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Comments on the PHQ-9 for Minnesota Department of Health from Hamm Clinic

Note:  The Patient Health Questionnaire-9 (PHQ-9) is a screening measure for depression developed by the Pfizer Corporation and is based on the diagnostic criteria from the DSM-IV for Major Depression.  All physician clinics, including mental health clinics, are required by the Minnesota Statewide Quality Reporting and Measurement System to use this screening measure to assess patient outcome, specifically depression remission at six months. The PHQ-9 score is also being used as part of the risk adjustment determination.

The Cost of Measurement
Hamm Clinic is a small community mental health clinic including 15 staff clinicians (MD, LP, LICSW), a $2.6 million annual budget, 9,000+ annual visits, and 900+ active clients.  We tracked the cost of our efforts to prepare and submit PHQ‑9 depression data for measurement and reporting purposes since 2011, the year reporting started. Hamm calculates that it has spent about $11,000 in database programming and about 100 staff hours, valued at about $3,000, for PHQ‑9 reporting since 2011.

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The Next Generation of RxP in MN

While many psychologists may have linear career tracks and interests; some others may be driven by unique opportunities and, more importantly, the pressing needs of their community.  

During graduate school, I never thought my career would move through significant paradigm shifts.  The foundation of the scientist-practitioner still holds firm; however, my work in mobile crisis, primary care, and now that attainment of an advanced (MSCP) psychopharmacology degree has awoken a deeper perspective.  And it is this advanced degree, fraught with future obstacles and aspirations, that has been handled with much care, consultation, and, yes, consternation.  But then again, I also never thought I’d be called to duty (Operation Iraqi Freedom III) during graduate school.  So it is here, that my story has parallel processes, in so much that I seem to have been called to duty on another front.

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Current Updates on the Affordable Care Act

As a member of the HCRC, I suggested to our committee chair Michael Sharland, Ph.D., L.P., ABPP, that a summary of the 6/10/16 conference “Ethics and Risk Management in the Age of the Affordable Care Act: Everything You Didn’t Want to Know and Were Afraid to Ask” might be helpful to MPA members who couldn’t attend (take a deep breath, run on sentence).  I thought much of the information provided by that conference is germane to the mission of the HCRC, namely keeping MPA members informed regarding likely changes to psychological practice because of the Accountable Care Act (ACA). 

The 6/10/16 conference was sponsored by MPA and The Trust (formerly known as APAIT).  Daniel O. Taube, J.D., Ph.D., was the presenter.  Every time I start to think of something the HCRC should discuss with MPA members, it feels like there is a moving target or we are herding cats.  Starting to work on this article, I came across a webinar offered 6/30/16 by the website OpenU that also seemed germane to this article. 

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Beltrami PACT Collaborates to Succeed in Implementing the Affordable Care Act

Recently I purchased a plain wooden microwave cart for the lake cabin from IKEA. The item came in a box with several descriptive charts, lots of little pieces and a baffling array of hardware.  I waded into the task trusting the directions and the accuracy of the assembler’s count of screws and bolts. I can say the project was a success and I am reminded how unlike an IKEA package, other things are in life! The directions for implementing the structure that supports participation in the Affordable Care Act have not always been very clear.  In Beltrami County, providers have had a slow start. While other parts of the state have large behavioral and health care organizations that have successfully applied for grants and help, we were largely unaware of the scope of the change. It became obvious to the 11 agency members that we needed to collaborate in order to share the financial benefits associated with the new payment models for Medicare and Medicaid.

The ACA goals also known as the ‘Triple Aims’ of increased health, reduced cost and happier patients are not new ideas any longer, but seemed like lofty goals without a list of tools to be used to attain them. For Beltrami County, our challenges were even greater as our school district is roughly the size of Rhode Island. We also have an isolated, poor population, without central transportation, poor access to services, low wages, high rates of incarceration and crime and suicide as well as high rates of drug and alcohol abuse. In addition, Red Lake Nation, Leech Lake and White Earth Reservations are effected by historical and complex trauma, racism and social exclusion, poverty and high unemployment. In short, the demand for services remains unrelenting and routinely overwhelms the agencies in the area. While mental health providers have had a history of competition and little integration, there has long been the belief that we would likely be better off if agencies collaborated in order to meet the overwhelming needs. The area agencies are often underfunded, with huge demand for services. Perhaps because we are not in competition for business, it made collaboration, despite our history of niche market providers, highly desirable.

