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Table of Contents CE for Massachusetts Psychology Professionals CHAPTER 1: COUPLES COUNSELING
CHAPTER 2: ELDERLY MENTAL HEALTH: DEPRESSION AND DEMENTIA
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This course is designed to help you understand the common types of mental health conditions and issues related to the diagnosis of mental illness in the elderly and how to facilitate different treatments of mental illness in the elderly and prevention, both through therapy and medications. Elderly Mental Health: Depression and Dementia Final Exam
CHAPTER 3: ETHICS
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Upon completion of this course you will be able to understand the professional values and ethics in psychology and distinguish between the general principles and the ethical standards of the American Psychological Association’s (APA’s) Ethical Principles of Psychologists and Code of Conduct. Ethics Final Exam
CHAPTER 4: HEALTHY LIVING PSYCHOLOGY
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In this course, we will take a look at the various elements and recommendations to help people have a healthy physical as well as mental lifestyle. You will better understand the importance of health psychology, the functions of various types of health psychologists and understand the impact of relationships and social interaction on physical health and quality of life. Healthy Living Psychology Final Exam
CHAPTER 5: UNDERSTANDING SCHIZOPHRENIA AND ITS TREATMENT IMPLICATIONS
55
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Upon completion of this course you will be able to identify several therapeutic models used with couples, including cognitive behavioral therapy, emotionally focused therapy and Gottman’s approach to work with couples. You will also understand the stages of marital conflict and how they are treated in therapy. Couples Counseling Final Exam
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This course is designed to help you assess characteristics in people who have schizophrenia, and analyze when the onset of schizophrenia occurs and how it affects different populations. You will also have an understanding of treatment implications and the currently recognized methods of treatment for schizophrenia. Understanding Schizophrenia and its Treatment Implications Final Exam
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Final Examination Sheet
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Course Evaluation
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All Rights Reserved. Materials may not be reproduced without the expressed written permission or consent of Elite Professional Education, LLC. The materials presented in this course are meant to provide the consumer with general information on the topics covered. The information provided was prepared by professionals with practical knowledge in the areas covered. It is not meant to provide medical, legal or professional advice. Elite Professional Education, LLC recommends that you consult a medical, legal or professional services expert licensed in your state. Elite Professional Education, LLC has made all reasonable efforts to ensure that all content provided in this course is accurate and up to date at the time of printing, but does not represent or warrant that it will apply to your situation or circumstances and assumes no liability from reliance on these materials. Page ii Psychology.EliteCME.com
Chapter 1:
Couples Counseling 5 CE Hours
By: Leah Kulakowski, LMFT, Kathryn Brohl, MA, LMFT and René Ledford MSW, LCSW, BCBA Reviewed and edited by: Wade T. Lijewski, Ph.D.
Learning objectives Review theoretical perspectives of couples therapy. Distinguish between marital education and marital therapy. List the stages of marital conflict and how they are treated in therapy. Describe the different measurement tools used in couples therapy. Identify several therapeutic models used with couples, including cognitive behavioral therapy, emotionally focused therapy and Gottman’s approach to work with couples.
Learn an overview of approaches to sex therapy with couples. Identify issues in working with couples in stepfamilies. Describe approaches to working with couples experiencing domestic violence. Identify and review ethical issues in couples counseling. List some research related to couples counseling.
Introduction – case examples Margaret and James Margaret and James are both 45 and have been married for 23 years. They have three daughters, ages 19, 15 and 11. They grew up in the same small town, dated from their junior year of high school and attended college together at a state university. They married at the age of 22, just after graduating from college. Margaret and James both hold very traditional views of marriage, with James being the primary breadwinner. Although Margaret was the superior student, graduating magna cum laude with a degree in accounting, she works only to supplement their income and has always placed James’ career first. James has a successful career as the high school principal in their hometown, a position he has held for the past five years. Margaret works part time as a bookkeeper in her father’s building supply business. Margaret is very close to her traditional parents, who have been married for more than 50 years and are well respected in their community. James acknowledges that his father, who was from a prominent family, was the “town drunk,” and his mother was forced to work to take care of James and his three brothers because of his
father’s alcoholism. His parents divorced when James was 15. James seldom speaks to his father, who has been sober and active in AA for the last 20 years. Margaret always thought she had a happy marriage but recently discovered James was having an affair with a divorced woman he met at their church. James wants a divorce and says Margaret is dull, boring and is constantly nagging him. He is resentful about having married young and missing out on dating more women. He feels his life is passing him by. He wants a divorce but he is afraid it will ruin his career, and divorce will force Margaret to work full-time, just like his mother, which fills him with guilt and shame. He always wanted a happy family for his children, with both parents present and a full-time mother, but cannot stand the thought of being married any longer. Margaret desperately wants to save her marriage and is willing to forgive him at any cost, which her mother supports, but her sister is telling her to dump him, telling her “once a cheater, always a cheater.” Margaret is desperate, hurt and confused.
Ron and Michelle Ron and Michelle have been married for two years. Ron is 49, and has a successful construction business. He was married for 20 years and divorced for two years before marrying Michelle, who owns a hair salon. He has two daughters, ages 20 and 22, who see him about once a week. This is the third marriage for Michelle, who is 39. She was married for a few years at the age of 20, a marriage that ended when her husband died. Shortly after his death, she married again at the age of 24 to the father of her two sons, who are now ages 10 and 12. She stated that she and the boys’ father argued constantly. The marriage lasted 12 years and ended two months before she met Ron. Her former husband is working overseas and hasn’t been able to see the boys very much in the last two years. Right now, she feels Ron is too strict with her sons, and they are becoming very rebellious towards him and say he is “mean.” Ron complains that Michelle is too easy on the boys and he has to exert control because she won’t do it. Michelle feels she is a good parent and prefers to talk things over with her sons and negotiate and compromise. Ron believes that his rules should be obeyed without question, just as they were in his family. When Michelle disagrees with Ron’s punishments, he accuses her of taking Psychology.EliteCME.com
her children’s side. Ron also resents the fact that Michelle’s ex cannot take the boys for any length of time to “give us a break,“ and says that between work and her children, they never have any “couple time.” Ron feels he has no authority in his own home; Michelle thinks that Ron is a tyrant. Ron feels he has to share Michelle with others too often, but Michelle argues Ron knew that the children were a full time commitment when they married, so he should “grow up” and get over how much time they take away from her and Ron as a couple. Michelle wants a divorce, and Ron thinks everything would be great if the kids weren’t around. He frequently thinks of just giving it up and filing for a divorce. These two scenarios describe two very different families, one a traditional, long-term marriage and the other a blended stepfamily. They both illustrate marriages that are clearly in crisis. The issues that face both of these marriages appear to be quite different. But both of these cases, while appearing different on the surface, can be assessed and treated by a therapist using the same theoretical orientation. A couples therapist using either emotionally focused therapy (EFT) or cognitive behavioral therapy could be effective in both of these Page 1
situations, even though they are very different approaches. However, treating couples in these types of situations is never easy, and to be successful in helping them, therapists need specific training and supervision in whichever modality they choose. In this course, we will explore the history of couples counseling, the theoretical basis for family therapy and couples therapy, and the
different models of intervention for couples in therapy. In addition, we will look at some subtypes of couples therapy, including work with stepfamilies, families with domestic violence and families with substance abuse, as well as the assessment of marital issues with measurement tools. Furthermore, the ethical issues that face clinicians performing couples therapy also will be explored. Finally, we will examine research related to the efficacy of couples counseling.
What is a couple? Marriage is often described as the one familial relationship that we can choose. As noted by the eminent scholar and practitioner, William Nichols, “Marriage is the lone voluntary relationship in the family,” (1988, p.6). We cannot choose siblings, children or parents, but we certainly can choose our spouses, and in some cases, “un-choose” them. Certainly, parents can cut off children; children can cut off their parents; and siblings can go for years without speaking. But unlike ex-spouses, we never hear someone refer to my “ex-father” or my “ex-child.” Marriage is also a rapidly changing relationship in our culture. Samesex marriage as well as multiple marriages and divorces throughout a lifetime were unknown a century ago. Marriage is in most states a legal union of a man and a woman. However, some states do allow same-sex marriages and some allow civil unions, which give couples certain rights but are not recognized as marriage. In addition, many couples, regardless of gender or sexual orientation, choose cohabitation over marriage or civil unions, short-term and permanently. Although this point could be debated at length, it is important to note that marriage is a socially recognized institution and does have a social meaning that differs from a long-term cohabitating relationship. Nichols (1988) observed several decades ago that relationships do change when couples enter the social realm of marriage and take on new roles of husband and wife. Marriage, he notes, “holds expectations and meanings for many persons that are not necessarily present in an unmarried coupling, regardless of the duration of the unmarried relationship,” (p. 12). As the acceptance of samesex marriages increases and more couples choose not to marry, it is difficult to know whether Nichols’ words will continue to be as true 10 years from now as they were in 1988.
However, in this course, the terms marital intervention, marital therapy, marriage therapy, couples counseling and couples therapy will be used interchangeably and unless otherwise noted, are generally applicable to all types of couples. It is critical to realize that some of the theorists and practitioners noted in this module may have only conducted research or performed these interventions with married couples and may not have intended for their work to be generalized to unmarried or same sex couples. When the writer has direct knowledge of this information, it will be noted. The oft-quoted statistic is that 50 percent of the approximately 2 million marriages that occur each year in the United States will fail (http://www.cdc.gov/nchs/fastats/divorce.htm). But that also means that 50 percent of marriages will not end in divorce. A recent study analyzing 20 previous studies of marriage and family therapy concluded that therapy is effective (Shadish and Baldwin, 2003). Despite these findings, only about one-third of divorcing couples have ever even attempted marriage counseling (Johnson, et al., 2002). The most commonly noted reasons for seeking counseling are problems with affection, problems with communication, a general desire to increase marital satisfaction and worries about the potential for divorce (Doss, Simpson and Christensen, 2004). It is also important to note that in this course, couples counseling is largely explored from the perspective of European or North American, middle- and upper middle-class persons from Caucasian backgrounds. There is a dearth of research in family therapy about people from lower socioeconomic backgrounds, African Americans, Asians and Hispanics or research in non-Western countries.
A brief history of marriage therapy Marriage therapy or couples therapy is a relatively new form of counseling. In the traditional focus of family therapy, work with families instead of the marital dyad received more attention overall. In fact, in major family therapy textbooks, only about one-quarter of the material emphasizes couples therapy (Nichols and Schwartz (1998) and Gurman and Kniskern (1981, 1991).
A course on marital therapy requires a general look at theoretical approaches to family systems and family therapy; in general, the therapy models can be divided into five groups: ●● Communication. ●● Psychodynamic. ●● Intergenerational. ●● Experiential. ●● Postmodern.
Communications model The communication models are further subdivided into the approaches of the Mental Research Institute (MRI), Milton Erikson, the Milan team, structural therapy, strategic therapy and solution-focused therapy. The communication models involved such influential family therapists as Don Jackson, Lyman Wynne, Milton Erickson, Jay Haley, Sal Minuchin, Steve de Shazer and Insoo Kim Berg. While these approaches may differ in technique and emphasis, the overriding common factor in these approaches is the emphasis on communication in the here and now, with little involvement with a person’s past experiences or internal, psychodynamic processes. In addition, these approaches place a good deal of emphasis on the power of the therapist to bring about change within the family (Piercy, Sprenkle and Wetchler, 1996). Don Jackson contributed insight into the martial relationship within the family system. His major contribution
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to couples therapy was the concept of marital quid pro quo, which is an unconscious set of rules that guide the relationship into essentially an exchange wherein one person in a couple gives something, then the other receives something in return. Jackson asserted that there are rules, though not always explicitly stated, that govern these exchanges. Jackson felt that establishing a clear quid pro quo was important to achieving harmony in a marriage (Lederer and Jackson, 1968). Jay Haley was also highly influential in marital therapy. He believed that all marital problems stemmed from power and control issues. Haley (1963) noted that, “the major conflicts of marriage center on the problem of who is to tell whom what to do and under what circumstances,” (p. 227). Haley did not care about the history or experiences of the couple, or about insight or feelings. He felt that the major job of the therapist is to create interventions that bring about change.
