PSYCHOTHERAPY

--- Features In This Issue ---

The Gender Socialized Therapist- A Case Study Quality, Quagmire, and Courage National Health Care Reform: Implications for Psychotherapy and Psychopharmacology

Utilization Review, Documentation, and the Adversarial Process On Psychology, Ethics and National Health Care Reform

VOL. 28. NO.2

OFFICIAL PUBLICATION OF DIVISION 29 OF THE AMERICAN PSYCHOLOGICAL ASSOCIATION

Summer 1993

Division of Psychotherapy of the American Psychological Association 1993 Officers

OFFICERS

President

Gerald P. Koocher, Ph.D. Dept. of Psychiatry Childrens Hospital

300 Longwood Ave. Boston, MA 02115-5737 Office: 617-735-6699

FAX: 617-730-0457

Past President Reuben Silver, Pb.D. 510 Huron Rd. Delmar, NY 12054 Office: 518-439-9413 FAX: 518-439-9413

President Elect

Tommy T. Stigall, Ph.D. The Psychology Group 701 S. Acadian Thruway Baton Rouge, LA 70806 Office: 504-387-3325 FAX.: 504-387-0140

Treasurer, 1992-1994

Alice Rubenstein, Ed.D. MolUO€ Psychotherapy Ctr. 59-E Monroe Ave. Pittsford, NY 14534

Office: 716-586-0410

FAX: 716-586-2029

Secretary, 199.1-1993

Patricia S. Hannigan-Farley, Ph.D. 24600 Center Ridge Rd., Suite 420 Westlake, OH 44145

Office: 216-871-6800, Ext. 19 FAX: 216-871-1159

LIAISONS/MONITORS Administrative Liaison Mathilda Canter, Ph.D.

4035 E. McDonald Dr.

Phoenix, AZ 85018

Office: 602-840-2834

BAPPI Monitor Irene Deitch, Ph.D. 57 Butterworth Ave.

Staten Island, NY 10301-4543 Office: 718-39().7744

CEMA Monitor

Lisa M Porche-Burke, Ph.D. CSPP-LA

1000 S. Fremont Ave. Alhambra, CA 91803-1360 Office: 818-284-2777

Liaison to APA International Committee

Ernst Beier, Ph.D.

44 N. Third South, #607 South Salt Lake Gty, UT 84101 Office: 801-581-7390

MEMBERS-AT-LARGE Ernst Beier, Ph.D., 1991-1993 44 West Third South,

Apt. #6IJ7 South

Salt Lake Gty, UT 84101 Office: 801-581-7390 FAX: 801-581-5841

Mo.ms Goodman, Ph.D., 1992-1994 One Cypress 5t.

Maplewood, NJ 07040

Office: 201-763-3350

Harry Sands, Ph.D. , 1993-1995 lOW.83rd5t.

New York, NY 10024 Office: 212-799-7777 FAX: 212-799-4676

Norine G. Johnson, Ph.D.; 1993-1995 110 W. Squantum, #17

Quincy, MA 02171

Office: 617-471-2268

FAX: 617-323-2109

Ronald F. Levant, Ed.D., 1991-1993 1093 Beacon St., #3C

Brookline, MA 02146

Office: 617-566-4479

FAX: 617-484-1902

Lisa M. Pordte-Burke.Ph.D., 1992-1994 CSPP-LA

1000 5. Freemont Ave. Alhambra, CA 91803--1360 Office: 818-2M-2m

FAX: 818-284-1520

Obseroer to APA & CAPP Practice Directorate Ellen MtGrath, Ph.D.

380 Glen Eyre, 5te. D Laguna Beach, CA 92651 Office: 714-497-4333

FAX: 714-497-0913

REPRESENTA1TVES TO JCPEP TommyT. Stigall. Ph.D.

The Psychology Group

701 S. Acadian Thruway

Baton Rouge, LA i'08Q5

Office: 504-387-3325

Arthur Wiens! Ph.D.

Oregon Health Services University 3181 SW Sam Jackson Park ReI. PortJand, OR 972.01

Office: 503-279-8594

Wade Silverman, Ph.D., 1993-1995 1514 San Ignacio, Suite 100

Coral Gables, FL 33146

Office: 305-661-7844

FAX: 305-661-6664

Suzanne B. Sobel, Ph.D., 1993-1995 1680 Highway AlA, Suite 5 Satellite Beach, FL 32937

Office: 407-773-5944

Carl Zintet, Ph.D., 1992-1994 4200 E. 9th Ave.

University of Colorado Medical School Denver, CO 80262

Office: 303-270-8611

FAX: 303-270-5641

REPRESENTATIVES TO APACOUNCIL

Donald K. Freedheim, Ph.D.

1993 - Feb. 1996

Dept. of Psychology Mather Memorial Bldg.

Case Western Reserve University Cleveland, OH44106

Office: 216-368-2841

FAX: 216-368-4891

Carol D. Goodheart, Ed.D.

1991 - Feb. 1994

21 Harper Rei. Monmouth J ct .. , NJ 08852 Office: 908-246-4224

EDITORS OFPUBUCA110NS Psychotherapy Journal

Donald K. Freedheim, Ph.D., Editor Dept. of Psychology

Mather Memorial Bldg.

Case Western Reserve University Oeveland, OH 44106

Office: 216-368-2841

Psychotherapy TC1llf'M1

Wade H. Silverman, Ph.D., Editor-Elect 1514 San Ignacio, Suite 100

Coral Gables, FL 33146

Office: 305-661-7844

FAX: 305-661-6664

Psychotherapy Bulletin

Linda Campbell, Ph.D.! Editor University of Georgia

402 Aderhold Hall

Athens, GA 30602-7142

Office: 706-542-1812

FAX: 404-594-9441

MID- WINTER MARCH 10-13, 1994 Program Chair

Convention Coordinator Louise Silverstein, PhD.

William R Fishburn, MD.

Associate Coordinator Loon VandeCreek" Ph.D.

Continuing Education Chair Barry Schlosser, Ph.D.

PSYCHOTHERAPY BULLETIN

Published by the

DIVISION OF PSYCHOTHERAPY AMERICAN PSYCHOLOGICAL ASSOClATlo.'J

3875 N. 44th Street Suite 102 Phoenix, Arizona 85018 (602) 952-8656

EDITOR

Linda Campbell, Ph.D.

CONTRIBUTING EDITORS Medical Psychology David Adams, Ph.D.

PSYColumn Mathilda Canter, Ph.D.

Washington Scene Patrick DeLeon, PhD.

Media, Marketing & Psychology Bruce Forman, Ph.D.

Professional Liability Leon VandeCreek, Ph.D.

Finance

Jack Wiggins, Ph.D.

Group Psychotherapy Morris Goodman, Ph.D.

Substance Abuse Harry Wexler, Ph.D.

Gender Issues Gary Brooks, Ph.D.

STAFF

Central Office Administrator Pauline Wampler

Associate Administrator Norma Files

PSYCHOTHERAPY BULLETIN
Official Publication of Division 29 of the
American Psychological Association
Volume 28, Number 2 Summer 1993
,
CONTENTS
4 President's Message
5 Edi tor's Column
6 1993 Award Winners
6 Washington Scene
11 Medical Psychology
14 State News
15 Feature: The Gender Socialized
Therapist - A Case Study
19 Division CE at APA
Special Pull Out Section -1993 APA
Hospitality Suite and Program Schedule
21 Feature: Quality, Quagmire, and Courage
24 Feature: National Health Care Reform:
Implications for Psychotherapy and
Psychopharmacology
27 Feature: Utilization Review,
Documentation, and the Adversarial
Process
29 Feature: On Psychology, Ethics and
ational Health Care Reform
31 Group Psychotherapy
33 Substance Abuse
35 Essay Gerald P. Koocher

PRESIDENT'S MESSAGE

I hope to meet and welcome many of you during the Toronto Convention. Dr. Norine Johnson has organized one of the best programs ever, and it will now be possible for our members who need continuing education credits to pick up fourteen hours of high quality learning free of charge. Details are highlighted along with the convention program elsewhere in this issue. I urge you to take advantage of these programs and help us to evaluate whether they should be

continued and expanded. L:.::1ll8[.L __ -.J~~~~ Finally, I have always wondered

whether people actually read columns by division presidents in their newsletters. Being a true scientist-practitioner, I want to obtain some empirical data. I therefore promise a valuable historical artifact to the first fifty colleagues who see me in Toronto and report that they actually read this sentence! Best wishes to all of you for a wonderful summer.

ested in assuring that the psychotherapeutic needs of Americans are adequately met. We will not win this struggle with raw dollar expenditures, but we have a strong team that has a solid chance to prevail if we arm them well. The cost of failure will be severe for our field, but devastating to the individuals and families who will find needed services beyond their means. Please ask your colleagues whether they have contributed, and urge them to do so, if they have delayed.

Dr. Ron Levant, a Member-a t- Large of our Board and Chair of the commi ttee overseeing the AP A Practice Directorate, reports that over a million dollars has been collected through the 1/$100 for 100 Days" campaign. This is a reassuring response, but a mere pittance compared to the money that will be expended by others less inter-

1992 APA DISTINGUISHED CONTRIBUTION AWARDS

Division 29 wishes to recognize our members who have been cited by AP A for excellence and distinguished contributions in 1992.

AWARDS FOR DISTINGUISHED CONTRIBUTION TO RESEARCH

IN PUBUC POLICY

AWARDS FOR DISTINGUISHED PROFESSIONAL CONTRIBUTIONS

AWARDS FOR DISTINGUISHED EDUCATION AND TRAINING CONTRIBUTIONS

Herbert J. Freudenberger Gerald P. Koocher

Gail E. Wyatt

Ronald E. Fox

Awards recipients will be honored at the 1993 APA Convention in Toronto, Canada. Some of our member awardees will be presenting addresses at the Convention. The information on the presentations will be in the annual convention program.

4

EDITOR'S COLUMN

Linda Campbell

An invitation was extended through this column, in the last issue, to current contributors and to members who have not written for the Bulletin. The invitation urged each of you to come forward with your ideas via feature articles, serial articles, case studies, reports, or any means by which your work and ideas can be conveyed. The response we have received is an affirmation that you, the Division 29 members, are representative of the heart and spirit that have shaped our profession and continue to define our identity.

The evidence for this statement lies in the diversity and depth with which you have responded. Members are confirming the need for our involvement in legislative and legal issues, clinical and medical issues, and health care reform. Members are also offering to write for the Bulletin on psychotherapy training and practice in areas of the chronically mentally ill, gender focused therapy, multicultural issues, therapy with the aging, women's perspectives on traditional theories, ADD and families, working with chronic diseases and more.

We have heard from members who have had long standing prominence in AP A and Division 29, members who are caIling on behalf of others who they believe could makecontribu tions, members who have never written but have wanted to, and members who have identified issues and topics they believe should be addressed.

Our members are scientists, practitioners, advocates, and policy-makers. They are also creative and gifted individuals who practice the science and art of psychotherapy. This response from you demonstrates that Division 29 members are the architects of the continued development of psychotherapy and are offering to bring aspects of training and practice in diverse areas to us.

To those of you who are interested in writing but haven't yet responded, don't be deterred by the initiatives you've just read about. There is room on the bandwagon for everyone.

STUDENT COLUMN

Student Paper Competition Winning Entry Abstract

Understanding Psychotherapy for Depression:

The Role of Techniques, Relationship, and Their Interaction Louis G. Castonguay

Stanford University

An attempt was made to understand the mechanisms of change underlying cognitive therapy for depression. As part of a research project conducted by S. Hollon and his colleagues, 30 subjects meeting cri teria for Major Depressive Disorder were treated by experienced therapists. Using different groups of judges, randomly selected sessions were coded for the therapists adherence to cognitive techniques and the quality of the working alliance. Results showed that the client improvement at mid-treatment and at termination was predicted by the alliance. On the other hand, adherence to one set of techniques of cognitive therapy correlated negatively with

improvement at termination of treatment. Preliminary qualitative analyses performed to better understand these findings suggested that increased adherence to technique may at times be a response to alliance ruptures, bu t may actually further damage the therapeutic relationship. The qualitative analyses also suggested that the therapist's skills, which help create a good alliance, may sometimes facilitate the achievement of specific goals of cogni tive therapy (i.e .. acquisition of a more realistic perception of self and others) with a minimal use of its prescribed techniques.

5

1993 AWARD WINNERS

Reuben J. Silver

Chair, Awards Committee

Patrick DeLeon, Ph. D., has been selected to receive the 1993 Division 29 Distinguished Psychology Award For Contributions To Psychotherapy and Psychology. This a ward, first established in 1970, is given to a psychologistfor sustained, outstanding contributions to the field of psychotherapy.

On the national level, Dr. Del.eon, who is Executive Assistant to Senator Daniel Inouye, is being honored for his outstanding achievements in expanding the boundaries of psychotherapy practice through his tireless ad vocacy.

[on Perez, Ph.D., is the 1993 recipient of the Krasner Award, which was established by the estate of Jack Krasner, Ph.D., a former President of Division 29. The award is restricted to those psychologists who have completed training within the last 10 years. Hence, it is an early career award.

Dr. Perez is honored for his Significant work in the area of trauma, and more specifically for his work wi th the Trauma Task Force of Di vision 29.

Both awards will be presented during the Social Hour of Division 29.

I hope to see all of you there.

WASHINGTON SCENE

The Clinton-Gore National Health Reform Movement

Pat DeLeon

During President Clinton's first Sta te of the Union Address he emphatically noted: "All of our efforts to strengthen the economy will fail-let me say this again; I feel so strongly about thisall of our efforts to strengthen the economy will fail unless we also take this year-not next year, not five years from now, but this year-bold steps to reform our health care system ... " The appointmen t of Hillary Rodham Clinton to Chair the President's Task Force on National Health Care Reform clearly underscores the vi tal importance of this issue to the Administration.

There is no question in our mind that mental health care will be included in the

6

Ad minis tra tion' s forthcoming legisla ti ve recommendations. In May, Senator Kennedy, Chairman of the Senate Labor and Human Resources Committee, held a special hearing on "Coverage for Mental and Addictive Disorders in Health Care Reform: A Cost-Effective Approach," with Mrs. Tipper Gore representing the Administration.

The Practice Directorate of AP A is doing ar outstanding job in ensuring that "psychology' voice will be heard" in this crucial national de-bate. We thought the readership would be inter ested in learning the observa tions of several "fror line" psychologists who have personally partie pated in the dialogue. In our judgment, t

Rural America truly provides psychology with

personal component of the political/legislative process is absolutely critical.

Mike Enright, Chair of the AP A Task Force on Rural Psychology (established by Past- President Jack Wiggins) and Gil Hill of the Practice Directorate " ... went to the White House on May 4th to meet with members of the Health Care Reform Task Force. The meeting was coordinated by Bernard Arons, MD, a Senior Task Force Fellow. Dr. Arons introduced Alan Trachtenberg, MD, MPH, Director of the Office of Science, Policy, and Analysis, National Institute of Drug Abuse and Gregory Bloss, Ph.D., an economist with the National Institute of Alcoholism and Alcohol Abuse. The meeting proceeded informally with the White House requesting information concerning rural mental health needs and the role of psychology in meeting these needs. The discussion opened up with Mike describing his practice in rural Wyoming with special emphasis on the posi tive effects of collaborative inter-

vention between psychologists, physicians, and other health professionals."

