Grist for the Diploma Mill
There was a blurb about this in March's Philadelphia Magazine. Kind of frightening, when you think about it.
Christopher J. Combs, Ph.D. on 02.29.04 @ 06:23 PM EST [link]
Christopher J. Combs, Ph.D.
Sunday, February 29th
Thursday, February 26th
Test Insecurity
Anyone need a set of Rorschach cards?
Christopher J. Combs, Ph.D. on 02.26.04 @ 06:37 AM EST [link]
Wednesday, February 25th
Mid-Course Evaluation
The problem with course evaluations is they usually come at the end of the course. Depending on the conscientiousness of the instructor, this may stand to benefit future students in the course, but has little impact on the experience for the current students.
Please feel free to leave comments about what you would like to see changed. I believe you can post anonymously here by using a made-up name and email address.
Would you like more factual information or less?
Do you like the semi-public weblogs, or would you rather have had a private journal? Do you read others' weblogs, and if so, do you find that valuable?
Now that we're halfway through the course, is it apparent there are any important topics missing from the syllabus?
Should I talk or lecture more, or should I keep quiet more often? (Note that there will be coming weeks without your presentations, so I expect to lecture more)
If you're more visually-inclined, or if words aren't your thing, feel free to use the emoticons to the left of the comments window.
Feel free to vent your spleen. Remember, I did ask for it. 
Christopher J. Combs, Ph.D. on 02.25.04 @ 03:49 PM EST [link]
Translating Knowledge Into Action
How can we help more psychologists act ethically?
We've seen how most psychologists are aware of the Ethics Code and the law. We've also seen how even the Masters of Ethics - the luminaries in the field who've written the definitive texts on the Code or even the Code itself - have had trouble adhering to it, at least in some situations. I have no doubt that you all, as bright, enthusiastic, and well-intentioned doctoral students, knew 80-90% of the factual of the information in this course before you stepped foot in the class.
So how do we get from here to there?
Because we know that knowledge and education are not really the problem, I think we first have to re-evaluate how we select our doctoral students. Most programs choose their students through reviewing an application, letters of recommendation, and a personal interview. In terms of job selection, we know that applications and interviews have the lowest validity coefficients in predicting job success. How much can you really learn about a person from
1. perusing an application created by that person
2. letters written on that person's behalf by people selected by the applicant, who probably don't want to rock the boat, and who may fear being sued for documenting anything negative
3. spending an hour with that person?
Some of you may be familiar with the drama that my wife and I have been going through trying to adopt a child . The state and the adoption agency has a vested interest in protecting the welfare of a vulnerable individual - in this case, the child - so we had to go through multiple procedures just to get approval to adopt. We had to:
1. complete an application and 15 page questionnaire about our marriage, attitudes about adoption, and parenting skills
2. meet with a social worker for a personal interview
3. attend multiple educational classes
4. have a home visit to ensure our house is safe and that our application responses are true
5. undergo a physical examination by our family doctor
6. pass a criminal background check
7. get a child abuse clearance
8. get fingerprinted and get clearance from the FBI
9. probably more that I'm forgetting
All of this, just to protect the interests of one person, albeit a vulnerable one due to his or her age. Our clients are vulnerable, emotionally, and most of us have many of them. Don't they deserve the same respect and due diligence to their interests?
Perhaps we should add a background check and psychological testing to the admissions procedures for graduate school in clinical psychology. If our tests are good enough to use with our clients, they should be good enough as a tool to help police ourselves. Clearly, a negative finding shouldn't necessarily exclude someone from becoming a clinical psychologist, but maybe that person needs more intensive scutiny, additional coursework, or prescribed psychotherapy in addition to the normal classwork and practica. There is something to be said for choosing people of good moral character (though not perfect people) for a noble profession that works with a vulnerable segment of the public.
