Feedback to achieve clinical excellence (summer 2014 ind psy)

Bulletin ofPsychologists in Independent Practice

A Division of the American Psychological Association

Independent Practitioner

Summer 2014 • Volume 34 Number 3 division42.org

Your Summer 2014 IP

President’s Column

Pat DeLeon

Duty to Protect Third Parties

Feedback to Achieve Clinical Excellence

Basics of Providing Diversity and Mediation Training

Holistic Team Approach to Divorce Mediation

An Attempt at Conducting a Group for Mothers of Young Children

From Research to Practice

Strategies for Identifying Cash Pay Services

Diversity and Disabilities

Free CEs!

Board of DirectorsExecutive Committee

Gordon Herz, PhD, PresidentJune Ching, PhD, President-ElectSteven Walfish, PhD, Past-PresidentMichael Schwartz, PsyD, SecretaryGerald Koocher, PhD, Treasurer

Members-At-LargeArmand Cerbone, PhD Michi Fu, PhDElaine Ducharme. PhD David Shapiro, PhDI Bruce Frumpkin, PhD Rachel Smook, PhD

Representatives to APA CouncilDouglas Haldeman, PhD Lenore Walker, EdD Nancy Molitor, PhD Robert Woody, PhDRobert Resnick, PhD Jeffrey Younggren, PhD

Early Career Representative Kristina Roberts, PhDStudent Representative Derek Phillips, MAGovernance and Standing Committee Chairs

APA Governance Issues: June Ching, PhDAwards: Steven Walfish, PhDFellows: Jean Carter, PhD

Independent Practitioner

Finance: Gerald Koocher, PhDMembership: Stephanie Mihalas, PhDNominations and Elections: Steven Walfish PhDProgram: Jennifer Imig Huffman, PhDPublications and Communications: Blaine Lesnik, PsyD and Erlanger

“Earl” Turner, Ph.D.

Continuing CommitteesAdvertising: TBDAdvocacy: Sallie Hildebrandt, PhDDiversity: Douglas Haldeman, PhDForensic Section: I. Bruce Frumkin, PhDMarketing and Public Education: Pauline Wallin, PhDMentorshoppe: Michael Schwartz, PsyD and Lisa Grossman, JD, PhD

AppointmentsBulletin Editor: Lawrence P. Riso, PhDBulletin Associate Editors: Stephanie Mihalas, PhD; Lori Thomas, JD, PhDContinuing Education: Edward Zuckerman, PhDFederal Advocacy Coordinator: Sallie Hildebrandt, PhDForensic/Assessment Conference: I Bruce Frumkin, PhDFast Forward Conference: Nancy Molitor, PhD

Division 42 Central OfficeJeannie Beeaff919 W Marshall Ave.Phoenix, AZ 85013602-284-6219Fax: 602-626-7914Email: [email protected]

Bulletin Staff Patrick DeLeon, PhD, JD, Special Contributor Stanley Graham, PhD, Special Contributor Jeffrey Barnett PsyD, Special Contributor Dave Shapiro, PhD, Special Contributor Rick Weiss, Layout Design Editor

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All materials are subject to editing at the discretion of the Editors. Unless otherwise stated, the views expressed by authors are theirs and do not necessarily reflect official policy of Psychologists in Independent Practice, APA, or the Editors. Publication priority is given to articles that are original and have not been submitted for publication elsewhere.

Independent Practitioner Summer 2014 71

President’s Column

Future Challenges to Independent Practice —Gordon Herz................................................................... 72

Opinions and Policy

It Always Seems Impossible Until it’s Done — Pat DeLeon ................................................................... 74

Liability, Malpractice and Risk Management

Misunderstandings Regarding Duty to Protect Third Parties — David Shapiro ..................................... 76

Focus on Clinical Practice

Featured Expert Review: Feedback Informed Treatment (FIT): Achieving Clinical Excellence One

Person at a Time — Scott D. Miller, Mark A. Hubble, Jason A. Seidel,

Daryl Chow, & Susanne Bargmann .................................................................................................... 78

Providing Divorce and Custody Mediation Services: The Basics — Lori C. Thomas ............................. 85

Divorce Mediation: A Holistic, Structured Team Approach — Crispino Pastore &

Sharon Pastore ................................................................................................................................... 87

An Attempt at Conducting a Group for Mothers of Young Children — Carrie R. King ...........................91

From Research to Practice — Andrea Peterson, Mattie McIntyre, and

Andrea Kozak Miller, Ph.D. ................................................................................................................ 93

Focus on the Business of Practice

Strategies for Identifying Cash Pay Services — Mel Whitehurst ............................................................. 96

Focus on Diversity

Diversity and Disabilities — June W. J. Ching ......................................................................................... 99

Division Announcements for upcoming APA convention in Washington DC

Division 42 Supports Your Hard Work: Show It Off This Year At Convention Social Hour Membership Committee .................................................................................................................102

Make Art with Your Peers — Alan Entin & Pamela McCrory .................................................................103

CE Quiz .................................................................................................................................................106

Table of Contents

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72 Summer 2014 Independent Practitioner

President’s ColumnFuture Challenges to Independent Practice— Gordon I. Herz

I previously avoided the temptation to write about how we can apply our unique position as psycholo-

gists in independent practice to shape and contribute to the future -- our deep knowledge of all levels of human systems, our skills as agents of growth and change. I hope you will bear with me if I take that opportunity now.

Much of what I write is not based on expert training or understand-ing of health care service delivery, of health care economics or econom-ics generally. But I do write from the experience of having provided psycho-logical and health services for 22 years now since being licensed, and on a full time indepen-dent basis for 14 years.

My introduction to being “managed” — even as an inde-pendent — occurred the first year after I was licensed and had taken a salaried position in a hospital. There, I had no difficulty being credentialed to provide, and have my home department reimbursed for, care I pro-vided to the hospital’s patients, by the HMO allied with the hospital. When I rented office space one block away and began seeing clients independently evenings and weekends, that same HMO would neither credential nor reimburse me for the same care to the same sorts of cli-ents. The lesson in who was attempting to control how I practiced and how I made my living was invaluable.

I also write as an independent psychologist who has been involved, to some extent, in activism to influ-ence the system. Division 42 became a natural home for me for this involvement, particularly through the (now sunsetted) “Task Force on Managed Care” (which soon expanded to “and Health Care Policy”). In 2007 we were able to move through APA’s Council the adoption of a “Statement of Principles for Health Care Reform,” emphasizing access to affordable care, the insepara-bility of mental and physical well being, prevention, rehabilitation and improving quality of life as neces-sary activities in a just and effective health system, and the recognition of the role behavior plays in the major causes of illness and death in our country. With the seemingly “renewed’ emphasis on “integrated ser-vices” as exemplified in even the most recent Special Issue of the American Psychologist (“Primary care and psychology”), we were either riding the crest of an

inevitable tsunami of change, were already trained in and were providing health services, or had some actual foresight (most likely, some of each). And in terms health care financing, as we wrote in 2009, “A for-profit, managed reimbursement financing system is fundamentally incompatible with the independent practice of psychology and unfettered access by the public to doctoral level psychological services.” Given that we are now — in theory, with “parity” — subject to no different oversight in third party reimbursement systems than our medical colleagues, perhaps our practices will benefit and

the public will be better served. But this will require holding payers accountable, and I urge all readers to respond to the APA Practice Organization’s (APAPO) call to report possible party violations.

In light of the history of independent practice and the cur-rent environment, the following seem to me to be likely future trends that will challenge independent practice.

• Downward pressure will almost certainly con-tinue to occur in third party reimbursement for services. There is nothing new about this trend, with many contributing factors. Just one of these variables may give a glimpse of the challenge. Psychologists are greatly outnumbered by other health professionals who can and do provide psy-chotherapy and other mental health services on an independent basis. For example, RNs, nurse practitioners and nurse specialists outnumber psy-chologists by a factor of almost 16 to 1 and social workers outnumber psychologists by almost 4 to 1 (Robiner, Dixon, Miner & Hong, 2014, Figure 3, U.S. Health Occupations Workforce).

• Models of reimbursement will change from fee-for-service to other configurations, as witnessed by the ongoing experiments in at least two models within Medicare, the Medicare Shared Savings Pro-gram, and the Advance Payment ACO Model.

• “Quality,” effectiveness and outcomes measure-ment will become expected. For example, the Physician Quality Reporting System (PQRS) — cur-rently a voluntary program within Medicare that operates on an “incentive” basis and is available to psychologists — will become mandatory in 2015,


with financial penalties assessed for nonparticipa-tion (in PQRS, not in Medicare). Are for-profit and other third party payers far behind?

• Technology demands will continue to evolve. Enforcement rules and other “incentives” (such as) for the The Health Information Technology for Eco-nomic and Clinical Health [HITECH] Act make it likely the expectation of “meaningful use” of health information technology and compliance with secu-rity requirements will become a part of everyday practice, even for the small group or solo indepen-dent practitioner.

Note that none of these even begin to recognize the need to keep up with an ever-growing body of clinical knowledge and practical applications.

How does the independent psychologist evolve, adapt, survive, thrive? I see at least two substantial trends in our profession, and a third way I will call a “hybrid.” First, many of our independent colleagues are already used to “integrated care,” collaborating regularly with a wide range of health professionals in a variety of settings. While the current buzz phrase may be “co-location,” in my view it is an empirical question whether this actually will be necessary to improve care and outcomes. It is possible that independents in the future will maintain separate locations and use technology to integrate care. These colleagues will nevertheless be fully integrated into health care sys-tems — in record keeping and information sharing dimensions, as well as in reimbursement models, with all the credentialing, outcomes measurement, busi-ness and reimbursement structures that implies. Many of our independent colleagues lament the perceived and actual reduction in autonomy and control. But the benefits of a “fully integrated” practice model include a greatly increased and highly diverse base of consum-ers of services. That, after all, was one of the principal promises of ACA: more citizens covered. One great additional risk to independent practice is that, as more of our citizens have insured themselves for coverage for health services, there is greater expectation to use the coverage. The extent to which people be willing to purchase services beyond those for which they have “pre-paid” remains to be seen.

However, this does point to another possible future model of independent practice. Many of our colleagues will choose to function entirely outside of this system, instead providing the full range of professional services for which psychologists are uniquely trained. Locate a human system and there is a need for applied psycho-logical knowledge and skill. Undoubtedly, this model also continues a longstanding tradition of psychological services, one that even pre-dates the era when psycho-therapy was not recognized (i.e., reimbursed) by health insurance, through the period of efforts to break free of constraints (e.g., Ackley, 1997 and many others) all the

way through our most current thinkers and leaders who identify myriad ways to do work that matters and that will be purchased (e.g., Walfish, 2010).

There is a third, “middle path.” My sense is that, given the demands of the above two models I believe we are likely to see, the challenges of this middle ground will be substantial. Some of our colleagues will develop and maintain involvement in both systems, responding to practice structures, flows of consumers, services needed and methods of reimbursement implied by both. The benefits in this approach include the potential to have a relatively predictable, even expanding, base of work, while developing and applying expertise to a broad range of individuals, systems and human problems.

My guess is this model will already seem familiar to many. It should seem familiar to any of us who have pro-vided standard services in the context of known referral and reimbursement patterns, while simultaneously developing specialty work. What remains unknown is whether such a hybrid practice will be possible or practi-cal in the future, given the likely commitment in time, learning, expertise and other resources. Or, perhaps such diversification will be just what is needed.

One thing does seem fairly sure to me. The challenge for Division 42 will be to support our members however they choose to maintain independence, in whatever balance they find. There may well be stage-of-career differences in choice. It is possible those who are early in their careers and closer to their training experiences may feel more comfortable with a more fully “inte-grated” model, while those at later career stages may want and be able to minimize third party intrusion in practice structures or service delivery. We need to sup-port our colleagues to pursue the joy and meaning this profession brings.

ReferencesAckley, D. (1997). Breaking free of managed care: A step-by-step

guide to regaining control of your practice. New York: Guil-ford Press.

American Psychologist (2014). Special issue: Primary care and psychology. May-June, 69 (4).

APAPO Practice Update. (April 10, 2014). Mental health parity: We need your help. Retrieved 4/25/2014 from http://www.apapracticecentral.org/update/2014/04-10/parity.aspx

Herz, G. (2009). Reimbursement for psychologists’ services: Trends, impact on access to psychologists, and solutions. Retrieved 5/19/2014 from http://www.drherz.us/blog42/ReimbursementAccessSolutions.htm

Robiner, W., Dixon, K., Miner, J. & Hong, B. (2014). Psycholo-gists in medical schools and academic medical centers: Over 100 years of growth, influence, and partnership. American Psychologist, 69 (3), 230-248.

Walfish, S. (2010). Earning a living outside of managed mental health care: 50 ways to expand your practice. Washington DC: APA Books.


Opinions and PolicyIt Always Seems Impossible Until it’s Done—Pat DeLeon

State Leadership Conference (SLC): At this year’s exciting Practice Directorate State Leadership Confer-

ence (SLC) titled “Creating Roadmaps for Practice,” visionary Executive Director Katherine Nordal emphasized: “The way the Affordable Care Act [ACA] is unfold-ing reminds us that no single advocacy strategy for psychology can address the diverse legislative, regulatory and mar-ketplace environments we see from one state to another. Meanwhile, our country still doesn’t pay nearly enough attention to mental health and substance use treat-ment. We’ve carved out this treatment from medical care and made people jump through hoops to get the psychological services they need. And mental health is chronically underfunded. About 20% of our population experiences a mental health disorder in any given year, compared to a life-time incidence of 6% for adults with cancer. Yet, in 2012, the federal government invested more than 5 billion dollars in the National Cancer Institute but less than 1.5 billion dollars in NIMH. Health care reform implementation is a work in progress. There are hope-ful signs, especially related to the goal of increasing the ranks of Americans with health insurance coverage. A combination of professional, marketplace, legisla-tive and regulatory developments encourages more collaborative, multi-disciplinary practice models. As the landscape shifts towards more integrated care, new reimbursement mechanisms will emerge. The demand for evidence-based practices and use of quality measures related to process and outcome, includ-ing behavioral health measures, will grow. And the increasing use of technology for electronic health record keeping and telepsychology service delivery will continue to evolve. Many of our members seem attuned to this evolution.” As Katherine also indi-cated at last year’s SLC conference: “Our practitioners increasingly will need to promote the value and qual-ity they can contribute to emerging models of care. If we are not valued as a health profession, it will detract from our value in other practice arenas as well. Health care reform is a marathon – we’re in it for the long haul. New models of care and changes in health care financ-ing won’t take shape overnight.”

Integrated Care: Katherine’s description of the “changing winds” of health care reform is extraor-dinarily accurate. The Alliance for Health Reform

recently sponsored a Hill briefing – “Is the Mind Part of the Body? The Challenge of Integrating Behavioral Health and Primary Care in a Reform Era.” “As more people gain coverage that includes behavioral health benefits, and given a limited supply of mental health professionals, analysts and advocates are raising concerns over how and whether new laws and regulations will be able to change that situation. One option being explored in many settings is the integration of behavioral health ser-vices with primary care. There is early evidence that coordinating care in this manner may deliver high-quality care more efficiently. For almost 20 years,

bipartisan majorities in Congress have been legislat-ing ways of bringing behavioral health services to the 62 million Americans in need of them. Beginning with the 1996 Mental Health Parity Act, Congress has steadily broadened access to these services.