"The following points were made: 1.) Psychiatrists do not practice in rural areas and it will not be possible to increase their numbers in rural areas in the foreseeable future since many psyehla tric residency slots go unfilled each year. 2.) Psychologists working collaboratively with primary care physicians have been and will continue to provide rural mental health care needs. 3.) There is a need for more doctoral level psychologists in rural areas to pr~ vide mental health care directly and also to supervise mid-level providers to insure the quality of care. The driving concern behind this discussion was the reality that rural residents may be treated differently from urban residents, receiving care from less trained and less competent providers simply because it is difficult to get doctoral level providers into remote rural areas. The point was also made that the rural population is at greater risk and is in greater need of competent providers because of the high incidence of elderly living in rural areas and the high incidence of poverty among rural residents. 4.) One means of increasing the number of doctoral level psychologists is for the DHHS to change its

policy and make psychologists eligible for loan forgiveness by serving in the National Health Service Corps in mental health professional shortageareas. 5.) Managed care must be regulated to insure that patients receive the mental health care they need. 6.) Any new managed competition program must be modified to meet the needs of persons living in rural and frontier America, since competi tion models will likely not generate much interest from insurance companies in meeting the needs of persons indigenous to remote areas. The discussion also included a wide ranging number of topics from the need to insure that psychologists are reimbursed for Medicaid, to the lack of substance abuse treatment availability in rural areas. We further discussed the Linkage Project that the AP A has recently completed developing a collaborative model between psychologists and primary care physicians for the treatment of alcoholism in rural areas. Overall the reception from the Whi te House Health Care

Reform Task Team was marked by a genuinely open, receptive attitude. The Task Force Team members took enough time to discuss the issues in depth and were apparently interested in integrating the information into their decision-making process." Rural America truly provides psychology with many exciting opportunities and challenges.

many exciting opportunities and challenges.

Bob Frank, former Robert Wood Johnson Congressional Science Fellow, attended a meeting arranged by Donna Daley of the Practice Directorate with members of the Jackson Hole Group to discuss mental health benefits. "The Jackson Hole Group is a band of health care experts who have put together a particular proposal for health care reform which many experts feel may ultimately become the basis for the Clinton-Core program. The group convenes at the home of Dr. Paul Ellwood, a neurologist turned health outcomes researcher, in Jackson Hole, Wyoming. Ellwood has collaborated closely with Alen Enthoven, an economist and professor in the Stanford Business SChool. More than 20 years agel Enthoven put forth a proposal for a market based reform of the health care system. In recent years, Ellwood and Enthoven have been joined by Lynn Etheredge, a health care consultant in

7

Washington. Etheredge worked for more than a decade in the Office of Management and Budget, eventually directing the Health Division."

"Ellwood, Enthoven, and Etheredge have recruited an eclectic group of individuals to work with them atthemeetings in Jackson Hole. Membershi p in the group ranges from members of the United States Senate (Senator Durenburger) to executives of academic health science centers to insurance company executives. The proposals put forth by the Jackson Hole Group have focused on creating an effective health market. They maintain the current health care system is dysfunctional because market influences have been divorced from consumer decisions. Currently, consumers purchase health care services with little financial impact. Our fee-for-service system encourages health care providers to use health resources. More, rather than less, testing or treatment is encouraged. At the same time, consumers, in our third party payment system, have no control, or personal interest, in limiting the utilization of health resources. They maintain that health care spending will continue to escalate as long as these conditions persist."

"To rectify these problems, the Jackson Hole Group proposes establishing a health care market based on consumer choice. In 1991, they issued a series of four papers describing the '21 st Century Health Care System'. Their health care system would group consumers into large purchasing groups which would use health insurance purchasing cooperatives or l-ITPCs. The most important of the Jackson Hole proposals, however, is grouping providers into large, vertically integrated health care systems, Accountable Health Partnerships (AHPs). Providers would have exclusive membership in only one health care system (with a few exceptions). These health care systems would then compete for consumer dollars. To make health care function as a true market system, consumer decisions would be based on health outcome data, quality of care, and consumer satisfaction, that would be provided by each competing health partnership. Health care services would be capita ted avoiding the inflationary spiral of the fee-far-service model."

"Other critical features of the Jackson Hole proposal include a move towards community rating

8

of health benefits. Under this approach each health care consumer is rated according to the cost in that community. The individual's health status is not considered in determining the cost of their health insurance premium. Community rating is perceived by consumers as a gentler health care system. Individuals are not penalized for their health care status and insurers are not rewarded for 'gaming' the system. The Iackson Hole model, or any community rating based model, does not provide incentives for insurers to 'skim' healthy individuals into their plans, avoiding individuals most in need of health care services."

"During the second session of the 102nd Congress, I served in the office of Senator J Bingaman, Democrat-New Mexico). It was during this session of Congress that interest in managed competition skyrocketed. During the Presidential campaign, Candidate Clinton became increasingly convinced that managed competition offered a way of controlling health costs. At the same time, Senator Bingaman duced several bills based upon managed "nT .......... >"O titian concepts. While drafting these bills, I many conversations with the AP A on how might affect the practice of psychology."

"On May 10th we met with members of Jackson Hole Group (including Dr. Straub, a fellow working with them) to focus the true costs of psychological or mental services. This format allowed the Jackson representatives to question the experts broug in by AP A on actual costs. The experiences of B South, a company that has developed an tive, extensive mental health package for its eITH ployees were extremely impressive. Over last five years, Bell South has substantially r duced mental health costs while increasing coy erage for mental health services. It has done byredudnginpatientdays,actively early outpatient treatments, and liberally Employee Assistance Programs."

"The vigorous and educational discussion t - followed the fine presentation by Bell South wa.. very impressive. Straub and Etheredge ask tough questions, all of which were readily swered by the Bell South representatives AP A staff. The meeting was a dear success."

"Although Etheredge and Straub appeare swayed by the information they had obtained

will likely tum to the expansion, follow-on, or utilization of the initial class of 'fellows' to begin independent prescribing or to include, other DoD patient communities, such as the retired military and CHAMPUS patient communities. A{p)A POSITION: The prescribing of potentially dangerous psychoactive medications should be limited to those professionals who have the proper medical educa tion and residency training. A{p)A believes that any move to expand, and follow-on programs or utilization of the individuals involved in the pilot must be explicitly prohibited until the time the pilot has been independently evaluated and Congressional hearings have been held on the need and appropriateness of prescribing authority for non-physician military psychologists." How insightful their predictions seem to be. However, recall that of the 135,896,000 prescriptions written in 1991 for

psychotherapeutic drugs, only 17.3 percent were written by psychiatrists, with both their internist (22.3 percent) ... of the 135,896,000 and family practitioner (23.0 percent)

colleagues being responsible for a greater percentage of mental health related prescriptions.

the meeting, the complexities and political nature of the task psychologists face became apparent two days later. Dr. Straub was an invited guest on the McNeil-Lehrer program for a panel discussion on mental health costs in the Clinton health care plan. In contrast to his more open view by the end of the meeting with MA, on McNeil-Lehrer, he appeared less certain that a broad-based mental health package would be useful. There is little doubt that the battle is far

from won."

PRESCRIPTION PRIVILEGES - SOME INTERESTING DEVELOPMENTS

In May of this year the Acting Assistant Secretary of Defense for Health Affairs testified before the Senate Appropriations Committee, providing a report on the DoD psychology prescription privilege training program. "Three of

the original four military psy-

chologists continue in this two-year training program. Their didactic requirements will be completed this month, and they will continue the clinical practicum phase at Walter Reed Army Medical Center for nine months. As the external evaluator of this demonstration program, the American College of N europsychopharmacology has offered a number of recommended improvements which are under review. Preparations have

begun to recei ve, in July, the next class of clinical psychologists for training." We understand tha t each of the Services are expected to assign post-doctoral fellows for the next class and further, that the didactic portion of the training will now be only one year, with the faculty of the Uniformed Services University of the Health Sciences (USUHS) developing integrated training modules specially for the psychology fellowsrather than continuing to require them to attend ongoing medical school classes. Progress is indeed being made!

prescriptions written in 1991 for psychotherapeutic drugs, only 17.3

psychiatrists ...

percent were written by

Organized psychiatry's opposition continues, however. Earlier this session of Congress our colleagues in the other ApA reported in their Legislative Lobbying Fact Sheet that "Debates over the BY 1994 Defense Appropriations Bill

In our judgment, a significant indicator of how far we have come as a profession in the prescription privilege evolution is the fact that questions on this topic are now appearing in various psychology comprehensi ve examinations and that the topic has become the subject of doctoral dissertations. Brenda Smith, who recently graduated with her Psy.D. from Indiana State University, provided us with a copy of her dissertation entitled "Attitudes Towards Prescription Pri1n1ege Among Clinical Psychology GratiUJ2te StudeTIts".

Her summary: "Are They Ready To Be The Force? In the debate regarding prescription privileges for psychologists, a frequent component has been the question of which should come first the legislation or the training. Many advocates have argued the training should be first and that when psychology can offer a 'ready force', the legislation will soon follow. Opponents of this posi tion maintain the students would not be willing to undergo training without a guarantee of privilege forthcoming. In a survey sent to 40 AP A approved graduate schools of clinical psychology (20 Psy.D. and 20 Ph.D.) across the nation, second and third year students were asked about

9

their attitudes about prescription privileges. The students responded with strong support forprivileges. The majority (61 percent) endorsed privileges for the field, and 47 percent reported they desired privileges for themselves. There were no significant differences in responses based on program type, theoretical orientation, gender, age, undergraduate major, or the student's choice of future client population."

"The students were asked to indicate their support for arguments supporting or opposing prescription privileges. Their choice for the two strongest supportive arguments were, ability to provide services to undeserved groups and collection of third party reimbursement. The two strongest opposing arguments were damage to credibili ty and distincti veness of psychology and possible impediment of collaboration with psychiatrists. In regard to the characteristics of prescription privileges, they most strongly supported a Formulary format (83 percent), which provided the right to prescribe a specified set of medications appropriate for psychology. The drugs most frequently chosen for inclusion within the forma t were antidepressan ts, anxiolytics and mood stabilizers. Asked what role, if any, physicians should take regarding prescription privileges for psychologists the majority preferred physicians act as consultants (71 percent) rather than co-signers or writers of standing orders, indicating the students are more supportive of the physician replacement model than the extender model. The students strongly endorsed placing the training for privileges at the Post-Doctoral level (77 percent) and 61 percent indicated that the opportunity to receive pharmacological training would influence their choice of a Post Doctoral training, with 18 percent stating they would definitely enter such a program were it available. Of those students reporting desire for prescription privileges, 63 percent were willing to help AP A obtain it. Given the results, it appears that many of today's graduate students are indeed willing to become the 'ready force' and want to help AP A in pursuit of prescription privileges for psychology."

10

At the State Association level, we also continue to see steady progress. Pat Pimental, chairperson of the Illinois Psychological Association PrescriptionPrivilege TaskForce, recently shared with us the results of two focus groups that were held earlier this year, specifically attempting to obtain input from psychologists "with a variety of opinions on the issue of prescribing authority." Pat's results indicated that the focus group participants: " ... went away more convinced that forces such as managed care, RBRVS's and outcome assessments will playa more pivotal role in the future of menta} health treatment than perhaps they believed coming into the ~1::;:'';:'lUll~., Interest among the psychologists in pursuing prescribing authori ty was high to begin with, bu even higher after the session. There was good awareness before the session regarding the at which many types of non-physician care providers have the authority to drugs. Rarely do psychologist refer patients physicians, including psychiatrists, for any of mental health treatment other than therapy. The majority of the psychologists well aware of the drug regimens prescribed their patients and feel strongly about being eluded in drug decision processes. There is luctance among the psychologists to believe a training program to prescribe could be completed in anything less than months."

For those interested in learning more about

ing legislative efforts, the Practice under the leadership of Anita Brown, will host meeting of State Association Prescription lege Task Force Chairs at the forthcoming convention in Toronto. This is currently uled for Friday, August 20 from 4:00 to 5:50 the Library Room of the Royal York Hotel. interested in attending should check with to ensure that the time and / or place has not changed.

MEDICAL PSYCHOLOGY

Pre-Existing Psychopathology:

Contraindications for Treatment

David B. Adams

Atlanta Medical & Neurological Psychology

Treatment proceeds from diagnosis, and limitations may be set upon the breadth of treatment based upon concerns for compensability and / or pre-existing pathology. An illuminating.. and likely necessary, investigative study would be the determination of which diagnostic tests and clinical procedures a doctor utilized when there is an overabundant supply of patients: a. Would all initially seen patients be given blood studies regardless of complaint, b. all virally ill patients be inappropria tely prescribed. antibiotics, or c. all psychotherapy referrals accepted for treatment?

This question of appropriateness of care addresses both clinical and fiscal issues. Our 700 billion dollar health care expenditure does not arise when diagnostic studies and therapeutic proc~ dures are prudently and appropriately ordered. This impressive expenditure arises when there are no controls. Studies and therapeutics were intended to be limited to those patients for whom such procedures are indicated by a combination of pa tient' s chief complaints and initial findings.

The impetus and justification for early psychological intervention was once based upon the contention that recovery from physical illnesses was expedited by psychological care. The ernergence, however, of proprietary mental hospitals' and the impressive costs of inpa dent "trea tment" soon illustrated that costs were not being contained but were merely using the mental health avenue as a new source of revenue growth and personal financial investment.

There is excellent product differentiation between a gynecological oncologist and a pediatric neu-

rologist or between a neuropsychologist and a hypnotherapist. Clinicians in each discipline are reasonably assured that patien ts referred to their office have specific symptoms, appropria te to the doctors' respective cognitive domains.

Patients, in tum, readily learn that they need an orthopedist for some complaints and a nephrologist for other concerns. The lack of pa~ tien! participation in primary care suggests that patients prefer access to specialists.

In mental health care delivery, however, the pa~ tient is quite unclear as to what is entailed in the education, training and credentiaIling in the alphabet soup of academic degrees which purport to deliver mental health services. It is unclear to consumers, insurers, referral sources, and even the government as to who is best equipped to diagnose mental disorder, to deliver psychological care, to admit to hospitals, to prescribe medications and to manage family, employer and social impact of the disorder.

In the throes ofthat confusion has come a govem~ mental plea that those engaged in hea ted competition in the men tal health marketplace somehow work cooperatively with each other. In the interim, each mental health discipline is quite certain that the other is not only inappropriately encroaching upon claimed terri tory but is doing so without training or skills. While some of the allegations have merit, the goal is not, as pur~ ported, to protect the public but rather to protect sources of revenue.

Without product differentiation in the clinical marketplace, however, the doctor is not assured of a needed supply of patie.nt material. Without a supply of patients, the clinician upwardly adjnsts the number of procedures, the frequency of patient visits, the length of care and the rates cbarged to insure an income standard. Concur-

I While !hexe are demonstIable physiad d~aOO menJ.1Il tzn.d emoticmal .d.isorders, there is no evidence that the term "psychiatric" adds emy diagnostic: clarification to the descriplive terms medialJ and psychoJQgicl.lJ. \oVhile "p~ychiatric" may suggest that a particular practitioner should beassocia!:ed with the treatment of the menial disorder, the term itself represents a terminological bias rather than scientific accuracy. This author, therefore, does not \JSe and does not recommend the use of the term in the literature, i:n case discussion,. in clinical consulta lion or in 'Written report.

11

The concept of containing costs has been offered through HMOs (IPOs, etc) which remove from the patient the freedom-oJ-choice of provider and assumes that a business concern, the HM:O, can make a better selection decision than the patient who has clinical or preventive needs. The goal of an HMO is not quality of care but control and containment of costs. Restraint of the system through managed care assumes that those providers in a managed care system are equal in talent and acumen to thosecompetingina purely private sector. It assumes that participating doctors are those whom the patient would have freely chosen. With the option ofpersonallychoosing a provider, the patient, however, is most likely to select a clinician based upon reputa tion, success, credentials and skill demonstrated to social or family contacts. The question remains if such exceptional clinicians would be part of a

12

rently, patients are accepted into care who are inappropriate for treatment.

In the teasing out of inappropriate health care deli very, some investigative media reporter will, in the near future, demonstrate that a financially needy doctor will accept any patient for psychotherapy and will hold that patient in treatment without clinical indication. This has been demonstrated successfully in inpatient settings (see Case History).

While the current concern has been for overt fraudulent accident claims and billing for patients in need of no care, the concern will soon shift to care which is not appropriate to condition and/or which expands excessive time period in order to meet the doctor and/or the hospital's financial needs.