Second, we need better role models for graduate students. When I was in gradute school, I was appalled at some of the behavior that I observed by some professors, and this was on a regular basis. Part of teaching should be leading by example. If we do a better job of selecting graduate students, as outlined above, perhaps this problem will take care of itself - eventually. But if we believe in vicarious learning and the power of modeling (Bandura's stuff), we need to hold professors to the same standards as students.
Finally, I think we need to have mandated peer-supervision as a requirement to maintain one's license. As it stands now, to practice in Pennsylvania you need to:
1. get permission to take the licensing exam by graduating from an acceptable school and do your post-doctoral hours
2. pass the national and state exams
3. get 30 hours of continuing education credit every two years, including 3 hours in ethics
4. pay the fee
That's it. The three hours of ethics is a step in the right direction, certainly. But I think we need to look out for each other, and more importantly, realize we need to be looked out for. Isolation and hubris are two dangerous ingredients in the recipe for a serious ethical violation. Mandatory monthly or bi-monthly peer supervision would ensure that we all take the time to discuss difficult situations with our peers, demonstrating that we took "reasonable" steps and were trying to maintain the general standard of care for our profession. It also allows us to spot problems in our peers - either their blindspots or problems they are having which they may be unaware of - that are impacting their work. And with the Internet, even a clinician who is geographically isolated from other professionals can become part of a peer-support network through online technologies.
If you've taken my Group Psychotherapy course, you may remember reading that Yalom has a monthly peer-supervision meeting with his colleagues. If it's good enough for him, shouldn't it be good enough for us?
Those are a few of my ideas about this problem. I am sure there are plenty of other excellent suggestions that would help alleviate this problem with being unduly burdensome on the clinician.
Christopher J. Combs, Ph.D. on 02.25.04 @ 08:51 AM EST [link]
Neologism
I think Amy invented a new word: "I was like damb!"
Christopher J. Combs, Ph.D. on 02.25.04 @ 07:43 AM EST [link]
Tuesday, February 24th
Comments
If you want to add a comments feature to your weblog, try Haloscan.com. Their privacy policy is listed at the bottom of the first page, and if you sign up with them, it does not appear it will result in more spam in your inbox. I have seen other weblogs that are using Haloscan, and it seems to work well.
So if you want to let a Dancing Bear leave little pic-a-nic baskets of rhetorical fun underneath your entries, think about adding a commenting feature.
Christopher J. Combs, Ph.D. on 02.24.04 @ 01:31 PM EST [link]
Emerich v. Philadelphia Center for Human Development
The warning was vague.
I read the Pennsylvania Supreme Court's opinion in Emerich v. Philadelphia Center for Human Development to gather some of the details we discussed in class. One interesting aspect of the case as it unfolded is that lower courts had ruled in favor of the defendant because the Pennsylvania legislature had not enacted a Tarasoff law.
The Supreme Court overruled the lower courts, finding the reasoning in the Tarasoff decision sound, and finding a basis for an affirmative duty in previous Pennsylvania case law. They specifically based this duty to protect the public on:
1. Physicians are obligated to inform the public (state health agencies) and potential victims of contagious diseases.
2. Psychiatrists have been held liable for the harm caused by psychiatric patients negliently released from their care (usually from a psychiatric hospital).
The Supreme Court also took up one of the arguments raised by the defendant, that clinicians have no real ability to predict violence. The Court found this argument unpersuasive, although they sympathesized with its difficulty:
"Mindful that the treatment of mental illness is not an exact science, we emphasize that we hold a mental health professional only to the standard of care of his profession, which takes into account the uncertainty of such treatment. Thus, we will not require a mental health professional to be liable for a patient's violent behavior because he fails to predict such behavior accurately."
The Court holds clinicians up to the standards of their profession, noting:
1. As noted above, clinicians have been held accountable for negliently releasing patients in their custodial care (i.e., a reasonable clinician would have foreseen the harm caused by the patient and not released him)
2. Clinicians routinely make determinations of violence potential, however imperfect, in involuntarily committing patients to the hospital, or encouraging voluntary hospitalization
3. Clinicians should be making a determination of violence and self-harm in every encounter with a patient, as the standard of care
4. Clinicians do receive, or should receive, information about managing the violent patient as part of their training.
The Court agreed that, like many instances in mental health, the warning given to the intended victim should be as discreet as possible, in order to protect the privacy of the patient.