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Psychodynamic model In contrast, the psychodynamic models of family therapy emphasized the internal process as related to a person’s present issues and problems, and are strongly rooted in the psychodynamic theories of Freud. The best known of these theories is object relations family therapy. Ronald Fairbairn (1952) popularized this theory, which is highly complex and is rather difficult to summarize. An infant learns to see his mother as “good” through her meeting his needs.
But when the mother fails to meet these needs and the child is angered by not having his needs met, he splits the mother into good and bad objects. The good mother allows the child to feel secure and loved. The bad mother is an internal object that causes the child to feel unloved. The “introjects” of the good and bad mother are integrated into an adult’s personality and continue to be projected onto others. The negativity and severity of these projections varies from person to person.
Intergenerational model One of the more influential models of family therapy is intergenerational, which was developed by Murray Bowen and later, Ivan BoszormenyiNagy. In general, the influences of our family of origin are carried with us into our adult relationships, and we are able, through processes such as differentiation and individuation, to work through these influences and become healthy adults with well-functioning marriages. Bowen described differentiation as the process of developing individual thought that is rational and not driven by emotions. Persons who are well differentiated are able to think logically, not be unduly influenced by emotion and separate their emotions from their actions. In other words, a person who married within days of meeting a spouse is likely to be poorly differentiated. A person who met someone and then dated the person for two years while determining whether he/she was a good potential marital partner is likely to show signs of higher levels of differentiation. Likewise, a person who is independent of the undue influences of a family of origin and can think independently is demonstrating characteristics of being well individuated. For example, someone who is individuated might choose, after much careful thought and exploration, to follow a different religion than his or her family of origin. This person is aware that this change will upset parents and siblings, but is willing to displease others in order to be happy with his/her chosen religious faith. These choices, though, are not reactionary and rebellious. Rebellion is not a sign of being well differentiated or individuated, but rather just the opposite. A person who chooses to become Jewish to shock or provoke Catholic parents is not behaving in a well-differentiated or individuated way. According to Bowen, a person who acts rebellious to upset his/her family is every bit as poorly individuated as someone who will not date a person of another religious faith solely because of fear of upsetting parents. Bowen further explores how persons of similar levels of differentiation tend to be attracted to one another and marry. Therefore, when two persons who are poorly differentiated marry, their relationship is likely to be characterized by heated emotional exchanges, impulsive behaviors and poor acceptance of responsibility. Another major concept of Bowen’s theory that is fundamental to marital therapy is the concept of triangulation. Triangles are formed when two persons incorporate a third person into the relationship to release tension. For example, parents who focus on a child’s behavioral issues can avoid focusing on their own marital issues. Triangles become unhealthy when they become static and unchanging. Bowen had stated that all family therapy eventually becomes marital therapy, indicating his belief that
most of the acting-out behavior of children was an attempt to draw attention to the parent’s marital problems and help the parents’ marriage by bringing them into therapy. It is important to note that Bowen’s theories were from the mid-20th century and were developed before the model of the nuclear family changed to what it is today. It does not always adequately explain how these processes work for persons who are not married, who do not have children or are single parents. Nevertheless, in work with couples, the key was to remain present but not triangulated into the marital conflict. Bowenian therapy has often been viewed as the bridge between individual psychoanalytic theory and systems-oriented family therapy. While the approach disavowed such concepts as the id and ego, it still paid attention to the inner workings of a person, but from the larger perspective of the impact of one’s family of origin and its related influences on a person’s thoughts and behaviors (Lebow and Gurman, 1998). Gurman and Fraenkel describe Bowen’s approach as acknowledging “the past as well as the present, to the intrapersonal as well as the interpersonal, and to the affective as well as the cognitive. It was the only couple therapy theory of its day emerging from family therapy that simultaneously addressed the individual, the dyad, and the family of origin,” (p. 218). As they built on the work of Bowen, Boszormenyi-Nagy and Ulrich (1981) explored the concepts of filial loyalty as a motivating factor in people’s behavior as marital partners and as parents. They theorize that people have a certain loyalty to the parental relationship and in a strange way of showing loyalty, have a difficult time becoming a better parent than their parents were. They believe that if a person acts very differently than his or her own parents did, it is a way of condemning the parents by implying that they were bad parents. Likewise, if a person has a better marriage than his or her parents, it is a way of admitting that the parents’ marriage was not ideal and was unhappy, and that triggers feelings of disloyalty in some people and blocks their ability to grow and change. The goal of therapy is to help people understand that changing behavior is not disloyal. Bowen also made several distinct contributions to marriage therapy. Bowen’s theory was that relationships caused all psychological problems, and that marital problems really stemmed from relationship problems in one’s family of origin. Bowen emphasized the calm and rational response to distressing situations and in marital therapy. A therapist who had a great deal of training on self-differentiation that enabled him to remain calm in highly emotional situations, Bowen would have the couple speak to him, rather than to each other. In this process, Bowen would reflect upon the situation and objectively coach each partner.
The experiential model The experiential theories are based in both communication and psychodynamic theories. However, unlike psychodynamic approaches, these theories emphasize thoughts and feelings in the here-andnow instead of the past. The inner working of one’s thoughts are acknowledged as very real, but are seen as a result of the processing of life experiences and not stemming from concepts such as Freud’s ego and id. This approach has been largely “personality driven” by Virginia Satir and Carl Whitaker; experiential therapy owed much of its success to the personal qualities of these practitioners. There is a good deal of emphasis on the therapist being open and vulnerable with a family and avoiding expert approaches. The therapist is expected to feel Psychology.EliteCME.com
emotions, and the emotions experienced are thought to mirror those of the family. If a therapist is feeling little emotion in the session, then it is likely that the family is not feeling much either. Experiential therapy is often spontaneous and even can appear irrational in its approach to a problem. The goals in experiential therapy are often more general than specific, emphasizing goals to increase self-esteem and overall functioning of a relationship instead of quantifiable, measured outcomes (Whitaker and Keith, 1981). Satir took these general goals further, involving an emphasis on world peace (Satir, 1988). Satir contributed to couples therapy through her strong emphasis on selfworth and communication as the cornerstones of successful marriage. Page 3
Post-modern models The post-modern models of family therapy include constructivist, postmodern, solution-focused and narrative, and in the most basic terms support the “concept that reality is an intersubjective phenomenon constructed in conversation among people,” (Wetchler, pg. 129). Steven Friedman (1993) noted “We no longer live in a coherent social world with a consistent set of truths, and meaning is co-constructed in conversation” (p. xiii). There is a great deal of emphasis on the therapist taking a collaborative approach instead of an expert stance with a family. There is much emphasis on not simply diagnosing families as pathological, particularly when dealing with persons of another culture, and instead accepting a family’s own culture rather than expecting it to conform to the standards of the dominant culture (White, 1995). The narrative therapy of White encourages families to tell their life stories, and through this process, move the family from emphasizing problems in those stories to talking about their successes when dealing with those problems. Other therapists of the post-modern stance have used reflecting teams, who observe a client and therapist and comment directly to the clients
about what they observe and think about the session. (Anderson, 1987). Another major approach of post-modern therapy is that of solution-focused therapy. This therapy, popularized by Steve de Shazer and Insoo Kim Berg (1992), is similar to narrative therapy in that the client is encouraged to move from being problem-saturated in his/ her life story towards retelling the story with an emphasis on success. They also made use of the well-known “miracle question” in which the client is asked what life might be like if a miracle occurred and the problem no longer existed. This is used to help clients discover the goals they have for treatment. The cause of the problems is not the point of this therapy; the emphasis is on change, regardless of the cause of the issues. In addition to the therapy models that are derived from these family systems theories, there are also three very important frameworks essential to the understanding of a clinician doing couples therapy. The first of these is the family life cycle, the second is ecosystemic and the third is family-stress theory.
The family life cycle The family life cycle approach theorizes that all families pass through predictable life stages, much in the same way that an individual passes through the stages of life. However, each family is influenced by the times in which they live. A classification table lists six stages of the family life cycle and the basic tasks of each cycle: 1. Leaving home: single young adults. Tasks are to form romantic relationships and establish one’s self in the world of work 2. The joining of families through marriage: the new couple. Adjusting family of origin relationships to incorporate the partner and develop ways to live together. 3. Families with young children. Tasks are to adjust the marital relationship to incorporate children. Develop parenting roles and incorporate the role of grandparents into the system. 4. Families with adolescents. Taking care of members of the family of origin and develop patterns of parenting that incorporate autonomy of the adolescents.
5. Launching children and moving on. Negotiate adult-to-adult relationships with children, incorporate new roles as grandparents into the family system. Adjust to living in home without children and refocus on couple issues again. 6. Families in later life. Dealing with loss of spouse and peers and adjusting to physical limitations that come with aging. Accept caregiving roles of adult children. Prepare for death. Each stage consists of developmental tasks that must be completed in order for the family to pass to the next phase successfully. When a family cannot complete the tasks, its members often become stuck and cannot move on to the next phase. It is helpful for therapists to understand these typical stages so that they can better understand the couple’s stage in the family life cycle and use this framework to help guide their interventions. The therapist’s job is to help families work through these tasks and move forward (Carter and McGoldrick, 1988).
Ecosystemic theory Ecosystemic theory is formed from the work of Urie Brofenbrenner (1979) and Richard Lerner (1991), who were developmental psychologists, as well as Margaret Bubolz and M. Suzanne Sontag (1993), who came from the field of family ecology. Brofenbrenner focused on the interaction of the environment and a person’s development, Lerner’s perspective was developmental change throughout the lifespan; Bubolz and Sontag’s perspective was the interaction of the family and the social and physical environment, with an emphasis on decision-making as it relates to the allocation of resources available to a family. While each of these perspectives is slightly different in general, ecosystemic theory emphasizes how the individual and the environment interact in a reciprocal fashion to influence human development (Bronfenbrenner, 1979, Lerner, 1991). It explores causality, not as a linear cause-and-effect outcome, but rather examines outcomes from a multidimensional perspective and is especially helpful in the examination of dyadic and triadic relationships (Braverman, 1993; Buobolz and Sontag, 1993). Brofenbrenner (1979) notes that there are four contexts for any individual and they are “nested,” meaning that each context is placed within the other, larger context. For example, the family context
is embedded, or nested, within the larger context of the community. The contexts that Brofenbrenner describe include microsystems, mesosystems, exosystems and macrosystems. The relationship of parent to child is a microsystem, as is the relationship of spouses. A mesosystem is the linkage of two microsystems, which, for example, could be the interaction of a child’s family and school. Couples and their children are embedded within the various mesosystems of schools, neighborhoods and church. An exosystem consists of areas beyond the control of the family, but is a system that affects a family, such as the ongoing relationship with social services agencies. Macrosystems are those systems over which a family has little control or influence, but which incorporate all of the above relationships and influence all the subsystems, such as society, culture and public policy, all of which can greatly affect relationships within the family. For example, a macrosystemic issue is gay marriage. The refusal of some states to recognize civil unions or marriages between same-sex persons affects these couples and their children tremendously at the microsystemic level. The macrosystem also includes elements regarding cultural patterns related to race, gender, socioeconomic status and history.
Family stress theory Reuben Hill (1949, 1958) was the originator of family stress theory, in which he developed a model that attempted to incorporate a developmental and systemic perspective in the study of families (Klein and White, 1996). He was curious as to why some families did well Page 4
under circumstances that destroyed other families, and began his search for what made families different from one another by studying families in the Great Depression and soldiers reunifying with their families after World War II. Psychology.EliteCME.com
The basic component of his model was the “ABCX” model of family stress. The A is any stressor that taxes a family’s resources, whether it is an internal issue, such as a marital problem, or an external issue, such as loss of a job. The B represents any resources that a family may possess to cope with the stress induced by the A event. Resources can be money, social support or a strong marriage. The C refers to a family’s perception of the event, and involves how stressful they perceive it to be. The interaction of these ABC factors thus results in the crisis, or the X. As an example, one family may see the event (A), the burning down of their home, as a crisis due to a lack of resources (B), if the family has no insurance or money to fix the home. This event is perceived as overwhelming, (C), because the family cannot see a solution to the problem of now being homeless, which results in a crisis (X) for this
family. Another family sees the same event as very upsetting, but their resources (B) are quite good. They have the money and homeowners insurance to take care of the problem and to find temporary shelter. Their perception of the event, while certainly not positive and very distressing, is not the overwhelming calamity that it was for the first family. The perception is quite different, and the outcome is that the crisis for the second family will not be as devastating as it is for the first family. With married couples, it is assumed that based upon Hill’s model, the increase of protective factors (B), such as strengthening the marital relationship, will enable the family to handle the inevitable stressors (A) that arise from daily life, or serious life events, and hopefully lessen the impact of a stressor that arises.