Adjusting the compensable charges upward creates a condition of inflationary alarm with demonstrable ripple effect: The insurers have little choice but to limit benefits to insure profitabili ty. The doctors counter with holding patients and / or seeing' them more frequently than the clinical condi tion warrants. Insurers attempt to maintain profitability, and doctors attempt to maintain a lifestyle. Pa tients, who are insu red, run increased risk of excessive and inappropriate treatment. Patients, with insurance limitations, run the counter risk, the lack of needed and appropriate care.

Chronic Low Back Pain

Lifetime Incidence of Pre"Existing Psychological Disorder

pre-existing, develop-

mental characterological c1993 Oavid B. Adams, Ph.D.

(e.g. personality disor- L- -'

ders) variables are governing the clinical picture. The doctor knows tha t this cannot be considered. a compensable target of care. Patients with borderline personali ty disorder may well be abusing medications, having major depressive episodes, becoming transiently suicidal and be explosive, demanding and chaotic. The psychologist must

managed care system or would prefer the competition of the private market place,

Of equal concern is the admitting of patients into treatment where such treatment is not warranted or for whom treatment was intended, by the limits of insurance coverage, to be limited to specific diseases or conditions. A neurosurgeon seeing a patient with cervical symptoms as a resul t of a motor vehicle accident may well recognize that the patient also has L-spine symptoms as a result of a previous domestic fall. Treatment for the lumbar complaints, however, is not authorized. The prudent surgeon would encourage the patient to seek care for the latter condition, explaining the limitations on approved care.

In psychological care, however, the doctor is able to blur the lines of demarcation between pre-existing and consequent. The patient may well have major depressive disorder (Cf. DSM-IV), but if the doctor knows that this is related to non-compensable substance abuse or a chronically recurrent condition not attributable to a compensable event or injury, does the psychologist acknowledge and accept the established limits? If the doctor crea tes the bulk of his income by making hospital rounds on a dozen patients prior to office hours, there is a decreased probabili ty of the patient being treated as an outpatient rather than being admitted for a prolonged, costly and dependency-producing hospi taliza tion.

When thedoctorissent a patient with chronic low back pain (CLBP) as a result of compensable injury, the competent clinician is familiar with the extent to which

No Psychopathology 23%

be comfortable clinically and economically that this is not related to an injury and should not be the target of treatment compensable for that injury.

In treating conditions such as CLBP, in which it is determined that there was a history of childhood sexual assault, a history of abandonment, or a history of unrelated phobia or sexual dysfunction, the clinician must competently explain to the patient wha t is au thorized for care and that for which the patient needs to pursue additional care either during or following current treatment. And if the patient can be seen 3 weeks for supportive care, the clinician must be able to accept that the patient is not a source of weekly and/or a source of ad infinitum revenue.

The concern has been expressed regarding the uneven d istribu tion of providers. There has been an unspoken presupposition that were enough doctors available to serve rural areas that the quality of care delivered by these psychologists is not an issue of concern. Further, when doctor impairment has been addressed, the emphasis has been upon impairment of psychologists by virtue of sexual abuse of their patients or their own substance abuse. There may, however, be a problem of equal concern inherent in failing men tal health practices; competency to engage in patient management may be a central factor.

Clinical Disorders

Although doctors may receive referrals of, and engage in broad treatment of, patients with CLBP, there are increasing indication that mental disor-

ders perceived as proximately arising from a back injury may not only have antedated the injury but may, in complex fashion, contributed to the occurrence of the injury and/ or its emotional sequelae. Differentiation origin from consequence, preceding from resultant, andtha t appro pria te for treatment from that which may not be compensable by the insurer

77%

13

are the responsibilities of dutiful and competent doctors. "Results showed tha t. .. (excl ud ing) somataform pain disorder ... 77% of patients (with CLBP) met lifetime diagnostic criteria (for mental disorder) .. .In addition, 51 % met criteria for at least one personality disorder.

(And) of these pa- L...-Cl_9s_~_D_aVl_-d_B_, A_d_aIn_S_. P_h._D. ---'

tien ts with a posi tive lifetime history .. .54% of those with depression, 94% of those with substa nee a buse, and 95% of those with anxiety disorders had experienced. these syndromes before the onset of their back pain. (Specific mental

Chronic Low Back Pain Pre-Existing Personality Disorders

No Personality Disorder

51%

Pre-Existing Personality Disorder

disorders) appear to precede ... the onset of chronic low-back pain ... revelling) that clinicians should be aware of the potentially high rates of emotional distress syndromes (sic) in chronic low-back pain and enlist mental health professionals to maximize treatment outcomes" (polatin, et al., 1993).

Reference

Polatin,P. B.,KiImey,RK.,GatcheL R.J., Lillo, E., and Mayer, T. G. (1993). Psychial:Jic illness and chronic low-back pain, the mind and the spine-which goes first? Spine, Th-O), 66--71.

STATE NEWS

The amendment to the licensing and CE bill in Committee stated that nothing in the article implied that psychologists could prescribe medication. IP A initially felt that it only stated the obvious and posed little serious threat. The Association was also in the position of either accepting the amendment or loosing the bill.

The bill passed the Senate and went to the House for consideration. It was at that time that I received an article from Pat DeLeon on the prescription issue. This reminded me that the bill might restrict psychologists wi th Indiana licenses from participating in federal programs such as the Department of Defense training project. IP A took these concerns to the Senator who declined to have the amendmen t removed but did agree to some additional language. The bill was passed and signed by the Governor with the following language:

14

Michael J. Murphy

The Indiana Psychological Association had no thought of the prescription issue when it advanced a bill to move from certification to licensure and to mandate continuing education for Health Service Providers in Psychology but an amendment to the bill introduced in a Committee of the Indiana Senate drew us into the issue.

Nothing in this article shall be construed as pennitting a psychologist to prescribe medication, unless a psychologist is participating in a federal govenunent sponsored training ortreatm.entprogram. An individual licensed as a psychologist may not prescribe medication unless the indi vid ual is a practitioner (as defined under IC 16-42-19-5).

The code citation in the last sentence is to an article that defines practitioner as holding a Iicensetopracticemedidneorsurgery. Theamendment that we introduced in the House committee had additional wording "Except as specified above," at the beginning of the second sentence. The phrase was dropped at some point in the process which creates confusion because of the contradiction between the two statements. Both have clear legislative intent and the second sentence places psychologists who may be nurse practitioners in an unclear position. Regardless of the contradiction, the legislative intent of the first provision is clear and insures that psychologists holding Indiana licenses may participate in federal treatm.ent and training programs. The message is clear that in the future states can anticipate an increasingly aggressive stand on prescription.

A few decades ago a therapist encountering a femaleciientwhowaspassive,deferential,overly emotive, devoted to children, or perpetually unable to leave an abusive relationship, was likely to limit etiological explanations for her behavior to issues within her psyche. Feminist analysis of psychotherapy has introduced new perspectives, including examination of the larger question of gender socialization and its effect upon a woman client's clinical presentation. Brovennan, et al (1970) pointed out the androcentric biases of therapy and the "double-bind" faced by women in the therapy setting - the impossibility of being a traditional woman and a "mature adult," As this line of stud y has evolved, a number of sexist therapy practices have been identified, and more gender-aware forms of therapy have been proposed (Brodsky & Hare-Mustin, 1980). More recently, a number of writers have described ways in which men may also be harmed by therapist's inattention to gender issues. In a new field of men's studies, attention has been given to how traditional male socialization constrains men in a variety of settings, including psychotherapy (Brooks, 1990; Meth & Pasick, 1990; Scher, et al, 1987), The central point of these writers is that gender socialization organizes peoples' experience, and therapists need to know how gender socialization differentially impacts women' sand men's definitions of problems, reactions to these problems, selection of coping strategies, evaluation of the utility of psychotherapy, and eventually behavior in therapy, Of late, an interesting new suggestion has been made - that we therapists ourselves are subject to gender socialization pressures and should be continually aware of how those pressures organize our beha vior with clients. The following case study (from my caseload) is provided to illustrate this issue, hopefully, to shed light upon the many levels at which gender socialization may affect a therapist's behavior.

FEATURE ARTICLE

The Gender Socialized Therapist - A Case Study

Gary R. Brooks

THERAPY WITH ALICE

Alice, 58, was a self-described "typical doctor's wife," She had been married for 34 years to a very successful physician and was mother of three children, Although referred for treatment of depression, she clearly was far more angry, bitter, and resentful than she was depressed. In the initial therapy session, I was able to say little beyond-hello, not even able to ask her about her view of the problems. She immediately launched into a lengthy, uninterrupted diatribe against her husband (Frank), his overwork, his dedication to his medical practice, and subsequent neglect of her. As therapy unfolded, Alice elabora ted abou t her resentment that Frank had been able to portray himself to the children as a benevolent, kindly, caring, and generous father of almost heroic proportions. The children even seemed to suggest that their father was an innocent victim of Alice's petty, yet vicious, verbal assaults. Frank's accumulation of honors for his distinguished medical career further infuriated Alice, who felt no reflected glory or satisfaction. She coped with her resentment with a masterful ability to ridicule and deflate Frank with an interminable series of barbs and put-downs.

My initial efforts with Alice were rooted in my customary therapy framework - try to get her to focus less on controlling Frank, and more on her own needs, help her clarify her goals, get in touch with the range of her feelings, to get her to look at her self-defeating behaviors and her negative self-talk. These initial efforts "crashed and burned." Consultation with the referring source, a respected senior male psychiatrist, revealed that Alice \ as somewhat of a "dump." He admitted that he made the referral because he felt she wasn't making progress in therapy, and, in fact, he couldn't tolerate being in the same room with her. He and his colleagues (males) agreed that she was a bitter woman, doggedly determined to remain miserable and unhappy.

15

Levels of Gender Analysis

In analyzing this case from a gender socialization perspective, I discovered a number of prominen t areas of gender-based conflict, tha t can be thought of as organized into a number of levels: (a) conceptualization of the presenting problems; (b) the process of therapy; (c) personal emotional reactivity; and (d) understanding the systemic context.

Conceptualization of Presenting ProblemsA Feminist Lens

There could be no arguing that Alice was a bitter and unhappy woman, as well as an unpleasant person to be around. From that perspective it would be simple to see her husband's withdrawal from her as a natural response to her negativism. Similarly, it would be possible to see her as refusing to take responsibili ty for her own behavior, instead blaming her husband for all her unhappiness. Although there certainly is some truth to this conceptualization, a feminist lens offers a critical additional perspective. (A thorough feminist analysis of this situation is, of course, not possible here, but a few illustrative points can be made.)

Alice's situation can be understood as an outgrowth of a sexist mari tal arrangement, one tha t, for some, offers a form of identity and security that ultimately becomes hollow and unfulfi1ling. Alice believed that by dedicating herself to advancement of her husband's career, and by subjugating some of her own needs to those of others, she would eventually feel personal esteem and satisfaction. Instead, she is disliked by her children, avoided by her husband, and rebuked by the therapy community. This feminist lens, though only one possible perspective, offered me a way of viewing Alice with empathy and compassion, Moreover, without this lens I could develop treatment goals without full appreciation of Alice' s sociopolitical si tua tion, and I could risk operating contrary to her best interests - since limiting her therapy goals to becoming a better adjusted doctor's wife needlessly restricts her life options. However, if I developed ambitious long-range plans for her without careful1y considering the shortcomings of her position, I would also put her at risk. Therapy efforts to help her define herself as more than a doctor's

16

wife had to be orchestrated with efforts to ensure that she didn't experience unnecessary economic and financial hardships.

The Process of Psychotherapy

A therapist's preferred style of interacting with clients is the product of a number of factors, such as theoretical orientation, experience, situational context, and client type. Recently, gender socialization has become recognized as another relevant factor. In anal yzing my thera py with Alice, I have recognized, as another relevant factor, that at times she and I were on "different wave lengths," i.e., we were wanting different things to happen in the sessions. These therapy reflectionshelped me to realize that I may have stylistic inclinations of which I have been only partially aware. Generally, I like to "be in charge" of the sessions - manage the time, prioritize the topics, suggest the transitions. I also seem to feel a need to offer suggestions, provide strategies, and work toward discrete solutions to client dilemmas. I suspect that, at some level, I want my "solutions" to be recognized as helpful and the client to show explicit appreciation for my expertise.

This stylistic preference was poorly received in therapy with Alice, as her process needs were quite antithetical to mine. First, Alice seemed to have a strong preference for structuring the therapy sessions herself, although doing so without violating any of critical therapy parameters (e.g., she carefully watched the time so she could call the session to a close at the a ppropria te time). To my dismay, she was so busy in describing her thoughts and experiences, she allowed little room for me to do my thing- sum up what she had said, express my empathy for plight, and offer new beha vioral stra tegies or cogniti ve coping al tematives. In fact, solutions seemed quite secondary to her, as she seemed far more concerned with making a connection with me, with conveying a sense of her distress, with feeling understood. She seemed to recognize that there were no simple solutions to her complex situation.

Of all the possible ways to account for the therapeutic impasse with Alice, many might have little to do with gender socialization. For the purposes of this illustration, however, I'd like to emphasize some of the more obvious ways in which gender socialization could have been relevant.

... my own gender

socialization issues should be taken

into account as they may affect how I react to the client's

As a traditionally socialized male I have come to prefer an instrumental, solution-focused approach to persons in distress. Though I usually experience strong empathic connection with my client's pain, I somehow feel that I have cheated them if I can't find a "tool" for them to help them fight their demons. Unfortunately, I am capable of becoming disappointed if this doesn't take place, if the client doesn't gratefully report a marked improvement in distress

level. Alice had little interest in a

magical performance from me, nor did she wish another male to organize an important aspect of her life. She seemed more concerned with assurance that her point of view had been conveyed and had been appreciated. She seemed to need more validation, than rescue. Solutions were not her objective, as she seemed reasonably able to sort through her al terna ti ves and make necessa.ry

choices. She didn't need any more

heroes, but she did need a supportive and empathic audience.

rity), Therapy with this unhappy woman required me to become exceptionally aware of my sensitivity to women's anger and criticism, as well as periodically seek appropriate consultation (with a colleague not having a similar sensitivity).

The second area of potential overreacti vity rela tes to the concordance between the client's family and my own on the dimension offamily organization, division oflabar, and relationship politics. As new fam-

ily patterns, such as dual-career families, emerge to challenge the exclusivity of traditional structures - husband as breadwinner, wife as homemaker and caretaker - therapists become critical as sources of values clarification and relationship negotiation. Pittman (1985) refers to this new role as that of "gender broker," someone who

helps families find a suitable gender arrangement for themselves through sorting out which traditional values they wish to retain and which they candiscard. Though Pittman made no direct mention of this, it seems apparent to me that ethical execution of this gender-broker role requires thera pists to be keenly aware of their personal values, as well as attuned to the ways that their own relationship arrangements might affect their therapy work.

issues.

The Therapist's Personal Gender Role Issues

At another level my own gender socialization issues should be taken into account as they may affect how I react to the client's issues. In reflecting upon this case I was able to identify two primary areas of potential difficulty or gender role blindness.

Alice clearly was a woman with considerable bitterness abou t many aspects of her life, and was not reluctant to engage others in a cri tical fashion. Her previous therapist had admitted tha the found her continual"carping" to be more than he could bear. To avoid overreactions myself I found it necessary to explore my own history of reacting to anger and overt criticism, particularly from women. To my dismay, I realized that I generally have trouble in this area, sometimes easily provoked to guilt and overreaction. As I grew up, I feared disappointing my mother, and sometimes made unreasonable efforts to avoid displeasing her. Needless to say, these issues were echoed in my relationship with my wife and two daughters (hopefully, somewhat muted by my years of struggle toward emotional rna tu-

At the time of my therapy with Alice, my own family organization was quite traditional in terms of division of labor and gender roles. I had a full-time V A position and also worked part-time teaching and in private practice. My wife had interrupted her social work career to work in the home. Given this si tuation, many of the paten tial trouble spots of our relationship could be expected to resemble those of Alice's family. Alice's complaints about Frank's chronic unavailability to her and the children couldn't help but raise haunting questions in my own mind - Am I available enough to my children? Will my own wife find her way into a therapist's office with identical complaints? To underscore this issue, Alice would sometimes leave a late-night session asking, "doesn't your family mind that you work so many hours?"

