THE

PSYC~OTHERAPY

• II

---- Features In This Issue ----

Relational Models of Development: Clinical Implications Shame and the Tenacity of Depression

A Marital Couples Communication Program Based on Gender Socialization Theory

Therapeutic Aspects of a Weight Lifting Program with Seriously Psychiatrically Disabled Outpatients

The Ethical Practice of Psychotherapy: Impact of the Newly Revised Ethical Principles and Code of Conduct

National Health Insurance: Too Late for Florida?

A Psychodynamic-Object Relations Model for Differential Diagnosis

VOL. 28, NO.3

OFFICIAL PUBLICATION OF DIVISION 29 OF THE AMERICAN PSYCHOLOGICAL ASSOCIATION

Fall 1993

Division of Psychotherapy of the American Psychological Association 1993 Officers

OFFICERS President

Gerald P. Koocher, Ph.D. Dept. of Psychiatry Children's Hospital

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

FAX: 617·73(}'0457

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

Apt. #607 South

Salt Lake City, UT 84101 Office: 801·581~7390 FAX: 801-581-5841

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

Coral Gables, Fl 33146

Office: 305-661-7844

FAX: 305-661...£.664

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

Office: 407-773-5944

Carl Zime!, Ph.D., 1992·1994 4200 E. 9th Ave.

University of Colorado Medical School Denver, CO 80262

Office: 303-270-8611

FAX: 303-27(}.S641

REPRESENTATIVES TO APACOUNCIL

Donald K. Freedheim, Ph.D.

1993 - Feb. 1996

Dept. of Psychology Mather Memorial Bldg.

Case Western Reserve University Cleveland, OH 44106

Office: 216-368-2841

FAX: 216-368-4891

Morris Goodman, Ph.D., 1992-1994 One Cypress SI.

Maplewood, NJ 07040

Office: 201-763·3350

Pas·t President Reuben Silver, Ph.D. 510 Huron Rd. Delmar, NY 12054 Office: 518-439-9413 FAX: 518-439·94·13

Norine G. Johnson, Ph.D., 1993-1995 no 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,h{A.02146

Office: 617-566-4479

FAX: 617-484-1902

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. Monroe Psychotherapy CII". 59-E Monroe Ave. Pittsford, NY 14534

Office: 716-586-0410

FAX: 716-586-2029

Lisa M. Porche-Burke.Ph.D .. 1992·1994 CSPP-LA

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

FAX: 818-284-152.0

Harry Sands, Ph.D., 1993·1995 lOW. 83rdSI.

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

Carol D. Goodheart, Ed.D.

1991 - Feb. 1994

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

Secretary, 1991~1993

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

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

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

4Q35 E.. McDcnaJd Or.

Phoerux, AZ 85018

Office: 602-84(}.2834

FAX: 602.-84(}.3648

Obser<>er to APA & CAPP Practis» Directorate EUen McGrath, Ph.D.

380 Glen Eyre, Sle. 0 Laguna Beach, CA 92651 Office: 714-497-4333

PAX: 714-497-0913

EDITORS OF PUBUCATIONS Psychotherapy Journal

DOI1ald K. Freedheim., Ph.D., Editor Dept. of Psychology

Mather Memorial Bldg.

Case Western Reserve University Cleveland, OH 44106

Office: 216-368-2841

Psychotherapy Journal

Wade H, SUwnnan,Ph.D" Edi.tor-Elect 1514 San Ignacio, Suite 100

Coral Gables, FL 33146

Office: 305-661-7844

FAX: 305·661-6664

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

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

REPRESENTATIVES TO fCPEP Tommy T. Stigall.. Ph.D.

The Psychology Group

701 S. Acadian Thruway

Baton Rouge, LA 70005

Office: 5{W.-387·3325

CEMA Monitor

Lisa M. Porche-Burke, Ph.D. CSPN.A

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

Arthur Wiens, Ph.D.

Oregon Health Services University 3181 SW Sam Jackson Park Rd.. Portland, OR 97201

Office: 5IJ3.:279-8594

Psychotherapy BuJ/ etin

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

402 Aderhold Hall

Athens, GA 30602-7142

Office: 706-542·1812

FAX: 404-594-9441

Liaison to APA International Committee

Emst Beier, Ph.D.

44 N. Third South, #6(J7 South Sal! Lake City, VT 84101 Office: 801-581·7390

MID- WINTER MARCH 10-13, 1994 Program Chair

COnvention Coordinator Louise Silverstein, Ph.D.

William R Fishburn, EdD.

Continuin.g Education Chair Barry Schlosser, Ph.D.

Associate Coordinator" Loon VandeCreek, Ph.D.

PSYCHOTHERAFYBULLETUN

Published by the

DIVISION OF PSYCHOTHERAPY' AMERlCAl.\J PSYCHOLOGICAL ASSOClA TION

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

EDITOR

Linda Campbell, Ph.D.

CONTRIBUTING EDITORS Medical Psychology David B. Adams, PhD.

PSYColumn Mathilda Canter, Ph.D.

Washington Scene Patrick Deleon, PhD.

Student Column Laura L. Myers

Professional Liability Leon VandeCreek, PhD.

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

Krasner A ward Interview 6

Membership Drive 8

Washington Scene 10

Medical Psychology 14

Gender Issues 17

Feature: Relational Models of Development:

Clinical Implications 22

Feature: Shame and the Tenadty of Depression 24

Feature: A Marital Couples Communication Program Based on Gender Socialization Theory ..... 27

Feature: Therapeutic As:\?ects of a Weight

5Y~ty~rCEt~~t:ntt~ ~~~.~~~~~:. .. ~~.:.~.~~~ ~~~~~~:. .... 30

Feature: The Ethical Practice of Psychotherapy: Impact of the Newly ReVISed

Ethical Principles and Code of Conduct 36

Feature: National Health Insurance: Too Late

for Florida? 38

Feature: A Psychodynamic-Object Relations

Model for Differential Diagnosis .41

Fellows 48

Council Report 51

Professional Liability 53

Substance Abuse 56

Group Psychotherapy 57

PSYCHOTHERAPY BULLETIN

Officio.l Publication of Division 29 of the American PsychologiCtlI Association

Volume 28, Number 3

Fall 1993

CONTENTS

President's Message 4

Editor's Column 5

Student Column 5

4

PRESIDENT'S MESSAGE

But, I Don't Want to Go to College! Gerald P. Koocher

In this final column of my presidency I want to call the membership's attention to a controversial proposal to found a National College of Professional Psychology. Depending on which proponent you are listening to the idea has either "been around

for more than a decade," or "has Second, let us not create needless

recently become a necessity be- credentials, imbue them with artifi-

cause of third-party reimburse- cial claims of validity, and force our

ment rules." The crux of the cur- . colleagues to earn (and pay for)

rent proposal is for APA to them. The proposed curriculum on

jump-start and spin off the Na- "hospital practice," for example, has

tional College with a mission of been the object of considerable legal

providing specialized continuing '--L- __ ~"'_:'=;;06...'" and professional scorn. Why should

ed u ca tion and issuing certificates of added qua lifi- psychologists practicing wi thin hospi tals and cation to the course graduates. In short, the medical centers be forced to obtain an added College is to bea CE program that grantsa special credential to validate what they are already dokind of diploma. ing well? Why should we tax these colleagues for such recognition? In addition, the whole idea of a conten t dornai n li nked to the notion of a specific site has not been validated. Will we later hear of the need for a credential practice in a "solo office" or a "community mental health center."

psychology, Let us not repea t the mistakes of the past by creating external bodies that ultimately become self-perpetuating cash generating entities thatultimatelycompete with AP A and are not responsible to a broad democratic constituency.

Proponen ts tell us tha t some third-party insurers have refused to reimburse fully-licensed psychologists for the trea tment of chemically dependent clients, while fully covering "certified alcoholism counselors" wi th less extensive professional training. They propose the National College as the urgent solution, and add that it would eventu ally develop other credentialling programs in needed areas such as "hospital practice." Psychologists already skilled in such practice domains would be permitted to present their credentials and for a fee be granted the appropriate certificate.

Third, let us not rush to create such programs wi thou t a careful anal ysis of their en vironmen ta I impact on our existing professional education systems. We have not studied what impact this program will have on current continuing ed ucation sponsors, including both divisions and state psychological associations. We do not know how it will affect state licensing authorities.

I am deeply troubled by third-party payers who place invalid limitations on the practice of psychologists, but I do not regard the proposed National College as the ideal sol u tion for several reasons.

The first step ought to be a carefully done needs assessment, and I want to invite your assistance in documenting the- need or lack thereof. Please write to me with your comments either favoring or opposed to the National College proposal. I would especially welcome documentation by any division members who have lost patients or been refused reimbursement because of lacking some added credential (as described above). Ishall make certain tha t all materials received are passed on to those who must review this proposal.

First, the AP A and several of its divisions already have the capacity and mechanism to offer high quali ty can tinuing ed uca tion. If a new credentia I is needed, let it be done within our organization. Inaddition, AP A should not grant an open-ended portfolio to create future topical credentials in

EDITOR'S COLUMN

Linda Campbell

The APA Convention in Toronto was a wonderful opportunity for Division 29 members to reconnect and to make contact with our new members. The continuing education workshops sponsored by Division 29 were very successful both in attendance and in responsiveness to the membership. The convention also afforded us the opportunity to refocus on the purpose and goals of Division 29, some of which remain steadfast over time and some of which are changing as the environment in which we work changes.

An area of need continued. to surface as various groups of members addressed these issues for Division 29 and tha t is the interest in developing a data base of outcome studies focusing on the efficacy of psychotherapy. Certainly, the number of process/outcome studies in psychology over recent years is plentiful. We now have a need, however, for particular focus in light of health care reform and our ability to support psychotherapy in terms of treatment outcome and cost. effectiveness as our strategic efforts move to the state level to Iegisla tors, public mental health administrators, and insurers.

Several of our members who are working diligently in the reform movement have asked that the Bulletin be a vehicle for networking information about outcome needs. Dr. Jack Wiggins is working on a particular aspect of advocacy for psychotherapy in which he is gathering data on income of patients/clients receiving psychotherapy both before and after treatment. He makes the argument that psychologists should

be included in health care reform because they increase the resources of individuals rather than deplete the resources of the health care system. (Please send any information you may have on this issue to our Central Office and we will forward it to Dr. Wiggins.)

Dr. Jack Rainer has proposed a monograph on efficacy, cost offset, outcome measures and research in psychotherapy. He recognizes the increased push to provide outcome data to managed mental health companies and insurers. He sees Division 29 as the appropriate Division to review the body of research that exists and to comment in terms of efficacy and other measures we may choose. He suggests a focus on defining "softer" measures of outcome, such as personal satisfaction or empowerment. There are not "good enough" descriptors ofthebenefi t oflonger term. psychotherapy and Dr. Rainer and others see a value in considering a comprehensi ve look at the way outcome is defined and measured. The results of this project could be offered to membership and the professional communities, including third party payers to psychotherapy ser-

vices. .

We are inviting all members who have an interest in either being involved in this project or who support the spirit and idea of the project to let us know through Central Office, or in direct contact with Jack Rainer or myself. Itis vitaUy important that we accurately respond to the needs of the membership and are "rowing in the same direcHan" on this matter. We are most interested. in hearing from you on this issue.

STUDENT COLUMN

Establishing A Professional Identity Laura L. Myers

As a student in psychology, you have probably been involved in discussions among your peers and professors regarding current issues in psychotherapy research and practice that are relevan t to your interests. You are becoming familiar with researchers and theorists in the field,as well as new faces just starting their publishing and practice careers. These discussions are one

very important way of staying current with what is happening in psychology. There are also many other ways students have found to not only be aware of research and practice issues but to participate in these important areas.

One very basic step in connecting with other psychologists is to join our student division of

5

AP A and become student members of AP A Divisions, in our case, Division 29. Since you are reading the Psychotherapy Bulletin. you may already have taken advantage of this opportunity. You have probably also discovered that there are special student rates for joining profes-

sional organizations. .

There are many opportunities for you to get involved with Division 29. Attending workshops and seminars such as those offered at AP A in Toronto this year, gives students a chance to learn about research, practice, and hear debate about current concerns in the field. AP A and affiliated conferences are viewed by many students as invaluable sources of networking for internship, post-doctoral experiences, and ernployment possibilities. Many students present papers at AP A and some become involved with committeesand special issue groups. It is inspiring to be able to meet leading psychologists who have made major contributions to our field.

The greatest advantage of becoming involved with APA and Division 29 is that one begins to establish one's own unique professional iden tity through relationship with the profession and other psychologists. Affiliation with others helps ascertain our own research and practice interests mel uding setting, popula Han, presenting issues, and techniques. We begin the process of advanc-

ing from a student identity in which others generally outline the direction of your study to a professional identity in which we define and delineate our direction.

Division 29 publishes a refereed journal, Psychotherapy, and the newsletter you are reading, Psychotherapy Bulletin .. These publications are part of the membership benefits of Division 29 and contribute to our ability to stay current with research, training, and practice issues in psychotherapy. The leadership of Division 29 is very supportive of student involvement in the Division. As part of this commitment, this column devoted to student issues is becoming an ongoing column in the Bulletin. This column wiUbe written by students and will reflect the interests and concerns of students in psychology and specifically those interested in psychotherapy.

We need you to participate in this column, to represent student interests and to help us network among ourselves. If you are interested in writing for this column as a contributing editor, please contact me at this address. I look forward to hearing from you.

Laura Myers

424 Aderhold Hall University of Georgia Athens, GA 30602 Phone: (706) 542~8508

Jack D. Krasner Memorial Award Interview

In 1979, Division 29 created the Krasner Award in honor of Dr. Jack D. Krasner. The award acknowledges a member of the Division of Psychotherapy with a doctorate awarded no more than 10 years prior to receipt of the award, who had made or was making unusually significant contributionls) in psychothera py research, theory or practice.

Beginning with this issue of the Psychotherapy BuIietin, a featured interview with a Krasner Award recipient will be conducted by the Psy~ chotherapy Bulletin edi tor, Linda Campbell. The interview will update the membership on the course of the honorees' professional activities and provide a view of their developing perspec~ byes on psychology and particularly on their own professional journey.

6

The first recipients of the Krasner A ward were Dr. Annette M. Brodsky and Dr. Gerald P. Koocher. Both individuals have contributed richly to our profession and the Psychotherapy Bulletin is pleased for the opportunity to revisit their careers.

Interview with Dr. Gerald P. Koocher

Biggraphy

Dr. Gerald P. Koocher is chief of psychology at Boston's Children's Hospital and Judge Baker Children's Cen ter and associate professor of psychology at Harvard Medical School. He has served as president of the Massachusetts and New England Psychological Associations. Dr.

Koocher has been elected to three terms in the Council of Representatives, served as president of Divisions 37 and 29 and as chair of the Board of Trustees of the Association for the Advancement of Psychology. He was selected last year as a recipient of the AP A Award for Distinguished Professional Contributions.

"Gerald Koocher is nationally recognized for his public service acti vi ties in the areas of children's legal rights, services to families when a child member has a life-threatening illness, and the education and protection of consumers of mental health services ... Our profession is indebted to this energetic and generous psychologist for his tireless efforts to advocate for consumers of psychological services, especially those who are too young or too vulnerable to effectively protect themselves."

Interview

You and Dr. Brodsky were the first Krasner Award recipients and you are the first recipient to become President of Division 29. Let me congratulate you on both achievements and acknowledge your valuable contribution to our Division and the profession.

1. You have been very active in Division 29 early in your career and now as President

(a) HowdoyouseetheroleofDivision29inAPA and are there ways in which you would like to see it develop?

(b) By virtue of being in the position of President, are there observations or perspectives that you now have that you would not have had without this experience?

The role of the Division has changed significantly in the 17 years I have been a member. The proliferation of divisions including those dealing with family therapy.group therapy, and private practice have had the net effect of altering the mission and scope of the Division of Psychotherapy. Although there are clear overlaps with these other groups that sprang from our core, we remain the only unit of AP A focused on practice, training. and research in psychothera py. The only change evident from my perspective as President is the degree of respect with which our division (and our views) are sought and appreciated by the AP A leadership and central office staff.

2. What events or experiences would you consider the milestones of your career since receiving the Krasner Award?

Being elected President of the Division of Psychotherapy is certainly a great honor, reflecting the confidence of my colleagues. Since the Krasner Award I ha ve been honored to receive "distinguished professional contribution" awards from the Massachusetts Psychological ASSOciation, the Section on Clinical Child Psychology and the Society of Pediatric Psychology (Division 12); the Nicholas Hobbs Award from Division 37, and AP A's award for distinguished professional contributions in the public interest. The biggest milestone, however, was probably receiving a major grant from N.I.M.H. to study preventive interventions for families that have lost a child. The government was actually paying me to test my ideas! That was qui te a thrill.

3. Has your professional work taken the course over time that you anticipated? How has it been different?

I never really thought of myself as a social "advocate" or researcher. I always wanted to be a clinician and a psychotherapist, but I found myself wanting to do more for my child clients than I could accomplish alone with them in my office. I found questions I wanted to answer and starting research on these issues just seemed to follow naturally. I never set out to be a "scientist-practitioner", but somehow it happened.

4. How has the profession in general and specificaIlyyourclinicalareachangedsince 1980? How do you view these changes?

There is far more regulation and demand for professional accountability in the practice of psychotherapy today. There is also a far greater body of scientific and professional literature on treatment issues in pediatric psychology and child therapy in the face of life-threatening illness. In general, I see the changes as positive. Accountability per se does not bother me, although I am troubled by the increase in paperwork and a corresponding effort to reduce benefi ts by some managed care entities.

7

5. How do you view the psychotherapy process and has your perspective changed during your career? What experiences or observations have affected that view?

Nearly fifteen years ago I was the "psych consultant" to a pediatric oncology ward. I had been working on the unit for four years when the five year old daughter of my wife's college roommate was diagnosed with a rare form of cancer. We had no children of our own at the time and we were Jennifer's godparents. When she died 14 months later I knew first-hand what the families I had been treating were feeling. I suddenly "knew" these thoughts and feelings in a way that my intellectual understanding of therapeutic process alone could not have enabled. Those experiences have been important influences on me as a person and a psychotherapist.

6. Are there personal or professional experiences that have Significantly altered your theoretical framework?

Yes, the experience of working with terminally-ill children and their families has had a significant impact on my theoretical approach. Most of my graduate and internship training focused on uncovering or assessing psychopathology and formulating therapeutic approaches

or making interpretations. That strategy is inappropriate for normal families facing overwhelming distress. I had to re-orient myself to meet their needs.

7. Other than the area of heal th care reform, w ha t do you see as the most important issues our profession is facing going into the 21st century?

An increasing loss of professional autonomy is the most significant issue facing psychotherapists as we approach the next century. We have the abili ty to demonstrate our accountability and professional efficacy, and should not be intimidated. We have the capacity to develop new interventions that can prevent human suffering as well as relieve it and need to move in that direction. We should be very ca u ti ous abou t urgen t calls to rush headlong after the Holy Grail of prescription privileges or the necessity to create new credentials (e.g., the National College of Professional Psychology) as a knee-jerk response to uninformed third party payors.

a.What question has not been asked that would contribute to a more complete or accurate view of your professional development?

Is this a projective test?

1993/1994 MEMBERSHIP UPDATE .

Profile on Richard H. Mikesell Division 29's Membership Chair

by Linda Campbell

Division 29 has been most fortunate this year in having Richard H. Mikesell at the helm of our membership campaign. Because of Dick's efforts, the membership of Division 29 has increased by gTeater number and percentage than a t anytime in the history of the Division. Dick headed up an equally successful membership campaign for Division 42 in 1992 and is Chair of AP A's Second Century Membership Initiative Committee which is spearheading an APA-wide 8

membership drive, currently underway to reach out to all psychologists who are not currently AP A members.

Dick has been a clinical psychologist in full-time private practice in Washington, D.C. for over 20 years. He is a Past President of the District of Columbia Psychological Association, APA's Division of State Psychological Association Affairs (Division 31) and APA's Division of Indepen-

dent Practice (Division 42). Dick is a co-founder of APA's Division of Family Psychology (Division 43) and presently represents Division 43 on the AP A Council of Representatives for this third term. Currently, he is Chair of AP A's Board of Convention Affairs and is Edi tor (with Don-David Lusterman and Susan McDaniel) of APA's first handbook in the field of family therapy, Family Psychology and Systems Therapy: A Handbook, which will be published in the near future.

Membership Campaign Success

Richard H. Mikesell

Chair, Division 29 Membership Committee

We are pleased to announce that the Division of Psychotherapy's 1993 special membership campaign wasanoverwhelmingsuccess. To date, we have enrolled over 2753 new members which is a 54% increase in membership. Division 29 is now AP A's second largest division.

Dick has been the architect of this successful membership campaign. Division 29 is indebted to him for his time, energy, and creativity.

TABLE 1

DIVISION OF PSYCHOTHERAPY MEMBERSHIP HISTORY 1980 - 1993

7988

7000

6000

5000

4000

3000

2800

1000

1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 issi 1992 1993

A special membership offer was extended to AP A members. The membership flyer emphasized the following themes:

(1) Division 29 is the only APA Division devoted to the survival of psychotherapy

(2) Division 29 is the home for all psychologists interested in psychotherapy.

9

WASHINGTON SCENE

Prescription Privileges - A Qualitative Difference Pat DeLeon

At this year's APA convention in Toronto there seemed to be a qualitative shift in the tone of the various discussions surrounding prescription pri vileges. Even a cursory review of the con vention program indicated that there were in excess of twenty presentations/ panels addressing the topic, ranging in focus from: A report of the AP A ad-hoc TaskForce onPsychophannacology (Mich Smyer); Pharmacologic Trends in the Treatment of Major Depression (Dan Egli); Prescription Privileges - Issues in Rural Settings (Bob

Frank); to Prescription Privileges for Psychologists: Marketing Breakthrough or Potentially Destructive Detour? (Gary DeNelsky) Those attending Jack Wiggins' APA Presidential Address heard the clear message that as a profession, we can no longer afford not to possess this clinical modality.

always be remembered is that: The Power to Prescribe is also the Power Not to Prescribe; that is, it represents the ability (responsibility) to ensure that those on psychotropic medications are being appropriately treated.

