Several risk assessment tools have been validated to assist in short-term risk assessment, stage two in SPJ. These include:

Violence Screening Checklist (VSC):
Brøset Violence Checklist (BVC):
Dynamic Appraisal of Situational Aggression (DASA):
Classification of Violence Risk (COVR):
Violence Risk – 10 items (V-Risk 10):

The START is a brief guide for assessing risks, strengths, and treatability. It was developed based on forensic mental health services, but can be applied in a variety of mental health settings. Preliminary evidence suggests the START has the potential to be a useful tool in informing clinical judgment. Studies have also indicated adequate reliability and validity in a variety of settings and different countries. The START assesses risk across the following domains: risk to others, suicide, self-harm, self-neglect, substance misuse, unauthorized leave, and victimization. It consists of 20 dynamic items that may change across days or weeks. Changes in the items could result in an elevation or reduction of risk. All items can be considered as both risk factors and protective factors. The 20 items include:

1.            Social skills
2.            Relationships
3.            Occupational
4.            Recreational
5.            Self-care
6.            Mental state
7.            Emotional state
8.            Substance use
9.            Impulse control
10.          External triggers
11.          Social support
12.          Material resources
13.          Attitudes
14.          Medication adherence
15.          Rule adherence
16.          Conduct
17.          Insight
18.          Plans
19.          Coping
20.          Treatability

The next step is to address the fourth and fifth stages of SPJ by considering risk formulation and developing risk management strategies. When developing a risk formulation, it is important to first address the question “risk of what” because risks can have different antecedents. One should consider different scenarios an individual may decide to be harmful in the future, called scenario planning. Scenario planning is not prediction, but rather it is based on identifying why an individual has acted in a violent way in the past.

The final stage includes risk management, or taking action to prevent the identified future scenarios from happening in the future. Risk management strategies include treatment, supervision, and victim safety planning.

Doyle, M., & Logan, C. (2012). Operationalizing the assessment and management of violence risk in the short-term. Behavioral Sciences and the Law, 30, 406-419.

Danielle McNeill, M.S., M.A.
WKPIC Doctoral Intern

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Category Archives: General Information

Summary of Giving Courts the Information Necessary to Implement Limited Guardianships: Are We There Yet?

Alert for Psychology Internship Applicants: Beware of Scams Claiming to Help You Match!

Summary of Gianoli, Jane, O’Brien, & Ralevski (2012): Treatment for Comorbid Borderline Personality Disorder and Alcohol Use Disorders

Friday Factoids: Good Resource for Treatment Planning

Article Summary: Operationalzing the Assessment and Management of Violence (Doyle & Logan, 2012)

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