As we discussed, the Court found that the warning given by the psychotherapist in this case did meet the duty. The therapist told the victim that she should not go to her old apartment that day to retrieve her clothes, without specifically saying that the patient had threatened to kill her. The Court found this warning adequate because:
1. The victim had been physically abused by the patient in the past, so she was familiar with his tendency to violence
2. The victim initiated the call to the therapist, suggesting to the Court that she had concerns that the patient might act violently toward her
3. The therapist told her not to go to the apartment, and the victim chose to not heed that warning.
Thus, the Court found that the proximal cause of the victim's death was her ignoring the therapist's warning. The Court determined that the warning was adequate, while still meeting the requirement of protecting the patient's privacy (i.e., what was said in the emergency session).
Two justices wroting opinions that concurred with the new "duty to protect by warning" but dissenting with respect to whether the warning in this particular case was adequate to discharge the duty. They both essentially argued that if you are going to require therapists to break confidentiality in warning a potential victim, the victim should know reason for the warning and be apprised of the threat. They believe that the therapist in this case should have told the victim that the patient threatened to kill her if she returned for her things.
It's a long opinion, and obviously covers a lot more ground than I've been able to summarize her. If you are interested in learning more, I would encourage you to read it, or at least sections of it. It's a bit on the dry side, as a lot of legal writing is, but it reads fairly smootly and is easily comprehensible to doctoral students, I would think. Heck, even I understood most of it, and I have trouble with them polysyllabic words.
Christopher J. Combs, Ph.D. on 02.24.04 @ 08:19 AM EST [link]
Wednesday, February 18th
In Pennsylvania, Aspirational in Mandatory
There was an interesting article, with potentially far-reaching consequences, in Winter 2004 State Board of Psychology Newsletter. In "Supreme Court Decides Case Involving the Practice of Psychology," authors Alex M. Siegel and Judith Pachter Schnulder describe the result of a case where a psychologist was disciplined by the State Board for failing to get permission from both parents before performing an evaluation on a child, where the parents shared legal custody. The Supreme Court essentially upheld the State Board's position. This confirms now the practical advice we have been giving about consent for evaluating or treating minors of divorced parents: you need to obtain permission from the person or persons with legal custody.
However, there was another result from the case that has an effect on every practicing psychologist in the state, regardless of your type of practice:
"In addition to following the [State] Board's Code of Ethics, (49 Pa. Code 41.60), psychologists often ask whether they must also adhere to the APA's Code of Ethics. Principle 3(e) of the [State] Board's Code of Ethics requires that a 'psychologist act in accord with APA Standards and Guidelines related to practice and ot the conduct of research with human beings and animals.' (49 Pa. Code 41.61(3)(e)). Psychologists have frequently questioned whether this is aspirational or mandatory. The question was settled in Grossman, when the Commonwealth Court upheld the Board's position that regardless of whether the APA intended the Guidelines to be aspirational for association members, the inclusion of the APA Standards and Guidelines in Principle 3(e) of the Board's Code of Ethics established a mandatory requirement for licensees in this Commonwealth. That is, the Commonwealth stated that the APA Standards and Guidelines must be adhered to as required compliance for the minimal standard of ethical practice. Consequently, the Court agreed that those sections which were considered aspirational in the APA Code became the minimal standard of ethical practice in Pennsylvania. (p. 7; italics added for emphasis)
Aspirational things are usually things that are strongly desirable, but perhaps not fully attainable. The APA Code of Ethics appears to recognize this, because it clearly separates the aspirational values from the specific guidelines, the latter being offered as the minimal standard of ethical practice while the former describe the "perfect" ethical practice. But here in Pennsylvania, we are being held now to a much higher standard as a matter of law. I suspect that the Supreme Court was basing its interpretation on a literal reading of the state's Code of Ethics: because it states clearly in Principle 3(e) that psychologist must adhere to APA Standards and Guidelines, therefore APA's Code in its entirety must be considered mandatory.