“All state Medicaid programs and plans sold on the health insurance marketplaces cover behavioral health services. Yet 60% of adults and 70% of children with a mental health disorder do not receive treatment. In children, the average time between onset and treat-ment of mental illness is nine years. And one in six adults has co-morbid mental health and medical con-ditions. More commonly their medical condition is being treated while their mental health condition goes undiagnosed and untreated. Do current models of inte-grating behavioral and physical health hold promise? Are there enough providers to meet the demand of the newly insured? What is needed to help primary care fill the gap? How are the states meeting the budgetary challenge in Medicaid programs? Is parity a reality?”

Our colleagues in the American Psychiatric Association (ApA) would appear to agree with Katherine, recently calling for much tighter integration of primary care and mental health care, thereby providing better services with a reduction in costs. “Studies have shown that concurrently treating behavioral and physical condi-tions leads to better control of the illness itself, but also better patient satisfaction, quality of life, and reduced costs [ApA President].” The ApA commissioned report shows that effective integration could save $26 billion to $48 billion a year in general medical care. Almost half of people with a mental disorder first consult with a primary care physician and approximately 50% of


the 38,000 individuals who commit suicide each year have seen a primary care physician within a month of the completed attempt. Their report, which drew on claims data for 20 million enrollees, found that only 14% of those who had a mental disorder were receiv-ing treatment but that they accounted for 30% of the spending reviewed. “Even though they are insured and are being treated for their mental illnesses, the lack of coordinated care represents lost opportunities…. The higher costs were mostly attributable to patients falling through the cracks or not getting proper care – which showed up in more emergency room visits, more hospitalizations, and hospital readmissions [ApA President-Elect].”

In our judgment, critical to the success of Katherine’s vision of psychology being recognized as a bona fide “health care profession” is affirmatively embracing our societal responsibility to provide proactive leadership in addressing society’s most pressing needs. Psychol-ogy is one of the “learned professions” and with that comes a fundamental obligation to effectively utilize our clinical skills, beyond the confines of traditional practice. Last year we were very pleased to learn of Gaby Toloza’s efforts on behalf of the Hawaii Psycholog-ical Association (HPA) to address the needs of families with an autistic child. Her “call to action” this year: “We are in need of about 6-7 psychologists to volunteer ONE hour of their time on Saturday at the Windward YMCA to give an interactive psycho-educational talk about an aspect of Self Care to a group of 15-20 parents of autistic children. Some previous topics related to mind body connection, achieving balance, how to change behavior, role of nutrition, stress management, financial stress management and relationship health. This is a wonder-ful way to give back to the community and promote psychology as a profession, but more importantly the necessity of self-care and a wellness model. This sup-ports HPA and APA initiatives for public education and it’s just a fun, simple and meaningful experience for both the families and providers. It is a collaborative project with HPA, YMCA, Hawaii Autism Foundation and Creative Connections Foundation, so it also rep-resents yet another way that the work of psychologists can be integrated and effectively used to support a given population. Thank you for your time and hope I hear back from many of you wonderful helping profes-sionals (Yes, shameless positive feedback in hopes of soliciting your time).”

Interdisciplinary Training For The Next Genera-tion: The Robert Wood Johnson Foundation (RWJ) Nursing and Health Policy Collaborative at the Univer-sity of New Mexico reports that over 100 doctoral level nursing programs have stand-alone, required courses in health policy, with numerous other programs incor-porating health policy content into related courses. In sharp contrast, we have been able to find very few

related courses within psychology’ training programs. An appreciation of the legislative and administrative process is essential for all health professions. For example, the Institute of Medicine (IOM) found that although the primary purpose of a state licensing board is specifically to protect the interests of the public, 52% of dentists thought that the primary purpose of their state dental board was to protect the interests of den-tists and 32% thought they protected the interests of both dentists and the general public. The IOM report also concluded that publicly funded health programs should not separate oral health from overall health. The IOM President: “Can you imagine a time when we fully incorporate mental and dental health into our thinking about health? What is it about problems above the neck that seems to exclude them so often from policy about health care?”

At the Uniformed Services University of the Health Sciences (USUHS), the next generation of psychologists and doctors of nursing practice (DNP) train together in a number of venues, including health policy. “My col-league, CPT Kathleen Young and I had the pleasure of attending the American Association of Colleges of Nurs-ing (AACN) Student Policy Summit held in Washington, DC. The Summit provided a panoply of distinguished nursing professionals and activists committed to the advancement of nursing and nursing practice that bestowed upon us the importance of uniting as a profes-sion to influence changes that affect our profession and the care that we provide to our patients. Astonishingly we have approximately 3.1 million nurses of which only approximately 100,000 belong to the American Nurses Association (ANA). While this statistic does not include the many other nursing organizations that nurses may be members of, it is nonetheless an astonishing fact that nurses make up the majority of the healthcare industry, yet we have the least amount of members participating in organizations that influence the very policies that impact our profession.

“The AACN Summit provided an opportunity to show the ease with which nurses can become politically involved to improve health status and the delivery of healthcare. Mindful of relevant DoD Directives, my colleague and I were graciously allowed to accompany Dr. Jane Kirschling, President of the AACN and Dean of the University of Maryland School of Nursing, as well as several bright undergraduate and graduate nurs-ing students from the State of Maryland as they were welcomed by the offices and staff of the Maryland Sena-tors and Congresspersons. The well-spoken students impressed upon their Representatives the importance for continued support for Title VIII funding for nursing education, increased funding for nursing research, and support for nursing practice bills designed to promote the role of Advanced Practice Nurses in the healthcare delivery system.


“The AACN Student Summit Policy Summit was an extraordinary opportunity to network with nursing leaders, advocates for the advancement of nursing prac-tice, and colleagues with the common goal of imparting change. In an era of unprecedented health care reform nurses, one of the most trusted health professions in the nation, have a unique opportunity and dare I say

obligation, to provide our expertise in matters that affect the profession of nursing and the delivery of care that we provide [Capt. Kellie Webb-Casero, USAF].” Aloha,

Pat DeLeon, former APA President – Division 42 – May, 2014

Misunderstandings Regarding Duty to Protect Third Parties

Liability, Malpractice and Risk Management

— David Shapiro

There is perhaps no other area of the law that has engendered more mis-understandings than the so called

“duty to warn/protect”. Many psycholo-gists believe that the “duty to warn/protect” demands an unquestioning, knee jerk, break-ing of confidentiality when a patient makes any threatening or potentially threatening statement. This concept of course origi-nated with the case of Tarasoff v. Regents of the University of California. In fact, there were two separate Tarasoff cases, the first in 1974 (Tarasoff I) and the second in 1976. The concept of “duty to warn” third parties that was enunci-ated in Tarasoff I was broadened in 1976 to include the “duty to protect” third parties ; this was largely due to a brief filed by the American Psychiatric Association raising concerns about clinicians’ abilities to predict future violence as well as their need to breach confi-dentiality. The second Tarasoff case actually gave the clinician greater discretion to utilize his or her clinical judgment. Therapists mistakenly focus on the narrow idea of “warning” third parties and therefore breaking confidentiality, rather than listening to the words of the second Tarasoff case, which spoke of “taking reasonable steps to protect the intended victim”; warning might have been one of those ‘reasonable steps “ but it was not the only one.

A careful reading of the second Tarasoff case reveals that the court discussed and concluded that clinicians did not need to change the basic ways in which they dealt with patients, but only needed to consider the steps they might need to take if a third party were in danger. The court did not specify what the steps had to be, but rather left it to the discretion of the therapist to determine what steps should be taken if he or she deter-mined that a third party was in danger. These might include (but are by no means limited to) increasing the

number of therapy sessions, putting the patient on medication, (or if already on medication, changing the medication or the dosage), vol-untarily or involuntarily hospitalizing the patient, giving the patient a way to contact the therapist in an emergency( cell phone or pager number) and , as a last resort, notifying the police or the intended victim.

The misunderstandings had an immediate impact. As early as 1978, in an article in the Stanford Law Review (Simon & Sadoff, 1978) , the authors noted that there had been an

increased number of unnecessary involuntary com-mitments, and a general reluctance on the part of therapists to see any patients who described problems with controlling anger; thus, since many of the people who were most in need of treatment were being denied treatment, the potential for violent behavior increased rather than decreased.

Leedy( 1989 ) in her doctoral dissertation surveyed licensed psychologists in two states, one of which had a mandatory duty to warn statute and another which did not. Her results demonstrated that over 90% of licensed psychologists misunderstood the law in their own state. One would hope that with more cases devel-oping over the years, and more attention being paid to the issue, psychologists would have a better understand-ing. However, subsequent studies continued to reveal widespread misunderstanding of these laws.

In workshops that I have taught regarding malpractice and risk management, another popular misconception is that violent acting out by patients in psychotherapy is a major cause of malpractice actions; workshop par-ticipants estimate that between ten and fifteen percent of such cases are due to the violent behavior of a psy-chotherapy patient; in fact, the figures from the APA Insurance Trust, consistently show that less than two


percent of successful malpractice actions have to do with failure to protect third parties.

Given these misunderstandings, what are the best risk management steps to take to guard against this area of litigation? The simple answer is the same as in any other area of risk management- informed consent, documentation, and consultation. Underlying all of these is the need for a careful and well documented assessment, a carefully crafted informed consent that is also fully documented, and consultation with col-leagues when there are doubts about the proper course of action to take. Givelber, Bowers, and Blitch (1984) also reported that in cases where the central issue was failure to protect third parties, none of the cases based liability on a failure to predict the violent behavior, par-ticularly if a careful assessment had been done in the first place. Rather liability was found where therapists failed to follow standard procedures, failed to consult with colleagues, and failed to document what they did. Gone is the day when a therapist would say “I do not have to take notes; I am a superb clinician”( these were the actual words stated by a therapist in response to an ethics complaint filed with the APA.

This leads us to a discussion on the nature of risk assessments; in fact, there is no one established proto-col but a clinician would have to demonstrate that he or she followed at least one documented approach to risk assessment. There is currently an ongoing debate among those who utilize a purely actuarial approach, an adjusted actuarial approach, or what is called “struc-tured professional judgment”. The idea of basing an assessment of future violent behavior on unaided clini-cal judgment is no longer recognized as an appropriate way to handle such situations. Each of the other three approaches will cite its own literature, and its own find-ings to demonstrate the superiority of its approach; nevertheless, each is a legitimate approach and no one appears superior to the others. The important issue is to find an approach with which one is comfortable, and follow that procedure according to the established manuals; that will be adhering to the appropriate stan-dard of care. There will always be people who claim to be able to predict future violent behavior with a high degree of accuracy, some without even seeing the person clinically, but an accumulation of empirical data can help end the influence of this kind of irresponsible testimony in court.

We should also note an encouraging trend in cases

where there is a question of whether a duty to warn/protect existed. When the cases first started emerging, in the 1970’s, there was an inherent assumption that we as clinicians could make accurate predictions of future violent behavior and therefore, should be held liable in cases where our patients did act out violently. As the empirical data have accumulated, demonstrating that we do not have such clairvoyant abilities, and identi-fying the limited parameters within which we could predict certain types of violent behavior, cases seem to have reversed direction, with a greater number noting the limited ability to predict violence and therefore, restricting liability only to those cases where there were unambiguous warning signals and the clinician failed to do anything about them. For example, in the case of Brady v. Hopper (1983), the Tenth Circuit Court of Appeals rendered a decision very supportive of mental health professionals, and avoided the hind-sight bias that often characterizes such cases. This was the case against John Hinckley’s psychiatrist, Dr. John Hopper, filed by press secretary James Brady who was wounded in Hinckley’s attack on President Reagan. The Court ruled that even if Dr. Hopper had known about Hinckley’s infatuation with Jodi Foster, his fascina-tion with the movie “Taxi Driver”, and his taking target practice at pictures of Reagan, this still would not have been considered a foreseeable risk; only if he had con-fided to Dr. Hopper that he planned to attack Reagan would there have been any potential liability and then, only if the doctor had failed to do a careful assessment of the threat. Therefore, the best risk management strategy is to do a careful assessment, document it carefully, include within the informed consent the pos-sibility of needing to protect a third party if the harm is imminent and cannot be handled by other means, and consult with colleagues when the situation is ambigu-ous.

ReferencesBrady v. Hopper 570 F. Supp.1333, 1339 (D.Colo.1983)Givelber, Bowers, and Blitch (1984). Tarasoff: Myth and Real-

ity. Wisconsin Law Review, 2, 443-497.Leedy, S. (1989) Unpublished doctoral dissertation. University

of Maryland, Baltimore County.Simon, R., & Sadoff, R. (1978). Where the Public Peril Begins.

Stanford Law Review, 31(1), 165-190.

Correspondence regarding this article should be addressed to David Shapiro, Ph.D. at [email protected].


Featured Expert Review

Feedback Informed Treatment (FIT): Achieving Clinical Excellence One Person at a Time

— Scott D. Miller, Mark A. Hubble, Jason A. Seidel, Daryl Chow, & Susanne Bargmann

“It is the big choices we make that set our direction.

It is the smallest choices we make that get us to the destination.”

— Shad Helmstetter

Clinical psychology outcomes research, and studies of high performance in other fields, indicate that the critical factors separat-

ing high-performing psychotherapists from average therapists have little to do with experience or the use of empirically-supported treatments. Instead, there appear to be systematic differences in how practitioners implement the tools of their trade (regardless of their therapeutic orientation). As therapists shift their focus from traditional methods of accumulating knowledge and experience toward a more empirically-supported methodology for improving performance (including the formal collection of feedback, a stance of non-defensive openness, and individually tuned programs of delib-erate practice), evidence suggests that the individual practitioner will be able to achieve superior outcomes, measure these outcomes, and compete more effectively in the behavioral healthcare marketplace.

A “great debate” is raging in the field of psychotherapy (Wampold, 2001). On one side are those who hold that behavioral health interventions are similar to medi-cal treatments (Barlow, 2004). Therapies work, they believe, because like penicillin they contain specific ingredients remedial to the disorder being treated. Consistent with this perspective, emphasis is placed on diagnosis, treatment plans, and adherence to so-called “validated” treatments (Siev, Huppert, & Chambless, 2009; Huppert, Fabbro, & Barlow, 2006; Chambless & Ollendick, 2001). The “medical model,” as it is termed, is arguably the dominant view of how psychotherapy works. It is also the view held by most people who seek behavioral health treatment.

On the other side of the debate are those who argue that improvements in effectiveness, and ultimately, clinical excellence, will not be achieved by mimick-ing the practices of medicine. In fact, they hold that

psychotherapy is fundamentally incompatible with the medical view (Wampold, 2001; Duncan, Miller, Wampold, & Hubble, 2010; Hubble, Duncan, & Miller, 1999). Proponents of what has been termed the “con-textual” perspective highlight the evidence for the lack of differential effectiveness among the 250 compet-ing psychological treatments, suggesting instead that the efficacy of psychotherapy is more parsimoniously accounted for by a handful of curative factors shared by all (Lambert, 1992; Miller, Duncan, & Hubble, 1997). While each therapist offers their own particular frame-work for treatment, of particular importance from this contextual point of view are extratherapeutic factors and the therapeutic relationship. The former refer to strengths, resources, life-circumstances—variables that clients bring to treatment. The therapeutic relationship includes the emotional bond between the participants and agreements on goals and tasks.