At the Toronto convention Steve Olmedo of the California School of Professional Psychology (and a member of the Board of Educational Affairs) agreed to chair the ad hoc coalition of State

Association Prescription Task Force Leaders, which had met for the first time last year at the Washington, DC Convention. Steve's report: "A group of some 50 leaders of state and provincial associ a Han task forces on prescription pri vileges for psychologists and other interested parties met for two hours during

the recent APA convention in Toronto. The meeting was hosted by Anita Brown from the APA Prac-

tice and Education Directorates. APA Board members Pat Deleon and Bob Resnick (APA President-Elect-Elect> addressed the group briefly with words of encouragement concerning progress at the state level in terms of organization and planning to pursue prescription privileges."

The Power to

Prescribe is also the Power Not to

Prescribe.

The two Department of Defense

(000) post-doctoral psychopharmacology fellows, Morgan Sammons and John Sexton, were highly visual throughout the convention and were enthusiastically received by numerous audiences. Those of us who have long been in favor of the movement had the sense that the underlying discussion has now moved to a different conceptual plane: to How to Develop Viable Training Modules and / or Wha t Legislative Strategies Would Work - A very far cry from the initial concerns of: What Do Our Colleagues Feel and / or Can (or Should) Professional Psychology Pursue this Agenda. This feeling which was overtly conceptualized by Chuck Paltz (APA Council Representative from the State of California) has been reflected during the past year in the increasing number of prelim examination questions being asked, and doctoral dissertations being approved, on the topic, not to mention policy seminars being conducted, for example at the University of Hawaii School of Public Health (Ray Folen), A key clinical concept. that must

10

"A key part of the meeting was a presen ta tion by Morgan Sammons and John Sexton, the two remaining U.S. Navy Psychopharmacology Fellows (of the other two, one has gone to medical school and the other left the program for personal reasons). Drs. Sanunons and Sexton indicated that they had completed the academic (didactic) part of the program and were now engaged in the clinical ("hands on") experience aspect of their training. They reported that the latter was going very well and that they felt accepted as peers by the psychiatric residents with whom they were sharing the clinical training. They also noted tha t whereas their academic

curriculum had consisted of the first two years of medical school, a new one-year curriculum specifically designed for psychologist prescribers had been developed for Iteration #2 of the psychopharmacology demonstration project to take place during 1993-1994. Copies of the new curriculum were made available to the audience and can be obtained directly from Anita Brown at APA."

"Next was a panel presentation by Elsie Go Lu, Charles FaItz, and Tom Marra of the California Psychological Association (CPA) and Esteban (Steve) Olmedo of the California School of Professional Psychology (CSPP). The presenters reported on the organizational activities taking place in California under the aegis of the CPA Task Force on Prescription Privileges chaired by Dr. Faltz. The presenters emphasized the need for: internal consensus, coalition building to address the public policy issues surrounding prescription privileges, and a partnership with a suitable academic institution to deal with the education and training components. Dr.Olmedo noted tha t professional schools such as CSPP are ideal 'partners' for state associations because they were founded to meet the need for professional psychological services and ha ve remained sensitive to the changing needs for practitioners in the market place. CSPP, for example, has for many years required courses in brain and behavior, and in psychopharmacology for all clinical Ph.D. and Psy.D. students. In addition, students enrolling in the Health Proficiency (Los Angeles Campus) track are required to take a year-long, two-course sequence on Medicine for Psychologists."

"CP A and CSPP are acti vel y collabora ting in the task of moving forward with prescription privileges in California. They have recently submitted a proposal to the APA Committee for the Advancement of Professional Practice (CAPP) for funding to support and staff a highleve1 Task Force of educators and practitioners. The Task Force would review existing proposed curricula for psychopharmacology training for professional psychologists, draft the education and training requirements to be included in proposed legislation, and develop a prototype training program designed to meet those requirements." In many, many ways our colleagues in Cali fomia con tinue

to lead the way in pressing for the "outer boundaries" of professional practice. Mahala!

Bob Frank, chair of the Prescription efforts in the State of Missouri, reported on efforts being made throughout rural America, where a concerted "access" policy argument could be very effective, as our nurse practitioner colleagues have discovered. "The atmosphere and tone of the prescription privileges programs at AP A was markedly more positive than in previous years. At previous AP A meetings, audiences appeared split between proponents and opponents. At the Toron to meeting, audiences were overwhelming supportive of prescription privileges. The issue appeared to be how do we do it and when will it be done, not should it be done."

"The successes of the effort to date were most apparent in the attention paid to the first two gradua tes of the Departmen t of Defense training program. Their willingness to persevere despite numerous obstacles was applauded during virtually every discussion on prescription privileges. At the same time, the importance of establishing viable state efforts was frequently discussed. Several excellent presentations discussed the status of the prescription privilege effort in an array of states. In our symposium, 'Issues in Prescription Privileges in Rural States', Jack Wiggins, the past-President of APA, opened the discussion by reviewing the financial implications of obtaining prescription privileges. Dr. Wiggins noted that psychologists recap only three times the investment they make in their education during the course of their careers. In contrast, physicians recoup more than six times the amount they invest in their educa tion during the course of their careers. Dr. Wiggins argued that practi tioners must obtain prescription pri vileges to be viable in the health-care marketplace that is developing. Moreover, from a policy perspective, Dr. Wiggins stressed the savings that could accrue from having psychologists prescribe medication could be Significant. States such as California that currently hire psychiatrists for their mental health systems at high cost, would enjoy enormous savings if psychologists could prescribe"

"Dr. David Nichols, chair of New Hampshire's prescription privilege task force, noted that phy-

11

sicians in rural states already rely upon psychologists' knowledge of psychotropic medications. A psychopharmacologist and clinical psychologist, Or. Nichols has a unique perspective on the prescription privilege debate. He argued that psychologists are well prepared to undertake this role. In many instances, he manages all psychotropic medica tions for his patients. In his experience, local physicians have been pleased he has the competence to perform this task and have been very willing to use his advice on medication issues. Dr. Nichols suggested the training criteria proposed by the AP A Task Force on Psychopharmacology were excessive and required a much higher standard of training than is currentIyapplied to physicians." (In-

terestingly, during the convention

several psychologists reported that when they had raised the issue of training psychologists at the post-doctoral level for this clinical responsibility with professors of pharmacy that they were personally acquainted with, "six months maximum" seemed to be the suggested necessary training).

chologists must also know where opposition will come from and be prepared to respond."

"Efforts in Missouri were reviewed by Dr. Kristopher Hagglund, a member of the Missouri Psychological Prescription Privilege Task Force. Dr. Hagglund reviewed the conclusions of a workshop sponsored by the Missouri Psychological Association in February, 1993 that was attended by Dr. Russ Newman, Director of the AP A Practice Directorate. The workshop focused on the essential ingredients of model prescription privilege legislation for Missouri. Workshop participants determined that the training for prescription privileges should occur at the post-doctorallevel. Education should be coordi-

nated with graduate training pro-

- grams or other training models capable of providing the level of training recommended by the AP A Task Force on Psychopharmacology. Clinical training would occur under the supervision of individuals knowledgeable in psychopharmacology. Implementation of prescri ption privileges would be facilitated by requiring at least one member of the Missouri Sta te Commi ttee ofPsy-

chologists (the licensing board) to obtain prescription privileges."

... physicians in rural states already rely upon

psychologists' knowledge of psychotropic

medications.

Dr. Douglas Wear presented an overview of key steps psychologists must

take to obtain prescription privileges. He noted that the Wyoming Psychological Association has already begun a multi-year campaign to obtain prescription privileges. Starting with the revision of their practice act during the previous legislative session (when an earlier express prohibition on prescription privileges was deleted from their statute), the Wyoming Psychological Association has begun meetings with key state officials to increase their knowledge of psychology. They have, also met frequently with members of the Wyoming State Optometric Association, attempting to learn from this grau p's recen t success in obtaining prescription privileges."

"Dr. Wear emphasized it is important to ensure all psychologists support the legislative effort. To do this, he recommended individual meetings with each psychologist in the state. If a psychologist is unwilling to support the effort, the Wyoming Optometry Association suggests, the individual is requested to not publicly oppose the issue ('knee to knee"). In addition to ensuring universal support, Dr. Wear said psy- 12

"Each of the presentations in this symposi urn on rural prescription privileges had moved beyond discussion of the appropriateness of legally acquiring this skill to how it can be done. Without exception, each presenter believed prescription privileges will be obtained in the near future."

Without question, one of the most humorous presentations made on the prescription privilege topic was that of Doug Wear, accounting his discussions with his colleagues in the Wyoming Optometric Association who have been successful in legislatively broadening their scope of practice. We would en thusiastically recommend Doug to any State Psychological Associa tion tha t wants a first hand glimpse - "the opponents won't necessarily tell the truth, you know",

"In considering action to obtain prescription privileges, it is essential to build a base of support and establish the need for these services beyond simply the psychologists' desire to provide them. In

Wyoming, this has thus far involved discussions with state government officials, mental health center directors, and Pharmacy Association leadership. Further, contacts are planned with other state officials, personnel working in rela ted fields, and advocacy groups such as the local NAMI cha pter. Results thus far indica te a large unserved or inadequately served population in the state, such that its five year mental health plan includes circuit riding psychiatrists traveling out of the single sta te hospi tal to try to meet these unfilled needs."

pass on merit alone. While merit can, and we would like to think should, be a relevant part of the process, a long term approach in political preparation, action, and advocacy is far more essential. Personal relationships with legislators, campaign contributions, and assisting them in their election process are among the prerequisites to have support and friends in the state houses."

"Unfortunately, it is not just developing friends in the poli tical arena that leads to success. Knowing your enemies and anticipating their actions is necessary. Preparations for the negative aspects of the political process, the fact that people will

lie, manipulate information, and work behind the scenes to kill bills are all issues that must be under... finn commitment stood and planned for in advance."

"Education and training of the membership of one's own state association are key to being able successfully to pass legislation. First,

awareness of the issues regarding

psychologists prescribing med ication must occur to gain necessary support. Later, those who will prescribe need to learn the necessary skills. While awareness of the issues is just beginning in Wyoming, we have learned a lot from our Optometric Association friends with whom we have shared a lobbyist. They twice struggled successfully to gain pre- political process. scription authority for both diagnos-

tic and therapeutic medications throughout the country. In Wyoming, 90 percent-plus were trained to prescribe before even proposing empowering legislation -spending $1500 each to obtain 125 hours of didactic training and then traveling to Pennsylvania at their own expense to obtain 25 hours of practicum for a total of 150 hours (exceeding their estimate of the usual 115 hours of medical school training that their specialty counterparts would have received). That is commitment!"

must also be made to membership

"The states are moving forward with the prescription privileges agenda. For the most part, they will do it alone while AP A sits on the sidelines. Some Council of Representatives members may move in February, 1994 to prevent any effort by APA to help states in this

area. Yet, the national association could do much to facili ta te dialogue among sta tes, provide the critical information and databases necessary to support this effort, organize academic support and develop curriculum, and offer sophisticated consultation for state-level political action. Another lesson from optometrists - they pulled together to accomplish their goal wi thou t dissension from the inside undermi ning their effort. While some disagreed, they did not block others wanting to expand their use of medication and, indirectly, their scope of practice. There's a saying out here in the West about shooting yourself in the foot.... Happy trails!"

training and active involvement in the

"Beyond the awareness and specialty skill training that must be undertaken, firm commitmen; must also be made to membership training and active involvement in the political process. The optometrists' success attests to the positive impact that training and preparation have on a legislative body."

"The political battle itself is always a hard fough t one. Be it current efforts in the areas of prescription privileges, experience shepherding a new practice act into la w, or learning from the optometrists' struggle, the lessons are clear. Of key importance is understanding that bills do not

Finally, we are pleased to report that in the State of Oregon, Representative Tom Mason has in troduced legislation, House Bil13541, which would authorize psychologists, after meeting competency standards to be adopted by the Sta te Board of Psychologist Examiners, to prescribe drugs from formularies adopted by the Board of Medical Examiners, in consultation with the State Board of Psychologist Examiners. The legisla tive process continues!

13

--

MEDICAL PSYCHOLOGY

Disability Management Problems: Managing Appropriate Care versus Managed Care

David B. Adams

The initial impetus for early and timely psychological care of medically ill patients was that such care would shorten the length of disability for patients with pathophysiologic conditions. Reducing disability returned patients to productivity, lessening the impact upon industry and decreasing general medical costs.

There was empirical validation of the belief that those patients who were appropriately psychologically assessed and who then received diagnostically-related psychological care would recover from their physiologic disorders in briefer periods than those for whom such diagnosis and treatment was not provided. Psychological care was thus promoted as a means of foreshortening periods of disability. Insuring return to productivity and decreasing ultimate impact upon the nations economy through absen teeisrn, extended and unnecessary medical and surgical procedures as well as lowered industrial productivity would be effectively addressed.

Since eighty percent of those needing psychological care were unlikely to access such care, making available mental health benefits was an inexpensive health insurance offering. Ideally, a patient with acute and chronic physical disorders would seek brief and directive psychotherapy, would mobilize as a result of treatment and return to productivity. Since the cost of outpatient psychological care was/is negligible in comparison to multiple and repeated radiological, hematological and invasive diagnostic procedures, the health insurance carrier was at once offering the employee a health benefit that was health promoting for the patient and cost-containing for the employer and insurer.

The concept of health promotion became fashionable and politically correct in a nation of impressive health care costs. Quality and quantity of life issues could be addressed through early

psychological intervention. Ideally, the concept of anxiety, depression, sexual dysfunction, and addiction would be disorders which the American worker could comfortably disclose, and seek appropria te, effective and brief care, demonstra ting the inappropriateness of mind-body dualism. An employee who was clinically depressed was just as ill as was a patient with a viral illness. Anxiety reduction was equally as important as reduction in cholesterol. Early detection, early intervention, and cost containment became the cornerstones of a third-quarter, twentieth century, mental health movement.

Lifetime benefi t packages with unlimi ted capitation on mental health coverage was inexpensive. Since most employees would never access mental health care, it was far less expensive to offer one hundred thousand dollar mental health lifetime benefits than offering similar cancer, cardiac or orthopaedic access. Simply, it would take inordinate visits to a psychologist to utilize even a fraction of such a mental health ceiling benefit in comparison to the cost for a four artery CABG, lumbar fusion or radical mastectomy.

14

While those seeking surgical procedures would see themselves as victims of unwanted disease processes and readily accept such invasive procedures, twenty years ago the public was less likely to seek psychological care even if it were covered by insurance. The employer and the insurer would experience only gains under such a system. They could offer a valid means of health promotion and essentially run minimal financial risk.

Realizing that there was suddenly a new mental health care market place, proprietary mental hospitals and hospital corporations began to spring from the well of guaranteed patient revenue. Patients who were perceived as depressed, anxious, phobic, and/ or, ideally, addicted, were offered elaborate and extensive inpatient services that lasted not days or weeks but months. The patients were housed, medicated, placed in a variety of "therapies" during the day, placed in groups where they were taught the nosology of being a "survivor" of a trauma or a "co-dependent" of an addiction, and concurrently, more maladapti ve beha viors were labeled as "addictive" and requiring intense inpatient treatment approaches. Simultaneously, there developed programs of partial hospitalization in which the institution, no longer able to account for an extended stay for a patient, was now offering pseudo-outpatient "treatment" in which the individual was back at the hospital daily and merely going home in the evenings.

Mental health practitioners who found outpatient practice both difficult to establish and uniquely, if not uniformly, exhausting, were offered offices within or adjoining the hospital as long as they continued to admit to those hospitals. Further, if that clinician were to admit most, if not all patients, morning rounds could be made on a dozen patients within less than two hours before office hours began. An extender could be sent to lead groups, and the clinician was placed in a position of income that rivaled the more expensive health care services with minimal expenditure of energy.

There were two responses which emerged:

a. insurers and employers, seeing that employees did not use these mental health services to shorten physical disability were now pulling in

the reins on mental health benefits. The employee's co-payment increased, the lengths of stays decreased, and often mental heal th benefi ts were being increasingly excluded from the basic health care insurance package offered, and

b. patients began to litigate for inappropriate or nonproductive mental health care which merely resulted in increased malpractice premiums, clinician trepida tion and more eri ticism than praise for psychological care.

The most succinct causal relationship is to attribute the erosion of the mental health system plan for increased physical health to the proprietary hospital corporations and/or to the greed of clinicians who affiliated in order to ensure quick profitability from their training. There is, however.ia more insidious problem: the doctor who is fearful of discharging a patient from psychotherapy, whether inpatient or outpa tient, independent of either diagnosis or litigation. The clinician is fearful that the supply of patients to the practice is finite and, therefore, all patients will be maintained in their role until benefits are depleted. Since patients can rapidly become dependent in psychotherapy, they may remain in treatment for extended periods, without significant improvement, themselves fearful of a life without psychological care. Avoiding the overused term addictive, perhaps the word symbiotic then applies.

In response, em players and insurers, left wi th no other cost-containing alternatives, present the concept of employee assistance programs in which the number of visits are defined, are less frequently delivered by psychologists and more often by counselors and often relegated to a third level of "delivery" called professional counseling organizations. In the latter situation, there is no diagnosis, there is no psychotherapy (although such counselors will freely call themselves "therapists"), but the costs to the employer is minimized. Inpatient care becomes so encumbered with pre-certification requirements that the proprietary companies begin to sell off their units w hen available beds begin to far exceed a vaila ble insurance-funded patients.

Managed CiZre is then introduced as a further control in which not only costs per service but length of service and even necessi ty of service as well as providers utilized is maintained by an outside agency. While this accurately is managed

15

financial impact, there is some reasonable doubt as to whether this is, indeed, managed care.

Insurers see the managed care concept from a clear and precise vantage point. Managed care is not intended to entice the best of available providers. On the contrary, managed care companies will first attract those who have not been able to build successful practices independent of wholesaling their services. Successful practitioners will remain successful and the public, in the efforts to contain accelerating and aIanning heal th care costs, will be sold marginal providers who will work for forty cents on the dollar and be grateful to have the patient flow. The implications would appear to be quite grave for the consuming patient. The situation is, however, more complex.

Al though the strong solo and group providers continue to initially thrive while the weak and needy aspire to be included in any managed care program, how long will the strong and independent maintain their base of practice? Rapidly patient populations, through their employers, are shifted to the managed care companies.

Even though a patient may prefer, trust, and be responsive to a specific doctor, the patient no longer has a choice as long as the employer / insurer pays for the visit. A country that encourages a concept of equal access to health care consequently builds patient populations which are not accustomed to paying for health care. Patients expect insurers to pay for care and obediently wilI go where insurers insist they be seen for health care. Managed care, thereby, becomes anti-competitive since it does not promote competition between doctors with regard to quality of care. In the managed care concept, quality-of-care becomes a consideration subservient to solely cost containment concerns.

Wi th the erosion of the population of self-selecting patients, those who chose their doctors based upon competence, the insurers are, therefore, appropriately confident that even the most excellent and independent of clinicians must eventual! y succumb to the necessi ty of joining the managed care roles.

Indeed, working on probability theory, employers and insurers anticipate that before the prac-

16

tice of the successful clinician does erode completely, the roles of managed care panels will fill so rapidly that fear of future erosion (depletion of available self-selecting patients) will motivate the excellent providers to abandon their independence for the sake of sheer survival. Thus, while managed care roles will initially contain the less successful provider, the assumption is that the skilled clinicians will fearfully join the roles in short order.

This process is intended to save tens of billions of dollars in the escalating and uncontrolled costs of health care. Costs which arose because of excessive and redundant ordering of nonrevealing diagnostics studies, overcharging on all levels of inpatient and outpatient medical and surgical care, and patients who remained in treatment for extended and nonproductive periods of time.

The management of patient care may, indeed, be managed care. This, however, has not been demonstrated.If a patient is treated by a less competent clinician, ordering less studies, seeing the patient for briefer periods, discharging the patient as protocol demands, we may find that the patient simply does not recover, absenteeism is extended, productivi ty does not return, and ul timate costs to the workforce have increased.

Mental health care forthe medically ill and physically disabled can, has, and will reduce the costs of heal th care in the U ni ted States, bu tit can onl y do when three conditions are met when:

1. Dependency producing, protracted and cost-ineffective inpatient stays are avoided.

2. Treating clinicians are selected from a pool of the most competent, most competitive and most aggressive providers rather than those who beat a hasty retreat to the "security" of managed care membership.

3. Those engaged in patient care are equally responsible and accountable for the rapid recovery of the patient, and the financial impact of clinical care upon the nation's annual health care expenditure.

In effect, competent care cannot preclude the accountability of individual doctors for the financial dilemmas of the country. Competent care is, by definition, briefand effective. It is designed to mobilize the patient and not to insure the financial security of the clinician.

GENDER ISSUES .

Men Helping Men:

A Vital Difference

Gary R. Brooks

From boyhood, males are raised to compete with each other for power, status, financial position, the attentions of "attractive" women, and for other goals only vaguely understood. As we men learn to view each other as competitors, we also learn that, while it may be acceptable to desire nurturance from women, it is unthinkable to crave affection from men. For this reason, the idea of men helping men - a male healing community - is a foreign concept. This can be a problematic situation, one that takes on greater meaning when viewed in light of recent changes in women's consciousness, reflected in many themes of the women's movement.

There are growing signs that women are profoundly unhappy about traditional masculinity, men's expectations of women, and about many aspects of traditional male-female relationships. For example, a recent and relatively modest film - Thelma and Louise - captured enormous public attention and impassioned analysis. Perhaps the film caused such a stir because it, much as Shere Hite's Women and Love, struck a sensitive chord in the area of intergender relations. Although much of the reaction of the film was focused on

whether the male characters were too negatively portrayed (a criticism also made of the film "The Color Purple"), a more troubling issue may have been the film's suggestion that, not only do women not benefit from men's protection, but that women may also be better off without the burdens of male-female relationships. Contemporary men have had a multiplicity of reactions to the women's movement and to women's growing empowerment. Of the many reactions 1 have witnessed (in others and in myself), I have been most impressed by men's fear of losing the a ttentionand nurturance of women. A cynical, though not necessarily inaccurate, observer might note that naturally this would be so, since men, as an entitled and privileged group, are concerned about threats to that status. Aside from that issue, however, is another factor that makes this a deeply troubling matter for many men, Joseph Pleck identified this anxiety when he observed that men have considerable dependence upon women, that men rely upon women for "masculinity validation," for "expressive power," and for a "refuge" from male-male competi ti ve struggles (Pleck, 1980). We men have wanted women to tell us (and show us) that we are manly, to serve as "social lubricants," and to provide emotional safe havens. Naturally, at some level, we men will have the impulse to resist anything that seems to jeopardize those functions, functions that, according to male socialization, must be performed by women, The

The IV European Congress of Psychology

The IV European Congress of Psychology, under the aegis of the European Federation of Professional Psychologists Associations, will be held in Athens, Greece from July 2 to 7,1995, organized by the Association of Greek Psychologists and the Hellenic Psychological Society.