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Adlerian Early Recollections: Application to the Client

Frequently, I hear professionals and students discussing Adlerian Early Recollections (ERs) as a tool.  Well, they are not a tool. To stay true to Alfred Adler’s Individual Psychology, we should see Early Recollections as a unique window with a view of one’s pattern of life – a pattern that both a client and a therapist may jointly discover. Because of their strong ties to the ethics and therapeutic fundamentals of Individual Psychology, the significance of ERs can only be understood based on major Individual Psychological assumptions. 

Several of these assumptions, very briefly, are outlined here:     

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CMS wrongfully denying PQRS incentives

Due to the dogged determination and careful attention to detail of Amy Rosett, Ph.D., a solo practitioner from Encino, Calif., the Center for Medicare and Medicaid (CMS) overturned its decision to deny a financial bonus for her 2014 participation in the Physician Quality Reporting System (PQRS).

Last September Rosett failed the Measure Applicability Validation (MAV), the data mining method that evaluates providers’ data submitted under PQRS.

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Health Professionals Services Program Summary

MISSION

Minnesota’s Health Professionals Services Program protects the public by providing monitoring services to regulated health care professionals whose illnesses may impact their ability to practice safely.

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MNsure and Health Insurance Basics

In late 2015, NAMI Minnesota received another MNsure grant to help people with mental illnesses and their family members obtain health insurance. In addition, NAMI Minnesota is working to educate individuals on how insurance works and how to utilize the benefits offered.  Two fact sheets on health insurance basics have been written, are on our website, and can be sent on request. Presentations are also being offered. Here are some health insurance terms that you or your clients will learn with these fact sheets and at these presentations:

Premium – Monthly amount paid for health insurance plan. This amount must be paid whether or not you actually use your health insurance.

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What Does Your Psychology Practice/Licensing Act Reveal That Can Help Your Efforts to Develop a Colleague Assistance Program?

As Chair of the Oklahoma Colleague Assistance program for the Oklahoma Psychological Association, I have been involved in helping establish a colleague assistance program over the past several years.  A critical turning point in my efforts occurred while working clinically with other health care professionals.  I began to examine the practice acts for various disciplines (i.e., medicine, nursing, pharmacy) and this led me to wonder how our psychology practice act compared.  I determined six areas in which we differed significantly from our health professional peers in Oklahoma.  I have posed these in the form of questions below.  Even if you have a formal Colleague Assistance Program (CAP) in your state, it may be useful to review your state’s practice act as it lines up with the workings of your CAP.  It may help to obtain a copy of your state’s psychology practice/licensing act as you read through the list.