17

The Larger Systemic Context

As a systems therapist, I find it cri tical to consider the larger context in which my therapy takes place. This seems particularly relevant with gender issues, since clients face a major challenge to find a comfortable balance between family values and those of the larger culture. In therapy with Alice, the larger context exerted a significant pressure that had to be recognized and mediated. Frank, as a successful and respected member of the local medical community, sought the assistance of another member of that community with his "troubled" and "troublesome" wife. Though the referring psychiatrist did not make an explicit statement, his implicit message was clear - "We'd like you to help us keep Frank functioning by getting his wife off his back." Since previous psychiatric interventions had resulted in hospitalizations for Alice, a precedent had been established to view Alice as the principal problem. To challenge this orthodoxy with gender-aware, feminist psychotherapy, one risked provoking considerable disruption in the medical community. Frank would be challenged to examine his traditional male values, and the medical community (almost exclusively male) would need to consider its patriarchal biases. As a psychologist in private practice, I had to consider whether my value asa referral source would be affected by how I chose to conceptualize Alice' 5 problems - would I accept a patriarchal framing of Alice's problems or would I "rock the boat?"

Summary

Space doesn't permit fuller discussion of the many issues that arose in therapy with Alice. I don't claim that my conceptualizations of the issues are the only "correct" ones, nor do I claim that my therapy was exemplary. What I have hoped to do by describing the case is to offer one framework for considering the multifaceted nature of gender issues and their impact on psychotherapy. I wish I could claim that I was fully a ware of all gender issues, at all levels, at all times in therapy. That is not true. In fact, when I first began an organized reflection on the case, I was surprised at the number of gender-related issues that came to light. If I were to see Alice again, I would see some things similarly, some differently. My primary change would be to incorporate this framework for gender analysis

18

into my initial case planning by addressing four critical questions.

1.) Does the adoption of a feminist lens add to the salience of my case conceptualization and/or help me feel empathy for my client?

2.) Are my usual ways of beha ving in the therapy room likely to constrain my effectiveness with this client?

3.) Are there any gender-related issues in this client's life that have resonance in my own life?

4.) Is there a system of gender-politics in the larger community that needs to be confronted for ethical therapy to take place?

When I answer yes to any of the four questions, I cannot comfortably proceed with therapy without attempting a full gender analysis of the case, through self-reflection, independen t study, and/ or case consultation. IngeneraI, I have found this process to be far less difficult after I developed a network of supportive, compassionate, and gender-aware colleague consultants. Gender analysis of therapy cases, like any form of critical self-examination, can be annoying, frustrating and humbling. Nevertheless, it seems well worth the effort in its potential to create far more empathic connections with clients and a more richly varied intervention repertoire.

REFERENCES

Brooks, G.R. (1990). Psychotherapy with traditional role oriented males. In P.A. Keller & L.G. Ritt (Eds.) Innovations in clinical practice.A source book. (pp 61-74). Professional Resource Exchange: Sarasota, FL

Brodsky, A.M. & Hare-Mustin, R. (Ed,;) (1980). Women and psychotherapy. New YorkGuillord Press,

Broverman, I., Broverman, D. Clarkson, F., Rosenkrantz, P. & Vogel, S. (1970). Sex role stereotypes and clinical judgements of mental health. Journal a/Consulting and Clinical Psychology, 34.1-7.

Meth, R.L. & Pasick, R.S. (1990). Men in therapy: The challenge of change. New York: Guilford.

Pittman, F. (1985). Gender myths: When gender becomes pathology. The Family Therapy Netuxrker, 9, 24-33.

Scher, M., Stevens, M., Good, G., & Eichenfield, G.A. (1987).

Handbook of CQunseling & psychotherapy with men. Newbury Park, CA: Sage.

-

Free C.E. in Toronto-

For Division of Psychotherapy Members

By attending the following specially designated symposia and invited addresses during the AP A meetings in Toronto this August, Di vision 29 members can earn up to 14 hours of APA Category I continuing education credit at no charge. No ad vance registration is necessary I but attendance will be limited by room capacity.

Instructions for requesting credits will be given at the sessions. Non-members wishing to receive credit may complete applications on site and qualify .

• FRIDAY, AUGUST 20

• SATURDAYtAUGUST21

9:00 ·10:50 (2 Credits) Symposium

9:00 - 10:50 (2 Credits) Symposium

Adolescent "Psychotherapy" A New Recent Developments in Psycho-

Definition: Facing the Realities therapy with Adults,

Alice Rubenstein, Chair Participants:

Jean Lau Chin

Herbert Freudenberger Karen Zager

Room 104D, Metro Toronto, Convention Centre

Reuben Silver, Chair Participants:

Nancy Boyd-Franklin Mary Koss

Ron Levant

Room 205B, Metro Toronto, Convention Centre

3:00 - 4:50 (2 Credits) Symposium

New Directions in Child Psychotherapy

1:00 - 2:50 (2 Credits) Symposium

Media Coverage of Therapist Sexual Misconduct: Anatomy of Two Cases

Rina Folman, Chair

Participants:

Lenore Walker Michael Blau Virginia Storring John Zeretsky

Room 202B, Metro Toronto Convention Centre

Gerald Koocher, Discussant, Participants:

Robert Brooks Byron Douglas

Jessica Henderson Daniel Rooms 20ZA/20ZB, Metro Toronto, Convention Centre

19

• SUNDA Y, AUGUST 22

10:00 - 11:50 (2 Credits) Symposium

3:00-3:50 (1 Credit) Invited Address

Lasting Lessons from Psychotherapy How Certain Boundaries and Ethics

Practice: Six Psychologists Reflect Diminish Therapeutic Effectiveness

John Norcross, Chair Participants:

Hans Strupp Alvin Mahrer Arnold Lazarus Florence Kaslow Albert Ellis

Room 20SD, Metro Toronto, Convention Centre

12:00 -12:50 (1 Credit)

State of the Art Invited Address

When Feeling Bad is Good: New Short Term Psychotherapy Techniques

N orine Johnson, Chair Presenter:

Ellen McGrath

Room 103A, Metro Toronto, Convention Centre

1:00 - 2:50 (2 Credits) Symposium

Psychotherapy with the Elderly Tommy T. Stigall, Chair

Participants:

Paula Hartman-Stein Michael Duffy Carmen Vasquez

Upper Canada Room, Royal York Hotel

Gerald Koocher, Chair

Presenter:

Arnold Lazarus

Upper Canada Room, Royal York Hotel

AP A Division 29 is approved by the American Psychological Association to offer AP A Category I continuing education for psychologists. AP A Division 29 maintains responsibility for the programs.

---------------------~~~--- ~-~-

20

t

f

r""I"·"~

.. to

'" to

'" ..

.... C..fH PSVCHOLOGICi='

FRIDA Y, August 20 8:00-8:50 9:00~9:50

10:00-10:50

11 :00-11 :50

12:00-12:50

1 :00-1 :50

2:00-3:50

4:00-5:50

SATURDAY, August 21 8:.00-8:50

9:00-9:50

..

1 0:00-1 0:50 11 :00- 1 2:50

DIVISION OF PSYCHOTHERAPY (29)

Hospitality Suite/Conversation Hour • 1993 Annual Convention Schedule

l'Hotel

Suite 4# Posted in Hotel lobby

Open for Division 29 Committee Meeting Use of Confronta.tion with Borderline Clients Patricia T aglione

Psychotherapeutic Implications of Pharmacotherapy of Depression: The Meani ng of Suffering Ronald E. Hopson

Use of Video in I ndividual and Group Psychotherapy with Cocaine Using Methadone Patients

Michal Seligman

Cognitive Eclectic Treatment of Adult Survivors of Child Sexual Abuse Margaret S. Beekman

Psychotherapy for Impotence: New Theory, New Treatment, New Resultsl Alan Baraff

Modeling lheProfessional· Self in Graduate School Lewis Gantwerk

Process of Change in Therapy: A Cognitive and Behavioral Perspective Diana Richman

Examining the Multicultural/Muhimodal/Multisystems Approach 1.0 Counseling Immigrant Families

Tania N. Thomas

Training in Brief Psychotherapy and Managed Care: Are Students Preparedl Alan J. Kent

Open for Division 29 Committee Meeting

Assessing the Characteristics of Substance Abusers & Selecting A,ppropriate Intervention Diana Richman

How to Provide Therapy Without Medication: Private Practice to Comprehensive Milieu Kevi n McCready

State of the Art Address: When Feeling Bad Is Good· New Short Tenn Psychotherapy (NO HOSPITALITY SUITE PROGRAM)

Ellen McGrath

Presidentia:! Address I Business Meeting. Developing Preventative Intervention for Family Bereavement (NO HOSPITALITY SUITE PROGRAM)

Gerald Koocher, Presenter; Tommy T. Stigall, Chair

Open for Division 29 Committee Meeting

Role of Dedsion in Substance Abuse Treatment: Rational Recovery Model Leo F. Poli.zotti

Mothers & Daughters: Myths and Realities of Adjusbnent Issues Claire M. Brody

Open for Division 29 Committee Meeting Recovered Memories of Child Abuse: Evolving Issues Martha Rogers

Open for Division 29 Committee Meeting

Touching ClientsJ: Gender Studies Perspectives on Physical Contact in Psychotherapy Gary Brooks, Richard Lazur, Susan Mikesell, and Barbara Wainrib

Invited Address (NO HOSPITALIlY SUITE PROGRAM)

Amold Lazarus, Distinguished Psychologist

Task Force on Men's Issues Committee Meeting

Richard Lazur, Co-Chair; Ron Levant, Co-Chair

Gerald Koocher, Ph.D., President

Norine G. Johnson, Ph.D., Program Chair Edward Bourg. Ph.D., Hospitality Program Chair

1 ;00-2:50

3:00-3:50

4:00-4:50

5:00-5:50

SUNDA Y, August 22 8:00~8:50

9:00-9:50

1 0:00-1 0;50 11 :00-12:50

1 :00-1 :50 2:00-2:50

3:00-3:50

4:00-5:50

DIVISION 29 1993 APA PROGRAM SCHEDULE

• Denotes one CE credit hour

FRIDAY AUGUST 20 •• Denotes two CE credit hours

Time

Event

Chair

Co-Sponsor

8:00-8:50

Hoffman

Workshop

·*9:00-10:50

Symposium

Rubenstein

11:00-12:50

Symposium

Mahrer

1:00-2:50

Newman

Symposium

3:00-3:50

Workshop

Parnell Day

TltlelRoom

The Marketing of Group Psychotherapy Briiish Columbia Room, Royal York Hotel

Adolescent "Psychotherapy" A New Definition: 43 Facing the Realities'

Room l04D, Metro Toronto, Convention Centre

Participants

Dr. Jean Lau Chin - Treating Adolescents Within Community Clinical Settings

Herb Preudenberger - Emotional Consequences of Abandoning our Teenagers

Karen Zager - Who Treats Adolescents: Therapists as Advocates

Empathy and Psychotherapy: New Directions 12

in Theory and Practice

Room HUB, Metro Toronto, Convention Centre

Participants

David MacIssac - Relational Development Through Mutual Empathy

Judy Jordan - Relational Development Through Mutual Empathy

Leslie Greenberg - Differential Aspects of Empathy Arthur Bohart - Empathy. Diversity and Technical Eclecticism

Prescription Privileges-Advances at the State Level

Room 201AlB. Metro Toronto, Convention. Centre

Participants

Raymond Folen - The Hawaii Experience:

Political Action

Ruth Paige - The Washington Experience:

Building Consensus

Tom Marra - The California Experience:

"So Goes Ihe Nation"

Discussants

Robert Resnick and Patrick Deleon

Munchausen Syndrome by Proxy: Evaluation 43

and Treatment

British Columbia Room, Royal York Hotel

Participants

Teresa Parnell- Assessment/Diagnosis Teresa Parnell - Child Clinical/Pediatric

Deborah Day - Psychotherapy/Treatment- Population

49

12,42

Time Event Chair TltIelRoom Co-Sponsor
**3:00-4:50 Symposium Koocher New Directions in Child Psychotherapy 24,37,43
Room 206B, Metro Toronto, Convention Centre
Participants
Robert Brooks - Treating the "Resistant"
Child or Adolescent: It Takes Two
(or more) to Tango
Byron Douglas - Psychotherapy with Troubled
African American Adolescents: Stereotypes,
Treatment Amenability Clinical Issues
Jessica Henderson Daniel- Black Mothers and
Adoclescent Daughters: Re-negotiating
Relationships. Maintaining the Bond
Discussant
Gerald Koocher, PhD
4:00-5:50 Symposium Egli The Biology of Depression: Men and Women 12,35,42
in Treatment
Rooms 201Al201B, Metro Toronto,
Conventio.n Centre
Participants
Dan Eigi - Pharmacologic Trends in the
Treatment of Major Depression
Ellen McGrath - Gender Considerations in the
Biologic Treatment of Depression
5:00-5:50 Workshop Morshead Clinical Supervision of Sexual Abuse Cases: 35,39,43
Untangling the Transference
Room 206£, Metro Toronto, Convention Centre
• Denotes one CE credit bour
SATURDAY AUGUST 21 .. Denotes two CE credit bours
Time Event Chair TitlelRoom Co-Sponsor
8:00-8:50 Workshop Derby Transference and Countertransference in 39
Supervision: Uncovering Therapists
"Interpersonal Allergies"
Room 203A, Convention Centre
Participants
Suzanne Sposs - Archeological Efforts in Group
Supervision Unearthing Hidden Agendas
Karen Derby - Punitive Impulses and Tacit Collusion
Neutralizing Destructive Therapeutic Dynamics
** 9:00-10:50 Symposium Silver Recent Developments in Psychotherapy with 20
Adults
Room 205B, Metro Toronto, Convention Centre
Participants
Nancy - Boyd - Franklin - Psychotherapy with
African American Women and Men
Mary Koss - Rising from the Ruins: Recent
Developments in Psychotherapy and Rape Victims
Ron Levant - Men and Psychotherapy
11:00-11:50 Workshop Callahan Group Psychotherapy and Psychodrama with 49
Wewerka Compulsive Overeaters: A Combined Model
Alberta, Royal York II

Time Event Chair Tltle.lRoom Co-Sponsor
1:00-1:50 Conversation Koocher What is Your Future in Psychotherapy?
Hour Room 202A, Metro Toronto, Convention Centre
Participants (Presenters)
Tommy Stigall
Reuben Silver
** 1 :00-2:50 Symposium Felman Media Coverage of Therapist Sexual 46
Misconduct: Anatomy of Two Cases
Room 202B, Metro Toronto, Convention Centre
Participants
Rilla Felman - High Profile Therapist Sexual
Misconduct Cases Reporting without
Hanning
Lenore Walker - Psychology and the Media in
High Publicity Legal Cases
Michael Blan - Protecting a Client's Interest
in a High Profile Sexual Misconduct Case:
Dr. Margaret Bean-Bayog Case Study
Virginia Storring - Producer: Dr. Doctor!My
Lover: The Making of a Documentary on
Therapist Sexual Abuse of Patients
John Zeretsky Director: My Doctor!My Lover:
The Making of a Documentary on Therapist
Sexual Abuse of Patients.
1:00-2:50 Workshop Molteni Bulimia Nervosa and Integrative Psychotherapy: 35,42
Three Perspectives
Salon B, Roya.l York Hotel
Participants
Andrew Molteni: Integrated Experiential Treatment of
Bulimia Nervosa
David Tobin: Integration of Psychodynamic and
Behavior Therapies
Lynn Hom Yale Self-Psychotherapy and Hypnosis:
Treatment of Bulimia Nervosa
2:00-2:50 WorkshOp Mack Cross Cultural Psychotherapy: The Challenge 12
of Self Awareness
Room201D. Convention Centre
Participants
Raquel Contreras
Eileen N athan
Nana Sadamura
3:00-3:50 Discussion Wilk Avoidance of the Subject of Menopause: 35
A Countertransference Block
Toronto Room. Royal York Hotel
Participants
Carole Wille: Elements of the
Countertransference Block
Mary Arm Kirk: Case Study Examples of
Countertransference Blocks
4:00-4:50 Division Stigall Developing Preventative Interventions for
Presidential Family Bereavement
Address Ontario Room. Royal York Hotel
Participant (Presenter)
Gerald Koocher Time 5:00~5:50

Event Social Hour

Chair Koocher

Tltle.lRoom

Social Hour/Awards Presentation Salon B, Royal York HOle!