The challenge for practitioners striving to achieve excellence—given the sharply diverging points of view and dizzying array of treatments available—is know-ing what to do, when to do it, and with whom. For the independent practitioner, these questions are especially pressing as therapists continue to lose their share of a market that increasingly looks for faster, cheaper, more effective solutions to psychological and rela-tional problems. Thankfully, recent developments are on track to providing an empirically robust and clini-cally feasible answer to the question of “What works for whom?” Based on the pioneering work of Howard, Moras, Brill, Martinovich, and Lutz (1996) and others (c.f., Lambert, 2010; Brown, Dries, & Nace, 1999; Miller, Duncan, & Hubble, 2005; Duncan et al., 2010), this approach transcends the “medical versus contextual” debate by focusing on routine, ongoing monitoring of engagement in and progress of therapy (Lambert, 2010). Such data, in turn, are utilized to inform decisions about the kind of treatment offered as well as whether to continue, modify, or even end services. Indeed, multiple, independent randomized clinical trials now show that formally and routinely assessing and discuss-ing clients’ experience of the process and outcome of care effectively doubles the rate of reliable and clini-

Focus on Clinical Practice


cally significant change, decreases drop-out rates by as much as 50%, and cuts deterioration rates by one-third (Miller, 2010).

Excellence is within the reach of all clinicians, whether aligned primarily with the medical or contextual views of psychotherapy. In short, they can benefit by using feedback to improve the outcome of the services they offer one person at a time.

What Kind of Feedback Matters?

“If we don’t change direction,

we’ll end up where we’re going.”

— Professor Irwin Corey

Feedback-informed treatment or FIT is based on several well-established findings from the outcome litera-ture. The first is: psychotherapy works. Studies dating back over 35 years document that the average treated person is better off than 80% of the untreated sample (Duncan et al., 2010; Smith & Glass, 1977; Wampold, 2001). Second, the general trajectory of change in suc-cessful treatment is predictable, with the majority of measured progress occurring earlier rather than later (Brown, Dreis, and Nace, 1999; Hansen, Lambert & Forman 2002). Third, despite the proven efficacy of psychotherapy, there is considerable variation in both the engagement in and outcome of individual epi-sodes of care. With regard to the former, for example, available evidence indicates that as many as 50% of those who initiate treatment drop out before achiev-ing a reliable improvement in functioning (Bohanske & Franczak, 2010; Kazdin, 1996; Garcia & Weisz, 2002; Swift & Greenberg, 2012; Wierzbicki & Pekarik, 1993). With regard to the latter, significant differences in outcome exist between practitioners. Indeed, a large body of evidence shows that “who” provides a treatment contributes 8 to 9 times more to outcome than “what” particular treatment is offered (Wampold, 2005; Miller, Hubble, & Duncan, 2007). Such findings indicate that people seeking treatment would do well to choose their provider carefully as it is the therapist - not the treat-ment approach - that matters most in terms of results. Fourth, and finally, a sizable portion of the variability in outcome among clinicians is attributable to the thera-peutic alliance. For example, in a study involving 80 clinicians and 331 clients, Baldwin, Wampold, and Imel (2007) reported that it was therapist variability in the alliance, rather than client variability, that predicted outcome. In other words, therapists who on aver-age formed stronger alliances, performed better than therapists who did not. Taken together, the foregoing findings indicate that real-time monitoring and utiliza-tion of outcome and alliance data can maximize the “fit” between client, therapist, and treatment. With so many factors at play influencing outcome at the time of service delivery, it is practically impossible to know a

priori what treatment or treatments delivered by a par-ticular therapist will reliably work with a specific client. Regardless of discipline or theoretical orientation, clini-cians must determine if the services being offered are working and adjust accordingly.

Two simple scales that have proven useful for monitor-ing the status of the relationship and progress in care are the Session Rating Scale (SRS [Miller, Duncan, & Johnson, 2000]), and the Outcome Rating Scale (ORS, [Miller & Duncan, 2000]). The SRS and ORS measure alliance and outcome, respectively. Both scales are short, 4-item, self-report instruments that have been tested in numerous studies and shown to have solid reliability and validity (Miller, 2010). Most importantly perhaps, the brevity of the two measures insures they are also feasible for use in everyday clinical practice. After having experimented with other tools, the devel-opers, along with others (i.e., Brown et al., 1999), found that “any measure or combination of measures that [take] more than five minutes to complete, score, and interpret [are] not considered feasible by the majority of clinicians” (Duncan & Miller, 2000, p. 96). Indeed, available evidence indicates that routine use of the ORS and SRS is high compared to other, longer measures (e.g., 99% utilization rates of the ORS & SRS, versus 25% utilization rate of the Outcome Questionnaire-45 [Miller, Duncan, Brown, Sparks, & Claud, 2003]).

Administering and scoring the measures is simple and straightforward. The ORS is administered at the beginning of the session. The scale asks consumers of therapeutic services to think back over the prior week (or since the last visit) and place a hash mark (or “x”) on four different lines, each representing a differ-ent area of functioning (e.g., individual, interpersonal, social, and overall well being). The SRS, by contrast, is completed at the end of each visit. Here again, the consumer places a hash mark on four different lines, each corresponding to a different and important qual-ity of the therapeutic alliance (e.g., relationship, goals and tasks, approach and method, and overall). On both measures, the lines are ten centimeters in length. Scoring is a simple matter of determining the distance in centimeters (to the nearest millimeter) between the left pole and the client’s hash mark on each individual item and then adding the four numbers together to obtain the total score (the scales are available at no cost to independent practitioners in numerous languages at www.scottdmiller.com/performance-metrics).

In addition to hand scoring, a growing number of computer-based applications are available which can simplify the process of administering, scoring, inter-preting, and aggregating data from the ORS and SRS. Such programs are especially useful in large and busy group practices and agencies. Detailed descriptions of the other applications can be found online at www.scottdmiller.com.


Creating a “Culture of Feedback”

“My priority is to encourage openness and a

culture that is willing to acknowledge when

things have gone wrong.”

— John F. Kennedy

Of course, soliciting clinically meaningful feedback from consumers of therapeutic services requires more than administering two scales. Clinicians must work at creating an atmosphere where clients feel free to rate their experience of the process and outcome of services: (1) without fear of retaliation; and (2) with a hope of having an impact on the nature and quality of services delivered.

Interestingly, empirical evidence from both business and healthcare demonstrates that consumers who are happy with the way failures in service delivery are handled are generally more satisfied at the end of the process than those who experience no problems along the way (Fleming & Asplund, 2007). The most effec-tive clinicians, it turns out, consistently achieve lower scores on standardized alliance measures at the outset of therapy thereby providing an opportunity to discuss and address problems in the working relationship—a finding that has now been confirmed in numerous, independent, real-world clinical samples (Miller, Hubble, & Duncan, 2007).

Beyond displaying an attitude of openness and receptiv-ity, creating a “culture of feedback” involves taking time to introduce the measures in a thoughtful and thorough manner. Providing the client with a rationale for using the tools is critical, as is including a description of how the feedback will be used to guide service delivery (e.g., enabling the therapist to catch and repair alliance breaches, prevent dropout, correct deviations from optimal treatment experiences, etc). Additionally, it is important that the client understands that the therapist will not be offended or become defensive in response to feedback given. Instead, therapists must take clients’ concerns regarding the treatment process seriously and avoid the temptation to interpret feedback solely in clinical terms. When introducing the measures at the beginning of a therapy, the therapist might say:

“(I/We) work a little differently in this (agency/prac-tice). (My/Our) first priority is making sure that you get the results you want. For this reason, it is very important that you are involved in monitoring our prog-ress throughout therapy. (I/We) like to do this formally by using a short paper and pencil measure called the Outcome Rating Scale. It takes about a minute. Basi-cally, you fill it out at the beginning of each session and then we talk about the results. A fair amount of research shows that if we are going to be successful in our work together, we should see signs of improvement

earlier rather than later. If what we’re doing works, then we’ll continue. If not, however, then I’ll try to change or modify the treatment. If things still don’t improve, then I’ll work with you to find someone or someplace else for you to get the help you want. Does this make sense to you?” (Miller & Duncan, 2004; Miller & Bargmann, 2011).

At the end of each session, the therapist administers the SRS, emphasizing the importance of the relation-ship in successful treatment and encouraging negative feedback:

“I’d like to ask you to fill out one additional form. This is called the Session Rating Scale. Basically, this is a tool that you and I will use at the end of each session to adjust and improve the way we work together. A great deal of research shows that your experience of our work together—did you feel understood, did we focus on what was important to you, did the approach I’m taking make sense and feel right—is a good predictor of whether we’ll be successful. I want to emphasize that I’m not aiming for a perfect score—a 10 out of 10. Life isn’t perfect and neither am I. What I’m aiming for is your feedback about even the smallest things—even if it seems unimportant—so we can adjust our work and make sure we don’t steer off course. Whatever it might be, I promise I won’t take it personally. I’m always learning, and am curious about what I can learn from getting this feedback from you that will in time help me improve my skills. Does this make sense?” (Miller & Bargmann, 2011).

The ORS and SRS are collectively called the Partners for Change Outcome Management System (PCOMS) which has been certified as an evidence-based practice by the Substance Abuse and Mental Health Services Adminis-tration (SAMHSA). A copy of the SAMHSA report can be found at: http://www.nrepp.samhsa.gov/ViewIn-tervention.aspx?id=249. Instructional manuals for the implementation of FIT and the PCOMS are available at www.scottdmiller.com and further training materials, articles, networking and educational opportunities, and instructional videos are available at the International Center for Clinical Excellence website: http://www.centerforclinicalexcellence.com.

In one example of how FIT can alter practitioners’ outcomes, Anker, Duncan, & Sparks (2009) conducted the largest randomized clinical trial in the history of couples therapy research. The design of the study was simple. Using the ORS and SRS, the outcomes and alli-ance ratings of 205 couples in therapy were gathered during each treatment session. In half of the cases, clinicians received feedback about the couples’ experi-ence of the therapeutic relationship and progress in treatment; in the other half, none. At the conclusion of the study, couples whose therapist received feedback experienced twice the rate of reliable and clinically sig-


nificant change as those in the non-feedback condition. At 6-month follow-up, couples treated by therapists not receiving feedback had nearly twice the rate of separa-tion and divorce.

The research evidence is clear: psychotherapy is effective for a wide range of presenting concerns and problems. At the same time, too many clients dete-riorate while in care, an even larger number drop out before experiencing a reliable improvement in function-ing, and outcomes vary widely and consistently among clinicians.

FIT enables practitioners to achieve excellence by routinely soliciting feedback regarding the client’s per-ception of the therapeutic alliance and progress and using the information to guide and improve service delivery. A significant and growing body of research documents that, regardless of theoretical orientation or preferred treatment approach, employing FIT improves outcome and retention rates and reduces deterioration. In short, FIT can systematically improve the effective-ness of independent practitioners of psychotherapy, one person and one therapy session at a time.

From Feedback to Excellence

“...[E]xperts are always made not born.”

— K. Anders Ericsson (2007)

As crucial as the use of feedback measures may be in delivering better outcomes, their use is not enough to develop expertise. The attitude of practitioners has been shown to play a significant role in their adoption and integration of feedback. For instance, De Jong, van Sluis, Nugter, Heiser, and Spinhoven (2012) found that not every therapist benefits from the use of formal feed-back measures. Only therapists who were committed and held an open attitude towards the use of feedback benefited from the utilization of feedback mechanisms. In other words, feedback functions like tuning equip-ment for a musical instrument. It indicates when a note is out of tune, but it does not necessarily improve the musician’s sense of pitch. Needless to say, it does not inform the user about how to compose a classic.

Another issue that hinders the adoption of feedback measures is attributed to self-assessment bias, also coined as the “Lake Wobegon” effect (Kruger, 1999). The phenomenon of self-assessment bias is not uncommon. Kahneman (2011) termed this “the illusion of validity,” describing the fallacy of judgments about one’s own abilities, especially without any feedback from exter-nal sources to confirm or disconfirm one’s intuitive responses. For example, Kahneman (2011) found that experts making political judgments, stock traders, and financial advisors were not only inaccurate in their predictions, but also over-confident in their judgments. Similar self-assessment biases have also been found

with physicians (Davis et al., 2006). Similar to studies of physicians, self-assessment reports by psychotherapists have revealed that the least effective therapists rate themselves as highly as the most effective therapists (Brown et al., 2006; Hiatt & Hargrave, 1995). Thera-pists are also more likely to overestimate their rates of client improvement and underestimate their rates of client deterioration (Walfish, McAlister, O’Donnell, & Lambert, 2012). In our recent investigation with a sub-sample of therapists who have been routinely measuring their own outcomes over a 5-year period (Andrews, Wislocki, Short, Chow, & Minami, 2013), their self-assessment of their effectiveness did not pre-dict actual client outcomes (Chow, 2013; Chow, Miller, Kane, Thornton, Andrews, n.d.). As such, it remains questionable if self-reported effectiveness actually does represent actual levels of competency.

Feedback can be helpful when an additional step is in place: engaging in deliberate practice (Ericsson, 1996; Ericsson, 2006; Ericsson, 2009; Ericsson, Krampe, & Tesch-Romer, 1993). Deliberate practice is defined as:

…Individualized training activities especially designed by a coach or teacher to improve specific aspects of an individual’s performance through repetition and suc-cessive refinement. To receive maximal benefit from feedback, individuals have to monitor their training with full concentration, which is effortful and limits the duration of daily training. (Ericsson & Lehmann, 1996, pp. 278-279)

This type of practice is often focused, systematic, carried out over extended periods of time, guided by conscious monitoring of outcomes, and evaluated by analyses of levels of expertise acquired, identification of errors, and procedures implemented at reducing errors (Ericsson, 1996; Ericsson, 2006; Ericsson et al., 1993). In a study of violinists, for example, “best” and “good” violinists spent almost three times longer than music teachers in solitary practice with their instrument, averaging 3.5 hours per day for each day of the week including weekends, compared with 1.3 hours per day for the music teachers (Ericsson et al., 1993).

Based on research in the field of expertise and expert performance, Ericsson and colleagues noted that superior performance is not a function of any innate talent (Ericsson, Nandagopal, & Roring, 2005; Erics-son, Roring, & Nandagopal, 2007), nor is it reflected by degrees earned, professional title, or experience. Rather, it comes from the incremental development of extended deliberate practice. Deliberate practice was found to mediate performance in multiple areas of expertise, such as music (Ericsson et al., 1993; Krampe & Ericsson, 1996), chess (Gobet & Charness, 2006), sports (Cote, Ericsson, & Law, 2005), business (Son-nentag & Kleine, 2000), and medicine and surgery (Ericsson, 2007b; Mamede et al., 2007; Norman, Eva,


Brooks, & Hamstra, 2006; Schmidt & Rikers, 2007). Ericsson and colleagues (1993) argue, “The search for stable heritable characteristics that could predict or at least account for superior performance of eminent individuals has been surprisingly unsuccessful” (p. 365), with the exception of certain sporting activities (e.g., ballet, basketball) that require a specific physical endowment.