  1. Does your practice act contain a reference to practicing with skill and safety that can be compromised by substance abuse and/or a psychiatric condition?  Does your state practice act go further to include medical conditions and neurocognitive conditions which can impair functioning?  Language about impairment is fairly commonplace in practice acts, but knowing how impairment is defined in your practice act is important.
  2. What does your state practice act say about reporting an impaired colleague?  In Oklahoma, there is no explicit mandate in their licensing act for psychologists to report.  Other professions in Oklahoma are explicit about a mandate to report impaired colleagues, and some professionals (e.g., physicians) are required to report across health profession lines.  In some states, like Oregon, there is a requirement to make such reports within a specific time period, 10 days (ORS 676.150, signed into law January 1, 2010).
  3. Related to reporting an impaired colleague, does your state practice act grant civil and criminal immunity if the report is made in good faith?  In our Oklahoma psychology practice act, this is not addressed.
  4. Will your colleague know that you reported her/him to the licensure board? In Oklahoma, the psychologist being reported to the licensure board will receive a copy of the Request for Inquiry (i.e., complaint form) that is sent to the board.  This complaint form contains a description of what is being alleged and the name and contact information of the person making the report.  Other boards in Oklahoma provide statutory protection of the identity of the person filing a complaint.  This of course, lowers the threshold for reporting.
  5. Does your state practice act require you to answer questions upon annual renewal of your license regarding impairment, treatment, or current suitability to practice with skill and safety?  In Oklahoma, this is not addressed in the practice act.  Other health professional boards do include a section in their practice act regarding continued suitability to practice with skill and safety. In addition, the licensee is required to complete an annual attestation about suitability or continued ability to practice with skill and safety, among other questions such as legal problems.
  6. Does your state practice act empower your state licensure board to create or affiliate with an entity that can aid in addressing impairment among psychologists?  In Oklahoma, the ability of our licensure board to affiliate with a program was not explicitly outlined in the practice act or Rules of the Board. An interpretation of the board rules by the State Attorney General’s Office determined that the licensure board had the authority to establish such an affiliation. Consequently, our licensure board moved forward with an agreement that allows psychologists to participate in the state's physician monitoring program. 

Examining our psychology practice act in Oklahoma and comparing it to the practice act of our healthcare professional peers illuminated some stark differences.  When I presented these differences at our annual state psychological association meeting several years ago it created strong momentum to make changes. 

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Risk Management: Who let the doggie on the airplane?

Most people enjoy dogs and find great pleasure in having them around. All of that is fine, but there is a growing trend among those who want to be with their dogs that should be of particular concern for psychologists.

Psychologists are frequently being asked by their patients to attest to their need for an Emotional Support Animal (ESA) for mental health purposes, which allows that animal to be present in what previously would have been a restricted environment.

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Meditation, Spirituality & Mental Health

Until relatively recently, yoga, meditation, and non-traditional spirituality – as opposed to classical religious practices – were widely perceived in the West as esoteric pursuits with little to offer mainstream society. Now they are highly-valued, prominent fields of endeavor with massive cultural buy-in. Having dedicated 40+ years to this “questionable arena,” it is rewarding to note the positive shift in public opinion, and, the appreciable enhancement such activities have made on so many lives. In fact, writing an article like this is challenging because there is no longer a dearth of information on the topic but, rather, an exhaustive volume of research requiring extensive time to read, process, and apply. On the up side, an abundance of scientific literature now attests to a range of psycho-social and body/mind benefits resulting from meditation and Sacred practices, (i.e., pertaining to religion or spirituality). Fortunately, these positive outcomes are no longer points of anecdotal testimony subject to academic dispute, but, matters of established fact. For psychologists then, several especially relevant questions arise regarding how to include this domain within the scope of practice. Specifically, when is it appropriate to engage patients on topics pertaining to the Sacred, meditation, and related activities? When is it viable to suggest patients explore such in adjunctive alignment with on-going therapy? And, when should these topics or practices not be addressed?

Such questions require more time and space to address than this brief article allows. Accordingly, readers may find additional value and a more comprehensive understanding of these issues in theAPA Handbook of Psychology, Religion, & Spirituality (Pargament, 2013).  However, to capsulize two key areas let me answer the last question first: Psychotic patients and those with too severe a character disorder are best served by not engaging in mystical or meditative pursuits as such activities could de-stabilize their mental coherence or trigger added psychiatric complications. However, many less severe patients confronting depression, anger, anxiety, stress, hypertension, addiction, insomnia, chronic pain, or, mild-to-moderate neuroses, defensiveness, compromised self-awareness, and self-destructive behaviors may benefit considerably from intelligently applied meditation if they are sufficiently motivated to practice. There is even related evidence suggesting that therapists who engage in meditative practices themselves, or hold to compassionate spiritual paradigms, may passively contribute to enhanced therapeutic outcomes.