The Topics of the congress cover all the areas of psychology in all their aspects; theory, research, practice and teaching. In addition to lectures, the program will include symposia, thematic sessions, poster sessions and workshops. The members of your division are welcome to make a presentation at the Congress. All inquiries should be directed toward the:

IV European Congress of Psychology

The University of Athens, Department of Psychology, School of Philosophy Panepistemiopolis

Ilissia 157 84 Athens, Greece

July 2-7,1995

17

result of this seems to be a rather ironic situation that is the thesis of this article - to the extent that men continue relating to each other in a highly restricted, predominantly competitive, and generally non-empathic fashion, we will be destined to remain unduly fearful of losing women's nurturance, Whatsmore, only when we learn to build a male healing community can we men fully commi t oursel ves to the struggle for gender equality.

But can this be done? Can men help men develop a male heal ing co mmunity or environment? There are many reasons to be doubtful, but there are also reasons to have hope.

ans at a V A Hospital, to illustrate that, even in a highly tradi tiona! mascu line environment manifesting most all of the shortcomings of the male relationships, there also are many notable strengths - strengths that can be built upon to revise male relationship patterns.

Scenes from a VA Men's Group

In a particularly tense group meeting, Jesse is overcome with emotions as he recalls a traumatic Vietnam experience. He was only 17 when his company was overrun at Ben Hit. As part of a desperate attempt to save a mortally wounded

buddy he carried and dragged him 300 yards across a "field of fire" to get him to the safety of a waiting chopper. Though hit twice himself, he made it to the chopper with his buddy on his back. Because of his own injuries, Jesse was forced to climb aboard the departing chopper and was thwarted in his frantic efforts to return for more injured comrades. As the chopper climbed to escape enemy fire, another injured troop, who had been trying to follow Jesse to safety, made a frenzied leap to get aboard. Jesse caught

him by the bloody wrist and strained to pull him in. For an ins tan t, as the chopper ascended, Jesse was able to hold him and stare into the man's terrified eyes. Then he lost his grip and the soldier fell SO feet to his death or certain capture. For over twenty years, Jesse has periodically awakened in panic, from nightmares where he sees the man's face and his hears his screams. Jesse is torn by guilt that he didn't jump from the chopper to try to rescue his comrade.

In his book The Male Machine, Marc Fasteau described the male as " a special being ... functional, designed mainly for work '" with armor plating which is virtually impregnable" (1974). In terms of in terpersonal relations, Fasteau said "he dominates and outperforms his fellows ... his relationshipwithothermalemachinesis ourselves to the one of respect, but not intimacy; it is '

difficult for him to connect his inter- struggle for gender

nal circuits to those of others ... his equality.

internal circuitry is maintained pri-

marily by humans of the opposite

sex" (p, 1).

Only when we

learn to build a male healing

community can we men fully commit

David and Brannon (1976), in one of the best known characterizations of the male gender role, iden tified "no sissy stuff," "the sturdy oak," II give 'em hell," and lithe big wheel" as critical to the male role. Over the past two decades many other descriptions of the male role have appeared, each emphasizing different restrictive features of male socialization, and none creating much more optimism about the potential of male-male emotional intimacy and nurturance.

Fortunately, this is not the complete story. Levant (1992) suggested a "reconstruction of masculinity" that walks the fine line between discarding whatis obsolete and dysfunctional about traditional masculinity and celebrating what is valuable and worthy. In that vein, I would like to argue tha t embedded wi thin even the most traditional masculine environments there are seeds of hope. As a basis for this, I will draw from my twenty years of experience with military veter-

18

George tells the group of his enormous anguish over the friends he lost in Vietnam. When the group discusses the "wall," (Vietnam memorial in Washington, DC), George admits that he never plans to visit, for fear that he will follow through on his 22 year plan to "off" himself - commit suicide to rejoin his buddies lion the other side." He distances himself from affectionate relationships, noting that any love or pleasure is a disloyal ty to Vietnam comrades who will never return. When under severe stress he isolates himself, repeatedly rewatching "Platoon," a movie that he feels helps him reexperince closeness with those he lost.

Buck, a 64 year old, retired county sheriff with heart problems and severe COPO, talks of his rage and bitterness at being forced to leave his life's work. Feeling worthless as a "civilian," he repeatedly reminisces abou t the camaraderie and closeness he fel t wi th fellow officers. After hearing that one close friend had been killed in the line of duty, Buck castigates himself - "this wouldn't have happened if I'd been where I should have been." With tremulous voice and wet eyes he says "I'd crawl five miles to get a guy out of trouble!"

The Masculine Honor Code

Male Pain in Hiding

many men's private lives are in a sorry state. Though men as a group often enjoy considerable political and economic muscle, individual men frequently display evidence of lives that are out of control. Pleck (1987) reported an aJarming increase in "bread winner suicides," whereby men kill themselves rather than face economic ruin or failure to fulfill the "good provider" role. More than two-thirds of the homeless population is male, perhaps, in part, testament to men's tendency to deal wi th problems through flight, wi thdrawal, and alcohol abuse (alcohol abuse is four times more common among men). Mendie7-10 years sooner than women - partially an outgrowth of their attraction to high-risk "heroic" life styles, and partially a product of failure to

engage in self-care behaviors. A large number of fathers are emotionally or geogra phically estranged from their children. Men in middle-age have trouble identifying close male friends. Men in retirement develop depression from the lost meaning of lives formerly focused on work. Pornography sales soar as men are increasingly sold a narrow, voyeuristic, women-degrading, objectified sexuality. Leading "successful" male public figures - Gary Hart Jimmy Swaggert, Ted Kennedy, Paul

Rubens (Pee Wee Herman), Mike Tyson, and Woody Allen - ha ve their reputations ruined by their sexual conduct (or by questions about their sexual conduct). Somewhere between five an fifteen percent of male psychologists ignore clear ethical guidelines, danger to innocent parties, and risk to career, by entering into exploitative sexual relationships with clients.

For too long

their pain

men have kept

invisible or

covered it

with a range of distasteful

behaviors.

Many men are not likely to help each other unless they see that other men are endangered. It may not always be obvious, but in many important ways, contemporary men are in deep trouble. Behind the occasional bra vado,strutting, or boasting, behind the "master of the universe" facade,

What should we make of these stories? Axe they only melodramatic portrayals of anachronistic, patriarchal, and aber-

rant male behaviors, generally the prod uct of military, paramili tary, and high-risk macho environments? Perhaps this is so, but that sort of critical analysis is not the issue here. The point of the stories is that there is an important theme in the traditional masculine code that could be helpful. This theme calls for a man to do all that he can to aid a comrade in danger, to rescue a buddy, even at risk of one's own life. Surely then, if a man is willing to go to such extremes to help a friend in danger,

then he can be expected to be available to him at times of emotional need. But this is frequently not the case, as men are peculiarly unavailable to each other at such times. Is this loyalty to other men a myth? a hoax? Perhaps this is so, but my experience with men suggests an alternative explanation. Men truly do want to help each other, but are seriously impeded by three other features of male role training - difficulty in admi tting fear and vulnerability, relative under-empowered status in the emotional realm, and homophobia.

The intent here is not to "bash" men, but to make observations that raise awareness about the need to change many traditional male behaviors. For too long men have kept their pain invisible or covered it .. vith a range of distasteful behaviors. In response to the tenet that men should not be weak or needy, many men express their pain in an indirect, or disguised manner; e.g., violence, social isolation, alcoholism, workaholism, sexualization of relationships, or reckless and foolhardy behavior that leads to injury or death. Troubled women often end up in therapists'

19

offices; troubled men often end up in jail, alcohol half-wa y houses, in the streets, or in early graves. This is a bad deal for both genders.

Men's Under-ernpowennent as Nurturers

The process of turning young boys into male machines necessitates emphasis on performance, strength, endurance, and denial of pain. Interpersonal empathy is discouraged in boys, though rewarded in girls. Nurturing roles, from child-care to elder-care, are generally assigned to females. Emotional sensitivity, affective awareness, and emotional expressiveness are not emphasized in male development, as men are taught to rely on women for help in these areas. A common observation of mixed-gender groups (whether work groups or therapy groups) is that women usually perform the nurturing functions (Aries, 1976; Stein, 1982). Therefore, if substantial change is to place, a method must be developed to change traditional gender patterns by empowering men as nurturers and freeing women from exclusive responsibili ty. This is far more easily accomplished in all-male 1 environments.

Homophobia

Nothing restricts the potential of all-male environments more than homophobia. Without refutingmythsabouthomosexualityandirrational fears of male-male intimacy, men will ha ve grea t difficulty moving beyond superficial relationships with each other. Consciousness-raising work in this area must not be left to gay men who are already overburdened with personal and political agendas, but must be taken up by "straight" men. Homophobia education has an interesting parallel with feminism, Many persons ha ve realized that feminism is not just about women's lives but about men's lives as well. Similarly, homophobia education is not just a bou t lesbians and gays, but is also about straight persons. Anyone invol ved in co nsciousness- raising or in gay rights political activism is likely to realize tha t the issue is not just a bou t tolerance for

psychosexual differences, but that it also is about the many complicated interactions between in timacyandsexuality. This is an area of exploration that should benefit all men, wherever they stand on the gay-straight continuum.

Building Male Healing Enyironments

There are many levels at which male healing environments can be developed and male psychotherapists are in ideal positions to facilitate this process. An exhaustive strategic plan is premature, but a few ideas are offered.

• Continued support for the empowennent of women.

Efforts to empower men as nurturers should be accompanied by continued efforts to obtain equity for women in political and economic arenas. The women's movement has created new role possibilities for men and a pro-feminist men's movement can provide important extensions to what is already underway.

• Consciousness-raising about men's lives

Men will be more likely to make use of therapy if men's experiences are understood and their private pain is recognized. Victimization of others cannot be condoned, nor can men be excused from individual responsibility for their actions. However, when possible, thera pists benefi t from understanding the desperation experienced by many men.

• Conducting gender-sensitive psychotherapy

Psychotherapy benefits when gender issues are given explicit attention and gender specific stresses are targeted. At times, there may be benefits from all-male groups. Gender-role psychothera py (Solomon, 1982) calls for greater self-dislosure by therapists, giving male therapists a special role in hel ping troubled men open themselves to therapeutic intimacy. In family therapy attention should be given to gender

1 Women therapists certainly halJe a major role in helping troubled men. Discussion of the advantages of each gender, however, is not tb! focus of this article.

20

"blind-spots" that may constrain men and women's potential. New models of fathering can be encouraged. Greater intimacy among men should be a therapeutic goal.

;f Changing professional relationships

we need to focus on the male role struggles we have in common.

Conclusion

There is much about the male heritage tha t inhibits men from recognizing the pain of other men Gender socialization affects not just male clients, and discourages efforts to reach ou t to allay that but also affects male therapists. In our profes- pain, Fortunately, there may be another rnascusional lives we can encourage greater role flex- line tradition-men's loyalty to endangered comibilityamong male psychologists. Though there rades - that may help therapists create a male certainly is a valued place for competition and healing environment. This process is advanced

politics within psychological organi- ----- when we find ways to uncover the

zations, there also should be opportu- P ain that men commonly disgu . ise,

In our

nities for men to put aside profes- when we empower men to become

sional roles and interact au thentically professio nal lives better nu rturers of each other, and

about issues confronted by men as when we challenge the noxious

h 1 . we can

psychologists. Male psyc 0 ogtsts power of homophobia. Men and

should make a commitment to men- encourage greater women therapists are able to par-

tor male students and early-career . ticipate in this enterprise, though

role flexibility

psychologists to help them wi th their male therapists have many a ven ues

gender role journeys. Greater atten- among rna letha t may be unavailable to women.

tion should be given to men's studies I am confident that if the challenge

in graduate school programs. (The psychologists. is properly presented, men will

Society for the Psychological Study of come through for each other. In the

Men and Masculinity [SPSMM] in- words of a male client - "if and when you need

dudes these as major parts of its agenda) me, just call and I'll be there for you."

;f Political action in personal lives

In our personal lives we male psychologists might provide leadership to other men by joining acti vities that challenge sexism and gender stereotyping. Men's C-Ractivities, abundant on the East and West coasts, are barely visible in many sociocultural niches. Participation in the enclaves of traditional men - civic organizations, fraterni ties, sports booster dubs, veterans organizations - may offer possibilities to expose traditional men to role alternatives. Many psychologists have provided leadershipinanti -rape and anti-violence campaigns (Raven and Brotherf'eace). In our outreach efforts we should guard against a tendency to focus undue attention on those groups we know best: middle-aged, white, heterosexual men. We need to reach out to men across the life cycle by defining helpful roles in the lives of adolescent and aging men. We need to know more about how masculinity and social class interact, so we can be relevant to men across racial and ethnic lines, Despite our differences,

REFERENCES

Aries, .E. (1976). Interaction patterns and themes of male, female, and mixed groups. Small group behavior, 7, 7~18.

David, 0$. & Brannon, R. (1976). The forty-nine pgrcent

majority: The male sex role. Reading, MA:

Addison- Wesley.

Fasteau, M. (1975). The male machine. New York-Dell.

HUe, S. (1987). Women and love: A cultural revolution in progress. New York: Knopf.

Levant, R. (1992). Toward the reconstruction oJ masculinity.

Journal of family psychology,S, 379-402.

Pleck, J.H. (1980). Men's power with women, other men, and society: A men's movement analysis. In E.H. Pleck & J-H. Pled (Eds.). The American Man (pp 417-433). Englewood Cliffs, NJ: Prentice-Hall.

Solomon ... K. (1982). Individual psychotherapy and changing ma.scu1i.ne roles: Dimensions of gender-role psychotherapy. In K. Solomon & N.B. Levy (Eds.) Men in lransition; Theory and therapy. New York: Plenum.

Stem, T S. (1982). Men's groups. In K. Solomon & N.R Levy (Eds.) Men in transition: Theory and Iherapy. New York: Plenum.

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FEATURE ARTICLE

Relational Models of Development: Clinical Implications Judith V. Jordan

Traditional Western psychological theories of development ha ve emphasized the developmen t of "the separate self". This perspecti ve views the self as separated out from its context, a bounded and contained entity. Autonomy, individuation and separation are seen as the hallmarks of development; an increasing capaci ty to use abstract logic and a movement toward self-sufficiency characterize the maturation of the ideal Western self. Interest in relationships is secondary to primary interest in a molecular self.

This perspective, which honors people's deep need to establish and maintain connections with other people, also views isolation as one of the primary sources of suffering. Movement toward mutuality lies at the heart of relational development and ushers us out of isolation. Mutuality involves both affecting the other and being affected by the other; one extends oneself au t to the other and is also receptive to the impact of the other. Openness to influence, emotional availability, mutual respect and responsiveness characterize growing and growth-enhancing relationships. Empathy and concern flow both ways; in this process there is affirmation of personal

experience and transcendence of a separa te sense of self; one's sense of self is experienced as part of a larger relational unit.

In the past decade a shift to a different paradigm of self or 'being' has been suggested by several theory groups. In particular Jean

Baker Miller (1976), Carol Gilligan

(1982) and the Stone Center Theory Group (Jordanet al, 1991) havechallenged existing models of personal organization; these have been referred to as "self-in-relation" (Sur-

rey, 1984; Jordan and Surrey, 1986), tional development relational self (Jordan, 1985), "being

in relation" (Miller, 1984) or and ushers us out of relational-being (Jordan, 1991). This approach emphasizes the contextual and process factors in experi-

ence. Rather than a primary per-

spective based on the formed and contained self, this model stresses the importance of the intersubjective, relationally emergent nature of human experience. The movement of rela ting. of mutual initiative and responsiveness are the ongoing central dynamics in people's lives.

Movement toward mutuality lies at the heart of rela-

In therapy we work on helping the client develop mutually empathic and empowering relationships. Much of therapy depends on the development of relational resilience, the capacity to move back into growth-enhancing con-

nection following disconnection, All rela tionshi ps are characterized by movement in and out of connection: what characterizes problematic relatedness is that the pattemshave become rigid and lead consistently in the direction of disconnection and isolation. This perspective emphasizes that psychological isolation is one of the, if not ~ primary sources of suffering. Thus, an important aspect of therapy is bringing awareness to the patterns which take people out of growth-enhancing relatedness and providing a relational experience which allows for a sense of being connected, an opportunity to rejoin the human community. Therapy expands empathic possibility. At the same time it provides an opportunity to learn about how disconnections, shame, and isolation arise.

isolation

Rather than viewing people as primarily motivated by a need for self-sufficiency and personal gratification, a relational perspective acknowledges our deep need to establish connections with other people. This includes a desire to contribute to the well-being of other people. Growth-enhancing connections lead us away from the extremes of narcissistic grandiosi ty and depressive diminishment characteristic polarities in a society which stresses individual rather than relational values.

22

The development of empathic expansion invol yes moving into an understanding of the growth of "self and other" or "relationalawareness"; people

grow in becoming a part of relationship rather than a part from rela tionship, Empathy depends on a complex affective-cognitive process, building onemotionaI resonanceand leading to a more differentiated understanding of the other person's

experience and relationship. .

Most work on the importance of empathy in therapy has focused on the role it plays in increasing the therapist's understanding of the client. While the expansion of understanding which occurs through empathy is of central importance, in empathic moments the client also experiences

a sense of being "joined "With"; there .

is a consequent decrease in the

sense of isolation. Empathy also lessens the experience of shame, a sense that one is not worthy to be in connection. From a rela tional point of view, shame is the loss of a sense of "empathic possibility"; one does not believe that another person will be empathically accepting. One feels that one is flawed in some essential way, that one's very being is such that another person will be unable to be empathically present. Shame is most impor-

tantly a felt sense of unworthiness

to be in connection, a deep sense of unlovability, with the ongoing awareness of how very much one wants to connect with others. While shame involves extreme self-consciousness, it also signals powerful relational longings and awareness of the others' responses. Rela tionaI therapy works on the expansion of empathy for both self (self-empathy) and others.

Therapy offers clients an invaluable opportunity to heal the long range wounds of shame. They are finally heard. Their reality is acknowledged. Clients are trusted and become trusting. They have an opportuni ty to join in crea ting a rela tionship in which they can more fully represent their experience and find acceptance. In an empathic context, shameful experience is looked at freshly, with a view to understanding how they came to be, rather than with a view toward judgment. Validation of the meaningfulness of the client's responses provides essential support for self acceptance.

Healing pathological shame involves enhancing empathy for sel f and other and bringing the person back into connection in which empathic possibility exists. Relational a wareness, rather than preoccupation with self-development alone, lies at the core of this new approach and increasing capacity for connection becomes the hallmark of growth.

From a relational point of view, shame

is the loss ofa sense of

"empathic po ssibil ity".

Shame is a major impediment to connection for many people. In shame we have great difficulty trusting that the rejected aspects of ourselves will be accepted by another; therefore we disconnect from ourselves and from others .. Often we then move into an illusion of connectedness while our capacity for authentic relating is vastly diminished "With each aspect of ourselves that is excluded from or distorted in the connection. The possibility of empa thic mutuality begins to e1 ude us. When someone trusted and to whom we ha ve revealed ourselves more fully (i.e. the therapist) sees us in a more whole way, sometimes before we consciously decide to reveal the shameful parts of oursel ves, our capaci ty for self revelation and intimacy can be greatly enhanced .. To be "accepted" wi thout really being known is hollow and may contribute to a sense of false self or emptiness, but to be really seen and accepted is freeing and healing.

Therapy is a dialogue characterized by a process of mu tun I change

. and impact. Both therapist and

client are touched emotionally by each other, both grow in relationship, gain something from one another, risk something of themselves in the process; both are affected, changed, part of an open system of feeling and learning. There is significant mutuality. It is not a fully equal or symmetrical relationship; the client's subjective experience is put at the center of the work and there is an agreement to attend to the therapist'S subjective experience only in so far as it might be helpful to the client. But there is real caring in both directions, an important sense of mutuality, with mutual respect, emotional availability and openness to change on both sides.

Therapist and client move back and forth, with awareness, between disconnection and connection: in this process the client learns a great deal about relational possibility as well as about the specific ways that she or he disconnects and then moves back into "growth-in-OOlUlection". Active learning about how one goes about making and sustaining a relationship and what interrupts these integrative patterns is a powerfully growth-enhancing experience. In therapy the client has the liberating experience of being authentically with someone whom she or he can emotionally affect but who can still remain in growing and resilient connection. This goes be-

23

yond interpreting projections, or "working through" the transference; developing new relational patterns of mutual responsiveness and influence isat the core of emotional growth. And in therapy this is done in the context of growing awareness of the patterns.

As therapists, we at the Stone Center stress the development of relational awareness and an interest in the movement of relationship, not just attention to self and other. This involves increased attention to connection, disconnection, and resilient movement back into relationship. "Relational resilience" , the capacity to move back into connection in the face of disconnection and psychological suffering, is a skill that gets built on in therapy. Under what conditions do people move out of connection? Under what conditions are we able to move back into connection, experiencing a sense of interpersonal flexibility and relational efficacy? Therapy assists people in expanding relational presence, a sense of realness and contact with one's inner experience and theinnerrealiryof theotherperson. Morebroadly, it enhances the capacity for movement into a mode of relating, being present, responsive and capable of creative action.

Relational images, of self, other and relationship are altered as the capacity for self-empathy and empathy for others gTOWS. Old, distortingexpecrations which have led to withdrawal,

self-rejection, immobilization begin to shift as active cognitive-affective, relational learning takes place in the therapy.

This therapeutic approach depends on shifting from a paradigm of "separate self' to "relational being". Re-focusing on a psychology of rela nonship, inter-su bjecti vi ty and mu tuali ty demands a major re-working of values, goals and theory. While the importance of this shift has become increasingly clear in our understanding of women's experience, it is likely that this paradigm shift from the primacy of separate self to relational being will assist us in better understanding all human experience.

REFERENCES

Belenky, M., Clinchy, B.., Goldberger, N., and Mattuck, J. (1986) Women's Way of Knowing the Development of Self. Voice. and Mind. New York, Basic Books.