In psychotherapy, neither training clinicians to improve the alliance nor greater experience conducting ther-apy have predicted clinical outcomes (Horvath, 2001; Anderson, Ogles, Patterson, Lambert, and Vermeersch, 2009). As described above, some therapists are consis-tently better at establishing and maintaining helpful relationships than others. Evidence that the difference is attributable to their possession of deeper domain-spe-cific knowledge (the kind of therapeutic resource that is attained by deliberate practice) was demonstrated by Anderson et al. (2009). In that study, differences in client outcomes between therapists were found to be unrelated to therapist gender, theoretical orienta-tion, professional experience, and overall social skills. Rather, the therapists who exhibited deeper, broader, and interpersonally nuanced knowledge obtained the best results. Regardless of presenting problem or client’s relational style, top-performing therapists were able to respond collaboratively and empathically, and far less likely to make remarks or comments that distanced or offended a client.

Acquiring this kind of understanding, perception, and sensitivity is a common goal for clinicians from the full range of theoretical orientations; yet the data from Anderson et al. (2009) and the broader evidence from Ericsson and colleagues suggest that some end up having such knowledge and using it effectively, while others (of equal experience and social ability), do not.

A recent research study investigated the contribution of therapist variables, their professional work prac-tices, professional development activities, and beliefs regarding learning and personal appraisals of thera-peutic effectiveness (Chow, 2013; Chow et al., n.d.). Although preliminary, results from this study are in line with earlier research on the factors that account for expertise. Similar to Anderson et al. (2009) and others (Wampold & Brown, 2005), therapist gender, qualifi-cations, professional discipline, years of experience, and time spent conducting therapy were unrelated to outcome. Similar to findings reported by Walfish et al. (2012), therapist self-appraisal was not a reliable mea-sure of effectiveness. Consistent with results obtained in other professional domains (e.g., Charness, Tuffiash, Krampe, Reingold, & Vasyukova, 2005; Duckworth, Kirby, Tsukayama, Berstein, & Ericsson, 2011; Ericsson et al., 1993; Keith & Ericsson, 2007; Krampe & Ericsson, 1996; Starkes, Deakin, Allard, Hodges, & Hayes, 1996), the findings by Chow and colleagues (n.d.) provide

preliminary support for the significant role of deliber-ate practice in the development of expertise among highly effective therapists. In sum, the amount of time therapists reported being engaged in solitary activities intended to improve their skills was related to outcome. Seventeen therapists were asked, “How many hours per week (on average) do you spend alone seriously engaging in activities related to improving your therapy skills in the current year?” The top quartile (in terms of clinical outcomes) group of therapists invested about 1.8 times more time on “deliberate practice alone” com-pared with the second quartile group of therapists. The top quartile group spent about 3.7 times more time on “deliberate practice alone” than the third quartile group.

Chow and colleagues (in press) also found that com-pared to other therapists in their cohort, highly effective therapists were more likely to report being surprised by their clients’ feedback. This surprise may signify qualities about the therapist’s openness, recep-tivity, and willingness to receive negative and positive feedback consistent with the concept of therapists taking a “not-knowing” stance to the dialogical process of therapy (Anderson, 1990, 2005; Anderson & Gool-ishian, 1988). That is, the therapist adopts a responsive and tentative posture, while conveying a sense of openness and newness towards the client’s unfolding narrative.

Providing further converging evidence for deliberate, Najavits and Strupp (1994) found that effective thera-pists were more self-critical and reported making more mistakes then less effective therapists. In a more recent study, among other predictors, therapist-reported pro-fessional self-doubt (PSD) had a positive effect on client ratings of working alliance, with higher levels of PSD suggesting an open attitude towards admitting their own shortcomings (Nissen-Lie, Monsen, & Ronnestad, 2010). Taken together, these studies suggest that highly effective therapists’ willingness to evaluate their contri-bution to the psychotherapeutic process, and emphasis on self-correction were associated with their better performance.

One Therapist at a Time

“A man walking is never in balance, but always

correcting for imbalance.”

— Gregory Bateson

Taken together, the findings above point to a viable and hopeful journey ahead for the field of psychotherapy. The three key features of knowing one’s performance baseline, obtaining feedback, and engaging in deliber-ate practice provide a practical framework for clinicians who seek to improve their craft (Miller, Hubble, Chow, & Seidel, 2013; Tracey, Wampold, Lichtenber, & Good-


year, 2014). A craft is defined as “a collection of learned skills accompanied by experienced judgment” (Moore, 1994; p. 1). Psychologists who want to improve must continously reach for objectives just beyond their level of current ability (Miller, Hubble, & Duncan, 2007).

For independent practitioners to thrive in a market-place increasingly driven by demands for quality and accountability, they must evolve beyond the study of psychotherapies in general (i.e., premises, models, pro-cedures, and techniques), and beyond the accumulation of credentials and years of experience. Instead, evi-dence points to the likely necessity (and certainly to the necessity of further research) of working to improve the outcome of each and every therapist, one client at a time.

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Providing Divorce and Custody Mediation Services: The Basics

— Lori C. Thomas

Increasingly parties who are seeking to avoid the financial and emotional, as well as collateral damage to their children,

have steered away from traditional court-based divorces process and have instead opted to purse divorce mediation. In divorce media-tion, the mediator serves as a neutral third party who facilitates a discussion between divorcing parties, as they negotiate a mutu-ally acceptable agreement in the dissolution of their marriage. As a neutral third party, the mediator is not empowered to make decisions for the parties.

In the process of mediation, parties may negotiate any aspect of the termination of their marriage including child custody, child support, and property distribution. Parties can enter mediation either privately or through a court-ordered process.

In some jurisdictions, courts will mandate that par-ties who file a petition for child custody or visitation attend mediation, with the goal of resolving their dispute before the court makes a ruling on their cus-tody matter. Court-ordered mediations are one way in which courts have attempted to relieve the court of the endless backlog of custody cases that flow through the family court system. In jurisdictions that con-tain court-ordered mediations, courts will typically maintain a list of mediators. There are varying require-ments for getting placed on a court list. For example, as

a mediator in Chester County Pennsylvania, I was required to have both basic and advanced mediation training. Additionally, the court required a specified number of supervised mediation cases prior to being placed on the court list. Once placed on the court list, the court then sets the fee for those court ordered mediations. Additionally, I was required to conduct a court-specified number of pro-bono mediations each year.

Divorce and custody mediation are typically governed by state statute, which provides the mini-mum qualifications mediators must have, the training required, as well as, ethical standards to be followed by mediators. Mediator qualifications typically include psychologists, lawyers, social workers and others in the behavioral health and social science fields. For exam-ple, in Pennsylvania, Title 231, Rules of Civil Procedure, Chapter 1940.4 provides the following:

a. (a) A mediator must have at least the following qualifications:

(1) a bachelor’s degree and practical expe-rience in law, psychiatry, psychology, counseling, family therapy or any comparable behavioral or social science field;

(2) successful completion of basic training in domestic and family violence or child abuse and a divorce and custody mediation program


approved by the Association for Conflict Reso-lution, American Bar Association, American Academy of Matrimonial Lawyers, or Adminis-trative Office of Pennsylvania Courts; (3) mediation professional liability insurance; and (4) additional mediation training consisting of a minimum of 4 mediated cases totaling 10 hours under the supervision of a mediator who has complied with subdivisions (1) through (3) above and is approved by the court to super-vise other mediators.

b. (b) The mediator shall comply with the ethi-cal standards of the mediator profession as well as those of his or her primary profession and complete at least 20 hours of continuing educa-tion every two years in topics related to family mediation.

c. (c) A post-graduate student enrolled in a state or federally accredited educational institution in the disciplines of law, psychiatry, psychology, counseling, family therapy or any comparable behavioral or social science field may mediate with direct and actual supervision by a quali-fied mediator.

While many state statues provide minimum qualifica-tions for the mediators, most states have not mandated special certifications for engaging in the practice of mediation (See mediation training institute inter-national for a review of state requirements). One exception is the Florida Supreme Court, which requires that mediators to be certified through their court train-ing program in order to become a family mediator with the court.

There are a variety of mediation styles that mediators can practice including but not limited to transfor-mative, facilitative and evaluative. Over the years, research has investigated the effectiveness of media-

tion and mediation styles (see e.g. Beck & Sales, 2000; Emory, Sbarra, & Gover, 2005; and Baitar, Buysse, Brondel, De Mol, & Rober, 2013). Psychologists wish-ing to participate in mediation would of course need to receive training and could obtain that training from a number of non-profit organizations in their state. Cost for mediation training may run upwards of $1000, which includes basic and advance mediation training along with supervised hours. Psychologists will also have to check with their malpractice carrier to ensure that they are covered for their work as a mediator. However, in some cases, malpractice carriers may con-sider mediation to fit within the auspices of the work of a psychologist.

If a psychologist is not interested in pursuing training as a mediator, there are other ways that psychologists may be involved in the mediation process. The Holis-tic Divorce Mediation model, proffered by Pastore and Pastore, is one example of how multidisciplinary teams of professionals may collaborate in providing compre-hensive services to individuals who are endeavoring to dissolve their marriage.

ReferencesBaitar, R., Buysse, A., Brondeel, R., DeMol, J., & Rober, P.

(Fall, 2013). Styles and goals: Clarifying the professional identity of divorce mediation. Conflict Resolution Quar-terly, 31(1), 57-77. doi# 10.1002/crq

Beck, C. J. A., & Sales, B. D. (2000). A critical reappraisal of divorce mediation research and policy. Psychology, Public Policy, and Law, 6, 989-1056. doi # 10.1037//1076-

8971.6.4.989Emory, R. E., Sbarra, D., & Grover, T. (2005). Divorce media-

tion: Research and reflections. Family Court Review, 43(1), 22-37.

Mediation Training Institute International (n. d). State requirements for mediators. Retrieved from http://www.mediationworks.com/medcert3/staterequirements.htm 231 Pa Code Rule 1940 (1999)


Divorce Mediation: A Holistic, Structured Team Approach

— Crispino M. Pastore and Sharon Pastore

After much focus on reconciliation of the rela-tionship and the marriage has clearly reached a “point of no return,” it is not uncommon to

find yourself in a position where one or both parties is asking you, their most trusted confidant, about what steps they should take in the dissolution of their mar-riage. How might you respond?

While you can certainly tell your client that this is not your area of expertise and recommend they consult an attorney for legal advice, you may consider another option. The standard court contested divorce process may be appropriate in some cases; however, the use of the adversarial process in divorce proceedings, may unnecessarily throw your clients straight into a “boxing ring,” unraveling the important work they may have done to preserve civility in their relationship and pre-serve the family unit.

This article takes the position that mediation is a far more effective option for clients to consider first, even when they cannot agree or communicate well together. Additionally, there is often a role that psychologists may play as a member of a divorce team in helping divorcing spouses successfully manage those emotions, both prior to and throughout the mediation process.

Unintended Consequences in the Court-Contested Divorce ProcessIt is important to take a moment to understand the potential set of adversarial chain reactions that could occur when your client retains a lawyer. When it comes to custody, for example, your clients will be advised to protect themselves, as well they should. However, liti-gation tactics are centered on things like proving who is the worse parent, and can cause a spouse to head down an emotionally and financially draining path of multiple hearings and court dates, sometimes even subjecting their children to have to testify in court. A custody trial alone often costs at least $15,000 in legal fees on average, digging an even deeper financial hole that has additional anger, shame and guilt attached. Other protective tactics might also appear subversive, such as withdrawing and shifting funds in and out of joint accounts and redirecting paycheck deposits, set-ting the tone for a long and bitter divorce.

From the divorce lawyer’s perspective, he or she is only doing what they have been trained to do- to zealously represent their client, regardless of the financial and emotional fallout that occurs. Judges are also part of an over-worked court system which often sadly does not

have the time to evaluate each case on its individual merits with the level of attention that it deserves.

While it is true that most contested divorce matters settle out of court, this is most typically at the eleventh hour on the courthouse steps before trial, two to four years may have past after numerous support, custody and property distribution hearings have taken place, and at a time when all the financial and emotional damage has already been levied on the family unit.

How a Holistic Divorce Mediation Model Works and the Psychologist’s RoleWhen spouses have decided that their marriage is over and cannot agree, the psychologist can play a pivotal role in steering clients toward the emotionally and financially healthier option of divorce mediation, while playing a vital role throughout the process. In our practice, divorce is viewed as a change, neither positive nor negative. Mediation is the process for managing that change. As such, we have developed the following model for divorce mediation (see, Figure). It is both facilitative and holistic, and focuses on four key aspects of divorce: legal, parenting, financial, and emotional.

Figure. Main Line Family Law Center Holistic Model for Divorce Mediation

A Holistic Model for Divorce MediationNot a cookie cutter approach, the process is tailored to the needs of each client. If minor children are involved, for example, and concerns about parenting separately are foremost, clients are advised to par-ticipate in the full program and possibly referred for co-parenting counseling. A child psychologist or thera-pist is also recommended if parents notice any unusual or prolonged changes in a child’s behavior that suggest their difficulty in coping with the change.

Clients are also encouraged to use their own psycholo-gist or therapist to recover from the overall trauma of divorce, or to work with a divorce coach to help them emotionally prepare for each mediation session. The psychologist may also act as a project manager, help-


ing a client to get better organized and prepared in planning for the change they are about to experience. We have a network of psychologists and marriage and family therapists who are oriented to this model as part of the divorce mediation team, should clients need a referral.

In addition, when clients submit to the mediation pro-cess, they agree to trust the process and therefore, agree not to retain lawyers. However, an independent attorney may be used to review their marital settlement agreement draft at the end of the mediation process. Otherwise, the reason for abandoning lawyers is so that spouses can demonstrate their commitment to the process, even when the trust of a spouse is in ques-tion. This “act of surrender” is critical to the good faith peace-making that makes mediation so transformative and relationship-preserving. Along with that commit-ment, a stronger sense of vulnerability, or perhaps a newfound voice of anger or resolve, can develop result-ing in the need for added support.

In these situations of higher conflict couples who want to mediate, we have found that the holistic, team facili-tative approach lends itself especially well. There are several reasons for this. First, this model is directed primarily by an experienced attorney-mediator. While

he or she cannot give legal advice, per say, spouses tend to feel they are still getting legally informed guidance, and have access to a seasoned practitioner who also has a keen sense of what is most fair for each divorce situation. Second, while not all spouses are ready to move quickly, they usually appreciate the ability to clearly see “the way out,” especially after feeling stuck in an unhappy marriage for so long. Third, clients generally seem to prefer to use the law as a starting point for their negotiations, as there is often a strong belief of “should” and the need to understand “rights and entitlements” when beginning the process. Stick-ing with what the rules say is fair is often a comfortable place for higher conflict couples to begin their negotia-tions. Depending on the needs of the client, our team of professionals includes any or all of the following: an attorney-mediator, parenting mediator, psychologist/therapist, divorce coach, draft review attorney, financial planner, and/or estate planner. With permission of the client (and when ethically appropriate), the attorney-mediator may discuss any concerning issues with the team to pave a smoother path toward resolution.