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Psychopathy: What Mental Health Professionals Need to Know

The media commonly uses the term “psychopath” to refer to persons, generally criminals, who act outside of the moral sphere. They may be real, like Ted Bundy or Charles Manson, or characters such as Hannibal Lector or Dexter Morgan – the lines between the fanciful and the factual can become blurred in our imagination. However, psychopathy is an important concept in forensics, and is increasingly prominent in mental health studies, and thus deserving of measured consideration.

Characteristically, a psychopath is defined as having such traits as charming, manipulative, deceitful, emotionally shallow, callous, impulsive, irresponsible, blasé, extravagant, and directionless (Hare, 2003). While the prevalence of psychopathy among the general population is estimated to be around 1-2% (Newman & Hare, 2008), it is thought to exist in around 30% of prison populations (Hart & Hare, 1997). Mental health professionals must be aware of several key points when dealing with the label of psychopathy.

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Stillness

A recent development in information technology is the advent of Google glasses.  These are smart goggles that allow streaming of data via the internet onto a sector of the lens and linked to a GPS embedded in the frame.  Imagine walking by any place of business and with a glance at the storefront accessing the company website (restaurant menu, movie marquee with IMDB reviews) or being able to encounter a bird in the wild and with instant photo with feature recognition see all the information you want about that bird displayed in your field of vision.  Pretty cool!   Without waiting for this next best thing to emerge, we already have instant access to more information than was available in the great library of Alexandria (or any historical repository of human knowledge).  If we wish, we can allow the information to roll over us in a continuous flow.  But is there a cost to wading through this incessant stream?

Although our brains are quite adaptable and resilient, they require the full cycle of a night’s sleep to prune unnecessary synaptic connections and consolidate and strengthen the connections of new knowledge.  They also require stillness and silence to find the depth and meaning in what we absorb.  For us (and our children) these moments of stillness are disappearing as rapidly as ice sheets in the polar regions.  I found a New York Times article by Pico Ayer to be a compelling reminder of the deep value of cultivating silence and stillness.  http://www.nytimes.com/2012/01/01/opinion/sunday/the-joy-of-quiet.html?pagewanted=all

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Fetal Alcohol Spectrum Disorder: A Review for Mental Health Professionals

Jerrod Brown, Adam L. Piccolino, Anthony Wartnik, Anne Russell & Tina Andrews

Fetal Alcohol Spectrum Disorder (FASD) affects the lives of millions of individuals in North America and is associated with a vast array of physiological, psychiatric, and neurological consequences that can significantly impair behavioral, emotional, developmental, and social functioning.  Our experience tells us that individuals with suspected or confirmed FASD are likely to come in contact with mental health inpatient and outpatient providers on a regular basis. As such, mental health professionals are strongly recommended to participate in continuing education on FASD. A more comprehensive understanding of FASD among mental health professionals should lead to improvements in identification, intervention, and treatment strategies, as well as an informed perspective when making recommendations on child welfare, custody assessments, competency to stand trial evaluations, and diagnostic and treatment planning. The overall goal of this article is to provide a review of FASD for mental health professionals.

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Huntington’s Disease (HD): A Basic Review for Professionals

Huntington’s disease (HD) is a terminal neurodegenerative disorder, which affects cognitive, motor and behavioral functioning (Abel & Zukin, 2008; Lin & Beal, 2006). The disorder has long been suspected to be heritable and in 1993, after decades of research, scientists identified the causal gene.  The genetic mutation is transferred to offspring by a single gene from one parent.  Carriers of the Huntington gene mutation have a 50% chance of passing on the mutation to every child (Andersson, Juth, Petersén, Graff, & Edberg, 2013).  A laboratory blood test verifies a positive diagnosis.  Additionally, research suggests that the onset and severity of Huntington’s disease are indicated by the number of repeated CAG counts on chromosome 4 (Vassos, Panas, Kladi, & Vassilopoulos, 2008).  Higher numbers of repeats indicate the possibility of earlier onset and more severe declines in functioning.  The aim of the current article is to provide brief educational material regarding this disorder, to present accessible information for professionals working with individuals who are affected by Huntington’s, and to encourage additional consultation regarding this topic.

