Fall is here. It is a time of change, of preparation for the end of a year and the beginnings of anticipation of the year to come.  This past weekend we completed our strategic planning meeting for my presidential year 2017.  It began with Robin McLeod, our current president, reviewing what has been accomplished and will be accomplished in 2016.  There was much to be proud of in that review, but I leave that review to her.

In planning for 2017, the current leadership team met to discuss the directions that MPA will go in the coming year.  That leadership team included the Executive Committee (EC), the Governing Council (GC) and the representatives of all the divisions of MPA as well as committee chairs/co-chairs.  The majority of that team (the EC, GC and Division Chairs/Co-Chairs) was formed was by people volunteering to take on roles as members of each of those bodies through an election process.  Our election process is set to begin in the coming weeks.  I would encourage all to consider being a part of the process.

The loss of a baby during pregnancy is estimated to be around 30% of all pregnancies and is almost always unexpected and sudden, thus is a traumatizing experience for the mother and her partner.  Regardless of the cause of the death, it is impossible to have another experience of pregnancy without stimulating memories of the painful past loss. As parents enter a new pregnancy rather than unresolved grief, parents experience a new layer of grief; for their deceased baby and fear that the new unborn child might also die.

Bereaved parents report common themes around their loss experience. These include viewing the loss as a major life event possibly even traumatic in nature, a sense of isolation and loneliness due to the stigma and silence around pregnancy loss, invalidation from family and friends who intentionally or unintentionally diminish their loss in some way as well as lack of support from family and friends. These themes remain as parents move into a subsequent pregnancy with additional themes including an increase in anxiety about the outcome of the subsequent pregnancy, conflicted emotions around how to grieve for one baby while trying to be hopeful for another, and lack of trust in a ‘good outcome’ for this pregnancy. For the pregnant mother, this can present as lack of trust in one’s own body to keep this next baby safe.

Before we decided to send this topic for consideration for the MPA 81^st Annual Convention we had conversations about the events that were happening around the country related to police brutality and killings of unarmed African Americans, the riots, and the protests. We wondered why voices of psychologists were missing from the commentaries in the media; both on local and national TV, and in print media. We wondered about the psychological impact of the traumatic events in Ferguson, Baltimore, Minneapolis and others to the communities and the country as a whole. We wondered how traumatizing it was for young children and adults to see the body of Michael Brown lying on their streets for hours. We wondered how it was possible for all, except psychologists to frequent newsrooms to comment, analyze, and condemn these acts. We wondered what was stopping psychologists from having a strong presence on the microphones to explain, teach, or even warn about long-term effects of trauma that were unfolding before our eyes. Then we decided to delve into psychology literature on Ethics and Social Justice, and the APA Ethical Guidelines. To say the least, there is ample work that has been done on this topic.  We looked at the history of psychology and social injustice, social justice, and through discussions explored ideas on the role of the psychologist and dilemmas on ethics and legal issues in media presence.

APA’s Multicultural Guidelines (2010)
“Psychologists are in a position to provide leadership as agents of prosocial change, advocacy, and social justice, thereby promoting societal understanding, affirmation, and appreciation of multiculturalism against the damaging effects of individual, institutional, and societal racism, prejudice, and all forms of oppression based on stereotyping and discrimination” (p. 382).

On April 15, 2016, Dr. Antony Stately (Ojibwe) and Jennifer Waltman (Lakota), a doctorate of psychology student, presented at the MPA Annual Convention on Working With Native American Patients & Clients. The presentation addressed the 3 C’s of integrating Indigenous consideration into your practice:  Context (Understanding the story); Comfort (Building it); Communication (Tools & Techniques for Indigenous relationship building). A recap of the presentation is provided below applying information from both research and applied experience working in the community and intended for generalization.

Context. Understanding historical trauma (HT) for Native Americans is key to conceptualizing the significant stigma related to issues of mental health and the greatest health disparity in Minnesota.  Native Americans commonly use humor to disguise trauma. Humor conversely provides strength to explore distress that may contribute to misdiagnosis and confusion for many non-Native healthcare providers. 

CLINICAL PEARL: Don't say (or write) "Parents should get an IEP for this child who is struggling in school." Instead, say (or write), "Parents should consult with the school staff, a child psychologist, LDA Minnesota, or PACER Center, to assess and design a plan to meet this child's educational needs."