Co-Sponsor

SUNDAY AUGUST 22

• Denotes one CE credJt hour .. Denotes two CE credit hours

Time

Event

Cha.i:r

TitlelRoom Co-Sponsor

1 1

8:00-8:50

Conversation Hour

"* 10:00-11:50

Symposium

-) I

12:00-12:50

Symposium

... 12:00-12:50

Invited Address

I J

** 1:00-2:50

Symposium

Updegrove

Dilemmas in Training Psychology Students 12

in Clinical Settings

Room 203A, Metro Toronto, Convention Centre

ParticIpants (Co-Presenters) Anne Updegrove

Kathryn Jacobi

Norcross

Lasting Lessons from Psychotherapy Practice: 42

Six Psych.ologists Re-flect

Room 205D, Metro Toronto, Converuion Centre

PartIcipants

Hans Strupp - Lessons from Psychotherapy Practice and Research

Alvin Mahrer • Lessons from an Old Experientialist Arnold Lazarus - Reflections after 30+ Years of Psychotherapeutic Practice

Florence Kaslow- Memorable Lessons from a Multi-Faceted Career

Albert Ellis - Lessons Learned from Practicing Psychotherapy from 1943-1993

Bishop

Clinical Implications of Findings from 28

Non-AA Approaches to Treatment

Room 2010, Metro Toronto, C onveniion C entrd;"; ..

.....

Participants

Mathew Snow - Spontaneous Recovery:

Common Influ.ences on the Process of Successful SObriety

Ceane Willis - Self-reported Reasons for Rejection of Alcoholics Anonymous Raymond DiGiuseppe - Which Beliefs to Target: Outpatient vs. TC Residents

Discussant Albert Ellis, PhD

Johnson

When Feeling Bad is Good: New 43

Short-Term Psychotherapy Techniques

Room l03A, Metro Toronto, Convension Centre

Participant Ellen McGrath

Stigall

Psychotherapy with the Elderly 20

Upper CaJUJda Room, Royal York Hotel

PartIcipants

Paula Hartman -Stein - Outpatient Psychotherpay with the Older Adult:

Therapeutic Tips and Treatment Considerations Michael Duffy • Psychotherapy Practice with

Nursing Home Residents: Therapeutic and Organizational Dynamics

Carmen Vasques - The Hispanic Elderly:

Treatment and Training Considerations

IV

Event

Chair

TitlelRoom

Co-Sponsor

Time

* 3:00-3:50

Event Invited Address

Koocher

How Certain Boundaries and Ethics Diminish Therapeutic Effectiveness,

Presented by Arnold Lazarus

Upper Canada Room, Royal York Hotel

Participant (presenter)

Arnold Lazarus

3:00-4:50

Symposiwn

Wicks

Psychology and HIV: The Need for a Flexible 12,38,44 Psychotherapeutic Stance

Room l03A, Convenuon Centre

Participants

Lucy Wicks: Psychology with HIV/AIDS: Patients in an Adult Psychiatry Specialty Clinic

Robert Remien: Psychotherapy and HIV: Countertransference and Boundry Issue in Private Practice

Claude Mellins: Children and Families Affected by HIV:

Redefining Psychotherapy

James Satriano: HIV Infection: Legal and Ethical Issues for the Chronic Mentally 111

MONDAY AUGUST 23

,. Denotes one CE credit bour U Denotes two CE credit hours

Time

Chair

TitlelRoom

Co-Sponsor

8:00-8:50

Workshop

McKeon

Management of the Suicidal Patient in the Office and Hospital

Confederation Room #3, Royal York Hotel

9:00-10:50

Symposium

Levant

Men Treating Men: A Case Study Approach 42,43

Room l04D, Metro Tororuo, Convention Centre

Participants

William Pollack - Treating the Fallen

Hero: Empathic Psychoanalytic Psychotherapy Designed for Men

Gill)' Brooks - Group Therapy for Resistant Traditional Men

Richard Lazur - Sex, Lies, and Virility:

One Man's Mid-Adult Transition

Robert Pasick - A Pamily Systems Approach to Men

Discussant Judith Jordan

11~00-12:50

Symposium

Wong

Who Said What: Men and Women in Comrnunciation

Rooms 201A/20lB, Merro Toronto, Convention Centre

35,43

Participants

Denise Twohey - Can We Talk: Case Studies about Gender and Intimacy

William Pollack - Finding Men's Voice:

Psychoanalytic Perspectives on Male-Female Communication

Ronald Levant - A Couples Conununication Program Based on Gender

Discussant Ellen McGrath

v

Time 12:00-1:50

TitielRoom Co-Sponsor

Rational Suicide: A Possibility?

Room 202B, Metro Toronto, Convention Centre

Event Symposium

Cbalr Werth

Participants

Eric Harris - Legal Implications of Accepting a Patient's "Rational" Suicide Decision

David Mayo - The Case for Rational Suicide John McIntosh - Arguments Against Rational and Assisted Suicide

2:00-2:50

Psychotherapy Across the Life Span: 37,43

The Changing Nature of Psychotherapy with

Children and Adolescents in Private Practice

Room 103B, Metro Torotuo, Convention Centre

Conversation Hour

Johnson

Paricipants (Co-Presenters) Norine G. Johnson

Joel Friedman

3:00-4:50

The Abuse of Power: Men. Women, 35,42,43

and Trauma

Room 101, Metro Toronto. Convention Centre

Symposium

Blackburn

Participants

Katy Swafford: Women, Abuse, and Trauma Trish Gu:nn: Women: The Interpersonal and

Therapeutic Interface

Art Baker: People Abuse in the Workplace (Work/Stress/Trauma)

Mary Koralewski: Sociocultural Perspective on Characteristics of Sexually Coercive Men

4:00-4:50

Symposium

Adult Sexual Abuse Survivors: Impact on Medical and Dental Health Behaviors Toronto Room; Royal York Hotel

Participants

Kate Hays - The Impact of Childhood

Sexual Abuse on Womens' Dental Experiences Paula Lundberg - Love - Identification of Adult Sexual Abuse Survivors: Implications for Preventative Medicine

Hays

Discussant Christine Coutois

TUESDAY AUGUST 24

• Denotes one CE credit hour •• Denotes two CE credit hours

Time

TitlelRoom Co-Sponsor

Event

Cbalr

9:00-10:50

Symposium

Challenges to Cognitive Therapy: 12

Entertaining and Mostly Affectionate

Room 203B, MelrO Toronto, Convention Centre

Block

Participants

Andrew Sweet - Cognitive Therapy:

"Is That All There Is ... ?"

Panl Block - Philosophical Foundations (and failings) of Cognitive Therapy

Gail Martz - Is Cognitive Therapy Cognitive Scientific James Coyne - Cognition Uber Alles? Some Unfortunate Consequences of Reducing Adaptation to Cognition

Discussant

Mary Ann Layden

TI e r:=oD-l:50

Event Symposium

Chalr Werth

TitIefRoom

Rational Suicide: A Possibility?

Room 202B, Metro Toronto, Convention Centre

Co-Sponsor

Participants

Eric Harris - Legal Implications of Accepting a Patient's "Rational" Suicide Decision David Mayo - The Case for Rational Suicide

10k Jldtr&:!(/r - httfl/fdlflff A(w! RRt)(JIIR} U;(} Assisted Suicide

_()(}"2:50

Johnson

Conversation Hour

Psychotherapy Across the Life Span: 37,43

The Changing Nature of Psychotherapy with

Children and Adolescents in Private Practice

Room 103B, Metro TOTonJo, ConvenJion Centre

Parlcipants (Co-Presenters) Norine G. Johnson

Joel Friedman

3:004:50

Blackburn

Symposium

The Abuse of Power: Men. Women, 35,42,43

and Trauma

Room 101, Metro Toronto, Convention Centre

Participants

Katy Swafford: Women. Abuse. and Trauma Trish Gunn: Women: The Interpersonal and

Therapeutic Interface

Art Baker: People Abuse in the Workplace <Y'Iork/Stress!frauma)

Mary Koralewski: Sociocultural Perspective on Characteristics of Sexually Coercive Men

4:004:50

Symposium

Hays

Adult Sexual Abuse Survivors: Impact on Medical and Dental Health Behaviors Toronto Room, Royal York Hotel

Participants

Kate Hays - The Impact of Childhood

Sexual Abuse on Womens' Dental Experiences Paula Lundberg - Love - Identification of Adult Sexual Abuse Survivors: Implications for Preventative Medicine

Discussant Christine Coutois

TUESDAY AUGUST 24

• Denotes one CE credit hour •• Denotes two CE credit hours

Time

Chalr

TitlefRoom Co-Sponsor

Event

9:00-10;50

Symposium

Block

Challenges to Cognitive Therapy: 12

Entertaining and Mostly Affectionate

Room 203B, Metro Toronto, Convention Centre

"

Participants

Andrew Sweet - Cognitive Therapy:

"Is That All There Is ... 1"

Paul Block - Philosophical Foundations (and failings) of Cognitive Therapy

Gail Martz - Is Cognitive Therapy Cognitive Scientific James Coyne - Cognition Uber Alles? Some Unfortunate Consequences of Reducing Adaptation to Cognition

Discussant

Mary Ann Layden

VI

Time Event Chair TitielRoom CO-Sponsor
11 :00-12:50 Discussion Craig Dreamwork: A Therapeutic Modality for the
Treatment of Incest Survivors
Room 205B, Metro Toronto, Convention Centre
Participants (Co-Presenters)
Johanna King
Jaqueline Sheehan
1:00-1:50 Workshop Gamble New Therapists and Trauma: Examining our 39
Countertransference Protecting our Hope
Room 202D, Metro Toronto, Convention Centre
Participants
Sarah Gamble - The New Trauma Therapist and
Vicarious Traumatization
Debra Neuman - Trauma Therapy and
Coumertransference Issues for the New Therapist
2:00-2:50 Discussion Lee Short - Term Therapy: More than Less of the 12
Same
Room 202D. Metro Tororuo, Convention Centre ·

FEATURE ARTICLE

Quality, Quagmire, and Courage

f

Ranee Smith Griffith

I ,

Does psychotherapy have quality? If so, what is it? Consider the definitions of quality that rely upon dollar amounts, compliance to guidelines and regulations, and procedures required to 'control', 'assure', or 'continuously improve' quality.

Reconsider Pirsig's (1974) definition: "Quality is the continuing stimulus that causes us to create the world in which we live" (p. 318). In Pirsig's (1991) more 'recent book, Lila: An Inquiry Into Morals, he declares that quality is an experience rather than a judgment or description. Heequates quality with morality which he claims as "the primary reality of the world" (p. 111).

anguishing challenges for those who are convinced that persons value high-quality human interactions.

The segment of this writing that is most obviously obvious is the reality of our professional, national, and global quagmire. A quagmire is defined as "boggy ground, yielding under the feet" or "a difficult or inextricable position" (Guralnik, 1980). The inextrica ble, ground-sinking experience felt somewhere near the belly and the bowels can be triggered by any of several unpleasant reminders. For instance,

heal th care is unaffordable and mental health care is an 'indulgent frill.' Insurance cannot support such ill-defined treatments that are not

Does psychotherapy have quality?

If so, what is it?

To illustrate Pirsig's notion of quality as an experience, he uses the example of sitting on a hot stove as an immediately known low-quality, negatively-valued experience, The uatue in the experience lies between the subject and the object and constitutes a separate category known as quality. Quality, then, contains within itself both subjects and objects. In the case

of the hot stove, neither the stove, the

heat, nor the "person uttering the oaths" possesses unto itself the value or quality (Pirsig, 1991, p. 76).

'medically necessary.'

If those phrases do not engender a sense of boggy ground, attend a workshop on ethics and managed care. If prescriptions of conduct packaged as ethics do not give you a cramp, wrestle

with the term 'managed choice' as privacy, autonomy, and freedom of choice are trivialized. Even worse, you find yourself ineligible to become 'managed' and you have been providing care to the insured for more than one or two years.

Quality as an experience within the therapeutic relationship involves the experiences of personal value within a larger value-based endeavor, namely psychotherapy. Scott Peck (Simpkinson, 1993,) affirms the impossibility of practicing therapy without a value system. From Freud to current approaches, loving, working and thinking have been positively-valued in psychotherapeutic stri vings. And to add another party to the interaction, psychotherapy's val ue-base is si tua ted wi thin the society's experience of quality and value. Tensions among these concentric interactions from which value and quality are experienced pose exciting and

If your fortitude and resolve are still intact, tune into the White House and Capitol Hill to witness the cri tical messages of social reform, civil righ ts, and health care being upstaged by presidential haircuts and blue-ribbon filibusters. And the despair in the faces photographed in Somalia and Bosnia would pierce all but those who fana ticall y deny the pain and destruction tha t humans are capable of creating and enduring.

This modern quagmire fertilizes confusion and conflict and diffuses focus due to the multitude of competing, essential needs. The quagmire

21

... psychotherapy's

value-base is situated within the society's experience of

quality and value.

requires persons to sit with helplessness and anxiety and to risk action based on one's values. Perhaps the hope and possibility in treading such soft, boggy ground may be found in the profound test of the traveler's personal beliefs and values when external reinforcements are nowhere in sight.

The quagmire summons the courageous spirit. TiUich (1952) described courage as both an ethical reality and an ontological concept. As an ethical reality, courage is reflected in a decision and action which expresses a value. Courage is caring enough to decide and to act despite opposition. Courage as an ontological concept is the self-affirmation of

one's being. Tillich considered

the ethical reality of courage to be rooted ultimately in the structure of being itself.

Nietzsche (1961) defined courage as the power of life to affirm itself in spite of its negativities and ambiguities - in spite of the dread of non-being. The dread of non-being is accompanied byanxiety which may be ontic (the anxiety of fate and death), moral (of guilt and condemnation), and spiritual (of emptiness and meaninglessness) (Magill, 1990). Tillich's descriptions of anxiety are especially relevant in the context of one's identification with professional survival.

Courage to face the anxiety of non-being would appear to be associated with particular personality styles. Yalom's (1980) review of research evidence on personali ty trai ts and psychopa thology examines two central variables: cognitive style and locus of control. Witkin (1962) identified two basic perceptual modes in cognitive style: field dependence and field independence. (When 'field' is read as the 'field of psychotherapy', expanded insights are possible.)

When field dependence is the pervasive cognitive style, the individual (profession) fuses body and field and has no sense of separateness (or specialness) from the background. This orientation predisposes a person/ professional to severe identity problems and perceived overwhelming helplessness. Such a style supports the defensive

fantasy of an ultima te rescuer or Fromm's "magic helper" who will observe, love, and protect us (cited in Yalorn, 1980, p.129).

Field dependent styles resemble "externals" in locus of control research gives that externals attribute control of personal destiny, forthcoming answers, as well as support and guidance to

sources outside of themselves (Rotter, 1966).

Field independent persons/professionals are more likely to believe in their own specialness and to share traits associated with "internals" in locus of control studies (Yalom,.1980). An extreme in

either direction is associated with symptoms; the extreme field independent orientation may result in "outward aggression, delusions, expansive and euphoric ideas of grandeur, paranoid syndromes, and depressive compulsive character structures" (Yalom, 1980, p.15S).