Anyone who is a carrier of HD will eventually exhibit symptoms of the disorder (Brouwer‐DudokdeWit, Savenije, Zoeteweij, Maat‐Kievit & Tibben, 2002).  Most individuals with Huntington’s disease are diagnosed in their 30s-50s, although rapidly progressing juvenile forms of the disease can be diagnosed during the early adolescent years (Scerri, & Cassar, 2013). In each of these versions, cognitive changes may begin up to 15 years early (Nance, Paulsen, Rosenblatt, Wheelock, 2001).  Those suffering from juvenile onset HD tend to have a larger range of clinical symptoms than those suffering from adult onset HD.  These clinical symptoms can include an increased likelihood of seizures, oral motor dysfunction, and increased behavioral disturbance (Gonzalez-Alegre & Afifi, 2006; Nance & Meyers, 2001).  The expected lifespan for individuals suffering from HD is generally 15-20 years post-diagnosis (Krobitsch & Kazantsev, 2010).

Huntington’s disease is typically first indicated by the declines in the ability to emotionally regulate, organize thoughts or spaces, and navigate complex decisions.  These symptoms make early diagnoses difficult.  The first visual symptoms characteristic to HD is chorea. Chorea is an uncontrollable, jerky “dance like” movement (Nance & Meyers, 2011). Individuals displaying chorea movement may appear to have a tic, twitch or appear intoxicated due to progressive loss of voluntary movements.  Eventually chorea becomes constant and has a significant effect on an individual’s metabolic rate such that weight loss becomes common during the later stages (Krobitsch & Kazantsev, 2010).

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Pat Frazier Receives Charlotte Striebel Equity Award

Professor Pat Frazier has been selected to receive the Charlotte Striebel Equity Award from the University of Minnesota. The award  “… annually recognizes a University of Minnesota faculty or staff member of any gender who goes above and beyond daily responsibilities to promote access for the common good, to undo bias and discrimination, or to build capacity for diverse and equitable campus communities” (this description is from the University Women’s Center website). Congratulations to Pat on this well-deserved honor!

APA Directorates Key Policies and Presidential Initiatives Surveys

Introduction

The American Psychological Association (APA) is the largest scientific and professional organization representing all psychologists and psychology in the United States.  Currently, APA has approximately 130,000 members with a variety of interest areas.    However, over the past several years, an increasing amount of members have dropped out of APA.  The possibility exists that this alarming trend is due to the fact that APA may not be representing its membership in the most robust way possible. As a consequence, the following surveys were done in order to gain a better understanding of the concerns of psychologists.

Methods

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Professional Practice Note from Thomas A. Pearson, Esq.

Timing may not be everything, but it is critical if consultation about practice issues is going to be most effective.

The practice of psychology is becoming more complex and challenging every day. As legal and ethical standards expand and evolve, psychologists and other health professionals increasingly face issues that require consultation with peers and others. Participating in a regularly-scheduled peer consultation group and seeking timely ethical and legal advice when necessary are key factors in avoiding or at least minimizing practice errors.

Even the best-trained practitioners will encounter ethical and legal issues that they have not previously encountered in their training or practice. As helpful as education, supervision and regular peer consultation are, they are often not enough to enable the practitioner to make appropriate decisions about unfamiliar practice issues. When those issues arise, the best time to seek ethical and legal advice is before making decisions that cannot be “undone” without considerable effort and expense, assuming they can be undone at all. Even if there is no clear answer to the issue, the fact that the practitioner sought consultation ahead of time can signify that she or he attempted to meet the professional standard of care in the circumstances.