Gilligan, C. (1982) In a Different Voice. Cambridge, MA:

Harvard University Press.

[ordan]. (1985) The meaning of mutuality. Work in Progress, No 23. Wellesley, MA: Stone Center Working Paper Series.

[ordan.j., Kaplan, A., Miller, l.B.,Sliver, 1., SUITey,!. Women's Growth in Connection. New York, NY: Guilford Publications.

Miller, J.B. (1972) Toward a New Psychology of Women.

Boston, MA: Beacon Press.

FEATURE ARTICLE

Shame and the Tenacity of Depression

Michael Greenwald

When our clients are experiencing depression, they are likely feeling negatively about themselves, their lives, and their future. Strong feelings of guilt and worthlessness are often prominent features of the symptom picture. In addition, these clients often feel 'bad' for feeling 'bad'. Part of their guilt and self-condemnation stems from the way in which they perceive they are affecting others. They see themselves as a thorn in the side of the world. This perception of their effect on others usually consists of seeing themselves as a burden, a nuisance, a problem, and as negatively affecting the lives of those around them by virtue of their being depressed. This

24

state of affairs positions the client for feelings of shame and humiliation, especially if the client is predisposed to these types of self-experiences by being narcissistically vulnerable. This may then exacerbate the depression. Furthermore, this secondary response to the depression, the shame for feeling depressed, may function to prolong the duration of the depression in a number of different ways.

Shame may deepen a depression by causing the client to feel even worse about him or herself. They see themselves as "bad" or "no good" in the first place, and then feel shame for feeling that way about themsel ves and for how they percei ve it affects others around them. They may say to themselves, "I'm so miserable and I'm such a lousy person for feeling so miserable and for upsetting those around me and causing all these problems. See, I really am no good," In this

The treatment of

depression exacerbated or maintained by feelings of shame

has cognitive-

behavioral and psychodynamic

imp lications.

fashion the shame for being depressed leads to further negative self-evaluations, thus adding fuel to the downward spiral of depression. Furthermore, shame may potentiate fears and expecta tions that the person will be left by someone close to them because they are depressed, and the anticipation of this impending loss may exacerbate the depression as well.

Another way that shame may lead to protracted depression is through the use of depression as a defense against the experience of feeling shame. The constricted affect associated with the depression may partially shield the person from the experience of the shame they may

have for feeling depressed. So the

depression may ha ve the dual function of leading to feelings of shame as a secondary response to depression, and protecting the individual from the distressing internal experience of shame by deadening their affective experience. The difficult and painful work of dealing with the feelings and beliefs that are at the core of the depression would typically give rise to feelings of shame if present. That is to say, dealing therapeu tically with the depression has the internal effect of

stimulating the emergence of shame for being depressed in the first place. As the client starts feeling a broader range of affects, shame may be included. Therefore, in order to avoid the experience of shame, the client, probably out of awareness, maintains the depression as a form of protective cloud or fog.

The trea tment of depression exacerbated or maintained by feelings of shame has cognitive-behavioral and psychodynamic implications. The issue of a client having a predisposition to shame by an underlying narcissistic vulnerability could be investigated and illuminated through psychodynamic inquiry. This exploration would likely reveal the early genetic underpinnings forming the basis of the current shame. Particular attention ought to be paid to the way in which the client's affects, especially those pertaining to anger and sadness, were responded to in the early care-giving surround. The experience of same within the context of

relatedness may then be seen to have laid the early groundwork for the current shame-based reactions to the depression. The acceptance and understanding from the therapist vis a vis the clien t and his or her in ternal experience serves to discon firm transference expectations of shaming and to provide a1 terna ti ve ways of responding to oneself.

With respect to a move symptom-focus, cognitive work on the underlying beliefs relating to the shame is often beneficial. This would include cognitive restructuring directed at the shame reaction. The shame component in depression

has inherent within it some key maladaptive beliefs and thinking errors which could be discovered with the client and then evaluated. For example, the client may be operating on the belief that he or she is "bad" forbeingdepressed; that the depression makes him or her an intolerable burden on others and that they will never be forgiven. The client may consider themselves a failure for becoming depressed, or expect others to leave them. These and other beliefs may lead to feeling of shame

in some clients which could exacerbate the depression, as discussed earlier.

In summary, the presence of shame with depressed clients may have an important role in the maintenance and exacerbation of the condition. This reaction on the part of the client to their emotional state can be explored, understood, and dealt with therapeutically to the benefit of the client. The diminu tion of the element of shame wi th the concomi tant development of self-understanding and acceptance of one's affectivestates would likely facilitate the improvement of depression.

Case Study

"Bill" is a thirty year old, Caucasian male, who was seen for marital therapy. His family of origin was reportedly one in which feelings were generally not expressed. The unconscious credo of the family was that the members had to deal with emotional issues on their own, and that looking

25

to others for help or understanding was a violation of the implicit family rules. Bill described his early home life as lacking in validation, support, praise, or recogni tion for the children. It was not until his teens, when he discovered an aptitude for sports, that he felt some degree of acceptance and value within his family and with respect to himself. He later became very involved in body building, eventually winning a state championship. Much of his self-esteem was thus dependent on his physical appearance and abilities.

Bill and his wife "Lisa" had been married for six years and separated for four months prior to beginning treatment. In addition to his marital discord, Bill was clinically depressed, having reported the following symptoms in an interview: depressed mood, loss of interest and pleasure in his usual activities, weight fluctuations, in termi ttent insomnia, periods of both psychomotor agitation and retardation, lowered energy level, feelings of worthlessness, difficulties thinking and concentrating, and thoughts of suicide. He denied having a current plan or intent to kill himself, and agreed to contact me prior to acting on any thoughts of harming himself.

It appeared as though his depression was related to the problems in the marriage, and visa versa, such that there was an interaction between his depression and the marital problems. Specifically, Bill felt like a failure for having marital difficul ties, and fel t as though he was letting his wife down by being depressed. In this way, the presence of marital conflict added to his depression.

Conversely, Bill's depression added to the marital conflict. Bill's shame for being depressed created more distance in the already strained relationship with his wife, necessitating that these feelings on his part become a focus during the couple sessions. A few sessions into the treatment, his wife reported feeling more ready to move forward in the marriage, sta ting that she felt more secure and had forgiven Bill for various transgressions. She was starting to pressure Bill to move back in with her.

Bill expressed that he was in a very different place emotionally than Lisa with respect to the marriage. While he sta ted the same goals as she, getting back together and making the marriage work, he did not feel ready or able to move forward at her pace. In sessions Bill would describe his view that it wasn't 'fair' for Lisa to ha ve to be with him before he was 'better'. This notion was investigated and illuminated in sessions to reveal Bill's belief that while he was depressed, he was terrible to be with, that Lisa

26

didn't deserve to be with someone so awful. He was convinced that he must therefore be 'cured' of his depression before he would once again be suitable material for the marriage. As he put it, "I need to clear this up and be 110% before I can thinkaboutgetting back together with her." Thus, Bill's notion of "cure" was to be absolutely over his depression and completely free of symptoms.

Further discussion of Bill's belief system with respect to his marriage and his depression showed tha t it was at least partiall y shame-based. Bill felt shame for being depressed, believing it made him unworthy and created an unfair burden for his wife. He felt 'bad' both for feeling depressed in the first place and also for being an 'unfit' marital partner. These feelings interacted in a cyclic fashion to deepen his depression and to cause continuing distance in his marriage, which lead to further exacerbation of his depression. Specifically, Bill's shame for feeling depressed directly contributed to the negative conditions contributing to his depression, as discussed above. In addition, he then perceived himself as being a negative influence on his wife, causing him to withdraw and isolate. This experience of loss associated with the marriage aggravated his depression even further.

Bill's depression was alleviated to some degree dearly on in treatment by addressing these processes and patterns through a combination o. cognitive and psychodynamic inquiry. His increased awareness of his feelings regarding himself, his depression and his place in the marriage was beneficial to him. He showed signs of relief and increased self-acceptance after discussing these ideas and feelings. Also helpful for Bill was his experience of his wife's reactions in the sessions as she listened attentively to the articulation and cognitive evaluation of his depressogenic, shame-based self-beliefs. She was frequently surprised and responded to Bill with empathy and deeper understanding, as well as a sincere desire to help him. Lisa's acceptance and understanding was unanticipated by Bill, given his family history. His wife's responses seemed to disconfirm some of his expectations and perceptions of himself as a 'bad' person and a burden, leaving him relieved and more hopeful. With these 'in vitro' experiences with his wife combined wi th our cogni ti ve restructuring work on his various thinking errors and underlying beliefs, Bill began to make slow but steady progress toward alleviating his depression. A prominent feature of Bill's depression was his experience of shame. Dealing with this issue in the therapy sessions served to remove an air stacIe which had been maintaining and exacerbating his depression.

FEATURE ARTICLE

A Marital Couples Communication Program Based on Gender Socialization Theory-

Ronald F. Levant

Theoretical Basis and Rationale:

Gender Socialization Theory

Most existing marital communication programs which are preventative in aim are based on therapeutic theories, whether a single theory (such as client-centered, Adlerian, or behavioral) or an integrati ve combina tion of theories (such as relationshi p enhancement). Many of these programs have been subjected to outcome research, and have demonstrated a reasonable degree of efficacy.

Psychotherapeutic theories, which are predica ted on the existence of pathology, and designed to remedia te dysfunction are not an adequa te foundation for the development of preventive programs. Preventive programs, are, after all, designed for people who by definition are not yet dysfunctionaL I propose instead that preventive programs be based on life span developmental theory which takes into account stages of the family life cycle.

When applied to the problem of marital couples communication, we should direct our attention to that section of developmental theory which describes the effects of gender role socialization. An examination of this developmental dimension illuminates the ways in which men and women have _different psychological skills and skill deficits (or different skill profiles), and, furthermore, differing ways of understanding the world (or frames of reference), by virtue of their gender role socialization during childhood.

Due to time limitations, I will not review the effects of gender role socialization on the psychological skill profiles and frames of reference of men and women. Since I have described this material in detail elsewhere (Levant, 1992), I will summarize the main points.

Gender-Based Skill Profiles

Gender role socialization produces men and women who have nearly opposite skill profileswomen are likely to be adept at emotional skills that build intimacy, such as empathy, emotional self-awareness, emotional express! vity, and nurturance: whereas men are more likely to be adept at the skills of survival, provision, and protection, such as problem-solving, assertiveness, staying calm under fire, and providing for others. Given the bifurcated nature of gender role socialization, it also should be noted that each gender tends to lack those skills tha tare more the province of the other gender. Hence men tend to lack the skills of emotional empathy and emotional self-awareness; whereas women tend not to be trained in the skills of instrumental problem solving or assertiveness

Gender-Based Frames of Reference and Communication Styles

Gender-based differences in frames of reference tend to break out along the "InstrumentalExpressive" axis, with males being more instrumental and females being more expressive. Another useful dichotomy is David Bakan's "Agency-Communion" distinction, with males being more agentic and females being communitarian. These differences in frames of reference are readily observed in gender-based differences in communication styles. To illustrate, consider a couple who has requested couples therapy, complaining of communication problems. Ask the wife what the communication problems are, and you will hear: "He never talks to me. He never lets me know that he's thinking or feeling. He's just such a clam." Ask the husband and you might hear: "She just never

1. An earlier l1ersion of this paper was published in Men's Studies Rel1iew, Vol. 9 #2, pp. 15-20. Reprinted by permission.

27

The skills-training part of the program occupies the first four sesThe time has come sions,inwhichthemenandwomen meet in separate groups, each led by the same sex co-leader. The skills-training sessions are structured, and follow a specific format: (1) Introduction and definition of the skill in a brief lecture; (2) Dem-

onstration of the skill using video-taped and live examples; (3) Discrimination training, aimed at improving participants' ability to discriminate good versus poor use of the skills. For this, the instructor and

one of the participants role-play several husband-wife interactions, demonstrating varying degrees of skillfulness, while the other participants rate and discuss the role-played examples; (4) Practice of the skill in the role-play exercises, using video for immediate feedback; and (5) Consolidating the skill and transferring it to their interaction with their spouses through homework exercises. The skills that each gender learns are outlined below.

stops talking. I don't know what she wants me to say. If there was something to tell her, I would."

To further illustrate this point, consider the wife who asks her husband how his day went: "Fine." From his point of view, he didn't sell $100,000 worth of merchandise, he didn't get fired, nobody died ... nothing happened. Yet his wifehoped to get a response more like the one she would have given: ''I got in early and found a message on my E-mail indicating that my proposal had been accepted, and I was just thrilled. That carried me through the morning, but then I learned that Sally is getting laid off, and so I was qui te down for most of the afternoon. I brightened up when I thought of seeing the kids after work."

The curriculum thus aims at: (a) skill development - so that individuals can function better in relationships; (b) the enhancement of perspective-taking ability - so that men and women will understand more completely their partners' frames of reference; and (c) the development of the ability to see oneself in perspective, so that men and women will more clearly understand the relative nature of their basic frames of reference. nus latter ability is known by the Piagetian term "de-centering", which refers to the ability to remove oneself from the center of one's view of the world.

Skills-Training

This issue of gender-based differences in frames of reference and communication, popularized in the best selling book, You Just Don't Understand, which coined the term "gender-lects" is also feted in the funnies. Here are a few examples:

Amy (instrumen tal-expressi ve), Kathy (communication), Dilbert I, Dilbert 2, Motley 1, Motley 2,.

to offer gender-

aware counseling programs for

couples.

The Intervention Program

In conjunction with a group of graduate students, I designed a preventive psychoeducational group program for marital couples based on gender socialization theory. This is an eight week program, which meets once a week in the evening for 3 hours, and accommodates 4 to 6 couples. It is both didactic and experiential, utilizing in-class role plays with video playback, as well as homework assignments. Optimally the group is led by male and female co-leaders.

This program has three aims. The first is to remedy the psychological skill deficits that tend to result from gender role socialization, through skills-training. The second is to help men (or women) learn about the other gender, in terms of the differences in gender role socialization, and the resultant different frames of reference and styles of communication. The third is to help men (or women) learn a bou t themselves, in order to pu t their own, gender-based ways of knowing into a larger perspective.

28

The skills that men need to learn:

1. Emotional sensitivity and empathy; emotional self-awareness and expressivity. (To reduce men's dependence on women as expressive leaders).

2. Ability to be comfortable with mature dependence and emotional closeness. (To overcome fear of loss of sense of self in close relationships).

3. Ability to nurture.

4. Reduction of boyhood sense of entitlement, passive-aggressive behavior, violence and au~ thoritarian rigidity.

The skills that women need to leani:

1. Instrumental problem-solving, and assertiveness. (To reduce women's dependence on men as instrumental leaders),

2. Ability to tolerate mature independence.

3. Ability to be authoritative.

4. Reduction of nagging, complaining, pressuring, and manipulating (of husbands); and of overprotection and overcontrol (of children).

Perspective-Taking

This part of the program builds on the foundation laid by the skills-training, which hopefully has resulted in some improvement in men's listening and expressive communicational skills and in women's problem-solving and assertiveness skins, and an enhancement understanding of the effects of gender role socialization for both genders. Perspective-taking r~ quires two sessions, and includes husbands, wives and bothco-Ieaders, The forma tis theme-centered discussion. Themes that are discussed include: (1) What is gender role socialization, and how do childhood experiences differ for men and women? (2) What are the positive and negative effects of gender role socialization? What should be changed, and what should be retained? (3) Do men and women really speak different dialects (or IJgender~lects")? What can be done to pro~ mote improved inter-gender communication? Participants experience a lot of personal sharing in regard to the effects of gender role socialization on their lives, and the beginnings of some very meaningful inter-gender dialogue, where men and women started to really teU each other wha t it was like to grow up" gendered". Some of the aims of this part of the program are outlined below.

What men need to learn about women:

1. That there are things of value in those behaviorstraditionally considered feminine. (To reduce the fear of feminity).

2. Women's focus on process, in contrast to men's focus on outcome; women's need to discuss, as a way of connecting, in contrast to men's orientation to solve problems.

3. How women show their love (through daily interaction).

4. Women's timetable about marriage, family.

What women need to learn about men:

1. Men's emotional socialization, and the resultant lirni ts to their express! ve, empa thic, and nurturing abilities.

2. Men's focus on outcome, and on solving problems.

3. How men show their love (by providing, protecting and doing for the other).

4. Men's sense of timetable regarding marriage and a family.

De-Centering

The last part of the program requires two ses~ sions, and includes husbands, wives and both co-leaders. The format is open discussion. At this point in the program skills have been irnproved and par ti cipants have developed theability to see things from the other gender' s perspec~ five. This latter process is aided by the group format, which affords the opportunity to learn from members of the other gender to whom one is not married, and hence, not emotionally en~ tangled .. With this as a foundation, de-centering occursas a direct result of continued discussion. Participants develop the ability to see thernsel ves in perspective, and come to more clearly understand the relative nature of their basic frames of reference. Some of the aims of this part of the program are outlined below.

29

What men need to learn about men:

Conclusion

'l, That there are limits to those things that men are taught to value (such as stoicism and success).

2. That there is a problem. That is, that male role socialization may limit men's fulfillment and even shorten their lives.

What women need to learn about women:

1. That much of a women's sense of helplessness is learned (and can be unlearned).

2. To place a higher value on those attributes that are traditionally feminine.

The time has come to offer gender-aware counseling programs for couples. Adults are not well prepared for the complexities of coping with marriage. In fact, gender socialization theory suggests tha t the opposi te may be true: Men and women are reared on separate gender tracts, developing opposite skill profiles and divergent frames of reference. Couples today need a fighting chance to make their marriages work. A gender-aware group program that offers couples the opportunity to develop skills, the ability to take the other person's perspective, and the ability to put oneself in perspective provides that opportunity.

FEATURE ARTICLE

Therapeutic Aspects of a Weight Lifting Program with Seriously Psychiatrically Disabled Outpatients

Mirella P. Auchus

Traditional group psychotherapy seeks to faeili- that involved leading a weight lifting group with tate interpersonal and social relations, increase psychiatric outpatients at the same facility. The problem solving, foster responsibility and purpose of my research project was to examine cornmittment, and enhance self-esteem and the effects of physical exercise on physical and self-concept among group members. I have ob- menta1 health. Interestingly, I began to observe served that these group processes can also occur that all of the therapeutic progress that I was within the context of a non-traditional group - attempting to foster in my psychotherapy group, a weight lifting group. I suggest that a weight was surfacing spontaneously in my weight liftlifting group may produce emotional growth ing group - the "non-therapy" group! As I and improved interpersonal relations in a rela- studied the literature on conducting group lively shorter period of time compared to tradi- therapy with seriously disabled psychiatric pational group psychotherapy. In this article I will tients, I realized that the group processes often describe how a weight lifting group program discussed, such as "working alliance", "bondevolved into a very therapeutic group experience ing", "social role transformation" (Wolkon & for seriously psychiatrically disabled outpatients. Peterson, 1986), "parallel play" (Stone, 1991),

and the therapist's role as "cataylst, reality tester My observations of the therapeutic value of a and educator" (DeBossett, 1991), were evolving group weight lifting program began when r was quite naturally in the weight lifting group! In leading a psychotherapy group with seriously addition, discipline, committment, responsibildisturbed psychiatric outpatients in a ity, problem solving, learning, and interest in psychosocial rehabilitation program. Concur- self-care also were developing rapidly in the rently, I was cond ucting a clinical research project weight lifting group, although these were not the

30

and serve as models for identification and admiration" (p. 66). As the weight trainer, I assumed this role in the weight lifting group (analogous to a group therapist). I taught, corrected, and reinforced members for their exercise performance. Not long after commencement of the group, it became evident to me that I had become a role model for many group members. Members began to emulate my behavior by instructing, correcting, and reinforcing one another's efforts and accomplishments. Members began to "refuel" one another by offering encouragement and support. In response to the encouragement she received from other group members, one memberstated,"Youallmakemefeelgood, telling me

how good I'm doing." The weight

lifting group created an environThe weight lifting ment that nurtured and enhanced members' abilities and did not focus on disabilities. The group was safe, supportive, and comfortable and provided a "holding environmerit" for members. (Winnicott, 1965). The physical experience of lifting weights and receiving assistance in "holding" the weight, paralleled the psychological experience of being held (Kaslow & Eicher, 1988).

group created an

environment that nurtured and en-

hanced members'

abilities and did

not focus on

disabilitie s,

foci or goals of the group. Meanwhile, I was struggling just to achieve a consistent group of members in my psychotherapy group! The "therapeutic" benefits of weight lifting, a "non-traditional group therapy", were clearly apparent.

DeBosset in the article Group Psychotherapy in Chronic Psychiatric Outpatients: A Toronto Model (1991), discusses the concept of a working alliance, the positive connection between therapist and patient that enables them to work together in therapy. DeBosset refers to Bordin's (1979) conceptualize tion of this term. According to Bardin, there are three aspects of a working alliance: 1) agreement on goals, 2)

assignment of tasks, and 3) development of bonds. These three aspects help build a working alliance between therapist and patient. The weight lifting group readily encompassed these three components. The weight trainer (myself) and each member easily agreed on goals. The goals were for each member to participate in weight lifting and gradually improve his/her exercise capacities by increasing strength and endurance. Each member's task in-

cluded engaging in pre- and post-exercise stretching and performing the weight lifting exercises as instructed. The concrete nature of weight lifting made it easy to identify goals and tasks of the group. The development of bonds between myself and group members was facilitated by my frequent reinforcement of members' exercise performance. Not only did bonding easily develop between myself and each member, bu t also among the group members. The group activity of weight lifting readily facilitated bonding. Group members participated in an acti vity where they helped each other by alternating as "spotters" (i.e. assisting each other in the execution of the exercise). Furthermore, spotting enhanced the development of trust, since members had to depend on one another for assistance when they encountered difficulties lifting the weights or performing the exercise.

DeBossett (1991) described therapists as "nurturing individuals who protect, heal, and refuel -

DeBossett (1991) also describes the role of the group therapist as a "catalyst, reality tester and educator" (p, 68). The group therapist encourages patients to share life difficulties and frustrations, focus on positive aspects of themselves, and learn about their illnesses. I assumed. an analogous role as a weight trainer for the group. I served as a "catalyst" for increasing members' confidence and self-esteem by challenging and encouraging them to increase the number of repetitions of the exercise and to lift heavier weights. In response to being challenged to increase herrepeti tions, a member sta ted, ''I didn't think I could do that many repetitions and then you say I can, and I do it!" Similar to a group therapist, I also functioned asa "reality tester and educator". I actively corrected member's exercise technique, taught them correct exercise form and spotting techniques, and educated them about their muscles and other topics of concern to the group members. Members eagerly and readily absorbed this information.