I've read the article three times now (it's only one page; you should read it too), and I can't see where this conclusion is directed only at custody evaluations. APA does have guidelines for custody evaluations (Guidelines for Child Custody Evaluations in Divorce Proceedings), so it's possible the Supreme Court's decision had a narrow scope pertaining only to these situations. But in reading the paragraph above, the language is pretty clear: the scope is much larger than that. If anyone else has read this and came away with a different conclusion, please let me know.
Christopher J. Combs, Ph.D. on 02.18.04 @ 08:44 AM EST [link]
Friday, February 13th
Mandated Reporting of Child Abuse in Pennsylvania
Tonight I was browsing one of my new favorite sites, Confessions of a Dancing Bear, when I saw that Jeff wrote:
"PA states that we report 'when (we) have reasonable cause to suspect, on the basis of their medical, professional or other training and experience, that a child coming before (us) in their professional or official capacity is an abused child.' Note this would require the client’s sister to be present and for her to have told us (impossible due to her age) or have some kind of physical evidence of abuse (not that any would be there from her brother trying to set her on fire!)."
I've had this discussion with many people, including mental health professionals, who don't believe that you are only required to report suspected child abuse in Pennsylvania if you actually see the child in your role as a professional. If the child's parent tells you he or she is abusing the child, you are not obligated to make a report. Furthermore, if you make a report against the abuser's wishes (as would often be the case) you run the risk of running afoul of confidentiality statutes.
So what would happen in Jeff's case if it occurred at a crisis unit in Pennsylvania, instead of New Jersey? Would he be excused from making a report, because he is working with the abuser? Under the Child Protective Services Law, the answer would be "yes." However, if he had good reason to believe that a child was at risk of serious harm (i.e., he believed the abuser's claims of abuse, and felt it was likely to happen again soon), he might be obliged to act in some way under Pennsylvania's version of the Tarasoff law. Unfortunately, the law is not too clear on this point, and in all likelihood it will be resolved in the courts one day instead of the legislature. This means, of course, that at some point, some psychotherapist is going to wind up in a heap of trouble.
You can read the Child Abuse Reporting Requirements for yourself, and we will be reviewing them in class.
Christopher J. Combs, Ph.D. on 02.13.04 @ 10:26 PM EST [link]
Thursday, February 12th
The Scary Part
We've now entered the scary part of the course. The Monahan article usually shakes up the students in the class, and this coming week's article on the Tarasoff law and its various permutations is probably even scarier. For a while, you look at every client as a Tarasoff risk and the potential beginning of the end of your career. If we can't predict suicide or violence with any degree of accuracy, how can we protect ourselves? Where is that empirically-supported prediction algorithm when you need it?
Christopher J. Combs, Ph.D. on 02.12.04 @ 03:14 PM EST [link]
Wednesday, February 11th
What My Parents Told Me
Gabe wrote:
Let’s first start off with a quote I am sure our parents taught us: “The best predictor of the future is the past.”
Gabe, your father was Dr. Riley?
My mother always said, "Why didn't I go into the convent?!"
Christopher J. Combs, Ph.D. on 02.11.04 @ 08:38 PM EST [link]
Monday, February 9th
When Laws and Values Conflict
At the end of class the week before last, I referred to a short article that involved a survey of 100 ethics experts. The "article" was a short, 2-page letter in American Psychologist:
Pope, K.S., & Bajt, T.R. (1988). When laws and values conflict: A dilemma for psycholgists. American Psychologist, 43(10), 828-829.