A tempered field independent cognitive style shares quali ties associated wi th optimal internal locus of control. Essentially, internals believe tha t they control their personal destiny and have a sense of personal power. Internals are more power-seeking and more reliant upon their own judgment. Yalom (1980) notes that clinical experience supports the observation that more persons seek therapy due to the failure of the rescue defense than due to a breakdown in persona:.. specialness. Personal specialness, in this sense, is kin to Tillich's (1952) concept of courage as self-affirmation in being.

Why practice psychotherapy when distinctiveness, non-support, and downright antagonism prevail? Is practice an altruistic gift from our profession to the culture? Is it for money? (The are easier ways to make money.) Do psychotherapists, as a group, represent a professional legitimization of the covert dynamics codependency?

Can we balance our striving like Bob, a chara in Wagner's (1986) The Search for Signs of lnie gent Life in the Universe, who dreams of beco . a holistic capitalist?

22

Guralnik, D.B. (Ed.). (1980). Webster's New World Dictio1lilry (2nd 00.). New York: Simon and Schuster.

Magill, F.N. (1990). The courlolge to be. In F.N. Magill (Ed.), Mt2sterpieces of WOTld philosophy (pp. 644-652). New York:

Harper Collins.

Miller.j.B, (1991). The development of women's sense of self.

In J .V. Jordan, A.c. Kaplan, J.B. Miller, l.P. Stiver, & j.L, Surrey (Eds.), Women's growth in connection. New York:

Guilford Press.

Nietzsche, F. (1961). Thus spoke ZaTllthus tr« (R.J. Hollingdale, Trans.). Baltimore: Penguin Books. (Original work published 1833-1885)

Nietzsche, F. (1969). Selected letters (c. Middleton, Trans.), Chicago: University of Chicago Press

Pirsig, R.M. (1974). Zen and the aTt of motorcycle maintenance.

New York: Bantam Books.

Pirsig, R.M. (1991). Lila: An inquiry into morels. New York:

Bantam Books.

Rotter, J. (1966). Generalized expectancies for internal vs. external control of reinforcement Psychological Monographs, 80 (1, Serial No. 609).

Satir, V. (1987). The therapist story (Special Issue: The use of self in therapy. Journal of Psychotherapy and the Family, 3 (1),17-25.

Simpkinson, C.H. (1993). The importance of being civil.

Common Boundry, 11 (2). 22-29.

Sussman, M.B. (1992). A curious cal/jng: Unconscious motivations for practicing psychotherapy. New Jersey: Jason Aronson Inc.

Tlllich, P. (1952). The courage to be. New Haven: Yale University Press ..

Wagner, J. (1986). The search for signs of intelligent life in lhe uninerse. New York: Harper and Row.

Witkin, H. (1962). Psychological differentiation. New York:

John Wiley.

Yalom, LD. (1980). Existential psychotherapy. New York:

Harper Collins.

Yalom, LD. (1992). When Nietzsche wept. New York: Harper Collins.

National Health Care Reform:

Implications for Psychotherapy and Psychopharmacology

Jack G. Wiggins

National Health Care Reform (NHCR) political speak of "highest quality of care at the lowest price" translates into reduced services at higher prices in government-sponsored "health alliance" plans. This is the message according to recent developments inNHCR policy, the scope of practiceinlndiana,andafeatureartide''DoesTherapy Work?" in U.S. News and World Report.

Some promising rhetoric has been advanced by the American Medical Association (AMA) in keeping with 12 criteria. In its testimony before the House Committee on Ways & Means' Subcommittee on Health, the AMA called. for unlimited outpatient visits "including services and supplies (and) individual or group therapy provided by physician, clinical psychologist, psychi a tric nurse or social worker." Under this plan, hospital and physician care benefits for mental disorders would equal coverage for other ill-

24

nesses, including lifetime coverage fa twenty-eight day treatment program for substance abuse, capped by a $3,000 limit. Marital 0: educational counseling services and halfway house benefits are excluded, at least for inpatient services.

Hospice care and unlimited outpatient prescription benefits are included, however. No cost sharing is required for preventive services.

This AMA benefit package places psychotherap_ in the domain of both doctoral level and non-doctorallevel practitioners. Yet, this proposal does not guarantee parity in reimbursement, nor specify how the public might access services of non-physicians. The availability "unlimited outpatient prescription benefits clearly recognizes that 'non-psychiatric ph dans write over eighty percent of the psycho-

pharmacological scripts and also treat the bulk of "identified" mental disorders. Similarly, the Depression Guidelines promulgated

by the medically dominated Agency

for Health Care Policy and Research ad vocate a three month trial on medication before psychotherapy is attempted. According to an American Psychiatric Association press release, success rates for Major Depressive Disorders with antidepressive medications is 65 percent. This figure increases to 85% "when alternative or adjunctive medications are used

or psychotherapy is combined wi th med ications." No efficacy rate is reported for psychotherapy alone. Psychology remains the principle champion of psychotherapy. Considering these propositions, it is essential that we remain vigilant about any health plan, no matter how well intentioned.

tants with Bachelor degrees are au thorize to prescribe as physician extenders in 34 states. Social workers have been studying prescriptive authority, as well.

Psychology remains the principle champion of psychotherapy.

Psychotherapy will be competing directly with psychopharmacy for funding in NHCR. Life threatening procedures will have priority over psychological services. Therefore, psychotherapists will be fighting for their livelihoods in this competition. It must be remembered that psychothera py is primary care, as it is the onl y health service that actually increases resources, rather than depleting resources. It is well documented that psychological therapy enhances human functioning and improves the overall quality of life. Reiss, Ross and the USHEW Statistical Note 23 show that people undergoing psychothera py tend to increase their incomes. Further, increased tax monies produced by gains in earnings offset the cost of treatment in only two years. Unfortunately, these fads remain unacknowledged by many, including the authors of the recent U.S. News and World Report article.

The current postures of both nurses and physicians' assistants on the issue of prescriptive authori ty necessitates a sharpeni ng of psychology's posi tion regarding psychopharmacology. At the March 29th hearing on NHCR, nurses and physicians' assistants argued strongly in favor of removing barriers they encounter while prescribing medication without prior authorization by physicians. Currently, nurses with Masters degrees or less have some form of prescriptive authority in 43 states, while physicians' assis-

At the February Council meeting, there was general agreement that practicing psychologists need more information and systematic training about psychopharmacology. The issues surrounding prescriptive authority and training will be discussed at the August meeting of

Council in the debate over the Task Force on Psychopharmacology Report. APA surveys show that one-third of health care psychologists are interested in obtaining prescriptive authority. Although this number is not a majority, it extrapolates to 20,000 practitioners who desire prescriptive authority, Those interested in prescribing cannot be ignored and their concerns must be addressed fully.

Psychothera py and psychopharmacology are not necessarily antagonistic systems - they can be mutually enhancing. There is growing evidence showing that psychopharmacology does not suffice when used alone. Similarly, for certain individuals psychotherapy alone may not be as effective as a combina tion of the two trea tmen ts. With this understood, the best way to protect psychotherapy in NHCR would be for psychologists to have prescri pti ve authori ty. Ifpsychology were known to be knowledgeable in psychopharmacology, we could make a convincing case for psychotherapy without appearing self-serving.

Although various states and divisions of APA ha ve established task forces to study prescripti ve authority for psycho tropics, the potentials for prescriptive power of the psychologists have been threatened. Recently in Indiana, as the sta te legislature was contemplating a bill for mandatory continuing education, an amendment was inserted to prohibit psychologists from prescribing. An alert psychologist, Dr. Michael Murphy, called attention to the Department of Defense's initiative to train psychologists to prescribe medication. This resulted in an exception in the law whereby it was acknowledged that some psychologists in federal service do have prescriptive authority. (See "State News", P14)

25

With these developments in mind, it is time for psychologists individually and collectively to re-examine our position in rela-

tion to political contributions to NHCR. In 1992, the American Medical Association, the American Dental Association and the American Academy of Ophthalmology combined contributed over $16 million, an increase of forty-five percent over 1990. Non-physician health care providers - including the American Chiropractic Association, the American Nurses Associations, and American Physical Therapy Association - - contributed $2.9 million, forty-eight percent higher than the 1990 figure.

fulfilled hopes for the "first 100 days" in office. Congress is serious about curtailing health

expenditures, then it can freeze tax-deductible limits on last year's expenditures for rations. This, of course, would control governmental spend

bu t a freeze on the increase of expenditures could be enacted, well. At this moment, it <1 ...... '"1""'" that inaction by the Clinton ministration has afforded DS'VCC10l' ogy more time to get its ..... .,.,,.. .. ,""" in place. APA's advocacy and the Practice Directorate functioning well and are NHCR policy. The time for

is now. Action requires your untary contributions to

advocacy of the Practice ate. Contributions to political didates must be through psychological PAC's.

It must be

remembered that psychotherapy is

primary care, as it is the only health service that

actually increases resources, rather than depleting

resources.

If psychologists want to be major players in NHCR, they must recognize their interests and make financial contributions accordingly. The Practice Directorate initiated its °$100 for 100 Days" campaign for psychological advocacy in NHCR. Thus far, our 1/$100 for 100 Days" campaign has raised over $1.2 million. This is approximately one-third of what is needed this year and next. In addition to advocacy, but separately through PAC's, psychologists can make donations to political candidates so that psychological interests will be represented. It is time to re-examine the contributions that states can make in behalf of political candidates through "24E" independent expenditures. Under the Federal Election Commission Guidelines, "independent expenditures" can serve a useful purpose for a favorite candidate as long as money does not go to the campaign directly. The time is right for psychologists to pull together and establish their priorities. Regarding health care, it is obvious that the Clinton Administration has not

26

'Bibliography

Does Therapy Work? (1993, May 24). U.s. News & Report, pp. 56-65.

Reiss. B. (1967). Changes in patient income concomitant psychotherapy. Journnl of Consulting Psychology, 31, 13[.

Ross, W.O. (1968). Some economic estimates in relation psychotherapy by general physicians and other health professionals. Canadian Psychiatric Association naI, 33. 17-23.

United States Department of Health, Education and Social and Rehabilitation Services. (1971). The proftle mentiZlly ill perscns rehabilitated in the fiscal year 196 Stillisticalnoteno.23. Washington,D.C.: u.s. )f'n,,,ITI,er:· of Health. Education and Welfare, Social and n'''''" .. ~u..,..' tionServices.

FEATURE ARTICLE

Utilization Review, Documentation, and the Adversarial Process

Jeffrey E. Barnett

Psychologists engaged in the independent practice of psychotherapy are finding their clinical work impacted upon by the managed care industry with increasing frequency. The process of utilization review purports to provide insurers and employees with cost savings while ensuring the adequacy of services provided. Unfortunately, this process has appeared to become intrusive, burdensome, and at times irrelevant. (Michaelson,1993) In addition to the many demands placed on psychotherapists, the manner in which it is carried out often makes utilization review an adversarial process. Additionally, several reports have already documented the lack of cost savings to managed care organizations, employers and consumers (Crenshaw, 1992).

As described by Resnick (1993) there are often many requirements for documentation of services provided, as well as for treatment plans, which often seem arbitrary, irrelevant, and even counterproductive. One handicapping condition for psychologists in this adversarial process is not being privy to utilization review criteria utilized by these organiza tions. While some such companies have complained that psychologists would misuse this information solely for their financial gain, psychologists have challenged that having these criteria would make for more meaningful utilization review and possibly even to reduce the adversarial nature of this process.

Psychologists in several states have worked to help alter managed care regulations (Youngstrom, 1992). In one state, Maryland, psychology's organized efforts have resulted in several helpful legislative changes to include making utilizations review criteria public information. Additionally, several major managed care entities have begun sharing their recommended guidelines for participating in this process. One valuable aspect of the material shared includes information on their utilization review decision trees to

include "red flags" whose presence typically causes utilization review personnel to initiate a more intensive and demanding (read "in trusi ve") utilization review process.

For one major utilization review finn numerous guidelines and standards are provided in its manual for providers which highlight many of the difficulties psychotherapists encounter. Initially, up to ten sessions of outpatient psychotherapy are authorized by utilization review personnel. The patient may not enter treatment without this initial authorization, however, it is provided before the patient is seen in treatment. No actual review of "medical necessity" occurs and psychotherapists have experienced patients having varying numbers of sessions authorized with no apparent correlation with presenting symptoms or complaints noted. This initial contact with utilization review personnel appears to be somewhat arbi trary and possibly related to an attempt on their part to begin asserting control over the psychotherapy process.

For many circumstances, the utilization review process then proceeds with telephone contact required to document the justification for receiving authorization to provide further trea tment. However, should any "clinical case indicators" be noticed by the utilization review personnel, then a much more intensive and intrusive "case management" process is initiated. A written format is then required which involves documenting treatment efforts thus far, short term and long term treatment goals, progress to date, a mental status examination, diagnoses, and detailed justification for providing further treatment.

The providers manual lists: "Examples of Clinical Case Indicators." The use of the word "examples" appears to indicate tha t this list is not all inclusive and that utilization reviewers may insti tute the more intensive u tiliza tion review pro-

27

cess at their discretion and 'Without advance notice, The list provided includes certain diagnoses to include Multiple Personality Disorder, Borderline Personality Disorder, Dual

Diagnoses, Conduct Disorder, and Adjustment Disorder; the presence of previous mental heal th care in the past six months; treatment plan indicators to include providing more than two sessions per week, estimating the length of treatment to be 20 sessions or more, lack of medical management in cases with diagnoses which reviewers deem require medication as the preferred treatment, and lack of family involvement 'With child and adolescent cases; and various Patient Characteristics to include

more intensive utilization review process wher the psychotherapist's treatment profile exceeds the mean number of sessions overall for provid-

ers of the same discipline by a tain percent. The more in utilization review is not based on the details of the particular but instead on the fact that a ticular provider is costing the co pany more money either by ing patients with more ""'"",,,,,'"" than others or by treating patients than others,

, .. utilization

review companies motivations in prescribing length and type of

treatment appear to be fiscally

Here the utilization review process. is not based on any particular cri reria which might be relevant to medical necessity or the appropriateness of the case provided. This level at, utilization review includes review

of complete case records to include. all notes of treatment sessions; a process man} psychologj.sts 'Will find to be very intrusive.

motivated rather than based on

clinical concerns.

non-compliance, medical compli-

cations, legal involvement, the patient being five years of age and younger, and the report of a history of sexual victimization.

To the psychotherapist who is untrained in utilization review practices some of these criteria for intensive utilization review may seem arbitrary or even inappropriate. Another company begins a more intensive utilization review process, requiring much moreextensi ve documentation and justification to provide treatment when the current Global Assessment of Functioning score on Axis V of DSM-UI-R is above a certain level,

Some psychotherapists may view the utilization review process as an unnecessary burden which is not cost effective and which is an invasion of privacy, but for many it borders on a coercive process. Psychotherapists may feel that the cri teria listed above may be arbitrarily utilized to deny treatment based on ambiguous standards of medical necessity. Some may be tempted to use alterna five diagnoses or to modify their documentation in an attempt to avoid the intrusiveness of this process. Unfortunately, other than working toward Iegislati ve change and increased regulation, no ethical alternatives to participating in this process exist at present other than to documen t honest! y and to then hope tha t further care is authorized.

One utilization review company only insbtu tes a 28

With all the examplesdiscussed, forces are presets which may result in a general interference 'Wifr. the psychotherapy process. The potential fo altering the clinical decision-making process exists in both subtle and overt forms, It is no' suggested tha t psychologists al ter their practice: so that the intensive utilization review process rnightbe avoided, bu t there does seem to be some pressure to provide treatment in ways that an' found agreeable to the utilization review company. Unfortunately, their motivations in prescribing length and type of treatment appear tc be fiscally motivated rather than based on clinical concerns. It is important for psychologists tt be sensitive to these forces and to work hare. through accurate documen ta tion, advocacy, anc challenging ad verse utilization review decision: to help ensure that our patients receive the quality care they deserve.

References

Crenshaw, A. (1992, June 28). Managed care not alwajs managing costs. The Washington Post.

Michaelson, R. (1993). Utilization review inhibits questz; provide therapy. The AP A Monitor, p. 23.