31

1993 APA Co

DIVISION 29 AWARDS

Herbert Freudenberger accepts APA's Distinguished Professional Contributions to Applied Psychology as a Profession Award.

Dona./d K. Freedheim is presented a plaque in appreciation of ten years as editor of the journal Psychotherapy. Making the presentation on behalf of DiuisiDn 29 is Reuben Silver, TWt president of the division.

Awards chair, Reuben Silver presents the Division 29 Distinguished Psychologist AUXlrd to Patrick Deleon.

32

Graduate Student Reception from 1 to r: Tommy Stigall, RelL Silver, Louis Castonguay, Abraham Wolfe and Gerald Kood

vention Highlights

DIVISION CONVENTION ACTIVITIES

Nerine C. Johnson and Alice Rubenstein at AP A Board Meeting.

Dioision 29 Executive Committee from I to r:

Tommy Stigall, Alice Rubenstein, Patricia Hannigan-Farley, Reuben Siloer, Miltty Canter and Linda Campbell. Seated is GeTilid Koocher, president.

Enjoying the IIwlITds ceremony at AP A lire from I to r: DOnilid Freedheim, Lindll Campbell, Alan Campbell and l.ouis Castonguay.

33

"exercise" or "weight lifting group". Again, the concrete nature of weight lifting facilitated the acquisition of a new skill and ultimately expan~ sion of members' self identities. This activity helped to "enlarge clients' expectations of themselves" (Cnaan, Blankertz, Messinger, & Gardner, 1988, p. 64) as it enabled members to see themselves capable of growth and progress.

In Stone's (1991) article, Treatment of theChronically Mentally I11: An Opportunity for the Group Therapist, he discusses the dynamics of group therapy with the chronically mentally ill. He draws a parallel between the dynamics involved with children playing in a sandbox and patients participating in group therapy. According to Stone, group mernbers engage in "parallel play, with little personal interaction" (p. 15), as young children do when they play together in a sandbox (Stone 1991). For example, young children playing in a sandbox are ir sume new tasks and dose physical proximity however each child is independently involved in his/her own project anc has little interaction with other children in the sandbox. Similarly in the early stage of group therapy members may not interact mudamong themselves, but instead, primarily interact with the group leader. Analogous to young children in a sandbox who eventually decide build a sandcastle together and thus, begin interacting with one another, patients also learn "play" or interact with one another by "building a common project" (p, 15). For example, during a group therapy session, the group may focus 0:helping a member deal with a specific probler. he or she is facing. The group engages in ~ unified effort to solve the problem, thus, togethe they work on "a common project" and berinteracting.

Within a therapeutic group there usually exists a "core group" (DeBossett, 1991) which consists of a small subgroup of members that are consistent group attenders, have strong bonds with each other and thus, "function as stabilizer and catalyst" (DeBossett, 1991, p. 69) for the rest of the group. A "core group" quickly developed and was readily identifiable within the weight lifting group. These core members attended the weight lifting group regularly, reminded and encouraged other members to attend, and were very committed to participating in the group.

Wolkon and Peterson (1986) discuss the concept of "social role transformation" (p. 45) among individuals with serious psychiat-

ric disabilities. According to these authors, psychiatric clients have a limited self-identity. Often they are solely identified as a "patient" or "ex-patient" and "are given the status of a non-person by society" (p, 46). Social role transformation involves the evolution of this passive, negative social role into an active, positive social role. It involves helping the client expand his/herrolein life and self-identity. Wolken and Peterson proposed six steps in this role transformation.

The last step in this transformation involves to "incorporate the new role into one's self-concept" (p. 52). In other words, as psychiatric patients acquire skills, they become motivated to assume new tasks and responsibilites, and by doing so, expand their self-identity. According to Wolken and Peterson, patients "internalize" these new skills and these skills become incorporated into their self-concept. On a microcosmic level, the "incorporation of a new role into one's self-concept" was certainly facilitated and demonstrated in the members of the weight lifting group. Each group member learned to perform a new activity and develop a new skill - weight lifting. Members observed improvement in their physical strength, endurance and appearance, and eventually performed this newly acquired skill independently, without any instruction. Each member incorporated a new role, that of "weight lifter", into his/her self-concept and no longer was subjected to solely identifying him/ herself as a "patient". Members could identify themselves as "weight lifters" belonging to the

34

... as psychiatric

patients acquire skills, they become

motivated to as-

responsibilities, and by doing so, expand their self-identity.

Stone's (1991) description of group dynamic, such as "parallel play" and "[playing] ... "Wi::one another in building a common project" :: 15) were dynamics readily observed in the weig:lifting group. First, members of the weight lifti:::.. group participated in "parallel play" by liftir-= weights together. They were in close physic, proximi ty of one another, yet they had the op ~

of as little or as much personal interaction as they desired. Second, members learned to "play" together by spotting one another, working in dyads or teams of three. "Playing" was facilitated by spotting, because spotting fostered interaction among group members in a non-threatening way (physical interaction may be less threatening than verbal interaction). Last, the "common project" that all group members engaged in was building muscles and improving muscular strength and endurance. This was the primary goal for everyone in the group. Thus, because of it's physical nature, Stone's description of the way in which a therapy group may be conceptualized was easily demonstrable in the weight lifting group.

In addition to the above mentioned processes, there were other achievements

observable in the weight lifting

group. Weight lifting enhanced structure and discipline, responsibility, committment, problemsolving and teamwork for the members. The group provided structure and discipline, because there was a predictable sequence of events and routine that occurred in each session: signing in,

pre-exercise stretching, weight lift-

ing, post-exercise stretching, journal writing, clean up and refreshments. Members readily adapted to and adhered to this structure. I believe the ability to respond to structure and discipline was a particularly important achievement for members, since many of them had not experienced much appropriate structure or discipline in their lives before.

attend the group and encouraged other members who were not part of the group to join the group, (some of these eventually did join the group). The group afforded members "the experience of belonging to a group" (Yalom, 1983, p. 44), and being accepted and useful (Yalom, 1983). In his book, Inpatient Group Psychotherapy (1983), Yalom clearly describes the significance of this experience, "Cohesiveness, - the sense of 'groupness', of being accepted, of being a valued member of a valued group - is the group therapy analogue of 'relationship' in individual therapy" (p.44). This was a valuable experience for members, since individuals who suffer from serious psychiatric disabilities often do not have a place where they "fit in". Thus, they have limited opportunities for acceptance, usefulness and close relationships (Yalorn, 1983). These are factors

that contribute to positive self-esteem. Also, thegrouphelped members develop problem solving abilities. For example, given the physical limitations of the weight lifting room, at times we encountered some minor difficulties involving a lack of space and or equipment. However, members worked together and creatively

solved these problems, without having to involve me in the problem solving process!

The interest in health and self-care

began permeating other aspects of

members' lives.

The weight lifting group fostered sharing of responsibility. For example, members spontaneously took the initiative to lead pre- and post-exercise stretching, a task that I originally performed myself. I no longer needed to lead stretching and could observe con ten tly members competently performing this function. Members also assumed the responsibili ty of setting up and putting away items in the weight room and obtaining refreshments for the grou p upon completion of each session.

The weight lifting group also afforded the opportunity for members to become interested in heal th related issues. Members began inquiring about nutrition and healthy eating. One group member commented, "I'm so glad I'm learning so much about eating. When you grow up in a family that's used toa lotoffat, you don'tknow," Some members began practicing both exercise and healthy eating habits at home. In fact, one member of the group creatively found items at home that simulated exercise equipment. This enabled her to exercise at home, in addition to in class. One day another member informed me, "I do fifty sit-ups a night!" The interest in health and self-care began permeating other aspects of members' lives. They independently were making healthy lifestyle changes.

Most importantly, the weight lifting group fostered teamwork and camaraderie among members. By it's very nature, weight lifting required

35

The weight lifting group enhancedcommittment among members. They reminded One another to

members to work in teams and pairs and help one another with exercise technique and performance. Group camaraderie was apparent as members genuinely encouraged each other during sessions.

The observations made of this non-traditional group have implications for group work with the seriously psychiatrically disabled. Perhaps a structured, tangible activity (like weight lifting) is ideally sui ted for enhancing interpersonal relations, discipline, and expanding self-concept in this population. A group that focuses on both individual and group goal-directed acti vities such as weight lifting, may reap great interpersonal and social benefits in a relatively short period of time. This type of "group therapy" can foster increased self-esteem, problem solving, role expansion, improved interpersonal relations, responsibility, discipline and committment. A structured, concrete group activity that offers opportunity for individual growth, within the context of a team approach, appears ideally suited for producing emotional and social development in this population.

REFERENCES

Bordin, E. S. (1979). The generalizability of the psychoarslytic concept of the working alliance. Psychotherap: I Theory, Research and Practice, 16(3), 252-260.

Cnaan,R.A., Blankertz, L.,Messinger, K. W., & Gardner,]. (1988). Psychosocial rehabilitation: Toward a definiti Psychosocial Rehabilitation Journal, 11(4), 61-77.

DeBossett, F. (1991). Group psychotherapy in chronic psy atric outpatients: A Toronto model. Internationalloc:-~ nal of Group Psychotherapy, 41(1), 65-78.

Kaslow, N. J., & Eicher, V. W. (1988). Body image therapy: combined creative arts therapy and verbal psycr therapy approach. The Arts in Psychotherapy, ~ 177-188.

Stone, W. N. (1991). Treatment of the chronically mentally An opportunity for the group therapist. Internatia:", Journal of Group Psychotherapy, 41(1),11-22.

Winnicott, D. C. (1965). The maturational processes and 1 facilitating environment. London: Hogarth Press,

Wolken, G. H., & Peterson, C. L. (1986), A conceptual fno. work for the psychosocial rehabilitation of the chrca mental patient. Psychosocial Rehabilitation IoumaJ,~ 43-55.

Yalom, 1. D. (1983). Inpatient group psychotherapy ..

York Basic Books, Inc., Publishers.

FEATURE ARTICLE .

The Ethical Practice of Psychotherapy: Impact of the Newly Revised Ethical Principles and Code of Conduct

Jeffrey E. Barnett

t 3

Psychologists have long been aware of the need for codified guidelines and standards which provide guidance for practice. These guidelines ha ve set minimal standards for professional practice as well as aspira tional goals for psychologists to strive to achieve. Numerous changes in these standards have occurred from AP A's first set of standards (AP A, 1952) through the present time. This article provides a brief overview of recent changes in the Ethical Principles of Psychologists and Code of Conduct (APA, 19992) which have an impact on the practice of psychotherapy.

Several additional areas have been added to this new set of standards which reflect changes in both psychology and in our society. Several standards reflect a greater sensitivity to the misuse of the psychotherapist's influence, taking steps to avoid harmful or exploitative dual rela-

36

tionships, and working more to establish s~ dards for appropriate treatment and profess] practice.

One major change from our previous e standards (AP A, 1990) is the prohibition aga:; sexual intimacies with former therapy patier We now have a standard which absolutely F" hibits this only for a period of two years a: therapy has ended. After that period a psyc - gist may only enter into such a relationshiz seven specific factors are considered and psychologist can then justify entering into s relationship. This justification must demo that entering into such a relationship is ncr ploitative and not contrary to the welfare best interests of the other party. This is s::.. controversial area as it may prove diffie: objectively evaluate those seven factors. ~.

Once again, the burden rests on the psychologist to justify that entering into such a relationship is neitherclinically contraindicated nor exploi ta tive. While this type of dual relationship may at times be necessary if patients are to have access to treatment great care must be taken to avoid exploitation or harm. Setting a reasonable value in advance on the goods or services offered may seem to be a simple solution, but several pitfalls exist. For example, what if a patient owns an office cleaning service? A reasonable fee is agreed upon for that service and both psychotherapy and regular cleaning of the therapist's office begin. What if the psychotherapist is not pleased with the quality of the cleaning? What if the cleaning is not performed on schedule? What if

cleaning solution stains the carpet? Numerous things might go wrong which could negatively impact on the therapy relationship

To be a functioning and on the psychotherapist's abil-

member of a com- ity to maintain objectivity. One must also consider the clinical impact of entering into a business relationship with a psychotherapy patient. Additional steps may ha ve to be taken to protect the confidentiality of other patients' records should a patient have increased access to a psychotherapist's office.

gument might be made that any psychotherapist who is considering such a post-therapy rela tionship could not objectively evaluate these factors because of his or her own interests and needs. Clearly, appropriate consultation as described by Adler (1988) would be helpful in making such decisions. The primary issues here, as elsewhere throughout these ethical princi ples, remain welfare of the consumer, as well as avoiding exploitation, harm, and misuse of the psychotherapists's influence.

An additional significant change in these newly revised ethical principles in vol ves the acceptance that in some settings certain types of dual relationships are often unavoidable (Standard 1.17, Multiple Relationships). In es-

sence, itis now acknowledged that

certain incidental and remote rela-

tionships often are unavoidable in many settings such as rural communities. To be a functioning member of a community both on a social and professional level it is often impossible to avoid all dual relationships.

munify both on a social and profes-

sionallevel it is often impossible to avoid all dual

Psychologist are cautioned to be sensitive to the potential of such relationships for impairing one's objectivity, interfering with the psychotherapy process, or potentially leading to exploitation or harm. Psychologists are warned

against entering into such relation-

shi ps when one or more of these condi tions exists and should they arise, steps should be taken which reflect a concern for the patient's best interests (p. 1601).

re lations hips.

An area of change stimulated by the Federal Trade Commission's concerns over fair and open access to treatment services includes the standards on advertising and public statements. While testimonials from current psychotherapy patients or persons who are otherwise vulnerable to a psychologist's influence are not allowed, psychologists may now solicit testimonials from former patients (Standard 3.05, p. 1604). Addi~ tionally, APA's agreement with the PrC stipulates that APA may not restrict psychologists from making public statements about the comparative desirability of services offered; from making public statements claiming or implying unusual, unique, or one-of-a-kind abilities; or making public statements likely to appeal to a patient's emotions, fears, or anxieties concerning the possible results of obtaining or failing to obtain offered services (APA, 1992). However, specific guidance for engaging in ethically ap~ propriate practice while carrying out such practices is provided in Standard 3.03 A voidance of False or Deceptive Statements and Standard 3.06 In-Person Solicitation. Again, care to avoid exploitation, harm, and undue influence is stressed

37

Another acknowledgement of the realities of many communi ties and settings is the addition of Standard 1.18 Barter (with Patients or Clients). This standard acknowledges that for some psychotherapists, if they do not accept the exchange of goods for services, it could Significantly limit many potential patients' access to treatment with qualified professionals. Specific guidance is pr~ vided which sets minimal standards for engaging in this practice. However, psychologists are cautioned to avoid this practice because of the " .. .inherent potential for conflicts, exploitation, and distortion of the professional relationship" (p. 1602). Bartering for services is onI y allowed if it is not clinically contraindicated and the relationship is not exploitative.

for psychotherapists contemplating engaging in such potentially harmful practices. Finally, the FTC agreement has stipulated that AP A may not prevent psychologists from giving or receiving payment for the referral of patients or from participating in patient referral ser-

vices. However, Standard 1.27 Referrals and Fees stipulates that when engaging in such practices the fee must not be solely for the referral itself hut the payment is based on clinical, administrative, consultative, or other services (p. 1603).

ing the Professional Relationship).

While this brief article cannot discuss all changes in psychologists' ethical princi ples and standards, this serves as a summary of the most significant

changes which may have an impact on the practice of psychoTo be a functioning therapy. The majority of the additional changes primarily provide member of a com- psychologists with greater specificity and detail on previously stated standards. Psychologists are

social and profes- referred to the newly revised Ethical Principles of Psychologists and Code of Conduct as a reference source on these issues. Again, the underlying tenants seen throughout these ethical principles include sensitivity to the welfare of those we serve, avoidance of exploita-

tion, harm, and misuse of our influence, and preservation of patients' rights.

munity both on a

sional leoel it is often impossible to

Several other areas of change which impact on psychologists engaged in the practice of psychotherapy have occurred. A psychologist may not withhold records which are requested and imminently needed for treatment solely because of lack of payment for services rendered (Standard 5.11, p. 1607). Additionally, a much more detailed and specific set of standards are now provided which add ress privacy and confidentiality (Standard 5, pp. 1606-1607). These guidelines provide psychologists with guidance on how to discuss the limits of confidentiality with patients, what efforts should be made to protect patients' confidentiality, how to minimize intrusions on privacy, how records should be maintained, when and how disclosures of information under the psychologist's control should be made, and how consultations with colleagues should be made with an emphasis on avoiding intrusions into patients' right to privacy and confidentiality. More specific guidance is also provided on terminating professional relationships so that patients are not abandoned, with an emphasis on a ttention to each patient's needs regardless of the reasons for tennination (Standard 4.09 Termina t-

avoid all dual

re la tionsh ips.

A subsequent article in a future issue of The Psychotherapy Bulletin will address the impact or AP A's documentation guidelines on the practice of psychotherapy.

Adler, W.N. (1988). The sexualization cf psychiatric practice, MPS News, Baltimore: Maryland Psychiatric Society, 34.

American Psychological Association, (1953). Ethical SI=dards of Psycholo&ists, Washington, D.C.

American Psychological Association (1990). Ethical Principle of Psychologists. American Psychologist 45, 390..395.

American Psychological Association (1992). Ethical Principle; of Psychologists and Code of Conduct. American P chologist, 4.7, 1597-1611.

American Psychological Association (1992). Consent Agr~ ment with the federal Trade Commission, Washlngtor. D.C.

FEATURE ARTICLE "

National Health Insurance: Too Late for Florida?

Suzanne B. Sobel and Roy H. Lusk

National health insurance is the big topic in Washington that will probably make or break the Clinton administration. As this article is being written in August, 1993, TUmors are flying but nobody knows for sure what type of proposal

38

will be made by the President regarding this However, even as such a proposal is made, there are states that have already enacted laws ilia. may make the national health care statem mute. Florida is one of these states. Other sta

include Minnesota, Washington, Oregon and Vermont.

bers, In addition to issuing requests for proposals, the CHP As will distribu te AHP comparison sheets to their members so that their members will have the information they need about the services, prices, and quality when they and their employees pick the AHPs they want to use. Because they will have large groups of potential health care customers, CHP As will be able to use the request for proposal process and their price comparison sheets to ensure that the AHPs offer competitive prices for their services. This is similar to the power buyers or volume buying that certain large stores advertise.

Under the Health Care and Insurance Reform Act of 1993, the Florida Legislature passed legislation tha t extends reforms of is previous year to included employers with one to fifty employees. It requires all insurers that issue policies to small employers to offer their prod uct on a "guarantee issue" basis to small employers, employees and dependents without regard to heal th status, preexisting conditions or claims history. It also requires a modified rating of small business products; adjustments are allowed "for age, gender, fa mil y composition, tobacco usage and goo- Memberships of a CHP A is available to: (1) small

graphic location. The purpose of this is to im- employers of up to 50 employees,

prove the efficiency of Florida's and, (2) the State for the purposes

health care markets .. This act ere- of providing health benefits to state

ates 11 Community Health Pur- Florida has adopted employees and their dependents,

chasing Alliances (CHPAs - pro- a managed compe- Medicaid recipients, MedAccess

nounced "chippas"). These participants and Medicaid buy-in

CHPAs are nonprofit organiza- titian model; which participants. To add to this an tions that will be subject to the will force a resiruc- employer that employs 30 or fewer

su pervision and approval of the 17 employees must offer at least two

member board of directors repre- turing of health care AI-fps or health plans to its em-

senta tive of alliance members con- market. ployees and an employer tha tem-

sumers and government purchas- ploys 31 or more employees must

ers that are appointed by the Cov- offer three or more AHPs or heal th

ernor. No member of the board may have any plans to its employees. A state level Agency for connection with a health care provider or in- Health Care Administration will be responsible surer. It is believed that this type of plan will for certifying the CHP As and actively supervisimprove the health care market by: (1)aUowing ing the CHPAs to ensure that actions that effect purchasers and consumers to pool their buying market competition are not for private interest, power; (2) promoting cost-conscious consumer but provide state and federal antitrust protection choice of managed care plans; (3) rewarding as intended by the legislation. CHP As may not providers for high quali ty and economical care; directly provide insurance, directly contract wi th (4) increasing access to care of the uninsured; and a healthprovider or bare any risk. The agency (5) controlling the rate of health care inflation. also directs the Agency for Health Care AdminBecause of their size, the CHPAs wilt be able to istration to create practitioner advisory groups to get the kind of volume discounts large employ- provide practitioner input into the utilization ers can secure from providers. Such alliances are review, administration, coverage, cost effective already in existence. For example, in the Orlando medical management and other operational dearea an alliance of large corporations and two cisions,except prices and fees, to be made by hospitals have started to make health care less AHPs ..

expensive for their members.

How will this system work? No one knows for sure. Plorida has adopted a managed competition model; which will force a restructuring of the heal th care market. The CHP As will develop specific request for proposals from networks of heal th care providers, called Accountable Health Partnerships or AHPs, to server the CHP As mem-

Wha t does all of this mean? Part of the legislation requires determining practice parameters. The Agency of Health Care Administration, in conjunction with health professional boards and associations, is directed to develop state practice parameters that will reduce unwarranted variation in the delivery of medical treatment, improve the quality of medical care and promote

39

This does mean that psychologists will have t make some changes in the way they practice.

This legislation requires us to form alliances with all health care pr<r viders, not only wi th psychiatrists We will be placed in a position 0:: assess our strengths having to look at how psycholog:

and weaknesses and fits into a continuum of care in the health care market. We will have

the appropriate use of heal th care services. It also requires the establishment of the work group of medical and technical professionals to develop uniform standards and methods for collecting and analyzing patient outcome data by diagnosis for each patient and forward the data to the Agency for Health Care Administration beginning June 1994. It provides for the Agency to establish a demonstration project to evaluate the effectiveness of practice parameters with regard to the cost of defensive medicine and professionalliability in conjunction with the Board of Medicine.