HERE'S A NEW RESOURCE TO LEARN ABOUT A 504 PLAN
Many of our patients whose schoolwork or attendance is affected by chronic health conditions may benefit from creating a "504 Plan." This is a written agreement for curriculum adaptations, within a regular education program, which ensures the school makes "reasonable accommodations" to meet the child's educational needs, without incurring "undue burden" to the District. A 504 Plan is guided by Section 504 of the Civil Rights Act which says that schools cannot discriminate against a student for needs that reflect a student's physical or mental disabilities. It is NOT "special education" and NOT an "individualized education program (IEP)" but a 504 Plan can be very helpful to students who just need "reasonable accommodations" to succeed with regular classroom instruction.

In 2011, the Institute of Medicine (1) reported that 100 million Americans, or almost one-third of the population, are affected by chronic pain.  Half that number, or 50 million people, experience severe or daily pain, with increased debility and costs to the health care system (2).  Chronic pain is persistent pain, continuing after an injury heals, or emerging in the absence of an apparent injury (3).  And so, a significant minority of our patients experience chronic pain, as well as the impairment in daily functioning, sleep and psychological and social well-being that accompanies it.

The disparaging comment that patients (rightly) dread is, “It’s all in your head,” is no less inaccurate than the more acceptable idea that pain is a strictly body-based phenomenon.  Chronic pain is a body-mind phenomenon, and current research on the theory of Central Sensitization elucidates the mechanisms by which chronic pain emerges (4).  Data supporting Central Sensitization suggests that chronic pain results from three types of changes in the central nervous system:  Sensitization of pain circuits, generalization of pain to non-pain circuits, and failure of inhibitory pathways to dampen pain.  Central Sensitization can occur after a single injury, repeated injury, or even no apparent injury to the body.  Sensitization of central nervous system pain circuits mean that mild or even benign stimuli (e.g., a gust of wind across the cheek of a Trigeminal neuralgia patient) produce pain.  Further, non-pain-related central nervous system circuits (e.g., those that carry temperature signals between brain and body) get “hijacked” into the pain system, generalizing, and thus enhancing, the pain experience.  Finally, central nervous system pathways from brain to body that inhibit pain fail to work effectively, creating another avenue by which pain is intensified. Interestingly, Central Sensitization is being explored as the common underpinning for seemingly diverse conditions such as chronic pain, irritable bowel syndrome, and PTSD. 

Trauma has been studied by physicians and psychologists alike for decades. Historical events and advancements in the field of psychology have changed our views on how trauma affects a survivor, our recognition of different clinical presentations, and our concept of how to best address varying symptoms in clinical practice. The rate of progress has increased in the last few years as new medical technology has allowed researchers and clinicians to better understand how traumatic experiences can cause long-lasting psychological and physical effects in survivors, in turn advancing the way we approach treatment.

Research beginning in the 19^th century began to identify a link between traumatic events and symptoms that could not be easily explained in medical terms. This understanding was later refined by Pierre Janet, French psychologist in the field of dissociation and traumatic memory, who asserted that intense emotions interfere with appropriate or accurate appraisal of and response to an event, leading to sensory experiences, overwhelming emotions, and behaviors that make it feel like the trauma is being re-experienced. This concept became a foundation to our current understanding of trauma. Later, soldiers returning home from World War I displayed new unexplained symptoms related to trauma, which were referred to using terms such as shell fever, mental shock, war shock, shell shock, and war psychoneurosis. Additional phrases such as battle fatigue and combat exhaustion were developed during and after World War II to try to describe the trauma-related syndromes being seen so commonly in combat veterans. It was at this time that Abram Kardiner, American psychoanalyst, began to describe some of the specific symptoms in greater detail such as chronic vigilance and sensitivity to the possibility of threat in his book, The Traumatic Neuroses of War.

By Kristin B. Webb, Psy.D. & Alexis T. Franzese, Ph.D.,
Colleague Assistance Committee Members

The North Carolina Psychologist Vol 65(3), 2013 

The Patient Protection and Affordable Care Act (PPACA) mandates increased communication between medical providers that has created significant challenges for psychiatrists, psychologists and other mental health professionals (MHPs).   In particular, use of Electronic Health Records (EHRs) raises concerns about the potential unrestricted flow of Protected Health Information (PHI) about mental health services among the patient’s medical professionals.

EHRs are mandated to have interoperability - to be able to transmit PHI from one EHR to another EHR.  Interoperability is currently limited, or aspirational, for most EHRs. As EHR providers overcome technical problems it will be increasingly common for mental health PHI to be available to other medical providers.  For MHPs, this raises significant concerns about who will have access to sensitive mental health PHI, and what they will do with it.  As a result, many MHPs in Minnesota have refused to adopt EHRs.  This raises concerns for physicians about whether they have access to complete information about their patients.