Resnick, R. (1993). Documentation of services and exd::;,sions: Can big brother be far behind. The Psycho/hera:::Bulletin, 27 (4), 25-26.

Youngstrom, N. (1992). State groups try to shape managa=:. care regulation. The APA Monitor, p. 31.

FEATURE ARTICLE

On Psychology, Ethics and National Health Care Refonn

Alan J. Kent

In recent months, numerous articles have been written warning of the specter of national heal th care reform and its impact upon our profession. A national campaign exists to raise money for the "battle" to save Psychology and ostensibly protect the public from the small but real possibility that psychologists could be excluded from any national health care plan. While I laud these efforts and certainly support them, I do sense a certain self-serving atti tude in many of the pleas. Psychologists do indeed need to advocate for themselves and the public, though the interests of the two do not always overlap. [For example, I am not convinced that it is in the public's best interest to exclude masters level professionals in any national health plan, though it is likely in the interest of Psychology to do so.]

Despi te some disagreement over

tactics or specific issues, organized Psychology must ad vocate and promote highquality,affordablernentalhealthservices. However, I doubt that the AP A's current position on managed care and health care reform adequately addresses the problem or if this position is serving the public or the profession well.

Having worked in the public community mental health system and the private managed care sector, I, for one, do not fear managed care and its intrusion into practice. Conununity facilities have been "managing care" for decades by distributing limited resources and priori tizing needs. I believe it is essential for the survival of our profession that those in the private sector learn from those who have been providing cost effecti ve care for years. Rather than figh ting managed care and health care reform, we need to jump on the proverbial bandwagon, embrace the inevitable change, and help shape the direction it takes. Further, we must recognize that we, as health care providers, are part of the problem that created managed care and the demand for

health reform. Wemustacknowledge the role that unscrupulous practitioners, excessive billing, and fraudulent claims have played in our profession fora long time. These practices are Psychology's "dirty little secret" thatfew seem willing to talk about.

.. .it is essential for the survival of our profession that those in the

private sector learn from those who have been providing cost effective care for

Much attention has been paid to the proliferation of managed mental health care. Organized psychology has been particularly virulentin its tirade against man-

aged care. I recently received some campaign literature for an APA division presidential race in which the candidate stated that "managed care is a failed system propagated to enhance insurance companies and deny services .. .it can be defeated. [This candidate] is the person best equipped to focus our energy and resources toward defeating managed care and protecting our practices." (Notice that the writer does not mention protecting the public.)

It is currently in vogue to cri ticize managed care and the other players in the health care industry. I think we need to look at our own practices first. I recognize that this is a highly controversial position to take, so it is important to ci te some specific examples of the

fraudulent, unethical, and illegal activities I have seen through the years. Since I am just one practitioner, it scares me to think of the impact these schemes have on the overall cost of mental health care. The list below is not inclusive, just a sampling of some practices evident in our field.

years.

• Psychologists hiring unlicensed, masters level practitioners and sending them to nursing homes to do "group therapy" and then billing

29

Medicare. Typically the recipients of such services are late stage OBS patients who sleep through the "treatment" and are unaware that any service was provided, Nursing home administrators are often treated quite kindly for making such a rich patient population available. While many truly needy Medicare recipients are not being served, this type of Medicare abuse is rampant and little is written about it.

• Psychologists seeing psychotherapy clients until their benefits have been exhausted and then abruptly terminating the therapy without proper referrals.

• Psychologists who abuse the inpatient benefit that clients have in collusion with the psychiatrist treating the case. One situation that recently came to my attention involved an eld-

erly overweight woman who wanted to lose weight. She was admitted for thirty days in an inpatient eating disorder program and diagnosed with major depression, although she displayed no symptoms or depression, nor was she medicated or treated for it The psychological evaluation supported the diagnosis, despite the fact the client denied being depressed, displayed none of the DSM ill - R cri teria for depression, and openly acknowledged she went to the hospital to '10& weight and get a little vacation.

She was shocked to learn she hac been labelled "depressed" and readily admitted that it was an abuse of the system. However, she felt like she had earned the "getaway" since she was a working class person who hac paid taxes all her life and couldn't afford i "fatty farm" on her own. "Besides" she addec " the doctors all go along with it and everyore makes some money."

• Psychologists billing extremely high rates (up to $150 per hour for psychotherapy) knowing well that they will willingly accept the 50% the insurance company pays and never expecting co-payments from the client. Numerous other fraudulent billing practices have been brought to my attention. For instance, if a client's insurance only pays 50%, a practitioner may overcome this obstacle by billing for two visits for every one that is provided. Another practice

for dealing with the "co-payment problem" involves billing insurance companies separately for a husband and wife even it they were seen for one hour of conjoint marital therapy.

Let's stop fighting reform and

managed care and

seek ways to

enhance ethical, cost effective

treatments which could be made mare widely available.

• Psychological testing is often used without any clinical justification, simply to increase the insurance billing. In some practices, MJviPlsare routinely used simply to cover the deductible that the client does not want to pay. In other cases, if a client has a separate maximum for psychological testing, they are routinely given a full battery before beginning therapy as a way of taking full advantage of the client's insurance benefit. While testing often is valuable, it is hard to justify giving a man and women a full test battery if they are coming in for routine marital adjustment counseling (a practice I have seen some psychologists attempt to implernent.)

• Psychologists hiring a "stable" of unlicensed recent graduates and exploiting them by assigning them full caseloads, providing minimal supervision, and then signing off on the insurance forms as if the psychologist provided the services.

30

While I recognize that the kinds of abuses listec. above require patients collusion and are not lim ited to psychology, I believe it is time our profession dealt with the problem. Health care frau; and abuse is everyone's concern. Managed em and health care reform cannot be blamed greedy insurance companies (as some withI:. AP A would have us believe). As psychologis we serve as role models for our patients and must not collude with fraud and abuse. Y: should be speaking out against these practice within our ranks and as a profession take respor sibility for unethical behaviors which have exac erbated the health care mess.

I urge AP A to continue its campaign for qualitaffordable mental heal th care. But let our leader not get sidetracked into a self-serving campaig;

which dearly goes against the current trends. Let's stop fighting reform and managed care and seek ways to enhance ethical, cost effective treatments which could be made more widely available. Let our clinical researchers develop valid and reliable means for conducting utilization review so that we can provide data to stop the abuses of some managed care companies. Let us develop partnerships wi th government, employ-

ers and insurance companies to identify those interventions that are both clinically effective and financially feasible. Finally, let us indoctrinate our students and trainees with the value of ethical business practices. We must stop fighting managed care and health reform and stop blaming the insurance industry for the problem. Continuing to keep our heads in the sand while the tide comes in makes little sense.

GROUP PSYCHOTHERAPY

Aspects of Termination in Group Psychotherapy Joseph c. Kobos

Most who have practiced psychotherapy become a ware that the end phase of the working relationship becomes the cornerstone of treatment. While forming and establishing a relationship are crucial and working through conflicts essential, the end stage and the nature of the goodby provides the lasting memory of the therapy. How many of you have felt involved and successful with a person but felt some struggle or tension when departure was on the horizon? Have you developed your own pattern for evaluating the end of therapy, initiating a goodbye process and expressing your continued availability to the elien t on their departure?

The ending process in groups, both time limited and open ended, is a complex activity which can be examined on many levels. Dealing with an ending in group can include any or all of the following, with the emphasis being determined by the needs of the patient. One, the patient says goodbye to the problem that initiated therapy. Two, the departing memberts) say goodbye to the individuals in the group. Three, there is a goodbye to the group as a whole; And four, a farewell to the therapist.

For me, it is important to consider the end of therapy from the beginning. Without some awareness of an imagined endpoint, the beginning and middle become muddled. Having a target in mind helps therapists evaluate themselves, the patient and the possibility of working together. To visualize some possible end points, therapists evaluate the presenting problem, the

history and personality of the individual, and themselves.

Certain presenting problems are more amenable to establishing a time frame. These include adjustment concerns, dealing with griet loss or change in circumstance and any issue which can be seen in the format of a commonly shared theme. Some examples are groups for college students confronting separation, responsibility, dating issues, and groups for separated, widowed, or retiring persons. Each of these themes utilizes group interaction to initiate support, energize confrontation of internal or external conflict and experimentation of new behavior.

While evaluating the specific problem, it is essential to evaluate the personality functioning and history of the individ uaI to develop some prediction about how the individual will respond to a time limited or open ended grou p format. Wi thout an adequate understanding of the patient's historyoflossesand major life changes, the therapist may be surprised by the patient's response to the ending of therapy.

In taking the history it is helpful to explore childhood losses and changes in family constellation. These incl ude deaths of parentis), grandparen ts, Significant caregivers, churns, teachers, coaches, and sometimes pets. The ini tia tion of school at all levels as well as departu re associated wi th moves and graduations also can fortell how the individual copes with the formation, growth and change in relationships.

31

Another childhood experience which involves change and loss is the individual's experience of vacation, summering with relatives, sleep away camps and overnite excursions. These are all opportunities for the child to say goodbye to parents, siblings and friends, experience autonomyand form rela tionships wi thou t the hovering eye of parents. Additionally, child and parents reform their relationship in the return home. In recent decades, adapting to divorce has challenged parents and children to cope with the death of a marriage while at the same time maintaining the parent/child relationship.

Another area to explore is the formation of friendship attachments outside the home. These can include teacher, coach, babysitter, best friends, neighborhood adults and scout leader. Alongside these relationships are the individual's attachments to siblings, cousins and other members of the extended family. In a sense we all grow up within two groups, family and society, and the two groups more or less overlap. For some, the overlap between family group and other social groups is almost indistinguishable, for others the difference is quite wide and the individual may experience a barrier or wide divide when they leave the family to join other social groups. The experience of these early movements between groups will fortell how the individual enters into a treatment group and how they leave. The particular attachments that the individual forms in an organization such as schools (elementary, high, and college) clubs, teams, as well as their role within the network can provide useful information.

As noted earlier, another aspect of the evaluation is for therapists to evaluate themselves and to consider how they experience the formation of the rei a tionship wi th a new patient and how they visualize working with the person in a particular group. It is helpful for you to consider how you say goodbye to people. Do you like to linger or do you stop abruptly? When you meet a new patient, w ha t is your reaction? Do you feel a pull to spend time with them, keep them at arm's length, experience the person as a burden or as full of untapped potential?

As a therapist, what are your expectations of providing therapy? Consider the following ques~ tions: Do you like to finish everything? Do

32

people come back to you? Is your goal to resolve every conflict? Are your leave takings sad, joyful, scary? Do you expect people to return? How do you like people to leave you? There are no right or wrong answers and more questions that you might find helpful. But such questions can help you decide whether you want to initiate time limited or open ended therapy within your own practice or with specific individuals or groups.

The ending of a therapy group or an indi vid ual' s departure from a group can stimulate many levels of thera peu tic work. First, there is the issue of the problem which ini tia ted the therapy. What's the status of the problem? Has there been behavioral change? What is the patient's attitude or feelings about the problem, him or herself, and the future. A second issue is the patient's working relationship with the therapist or co-therapist. Are there unresolved tensions, angers or idealization which merit attention. Departures and leave takings may stimulate unfinished grief from early life. The therapy relationship can provide a stable setting in which the conflict may be reexperienced and worked through.

A third issue is the departure from the various individual members. Group members may represent siblings, peers, relatives, competitors, collaborators, enemies and lovers. These relationships may also be reworked through the goodbye. Finally when leaving a group the individual says goodbye to the group as a whole. This is sometimes described as the alumni feeling. As we are aware people can be proud or ashamed of their family roots. Individuals may feel guilty having surpassed their family of origin. People can be proud of having buil t on the legacy of neighborhood, family, and school. Some people leave a group trying to get out from under its influence, others swing a way au t in to the sea knowing they can always return to harbor. (I am writing this in San Diego.)

Not everything that I have described can or will happen in every group. I do think it is helpful when planning a time limited or an open ended group to consider such issues when planning treatment goals for the individual and for the group.

Reprinted with permission of the Louisuma Psychological Association.

I

SUBSTANCE ABUSE

Substance Abuse Updates Harry K. Wexler

The Clinton Administra tion has all but ignored the substance abuse problem and has failed to make any meaningful policy statements. In his anti-drug budget presented last month, Ointon called for $8.3 billion for law enforcement (60.6%) and $4.7 billion for treatment and prevention (36.3%). (This is essentially the same budget prepared by the prior Republican Administration.)

Treatment advocates, however,

would like to see an equal split. The National Institute of Health (which includes the National Institute on Alcohol Abuse and Alcoholism and the National Institute on Drug Abuse) has been asked to make spending cut-backs. Even with Attorney General Reno's support of drug courts and treatmentin-lieu-of-incarceration, no extra money for drug treatment was allo-

cated to the Justice Department. Fur-

thennore, there is still no director of the Center of Substance Abuse Treatment, which is the primary federal agency responsible for funding public treatment initiatives. Apparently, the issue of substance abuse is of low priority for the current administration.

possible so that psychologists are represented in this national debate.

Etlmidty is becoming recognized as a critical variable in substance abuse research. Clinicians need to be aware of ethnic differences in responsiveness to treatment and of the importance of

cultural sensitivity when designing treatment interventions. A recent study of over 6500 racially diverse 6th and 7th graders found differential risk factors related to lifetime substance abuse. The study explored the role of 10 common risk factors; low family pride, family substance abuse, parental smoking, low self-esteem, depression, prior suicide attempts, perception of high peer drug use, perception of peer

approval for substance abuse, willingness to engage in non-normative behavior, and delinquent behavior. All ethnic groups showed Significant correlations between drug use and low family pride and willingness to engage in non-nonnative behaviors. Depression was a significant predictor only for whites. Low self-esteem, suicide attempts, and delinquent behavior were Significant predictors only for Hispanics. The relationship between risk factors and drug use was least strong for Blacks, which suggests a resistance to these risk factors and the need to identify other ethnic specific predictors. (For more information, please see "Risk factors for early adolescent drug use in four ethnic and racial groups", American Journal of Public Health, 83,185-189)

Ethnicity is becoming recognized as a critical variable

in substance

abuse research.

Treatment advocates are waiting to hear what Hillary Clinton's Heal th Care Reform Task Force will do for substance abuse treatrnent. TheAmerican Society of Addiction Medicine (ASAM) recently presented the Force with its recommendations for a core substance abuse benefit. ASAM views substance dependencies as primarily diseases and hopes that this benefit can offer, at a minimum, prevention through patient drug education, assessment, and treatment. If residen tial treatment is required, the cost is to be shared by the heal th care and social service systems. Many substance abuse professionals believe that if substance abuse treatment is made available to all in need of it, then there will be less need to fight for a bigger piece of the anti-drug budget pie. The American Psychological Association needs to develop a position paper on this topic as soon as

The Sentencing Project (a group that promotes alternatives to incarceration and improving sentencing practices for indigent defendants) has reported striking race and class sentencing disparities for drug and alcohol related offenses. Drunk driving causes more deaths a year than all drug-related offenses, but drunk drivers, who are predominantly white males, are typically only charged with misdemeanor, fine, and com-

33

munity service. Those con victed of drug possession, who are predominately low-income blacks and Hispanics, receive felonies and prison terms, even for a first offense. In New York, blacks and Hispanics are three times more likely than whites to be sentenced to prison for a drug possession conviction. To help combat these inequalities, the Sentencing Project reconunends that drug courts be expanded, that mandatory sentencing be repealed, and that sentence lengths for drug offenders be reduced. To obtain a copy of this report, please contact the Sentencing Project directly at (202)628-0871.

treatment against the reinforcing effects of cocaine. Dr. Donald Landry of Columbia University College of Physicians and Surgeons has found a catalytic monoclonal antibody that binds specifically to cocaine and accelerates its metabolism. This process breaks cocaine into two inert components (ecognine methyl ester and benzoic acid) which have no stimulating effects, While the chemical effects have been demonstrated successfully in test tubes, Rhesus monkey testing begins in the next six months. If promising, application to humans is expected to begin in 2 to 5 years. A major limitation of this approach is the

likelihood that cocaine abusers may just switch to other readily available stimulants like methamphetamine.