The process begins with parenting mediation, to allow focus on children’s needs first, followed by one to two financial mediations and a final agreement draft review meeting. The process̀ takes as little as 3-7 months, and

Table 1 Plan for Resolution Using a Facilitative Model

Process and Timeline (Average 3- 7 months)

Role of Psychologist

Step 1: Initial Consultation with Attorney-Mediator, Overview of Process

Similar to a coach, work with client(s) to review information from consultation and come to a decision on whether/how to move forward.

Step 2: Emotional Preparation Holds either individual and or joint session with client(s) to focus on intentions, managing anger, guilt, and effect on decisions in mediation.

Step 3: Gather Financial Documents Works with client to relieve sense of overwhelm around docu-ment gathering, understand importance of full disclosure of information and increased sense of vulnerability.

Step 4: Parenting Mediation Works with one or both parents around decisions in a healthy parenting plan, co-parenting, trust, telling the children. While children are not involved in this process, parents are encouraged to monitor children’s signs of difficulty coping, and work with child psychologist.

Step 5: Financial Mediation Works with client to understand emotional connections to money

Step 6: Financial Planning and Analysis Reviews financial scenarios with client to sort through options and potential outcomes from an emotional perspective.

Step 7: Financial Mediation Same as step 6

Step 8: Draft Review Reinforce the careful selection of a mediation-friendly attorney who will not derail the progress of mediation.

Week 10: Filing for Divorce Decree or Sign Separation Agreement Helps client adjust to finality, and use the mandatory 90-day wait period as a time to rediscover and start anew.


clients are encouraged to proceed at the pace that is comfortable to them.

One other major distinction in this mediation model, not to be underestimated, is that clients finish the program with a legally-binding marital settlement agreement and a final divorce decree (if they desire a divorce) - as opposed to a memorandum of understand-ing of their settlement terms that then has to be taken to an independent attorney to memorialize in an offi-cial agreement draft, and then file with the court. In this model, clients enjoy the convenience of having all services in one place, at the same time, all managed by an experienced divorce attorney, including administra-tive support and guidance with the county court filing to obtain their divorce decree.

Results from Holistic, Structured Approach Divorce MediationIn our practice, we have found that approximately 7 of every 10 couples who decide to separate or divorce are indeed appropriate for, and can take advantage of the divorce mediation process. Unfortunately, however, we find that many couples are unaware of the benefits of divorce mediation . Of the 121 individuals served since our firm began in 2012, approximately 90% (n=109) of them have successfully completed, or will have success-fully completed our program in between 3-7 months. Ten percent (n=12) did not complete the mediation, and of those, 9% (n=11) opted to finalize their divorce process utilizing the standard model of private attor-neys in a court-contested process, and one reconciled. Note that a proper screening process has been a criti-cal factor in achieving this high success rate, and so you will want to carefully consider who is appropriate prior to a referral to this process. Our practice model incorporates the use of a facilitative model of divorce mediation to assist clients with reaching a mutual reso-lution to their divorce process. We collaborate with psychologists and other mental health professionals who fulfill various roles and tasks throughout the pro-cess (see, Table 1 on page 88).

Assessing Proper Candidates for MediationWhile no two cases are the same and they each present with their own unique nuances and dynamics, here is a handy assessment of how the psychologists we collabo-rate with determine whether a client is appropriate for divorce mediation (Table 2 below):

Cases of past physical or mental abuse do not necessar-ily preclude spouses from mediation, unless the abuse is more immediate and/or there is a pending protection from abuse order with the court (see Beck et al., 2011 for a study of divorce mediation in the context of court-ordered mediation) . Likewise, even if a couple has been in litigation for years, it is still never too late for them to finish in mediation. Speaking directly with the attorney-mediator about the specific dynamics involved in each case is the best way to determine if it is appro-priate for mediation.

While it is ideal for spouses to finish in mediation, we recognize that this is not always the case either. It may be that spouses were able to come to agreement on, say, a parenting plan, but that alimony became so heated that an attorney was retained to finish the settle-ment. The privately-retained attorney would, thus, be called upon the assist a spouse with the negotiation of a particular sticking point that could not be resolved in mediation.

On the flip side, spouses might come to us with parent-ing or financial issues already worked out, especially if they have been physically separated for some time. Thus, they may have only a few remaining issues left to mediate.

Will a Holistic Mediation Model Work for Your Client?Even after using the quick assessment (in Table 2 below) and still not 100% certain, the initial consulta-tion may be seen as an experiential test as well as the beginning of the mediation process. Based upon our

Table 2. A Quick Assessment to Determine if the Client is Appropriate for Divorce Mediation_____________________________________________________________________________

To be considered an appropriate candidate for divorce mediation, both spouses should agree to the following nine statements:• My marriage is over.• I want to retain control over decisions in my divorce.• I want to keep my children’s best interests in mind and at heart at all times. • I don’t want to hurt my spouse emotionally or financially.• I believe my spouse is not out to hurt me emotionally or financially. • I am willing to disclose all financial documents and other information for my spouse to view. • I want to be educated and informed throughout the process.• I am willing to trust in the process, even if I don’t fully believe it can work for me yet. • I want to use the divorce experience as a lesson in my personal growth.


practice experience, the ability to complete this step successfully together is actually one of the strongest indicators as to whether a client will finish their divorce process in mediation.

Prior to attending the consultation sessions, clients must both attend and complete a marital inventory form together– which may, depending on the conflict level of the couple, be a challenging task! During a consulta-tion, the attorney-mediator will provide: 1) overview of PA Divorce Law, 2) an understanding of the mediation process and the role of the attorney –mediator, 3) a dis-cussion of what the clients’ roles and expectations are in order to successfully participate in the program, 4) detailed explanation of the holistic approach and which professionals clients may choose to work with as part of their team, and 5) comprehensive assessment of the marital estate and all attendant issues that are involved in a divorce. Notice that there is no discussion in the consult of what brought the couple to this point. Not only does this approach help clients start on equal footing, but it also prepares them to present a fair proposal to their spouse and further acclimates them towards the process, should either one or both spouses ever doubt that they can “do it.” More amicable (and frankly, more educated) clients recognize they can confidently depart from the dictates of the law, should they choose, and make up their own rules for fairness. Either way, the process is empowering for spouses who are firmly in control of their own decisions.

The Sessions: What Goes on Behind Closed DoorsAs mentioned previously, our practice model includes a variety of consultation sessions with the couple including, but not limited to, parenting mediation and financial mediation. Below, we provide sample of what may be included in those sessions.

The goal of the parenting mediation is to have a com-prehensive, yet fluid parenting plan in place that addresses both the current needs and best interests of the children as well as other family dynamics, but that also stands the test of time as the children’s needs change over time. A comprehensive agreement, with the assistance of the parenting mediator, can usu-ally be accomplished in as little as one 2 -2 1/2 hour session. This plan, once finalized and signed by the parties, becomes a legally-binding agreement which is fully enforceable in a court of law once approved by the assigned divorce judge.

A typical parenting agreement will address the follow-ing at a minimum:

• Parenting time (physical custody and overnight time decision making;legal custody)

• Transportation and exchanges

• Holiday time/special occasions

• Annual vacations and school breaks

• Contact with relatives and significant others

• A dispute resolution process through mediation

• Contact information, relocation and foreign travel

• Social activities and school functions

• Communications and mutual decision-making

• School districts attended and access to records

A typical list of issues discussed and resolved in finan-cial mediation sessions are as follows:

• Equitable distribution of marital property, including real estate, retirement, auto, valuables, etc.

• Equitable distribution of marital debts, including house debt, credit cards, loans, etc.

• Child support

• Spousal support and alimony

• Life insurance issues

• Taxation issues upon a divorce

• Family medical insurance issues

• College and college savings for children

• Estate matters

• Financial planning guidance

• Post-separation/divorce budget analyses

One or two sessions (or more, if necessary), each last-ing about 2- 2 1/2 hours in length are usually sufficient to discuss and obtain mutually fair and creative resolu-tions around the above issues.

The attorney-mediator will require full disclosure of all financial documents before the sessions begin so that all cards are on the table for discussion. In the first session, the attorney-mediator will review the entire marital inventory with the clients and they will come to agreement on what are the date of separation values of all assets and debts that are subject to equitable division. Spouses will also discuss the applicability of a child support payment in accordance with the appli-cable state support guidelines (in our case, it is the Pennsylvania Support Guidelines), as well as discuss all other child-related expenses over and above the basic child support mandate.

Spouses will also review their post-separation budgets to determine what their living expenses will be so they can be more financially secured in the residence they wish to reside in after the divorce is final. Further, spouses will discuss the division of all personal prop-erty and contents of the marital home as well as family medical insurance issues. In the second and final ses-sion, spousal support and alimony will be covered, as well as life insurance, estate matters, taxation issues, college expenses for children and then coming to reso-


lution on the equitable division of the net marital assets for the settlement.

In between sessions, spouses may ask the mediator any question they may have that is substantive to the medi-ation. All communication with the mediator is made with the other spouse either being present, or otherwise being made aware of the communication. As a neutral third-party to the process, the mediator cannot advise any one spouse on how to negotiate with the other, or what settlement offer(s) they should be making. Rather, it is the responsibility of the spouses to negotiate a fair settlement together after they have been armed by the attorney-mediator with the legal knowledge, informa-tion and perspective to make settlement offers that are fair, reasonable and practical for everyone concerned.

SummaryThere are a number of ways psychologists can be part of a team in this holistic divorce mediation model and

serve a very valuable and important role in the process. When a psychologist can team up with a mediator, it can greatly helping divorcing couples struggling with anger, resentment, fear, depression, and mistrust. As such, when your clients mutually arrive at the conclu-sion that their marriage is over, you now have another referral option that focuses on family preservation and a healthy recovery.

ReferencesBeck,C.A,, Walsh, M.E.,Mechanic, M.B., Figueredo, A.J., & Chen, M.K, (2007). Intimate partner abuse in divorce mediation: Outcomes from a long-term multi-cultural study. U.S Department of Justice. https://www.ncjrs.gov/pdffiles1/nij/grants/236868.pdf

Sharon Pastore, MPA is Partner, Co-Founder and VP of community relations at Main Line Family Law Center. The found of the center is Crispino Pastore, Esquire is President, Attorney Mediator and Co-Founder of the Center.

An Attempt at Conducting a Group for Mothers of Young Children— Carrie R. King

The idea for a new format to my parenting group grew organically from an exchange with a client desperate for guidance and more time in her

everyday life. She mentioned off-hand that she had a book focused on rearing a child like hers, but it had been sitting unopened for months. I said, “I’ll read it for you. I’ll tell you what’s in there and if it’s worth your time.” I didn’t plan on making the offer. It was impul-sive and likely stemmed from a genuine desire to give something concrete to my client and to reduce her burden (I think). It could also have stemmed from my impatience as I waited for her to act, or, from my own guilt from not reading more literature in the popular press. Perhaps it stemmed from a sleeping and distant memory of an unspoken deal I struck with a tween a few years back: “I will read your beloved Twilight (yuck!) if you will keep coming back.”

I ascribe to the faction of clinicians who did not cringe (at least not entirely) while reading Dr. Jonathan Alp-ert’s New York Times article “In Therapy Forever? Enough Already” where he criticized non-directive work and espoused his belief that patients “need a therapist’s opinion, advice and structured action plans” (Alpert, 2012). Even if one disagrees with Alpert’s professional opinion, one cannot ignore the clients clamoring for quick and directive services.

My client was grateful of my offer. Her enthusiastic reaction to the proposal reflects the growing demand on

the part of mental health consumers to receive similar hands-on treatments that will save them time. Con-sider the proliferation of mobile software applications, or “apps”, that directly address mental health needs and treatment (Boschen, 2009; Luxton, McCann, Bush, Mishkind, & Reger, 2011; Trudeau, 2010). And the pres-sure is on. Even Psychology Today offered last spring “The Top Ten Happiness Quick Fixes” to its readers (Raghunathan, 2013).

Psycho-educational groups provide one avenue to mental health and they are directive and goal-oriented enough to meet the trending consumer demand. Group therapy works (Burlingame, Fuhriman, & Mosier, 2003; Frisch, Hofecker-Fallahpour, Stieglitz, & Riecher-Rössler, 2013) and there are further data supporting the effectiveness of women’s groups that add educa-tional components (Hoogenhoutab, de Grootac, van der Elsta, & Jollesd, 2012; Penckofer, Ferrans, Mumby, Byrn, Emanuele, Harrison, Durazo-Arvizu, & Lust-man, 2012). Group work makes certain client-friendly perks possible (provided they do not violate our ethical codes or boundaries). For instance, in a recent study of depressed new mothers in Switzerland, the authors highlighted the importance of offering childcare during the group sessions, which clearly made it easier for the women to attend (and, I would add, may therefore have helped improve its effectiveness; Frisch et al., 2013).

So how do we fit therapy onto that calendar where


many women cannot fit a trip to the gym (which is a self-help task likely higher on their lists than mental health)? We tell them we will save them time and offer to lighten their load. Of course we are always telling our clients that working toward the change they desire will save them time in the end. For example, “If you make a behavior chart for your child (and USE it), you will save time by doing less stressing, reminding, argu-ing, punishing.” However, these incentives are not always motivating enough for many clients to imple-ment new practices that require increased energy and time upfront. Many of our clients are packing in more activities and responsibilities each week. They expect (and receive) time-saving and personalized services to accommodate their increasingly crowded schedules. The demand for focused, active therapy is here.

ImplementationI offered my clients what they asked for: a solution-focused, psycho-educational group. I collected a small group of moms who I knew previously from work-ing with their families or evaluating their children. This history allowed me to select individuals who I determined were empathic, emotionally mature, collab-orative, and who evidenced healthy boundaries. I also selected women who have flexible schedules and could attend group during school hours. Via email, I shared with them that all of the invited women “have several things in common at home.” I stated that I wanted to create a space where they could share “frustrations and ideas,” and framed it as a group that would meet monthly “over lunch.” Finally, I asked who had a parent-ing book on her bedside table that I could read for her, summarize, and report back to the group. And it was that offer, I believe, that sealed the deal.

As do all groups, my Moms Group, once assembled face-to-face, created its own group personality and flow. This selection of women wanted two distinct things, which only became clear once they were gathered – education and guidance with their children, and help co-parenting with their husbands.

Mothers struggle to make what they feel are the “right” choices regarding screen time (television, videogames, etc.), homework assistance/supervision, helping chil-dren negotiate friendships, knowing when and how to intervene with sibling squabbles, handling fits/out-bursts, internet safety, etc. In our group they utilized the words of professionals and the stories of their sisters to develop plans and confidence to carry them out.

These women struggled with their partners and even when it was not the topic at-hand, marital problems were raised by the group in each of our meetings. Issues were brought to the group such as: “my husband doesn’t understand our child’s diagnosis,” “he has a short fuse,” “he makes situations worse,” “he doesn’t take my advice or follow my lead,” “he undermines me.”