In addition, the legislation creates

rural health networks to provide a continuum of care, integrate public and private resources, coordinatehealthserviceplanningarnong providers and link rural and urban facili ties. It adds a MedAccess program for Floridians with income up to 250% of the federal poverty level that allows premiums to be paid by the individual or the individual and the employer and al-

lows the providers to be compen-

sated at the Medicaid reimbursement rate, which in Florida is a pproxima tely $31.00 per therapeutic hour for psychologists.

mum of five outpatient visits. Other discussions involve 20 sessions or a financial cap. Still others believe it would be prudent to wait until the federal government has made its proposals on mental health. The speed that this is happening is rapid. One needs to stay ever alert to what is ha ppening for the fu ture of psychology and psychotherapy practice is very much in jeopardy at this point in time and the practice type that is most vulnerable is the solo practitioner.

We will have to

potential for

to assess our strengths and weakforming strategic nesses and potential for forming strategic alliances. Psychology have to accumulate informati

on outcomes in quality and desi

information systems to capture clinical outcome and cost data before other pr - fessions do it for us. We will have to streamlire and simplify access and management struc and evaluate space in terms of shift of focus Once it is in place, providers will need to understand the business of delivering insurance, i= particular, risk assessment, risk management an: pricing to compete effectively in an AHP. Th_ wil1 need to join insurers or develop campara b - insurance products internally. The bottom li - of all of this, is that Floridians will probably haw to prepare for the possibility of increased taxes including additional taxes on providers. Sue taxes will likely be need to fund the Med Access plan. We need to be on top of everything that is going on. National health care? It looks like the battle is state health care at least in Florida anc this may be the direction of all states. Whateve: the final outcome, we in Florida need to be ver aware because these CHPAs and AHPs are wha are going to determine psychology's future UTless we step forward and form our own preferre.: provider networks so that we can control tl practice of psychology. This may be one of 0 last chances to maintain control of the practice psychology .

alliances.

What does this mean for PSYCHOLOGY? Nobody knows. It is obvious that things are moving rapidly within the state and that psychologists will have to become acutely aware of what is going on. The AHPs will be composed of HMOs, preferred provider networks and exclusive provider networks. In addition, traditional indemnity insurers will be allowed to seek designation as AHPs. Florida's mental health centers are also expected to provide strong competition in the formation of AHPs as will hospitals. Various groups are already laying the groundwork to form AHPs. In our area, we know of some large multispecialty medical groups that are actively doing this. If psychologists do not become involved in the process, they will have little or no influence later. We should also be aware that AHPs will be multidisciplinary and need to be capable of offering a broad range of services, from outpatient to inpatient hospitalization.

Few specific services are mandated under mental health. There is some discussion of a mini-

40

FEATURE ARTICLE

A Psychodynamic-Object Relations Model for Differential Diagnosis

Marolyn Wells and Cheryl Glickauf-Hughes

For therapists, the identifying and integrating phasesofpsychodiagnostics entail relatively complica ted and difficult processes. A number of models have been proposed to help structure this endeavor (A.P.A., 1987; Kernberg, 1975; Millon, 1981). Many models, like the DSM-m-R, however, employ a symptom-based, descriptive approach which does not address ego-structural development or psychodynamic / motivational theory. Like Kernberg (1975) the authors believe that the problem with such atheoretical approaches is that they limit connections to salient treatment considerations.

The authors of the present article advocate a two-part diagnostic model of ego-object relations development and character organization designed to assist therapists in their efforts to make important distinctions among three broad structural organizations (i.e. borderline, preneurotic, neurotic) and six character styles (i.e, schizoid, hysteroid, narcissistic, masochistic, obsessive-compulsive and hysterical) commonly encountered by practicing clinicians. Due to space limitations the structurallevels of normal and psychotic will not be covered. Finally, because structural deficits take therapeutic precedence over characterological conflicts (Homer, 1979), structural issues will be presented first.

Modified Kemberg Model of Ego /Structural Diagnosis

The diagnosis of a patient's level of ego development is crucial to treatment strategy (Kemberg, 1980). For example, the use of therapeutic abstinence, the promotion of regression, and the goal of uncovering or making the unconscious conscious is appropriate for the neurotic ego which can sustain such abstinence without decompensating, but inappropriate for the borderline ego which tends to rely upon splitting when stressed and is prone to temporary decompensations when

faced with prolonged therapeutic abstinence and / or assa uIts on higher level defenses (Goldstein, 1985; Masterson, 1976). For borderline clients, therapeutic goals should focus on ego building interventions and the resolution of more primitive defenses, such as splitting and projective identification.

Consider the ramifications of misdiagnosing a basically schizoid-borderline patient who employs 'many obsessive defenses as an obsessive-compulsive neurotic. The obsessive-compulsive neurotic patient maintains the ego strength to manifest a cohesive and integrated sense of self under stress and intense affect but presents a personality style that is generally over constricted and counterdependent. In this case example, the consequence of such a misdiagnosis was that the therapist explored and encouraged the activation and expression of the patient's feelings (incl ud i ng anger) as well as his dependency needs. When the therapist then wentona one week vacation, the patient abruptly decompensated (e.g. had panic attacks, suicidal ideation, severe dissociative reactions) and prematurely left the therapeutic relationship out of fear of total abandonment and rage over feeling invited to depend upon the therapist and then rejected by the therapist's leaving.

Had the therapist recognized that the patient's obsessive-compulsive defenses and cognitive style masked a schizoid borderline ego organization, she would have avoided encouraging the expression of the patient's underlying feelings (e.g. rage) until he had established a relatively stable and positive relationship with the therapist and had been able to use that relationship to augment self-soothing and self-validating functions. In addition, the therapist would have focused upon the patient's tenuous capacity for object constancy rather than upon the expression of his dependency needs per se, As a resu It 0 f th is change in focus the therapist could have helped the patient to better anticipate his reactions to the therapist leaving on vacation and could have

41

joined the client in creating strategies for managing his internal turmoil/ separation anxieties during the therapist's absence. For a listing of such strategies (e.g., the appropriate use of transi-

Orientati of Thought Process:

tional objects) or detailed technical approaches to the development of object constancy (see Wells & Glickauf-Hughes, 1986).

Differentiation of Three Major Ego Organizations

Neurotic Personality Organization

Secondary process thinking (rational thoughtas trial action based on reality pnnciple, rational, logical, reality-based thinking intervenes between impulse and behavior (Kernberg, 1%7).

Preneurotic Personality Organization

Borderline Personality Organization

Primarily secondary process thinking.

Tendencv to ward prima zy prtr ~ (immediate discharge) thinking on unstructured tests or under the influence of alcohol, drugs or stress (Kernberg, 1967).

Primary Anxiety Level:

Fear of impotence, punishment or castration. Fear of loss of object's love/approval. signal anxiety.

Fear of loss of object's love/ approval; Fear of abandonment by primary other.

Upper level: Fear of object loss (total isolation from significant others). Lower level: Fear of loss of selfhood (engulfment).

Object Relations:

Whole-object level. Capadty for real object love and lasting relationships of some considerable depth. Capable of reciprocity, giving, caring for objects for reasons other than the functions they can provide.

Unstable whole object level. Regression to need-satisfytngtevel can occur during threat of loss of security object.

Need-satisfying level. Limited mature love. Intense transient, or superficial relations.

Identity:

Neurotic

Ego Organization

Integrated Ident] ty

A stable, well integrated (good & bad), realistically based sense of sell with which the therapist can empathize and construct a predominateiyconsislentinternalimageof the client. Peripheral inconsistencies are ego dystonic.

Preneurotic Ego Organization

Borderline Ego

Stable Object Constancy

A stable, well integrated, realistically based representations of others. The ability to main lain a stable emotional tie with others. The abil-

to self-soothe when distressed.

Basic Trust

Able to depend on others. View others as a mix of good and bad but predominately good until proven otherwise. Able to depend on/ trust (i,e. one's own perceptions, feelings).

42

Week Identity

Formulated cohesive but weakened sense of self. Highlyambivalent.

Identity Diffusion

A contradictory set of self representations which are poorly integrated and actively (thouRt unconsciously) kept mutuaIl~ exclusive. The therapist ofter; can construct only a vague chaotic inconsistent internal image of the client. Contradictions lr; self experience are mainly ege syntonic.

Weak Object Constancy Dependency upon a somewhat idealized object to main tain sense of well-being. Vulnerableto anxiety and depression.

Objes:t Constancy Defects

A contradictory, poorly integrated non-reality based re sentation of others. The inabili to maintain a stable emotional to others. The inability' sell-soothe when distressed.

Weaknesses of Basic Trust Particular weaknesses of trust in sell and specific over-reliances on others.

Lack of Basic Trust

Unable to really depend on oCers, Predominately nega . anticipation.

Ego Development and Personality Style

Wi thin each level of ego development described in the previous section, there exists a number of typical personality styles. For example, if one first assesses that an individual is functioning at a borderline level of ego development, one must then determine what "flavor" of borderline the client is presenting in order to strategize the most effective treatment approach. The same approach is also relevant at the neurotic and preneurotic levels of ego structure.

Furthermore, it has been postulated that there are two basic contin uums along which different personality styles are organized. The hysteric con tinu urn includes those who tend to overrely upon others while the schizoid continuum indudes those who tend to overrely upon themselves for rewards and comforts (Millon, 1981). The authors propose the following typical evolution of structure and character development:

Overrely on Self

Overrelt on Others

Borderline:

Preneurotic:

Neurotic:

Schizoid Narcissistic Obsessive

Hysteroid Masochistic Hysteric

Borderline Level of Egp Development:

Schizoid and Hysteroid Styles

At the borderline level of ego development the

authors have charted the prototypic schizoid (Guntrip, 1969) and hysteroid (Krohn, 1978) character organizations along a number of critical dimensions. The hysteroid style presents a clinical picture of emotionallabiIity and vacillations between in tense demands around needs for support and hostile, denigrating attacks.

In contrast, the schizoid style presents a clinical picture of emotional detachment and isolation, a preoccupation with inner live, and an exaggerated reliance on thought processes. Projective distortions of aggression or destruction love induce emotional withdrawal. Relationships manifest an underlying lifelessness and social communications are typically irrelevant or tangential (Millon, 1981).

Both the hysteroid and the schizoid styles present a sol ution to intense need-fear dilemmas. For the schizoid, the individual's grea t need for others is countered by a great fear of engulfment (i.e., loss of self) and lor destructive love (i.e., one's neediness will devour others). For the hysteroid, the individua I' s great need for others is countered by a great fear of abandonment or being left bereft.

The schizoid and the hysteroid also present distinctively in terms of ego structure. Self/other differentiation or psychological boundaries are vigilantly maintained by the schizoid in order to protect the sense of self. In contrast, hysteroids tend to deny differences or blur psychological boundaries in order to secure a protecti ve "good mother / good child" connection wi th the object.

Division of Psychotherapy 29

ON THE LEADING EDGE

in Psychotherapy

Education • Research • Training • Practice

To maintain our "EDGE" in these areas Division 29 must have more representation on the APA council.

Give your division that "EDGE" by casting your votes for 29!

We NEED your 10 votes or the best you can do!

43

Differentiation of Two Borderline Personality Disorders

Personality Disorder

Hysteroid /Infantile

Cognitive Emotional Style:

Major Defenses:

Patient's Aims:

Related Entitlements & Strivings

Ego Mode:

Superego Mode:

Prevailing Patient Myth:

Major Fears/ Defensive Arena:

Schizoid

Intellectualized, deemotionalized style of relating. Primary process is rare. Tendency to blur differences. Preoccupation with inner world.

Diffuse, global, dramatic style of relating. Intellect often overwhelmed by intense affect. Subject to transient affect storms and primary process thinking when regressed.

Emotionaldetachment & isolation: avoidance; obsessional defenses; depersonalization; exhibitionism and intellectualization.

Validation for the right to exist and not be devoured.

Acting out; splitting.. projective identification; extemalizations; self-mutilation and/or suicide gestures at times of stress; and coercive, aggressive manipulation.

Preserving a sense of security, soothing, and wholeness.

Entitlement to a relationship without any rejection or humiliation. Guarantee of uncritical acceptance.

Entitlement to an oceanic sense of oneness wi th a: idealized other. Entitlement to need gratiIicatia.;.

Organization is maintained as long as rigid defense system is upheld. Regressions are rare. Minimal acting out. Reality testing is usually intact.

Tendency to transitory regressions. Concomitant non-specific ego immaturity. Basic realir testing is usually intact but feelings of reality (Z be compromised.

Consisten tl Y organized around primitive precursors. Punitive, rejecting and rigid. Tendency for superior aloofness/ grandiose self-sufficiency. Ego Ideal: '1 am very special, autonomous, and unique."

"Myth of self sufficiency."

Guilt/depression that tends to slide into projec tion & blaming. Value system can shift depenc ing on approval of designated good object. fu. Ideal: "I am good boy/girl who can bel recogr;;tion/soothing."

"Myth of fusion with the all good object."

Fear of intimacy. Fear of engulfment & loss of self or n arcissistic injury leading to uncontrollable regression. Hypersensitivity to potential rejection or shame.

Fear of abandonment or death. Fear of separation/object loss. Fear of experiencing the terrfying emptiness of absolute isolation.

Preneurotic Leyel of Ego Development:

Narcissistic and Masochistic Styles

At the preneurotic level of ego zobject relations the authors have charted the narcissistic and masochistic personalities (Meissner, 1984), The schizoid's central defense of emotional withdrawal is replaced by the narcissist's central reliance upon the grandiose false-self structure while the hysteroid's central defense of acting out and globalized splitting are replaced by the masochist's central defenses of masochistic splitting and reaction formation.

At the preneurotic level of ego development, narcissistic defenses primarily function to provide positive valence to the self-representation

44

J

(Stolorow, 1975) and to solidify object constant while reducing feelings of inferiority and unwcthiness. The narcissist's central ego or real self thus deficient and extremely sensitive to sligh: rejections and disappointments and prone to ccresponding feelings of inferiority, envy, sham' and rage. The preneurotic narcissistic perso - ity compensates for or tries to defend agair.:. these feelings through attachments to admiri ~ admired objects who feed the narcissists' gra osity, reinforce their self-confidence, and - vide psychic direction. As a substitute (or w this mechanism fails), the narcissist tends to _ ther choose new admiring / admired objects 0- rely on the invocation of their grandiose falsestructure.

While the grandiosity of the narcissist revolves around personal perfection ("I am the greatest"), the grandiosity of the masochist focuses on goodness ('1 am the most generous, giving and loyal of all"). Both character styles function in many ways as compensa tions for acu te, hidden or overt feelings of inferiority and worthlessness. In this regard the narcissistic character thus feels entitled to admiration and adoring regard because of the compensatory illusion of personal perfection (i.e., "I'm great, talented, wonderful and am entitled to wonderful and great regard"). In contrast, the masochistic character feels entitled to loving relationship because of the compensatory illusion of control related to the myth of faimessand reciprocity (Glick and Meyers, 1988).

The masochistic character is organized around the compelling need to obtain love from a predominately hurtful love object (Berlinger, 1947) as reward or compensation for great effort, suffering, or submission. In addi tion, the preneurotic masochist has a self-defea ting way of indi vidua ting which tends to manifest through a process of projecting and/ or an ticipa ting the forcefu 1 domination of another's will and then resisting such domination via such tactics as: (a) passi ve-aggressi veness, (b) assuming a caretaking role, (c) an overcontrolled presentation which establishes a position of passive dominance, and (d) subtly provoking others into power struggles so as to give justification to the client's need to differentiate and self-affirm through resistance (Glickauf-Hughes and Wells, 1991).

Differentiation of Two Preneurotic Level Personality Disorders

Personality Disorder

Masochistic

Narcissistic

Cognitive Style:

Major Defenses:

Patient's Aim:

Related Entitlements and Strivings:

Ego Mode:

Superego Mode:

Prevailing Patient Myth:

Defensive Arena:

Omnipotence, grandiosity, devaluation, idealization, sexualization of intimacy needs; avoidance of self-deflating situations, and pseudo-humility.

Admiration for being perfect.

Self-esteem for being perfect. Admiration, adoration, mirroring and empathy. Avoidance of criticism.

Better impulse and frustration control than borderlines. Reality testing compromised by massive denial (via grandiosi ty).

Wants approval and admiration without consideration of others or effort (l.e. an audience, not a reciprocal relationship). Corruptible value system. Unrealistic ego ideal. Ego Ideal: '1 am above others."

"Myth of self perfection." Seeksperfection mirror- "Mvth of fairness and reciprocity" (wants coning of his/her grandiosity (Wants narcissistic trolover objectlovel, Confuses love and longing. self-object to sustain self-worth).

Denies/distorts reality in order to maintain self-esteem.

Negative distortion of self. Positive distortion of significantother{s) (Glickauf-Hughes& Wells, 1991).

Reaction-formation, introjection, projection, denial; idealization and devaluation. Believes self-deflation accompanies being loved.

Love/reward for great effort, suffering and/or submission. Appreciation for good works.

Object love or self- worth for self-sacrifice. To get critical, rejecting objects to give love and approval. To avoid fear of abandonment or loss of the object's love.

Good impulse control. General difficulty of ego in modulation of harsh superego. Reality testing compromised by denial (via idealization).

Excessively harsh, punitive conscience. Unrealistic ego ideal. Ego Ideal: I am good and giving."

Defends against paranoia. depression, mourning. fear and sadness (Kemberg, 1975).

Defends against experiencesof object loss (Avery, 1977), loss of object love, anger and negative perceptions of idealized others.

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Obsessive and Hysteric Style

At the neurotic level of ego development the authors have chosen to describe the obsessive and hysteric character disorders. The obsessive tends towards a more microscopic, detailed precise cogniti ve style in contrast to the hysteric who tends more towards a macroscopic, global, impressionistic cognitive style (Shapiro, 1965). Obsessives are thus susceptible to losing the forest for the trees because they are overinvolved in endless details while hysterics can overlook important details and seem unduly vague or imprecise. Obsessives are also subject to excessive rumination or trial action through thought. The neurotic obsessive is able to sustain in-depth relationships, but retains a proclivity to sacrifice dependency needs in order to appease the standards and dictates of an excessi vely harsh superego (Salzman, 1980).

In this vein, the obsessive is appropriately placed on the schizoid continuum, although more advanced defenses such as intellectualization and isolation of affect have replaced the narcissist's reliance on a grandiose false self. In addition, the rigidity of the narcissist's false self has been replaced by the more integrated, but excessive role consciousness of the obsessive. The obsessive's often secret grandiosity is also more mediated and integrated into the central ego and has more to do with "doing things perfectly" or "being right" than with the narcissist's "desire to be perfect".

The neurotic obsessive has an overdeveloped need for control because of deep-seated, excessive insecurities about the self and the world. Obsessives attempt to gain the illusion of control throughanovervaluationofintellectand through pseudo-moralistic rules which dictate what is "right". What is technically correct is often more important to the obsessive than what is emotionally needed. The obsessives' fear of making mistakes or being out of control leads to difficulties in making decisions or commitments, or being spontaneous. In fact, much of the obsessive's pickiness, ambivalence, constricted affect and lor perfectionistic strivings is motiva ted by the wish to avoid making mistakes and to secure guarantees.

The obsessive psychologically wrestles with a number of polarities: (a) compliance versus defiance (i.e., "I'll do whatever you want" vs, "You can't make me"); orderliness versus messiness (b) and parsimony of manifest affect versus private, intense feelings of insecurity, shame, and anger. Whenever one side of these polarities is visible, the other is always present, if hidden.

While obsessives can be caricatured as aspiring to be Mr. Spack of Star Trek, the neurotic hysteric may be caricatured as an aspiring heroine in c. happily-ever-after romantic novel. The hysteric replaces the masochist's over-reliance or reaction-forma tion and masochistic splitting witt pseudo-emotionality, repression, and cognitiv fog. Hysterics are interpersonaIly characterizec as: (a) hypersensitive to the feelings, motivations, and expectations of others, (b) trend cfashion-consciousness, (c) extremely emotiona, (d) flighty, (e) engaging, and (f) dramatic. - contrast, obsessives are often characterized l:i social stiffness or awkwardness as result of th excessive role-consciousness.

Hysterics, like masochists, appear highly rela tional and oriented towards pleasing sigruficar others in order to gain their love and approve Hysterics, however, take a manifestly more dependent, childlike and / or seducti ve role in orde to be appealing and win love and appreciatic:: while masochists typically act industriou - counterdependent and take on the role of e - tional caretakers in order to earn love and grartude.

The hysteric personality is also organized arour a number of polarities, the central theme refleeingwhatKrohn (1978) termed thehysteric'sm of passivity. As a result of feeling unprepared cope with life, desiring to be taken care of, a centering on the love object, the hysteric min, mizes his or her own substantial capabilities presents an interpersonal style described as d pendent, superficial, and affectively shallo (Mueller & Aniskiewicz, 1986). The hysteric cognitive style complements character traits (i flightiness and hyperemotionality), defenses(' z: externalization), and feeling states (i.e., helpl victims without mastery or control) so as to rer force the repression of what Mueller a= Aniskiewicz (1986) termed the II submerged

46

that is the experience of the self as responsible" (p.50) and a self-image that reflects a person "to be reckoned with."

By abdicating responsibility and competence, the hysteric's manifest behavior is designed to elicit caretaking from the love object. Such abdica tion, however ,also tends to ind uee anxiety and controlling behaviors in the significant other and

thus tends to reactivate the hysteric's fears of being dominated and controlled by an insensitive and self-indulgent object upon whom they depend. In significant relationships, hysterics are thus often caught between their wishes and their fears, between their dependency needs and their anxieties about being controlled (Mueller & Aniskiewicz, 1986).

Differentiation of Two Neurotic Level Personality Disorders

Personality Disorder

Hysteric

Prevailing Patient Myth:

Defensive Arena:

Obsessive-Compulsive

Cognitive Style:

, Detailed, ruminating (Shapiro, 1965). Black and white thinking related 10 right and 'WrOng dichotomies.

Major Defenses:

Patient's Aim:

Related Entitlements & Strivings:

Ego Mode:

Superego Mode:

Isolation of affect, intellectualization; rationalization, reaction-formation, undoing, and doubting.

Approval for "doing perfectly" and correct performance (Wells et al, 1990).

Control and order (slli vilIg for independent control of self and things). Dong things right or perfec tl y (Salzrn an, 1980).

Excessive trial action through thought or tendency to "think out" (Shapiro, 1965).