The hidden problem of substance abuse among professionals is slowly surfacing. Programs specifically designed for professionals are starting to be implemented. The Robinson Institute in New York City [(212)459-8900] isoffering outpatient treatment services for recovering professionals. The program provides psychotherapy, counseling, evaluation, stress management, acupuncture, relapse prevention,and treatrnentforfanxUy members.

I would like to offer special appreciation to Taumi Neikirk wJw hasassisted me in. the preparation of both the Spring and Summer issue oftJUs column.

The hidden

problem of substance abuse among professionals is slowly surfacing.

Useful summaries of recent reports of substance abuse research and treatment can be found in the Business Research Publication's "Substance Abuse Report" and the American Psychological Association's "Clinicians Research Digest."

A recent study (reported in Science, March 26, 1993) has found an enzyme which may provide

Corrected Information on CE Workshop Endorsed by Division 29

The CE workshop #129, "Behavioral and Pharmacological Treatment of Obsessive Compulsive Disorder:, endorsed. by Division 29, to be presen ted on August 22 at the AP A Convention, will, in fact, cover Obsessi ve Compulsi ve and Related Disorders. The mention of related disorders was inadvertently left out of the "Monitor" Booklet description.

The related disorders to be addressed are body dysmorphic disorder (BDD), hypochondriasis (HC), and compulsive self mutilation (SM). To enroll in the workshop with a Visa or MasterCard, call the CE Programs Office at 1-800-374-2721.

34

ESSAY

The Psychologist/Psychotherapist As Citizen John Stuart Currie

Good citizenship is good for the profession of psychology and the practice of psychotherapy. Our visibility in state legislatures and the U.S. Congress has increased dramatically over the past decade. This visibility has made lawmakers more comfortable with supporting our requests in the interest of our clients. It is also important to have influence in the executive branch of government. During the Carter administration we probably had unprecedented credibility. This was partly due to the fact that when President Carter was Governor of Georgia there were a number of psychologists who took time to get acquainted wi th him and served on men tal heal th groups; therefore, being visible to him and his wife who was and still is very active in mental health matters.

I have found that getting active in political campaigns, on any level, is good for organized psychology. Often the candidates are not elected. However, usually these contenders for public office are community leaders, and lending them a hand at election time leaves a positive impression for psychology.

It is only fair that we contribute our talents to a society that has treated us so well. Therefore, service on charitable and civic bodies both gives an appropriate outlet for talent and also fills important needs for the community. I have been involved with the Heart Association, Red Cross and other groups. I continue on my state's Human Relations Commission, having been appointed by a previous governor. This body is charged with investigating and resolving grievances brought by minority groups. A gratifying experience has been service on the subgroup for Native American Indian Affairs which succeeded in legislating restraints in disturbance of grave sites and sacred artifacts.

As experts on human behavior and compassionate persons, psychologists can, through community service and political campaigns, make valuable contributions to society, both directly and indirectly.

"Understanding Psychotherapy for Depression: The Role of Techniques, Relationship, and Their Interaction."

1993 Division 29

Student Paper Competition Winners

First Place

Louis G. Castonguay Stanford University

Honorable Mention

Carolyn A. Burke Randolph B. Pipes Auburn University

Co-Authors

"Until Death Do Us Part?: The Ethical Principles of Confidentiality and Privacy:

The Case of Anne Sexton"

An abstract of Louis Castonguay's winning paper is included in this issue of the Bulletin. He will present his paper during the Student Conversation Hour Saturday August 21st in Toronto, Canada.

35

ESSAY

The Psychologist/Psychotherapist As Citizen John Stuart Currie

1993 Division 29

Student Paper Competition Winners

An abstract of Louis Castonguay's winning paper is included in this issue of the Bulletin. He will present his paper during the Student Conversation Hour Saturday August 21st in Toronto, Canada.

Good citizenship is good for the profession of psychology and the practice of psychotherapy. Our visibility in state legislatures and the U.S. Congress has increased dramatically over the past decade. This visibili ty has made la wmakers more comfortable with supporting our requests in the interest of our clients. It is also important to have influence in the execu ti ve branch of government. During the Carter administration we probably had unprecedented credibility. This was partly due to the fact that when President Carter was Governor of Georgia there were a number of psychologists who took time to get acquain ted with him and served on men ta 1 heal th groups; therefore, being visible to him and his wife who was and still is very active in mental health matters.

I have found that getting active in political campaigns, on any level, is good for organized psychology. Often the candidates are not elected. However, usually these contenders for public office are community leaders, and lending them a hand at election time leaves a positive impression for psychology.

"Understanding Psychotherapy for Depression: The Role of Techniques, Relationship, and Their Interaction."

First Place

Louis G. Castonguay Stanford University

It is only fair that we contribute our talents to a society that has treated us so well. Therefore, service on charitable and civic bodies both gives an appropriate outlet for talent and also fills important needs for the community. I have been involved with the Heart Association, Red Cross and other groups. I continue on my state's Human Relations Commission, having been appointed by a previous governor. This body is charged with investigating and resolving grievances brought by minority groups. A gratifying experience has been service on the subgroup for Native American Indian Affairs which succeeded in legislating restraints in disturbance of grave sites and sacred artifacts.

As experts on human behavior and compassionate persons, psychologists can, through community service and political campaigns, make valuable contributions to society, both directly and indirectly.

Honorable Mention

Carolyn A. Burke Randolph B. Pipes Auburn University

Co-Authors

''Until Death Do Us Part?: The Ethical Principles of Confidentiality and Privacy:

The Case of Anne Sexton"

35

WOMEN BATTERING: PRACTICAL USES OF RESEARCH AND THEORY

AP A PRECONVENTION CONTINUING EDUCATION WORKSHOP Sponsored by Division 9

The Society for the Psychological Study of Social Issues

Thursday, August 19,1993 1-6 PM

Toronto, Canada

5 CE Credits ~ $90.00

PROGRAM

Chair/Facilitator: Lisa Goodman "Historical Overview: Battering in a Cultural Context" Presenter: Angela Brown

"Working with Battered Women: Approaches to Assessment, Treatment and Program Intervention"

Presenter: Mary Ann Dutton

"Special Issues of Ethnic Minority Women" Presenter: Gwen Keita

"Battering Among Lesbian Couples" Presenter: Valli Kanuha

"Taking the Stand: Expert Witnessing and Other Legal and Policy Issues" Presenter: Lenore Walker

For further information contact Sue Rosenberg Zalk (212) 642~2954

To register fill out the form below and enclose a check. for $90 to SPSSL Mail to SPSSI, P.O. Box 1248.1 Ann Arbor, MI 48106..-1248.

• • • • • • • • • • • • • • • • • • • • • • • • ••• • • • • • • • • • • • • • • • • • • • • • • • • • • • •

•
•
•
• Name
•
•
• Address
•
•
• Phone
•
• Women Battering: Practical Uses of Research and Theory

Affiliation

· . . . . . . . . . . . . . .' . . . . . . . . . . . . . . . . . . . . . .. .. . . . . . . . . . . . ..

36

,-------------------------------1

I DIVISION 29 Change of address Form I

I I

I Please keep us informed of any changes in your address I

I I

I Name I

I I

I Title I

I I

I Company I

II

I Address I

I I

I City St Zip I

I Phone Date I

I I

: Please return to: :

: DIVISION OF PSYCHOTHERAPY - Central Office :

I 3875 N. 44th St. • Suite 102 I

I Phoenix, AZ 85018 I

I or FAX #602-952-8230 I

L ~

The BULLETIN is the official newsletter, published quarterly and sent to over 5,000 members of the Division. Please contact Editor for further information.

FREQUENCY: Quarterly CIRCULATION: 5,000 EDITORIAL OFFICE:

Division of Psychotherapy 3875 N. 44th St., Suite 102 Phoenix, AZ 85018

(602) 952-8656

Fax #: (602) 952-8230

ADVERTISING CLOSING DATES:

Sept. 1, Dec. 1, Feb 1, May 1 PREFERRED MATERIALS:

Camera Ready Copy.

RATES: Ix 4x

Full Page $150 $125

One-half Page 90 75

One-Quarter Page 50 40

Cover - 3 175 150

Cover - 4 (1/2) 175 150

37

TASK FORCE ON CHILDREN & ADOLESCENTS

Marketing Brochure for Children & Adolescent Therapy Available

It's always difficult for parents to makethe decision to put a child in therapy. Now there's a brochure you can use to make it easier for parents to make the decision and to encourage them to address children's problems early with outpatient therapy rather than later when expensive hospitalization maybe required.

Produced by the Division 29 Task Force on Children and Adolescents, "Psychotherapy with Children & Adolescents: A Guide for Parents" explains what child and adolescent therapy is, howto tell when your child needs therapy, what parents can expect from therapy and how to find a child/ adolescent therapist. It addresses questions such as whether parents should expect the child to discuss therapy sessions or not, how to tell if child and therapist are compatible, confidentiality and parent contact with the therapist and insurance reimbursement.

Task Force Chair Dr. Alice Rubenstein and her committee have succeeded presenting this information in a clear, concise way addressing most of the questions and fears parents havea bout putting a child in therapy. The resulting attractive tri-fold brochure is available for you to use in educating parents in your community. The brochure is also an excellent educational piece for professionals such as pediatricians, school counselors and dentists to give to parents when referring to you.

There is space on the back page for you to personalize the brochure with your name, address and phone number so that it also becomes a marketing tool for your practice. This area can either be professionally printed on your brochures or can be left blank for personalizing with a name and address stamp or label. Prices for AP A members are as follows:

Division 29 Member Prices

Quantity No Imprint Imprinted w/Name

address

$40.00

50.00

80.00

150.00

100 200 SOD 1000

$22 .. 50 37.95 68.95 128.95

,------------------------------,

I Children & Adolescent Order Form

I I I I I I I I I I I I I I I I

I Phoenix, AZ 85018-5435 I

I Phone #602-952-8116· FAX #602-952-8230 J

L _

Please Print:

on-members may also order at slightly higher prices:

Quantity

Imprinted w /Narne address

$ 50.00

65.00

100.00

185.00

a Imprint

100 200 500 1000

$30.00 SO.OO 85.00 160.00

Name _

Company __

City

Address _

Zip _

o Payment Enclosed

o VISA

Card No.

Please return to:

Alice Rubenstein, Ed.D. DIVISION 29 - Central Office 3875 N. 44th S1. - Suite 102

St _

o MasterCard

Exp. Date _

Division of Psychotherapy of the American Psychological Association 1993

STANDING COMMITTEES Educaticm aM Training

Jeffrey Binder, Ph.D., C~Chair Georgia School of Psychology 990 Hammond Dr., 11 th Floor Atlanta, GA 30328

Office: 404-671-1200 FPC<:~671~76

Hans Strupp, Ph.D" C~Chajr Dept. of Psych., Vanderbilt Univ. Nashville, TN 37240 C>filce:615-322-OO58

Fellows

Suzanne B. Sobel. Ph.D., Chair 1680 Highway AlA, Suite 5 Satellite l3each, FL 32937

Office: 407-773-5944

Finance

Alice Rubenstein, Ed.D., Chair Monroe Psychotherapy Ctr. 59-E Monroe Ave.

Pittsford, NY 14534

Office: 716-58~10

FPC<: 716-586-2029

Gender Issues Committee

Gary Brooks, Ph.D., Co-Chair Psychology Service

116 B4, DE Teaque VA Center Temple, TX 76504

Office: 817-778-4811

Barbara Wainrib, Ph.D., Co-Chair R.D. #1, Box 1290

Moretown, VT 05660

Office: 514-481-8272

FAX: 514-484-2864

Membership

Richard Mikeseu. Ph.D., Chair 4801 Wisconsin Avenue NW Suite #503

Washington, D.C 20016 Office: 202-966-7498 FPC<: 202-966-3745

Muitialitural Affain;

Samuel S. Hill,. m, Psy.D" Chair Corpus Christi State University 6300 Ocean Drive

Corpus Christi, TX 78412 Office: 512-994-2394

FAX: 818-993-4202

Nominations and Electicms

Tommy T. Stigall, Ph.D., Chair The Psychology Group

701 S. Acadian Thruway

Baton Rouge, LA 70806

Office: 504-387-3325

FAX: 504-387-0140

Professional Awards

Reuben SilVer, Ph.D., Chair 510 Huron Rd.

Delmar, NY 12054

Office: 518-439-9413

FAX: 518439-9413

Professiona,l Practi.ce

Ellen McGrath, Ph .. D., Chair 380 Glen Eyre, Ste, D. laguna Beach, CA 92651 Office: 714-497-4333

FAX: 714-497-0913

1993 Program Cummitke Norine G. Johnson, Ph.D., Chair, 1991-1993

110 W. Squantum, #17 Quincy, MA (12171 Office: 617-471-2268 FAX: 617-323-2109

Edward F. Bourg.. Ph.D., Associate Chair, 1993-1995 1005 Atlantic Ave. Alameda, CA 94501 Office: 510-523-2300

FAX: 510-521-5121

William S. Pollack. Ph.D., CL. Chair, 1993-1994 Dept. Post Graduate & Continuing Education

115 Mill Street

Belmont, MA 02178 Office: 617-855-2230

FAX.: 617-855-2349

Publications Board Chair

Herbert J. Freudenberger, Ph.D. 18 East 87th St.

New York, NY 10128 Office: 212-427-8500

Student De'!1elo('!!tent

Michael Carifio, Ph.D., Chair 2410 Brickell Ave. 209C

Miami FL 33163

Offire:' 305-943-7638

VoiCE Mail: 3(5..4.47-7941

Abraham Wolf, Ph.D., Co-Chair Metro Health Medical Or.

2500 Metro Health Drive Oeveland, OH 441OO-I998 Office: 216-459-4647

FAX: 216459-5907

DIVISION OF PSYCHOTHERAPY (29)

Central Office

3875 N. 44th Street, Suite 102 Phoenix, Arizona 85018 (602) 952-8656 FAX: (602) 952-8230

TASK FORCES

Task Force on Adolescents and Children

Alice Rubenstein, Ed.D., Chair Monroe Psychotherapy Center 59 E. Monroe Avenue

Pittsford, NY

Office: 716-586-0410

FAX: 716-586-2029

Task Force on Aging

Norman Abeles, Ph.D., Co-Chair Psychology Research Bldg. Michigan State University

East Lansing, MI 48824

Office: 517-355-9564

FAX: 716-586-2029

Carl Eisdorfer, Ph.D., Co-Chair Dept. Of Psychiatry, 0-28

P.O. Box 016960

Miami, FL 33136

Office: 305-545-6319

Task Fan:!:! on Ame7ialn Indian Mental. Health

Diane W11lis; Ph.D ... Chair Orild Study Or. University of Oklahoma 1100 NE 13th St. Oklahoma Oty, OK 73117 Office: 405-271-6876

Task Force on Men's Roles and Psychotherapy

Ronald Levant, Ed.D., Chair 1093 Beacon St., Ste. 3C Brooklin~MA 02146

Office: 617-566-4479

Task Force on Trauma Response & Research

Ellin Bloeh, Ph.D.., Co-Chair Behavioral Science Center 2522 Highland Ave. Cincinnati, OH 45219 Phone: 513-221-8545

FAX: 513-321-8405

Jon Perez, Ph.D., Co-Chair Apache Behavioral Health Services P.O. Box 2954

Pinetop, AZ 85935

Office: 602-338-4858

DIVISION OF PSYCHOTHERAPY Ameriazn Psychological Association 3875 N. 44th St., Suite 102 Phoenix, AZ 85018

Non-Profit Organization U.S. Postage PAID Phoenix, AZ 85018 Permit No, 311

ABHAHAi"I 1,.,1 WOLF :3:~{r-~:j !)CI'~AI'llOH HD

r1l:::nwp 0 I... I rAI'i GEl'! Hm;P/I)FI:) r OF' p~; CL_EVELAND~ ON 44109