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.

1)  What is your background in psychology (e.g., education)?

My undergraduate studies were completed at California State University, Fresno, where I double-majored in Criminology, Law Enforcement emphasis (BS) and Psychology (B.A.). I was one of few students to be selected and inducted into the university’s first Criminology Honors Program, and graduated with highest honors. In 2008, I began my graduate career in forensic psychology at Alliant International University, Fresno. In 2010, I was awarded a Master of Arts (M.A.) in Forensic Psychology, and a Doctorate of Philosophy (Ph.D.) in Clinical Forensic Psychology in 2013.

Years ago when I was in the early days of building my psychology practice, day-to-day life centered around raising two toddlers, keeping a relatively young marriage healthy, and working to maintain some important friendships.  Day-to-day life seemed full, and so I sat back and trusted that my psychologist-colleagues who were in leadership positions within the Minnesota Psychological Association were keeping watch over the professional interests that are so important to all of us.  I knew that someday I would want to get more involved in my professional association, and at the same time, building a family and a practice was at the top of my priority list. 

Fast forward 20 years to today.  My now-adult children are focused on “adulting” as they near the end of college and prepare to enter the workforce.  My focus in recent years has turned toward professional adventures outside of family life and a psychology business, and instead has turned toward volunteering in our state and national professional associations.  Surrounded by intelligent, highly competent and dedicated peers, you all have entrusted me with a leadership position in MPA that is both rewarding and challenging.  Looking back over the past 7 months, being President of MPA sometimes has felt like jumping into the deep end of the pool – thank you God, that I know how to swim! 

I hope that this article finds you all having a relaxing and renewing summer. 

Summer is a time of fun and sun.  A time of green plants and blue skies and waters.  We are lucky to live in such a beautiful state and we should all be sure to take the time to relax and enjoy the wonders of nature that abound around us.  This is something that we, the volunteers that run MPA on a day to day basis, need to be sure to remember to do.  Having come off a three week period where I have devoted over 25 hours of volunteer time to address issues important to our profession, I am planning to relax and sail this weekend, anchoring at times to enjoy the peaceful rocking of the boat on the waves. 

There is much going on in the world of our profession that many of you are not aware of.  The financial margins in our industry are getting tighter and tighter and so time seems to be a commodity that we loath to spend unless we get true value for it.  Many do not spend the time needed to stay informed and be involved.

On May 13, 2016, Dr. Abigail Gewirtz presented a Friday Forum Encore on Promoting Resilience in Highly-Stressed Children: Long-term Program Findings. In her presentation, Dr. Gewirtz addressed three key questions: What is resilience in children? What do we know about parenting and its association with child adjustment among families facing traumatic and/or highly stressful events? And, can prevention programs to strengthen parenting improve children’s resilience? A recap of the presentation is provided below.

What is resilience? Children and youth are considered resilient, if they appear to be ‘doing OK’—that is, functioning in the normative range with regard to social, emotional, behavioral, and academic adjustment, despite experiencing adversity (i.e., stressful and/or traumatic living conditions). Several long term studies on resilience have revealed individual, family, and environmental conditions or characteristics that promote resilience. Across multiple studies, the ‘shortlist’ of factors that are associated with children’s resilience includes effective parenting or caregiving. [1]

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.

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. 

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.

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:     

Anxiety disorders are the most common mental health condition in the United States, affecting approximately one-third of the population.¹ They frequently co-occur with depression, substance, and other anxiety-related conditions. Anxiety disorders are disproportionately associated with a variety of chronic disease risk factors, such as nicotine use, alcohol consumption, and sedentary behaviors, and chronic diseases, such as cardiovascular disease, diabetes, and asthma.² The public health impact of untreated anxiety disorders is staggering. The adjusted estimated annual economic impact of anxiety disorders is $62 billion through disability, lost wages, and healthcare costs.³ Although highly effective treatments exist for anxiety, only a minority of patients with clinical anxiety receive some form of care. Unfortunately, even among those individuals being actively treated for their anxiety disorder, very few are receiving pharmacotherapy and/or psychotherapy that meet evidence-based practice guidelines.⁴

Cognitive behavioral therapy (CBT), especially exposure-based interventions, is the most effective treatment for anxiety disorders. ⁵ CBT is highly acceptable to patients, and typically outperforms evidence-based pharmacotherapy in the longer-term maintenance of treatment gains.⁶ Although access to CBT remains challenging, large-scale efforts are being made to change health care delivery systems to improve the dissemination of evidence-based treatments.