The developmental phases of couples therapy Despite the legacy of numerous theoretical orientations in the field of family therapy, couples therapy often seemed to develop without a real theoretical basis and did not necessarily link to any of the established family theories. Gurman and Fraenkel (2002) note that there were four phases that led to the development of couples therapy: I. Atheoretical marriage counseling formation (1930-1963). II. Psychoanalytic experimentation (1931-1966). III. Family therapy (1963-1985). IV. Refinement, extension, diversification and integration (1986-present). The first phase involved the practice of counseling by persons who were in related professions, such as pastors, obstetricians and social workers, who were viewed as assisting with marital adjustment and not dealing with major mental health issues. Marriage counselors focused on the here and now, the presenting issues and provided guidance to resolve problems. The help focused extensively on giving advice and was oriented toward education. Interestingly, the vast majority of these counseling sessions during the 1930s, ’40s and ’50s were not done with couples at all, but with individuals. By the mid-1960s, couples were usually seen together. During this time, the practitioners in the field also established the American Association of Marriage Counselors. A large portion of Phase II actually ran parallel to Phase I. Many psychoanalytic practitioners, who were all psychiatrists at that time, were performing individual psychotherapy. Over time, many of the analysts became frustrated with the lack of progress in individual therapy when marital issues were a major problem for their patients. Psychoanalysis placed a great emphasis on the relationship of the therapist and client, with its emphasis on transference from patient to analyst as an agent of change. Psychoanalysts also held very strong views against confusing this relationship by bringing in others. Despite this traditional resistance to anything other than individual therapy, Gurman and Fraenkel (2002) cite Clarence Oberndorf, who wrote in a paper in 1934 about the emergence of consecutive psychotherapy of a couple by the same psychoanalyst, who would treat one martial partner and then start seeing the other partner once the first partner had completed psychoanalysis. Gurman and Fraenkel then note that Bela Mittelman (1948) began performing concurrent treatment, in which both parties were treated simultaneously in separate sessions
by the same practitioner. Eventually, the psychoanalyst would then hold joint sessions with the couple. Mittelman undertook this process because he would get different stories from each spouse about the same events and felt joint sessions would help him discern the truth of what was taking place. Gurman and Fraenkel note on page 208 of their journal article that although these methods were used on occasion, individual therapy was still the predominant modality of couples therapy, and thus, the practitioner was still seen as the “central agent through which change must perforce occur.” This reflects the expert-oriented approach that predominated much of family therapy until the postmodern schools of thought began to emerge. Gurman and Fraenkel acknowledged that although therapists in the 1960s began to use conjoint therapy more and more, there was still a heavy emphasis on psychoanalytic theory, with its use of defenses, free association, dream analysis and the examination of the underlying internal processes of individual pathology, which were then manifested in the marriage. They quote Ralph Gundlach (1971): “I am not primarily involved in treating marital disharmony, which is a symptom, but rather in treating the two individuals in the marriage.” This model of couples therapy eventually would fall out of favor, primarily because it was not particularly effective because it still emphasized individual treatment and did not address the issues between partners. But Phase III, family therapy incorporation, brought a systemic perspective to the field, which focused on interactional patterns but also pushed couples therapy, with its individually oriented approaches, out of the limelight for about 20 years. From 1963-1985, family therapy emphasized the systemic process of the whole family, but did not really focus much on the dyadic interaction of the couple. Nonetheless, Gurman and Fraenkel (2002) noted that several of the prominent family therapists, including Murray Bowen, Don Jackson, Virginia Satir and Jay Haley, made major contributions to couples therapy during this time. There are numerous forms of couples counseling, and the major interventions will be discussed in greater detail. It is important to note that not all interventions for couples are the same. Some are better classified as marital education, while others are marital interventions. The major differences are highlighted in the next section.
Marital education Marital education differs from marital therapy or couples counseling in that marital education is designed to enrich or enhance a relationship, not to solve major problems or save a rapidly failing marriage. Marriage education is designed to build skills, such as communication, and is more general in nature instead of focusing on specific problems. Marital education harkens back to the early marriage counseling movements with the emphasis on giving advice, but has been refined over decades to place greater emphasis on problem-solving and communication skills. Moreover, the participation in such educational programs today Psychology.EliteCME.com
is usually conjoint. There is a good deal of evidence that marriage education is effective for couples who are not in crisis (Adler-Baeder, Higginbotham and Lamke, 2004; Halford, Markham, Kline, and Stanley, 2003; Hawkins, Blanchard, Baldwin and Fawcett, 2008). The intended outcome of marriage education is to improve marital satisfaction, which can be affected by three general components: interactions, contextual factors and personal characteristics (Bradbury, Fincham and Beach, 2000; Halford, et al., 2003; Larson and Holman, Page 5
1994). Marriage education tends to focus mostly on interactions between the couple, as these are the issues most likely to change with a short-term intervention. More in-depth issues, such as ongoing stressors like money or substance abuse as well as individual personality disorders, are very hard to change, and are best addressed in the setting of long-term intensive marital therapy (Halford, et al., Karney and Bradbury, 1995). Overall, it was determined that successful marriage education programs should emphasize positive exchanges of love and emotional support, encourage honesty and the open exchange of feelings and emotions, and encourage couples to spend time together. It is also important for couples to learn to express fewer negative emotions, such as contempt and criticisms. And it is helpful with marriage education to incorporate education about the process of marriage in general, such as life stages and typical adjustments that are common to marriages. Interactive participation was also very helpful as it
allowed couples to practice communication skills (Adler-Baeder, Higginbotham and Lamke, 2004). Some of the most popular forms of marriage enrichment or education are the Association of Couples in Marriage Enrichment (ACME), Marriage Encounter, and Prevention and Relationship Enhancement Program (PREP). ACME is led by other couples who have been trained in the process. ACME does not have a religious focus. Worldwide Marriage Encounter is supported by the Catholic Church but is used by those of many different faiths and presents an emphasis on God and spirituality. PREP has several components, including modules specifically designed for presentation to lowincome couples and couples making the transition to parenting. PREP is also recognized by the Substance Abuse and Mental Health Administration (SAMHSA) as an evidenced-based practice that has demonstrated efficacy in several research studies. PREP was found to increase relationship satisfaction, improve conflict management and communication and decrease levels of problem intensity.
Cognitive behavioral therapy Marriage education may be helpful for some types of couples’ conflicts, but more serious cases of conflict needs treatment through couples therapy. A popular approach to couples therapy is cognitive behavioral therapy. According to Schmaling, Fuzzetti and Jacobson (1989), behavioral therapy has its roots in the work of B.F. Skinner. Negative material interactions were controlled by the threat of punishment. The purpose of early behavioral therapy for marital problems focused on the replacement of negative interactions with positive interactions that would have spouses act in ways that elicit positive reactions from one another. As the sophistication of this approach evolved, the impact of cognitive processes became more evident. As they note, “the clinician must assess the attributions that spouses make for their own and their partner’s behavior. Attributions are the beliefs spouses have about the causes of and reasons for each other’s behaviors. In addition to assessing the perceived causes of behaviors, a marital therapist must assess the way in which each spouse interprets the impact of his/her own and the partner’s behavior (cognitive style),” (p. 349-340). The authors note that couples may come to therapy for marital problems, but an individual often will present with anxiety or depression, and issues about marital problems will arise during the course of therapy. This means that a thorough assessment of any client for relationship issues is important. They go on to describe the behavioral patterns of distressed couples. Couples with relationship issues will engage in reciprocated negative behavior in which each partner behaves negatively in response to negative behavior from the other, thus setting up a vicious cycle. These couples are also highly reactive, and their perceptions about the relationship can change rapidly in response to seemingly minor events. In addition, couples with these issues expect to be criticized for a particular behavior, so even the slightest mention of something related to that behavior may set off a reaction, even if the topic is mentioned using non-critical language. Consequently, reactivity makes it harder to listen to each other because each is so wrapped up in preparing his/her own responses to this perceived attack that he/she cannot stop and hear the other person. Over time, a buildup of unresolved arguments leads to increasing bitterness and anger, as well as a loss of hope that future conflict can ever be resolved successfully. Cognitive behavioral therapy approaches involve several sessions of assessment. This includes identifying problems areas with couples as well as gathering relationship histories, which are designed to identify positive areas of relationships that used to be prevalent and could possibly be again. The authors also recommend an individual session for each partner to assess past relationships, trauma history, family of origin, sexual history and the partner’s commitment to therapy. Couples therapy is contraindicated when either partner is having a continued affair, has severe mental illness or wants a divorce. Couples Page 6
with issues of physical violence and substance abuse will need additional interventions to be able to work in couples therapy. After these assessments are completed, then the couple will meet with the therapist who will outline expectations for the therapy. In addition, the therapist will emphasize to the couple that the situation is mutual and that one partner alone is not to blame. Each subsequent session is 90 minutes long, and is quite structured. The therapist sets an agenda at the beginning of each session, evaluates progress, debriefs homework assignments, opens discussion of new skills and assigns tasks. The therapist is also required to provide: ●● Structure: The therapist is very much in control of these sessions and must be able to keep the couple on task and not allow one or both to derail the session to lodge complaints against the other. ●● Instigate: The therapist is trying to enable the couple to eventually be able to solve their own problems. The therapist encourages compliance with homework, encourages collaboration and gradually gives the couple more and more responsibility to practice skills without the therapist present. ●● Teach: The therapist has to teach and model various skills and provide direct feedback to each partner in skill demonstrations. ●● Create positive expectancies: The therapist needs to convey both optimism and realistic expectations to a couple. It is also important to predict some setbacks after the couple’s relationship becomes more positive. Otherwise, as the couple begins to have a recurrence of the issues that brought them into therapy, they may discredit the therapist as not really having helped them after all. But the therapist should also remind the couple that after some initial setbacks, progress will be regained to a large degree. ●● Provide emotional nurturance: The therapist needs to provide an atmosphere of support to enable the couple to continue with the difficult process of therapy. ●● Alliance building: A therapist must be able to find empathy for both clients, even if one of them is unpleasant or hostile. The therapist should also be careful to not blame one partner for the whole problem and focus too much on this partner. Nonetheless, the therapist must be able to recognize that some issues do require one partner to be more challenged to change behavior than the other partner. Typical techniques used by cognitive-behavioral therapists use behavioral exchanges to increase positive feelings. Couples are assigned tasks to do positive things for one another, drawing from positive courtship experiences and asking what actions that they believe would please their spouses. Partners are asked to develop lists and share them with one another, although the spouse who performs the tasks will choose which tasks to engage in. This allows the other partner to feel that the spouse’s positive actions towards them are not forced and
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thus allows the receiving spouse to assign a positive attribution to the spouse’s giving actions. Therapists also use cognitive interventions. The meaning given to a spouse’s behavior is derived from beliefs about the intent of a spouse’s actions. This meaning will then contribute to a person’s emotional response, whether it is anger or pleasure. Partners are encouraged through this intervention to find positive attributions for their partner’s behaviors. The therapist works through examples of these types of situations with the couple and helps them determine whether the behaviors are misinterpreted or whether it is an action or behavior that it coming from a negative intent, in which case the behavior is targeted for change. Communication skill building is a very important component of the cognitive behavioral approach. The therapist begins by modeling these skills and then gradually becomes a coach as the couple uses these skills. Communication skills training steps are broken down into the following steps: 1. The therapist models “negative non-listening” by looking away and doodling while a client speaks and elicits information from the client about their feelings about this lack of attention when he/ she was speaking. The therapist then models “positive non-verbal listening behaviors,” such as making eye contact and then asks both participants how this felt to them. 2. The therapist models “negative verbal receptive skills” such as interrupting, and then asks the couple to provide examples of times they have demonstrated these behaviors. 3. Another learned communication skill is to paraphrase, by having the therapist speak and have each partner practice by asking the therapist whether the client’s perceptions about what is being said are correct. The authors cite such examples as asking, “Is that
right,” or “Is that what you meant?” The couple then practices paraphrasing each other using a positive topic. 4. The last step is to have the couple identify emotions in paraphrasing. This helps the couple realize the effect of an action on the partner. An example of this would be to have the couple practice saying things like, “I feel happy when you bring me flowers.” Problem-solving is also integral to this approach and can be divided into phases of identifying the problem and coming up with solutions. In problem definition, the spouses identify a particular issue, acknowledge they each contribute to it and then brainstorm possible solutions. Troubleshooting can also be used when couples report unresolved arguments between sessions. The therapist guides the couple through a reconstruction of the arguments and discusses such topics as the intent of behaviors and actions, how each partner felt about those behaviors and exploring with the couple what behaviors might have stopped the argument or solved the problem. Another intervention is to identify and alter negative patterns of interaction. This intervention will help clients recognize what general pattern their conflict follows. Typical patterns are: ●● Demand/withdraw in which one partner tries to demand emotionally from the partner who keeps withdrawing. The harder the demander pushes, the more the other withdraws. The demander feels ignored and discounted, and the one who withdraws feels overwhelmed. ●● Relationship vs. work. This pattern has one partner who is more invested in a career and one who is more invested in the relationship. ●● Emotional/rational. In this situation, one partner becomes highly erratic and the other remains calm.