Integrated but excessively harsh. Endures beyond expectations of the immediate personal or cultural milieu. Loyalty to introject. Ego Ideal:

"I am honorable and just."

"Myth of control and power". Believes it is better tobe right than liked.

Defends against feeling out of control - especiall y of tender feelings. Loss of approval of superego.

Global, impressionistic thinking (Shapiro, 1965).

Repression, displacement, cognitive fog, pseudo-emotion ali ty, dissociation and pseudo-sexuality.

Love for being by incestuous object or parent substitute (Krohn, 1978).

Protection, atten lion, and approval from incestuous object (or parent substitute).

Excessive trial action or tendency to "act out" conflicts (Shapiro, 1965).

Far more negotiable. Reflects what is current and fashionable. Aim is more interpersonal. Emphasizes what will bring acceptance, praise, and love from others. What is "right" is largely defined by what will bring approval. Ego Ideal: '1 am attractive and appealing."

"Myth of passivity and helplessness". The ego lets the self feel overwhelmed (Krohn, 1978).

Defends against inoestuoussexual desires. Competitive feelings.

ERRATA!

In a recent mailing to the Division 29 membership,

the secretary was incorrectly identified.

Dr. Patricia Hannigan-Farley is secretary and Dr. Diana Willis is secretary-elect.

47

Goldstein, W. (985). An introduction to the borderline conditions. Northvale, N.J.: Jason Aronson.

Conclusion

This article describes a two part psychodynamic/ object relations model of differential diagnosis based upon ego-structural, developmental, and motivational theory. The first part of the model is designed to assist therapists in their efforts to make important distinctions among five broad ego-structural organizations (e.g. normal, neurotic, preneurotic, borderline, psychotic). In the second part of the model, six personality disorders (falling wi thin three levels of ego-structure) are compared across a number of critical dimensions. While this model oversimplifies and reduces many aspects and categories relevant to differential diagnosis, it attempts to give clinicians a sufficiently clear schema to assist therapists in disconcerning assessments and appraisals of client dynamics.

References

American Psychiatric Association (1987). Diagnostic and statistical manual of mental disorders (Vol, 3, rev). Wa.shington, D.C.: AP.A

Berliner, B. (1947). On some psychodynamics of masochism.

Psychoa.nalytic Ouarterly, 16(4}, 459-471.

Glick, R.A. & Meyers, o.i (1988). Masochism: Current psychoanalytic perspective. Hillsdale, N.J.: The Anal yti c Press.

Glickauf-Hughes, C. & Wells, M. (1991). Current conceptualizations on masochism: Ge.neric and object relations. American Journal oEPsychotherapy. XLV(1), 53-68.

Guntrip, H. (1969). Schizoid phenomena, object relations and the self. N.Y.: International Universities Press.

Horner, A (1979). Objes:treiations and the developing ego in therapy. N.Y.: Jason Aronson.

Kern berg, O. (1975). Borderline conditions and pathological narcissism. N.Y.: Jason Aronson.

Kern berg, O. (1980). Internal World and External Reality. NY:

Jason Aronson.

Krohn, A (1979). Hysteria: The elusive neurosis. N.Y.: international Universities Press.

Masterson, 1. (1976). Psychotherapy of the borderline adult N.Y.: Brunner/Mazel,

Meissner, W.W. (1984). The borderlinespectnun: Differential diagnOSiS and developmental issues. N.Y.: [asor. Aronson.

Millon, T. (1981). Disorders of personality DSM-lII: Axis r N.Y.: John Wiley & Sons.

Mueller, W. & Aniskiewicz, AS. (1986). PsNhotherapeu "

intervention in hysterical disorders. orthvale, N.]

Jason Aronson.

Salzman, L. (1980). Treatment of the obsessive personali Northvale, N.J.: Jason Aronson.

Shapiro, D. (1965). Neurotic styles. N.Y.: Basic Books. Stolorow, R.D. (1975). The narcissistic functions of masoc:: ism (and sadlsm).lnternational Journal of Psycho anal ~ ,'iQ,441-448.

Wells, M. & Glick auf-Hugh es, C. (1986). Techniques ~ develop object constancy with borderline clients. Ps: chotherapy, 23(3), 460468.

FELLOWS j

Everything You Wanted To Know About Applying For Fellow Status In The APA And Were Afraid To Ask

Suzanne B. Sobel

Each year Division 29 actively encourage i trnembers to apply for Initial Fellow status in the American Psychological Association. We also encourage Division 29 members who are Fellows of other divisions to apply for Fellow status within our Division. It is hoped that this short article will encourage you to apply to become a Fellow of the Division of Psychotherapy.

1. How do I go about obtaining material to apply for Fellow?

48

All you have to do is write to the Division 2- Central Office at 3875 N. 44th Street, Suite 10:' Phoenix, Arizona 85018 and request an application packet. Induded in the packet will be Uniform Fellows Blank, four Standard Evalua tion Forms and a packet of guidelines develope; by our Division to help you to obtain Fello status. You are encourage to nominate yourse_

2. Is the same procedure used for psychologist who are Fellows of APA and Initial Fellows?

No. If you are already a Fellow of another divisian of APA, you will only need to submit a statement of accompIislunents outlining you contributions to psychotherapy and a copy of your resume which will be dis tributed to our committee. Your nomination does not need to be reviewed by the APA Membership Committee.

3. What process does an Initial Fellow need to foHow?

An Initial Fellow has to submit three letters of endorsement, all from AP A Fellows. Division 29 requires that two of these Fellows must be Fellow of Division 29. In addition, you are requested to write a statement of your accomplishments in the field of psychotherapy. Each Committee membel' will review your credentials independently and rate your application. To have your application sent to the AP A Membership Committee, 2/3 of the Division 29 Fellows Committee will have to vote to endorse your application.

4. What if J do not know two Fellows in Division 29?

This problem often occurs. If you know three Fellows of AP A, all of whom are not Fellows of Division 29, you can have them write endorsing letters. In addition, however,you win have to submit your qualifications to the Division 29 Fellows Committee Chair who will then submit them to a Pellow of Division 29 and ask that Fellow if he or she will write an endorsing letter for you. It is to your advantage to have Fellows who know you and your work to write the letters of endorsement.

5. What other types of informa tion can I submit?

Any type of supporting information to document the contributions that you have made to psychotherapy is acceptable by the Division 29 Fellows Commi ttee. Included can be letters from colleagues in your community who can a ttest to the contributions you have made. Copies of a wards and other recognitions can be attached as well as any newspaper articles abou tyou. VV'hen attaching such materials, the goal is to be able to further document that your contributions have been outstanding. sustaining and important to psychotherapy.

6. What areas of contributions can one present for Fellow status?

There are a number of area. These include:

a. Distinguished Service - This invol ves evidence of distinguished and sustained service in the practice of psychology and psychotherapy. A practitioner has to be licensed and devote a rnajority of his/her professional time to service de~ livery over a period of years, usually over ten.

b. Achievement of Excellence - This involves recognition of other professional and scientific groups that is not rou tinel y accorded to all Di vision 29 members. For example, this could be recognition by an appropriate specialty, serving as an editor for a scholarly Journal which has national and international circulation, recognition in a national or international professional association which is based upon peer review and recognizes contribu tions beyond those ordinarily expected of members in general.

c. Extraordinary Recognition ~ This involves evidence of having received national or internationa! recognition from one's colleagues for contributions to psychological practice. Included would be selection as president of a national psychology or other mental heal th focused organizarion, receipt of an honorary degree of acknowledgment by a federal or state legislature.

d. Significant Contributions - The publication of practice and/or scientific articles, books, monographs and so forth which have made a demonstrable impact on the practice and thinking of colleagues falls in this category. Educational innovations, legislative initiatives or policy d~ velopments which have enhanced the nature of psychological services, increased public access to services and/ or positively altered the form of services fall in this category.

e. Personal Goals ~ This category recognizes the ability and interest of the person in supporting the goals of the Division. Participation and lead ~ ership inassoda tions and organiza tions rei evan t to psychological practice and outstanding service on APA boards and committees that relate the practice are appropriate.

7. When do I have to submit all of these documents?

49

The AP A has moved the da te of submission of all materials to April 15, 1994. As a result of this, the Di vision 29 Fellows Committee is requesting tha t you submit all of your materials to our Committee by February 15, 1994. This includes the Uniform Fellow Blank, letters of recommendation and statement of accomplishments for Initial Fellows, or a statement of accomplishments and vita for Fellows of AP A.

8. Can anyone nominate a Division 29 member for Fellow status?

The Division 29 Fellows Committee not only welcomes self nominations, bu t welcomes nominations from any Division 29 member about

another member. Often there are many n-o,,","<31 who have made sustained and outstanding tributions that have not been brought to attention of the Committee that we need to about. You can help us by writing to the Chair and asking that a packet of materials sent to a member that you believe should recognized.

9. Is there anything else that I should know? You should feel free to contact the Division Central Office or the Fellows Chair if you any questions about the procedures. The Chair can be reached at (407) 773-5944. You also call the Division 29 Central Office at 952-8656.

Report of the 1993 Fellows Committee

Suzanne B. Sobel, Ph.D., Chair

This year we are pleased to announce that Laura Barbanel, Ed.D. and Bruce Bongar, Ph.D. accepted by APA as Initial Fellows through Division 29. We congratulate them on their and outstanding contributions to psychotherapy.

In addition, the following AP A Fellows have been accepted as Fellows of Division 29 effective 1 ~

Aronson, Marvin L., Ph.D. Baker, Elgan L., Ph.D. Balter, Lawrence, PhD. Barclay, Allan G., Ph.D. Barrell, Robert P., PhD. Berman, Alan L., Ph.D. Bernay, Toni, PhD. Billei-Ziskin, Mae Lee, Ph.D. Birk, Janice M., Ph.D.

Blum, Lucille, Ph.D. Bricklin, Patricia M., Ph.D. Burkhart, Barry R, PhD. Claiborn, Charles D., Ph.D. Clarice, Pauline, Ph.D. Courtois, Christine A., PhD. Crego, Clyde A., PhD. Currie, John S., PhD.

Dell, Paul F., Ph.D. DeNelsky, Garland Y., PhD. Dreyfus, Edward A., Ph.D. Efran, Jay F., Ph.D.

Epstein, Norman 8., PhD. Epting, Franz R., Ph.D. Fodor, Iris, Ph.D.

Fraenkel, William, Ph.D. Fuld, Paula, Ph.D.

Garnets, Linda, Ph.D. Gehman, W. Scott, Ph.D. Goldberg, Carl, Ph.D.

50

Mount Vernon, NY Indianapolis, IN New York, NY Masonville, 10 Richmond, V A Washington, DC Beverly Hills, CA Los Angeles, CA Silver Spring. MD NewYork,NY Wayne, PA Auburn, AL Tempe,AZ Atlanta, GA Washington, DC Long Beach, CA McBee,SC Norfolk, VA

Shaker Heights, OH Santa Monica, CA Philadelphia, PA COllege Park, MD Gainesville, FL New York, NY Flemington, NJ

Los Angeles, CA Santa Monica, CA Durham,NC

New York, NY

Grzesiak, Roy C; Ph.D. Gurman, Alan S., PhD. HagHn, Richard P., Ph.D. Hersch, Charles, Ph.D. Kahn, Michael D., PhD. Kalafat, John, PhD. Knox, Michael D., Ph.D. Koile, Earl, Ed.D.

Lamb, Douglas H., PhD. Leidig. Marjorie, Ph.D.

Leland, Lorraine A., Ph.D. Leventhal, Allan M., Ph.D. Lustennan, Don-David, PhD. Margolin, Gayla, PhD.

Martin, Jack, Ph.D.

McDaniel, Susan H., Ph.D. McNamara, Kathleen M., PhD. Newcomb, Michael D., PhD. Newman, Frederick L., Ph.D. O'Connell, Agnes N., Ph.D. Ownby, Raymond L., Ph.D. Pfeiffer, Steven 1., Ph.D.

Pope, Kenneth 5., Ph.D. Porche-Burke, Lisa M., PhD. Post, Robin D., Ph.D.

Rayburn, Carole A., PhD. Resnick, Jerome H., PhD. Rice.joy K, Ph.D.

Robertson, Malcolm H., Ph.D.

Westifeld, NJ Madison, WI Amherst, MA Lincoln, MA West Hartford, Lousiville, KV Tampa, FL Austin, TX Normal, IL Boulder, CO Rosley,NY Washington, DC Baldwin, NY Los Angeles, CA Burnaby, B.c., Rochester, NY Kula,IL

Santa Monica, CNorth Miami, Fl Matawan, NJ

Ft. Lauderdale, F_ Devon, PA

Los Angeles, C,,_ Alhambra, CA Denver, CO Silver Spring. L Philadelphia, P.-. Madison, WI Kalamazoo, MI

Report of the 1993 Fellows Committee

Roehlke, HelenJ., Ed.D. Roseman, Morris, Ph.D. Samuels, Richard M., Ph.D. Sands, Harry, Ph.D. Schaefer, Charles, PhD. Sheridan, Edward P., PhD. Sperry, Len, Ph.D.

Stopol, Murray S., Ph.D. Strassburger, Fred, Ph.D. Strunk, Orlo [r., PhD. Tanney, Faith, Ph.D. Tobias, Lester L., Ph.D. Toomey, Laura c., PhD. Wachtel, Paul L., Ph.D. Watkins, C. Edward, Ph.D. Welch, Bryant L., PhD. Weiner, Marcella B., Ed.D. Willis, Diane L Ph.D.

Columbia, MO Baltimore, MD Westwood, NJ

New York, NY Crestwood, NY Orlando, FL

Mil waukee, WI Woodland Hills, CA Washington, DC Calabash, NC WaShington, DC Westborough, MA Middletown, CT New York, NY Denton, TX Washington, DC New York, NY Oklahoma City, OK

1993 Fellows Committee June Tuma, Ph.D.

Janet WaIlersheims, Ph.D. Donald Freed.heim, Ph.D.

Larry Beutler, Ph.D.

Suzanne B. Sobel, Ph.D., Chair

COUNCIL REPORT

I

August, 1993

Carol D. Goodheart

The annual convention meeting of the Council of Representatives was held in Toronto, Canada, where the city seemed especially open and welcoming of AP A, al though some of the exci temen t may be attributable to the winning streak of the Toronto Blue Jays at the time. The business of Council contained quite a few items-that are of interest to members of our Division.

Health Care Reform took front and center stage as a challenge to all psychologists, regardless of work setting or orienta tion. With the knowledge that regardless of the package proposed by President Clinton there will be many suggested and contested changes to it when it goes to the Con-

gress, the Council voted to approve the funding for the proposed APA Health Care Reform initiative. For 1993, the budget of up to $1,578,000 will be funded from the contribu tions obtained from the fund-raising campaign. If those funds raised fall short of the requirement, the shortfall will be funded from general APA funds. For 1994, a budget of up to $1,521,600 will be obtained. from (a) a $30 levy to all special assessment payers, which is expected to yield up to $930,000 (those who contributed to the 1993 voluntary campaign may exempt themselves from the levy; (b) $322,000 from AP A general funds (already built into the 1994 preliminary budget); and (c) any further 1994 voluntary fund-raising

51

that might be initiated. Any shortfall to the approved budget will be funded from general AP A funds. These budges for this year and next year, support APA's comprehensive plan to address the health care crisis and ensure psychology's future.

There was a two hour debate on-the proposal for the formation of the National College of Professional Psychology. As often happens with controversy (remember the Ethics Code debates), Council arrived at a position that should leave the opportuni ty for commen tary and resolution:

"The Council accepts and appreciates the report submitted on the National College. We urge CAPP to continue to develop the concept with its resources while the presently available material is submitted to Boards and Committees, Divisions, and State Associations for their input. This item is referred to the February, 1994 Council for action on the National College proposa1."

The Dual Service Prohibition (Association rule 30-7 which prohibited National Register Officers from serving on AP A Boards and Committees) was rescinded. It was made retroactive in the particular case of an APA member, who will be reinstated on the AP A committee from which he had been removed. In a related item, the CAPP proposed Guidelines for Identifying/Resolving Organizational Conflict of Interest were referred for review by the appropriate Boards and Commi ttees. The Guidelines will be considered at the next meeting of Council in February.

Council supported Frank Farley's presidential initiative to convene a Second Century Assembly, and approved the Second Century Mem bership Campaign to make APA more accessible. The Task Force on Urban Ini tiatives was funded to proceed, based on strong member response to the call for information and on interest and support from the National League of Cities. The Task Force on Psychological Intervention Guidelines meetings were funded as well. In the international arena, Council approved funds for AP A' s contribution to advanced training seminars for psychologists from developing countries, in conjunction with the 23rd International Congress of Applied Psychology, and approved contingency funds to support the Committee on International Relations in Psychology (CIRP) TaskForce on Psychology in the Commonwealth

52

of Independent States (formerly the Soviet Union and Easter Europe states). Our other Council representative, Donald Freedheim, is active in these international projects as the immediate past-chair of CIRP.

The birth of a new Division 49 journal was approved, tentatively title American Journal of Grou p Psychology and Psychotherapy. In other education affairs, the report and recommendations of the National Conference on Imp lementing Public-Academic Linkages for Clinical Training in Psychology were acknowledged with appreciation. Also, a proclamation in support of the United Nations International Year of the Family was adopted, which calls for program initiatives that weave the theme into the 1994 APA Convention.

There were some items significance in the pu blie interest sector. The continuation of the Ad Hoe Committee on Psychology and Aids was authorized for a five-year period, based on the fact that the Aids epidemic is not expected to ease in the foreseeable future and its mental health implications are profound. Returning to old business a_ the situationshifted, Council passed an amendment to the original anti-dis crimination resolution adopted in February, 1993. In response tc Colorado'sreferendumtolimitanti-discriminatior legislation as it applies to lesbian, gay, and bisexual people, the following intentions were added: "Therefore be it resolved that the American Psychological Association take immediate steps to provide any pertinent psychological information and consultation to the parties invol ved in the consti tutional challenge to Amendment 2; and if Arnendmen t 2 is not overturned by the courts in 1993, be it resolved that the American Psychological Association then consider the issue of a boycott.

The agenda was so full that some importan i terns were tabled until the next morning, e.g. tho Task Force on Psychopharmacology Report recommendations. Nevertheless, it seemed to be ~ satisfying and productive set of meetings.

If you have an issue you would like presented Council, or if you have questions about ali Council matters, please let me know.

PROFESSIONAL LIABILITY

Personal computers are routinely equipped with 80 to 120 megabyte hard disks, which roughly hold the equivalent of 50 to 75 thousand typed pages of data. The industry standard for floppy disks is currently the 1.44 mega byte 3.5 inch disk. Practitioners could easily keep all of their client data on a few of these disks, either permitting a high level of protection against unwanted access (these disks stay with the professional, or better yet, are locked up when not in use), or, if these small object are lost, stolen, or misplace, making all of that data available to anyone who obtains them. Also, it takes only a ing dependence and few minutes and the most rudimentary of compu ter skills to copy a floppy disk, thus easily allowing someone else to make a copy of an entire fund of information.

Technology and Confidentiality in the Office

Robert A. Brockman and Leon Vandecreek

Information technologyisa rapidly growing and changing field, barely keeping pace with, though being intimately tied to, the explosive computer revolution. Fax machines have become commonplace in offices, as have photocopiers, computers, cellular telephone, and answering machines. Moreover, each of these technologies is becoming more powerful (faster, improved quali ty, and, usually, easier to use) and less expensi ve on an almost daily basis.

It is likely because of this improving price/performance ratio that this technology has come to play an increased role in all business fields, including psychotherapy. From compu terized psychological assessment and billing to the ability to immediately send and receive data from another professional via fax or computer, each advance has brought with it the po ten tial for grea ter personal freedom, plus a higher level and increased latitude of professional

service. But for each of these potential advantages there exists potential disadvantages, typically in the area of increased risk for breaches of confidentiality. It is not surprise, then, that the growing dependence and emphasis on this technology brings with it growing concern about privacy issues.

VCRs have in homes. But many of the most attractive features of computing are also potential danger points in confidentiality.

Problems with the Technology Itself

It is no surprise, then, that the grow-

emphasis on this technology brings

with it growing

concern about

privacy issues.

This article briefly outlines potential problems these technologies pose to confidentiality and suggest some solutions to these dilemmas.

Computers; The Omnipresen Appliance

Generally, it is wise to not keep any data files on the computer itself, only the application programs

themselves. Data should always be stored on removable media, such as floppy disks, which should be secured when not in use.

Too Much of a Good Thing

Since computers allow for easy collection and manipulation of information, manypracti tioners feel they ought to collect and keep all data, which can also become a problem. Between word processing (client notes and reports, which in themset 15' containverydillerent types of data)

data base and acrounting programs (insurance, or financial data), therapists could ha ... -e a great deal of personal information about any gi.-en client It is important, then, to keep a _ information that is absolutely necessary for use.

53

Modems: Fax and otherwise ...

Portable telephones, not to be confused with cellular telephones, were originally designed to operate on high-end AM radio bands. Conversations on these devices can be moni tored via home

... electronic mail is stereo or even portable

(Walkman-type) radio equipment. More recent units rely on UHF frequencies which are less easily monitored, but are still within the eavesdropping realm of the home electronics enthusiast.

Computers are increasingly being used for electronic mail and faxing. These dangers will be expanded upon more in the section covering fax machines, but basic dangers inel ude sending sensitive data to the wrong person, or unwanted persons having access to the data as it makes its way to the appropriate person. In fact, electronic mail is much more easily opened and ready by unwanted persons than is traditional mail, withou t the signs of tampering that a paper envelope might show.

In terms of electronic mail or faxing from a computer,careful use of'electronic addresses or phone numbers, as well as cover pages

(for fax) are appropriate, and will

be elaborated on further in the section on fax machines.

being projected by analysts as the next step in the evolution of information technology. PIMs are small, hand-held, electronic devices that combine the functionality of date and address books, post-it notes, and free-form data bases, and typically include built-in cellular fax and printer connections. This would penni t someone to write a memo anywhere on an airplane or park bench and instantly print it on any fax machine or printer (specially equipped with a receiving device).

Problems with the Teclmology Itself

Parallel Issues in Manual Systems

much more easily opened and read by

unwanted persons than is

Files and other sensitive information, even in a well automated office, will still exist, on some level, on paper. Precautions should always be taken so that these data

are not left laying about, that cabi-

nets are not left open, and that appropriate documents are not without warnings such as Confidential on them. It is generally best to have a certain area where sensitive information is kept, and access to that area be limited, both by physical entry into the section as well as by locked cabinets.

traditional mail ...