Over the course of the past year I have provided book summaries on establishing family values, effective communicating, sibling rivalry, understanding and dealing with emotional explosions, limit-setting, help-ing children navigate friendships, and reviews of books aimed to improve communication between intimate couples. At the end of each meeting, I made my same offer, who has a book for me to read for our next meet-ing?

Barriers for Psychologists to Add Group Work to PracticeAny clinician who has attempted to add group work to her practice knows immediately why she has never done this before, or why when she looks for groups for her individual clients, they are so difficult to secure. Group work in private practice can be a leech on the precious time you have in your office. Scheduling is a nightmare. Then, if you can miraculously get five kids or (gasp) five actual couples together at once, when they walk out you have five notes to write. With some group formats you now have five families who need feedback, and for psycho-educational groups, there is a good deal of preparation that awaits before your next session.

Like our clients, therapy works best for us clinicians if we, too, invest a good deal of effort upfront. One method I have come to use to make the scheduling piece easier and the vitality of the group more likely, is to first think of my eligible candidates. For this group, these questions were: Who is motivated to make par-enting changes? Who has a flexible schedule? Who is appropriate for group work? Lastly, do these women have any clinical issues in common? This approach wins the battle with my former approach every time: “I have several families attending individual family ther-apy. I’m going to do a parenting group on Wednesdays at 6:00 and invite all of the parents.” In other words, I learned to select the appropriate members and their “fit” for group first. Then, I designed psycho-educational content for that particular collection of people instead of developing a good curriculum and inviting all of my families to join.

Feedback from Group MembersWhen you can successfully assemble a workable group, the payoff is great and the work on the tail end is not as tedious. The moms in my group might be my most satisfied clients. When I asked them individually at the end of the year to tell me why they liked their group, they shared the following reasons:

i. It meets every 4-6 weeks which alleviates a lot of “pressure”

ii. It is inexpensive

iii. It meets during the day which makes it possible

iv. It’s relaxing and judgment free. No one in the group


presents with a perfect child or perfect marriage (a presentation they dread in informal gatherings of women)

v. They learn significantly from listening to others with similar problems and they feel better knowing “I’m not the only one”

vi. They hear descriptions of themselves in the com-plaints of fellow members (e.g., when someone shares frustrations about her husband) and it pro-vides a different point of view and added insight

Please note: not one group member, despite their col-lective enthusiasm, elation, grateful thanks at the premise of this group, mentioned in her feedback that she appreciated the book reviews or direct advice she received. So, our clients may think they know what they want but good old-fashioned empathy, positive regard, and normalization might just work every time. As further evidence, I did read Twilight and my tween kept returning to treatment. She, of course, never men-tioned my reading of her book as a curative factor. But perhaps it was the offer that allowed us to move into a relationship where we liked each other a lot, she felt understood, and her symptoms improved significantly.

ReferencesAlpert, J. (2012, April 21). In Therapy Forever? Enough

Already. The New York Times. Retrieved August/25, 2013, from http://www.nytimes.com/2012/04/22/opinion/sunday/in-therapy-forever-enough-already.html?pagewanted=all&_r=0

Boschen, M. J. (2009). Mobile telephones and psychotherapy II: A review of empirical research. The Behavior Therapist, 32, 175-180.

Burlingame, G. M., Fuhriman, A. J., & Mosier, J. (2003). The differential effectiveness of group psychotherapy: A meta-analytic perspective. Group Dynamics, 7, 3–13.

Frisch, U., Hofecker-Fallahpour, M., Stieglitz, R-D., & Riecher-Rössler, A. (2013). Group Treatment for Depression in Mothers of Young Children Compared to Standard Indi-vidual Therapy. Psychopathology, 46, 94–101.

Hoogenhoutab, E.M., de Grootac, R.H.M., van der Elsta, W., & Jollesd, J. (2012). Effects of a comprehensive educational group intervention in older women with cognitive com-plaints: A randomized controlled trial. Aging & Mental Health, 16(2), 135–144.

Luxton, D. D., McCann, R. A., Bush, N. E., Mishkind, M. C., & Reger, G. M. (2011). mHealth for mental health: Integrat-ing smartphone technology in behavioral healthcare. Professional Psychology: Research and Practice, 42(6), 505- 512.

Penckofer, S.M., Ferrans, C., Mumby, P., Byrn, M., Emanuele, M.A., Harrison, P.R., Durazo-Arvizu, R.A., & Lustman, P. (2012). A Psychoeducational Intervention (SWEEP) for Depressed Women with Diabetes. Annals of Behavioral Medicine, 44, 192-206.

Raghunathan, R. (2013). The Top 10 Happiness Quick-Fixes. Retrieved August/31, 2013, from http://www.psychologytoday.com/blog/sapient-nature/201304/the-top-10-happiness-quick-fixes

Trudeau, M. (2010). Mental health apps: Like a ‘thera-pist in your pocket’. Retrieved August/25, 2013, from http://www.npr.org/templates/story/story.php?storyId=127081326

Dr. King is in private practice in California. Correspondence regarding this article can be addressed to Dr. King at [email protected].

From Research to Practice— Andrea Peterson, Mattie McIntyre, & Andrea Kozak Miller

Depressive Symptoms and their Predic-tors in Marriage

Many clinicians work with married couples in which one or more of the individuals are experi-encing symptoms of depression. This study by Peterson-Post et al. presents research on marital adjustment and perceived spousal criticism, two possible predictors of depressive symptoms within marriages. The study assessed 249 spouses during their first year of marriage, as well as at 3 different times through a span of 10 years. Researchers found that for both husbands and wives, initial marital adjustment was a significant predictor of depres-sive symptoms at all assessments, while perceived criticism was a significant predictor of depressive

symptoms at the 5- and 10- year assessments. As for the one-year assessment, perceived criticism was only significant for husbands, and not for wives. Overall, data suggested that both predictors play independent roles in the prediction of future symptoms of depression. These findings stress the importance of increasing marital adjustment and decreasing perceived spousal criticism in the begin-ning of a marriage, while being aware of initial gender differences, in order to reduce symptoms of depression throughout the marriage span. Clini-cians may be interested in the tables displaying statistical data on each assessment over the 10-year span.

Peterson-Post, K. M., Rhoades, G. K., Stanley, S .M., & Markman, H. J. (in press). Perceived criticism and


marital adjustment predict depressive symptoms in a community sample. Behavior Therapy. Retrieved from http://dx.doi.org/10.1016/j.beth.2014.03.002

Reprint requests to Kristina M. Peterson-Post at [email protected]

Looking for Hope Where There is no Hope

As mental health providers, we provide comfort where there is no other comfort and hope when there seems to be no hope. We attempt to be mindful of the client’s spirituality and any other inspirational signs that he/she may exhibit that can assist us, but what if we don’t have any influences our self? A possible overlooked element of effec-tive psychotherapy may have to do with the depth of our spiritual relationship with the client. Coping mechanisms vary from person to person, and it appears that health care providers are less likely to turn to the spiritual realm than are the general population of the United States. Kenneth Parga-ment suggests that spirituality is an important asset that we need to be aware of, not only for our own well-being, but to also help build rapport with our clients. Pargament humorously compares health care professionals as “Eeyore” from Winnie the Pooh, or You Tube’s equivalent in the “Grumpy Cat” while emphasizing the high number of burnouts and psychological problems that happen within the field. Pargament utilizes prior research, theory, and examples to facilitate methods that could assist providers in maintaining their enthusiasm as well as build and sustain their own hope and spiritual-ity. Spirituality, in this sense, does not necessarily mean religious views. Spirituality can be the basic understanding of how important our line of work is or our ability to understand and even experi-ence the various ‘sacred’ facets of happenings in our clients’ lives, or to sit in on a revered moment of healing. We have an obligation, but when we have a calling to our field and regard it as sacred and fulfilling, we become imbued with a sense of sacredness that will enhance and enlighten our life as well as the lives of our clients. With our feet firmly planted in hopeful realism, we must find the fine line between sympathy and empathy. As providers, we may feel the occasional ups and downs of our clients, but we must also understand the difference between experiencing the client’s pains and attending to the client. Just as we can be lifted up we can also be dragged down, and so may our clients. The key may lay in our own ability to recognize and hold spiritual conversations. Client – provider rapport is crucial for a good therapeutic relationship. Part of that relationship often includes spiritual moments and if therapists are not attuned to their client’s spirituality, they miss an oppor-

tunity for change or a great therapeutic alliance. Spiritual practices such as meditation, inspirational reading, spiritual visioning, mantras, or whatever we hold sacred, will help us to maintain a more positive attitude which in turn will assist us and our clients to a fuller extent. In order to maintain our own sense of normality in a world that seems so dark and we hear Eeyore’s gloomy voice trying to take us down, we should look for hope inside and outside of ourselves; looking for whatever we hold sacred. It could be a relationship, a job, a pet, or an object. It can be of another dimension or world, or something as simple as remembering that special moment when you had a ‘sacred moment’ with a loved one, a friend or even a client. As Kenneth Pargament stated, “Never let Eeyore have the last word.”

Pargament, K. (2013). Conversations with Eeyore: Spirituality and the generation of hope among mental health providers. Bulletin of the Menninger Clinic, 77(4), 395 – 412. Reprint requests to Kenneth I. Pargament at [email protected]

Video Self-Modeling and NoncomplianceMany psychologists work with noncompliant chil-dren and their families. Axelrod et al. examined if video self-modeling (VSM) might be an effective technique for decreasing aggressive behavior in children. In positive self-review VSM, individuals view themselves engaging in the desired behavior, even though it might only occur at a low frequency. Another type of VSM, video feed-forward, shows an individual engaging in a desired behavior (which may currently require support) but edits out the support to show individuals engaging in the behav-ior on their own. Axelrod et al. studied positive self-review VSM for noncompliant behaviors with three children, ages seven to eight, from an inpa-tient psychiatric unit. A baseline was established with the percent of compliant behaviors to tasks the participants could independently complete within one minute. Tasks with under 50% compliance were chosen for the study. Videos were recorded for various tasks within the settings and edited to show examples of compliance. The VSM interven-tion lasted 12 days. Participants first viewed 4 clips of compliance in the hospital setting for the first 2 days of the 12 day treatment, and then added in an additional 4 clips of compliance in the classroom setting for the remaining 10 days. Compliance was increased during the VSM intervention for all three individuals and during follow up for two of the three individuals across settings and for the third individual in the hospital but not the classroom setting. All three participants showed a decrease in aggressive behaviors both during the VSM intervention as well as at follow up. The authors


discussed relating the change in behavior to obser-vational learning as well as priming. Clinicians might be interested in the full article for a further breakdown of the treatment as well as a graphical representation of the behavior change.

Axelrod, M. I., Bellini, S., & Markoff, K. (2014). Video self-modeling: A promising strategy for noncompliant children. Behavior Modification. Advance online publica-tion. doi: 10.1177/0145445514521232. Reprint requests to Michael I. Axelrod at [email protected]

The Effect of Support Through Internet-Delivered Insomnia Treatment Based on Depression Severity

Many clinicians have found internet-delivered cog-nitive-behavioral therapy (CBT) to be an effective first choice when treating patients with insomnia. Additionally, it has been established that patients with insomnia often experience depressive symp-toms and it is suggested that motivational support may improve treatment response. This study by Lancee et al. discusses internet-delivered treatment and support for insomnia, along with the rela-tion between insomnia and depression, and tests whether depressive symptoms impact the effect of support. Researchers conducted a multilevel intention-to-treat analysis on 262 participants with insomnia in a randomized control trial. The treat-ment included elements such as psycho-education, diary entries, relaxation exercises, stimulus control and sleep hygiene, challenging sleep misconcep-tions, paradoxical exercise, and sleep restriction. Participants in the support condition each received on average 39.8 minutes of weekly feedback via email that reminded and encouraged participants to complete their exercises, along with minor assis-tance and tips. For both the post-test and six-month follow-up, results showed that for participants with high depressive symptom levels, the effect of sup-port was considerably larger than for participants with low depressive symptom levels, who improved regardless of support given. These results indicate that individuals with high depressive symptoms need support in order to equally benefit from internet-delivered treatment for insomnia, as base-line depression severity plays an important role in the delivery of internet treatments. Overall, this data is beneficial for practicing professionals who work with clients with insomnia, as it opens up opportunities to personalize support offered in internet-delivered treatment. Clinicians might be interested in the numerous tables presenting detailed data on participant characteristics and statistical results.

Lancee, J., Sorbi, M. J., Eisma, M. C., van Straten, A., & van den Bout, J. (in press). The effect of sup-port on internet-delivered treatment for insomnia: Does baseline depression severity matter? Behavior Therapy, Retrieved from http://dx.doi.org/10.1016/j.beth.2014.02.012 Reprint requests to Jaap Lancee at [email protected]

Naturalistic RecoveryWe often work with individuals who experience symptomatology related to aversive life events. Past studies have tracked symptomatology over time as well noted sudden gains in symptoms followed by a decrease in symptoms with the hypothesis that this change was related to emo-tional processing. Larsen and Berenbaum studied 63 adult women from a community sample who had “experienced an aversive event between 3 months and 3 years ago” (p. 3) and had “at least started to recover from the event” (p. 3). After an initial screening for inclusion, participants completed an interview, demographic question-naire, a Life History Calendar (LHC), the Positive and Negative Affect Schedule (PANAS), The PTSD Checklist (PCL), and the Anhedonic Depression subscale from the Mood and Anxiety Symptom Questionnaire. During the recovery period 75% of participants indicated considerable improve-ment on at least one symptom. The authors found 41% of the sample had a significant brief increase in symptoms, with a variety of reasons stated for this change. In looking at the data as a whole, the authors indicated there were substantial symptom increases seen in the naturalistic recovery pro-cess. Larsen and Berenbaum discussed that these increases are different from the past research on emotional processing and reported that the women attributed these increases to external events in their lives; however, the rate of symptomatology increase seen in naturalistic recovery was similar to the rate of increase in past studies on individuals undergoing psychotherapy. The increase, though, in natural recovery was likely tied to additional external stressors while the symptom increase in individuals undergoing psychotherapy was tied to processing of information (followed by decreases in symptomatology). The increases in symptom-atology in the naturalistic recovery group did not predict outcomes. Individuals might be interested in a full copy of the article to review the breakdown of symptomatology change over time.

Larsen, S. E., & Berenbaum, H. (2014). Substantial symptom changes in naturalistic recovery from aver-sive events. Journal of Clinical Psychology. Advance online publication. doi: 10.1002/jclp.22092. Reprint requests to Sadie E. Larsen at [email protected]


Focus on the Business of PracticeStrategies for Identifying Cash Pay Services

— Mel Whitehurst

Nearly all clients come to psychologists for help with diagnosable mental disorders and insur-ance companies only pay for diagnosable mental

disorders. However, there are many other services that we can provide if our clients pay cash. With cash pay services we can extend the boundaries of what we offer because there are no guidelines or restrictions placed on us from insurance companies. In this article I present several ideas on how to identify cash pay services.