Assessing marital conflict Some forms of couples counseling places a good deal of emphasis on assessing couple’s conflict stage or type, in order to determine more specific couple interventions that are designed for the specific stages of conflict that a couple is experiencing. As any clinician who has ever worked with couples knows, assessing relationship conflict can sometimes be difficult when couples enter the therapist’s office, bickering, angry or refusing to speak at all. At first glance, all conflict can appear to look very much alike. However, to the trained clinician, subtleties in various dimensions of conflict do emerge with further assessment. Marriage therapists Guerin, Fay, Burden and Kautto (1987) describe four stages of marital conflict as it is manifested in interpersonal relationship, and they emphasize that it is important for a therapist to understand and assess what stage of conflict a couple is in to determine which interventions need to occur. The stages of conflict are like a map that guides the therapist to utilize certain interventions. Thought their work was developed with married couples, it can be utilized for all couples. Their guidelines for assessing marital conflict are listed below. Most stage I couples have little conflict and are unlikely to enter therapy. Occasionally, a stage I couple will enter therapy, but this is relatively rare. Guerin, et al., (1987) notes that Stage I occurs mostly in the first few years of marriage when couples both come from families
of origin with fairly low levels of stress and that have been relatively functional. In Stage II, there is increased criticism and there is less intensity of passion. Power struggles are minimal. Often, there is a tendency for one partner to be a pursuer who pushes the other partner to engage in interactions and be closer, while the other partner feels overwhelmed by this pursuit and retreats. This sets up a pattern in which the pursuer keeps pursuing, the “distancer” keeps retreating when feeling pressured, which in turn just encourages the pursuer to keep chasing even harder. Stage III, in addition, is marked by sudden changes in the emotional climate. There is a good deal of emotional reactivity, criticism is high and couples spend little time together. Couples become locked into power struggles and want to win at all costs. Self-disclosure takes the form of suppressed anger that is unleashed without restraint. There is a great deal of blaming the other and avoiding responsibility for one’s part in the conflict. Stage IV is extreme and is often characterized by one or both spouses hiring an attorney to proceed with a divorce. Guerin et al., notes that couples in this stage are past treatment, and treatment typically becomes divorce therapy, with the therapists assisting the couple in getting through the dissolution of the marriage with the least emotional damage to the couple and any children.
Marital conflict Stage
I
II
III
IV
Communication
Open, some conflict
Open, with conflict
Closed, with conflict
Closed
Information exchange
Excellent
Good
Compromised
Poor
Self-disclosure
Good
Adequate
Reactive
Absent
Criticism
Low
Moderate
High
Very high
Credibility
Very high
High
Moderate
Low
Relationship time and activity
Excellent
Good
Compromised, minimal
Minimal
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Treating Stage I Interventions do vary greatly by stage. In Stage I, couples are treated through psycho-educational interventions, which are primarily presented in a group format. Couples are educated on such issues as normative family life cycle changes, the impact of the couple’s family of origin on current relationships, and the toxic situations
that often arise in marriage: sex, money, alcohol and death. There is also an emphasis on the transition to parenthood for young couples and parenting adolescents for older couples. The emphasis is on encouraging couples to confront and discuss issues in a healthy way.
Treating Stage II In Stage II, the therapist works with the couple around issues of pursuit and distance. Guerin and his colleagues see the pursuer and distancer patterns as a key issue in this stage. Pursuers are encouraged to back off from chasing the emotional distancer, who will often begin to move closer to the pursuer with the intense pressure to connect being lifted. Extended family work with each person is also important. Guerin et al. describe the reasons for this work as threefold: 1. To establish a linkage between what is happening in the extended family and the interaction within the marriage. 2. To increase each spouse’s sense of belonging and support in his or her family. 3. To bring out the connections between the key triangles of the extended family that later drive the marital conflict to Stage III (p. 193).
Typically, the emotional distancer needs to begin extended family work sooner than the pursuer. As the distancer would rather defocus on the relationship with his or her spouse, the beginning of therapy is an ideal time for the distancer to work on extended family issues. Typically, when the pursuer initially enters therapy, the pursuer is usually too focused on the primary relationship and solving the problems with the spouse to be able to step back and look at the various issues within the extended family that also need to be explored. The pursuer usually needs time to be ready to be redirected into other issues rather than their relationship with the partner. However, once the pursuer can begin working on other issues, the extended family work offers an alternative place for the pursuer to expend emotional energy. Usually, if these efforts are successful, the pursuer retreats and works on his/her extended family, which then gives the distancer the responsibility to work on his or her own family issues.
Treating Stage III Stage III conflict is overt, but couples may also come into therapy to deal with a symptom, such as depression, or problems with a child. Therapists must be careful in these situations to not force the couple early on to deal with the underlying problem of the marriage and instead work on the presenting symptom first. Going straight towards the marital conflict will usually cause these couples to quit therapy because they often carry a high level of denial about their marital issues, instead focusing on the other symptoms as the real problem. When couples enter treatment in Stage III, one of the first interventions is for the therapist to reduce emotional reactivity. This often requires the therapist to get an agreement from the couple to refrain from hostility in session and to direct their comments to the therapist instead of each other. Couples in this stage have a large amount of bitterness that has built up over time.
In order to process bitterness, the couple has to acknowledge fantasy solutions to the problem (such as death of spouse or divorce). The therapist encourages the person to stop daydreaming about ending the relationship as a way to escape reality and instead focus on real change with the spouse. If the partners agree to work on the relationship, bitterness is then explored. Guerin and his colleagues call this the “bitter bank,” in which a person stores up hostility towards the partner over wrongdoing and allows it to control him/her emotionally. Tracking bitterness is the next step, and it involves focusing on each partner’s emotional journey through the marriage, which actually creates more self-focus. But when couples cannot make these changes, and either one makes a move towards divorce, they have entered Stage IV.
Treating Stage IV For couples in Stage IV, there is such conflict and bitterness that divorce is on the horizon. Very often, in Stage IV, one spouse will want a divorce but the other does not. It must be noted, though, that some couples enter treatment with both wanting therapy to help minimize the emotional impact of divorce on their children. This type of intervention is unusual, as conflict usually prohibits this kind of cooperation. Sometimes couples who were thought to enter therapy in Stage III may well have been what Guerin et al. call “pseudo Stage III” clients. These couples go through the motions of Stage III therapy knowing full well they want out of the marriage but also want to say they have done all they could to save it. Therapy is a way
of minimizing guilt in these cases. In other cases, a person entering therapy as a pseudo Stage III client wants to hand over the care of the spouse to a therapist who can help the spouse through the upcoming divorce. The basic functions of Stage IV are to help the couple transition their relationship in such a way that children and extended family are damaged as little as possible. Parenting plans are often part of this therapy. In addition, helping a couple to realize that each played a role in the marriage’s demise is critical to help them move past the rigid perceptions of “villain and victim.” This enables them to move on with their lives without lingering bitterness.
Divorce therapy In a similar fashion to Guerin and his colleagues, researchers Douglas Sprenkle and Pilar Gonzalez-Doupe (1996), note that divorce therapy is a very important component of couples therapy that has been paid relatively little attention in the field of marital therapy. They presume this lack of attention to divorce therapy is related to the perception by therapists that divorce is a failed outcome of therapy. Conversely, the authors argue that this is not the case. The reality is that many couples get divorced in this country each year, and some of these divorces certainly could have been preventable if treatment was more successful. In some cases, divorce may be the best option for many Page 8
couples for many different reasons. Therapists who feel their work is over once the couple goes ahead with divorce and who continue to perceive divorce as a failed therapeutic outcome are missing out on a vitally important opportunity to assist one or both partners in emotional healing and transition beyond divorce into another phase of life. There has been quite a large amount of research on the effects of divorce on children, and typically, when a couple continues to seek therapy during or after a divorce, it is to get counseling for the children to deal with the divorce. Traditionally, researchers have paid very little
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attention to the effects of divorce on the couple themselves. Sprenkle and Gonzalez-Doupe outline the three stages of divorce therapy: 1. Therapy for pre-divorce decision-making. This stage of therapy has not quite reached the level of the decision to divorce. The therapist spends a good deal of time assessing the couple’s willingness to commit to treatment as well as the likelihood that their differences can be worked through. However, the couples have erratic behavior patterns and switch between commitment and threats to separate, which it is important for the therapist to manage effectively. In this phase, separation may occur, but can be time-limited and used as a tool to examine the ability of the couple to reunify. During separation, couples attend therapy weekly. 2. Therapy for divorce restructuring. This phase is a lot like mediation in that the therapist helps the couple negotiate issues about parenting, finances and various legal and emotional issues they face when divorcing. The spouse who did not really want the divorce often will seek counseling, but the spouse who chose to leave will be difficult to engage in therapy, if the person
participates at all. The therapist will typically dedicate a good deal of time to helping the couple’s children deal with the emotional issues related to divorce. 3. Therapy for post-divorce recovery and remarriage. This phase typically takes place after the issues of life that occur immediately after a divorce are somewhat resolved. The focus of this stage of therapy is on rebuilding of social relationships and moving on towards a new life stage. Very often, clients will participate in group therapy as part of this process. There is also an emphasis on continuing support for those who are single parents, with therapeutic interventions that focus on parenting. The other facet of treatment in this stage includes the development of rituals to mark the change in life stage, such as having a party to mark the anniversary of the divorce. In addition, the final phase of this stage of treatment would be the transition to remarriage. The typology varies to a certain degree from Guerin, et al., but Sprenkle and Gonzalez-Doupe’s Stage 3 is similar to Guerin and his colleagues’ Stage 1. Stage 2 in this model is similar to Guerin’s Stage 4.