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Choosing a Violence Risk Assessment Tool: What Forensic Psychologists Need to Know

What is the most accurate violence risk assessment tool on the market today? This is a question asked every day by mental health, correctional, and legal professionals working across the globe. This is particularly the case in the United States, where surveys have estimated that over 80% of forensic psychologists use a structured instrument when conducting risk assessments. But you may be surprised to learn that there are over 400 risk assessment tools currently being used on six continents – all claiming to produce the highest rates of validity and reliability. Recent large-scale research has concluded that there is not a single risk assessment tool that consistently predicts future incidents of violence better than all others. Indeed, the risk assessment tool that is going to be most accurate for you is not the one with the best marketing campaign or even the one with the most studies published related to it. Rather it is the instrument with the strongest goodness-of-fit between how the tool was designed and how you use it. But how do you determine this goodness-of-fit? When deciding upon which violence risk assessment tool to adopt in practice, there are three key factors to take into consideration:

  1. Population: Compare your average patient to the sample on which a risk assessment tool was normed, taking into consideration age (child, adolescent, adult), sex, race/ethnicity, nationality, offense history, and diagnostic group. For example, if an instrument was developed in a rural area of Canada on a predominantly Caucasian sample of men with an unclear diagnostic background, that risk assessment tool will likely not perform to its maximum ability in a unit serving predominantly minority female patients in downtown Chicago.
  2. Setting: Compare the setting in which you are evaluating the average patient with the setting in which the normative sample was assessed. For example, if an instrument was developed using a group of patients evaluated upon admission to a forensic psychiatric facility, that risk assessment tool will likely not perform to its maximum ability when used by a parole board to make release decisions.
  3. Outcome: Compare the outcome for which a risk assessment tool was designed with the outcome you are interested in predicting. For example, if an instrument was developed to evaluate the risk of general recidivism, that risk assessment tool will likely not perform to its maximum ability when used to predict sexual recidivism, specifically. Make sure to pay particularly close attention to the operational definition of the outcome in the risk assessment tool’s manual – instruments differ in terms of whether new arrests, charges, convictions, incarcerations, and/or self-reports of offending are included. Further, some risk assessment tools were developed for the prediction of intra-institutional infractions, whereas others were developed for the prediction of misconduct in the community.

Jerrod Brown, MA, MS, MS, MS, is the Treatment Director for Pathways Counseling Center, Inc. Pathways provides programs and services benefitting individuals impacted by mental illness and addictions. Jerrod is also the founder and CEO of the American Institute for the Advancement of Forensic Studies (AIAFS) and the lead developer and program director of an online graduate degree program in Forensic Mental Health from Concordia University, St. Paul, Minnesota. Jerrod is also currently pursuing his doctorate degree in psychology.

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Integrating Behavioral Services: Challenges and Benefits

“Integration is in response to the fragmentation of health care. As individuals we are not fragmented, we are whole people. The current health care system does not recognize this. Integration is trying to fix a big problem, which is that we have two separate systems that take care of our health. Integration is a game changer for health care.”
Benjamin Miller, Psy.D., A Family Guide: Integrating Mental Health and Pediatric Primary Care

Behavioral health (BH) services are part of general medical services, but typically function in parallel, or even separately, from the rest of the medical field. There are many reasons for this, but there also are many benefits when integrating care. While integrating care may be challenging for professionals, it would provide significant benefits to patients with behavioral concerns—and professionals are likely to benefit as well.

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Diversity Statement

The Minnesota Psychological Association actively encourages the participation of all psychologists regardless of age, creed, race, ethnic background, gender, socio-economic status, region of residence, physical or mental status, political beliefs, religious or spiritual affiliation, and sexual or affectional orientation.Although we are an organization of individuals from diverse cultures and backgrounds, the Minnesota Psychological Association also recognizes our core unifying identities as Psychologists who practice in America. We also recognize that we may hold unintentional attitudes and beliefs that influence our perceptions of and interactions with others. Within this context of unity and self-exploration, we are committed to increasing our sensitivity to all aspects of diversity as well as our knowledge and appreciation of the unique qualities of different cultures and backgrounds.We aspire to becoming alert to aspects of diversity, previously unseen or unacknowledged in our culture. In this spirit, we are committed to collaborating with multicultural groups to combat racism and other forms of prejudice as we seek to promote diversity in our society. To this end, we are dedicated to increasing our multicultural competencies and effectiveness as educators, researchers, administrators, policy makers, and practitioners.