Cash pay services should be designed to help clients achieve one of three goals:

1. Solve or diminish a problem.

2. Achieve a desired goal.

3. Get more of something they already have.

Idea Lab StrategyConsider using an idea lab. (Gertner, J.2012; Chen,Kay-Yut, 2010) The purpose of an idea lab is to generate multiple ideas for cash pay services and then to pick one idea and fully develop it. With three or four interested friends or colleagues set up an idea lab to generate ideas for cash pay services. Ask idea lab mem-bers to email you one or two ideas weekly for six weeks. Or, you may want to meet with your members weekly for a period of time to brainstorm ideas. After generat-ing an extensive number of ideas, eliminate redundant ideas and prioritize the remaining ideas. Market only your top priority idea.

The Steve Jobs StrategySteve Jobs, the late Apple Computer co-founder, refused to use market research to decide on products to create. (Gallo,C. 2010) He did not want to “waste” time in this endeavor when he could be putting effort into designing new products. His strategy worked for Apple.

He unilaterally developed a product and offered it to the public. If it did not sell promptly, he developed another product. He continually developed new prod-ucts, offering them and responding rapidly according to the outcome.

Using this approach, decide on a cash pay service and market it. If there is an acceptable response, fur-ther build an active and ongoing program around this cash pay service. If cash pay service does not succeed promptly, develop and market another one, etc, etc.

Test Market StrategyToday there are over a numerous experimental labs around the world running experiments to test the eco-nomic viability of products. It is a standard procedure by business and industry to do this kind of market research on new products before offering them for sale.

Perhaps this should become a normal practice in our profession. If we learn ahead of time that a cash pay service has a high probability of being successful we can save ourselves money and time.

Put together a list of potential cash pay services, con-struct a short survey to assess interests in the services, and give it to your friends or anyone you can find who will complete your survey. Survey in-office clients to determine if they have an interest in any of the ser-vices. If you find an interest, develop and implement the service. Internet surveying is also an excellent way to assess interests in cash pay services.

“Do It Better” StrategyDecide what you do well and what you enjoy doing the most. Then set out to do it better than everybody else. Start with a specific cash pay service and build it. According to a market researcher, no one can go to the highest level and remain a generalist.

Once you decide what you do well or enjoy doing the most, become an expert on providing this service. Over time you can expand by developing multiple products associated with your base cash pay service. Look at the following abbreviated example:

Service: Motivating Underachieving Adolescents

Products: A fifteen session six-month program with parents and adolescent that intensifies and amplifies motivation to achieve in an underachieving adolescent

Self-instructional CD:

One for parents and one for teenagers

Brief Learning Guides:

How Parents Can Help Motivate Their Children

Ten Ways to Help Your Adolescent Improve Grades


How to Help Your Teenager Work Smarter, Not Harder

Observer of the World StrategyDeliberately observe what people are saying and doing. (Smith, K, 2008) Paying attention to what people are seeking to improve upon or the goals they want to attain can provide you with valuable information. Attentively scrutinize their behaviors in their environ-ments. Keep a record of your observations.

As you actively observe, pay attention to your intuition and hunches—the things you are feeling and sensing when observing. When you feel or sense something, document the feelings and reasons for your feelings.

Observe human problems, goals people are trying to accomplish, and what they are attempting to get more of. Keep a list of what you find.

• Observe newspaper articles, television newscasts, magazines, self-help books, and internet news.

• Search topics of books being sold by amazon.com and barnesandnoble.com in the area of human behavior, psychology, counseling, psychotherapy, and self-help.

• Get involved with Linkedin and Facebook.

• Conduct a keyword search on psychnet to deter-mine the amount of research being conducted on various problems, goals, or strivings.

Most people are pursuing more happiness, seeking a greater sense of well-being or simply tying to have a better life. They are trying to accumulate more finan-cial resources and progress their careers. Can you offer cash pay service that hpes them with any of these goals?

The Competitive Landscape StrategyFind out what your competition is doing as well as what they are not doing. You can get many ideas from seeing what the rest of the counseling world is doing.

Conduct a website study of your competitors. Identify the most successful and learn what they are doing. I reviewed 40 websites of psychologists, counselors and family therapists. Most websites I reviewed used techni-cal terminology, not client-directed language.

Websites did not have a unified focus, but presented scattered, “I can do everything” approaches. Several websites gave me the impression that psychologists could do just about any kind of therapy for any kind of problem. I can see where this might provoke skepticism in many potential clients.

The websites of psychologists, counselors and family therapists were similar in content and design. I did not see a noticeable difference between the websites psy-chologists, counselors and family therapists. We can

definitely benefit by more clearly differentiating our-selves from other licensed professional groups.

I believe that potential clients are usually looking for help with a specific problem, and if the website has a strong focus on that particular problem instead of on multiple services, clients will schedule an appointment with that psychologist. I found only one website that had a clear and unified focus on a specific problem. I checked out the psychologist and found that he was extraordinarily successful by using this approach.

See What Others Don’t See StrategyOccasionally someone identifies a game changer in our field and becomes fabulously successful. (Fisher J.& Boynton, A, 2011) Since we live in a changing and evolving world, new human problems are developing continuously. Be alert to emerging problems. It is pos-sible that while you are making multiple attempts to find cash pay services, a uniquely new problem or ser-vice may fortuitously materialize. I read an account of an astronomer who said she went into astronomy to be an observer of the universe and to just gather good data. Unexpectedly she made several noteworthy discoveries along the way that put her close to the top among scien-tists in her field.

Potential Cash Pay ServicesBelow are some of my “best guesses” as to what I believe can be potential cash pay services.

Health CounselingHealth issues are among the top problems people face. Clearly, there is a need for health counseling in a number of areas. The integration of physical health and psychological health services can be an important cash pay service area if you choose to pursue it aggressively.

Self-management tactics and strategies for managing a chronic illness, building skills to cope with stress after a heart attack, or problem-solving skills in identifying and resolving problems caused from an illness are some examples of possible cash pay services.

Research the kinds of problems physicians have with patients, then design a cash pay service to help the physician assist the patient. Make it beneficial for a physician to refer to your cash pay service.

Programmatic ServicesA programmatic cash pay service is an excellent way to provide a service directed at achieving a specific goal. With a programmatic service you let clients know ahead of time that you will help them accomplish a spe-cific goal over a specific period of time for a specific fee. When they show up they already have a strong interests in the cash service program and are likely to be more motivated than traditional therapy clients.


I once conducted a 12-session anger management pro-gram. I had one to two scheduled cash paying clients a week for more than two years. When I look back over my past years in private practice, I should have done more programmatic services. The following are a few examples that might be of interests to clients.

Depression Reduction Skills Counseling Program

Anxiety Reduction Skills Counseling Program

Program for Parents With a Non-Cooperative Child

Note the emphasis on skills development with depres-sion or anxiety as compared to therapy for depression or anxiety. If you do a cash pay service make certain the difference is explained and understood by the client.

Fear ReductionFear in our country has been, especially since 9/11. A significant number of people simply see the world as a more fearful place. Last year I conducted a study for two months to identify the number of stories from national news networks and newspapers that were either primarily fear-driven (negative), neutral, or positive. I randomly reviewed 956 stories from three national news networks, three cable news networks, two internet news web sites, and the front page, edi-torials and letters to the editor of a major newspaper. The number of fear-based stories among these sources ranged from 66% to 84%. Obviously we are getting many more stories using scare tactics than positive stories or articles that just state the facts. With so much frightening content being installed into the psyches of Americans, it is easy to see the negative effects these sensational stories have on many Americans.

Some of my research indicates that if people fear some-thing, they will want to take action, but will not do so if they do not have a clear path to eliminate the fear. Can you identify one significant fear and develop a cash pay service to reduce or eliminate that fear by providing a service that helps clients with a clear path to reduce the fear?

Separation and Loss: Coping With The Death of a Spouse, Friend, or Family MemberI talked with a funeral director last year while attend-ing a wake. We had an amiable talk after he found out I was a psychologist. I walked away from my conver-sation with him thinking that if I wanted to develop a cash pay service in the area of grief and loss, he would be a good resource.

My thoughts are that many who suffer grief or loss will need treatment for depression. Nevertheless, not every-one with loss is clinically depressed. Hope building groups or moving-on- with-life groups may be good cash pay services.

Caregivers Coping With a Family Member With Chronic IllnessOur growing population of seniors calls attention to the many problems faced by caregivers. Caregiving for those who have medical disabilities such as dementia, Alzheimer’s, diabetes, and strokes is a current society-wide issue where psychologists can provide cash pay services.

Caregivers need help and support! They especially need help navigating the caregiving system. They need help in determining if their loved one should remain home, in assisted living or a nursing home. Psychologists with knowledge of these systems can create a really outstanding service in helping caregivers learn how to interact with the staff of hospitals, hospice, assisted living, nursing homes, Medicare, social services, family, etc.

Educational PublicationsIf you have a proclivity for writing, the development of ebooks, instructional guides, and newsletters can establish you as an expert and provide you additional income.

Develop “how to” booklets or a series of self-instruc-tional guides.

How to Stop People from Taking Advantage of You

Combating Workplace Failure: A Guide for Workers

Managing Memory Problems

How to Manage Adult ADHD

Compulsive BehaviorsResearch indicates that between 5 and 6% of the adult population are compulsive buyers. Since this is not a DSM V diagnosis, cash pay is perhaps the way people will get help. Compulsive buying is characterized by excessive or poorly controlled preoccupations, urges or behaviors regarding shopping or spending which lead to adverse consequences. There are also numerous other compulsive behaviors that we can help clients to resolve.

ConclusionClinicians need to take the utmost care when attempt-ing to expand their practice in some of the areas that I have described. New areas need to be studied closely and should be based on careful analysis and on sound psychological principals and research. Steven Walfish (2014) has clearly shown in his course provided through the American Psychological Association “Using Science and Entrepreneurship to Identify Practice Markets and Opportunities” that science and initiative can lead psy-chologist successfully into new markets. When new cash pay services are identified, clinicians should make


certain to they have the skills to provide the service and should be cautious about practicing outside their areas of competence. However, I am optimistic there are numerous areas that psychologists can provide cash pay services if they are willing to take the time to iden-tify them, develop the appropriate expertise, and then provide the services.

ReferencesChen, Kay-Yut & Karadovsky, M. (2010). Secrets of the Money

Lab. Portfolio Penguin, New York, New York.Fisher, J. & Boynton, A. (2011). The Idea Hunter, Josey-Bass,

New York, New York, 2011.Gallo, C., (2010). The Innovation Secrets of Steven Jobs, McGraw

Hill, New York, New York.Gertner, J. (2012). The Idea Factory. Penguin Books. New

York, New York.

Haley, K. & Heise, K. (2008). Building the Successful Online Course. Information Age Publishing, Inc., Charlotte, N. C.

Walfish, S. (2011). Using Science and Entrepreneurship to Identify Practice Markets and Opportunities. American Psychological Association, Continuing Education Course.

Smith, K. (2008) How To Be An Explorer of the World, Penguin Group, New York, New York, 2008.

Dr. Mel Whitehurst is a psychologist in Plano, Texas. He worked in an independent private practice for 27 years. He retired from private practice and currently serves as a volunteer in supervising doctoral interns and conducts a group supervision class at a non profit counseling agency. Additionally, he is con-ducting a pilot program for assessing and improving memory in seniors. Email: [email protected]

Focus on DiversityDiversity and Disabilities

As a second generation Chinese-American born and raised in Hawaii, diversity issues have always been front and center for me. However,

in addition to the culturally and ethnically diverse population of individuals I serve, my clientele also encompasses a broader definition of diversity which includes disability, gender, sexual orientation, reli-gion, age, socioeconomic background and immigration status. In this article, I will focus on disability issues as an expanded concept of diversity, which is often over-looked in psychology research, training and practice.

Psychologists receive intensive educational program-ming in the assessment and treatment of mental health disorders. Unfortunately, they rarely receive adequate instruction or training in disability issues (Strike, Skovholt & Hummel, 2004). Kaley Roosen (2009) pro-poses that “psychotherapy is not delivering its services to meet the needs of individuals with disabilities.” This deficit is due to “lack of disability sensitivity training for therapists, a negative and prejudiced view of dis-abled people from psychological and medical research, lack of representation of disabled professionals, as well as communicative and structural barriers that exclude both disabled clients and disabled professionals” (Reeve, 2002).

My impetus in highlighting these primary key concepts on disabilities is to foster a greater sensitivity, aware-ness, and understanding of disability culture. Most of us have been raised in a society in which the rights of individuals with disabilities are often not addressed.

Only through an appreciation of this diversity variable in our work as psychologists and through discussion of various models of disability and their historical under-pinnings, can we address barriers and apply relevant guidelines in the implementation of appropriate and effective methods of professional practice.

Models of DisabilityBroadly defined, disability encompasses a wide range of impairments, functional limitations, and barriers to participation in community life. Some disabili-ties are visible and obvious (i.e., blindness, cerebral palsy, spinal cord injury), while others are invisible (i.e., learning disabilities, ADHD, seizure disorder, mental illness). Some disabilities are through genetic inheritance and others are acquired through accidents, medical illness, violence, environmental conditions or aging. According to Kathleen Brown, Ph.D. (2014), a health and rehabilitation psychologist, impairment, or the loss of or limitation of physical, mental or sensory function on a long-term or permanent basis should be differentiated from disability, the loss of or limitation of opportunities to take part in community life on an equal level with others due to those impairments.

In 2001, the World Health Organization (WHO) Inter-national Classification of Functioning, Disability and Health (ICF), which guides the understanding of dis-ability for the American Psychological Association (APA), defined disability as “the outcome of the inter-action between a person with impairment and the

— June W. J. Ching


environmental and attitudinal barriers he/she may face.” The Americans with Disabilities Act (ADA) Amendments Acts of 2008 defines disability as a physi-cal or mental impairment that substantially limits a major activity, or having a record of such impairment, or being regarded as having such impairment because of an actual or perceived physical or mental impair-ment.

The different models of disability represent ways of understanding how a group of people fit into the world and have evolved over time. Each model of disability has a unique history and idea of what it means to be a disabled individual. Each of us understands disability differently depending on which model we were exposed to and how we integrate this in our conceptualization of how the world functions (Neisser, 1967). Attitudinal barriers, discriminatory behaviors, and social stigma may serve to limit and devalue persons with disabilities without embracing their strengths and culture of self-determination.

Moral or Religious Model: “The Chosen”The first historical understanding of disability was through a moral or religious perspective. In bibli-cal times, disability was seen as something God had chosen an individual to bear or the person was seen as being punished for their sin (Olkin, 2001). During this Judea-Christian culture, persons living with disabilities would have been treated with pity, shame, and exclu-sion. This moral model is still widely prevalent today, portraying the message that disability is a personal tragedy in which humans could not fully understand the reason for the suffering, but need to take comfort in recognizing it as a test of faith. Some clients will recite the religious attribution, “God would not have given you this cross to bear unless he knew you could bear it.” The potential drawback would be if therapists viewed the disability with a sense of misfortune and elicited feelings of pity for the client, which then may serve to devalue and disempower the person. Whereas, some clients with disabilities find strength and peace derived from their deep spiritual beliefs and this needs to be recognized and respected.