Assessing marital quality At this point, we have examined several types of therapy, and noted that the assessment of marital conflict and satisfaction can be an important component of the therapeutic process. It is important to note there are several instruments therapists can use to determine the severity of dissatisfaction in a relationship. All of them can help a counselor evaluate a relationship, and most can be used pre- and postintervention for measuring change. The most popular tools are: ●● Marital Satisfaction Inventory, Revised, which is the most commonly used by therapists in working with couples. This is a multi-dimensional evaluation of the couples’ assessment of many areas of their relationship, including subscales measuring problemsolving, affective communication, sexual dissatisfaction, time spent together and disagreements about money. ●● Revised Dyadic Adjustment Scale. It is a general measure of relationship satisfaction and consists of 14 items that provides a total score and four sub-scores of dyadic consensus. These measure the degree to which couples agree on matters of importance to their relationship; affective expression, which
measures the degree of the demonstration of affection and sexual intimacy; dyadic satisfaction, which measures the degree to which couples are satisfied with their relationship; and dyadic cohesion, which measures the degree of closeness and shared activities experienced by couples. The overall scores range from 0-69, with higher scores indicating great relationship satisfaction. The instrument has high internal consistency and constructs validity. ●● Kansas Marital Satisfaction Scale. Developed by Schumm, et al. (1986), it is a general measure of relationship satisfaction that includes three Likert items that assess a spouse’s character. It is a widely used instrument for measuring marital satisfaction. Higher scores indicate greater marital satisfaction. Recognizing levels of conflict and areas of distress in the couple’s relationship can give a therapist several areas on which to focus treatment. But in addition to this assessment, several recent approaches have provided more focused forms of treatment with greater emphasis on theoretical orientations and evidenced-based practices.
John Gottman and the sound marital house model John Gottman’s 1999 book, “The Marriage Clinic,” introduced the model of the sound marital house. He notes that the two “necessary staples of marriages that work are 1) an overall level of positive affect, and 2) an ability to reduce negative affect during conflict resolution … to create lasting change … interventions needed to enhance the overall level of positive affect in both no-conflict and conflict by accepting one another’s influence,” (p. 105). The goals of receiving the intervention is to have the couple create a strong foundation of friendship, which is a longer-lasting relationship than just having feelings of attraction; increase positive exchanges, which enable a couple to increase their affection and love for one another; manage conflict; and develop shared meaning in a relationship, such as having shared dreams and values. It is important to note that the absence of conflict is not a goal. In reality, the expectation is that the couple will be able to create enough positive exchanges to buffer their relationship from harm when difficult subjects are discussed. The conflict can remain, but is handled in such a way that it does not do damage. Gottman also explored the types of communication that should not occur in relationship in order to increase positive exchanges and manage conflict appropriately. He notes that a “harsh start-up” is a discussion that is likely to not end very well, as it starts with negativism and sets the stage for defensiveness on the part of the person being verbally attacked.
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The person who engages in a harsh start-up is engaging in one or more of the “four horsemen of the apocalypse” in relationships: criticism, contempt, defensiveness and stonewalling. Criticism is an attack on someone’s personality. Contempt is more than just criticism; it is actual disdain for one’s partner. Defensiveness is a refusal to accept responsibility for one’s actions and to try to place the blame for the behavior on someone else. Stonewalling is literally just that: a person symbolically puts up a stone wall and refuses to engage in further discussion and may walk out of the room. The person who shuts down is feeling overwhelmed by negative emotions from the partner and feels no other option except to escape and cut off the discussion. Gottman recommends 12 sessions of therapy, which include: ●● Stage 1: Forming a therapeutic alliance and assessment. ○○ Sessions 1-4: Establishing rapport, assessment through oral history interview, battery of assessment instruments, review of assessment, outline of treatment goals (building friendship, reducing destructive conflict) and an overview of the sound martial house theory. ●● Stage 2: Implementation of the relationship education program. ○○ 5th session: Creating love maps, nurturing fondness, admiration and turning “toward” instead of turning “away.” ○○ 6th session: Positive and negative sentiment override, flooding, exercises for developing a break ritual, four destructive behaviors.
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○○ 7th session: Acceptable emotions, lectures on differentiating between anger and abuse, regulation of conflict and effective problem solving. ○○ 8th session: Repair attempts, exercises on softened start-up. ○○ 9th session: Accepting influence and the art of compromise and practicing skills.
○○ 10th session: Dreams within conflict, shared meanings and rituals of connection. ●● Stage 3: Fading/assisting in transition. ○○ 11th session: Relapse prevention, promotion of treatment gains. ○○ 12th session: Post assessment data gathering and referrals for further services if needed. Termination of therapeutic relationship.
Emotionally focused therapy (EFT) Emotionally focused therapy EFT is a popular therapeutic approach to working with couples that was developed by Sue Johnson and Les Greenberg (1988). The major goal of EFT is to change emotional interactions through a combination of systemic therapy and experiential/ humanistic therapy. There is a major emphasis in this therapy on affective emotion. In general, EFT works with troubled couples. It is generally a short-term therapy lasting from eight to 20 sessions. Johnson and Greenberg based the EFT approach in attachment theory, noting that many previous approaches to couples therapy lacked a theory and were only a group of techniques without a focus about why couples really behaved the way they did.
the key moments and processes that lead to dysfunction. I think in a very concrete way, it focuses the couple’s therapist on what matters. It gives you a compass. It tells you what matters; what to focus on in the session. It tells you where the couple needs to go next. As it seeps down through various levels, it translates into knowing what interventions to use” (p. 265).
They believed that most behavior that appears dysfunctional is really an expression of an emotional need that is not being met. Johnson and Greenberg had felt that other therapeutic approaches to couples therapy lacked this focus on the emotional aspects of a relationship, and they attempted to create this focus on emotion through the EFT approach. Greenberg noted, the fundamental premise behind EFT is that all human beings have a wired-in need for consistent, safe contact with responsive and caring others, i.e., an innate need for relational security. EFT, then, sees marital conflict and disharmony as dependent upon the degree to which marital partners’ basic needs for bonding and attachment are satisfied, (p. 20). In one interview, Johnson noted:
The nine stages of EFT are: 1. Delineation of conflict issues. 2. Identification of the interactive cycle. 3. Accessing unacknowledged feelings underlying partners’ interactional positions. 4. Reframing the problem in terms of partners’ underlying feelings and attachment needs. 5. Identification of disowned needs and aspects of the self, and integrating these into the relationship. 6. Promoting acceptance of the partner’s experience and being responsive to partner’s new behavior in the interaction. 7. Facilitating the expression of needs and wants, and creating emotional engagement. 8. Facilitating the emergence of new solutions to old issues and problems. 9. Consolidating the new positions the partners take with each other.
“I think applying John Bowlby’s attachment theory to adults and using it as a map for couples therapy is what I mean by ‘map.’ It gives you a direction for therapy. It helps you understand what is wrong. It helps you understand what doesn’t fit in this landscape, what is wrong in the landscape. It gives you a direction. It tells you what health is. It gives you a sense of key moments and key processes that lead to health, and
The goals of EFT are “to expand and re-organize key emotional responses – the music of the attachment dance; to create a shift in partners’ interactional positions and initiate new cycles of interaction; and to foster the creation of a secure bond between partners,” (www. iceeft.com).
Other treatment for couples Issues related to intimacy are really the underlying elements of most issues that couples face. Edward M. Waring (1988), a researcher who studied intimacy extensively throughout his career, states that intimacy is made up of eight elements: 1. Affection – the degree to which feelings of emotional closeness are expressed by the couple. 2. Expressiveness – the degree to which thoughts, beliefs, attitudes and feelings are communicated within the marriage. 3. Compatibility – the degree to which the couple is able to work and play together comfortably. 4. Cohesion – a commitment to the marriage. 5. Sexuality – the degree to which sexual needs are communicated and fulfilled. 6. Conflict resolution – the ease with which differences of opinion are resolved. 7. Autonomy – the couple’s degree of positive connectedness to family and friends. 8. Identity – the couple’s level of self-confidence and self-esteem, (p. 23). Waring also notes that intimacy is the cornerstone of relationships, stating, “The behavioral aspect of intimacy is predictability; the emotional aspect is a feeling of closeness; the cognitive aspect is understanding through self-disclosure; and the attitudinal aspect is commitment,” (p. 38-39).
Sherman, Oresky and Rountree (1991) note the differences in attitudes towards intimacy that are often a source of differences. Ten different types of differences are described here. 1. Symbiotic attunement. In this instance, a person who has emotional needs expects the partner to know what he or she needs. The person does not like having to tell the other person what those needs are and feels that the partner should understand these needs without them having to be explained. 2. Intensity. Issues around intensity can often involve a situation in which the listener does not pay attention because the sharer is either not expressive enough and the listener does not realize that the emotions expressed are significant. In other situations, the sharer is so overwhelming in the expression of feelings that the listener refuses to listen. 3. Being vs. doing. In general, women prefer to share, or what the authors term as “being,” in that they like to interact verbally, share feelings and express issues as a way or creating intimacy with their partners. Usually, men tend to prefer shared activities, including sex, as expressions of intimacy. Men tend to share less openly, and this often leads women to get upset and feel that men do not share. 4. Control. This can take many forms. At times, people may demand a great deal but give very little in return. A person may withhold sex, money, affection or information as ways of maintaining control over others. 5. Territoriality. This involves the issues of possessiveness over both the physical and emotional. It can include jealousy over emotional alignments. Furthermore, there are often issues with
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how tolerant each person can be of emotional closeness, and one partner can often feel intruded upon by the other. 6. Private language of intimacy. Everyone has his or her own pattern of preferred intimacy, which is typically learned in the family of origin. There are marked differences in these preferences. For some people, being together without sharing information is seen as closeness. For others, sitting near someone and not sharing is perceived as a non-intimate activity. Misunderstandings about these interpretations lead to conflicts. 7. Wanting to change the other. Relationships in which one or both parties are very dissatisfied with the other and then try to force the other person to change will lead to problems with intimacy. The authors posit that this push for change stems from a lack of respect for each other’s differences. 8. Being of several minds. The authors describe this intimacy issue as a situation in which a person may want intimacy and then rejects it when it occurs. The withdrawal is confusing to the person who offers the intimacy. Typically, the person who wants and yet fears intimacy is someone with a fear of abandonment or abuse in life. 9. Sexual intimacy. At times, there is sexual performance without an emotional connection, which does not build intimacy and leaves a partner feeling lonely and used. There are a great number of issues that can block sexual intimacy: guilt and shame about sex, underlying anger towards a partner, variances in sexual desire levels, refusal to participate in certain sexual behaviors or a history of abuse. Other problems can include fears of losing oneself or a loss of power. 10. Common blocks to intimacy. Fears of being dependent, projections on partners, the extreme need to always be right, being negative and critical – are all common behavior patterns that block intimacy. The approaches described by Sherman, Oresky and Roundtree are used by many couples therapists in treating relationship issues and contain a good deal of interventions that are drawn from the cognitive behavioral model. The authors recommend dealing with intimacy issues through the following steps: 1. Assign good intentions. This phase has client engage in reframing intentions and learn to ask for clarification of meanings of actions and words. 2. Teach and practice psychoactive listening. Couples are taught to fully pay attention to each other when their partner speaks to them. It is also important that both of them note that they heard the other. The therapist should remind the couple that in psychoactive listening, the point of listening is to hear, and agreement is not necessary.
3. Enjoin the partners to take an “I” position to bring about change. This technique involves having both persons take responsibility for themselves, their behavior and their change. An example cited by the authors is when a spouse says: “I feel upset when you come home late and don’t call,” rather than “You are mean and inconsiderate or you would be home on time.” 4. Reframe differences among the partners as positives. This technique involves reframing behaviors as the result of being different people with different personalities, rather than attributing behaviors to being mean or intending to do harm. 5. Label each person a “good-hearted teacher.” This approach has the therapist attribute behaviors that each partner finds offensive as stemming from a partner’s attempt to “teach” something to the partner. In other words, a man who is not sharing with his wife can be asked whether he is, by withholding sharing, trying to teach his wife to be more independent. 6. Explore gender expectations and resentments. The therapist explores with both partners their perceptions about gender roles. The therapist might ask the couple to complete sentences like, “As a man, I must ...” or “As a woman I must. ...” 7. Help them identify and spell out their feelings and beliefs about territoriality. The therapist discusses with the couple the issues about jealousy, about physical boundaries and taboo subjects. The increased awareness of these differences can help the couple reach compromises about these issues of territoriality. 8. Construct an intimacy genogram. The issues in each partner’s family of origin can be explored using a genogram, which charts each family member and their relationships to one another. Through the genogram, couples can explore the impact of their families of origin on their current relationships in relation to intimacy. 9. Construct a family floor plan. In this intervention, each partner draws out a map of how each of them uses physical space in the home and the rules that exist for the physical space. In addition, couples can do the same for the homes in which they grew up. There is also further questioning about closeness, distance and privacy. 10. Examine language and style in expression of emotions. This approach involves the examination of how each partner knows when the other is expressing something important; how they show important emotions to others; what did they like about emotional expression growing up; and what did they dislike about emotional expression in their families of origin. This helps the partners to increase their mutual understanding of differences as differences in behavior and not as a lack of caring.