Both portable and cellular phones

typically offer a choice of frequen-

cies, set via a small switch ont he unit itself, which are often mistaken by the use as a form of confidential protection. What swi tching codes actually does, however, is merely change among a rigidly defined set of radie frequencies, in the event that another device using the same frequency is operating in the immediate vicinity. Devices that use this technology, including phones and fax machines, USE one of a finite, and thus monitorable, number 0:

AM or UHF bands.

Telephone-Related Technology:

Calling for Trouble?

Cellular technology allows nearly unlimited freedom from the traditional, "wired" telephone. These devices allow clients or therapists, wherever they are, to can tact their thera pist or clien ts, wherever they are. This permits time previously considered dead (non-billable), such as time in transit, to be used more productively, in consultation with secretarial staff, fellow professionals, or even in contact with clients.

Additionally, new types of computers known as ~rsonal information managers (or PIMs) are

These problems represent a severe gap in confidentiality. Just as many people enjoy listening tc airport tower, aircraft, and emergency (police ambulance, etc.) communications, a new realrr of electronic voyeurism has opened: the abilif to intercept printed informa tion as well as audi. data reduces confidentiality of this data, pater tially, to zero.

A simple solution is available: it is best not to u portable or cell ular technologies for any in for - lion, verbal or printed, that is even remote.

confidential. Different types of data encryption and transmission frequencies are being considered for future devices, but, even then, the ease with which these transmissions can be intercepted make them undesirable for all but the most innocuous professional use. The more traditional wire-based phone and fax technology is much more reliable, both in terms of da ta quali ty and for ensuring confidentiality.

When a therapist accepts from or places a call to a client, especially if the conversation is more than basic logistical information concerning and appointment, the therapist might wish to ask if the client is using a portable or cellular phone. If the client is using this technology, the therapist should alert the client to the potential risks in confidentiality, and then give the client the option of calling back on a regular phone (Hyman, 1989).

the appropriate scoring center, and have fully scored and interpreted results transmitted back almost instantly. There are also services that allow therapists to fax all financial informa tion to them at the end of each day, allowing a remote agency to handle aU billing matters, freeing the therapist from this potentially tiresome and complex duty.

But fax information can be sent to the wrong machine, or otherwise become misdirected. Some facilities have one fax machine in a central location, such as the mailroom, which means it may take a day or so for a fax to be routed to the appropria te person via inter-office mail, or, at the very least, it may be viewed by any number of people, for faxes, unlike regular mail, do not arrive sealed in an envelope (Feste, 1991 i Caserta, 1989).

On Answering Machines

Extraneous, unneeded, or unwanted information may also be transmitted. Similar to the "collect cover sheets should it all" philosophy discussed with

computers, in absence of clear instructions or understanding of wha t information is to be sent, some in-

dividuals or facilities will send much more of a client's file than is appropriate (Peste, 1991).

Clearly designed

Answering machines present a danger to client confidentiality in that sensitive information may be left on the tape, and then made available to anyone who has access to the machine, directly or

remotely. Clients may call and leave explicit or identifying information about themsel ves which custodial staff, for example, might be able to listen to.

always be used when sending fax.

The outgoing message on a therapist's answering machine should clearly indicate tha t only the barest of information should be left, such as name and phone number, to protect the client as much as possible. The message should be time-limited, also, so that clients are given only a 30-60 second time to leave their message. Care should be taken when playing back messages to that others do not overhear the info rma tion shared on the tape.

Fax Technology. The Commonplace Time-Sa er

Clearly designed cover sheets should always be used when sending fax. These cover sheets should describe who sent thedocumen t, from what number, how many pages (including cover sheet) are being transmitted, the date and time of the transmission, who is to receive the information, at what number, the authorized receivers name, statement regarding redisclosure, statement regarding destruction of facsimile, and instructions for receiver to verify correct receipt of document (Fesle, 1991). Most machines now include automatic dialing. which helps prevent misdirected transmissions.

Frob ems with the Technology Itself

_ _ earl_ r inexpensive fax machines use a special thennaI sensitive paper that is unstable, as deteriorates over time, and thus must be

tocopied. The photocopy produces yet another copy of the sensitive document, and introduces even more image degradation, as the copy 55

is now one more step away from the original document.

Use of plain-paper fax machines eliminates the need for making an archival photocopy for the permanent record. The cost of plain-paper machines is rapidly dropping, and fax technology is now being buil tin to many laser printers, permitting a very high-quality fax document.

Conclusion

Technology itself obviously is not the only cause of breaches of confidentiality. Violations of confidentiality can also occur by use of poor judgment, such as when data are shared by staff who feel pressured by others with professional titles or who threaten a lawsuit (Wolkon & Lyon, 1986). The mostcomrnon threats to confidential-

ity occur passively due to laxness on the part of the professional, such as by leaving folders laying open arnot taking proper steps when disposing of client information (which should always be shredded) rather than actively, due to someone purposely trying to gain access to the information.

Caserta.j.E, (1989). To fax, or? Home Heal th care Nurse. 7, (5), 4.

Feste, L. (1991). Practice bulletin: Guidelines for faxing patient health information. Journal of the American Medical Record Association, 62, (6),29-35.

Hyman, D.S. (1989, November/December). The wireless phone and confidentiality. The Maryland Psychologist. p.18.

Woldon, G:H., & Lyon, M. (1986). Ethicalissues in computerized mental health data systems. Hospital and Community Psychiatry, 37, 11-16.

SUBSTANCE ABUSE

Substance Abuse Updates

Harry K. Wexler

• The many substance abuse presentations at the 1993 AP ANa tional Can ven tion is a strong indication of the increasing interest in the area by psychologists. Substance abuse was the 12th most popular topic (among 57) in the Convention Program Subject Index.

The formation of AP A's National College of Pro-fessional Psychology was actively discussed at the National Convention in Toronto. The College is designed to provide a new standard for the training of practicing psychologists and to offer training in specialty areas for PhD. licensed psychologists. If AP A governance agrees to implement the College, the first area of specialization to be offered will be substance abuse. Certification will be offered to all psychologists who can document adequate substance abuse experience. Those who cannot document sufficient experience will be able to take a competency test. Doctoral graduates can also take an exam and receive certification when receiving state

licensure. A certification in Hospital Practice has also been developed and piloted.

·Por important current information on theory, practice, and research on psychotherapy for the addictions, interested readers should see the Surruner 1993 issue of Psychotherapy, a special issue dedicated to the addictions (guest-edited by George DeLeon, Herbert J. Freudenberger, and Harry K. Wexler).

.Attention Deficit Disorder (ADD) is receiving increasing attention in all areas of psychology. ADD characteristics include: inattention, impulsivity and motor hyperactivity. There is often considerable shame and depression associated with the disorder. Anew look atthe role of ADD in substance abuse is needed. Research has shown unusually high rates of substance abuse among untreated ADD males (perhaps a form 0: self-medication) and an exceedingly low rate 0; addiction among males who have been diagnosed with ADD and treated will" psychostimulants. ADD is typically not considered during assessment of addictive disorders Practitioners need to become familiar with t

56

clinical signs of ADD and begin assessing substance abusing clients for ADD so that they can be treated. The study and treatment of ADD has become a primary area of interest at The Psychology Center and persons interested in sharing information on this topic are invited to contact me at (714) 497-0915.

• Most experienced clinicians who have been in the field for about ten years or longer have noticed a dramatic shift in attention and public funding from mental health to alcohol and drug abuse. An analysis of this historical development is the subject of an insightful article by Humphreys and Rappaport in the August issue of American Psychologist. Public substance abuse programs have inherited the funding and clientele of the Community Mental Health (CMH) movement spawned in the Progressive 1960s. Tills shift occurred mainly because of the censerva tive Reagan-Bush administra tions, which conceptualized substance abuse as an individual moral failing (i.e., the failure to "just say no") rather than a product of unjust social conditions, psychological trauma, financial inequality, or the American political agenda. By focusing on the individual rather than the larger society, policy makers have been able to justify expanded police powers and aggressive foreign policy. The focus on moral failings of individuals who abuse drugs also helps foster the view of certain minority group as morally weak and inferior; these

ethnic groups are then more likely to be viewed as the cause of the social problems that accompany drug abuse (e.g. crime, AIDS, drug babies, and the like). Poverty-stricken drug abusers are often viewed as a component of SOciety labeled the "undeserving poor." Humphreys and Rappaport contend that until the SOciopolitical climate changes, funding, research, and treatment will continue at the individual level and scientific research willlikel y con tinue to valida te the conservative ideology.

=The Psychology of Addictive Behaviors Division (50) had its first official meetings at the AP A convention in Toronto. The board is expected to meet again in November. Committee Chairs have been appointed, and both the newsletter and journal editors have been approved, so both publications should begin relatively soon. The Division on Addictions has expanded to include not only alcohol and other drugs, but also smoking, food, and gambling. The division is interested not only in treatment of the addictions, but also research and training, and warmly invites interested psychologists to join. For applications and membership information, please contact James Sorensen, Ph.D., at (415) 206-8764.

I would like to offer special thanks and appreciation to Beth Twamley for her considerable assistance in the preparation of this column.

GROUP PSYCHOTHERAPY

Redecision Therapy

John Gladfelter

Redecision Therapy, a humanistic approach to group psychotherapy was developed by Robert and Mary Goulding and is based on a combination of Transactional Analysis and Gestalt technique. This methOO is derived from the Transac-

tio -: Ego T ,0,-

Ganes actional _Ana.."!SiS o;:. .... ~_

sizes the a bou t ch.;mrg~ lledlll!C&1C8. f"::IeD:'1'SE~C

Transa ,-- _..........: ..

techniquesofi __ ~ ..... II:R:~_u. techniques State in

therapist in vites the pa tien t to re-experience from the Child Ego State emotionally laden events from the past and to change the earl y choice in the now. In those early life experiences the Child Ego Sta te made the best choice possible for tha t developmental stage; these early choices however, set the scene for later life events that develop into impasses.

57

tive processing abilities. The early decision or intention to feel bad made sense to the young child in the context of his family and his life.

The intrusion of the bad feeling and the conflicted thinking bring the grownup into treatment, usually in the context of a current life even t which parallels an early family conflict. The adult in everyday life struggles with the cognitive incongruity between the bad feeling and an otherwise Seemingly neu tral life event. The resolution of the impasse comes about in therapy w hen the patient chooses to think and feel differently about the early experience. The resolution must take place from the Child Ego State. The redecision process is followed by repeated sessions of working through current life situations in which bad feelings are experienced again and in which the patient experiences the possibility of responding differently. An impor-

tant belief of this approach is that the power for change lies within the patient; the effective group therapist facilitates the patient's using his or her own cognitive, behavioral and affective power.

described at the intuitive part of one's self. After the Redecision experience the patient is supported in working through ways in which he/ she can employ those new thinking and feeling changes in everyday life. The group's encouragement, support and acceptance of changes in the patient are fostered by the therapist. Reluctance to change is dealt with on an individual basis and is related to the person's readiness to deal with personal issues.

There are often moments when the group therapist will encourage bragging or self-stroking for important changes being made by the person. Critical, angry or distressed comments made by one group member to another are considered an indica tion that the member is needing to resolve so me feeling. ~nera. ted by the therapy in p .. mgr. ess and is in his /her Child Ego State. The therapist

will block an interruption of a

member who is in distress and afThe contract often ter completing ongoing work, will work with the distressed patient From a Rededsion viewpoint, the use of one-to-one in the group at the pain t of a member's distress is seen as a direct intervention which will facilitate a resolution of the conflict. A non-protagonist who is commenting is urged to wait un til work is completed and then a possibility of a contract is explored with the interrupting patient.

involves exploring current life

experiences which are replays of the

A significant aspect of Redecision Therapy is the development and maintenance by the group therapist of a supportive and nurturing environment. From the intake experience on, the patient is supported and encouraged to think

about what they want to change. They bring those conflicts into the group in the first session. The therapist works with each member of the group each session and is both supportive and confrontive around the contract for change.

patient's early

distress ...

In Redecision Therapy the therapist is mindful of working from a contract ora treatment agreement with the patient. Contracts areconsidered an importan t vehicle for working within the constraints of what the patient consciously wants to change. This enables the therapist to help the patient resolve some of the reluctance engendered by the thera py process. The contract often involves exploring curren t life experiences which are replays of the patient's early distress and bringing tha t past life experience into the present. The therapist's tasks is to help the patient decide how he/she want to feel and think differently about those earl yexperiences, The therapist then engages the patient in a dialogue between archaic Ego States from those early experiences and the Little Professor Ego State to bring about a Redecision. In adults the Little Professor is

58

The leadership style in Rededsion Therapy is moderately directive. Some therapists describe it as one-to-one therapy in a group. This does no: mean that the therapist is oblivious to the group Most Redecision therapists have trained ir psychodynamic group therapy and arecognizant of the nature of transference anc counter-transference. A solid foundation ir psychodynamic group psychotherapy is a major advantage for the therapist, it enables the therapist to be aware of the group processes. The group process will be monitored but not used as a part of the thera py. An important di fference if Redecision Therapy from psychodynamic grour therapies is the place of transference. Tho Redecision therapist attempts to minimize transference, does not invite transference and doe what is possible to direct the patient's wor. toward resolving the impasse which transfer ence represents.

The negative feelings of any group member ar an important resource for the group. They represent an opportunity for the person to express a r

change those feelings and explore ways in which they may resolve archaic issues. The group is encouraged to give supportive and positive comments to the patient who has just completed his/ her work; the support and reassurance of the group and the therapist assists the person in anchoring the good feelings. Anchoring means that the person experiencing a situation that ordinarily produces bad feelings can access positive feelings from the prior therapy work.

In Redecision groups the therapist is the person who does the therapy and that the group's role is that of support and encouragement. There are many aspects of the group life which are readily shared with the group. Contagion of feelings allows each person in the group to access old bad feelings which then become a part of the contract and redecision process. Each patient provides a model for other group members as to how to proceed with their own issues in therapy. Responsibility for time structuring is shared with the group. The therapist makes it dear that group members may expect protection from the leader when there are attacks or distorted affect-dri ven in terventions made by group members. Sensitivity of the group leader is paramount for modulating the interaction of group members. The agenda of group is that of the individual group members being held responsible for their psychotherapy and held to contracts made previously unless dearly changed or

redefined. Each group member knows he/she holds some responsibility to other group members so others can work on their contract each session. It is also the working chaUenge to the group leader that each member can work each session on their contract unless they dearly decline such an opportunity.

Therapists generally allow twenty minutes as a maximum for each patient in the group. Such a frame may be altered and managed by the therapist but must be respected in the interests of the individual group members each session. The Redecision therapist believes that the process of therapy can be understood by the patient; there may be situations in which the therapist will discuss the previous therapy work with other patients with the permission of the working patient.

Redecision therapy by the nature of the process and theory is an approach which readily lends itself to either short term or long term group therapy. It is a treatment method which has applicabili ty to a wide range of human problems. Although extensive supervision and training are required for the use of this method, the advantage to a practicing psychologist is considerable. Almost all such training is only avail a ble ou tside of the traditional clinic or university setting. Experiential workshops which allow a sampling of the approach are available in state, regional and national professional meetings.

- -- - - - -- - ------ ---- -- --- '-- ---

New Section on Clinical Geropsychology Seeks Members

A Section on Clinical Geropsychology has recently been established in APA Division 12 (Clinical Psychology) in order to further the professional goals and interests of psychologists who practice with older adults, teach the clinical psychology of aging, or conduct related clinical research. Division 12 allows interest subgroups to become formal, permanent organizations within its structure. The new organization, designated as Section Il, joins five other existing sections and is open for membership applications.

The section's purposes are: to support and to encourage the evolution and development of the subspecialty of clinical geropsychology in both its scientific and professional aspects; to increase scientific understanding of the mental health of older adults; to promote the development of models for the delivery of psychological services for older adults, as well as other ways of enhancing the welfare and mental health of older adults; to foster the collaboration and sharing of information among clinical geropsychologists; and to increase the quality and availability of training opportunities in clinical geropsychology.

As Section IT develops, it will offer a variety of opportunities for members to pursue these goals, such as through a possible newsletter, increased participation in the Division 12 program at APA Conventions, an enhanced voice for clinical geropsychology in arenas both inside and outside AP A, and other ad-

vocacyefforts. The Section is not intended to be competitive with other geropsychology in arenas both inside and outside AP A, and other advocacy efforts. The Section is not intended to be competitive with other geropsychologists entities but, rather, to provide a "horne" for clinical geropsychologists within the organizational framework of AP A and Division 12 and facilitate a greater emphasis on aging-related clinical issues in AP A and divisional programs, publications, committees, and other activities.

An ad hoc steering committee has been organized to oversee the Section's start-up acti vities. Its members are Barry Edelstein, Dolores Gallagher-Thompson, Margaret Gatz, Alfred Kaszniak, George Niederehe, Mick Smyer, George Stricker, and Linda Teri. An election of officers for 1994 will be held in the fall of 1993.

All AP A members and students with interests in clinical geropsychology are invited to apply for membership and to participate in Section II. Membership in Division 12, although encouraged, is not a prerequisite. In most regards, the Section's Affiliate Members (nonmembers of Division 12) and Assodate Members (Associate Members of AP A) will be eligible to participate in the Section on the same terms as Divisional Members. For 1993, dues have been set at the nominal level of $10 for members, and at $5 for student members. The dues are expected to remain the same in 1994.

For further information and application forms contact:

Dolores Gallagher- Thompson,Ph.D., Geriatric Research, Education & Clinical Center, GRECCJ182B, VA Medical Center,

3801 Miranda Avenue, Palo Alto,

CA 94304, (415) 617-2774, Fax: (415) 617-2778.

60

CALL FOR PROGRAMS

ANNUAL CONVENTION

AMERICAN PSYCHOLOGICAL ASSOCIATION

LOS ANGELES, CALIFORNIA

AUGUST 12-16, 1994

Proposals Must Be Received By December 3, 1993

Division 29's Theme For The 1994 Convention Is Psychotherapy In The Era of Health Care Reform

Program Proposals That Address Psychotherapy For

Children, Adolescents, Adults and Or The Elderly Are Invited

Please Send Programs For Division 29 To:

Edward F. Bourg, Ph.D., Program Chair

c/o Division of Psychotherapy Central Office 3875 . 44th Street, Ste. 102, Phoenix, AZ 85018

~x 6 2) 952-8230

CALL FOR PROGRAM REVIEWERS

Di vision 29' s program has been particular! y exci ting over the years because of your partici pa tion. If you are willing to be a reviewer for the Division of Psychotherapy (29) 1994 Convention Program, please fill in the Reviewer Form below. It is especially important you include your areas of interest and expertise.

The deadline for submissions this year is December 3, 1993. As soon as basic data from the program submissions is entered into our computer, program proposals will be mailed au t forreview. For your information and consideration of being a reviewer ... the time frame for review of proposals will be approximately December 17, 1993 to January 5, 1994.

Please mail the completed form below to:

Edward F. Bourg, Ph.D. 1994 Program Chair

The Division of Psychotherapy (29) Central Office

3875 N. 44th Street, Ste. 102 Phoenix, AZ 85018

1-------------------------------1

I (clip and mail)

I I I I I I I

I (please print)

: Name--------------------------I Business Name---------------------------

I Addre~--- _

1 Street!City!Zip _

I DayPhone EverungPhone-----------

I FAX# _

I

I Areas of interest, specialty and! or expertise: _

I I I I I

I Form must be RECEIVED by November 30,1993

L _

DMSION OF PSYCHOTHERAPY (29) REVIEWER FORM

Yes, I would like to be a REVIEWER for the Division of Psychotherapy (29) 1994 Convention Program.

62

Division of Psychotherapy of the American Psychological Association 1993

STANDING COMMITTEES Education and Training

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

Office: 404-671-1200

FPC<; 404-671-0476

Hans Strupp, Ph.D., Co-Chair Dept. of Psych., Vanderbilt Univ. Nashville, TN 37240

ors ce: 615-322-0058

Fellows

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

Office: 407-773-5944

Finance

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

Pittsford, NY 14S34 ()Blce:716-586-0410

FAX: 716-586-2029

Gender Issues Committee

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

116 84, DE Teaque V A 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 Mikesell, Pb.D~ Chair 4801 Wisconsin Avenue NW Suite #503

Washington, D.C. 20016 Office;f02-9~7498 FAX: 202-966-3745

Multicultlmll Affairs

Samuel S. Hil~ III, Psy.D~ Chair Corpus Christi State University 6300 Ocean Drive

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

FAX: 818-993-4202

Nominations and Elections

Tommy T. Stigall, Ph.D., Ch4ir 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., Ctuur 510 Huron Rd.

Delmar, NY 12054

Office: 518-439-9413

FAX: 518-439-9413

Professional Practice

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

FAX: 714-497-0913

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

110 W. Squantum, #17 Quincy, MA 02171

Office: 617-471-2268

FAX: 617-323-2109

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

FAX: 510-521-5121

William S. Pollack,. Ph.D., C.E. 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 Development

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

Miami, FL 33163

OffiCE: 30:>-943-7(88

Voice Mail: 305-447-7941

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

2500 Metro Health Drive Oeveland, OH 44100-1998 Office; 216-459-4647

FAX: 216-459-590'7

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 Oil Adolesants 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: 7Ur586-2029

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

P.O. Box 016960

Miami, FL 33136

Office: 305-545-6319

Task Force 011 Amerialn Indian Mentld Health

Diane Willis, Ph.D., Chair Gtild Study Ctr. University of Oklahoma 1100 NE 13th St. Oklahoma City, OK 73117 Office: 405-271-6876

Task Force on Men's Roles and PsychothErapy

Ronald Levant, Ed.D., Chair 1~3 Beacon a, Ste. 3C Brookline, MA 02146

Office: 617-566-4479

Task Force on Trauma Response & Resean;h

Ellin Bloch, 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 American Psychological Association 3875 N. 44th St., Suite 102 Phoenix, AZ 85018

Non-Profi1 Organization U.S. Postage PAID Phoenix, AZ 85018 Permi.t No .. 311

1,1" J ,I, ,1",1111,,, 1,1",,1, II ABRAHAM W WOLF 3395 SCRANTON RD

METROPOLITAN GEN HOSP/DEPT OF PSYCH CLEVELAND OH 44109