The authors mailed an anonymous survey to 100 senior psychologists, which included:
* 60 current or former members of state ethics committees
* 10 current or former members of the APA Ethics Committee
* 10 authors of textbooks on legal and ethical issues in psychology
* 20 diplomates of the American Board of Professional Psychology (ABPP)
So clearly this was an All-Star panel in terms of familiarity with ethical and professional issues. Even though the survey was anonymous, it's quite likely that many of these psychologists helped craft the APA or various states' ethics code.
Their return rate was 60%, so running that through my calculator because of the complicated math, I get approximately 60 surveys were returned.
Fifty-seven percent (57%) responded they had knowingly violated a law or ethical principle in answering this question: "In the most serious, significant, or agonizing instance, if any, what law or formal ethical principle have you broken intentionally in light of a client's welfare or other deeper value?"
And what was the breakdown? Here are the responses endorsed by more than one psychologist:
* 21 % refused to report child abuse (presumably as mandated by state law)
* 21 % illegally divulged confidential information
* 9 % engaged in sex with a client
* 6 % involved non-specified dual relationships (perhaps sexual, perhaps not)
* 6 % refused to make legally required warnings regarding dangerous clients
As you can see, in some cases these violations might be understandable decisions of conscience. For example, mandated reporting laws for child abuse are not popular among all psychologists because it is feared they keep abusers from seeking or remaining in treatment. The same type of argument has been made for Tarasoff laws: is public safety better served by keeping violent clients in treatment by protecting their confidential utterances or fantasies, or by warning potential victims, knowing our prediction algorithms for violence are far from perfect?
In other cases, it's difficult to imagine how violating the law or ethics code in service of a higher principle best serves the client. The 9 % who engaged in sex with a client is certainly consistent with other survey of client-therapist sexual relationships, at least male therapists with female clients. And what do we make of the 40 psychologists who didn't return surveys? Were they too embarrassed or ashamed to admit ethical wrongdoings, even on an anonymous survey, and even in the name of a higher-order value? Or were they less likely to return the survey because they didn't have anything to report in terms of their "civil disobedience"? Would the rate of therapist-client sex have been even higher if the silent 40 had returned their surveys?
So we return to the fundamental questions of how we teach psychologists to behave ethically. The psychologists in this survey clearly knew the ethics codes, and probably wrote them, too. Therefore, it doesn't seem like a simple matter of education. Somewhere between knowing what to do, and actually doing it, things get lost. And if these uber-psychologists had trouble adhering to the ethics code and law, what chance do the rest of us Average-Joe psychologists have?
Christopher J. Combs, Ph.D. on 02.09.04 @ 08:26 AM EST [link]
Saturday, February 7th
The Readability of the APA's Insurance Trust's Sample Informed Consent Document
Every once in a while I, too, even glance at the syllabus. I was curious as to how the APAIT's informed consent document stacked up against others. Had they heeded the previous research on informed consent documents, and how they are written at a level too high for many clients?
I downloaded the sample document and, like we did Thursday, opened it in Microsoft Word. Here are the readability statistics:
Paragraphs: 40
Sentences: 116
Sentences Per Paragraph: 4.2
Words Per Sentence: 20.5
Characters Per Word: 4.7
Passive Sentences: 12%
Flesch Reading Ease: 50.7
Flesch-Kincaid Grade Level: 11.2
Note: I deleted the first two pages of instructions to the psychologist before running the analysis, in case you want to replicate.
This document shows improvement over studied IC forms in some ways: it uses easier-to-understand active sentences, and it doesn't use too many big words. It also keeps the paragraphs simpler (4 sentences per paragraph). However, the sentences are on the long side (20 words on average), and as a result, it comes out as a relatively complicated document. If you review the Microsoft word entry for the readability statistics, it recommends aiming for a 7th-8th grade reading level, or a reading ease score of 60-70, with higher scores meaning easier readability.
So even this sample or model document doesn't do everything well.
Christopher J. Combs, Ph.D. on 02.07.04 @ 04:13 PM EST [link]