Ethical issues in couples counseling There are several issues related to professional ethics that arise in couples therapy that do not occur in individual therapy. According to Gottlieb, Lasser and Simpson (2008), these ethical issues can be difficult to handle correctly. One important issue is that of confidentiality. Many therapists have found themselves caught in the situation of being asked to keep secrets for one or both persons in a couple. For example, a woman may reveal to the therapist that she is having an affair. Naturally, the woman wants to keep this hidden, but hiding such information from the woman’s partner is uncomfortable as well as potentially damaging to the therapeutic relationship of the therapist and the woman’s partner. One suggestion is for therapists to have couples sign clearly worded consents that indicate that all information brought to a therapist is to be shared with all parties, and no secrets can be kept. Unfortunately, this approach has the potential to stifle the sharing of information critical to working on problems in a relationship. Another issue that arises in conjoint therapy is record keeping. When a couple attends therapy together, therapists often keep one record. But when records are released, is it acceptable to release the joint record with only one person’s consent? This often becomes an issue when Psychology.EliteCME.com
couples later divorce, and especially in child custody cases. How does a therapist decide to release information that could harm one client and help the other? Nonetheless, the ability to keep a coherent record for couples really does require keeping a joint record. The authors suggest that keeping joint records is best for clinical practice, but that a therapist should refuse to release information without the consent of both parties, and only do this under court order. Gottlieb, Lasser and Simpson (2003) also noted that couples therapists also have to identify who the client is in couples therapy. Is it each individual, one individual or the dyad? This is very important to discern, because any intervention with a person will have an effect on the other person in the relationship. The competing needs of a couple can also present difficult ethical dilemmas for therapists. For example, a woman may be happier if she were no longer married to a depressed husband. It is possible, though, that the husband might develop worse depression if she were to leave the marriage. In whose interest should the therapist act? A couple may be better off divorced from their own perspectives, but what about the impact of divorce on their children? The authors note that legally, a therapist is not responsible for the other Page 11
people in their client’s family system, but how ethically responsible a therapist is to these other parties is not really always clear. Values are another ethical issue that surfaces in couples therapy. A common question that arises is: should a couple divorce or not? Is it better, as a whole, for society to have intact families, or should an individual’s personal happiness dictate whether a couple ends their relationship? This situation is addressed in the AAMFT Code of Ethics (2001) that clearly states in section 1.8: “Marriage and family therapists respect the rights of clients to make decisions and help them to understand the consequences of these decisions. Therapists clearly advise the clients that they have the responsibility to make decisions regarding relationships such as cohabitation, marriage, divorce, separation, reconciliation, custody and visitation.” It must be noted that the therapist’s own beliefs about personal happiness at any cost, or the belief that marriage is sacred and divorce is always bad, could color their work with clients. This was highlighted by the views of scholar and therapist Dr. William J. Doherty, who in addressing the 1999 Smart Marriages conference stated that he while did not want clients to stay in abusive or truly terrible marriages, he felt that martial counselors were too likely to encourage divorce when the persons involved were unfulfilled or just tired of a marriage. He blamed much of this on a push toward “individual fulfillment at any
cost” movements in the 1970s and the changing attitude in society toward marriage as a temporary, rather than lifelong relationship. He referred to this as “hyper-individualist” attitudes towards marriage. Doherty goes on to note that many therapists hear only one aspect of the above-mentioned code of ethics provision that states that decisions are up to the client. He noted that many therapists would never dream of telling a client they should stay married, as that is correctly perceived as being unethical because the therapist should not tell a client what to do. Yet many are guilty of telling clients that they should leave relationships in order to be happy and encourage this behavior. Both attitudes violate the stance of neutrality. Doherty’s main point is that therapists who do couples therapy should be careful not to undermine marriages that stand a chance of survival by jumping too quickly onto the bandwagon of individual fulfillment and personal happiness. He made many valid points in his address, but the movement towards the preservation of marriage continues to be highly debatable. Regardless of the feelings that a therapist may have towards his issue, it is helpful to examine the points that Doherty makes in his argument. His essay illuminates how challenging the job is for a therapist to try to advocate for both persons in a couple and still maintain neutrality, especially if one partner really wants a divorce and the other does not.
Same sex couples Most of the literature on couple’s issues and therapy deals with heterosexual couples. There has been rather limited literature on therapy with same sex couples. Interestingly, a recent comprehensive study indicated that the emotional processes in marriage are similar to heterosexual couples. While this study did not examine interventions with same sex couples, the authors did note some interesting differences between them and heterosexual couples. In general, gay and lesbian couples tend to handle disagreements in a more positive fashion, tend to be less controlling and are less likely to have their feelings hurt by a negative comment from their partner. However, when it comes to conflict repair, male gay couples differ from straight and lesbian couples. If the initiator of conflict in a gay relationship becomes too negative, his partner is not able to repair as effectively as lesbian or straight partners. “It is therefore possible that gay men could render more damage through negativity directed at a partner than lesbian women or heterosexual men or women. One inference from this data is that gay men need to be coached to be extra careful in expressing negative emotions in a relationship,” (Gottman, et al., 2003).
heterosexual culture, but it occurs much more frequently in gay and lesbian culture. The authors believe that this common acceptance of former lovers in the social network of a gay or lesbian couple is due to a traditional isolation of homosexual persons from their families of origin over their sexual orientation. Consequently, gay and lesbian persons have had to rely on friends to be a “family of choice” and are loathe to cut off someone as a friend even after they are no longer a couple due to the loss of social support. It is important for a couple’s therapist to understand this behavior as normal in gay and lesbian couples.
Another scholarly examination of gay and lesbian couples in therapy notes that these couples’ relationships are affected by homophobia in overall culture, the coming-out process and different expectations of social and family support than exist in heterosexual culture. The authors note that homophobia can lead many couples to act artificially distant in public for fear of violence and job discrimination. The act of coming out also needs to be understood as a critical process in the life of the gay or lesbian person, but that each person may choose to come out in different ways and at different times, and the differences in the coming out process can lead to conflict.
Counselors also need to be aware that lesbian couples also have conflicts surrounding female friendship. Where a woman in a heterosexual couple can confide in other women regularly, in lesbian couples, there can be high degrees of jealousy about a partner’s female friendship becoming sexual, particularly if the friend is also lesbian. This is similar to the tension that heterosexual couples would have if a woman became friends with a man. It is also important to note that in general, gay and lesbian couples often assign different meanings to monogamy and sex than do heterosexual couples. It is critical for the therapist to be non-judgmental and explore these meanings to see whether they are shared by each partner. The attitudes are only problematic if the couple does not share the same attitude (Bepko and Johnson, 2000).
Furthermore, a phenomenon often exists in the gay culture that gives a high level of acceptance to former lovers remaining friends after the romantic relationship has ended. This occasionally happens in
Furthermore, many gay and lesbian couples have a great deal of conflict over how “out” to be with their families of origin. One partner wants both families to accept the relationship totally and for the pair to hold nothing back as far as displaying affection around their families; the other prefers to downplay relationships out of respect for family members or fear of conflict with relatives who tolerate, but do not embrace them. This is not an issue with most heterosexual couples, and is a unique tension for gay and lesbian couples that counselors need to understand is a common issue of conflict.
Sex therapy Early sex therapy was developed by Masters and Johnson, (1966, 1970), as well as Helen Singer Kaplan (1974). These researchers helped to identify different types of sexual dysfunctions as well as appropriate clinical treatment of these dysfunctions. These scientistpractitioners emphasized various techniques to overcome such issues as premature ejaculation, erectile dysfunction and low sexual desire. However, these early approaches apparently did not treat psychological
issues that could be sustaining or creating these problems within the couple’s relationship. There has been a curious disconnect between the fields of sex therapy and couples therapy, which would seem to be two areas that would carry over to each other. Yet this has not traditionally been the case. Fragmentation is noted in both professional identity and theory. At
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the professional level, such national organizations as the American Association for Marriage and Family Therapy (AAMFT) and the American Counseling Association (ACA) have required little in the way of education or professional development in the field of sex therapy or human sexuality, which ignores a large area of problems for many couples. Likewise, the American Association of Sex Educators, Counselors and Therapists (AASECT) does not emphasize developing skills in couples therapy as part of the training to be a sex therapist, which ignores much of the relationship component of sexual problems. This disconnect in professional organizations should not be too surprising given that the development of theory in the field of sex therapy tended to emphasize focusing on sexual problems without attention being paid to couple’s other problems. However, some recent developments have led towards a more cohesive approach to combining family systems theory with sexual interventions. David Schnarch, a prominent therapist and scholar, noted in his wellknown 1991 book, “Constructing the Sexual Crucible,” that the emphasis of sex therapy needs to be more on the intimacy issues between couples than on actual physiological techniques of treating sexual dysfunction. Schnarch noted, “If you have a sex problem, you have to get your relationship to a state that supports good sexual functioning,” (2002). Schnarch’s work is based in Bowenian therapy, and encourages the development of differentiation and autonomy as the key to interpersonal happiness. Differentiation is the balance of the need for individuality and togetherness (Schnarch, 1991). The lack of differentiation in a person is what leads to relationship issues and sexual dysfunction. His approach is best summarized as “poorly differentiated persons experience an anxietydriven pressure for togetherness, thus losing autonomy, and in turn placing responsibility for adequate functioning in the hands of the other person in a relationship,” (Goldenberg and Goldenberg, p. 338).
Another recent approach to sex therapy, the intersystems approach, attempts to maintain the focus on not only the systemic factors surrounding a couple, but also to provide more direct treatment of sexual dysfunction than Schnarch’s approach. The approach assesses the couple at the individual and dyadic levels. The levels of assessment are: ●● Individual – The individual is assessed for cognitive distortions about sex, through assessing the person’s beliefs and attitudes towards sex. ●● Intergenerational – Both people are questioned about sexual history, such as what they learned about sex in their family of origin, messages they received about sex from families and as episodes of trauma. ●● Interactional – This portion assesses how couples behave sexually with one another, including typical patterns and communication surrounding sex. This multidimensional approach provides a broader perspective of how sexual dysfunction may develop, and helps the therapist focus on the underlying relational aspects of sexual dysfunction, as well as how sexual dysfunction can lead to relationship difficulties through feelings of blame and anger (Hertlein and Weeks, 2009). It is similar to Schnarch’s approach in that it emphasizes relationship issues as key to achieving sexual harmony, but it does focus more on actual techniques to overcome sexual dysfunction. In addition, intersystems theory does not place quite as much an emphasis on differentiation and autonomy as Schnarch’s. In summary, recent advances in sex therapy are showing a greater integration of couples therapy and sex therapy than was present in past decades.
Stepfamilies Stepfamilies present a unique challenge in couples therapy. According to White and Booth, (1996), stepfamilies with children are twice as likely to be divorced as families without children. Stepfamily couples were also much more likely to report unhappiness in their marriages and to say that they would not marry again, compared with couples without children. The stepfamily will have marital issues that are related to the children in a stepfamily, usually not the same types of issues that couples with only their own children have in a relationship. Stepfamilies have conflicts that non-stepfamilies will not face, such as visitation schedules, tension between the children’s two households, and arguments about rules at one house versus another. Mark Fine and Lawrence Kurdek (1995), two researchers who have extensively examined divorce issues and stepfamilies, did find a strong correlation between the quality of the stepparent and child relationships and the quality of the marital relationship. This relates to one of the key elements of successful stepfamily marriages: Agreement on the expectations of the stepparent roles between the couple has the greatest impact on preventing divorce. Overall, it is not the intensity of a child’s behavior that has the greatest impact on marital happiness, but rather an agreement over parenting that predicts conflict and divorce (Pasley, Koch and Ihinger-Tallman, 1993). Papernow is one of the few researchers who have focused on stepfamilies. Papernow (1993) noted that stepfamilies go through seven stages of development: 1. Fantasy: All members are naïve and believe that everything will work out without conflict. 2. Immersion: Members struggle with the unreality of the fantasy and developing the ability to state needs and wants. 3. Awareness: Each member becomes aware of others’ needs and feelings. 4. Mobilization: Confronting differences about each person’s belief about the family.