Biomedical Model “The Impaired”The biomedical model views an individual’s pathologi-cal condition or impairment in medical terms. The person with the disability has a medical error within their physiology or psychology due to factors such as environment, genetics, or lifestyle which prevents them from being fully functional (Olkin, 2001). The con-centration is on the person’s deficits and elimination of the pathology or restoration of functional capacity through fixing, correcting and excising. Most tradi-tional psychological therapies rely on this model to target symptom alleviation or adjust to disability. The biomedical model is beneficial for dealing with medi-

cal and health complications, such as the alleviation of pain, but may impede the task of living and adapting. Additionally, when the person is disabled physically, there is often the automatic, though erroneous assump-tion that he is simultaneously dysfunctional in all capacities including cognitively and emotionally. Dis-ability does not necessarily equate to poor health. For example, the error in viewing a sight impaired person as also being intellectually compromised or motorically dysfunctional.

Social Model: “The Oppressed”The social model emerged from the disability rights movement during the 1960s and suggests that society and the environment contribute to and define disabil-ity in contrast to the idea that disability was a personal deficit problem. Individuals with disabilities are viewed as members of a minority group subject to discrimina-tion found in an ableist society that promotes the view that nondisabled people are superior (Barnes, Mercer & Shakespeare, 1999). The social model illuminates how environments may impede or facilitate individual functioning by erecting or removing variables to full participation while emphasizing social and functional accommodations. The social model was instrumen-tal in gaining significant political advancements, as those with disabilities cannot be discriminated against, excluded from participation, or denied resources such as shelter, employment, public service access and edu-cation. In this model, a psychologist can facilitate a client’s positive disability identity and promote empow-erment through self-advocacy skills, or consult with others to ensure that the client has necessary accom-modations and a voice in decision making.

Humanistic Model “The Human Being”Roosen (2009) suggests eliminating the distinction between disabled altogether and instead view people on a continuum of functionality. The humanistic model of disability views disability as part of the human condi-tion.

Cultural ModelIndividuals with disabilities exist within a cultural group of shared ideals, interests and beliefs. As in other cultural groups, persons with disabilities have their own language style, using ‘crip-talk,’ art, literature, clothing and movies. In the cultural model, people with disabilities have forged a group identity and share a common history of oppression.

For example, the “Disability Culture and Pride Model” was introduced by Steven Brown, Ph.D., a professor on Disability Studies at the University of Hawaii, Manoa. He was a featured speaker at the recent Hawaii Psy-chological Association conference on Disabilities as a Diversity concept (April, 2014). As a child, Dr. Brown was diagnosed with a rare genetic disorder, Gaucher’s


Disease. He became interested in the disability reform movement and became an advocate in his 20’s after being discriminated based on his physical disability. In 1982, a year after earning his doctorate, Dr. Brown was interviewed, over the phone to write a history of a pri-vate company in Oklahoma. When his contact learned he used crutches, the conversation changed. Eventually he was not hired and was told that they did not think someone who used crutches could do the research and write a book. He became “radicalized overnight” as a disability advocate and his journey began working in disability rights organizations. He defined disabil-ity culture as “[a] forged a group identity. We share a common history of oppression and a common bond of resilience. We generate art, music, literature, and other expressions of our lives and our culture, infused from our experience of disability. Most importantly, we are proud of ourselves as people with disabilities. We claim our disabilities with pride as part of our identity. We are who we are: we are people with disabilities.”

Implications for PracticeIn light of the changing demographics and the health-care needs of diverse clientele, it is imperative that psychologists strive to learn about the various disability paradigms and their implications for service delivery. An excellent reference point is the APA document on Guidelines for Assessment of and Intervention with Persons with Disabilities (2011). These Guidelines were developed by an APA Task Force charged with helping psychologists conceptualize and implement more effec-tive, fair and ethical psychological assessments and interventions with persons with disabilities by making their practices more accessible and disability-sensitive, and enhancing their working relationships with clients with disabilities. These guidelines were adopted by APA Council of Representatives on February 18, 2011. I would also recommend viewing the 2012 training conducted by Julie Williams, Psy.D. and Linda Mona, Ph.D. for the 2012 APA Consolidated Meetings on Dis-ability as a Diversity Variable: A Call to Action within Psychology. This training was an effort to destigmatize disability and help psychologists work more effectively with people with disabilities.

As a psychologist working with persons of disability, it is important to be aware of, comprehend and acknowl-edge the client’s own model of disability and their own intersecting identities of self, while being able to bring out the positive aspects of their disability as they impact the individual and our communities across their lifespan. In the understanding and work with persons with disabilities, Roosen (2009) finds that it is useful to adopt a disability-affirmative model, apply-ing the concept of self-determination to guide services and programs for people with disabilities. The term disability-affirmation in psychology was developed as a psychotherapy tool for guiding therapists working with

disabled clients (Swain & French, 2000). They recom-mend the understanding of four important areas: 1) models of disability, 2) ways disability can influence development, 3) developing a positive view of disability culture and community, and 4) both the psychological and social factors impacting individuals with dis-abilities. Hence in the disability-affirmative model, disability is viewed as having value and worth.

Equally important is for psychologists to examine their beliefs and emotional reactions toward various dis-abilities and determine how these might influence their work. Oppression and devaluation still exist and the social reality of persons with disabilities is less than optimal. Psychologists can question and evaluate their own preconceived notions of disability and reflect on influences that have shaped their views, behaviors, and feelings about disabilities. Psychologists working in the field can ask themselves the following questions: How has the world informed you about disabilities? What are three words you think about when you define disabilities? What messages were you taught about disabilities? Self-examination and familiarity with dis-ability-related issues are ways to minimize biases and faulty assumptions. Have a dialogue with colleagues on the topic of diversity and disabilities to promote the awareness and understanding of disabilities.

Another useful guideline item encourages psycholo-gists to strive in their use of appropriate language and respectful behavior toward individuals with disabilities. People-first language is advocated to maximize focus on the person as primary and their disability as secondary. Place the person before the disability. Say “person with a disability” rather than “disabled person.” A person is not a condition. Avoid stereotypical phrases that imply deficiency such as “deaf mute” since a deaf person is perfectly capable of intelligent conversation (Olkin, 2002). Appropriate communication also entails learn-ing about disability etiquette toward individuals with disabilities. Examples of appropriate responses include giving eye contact and talking directly to the person who has a hearing loss, and not to the sign language interpreter. Look but do not stare even though we are naturally drawn to things that look different.

When in doubt, ask a client with a disability if they need specific assistance with a task instead of assuming they are unable to perform the task. Yet another useful tip is to respect the person’s personal space. This includes not pushing a person’s wheelchair or grabbing the arm of someone walking with difficulty without first asking if you can be of assistance and how. Per-sonal space extends to the person’s wheelchair, scooter, crutches, walker, cane, or other mobility aid. More specifically, their wheelchair is not meant to be a place to hang backpacks and purses.

With adequate training and education in the area of


diversity and disabilities, psychologists have much to offer in their work with people who have disabilities. Likewise, psychology research and practice will benefit from involving and learning from this rich and diverse group of individuals in the disability community.

ReferencesAmericans with Disabilities Act (ADA) Amendments Act of

2009. Public Law 110-325. 42 USCA S 12101.American Psychological Association. Guidelines for assess-

ment of and intervention with persons with disabilities. (January, 2011). Retrieved from, https://www.apa.org/pi/disability/resources/assessment-disabilities.aspx?item=7

Barnes, C., Mercer, G. & Shakespeare, T. (1999). Exploring dis-ability: A sociological introduction. Cambridge: Polity Press.

Brown, K. (2014). Best practices for psychologists who work with persons with disabilities. Presentation at the 2014 Hawaii Psychological Association Diversity and Disabilities Conference.

Neisser, U. (1967). Cognitive Psychology. New York: Appleton Crofts.

Olkin, R. (2001). What psychotherapists should know about dis-ability. New York, NY: Guilford Press.

Reeve, D. (2002). Oppression within the counseling room. Counseling and Psychotherapy Research, 2, 11-19.

Roosen, K. (2009). From tragedy to ‘crip’ to human: The need for multiple understandings of disability in psychother-apy. Critical Disability Discourse/Discours Critiques Dans Le Champ Du Handicap, 1, 1-25.

Strike, D. L., Skovholt, T.M. & Hummel, T.J. (2004). Mental health professionals’ disability competence: Measur-ing self-awareness, perceived knowledge, and perceived skills. Rehabilitation Psychology, 49(4), 321-327.

Swain, J. & French, S. (2000). Towards an affirmative model of disability. Disability and Society, 15, 569-582.

Williams, J. & Mona, L. (2012). Training presentation on Disability as a Diversity Variable: A Call to Action within Psychology. APA Consolidated Meetings 2012.

World Health Organization (2001). The world health report – Mental health: New understanding, new hope. Geneva: World Health Organization.

Dr. Ching is in private practice in Honolulu, Hawaii. Correspon-dence regarding this article can be addressed to Dr. Ching at [email protected].

Division 42 Supports Your Hard Work: Show It Off This Year At Convention Social Hour

Are you interested in displaying your books, CDs, or other publications at convention this year to show other Division 42 colleagues what you have been working so diligently on all year long? If so, bring your items to the Division 42 social hour this year in Washington DC. We will have a dis-play table set up for you! You are responsible for lugging, displaying, and selling your own goods, and Division 42 will support your hard work! Two item limit per author, please. If you have any questions, please contact the Membership Chair, Stephanie Mihalas, [email protected] for questions.

Free Food... Cash Bar... raffles... free membership .... PLEASE JOIN US!

See the Terrific DIVISION 42 CONVENTION PROGRAM on the APA.org website to be presented in Washington DC. The program is here:

http://www.apa.org/convention/programming/divisions/division-42.pdf


Make Art with Your Peers

— Alan Entin and Pamela McCrory, CoChairs

APA members and convention attendees are invited to contribute to a large art sculptural installation whose aim is to represent psychology.

Called “Uniting psychology: express yourself” the work will first be assembled at the APA Annual Con-vention in Washington, D.C., Aug. 7 to 10. There, members will have an area where they can work with provided art materials, but they are encouraged to bring objects, such as drawings, photos or words that they can add into the piece which expresses their views of psychology and themselves. The site will be in the Registration Area.

Our goal is to have full participation from attendees – as many voices as possible, says Pamela McCrory, PhD, co-chair along with Alan Entin, PhD, of the APA subcommittee that is helping to develop the project. While the final sculpture will be determined by the creative process and shepherded along by Boston artist Mark Cooper, the subcommittee suggests bringing or creating on site objects that express who you are as a psychologist or person or both, or what you see the field as being or as evolving into. Committee member Stewart Cooper, PhD, is bringing a symbol that represents “personkind’s capacity for develop-ment,” and Entin is bringing a photograph that represents psychologist as artist, artist as psychologist. Lauren Siefert, PhD, is making “small-ish papier mache masks to join the concepts of psychology with humans’ physiognomies.”

“The piece will likely be constructed from shards of shaped wood that can be arranged in different con-figurations, like stones in a Japanese garden”, says Cooper, who teaches at Boston College and the Tufts University School of the Museum of Fine Arts and who specializes in collaborative works. The collabora-tive sculpture becomes a magical installation because of the conversation between the contributions whether they are a word, a phrase, an image, an object or a photograph. What will develop between the many different of types of inclusions, from words to simple line drawings, is the heart of the project. The many contributions will float among the wood patterns in aesthetically pleasing and meaningful ways.

The final product – or one version of it – will be installed on the rooftop garden at APA headquarters, 750 First St., NE, in Washington. It’s also likely to travel to museums and other public sites and possibly recon-figured conceptually or literally to fit the venue, Cooper says.

The aim is to use an artist’s technical expertise to illuminate psychologists’ creative ideas about their field and where it’s going, says Cooper, whose works have been shown at The Museum of Fine Arts in Boston, the Whitney Museum of American Art In New York and the Corcoran Museum of Art in Washington, D.C. “My job is to keep the process on track so it becomes a remarkable, transformative piece that represents psychology and is a catalyst for viewers and participants to see and understand the world differently,” he says.

Contact Alan Entin for further information: [email protected]


MENTORSHOPPE NEEDS MENTORS!!

Want to pay it forward? Please consider becoming a mentor to either a student or Early Career Psychologist or for a psychologist seeking the clinical ABPP. It doesn’t take much of your time but will mean the world to those you mentor.

• To be a mentor for Students and ECPs, please click here for more information and applications or contact Dr. Lori Thomas at [email protected].

• To volunteer to mentor those wishing to obtain their clinical ABPP, please click here for more information and applications or contact Dr. Fred Alberts at [email protected].

OR…

Go to the Division 42 website (www.division42.org), log in, and then hit Mentor-shoppe at the top toolbar.

Regards,

Lisa Grossman, JD, PhD, ABPPMichael E. Schwartz, PsyDCo-Chairs Mentorshoppe

See the Terrific DIVISION 42 CONVENTION PROGRAM to be presented in Washington DC.

The program is here: http://www.apa.org/convention/programming/divisions/division-42.pdf

Fast Forward is Division 42’s annual practice conference for psycholo-gists and psychology graduate students. This year’s focus is on “Innovative Practice” within and outside of the healthcare delivery system. Visit the Division 42 website to see when registration opens www.division42.org

Save the Date...

AND JOIN US IN LONG BEACH THIS OCTOBER!

Fast Forward 2014 Conference

Practice Inspiration, Business Innovation, and Clinical Skill Building for Psychologists

Conference Date:

October 10, 11, and 12Renaissance Hotel

Long Beach, California


You may earn one (1) credit of CE through Division 42 for correctly answering 80% of the following five questions correctly. These questions are based on articles that appear in this issue of the Independent Practitioner. This is a member benefit and there is no charge to receive the CE. You have two options for taking the Quiz. You may take it online at: http://www.division42.org/content/ce-quiz-2014-summer-ip or you can tear off or photocopy this page – mark your answers – and send the page to the Division Central Office:

Division of Independent Practice —American Psychological Association

919 W Marshall Ave.

Phoenix, AZ 85013 (or fax it to: 602-626-7914)

Upon receipt and checking of answers, the Division will email you your certificate.

Your full name: ______________________________________ Email address: _______________________________________

1. In the article, “An Attempt at Conducting a Group for Mothers of Young Children” King selected clients for her “mothers of young children” who:

(a) were empathic (b) had flexible schedules (c) evidenced healthy boundaries (d) all of the above

2. According to the Feedback Informed Treatment (FIT) Model, treatment success is reliant mainly upon: (a) treatment modality (b) therapeutic alliance (c) therapeutic integrity (d) all of the above

3. Thomas discusses types of mediation styles. All of these were included as styles mediators practice except: (a) transformative (b) persuasive (c) evaluative (d) facilitative

4. What is the “Steve Jobs” approach to help your private practice grow, that Whitehurst discussed in his article? (a) use Apple products (b) switch to primarily online telemental health services (c) continually test products and see how the market responds (d) build a large group practice

5. When working with persons with disabilities, issues to consider according to Ching, include: (a) using person-first language (b) ask whether assistance is needed with a task rather than making an assumption help is wanted (c) examination of your own notions and values related to “disability” and oppression (d) all of the above

CE Quiz

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