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5. Action: Reorganizing the family. Developing new rules and rituals. 6. Contact: Boundaries and roles are more clearly defined by the family. 7. Resolution: Family is secure in its identity. Only a few studies have examined marital relationships and stepfamily issues. It was found that couples in blended families have several different unique stressors that are not present in couples who do not have stepchildren. These issues include: ●● Lack of alone time to develop as a couple before parenting. ●● Arguments over the role of stepparents. In contrast, non-blended families have fairly well prescribed social roles and expectations, like father and mother. ●● The adjustment of a couple to each other may be quick; however, children do not always have the ability to accept shifts in parental and stepparent roles, which leads to conflict. A couple may feel happy with one another but be distressed and have conflict over their children’s failure to adjust. ●● The family lifecycle stages can be out of sync and at odds. For example, just as a couple is forming a new family and desiring time to build a family unit, there might also be children in adolescence who want to be independent, which makes the normal stages of developmental progress difficult to achieve. ●● The pre-existing parent-child bond predates the marital bond and may be stronger than the marital bond. Single parents and their children often become very close, and this can make accepting a stepparent very difficult. ●● Stepchildren can sometimes attempt to undermine the marriage. There is no integrative model of therapy yet for stepfamily marital therapy. Nor are there any empirical evaluations of marital therapy with stepfamilies that could be located. Nevertheless, it is important for couples therapists using any form of marital therapy to be aware of the unique issues inherent to stepfamilies. Page 13
Domestic violence Therapy with violent couples is a very controversial topic. As noted by family researchers Eric McCollum and Sandra Stith, (2008), “Women are asked to be open and honest about their complaints and grievances in a conjoint session, sometimes with a false sense of security arising from the fact that the man has agreed to treatment – only to face retaliatory violence after the session for embarrassing or challenging him.” They argue that conjoint treatment is better because most violent couples stay together ultimately, and traditional batterer’s intervention programs focus only on the man’s anger and violence but offer no venue for the couple to deal with their marriage. However, in cases of very severe abuse resulting in severe physical harm, couples therapy may not be appropriate. Family therapist Dr. Virginia Goldner has worked extensively with couples with domestic violence issues. In her 1998 article on couples therapy and domestic violence, she outlines an approach to conjoint therapy with couples with whom violence is the presenting issue. She says that the traditional stance against conjoint therapy that “placing a violent man and his victim in close quarters and inviting them to address contentious issues in their relationship has the potential to re-victimize the woman physically and psychologically and to provide the offender with a platform for self-justification,” is somewhat correct ( Goldner, 1998, p. 1). But she also notes that there is no evidence that men-only batterer’s treatment has been shown to be more effective than couples therapy for domestic violence, and many couples do want couples therapy. Furthermore, as many of these couples do not separate during the course of treatment, how is it that separate treatment can promote safety? She also notes that she is emphatic that the violence is in no way caused by the relationship and is a real part of the relationship dynamic. She emphasizes that treatment must be initialized based on a combination of different types of abusers and victims, and for many couples, conjoint therapy is appropriate for dealing with domestic violence. She notes that this type of work is difficult, and the therapist must be careful not to allow “the perpetrator to misuse psychological insight to avoid taking responsibility for his actions,” (Goldner, 1998, p. 4).
It is also critically important to distinguish between the violence as one issue and relationship problems as another issue. Otherwise, the batterer can start using relationship problems as an excuse to resort to violence out of frustration. Goldner outlines a model that begins with a therapeutic paradox. Traditionally, before couples therapy could take place with these people, the therapy community asked “couples to resolve the presenting problem of the man’s violence and the woman’s lack of safety before getting the therapy they need to accomplish this goal,“ (Goldner, 1998, p. 7). Thus, the first few sessions of therapy are described as a consultation and not as therapy, to convey to the couple how they must accomplish the goals of abstaining from violence and creating safety. Consequently, “we take the position of officially withholding therapy unless the violence stops, while de facto providing therapeutic input to make sure that the violence stops,” (p. 7). During this time, assessment occurs and suitability for treatment is determined. The two major goals of therapy are to have men take responsibility for their actions and for women to commit to putting their safety first ahead of anything else. For the men, the therapist is careful to acknowledge the man’s experiences, but must emphasize it is his choice to act out. Goldner notes that the therapist can respond to a man saying he “lost it” by asking, “what made you chose to lose it?” For women, it is reminding them that regardless of whatever else exists in the relationship, “personal safety must be their primary concern,” (Goldner, 1998, p.12). To date, there have been no empirical studies conducted on Goldner’s approach, but her approach and others similar to it have become more acceptable and are used with some frequency. Nevertheless, critics such as Rivett (2001) are concerned with the treatment of domestic violence by solo-practitioner therapists who do not have the community resources to ensure women’s safety in these scenarios. He emphasizes that there must be a systemic effort between law enforcement and protective services agencies to ensure the safety of women and children if they are in the home.
Substance abuse Researchers and practitioners Steinglass, Bennett, Walin and Reese (1991) noted that there is a good deal of debate as to how frequently the use of alcohol contributes to severe marital discord. Some research indicates that alcohol usage is linked to spousal abuse and higher divorce rates. However, Steinglass and his colleagues argue that it is impossible to prove that alcohol causes these issues, and that many more families manage to cope with alcoholism:
“The family disease approach, the best known model, views alcoholism and other drug abuse as illnesses of the family, suffered not only by the substance abuser, but also by family members, who are seen as codependent. Treatment consists of encouraging the substance-abusing patient and family members to address their respective disease processes individually; formal family treatment is not the emphasis.”
“By making do, we mean that a substantial group of families with alcoholic members seem to remain intact over their life span (no divorce, continue to live with the alcoholic member), are economically viable, avoid the more dramatic and devastating types of family violence, and suffer no higher levels of anxiety and depression than the general population. … They seem to know that they are hurting, but it feels more like a dull ache than a sharp, localized pain,” (p. 23).
“The family systems approach, the second widely used model, applies the principles of general systems theory to families, paying particular attention to the ways in which family interactions become organized around alcohol or drug use and maintain a dynamic balance between substance use and family functioning. Family therapy based on this model seeks to understand the role of substance use in the functioning of the family system, with the goal of modifying family dynamics and interactions to eliminate the family’s need for the substance-abusing patient to drink or use drugs.”
They go on to note that these conclusions are based on several surveys in which many respondents say that alcoholism has a negative impact on their families, but then are not able to say in which specific ways that the alcohol usage actually affects them. As Steinglass et al., note, “over time, alcoholism may sap the family’s energy and resources, but in the short run, it may not be perceived by the family as a significant threat to its survival,” (p. 24). Substance abuse does present often as an issue in couples counseling. There are several key theoretical approaches to working with couples counseling in which substance abuse is involved, as noted by FalsStewart, O’Farrell, Birchler, (2004):
A third set of models, a cluster of behavioral approaches, assumes that family interactions reinforce alcohol- and drug-using behavior. Therapy attempts to break this deleterious reinforcement and instead foster behaviors conducive to abstinence,” (p. 31). Steinglass and his colleagues utilize a family systems approach. The typical course of therapy involves: Stage I: Diagnosing alcoholism and labeling it a family problem. This phase involves assessment of the level of substance abuse, the family interactional patterns and whether or not a family is committed to treatment.
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Stage II: Removing alcohol from the family system. Abstinence is emphasized as a key factor in the progression of treatment. The therapist acknowledges that the path to recovery may involve some lapses in sobriety, but the alcoholic cannot be allowed to drink without the issue being confronted. Stage III: The emotional desert. As the typical alcoholic family has been organized around the alcoholic’s drinking, the family may have a difficult time changing behaviors that involved alcohol. Most aspects of interaction have modified in response to the alcoholic’s drinking. As a result, many times a family does not rejoice over the cessation of drinking, but instead finds themselves at loose ends, unsure of where to go next. Stage IV: Family restabilization versus family reorganization: After a period in the emotional desert, families move into the next phase in which resolution is reached. Very often, couples and families fall into a pattern in which the alcoholic may not drink, but the patterns remain the same. Sometimes in this phase, couples reach a crisis point, after which there is a major change in family patterns. Another approach that draws from the behavioral treatment approach is behavioral couples therapy (BCT). This frequently used approach has three major components: Stop the drug or alcohol user from using substances; enlist the family to provide support to the addict/alcoholic; and stop the patterns of behavior that have enabled this to occur over time. This approach requires the processing of a good deal of information and is therefore not an ideal approach for those who have moderate to severe cognitive deficits. In addition, it is most effective
when only one person has alcohol or drug problems. Couples are seen 15-20 times over six months of treatment. In this approach, the typical behavioral techniques are utilized. Couples make abstinence contracts in which one or both agree to abstain from using alcohol and/or drugs. Partners agree to have daily check-ins regarding the use of substances. The other partner will in turn thank them for not using. The non-using partner records these activities daily as a way of being accountable to the therapist for following the treatment plan. Other activities include a “caring day” in which each partner plans pleasant surprises for the other, planned family activities and practicing communication skills taught by the therapist to the couple. Couples are asked not to discuss past substance abuse or concerns about sobriety in the future when they are not in sessions with the therapists. The authors have found that such talk often ends in conflict and often ends in relapse. There is also a good deal of work that is done with the non-abusing spouse to address the relapse/recovery cycle and for them to not view a relapse as a total betrayal of trust, but to normalize it as part of this process. There is a strong emphasis on couples committing to completing their homework assignments in between sessions and addressing noncompliance as it occurs. Couples therapy combined with alcohol treatment may be particularly beneficial for the female alcoholic. A recent study (Fals-Stewart, Birchler and Kelley, 2006) compared females in treatment using this approach to women who received only individual counseling and found that women who received couples therapy demonstrated significant increases in relationship satisfaction and significant reductions in drinking.
Research A recent meta-analytic study indicated that a couple receiving therapy was 84 percent better off than couples who had none. Overall, couples therapy is effective, regardless of the specific model used and what the presenting issue might be (Shadish and Baldwin, 2002). Davis and Piercy (2007) examined three models of couples therapy in search of common factors, which are described as those factors that were helpful to couples being treated with three different therapy models: EFT, cognitive behavioral therapy and internal family systems theory. Common factors found across models of marital therapy that seemed to be linked to change were: ●● The therapist having a theoretical framework to guide treatment towards goals. ●● The therapist’s success in conveying to the couple what he/she believed the problem to be, based upon a specific model being used. ●● The therapist’s ability to raise awareness of the cycle. This last concept involves three phases as well: ○○ Slowing down the process by giving each person time to talk in a structured way so that each can express him/herself openly. ○○ Helping both people to be aware of their actions and to be more objective about their partner’s intentions and motives. ○○ Getting both partners to take responsibility for their actions. ●● Other common factors included the use of metaphors, explaining the influence of the family of origin on current-day problems
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and issues, reframing of partner intentions; educating clients to regulate their affective emotions; and encouragement of changing behaviors. While there are common factors to many approaches to couples therapy, there is some debate over which models are the most effective. In one study, EFT and behavioral therapy appear to be the most effective, (Johnson and Lebow, 2000). Gurman and Fraenkel (2002) reported that overall support was strongest for EFT and for insight-oriented therapy. Wesley and Waring (1996) found that overall, EFT, insight-oriented, cognitive therapy and behavioral therapy all appeared to be effective, and no one model was superior to the other. It does appear that in three of these studies, EFT is found to be the most effective, and in the Wesley and Waring study, at least as effective as other modalities. In summary, the growth of couples therapy has come a long way in less than 100 years. From its roots in advice by clergy and lay persons, to individual psychoanalytic sessions that eventually became conjoint sessions, and then on to an explosion of theory-based efforts in the 1960s and 1970s, couples therapy today is now growing into a an evidence-based practice with a strong theoretical underpinnings. Future challenges for couples therapy will include keeping up with the changing definition of what a “couple” really is, and to work with diverse partners beyond middle- and upper-class Caucasian, heterosexual married couples.
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References 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22.
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AAMFT (2001) AAMFT Code of Ethics. Retrieved from http://www.aamft.org/resources/LRM_Plan/ Ethics/ethicscode2001.asp Adler-Baeder, F., Higginbotham, B., & Lamke, L. (2004). Putting empirical knowledge to work: Linking research and programming on marital quality. Family Relations, 53, 537-546. Andersen, T. (1987). The reflecting team: Dialogue and meta-dialogue in clinical work. Family Process, 26, 415-428. Bepko, C., & Johnson, T. (2000). Gay and lesbian couples in therapy: perspectives for the contemporary family therapist. Journal of Marital and Family Therapy, 4, 409-419. Boszormenyi-Nagy, I., & Ulrich, D. N. (1981). Contextual family therapy. In A. S. Gurman & D.P. Kniskern (Eds.), Handbook of family therapy (pp. 159-186). New York: Bruner/Mazel. Bradbury, T. N., Fincham, F. D., & Beach, S. R. (2000). Research on the nature and determinants of marital satisfaction: A decade in review. Journal of Marriage the Family, 62, 964-980. Bronfenbrenner, U. (1979). The Ecology of Human Development: Experiments by Nature and Design. Cambridge, MA: Harvard University Press. Braverman, S. (1993). A Systems Therapist Looks at Transference: Widening the Lens. Journal of American Academy of Psychoanalysts and Dynamic Psychiatry, 21, 327-337. Bubolz, M.M. & Sontag, M.S. (1993). Human ecology theory. In P.G. Boss, W.J. Doherty, R. LaRossa, W.R. Schumm, & S.K. Steinmetz (Eds.), Sourcebook of family theories and methods: A contextual approach (pp. 419-448). New York: Plenum Press. Carter, B. & McGoldrick, M., (1988). The Changing Family Life Cycle: A framework for family therapy . 2nd Ed. Boston: Allyn & Bacon. Davis, S. D., & Piercy, F.P., (2007). What clients of couples therapy model developers and their former students say about change. Part I. Model-dependent common factors across three models. Journal of Marital & Family Therapy, 33, 318-343. de Shazer, S., & Berg, I. K. (1992). Doing therapy: A post-structural re-vision. Journal of Marital and Family Therapy , 18, 71–81. Doherty, W.J. (1999, July). How therapy can be hazardous to your marital health. Presentation given at Smart Marriages Conference. Retrieved from www.smartmarriages.com/ hazardous.html. Doss, B.D., Simpson, L.E., Christensen, A. (2004). Why do couples seek marital therapy? Professional Psychology: Research and Practice, 35 (6), 608-614. Fairbairn, W. R. D. (1952). Psychological Studies of the Personality. London: Routledge & Kegan Paul. Fals-Stewart, M., Birchler, G.R., & Kelley, M. L. (2006). Learning sobriety together. A randomized clinical trial examining behavioral couples therapy with alcoholic female patients. Journal of Consulting and Clinical Psychology, 74, 579-591. Fine, M. A., & Kurdek, L. A. (1995). The nature and assessment of cognitions in stepfamilies. In D. Huntley (Ed.), Understanding stepfamilies: Implications for assessment and treatment (pp. 113-125). Alexandria, VA: American Counseling Association. Freedman, J. and Combs, G. (2000) Narrative Therapy with Couples. In Comparative Treatments for Relationship Dysfunction. F.M. Datillo & L.J. Bevilacqua (Eds.). pp. 342-361. NewYork: Springer Publishing Company, Inc. Friedman, S. (1993). The new language of change. New York: Guilford. Goldner, V. (1998). The treatment of violence and victimization in intimate relationships. Family Process, 37, 263-286. Gottman, J. M. (1999). The marriage clinic. New York: W.W. Norton and Company. Gottman, J.M., Levenson, R.W., Gross, J., Fredrickson, B., McCoy, K., Rosentahl, L., Ruel, A., and Yoshimoto, D., (2003). Correlates of Gay and Lesbian Couples’ Relationship Satisfaction and Relationship Dissolution, Journal of Homosexuality, 45(1), 23-43. Gottlieb, M. C., Lasser, J. & Simpson, G. (2008). Legal and Ethical Issues in Couple Therapy. In A. Gurman (4th Ed.), Clinical Handbook of Couple Therapy (pp. 698-717). New York: Guilford. Gundlach, R.H., Kremer, M., Lenz, R., & Royce, J.R. (1971). The marriage contract. Family Process 10, 311-326. Gurman, A.S., & Fraenkel, P. (2002). The history of couple therapy: A millennial review. Family Process. Summer. Gurman, A.S., & Kniskern, D. (1981). Handbook of family therapy. New York: Bruner/Mazel. Gurman, A.S., & Kniskern, D. (1991). Handbook of family therapy. Volume II. New York: Bruner/ Mazel. Goldenberg, H., & Goldenberg, I., (2008). Family Therapy: an overview, 7th Ed. Belmont, CA. Thomson Brooks Cole. Gottman, J.M., Levenson, R.W., Gross, J., Fredrickson, B.L., McCoy, K., Rosenthal, L., Ruef, A., Yoshimoto, D. (2003). Correlates of gay and lesbian couples’ relationship satisfaction and relationship dissolution. Journal of Homosexuality, 45, 23-43. Guerin, P.J., Fay, L.F., Burden, S.L. Kautto, J.G, (1987). The evaluation and treatment of marital conflict. New York: Basic Books. Haley, J. (1963). Marriage Therapy. Archives of General Psychiatry, 8, 213-234. Halford, W. K., Markman, H. J., Kline, G. H., & Stanley, S. M. (2003). Best practice in couple relationship education. Journal of Marital and Family Therapy,29, 385–406. Hawkins, A. J., Blanchard, V. L., Baldwin, S.A, Fawcett, E.B., (2008). Does marriage and relationship education work? A meta-analytic study. Journal of Consulting and Clinical Psychology, 76, 723-734.
41. Hertlein, K.M., & Weeks, G.R., (2009) Toward a new paradigm in sex therapy, Journal of Family Psychotherapy, 20, 112-128. 42. Hill, R. (1949). Families under stress. New York: Harper & Brothers. 43. Hill, R. (1958). Generic features of families under stress. Social Casework, 39, 139-150. 44. Johnson, S. & Greenberg, L. (1988). Curative principles in marital therapy. Family Psychology, 2, 28-32. 45. Johnson, C. A., Stanley, S. M., Glenn, N. D., Amato, P. R., Nock, S. L., Markman, H. J., et al. (2002). Marriage in Oklahoma: 2001 baseline statewide survey on marriage and divorce (S02096 OKDHS). Oklahoma City: Oklahoma Department of Human Services. 46. Johnson, S., & Lebow, J. (2000). The coming of age of couple therapy: a decade review. Journal of Marital and Family Therapy, 26, 22-38. 47. Kaplan, H. S. (1974). The New Sex Therapy: Active Treatment Of Sexual Dysfunctions, New York, Brunner/Mazel. 48. Karney, B. R. & Bradbury, T. N. (1995) The longitudinal course of marital quality and stability: A review of theory, method, and research. Psychological Bulletin, 118, 3-34. 49. Klein, D. M., & White, J. M. (1996). Family theories: An introduction. Thousand Oaks, CA: Sage Publications. 50. Larson, J. H., & Holman, T. B. (1994). Premarital predictors of marital quality and stability. Family Relations, 43, 228-237. 51. Lebow, J. & Gurman, A. (1998). Family systems and family psychology. In E. Walker (Ed.), Comprehensive Clinical Psychology Volume One: Foundations of Clinical Psychology. New York: Pergamon. 52. Lederer, W. J., & Jackson, D. (1968). The mirages of marriage. New York: W. W. Norton. 53. Lerner, R. M. (1991). Changing organism-context relations as the basic process of development: A developmental contextual perspective. Developmental Psychology, 27, 27-32. 54. Masters, W.H, & Johnson, V.E. (1966). Human Sexual Response. Toronto; New York: Bantam Books. 55. Masters, W.H., & Johnson, V.E. (1970). Human Sexual Inadequacy. Toronto; New York: Bantam Books. 56. McCollum, E. E., & Stith, S. M. (2008). Couples Treatment for IPV: A review of outcome research literature and current clinical practices. Violence and Victims, 23, 187-201. 57. Mittelman, B. (1948). The concurrent analysis of married couples, The Psychoanalytic Quarterly, 17, 182-97. 58. Nichols, W. (1988). Marital therapy: an integrative approach. New York: Guilford. 59. Nichols, M.P., Schwartz, R.C. Family therapy: Concepts and methods (4th ed.). Boston: Allyn and Bacon. 60. Oberndorf, C.P. (1934). Folie a deux. International Journal of Psychoanalysis 15, 14-24. 61. Papernow, P. (1993). Becoming a stepfamily: Patterns of development in remarried families. San Francisco: Jossey-Bass. 62. Pasley, K., Koch, M., & Ihinger-Tallman, M. (1993). Problems in remarriage: An exploratory study of intact and terminated remarriages. Journal of Divorce and Remarriage, 20(1/2), 63-83. 63. Piercy, F.P., Sprenkle, D.H., Wetchler, J.L., (1996). Family therapy sourcebook, 2nd ed. New York: Guilford. 64. Rivett (2001). Working systemically with family violence. Controversy, context and accountability. Journal of Family Therapy, 23, 378-404. 65. Satir, V. (1988). The new peoplemaking. Palo Alto, CA: Science and Behavior Books. 66. Schmaling, K.B., Fruzzetti, A.E., Jacobson, N.S. (1989). Marital problems. K. Hawton, P.M., Salkovskis, J. Kirk, & D.M. Clark (Eds.), In Cognitive behaviour therapy for psychiatric problems (339-369). New York: Oxford University Press. 67. Schnarch, D. (1991). Constructing the Sexual Crucible: An Integration of Sexual and Marital Therapy. New York: W. W. Norton. 68. Schnarch, D. (2002). Resurrecting Sex: Resolving Sexual Problems and Rejuvenating Your Relationship. New York: HarperCollins. 69. Shadish, W.R., & Baldwin, S. A. (2003). Meta-analysis of MFT interventions. Journal of Marital and Family Therapy, 29, 547-570. 70. Sherman, R., Oresky, P., & Rountree, Y. (1991). Solving problems in couples and family therapy. New York: Bruner/Mazel. 71. Sprenkle, DH, & Gonzalez-Doupe, P. (1996). Divorce therapy. In F.Piercy, D.H. Sprenkle, J.L. Wetchler, and Associates (Eds.), Family therapy sourcebook (2nd ed). (181-219). 72. Steinglass, P., Bennett, L.A., Wolin, S.J., Reiss, D. 1987). The Alcoholic Family. New York: Basic Books. 73. Thomas, J. (2009, February 19). Interview with Dr. Sue Johnson. Retrieved January 2, 2010 from www. jamft.org. 74. Waring, E.M. (1988). Enhancing marital intimacy through facilitating cognitive self-disclosure. New York: Brunner/Mazel. 75. Wesley, S., & Waring, E.M. (1996). A critical review of marital therapy outcome research. The Canadian Journal of Psychiatry / La Revue canadienne de psychiatrie, 41, 421-428. 76. Whitaker, C., & Keith, D. (1981). Symbolic-experiential family therapy. In A. S. Gurman & D.P. Kniskern (Eds.), Handbook of family therapy (pp. 187-225). New York: Brunner/Mazel. 77. White, M., (1995). Re-authoring Lives: Interviews and Essays, Adelaide, Dulwich. 78. Zimmerman, T. S., Prest, L. A., & Wetzel, B. E. (1997). Solution-focused couples therapy groups: An empirical study. [Special Issue] Journal of Family Therapy, 19, 125-144.
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COUPLES COUNSELING Final Examination Questions
Choose True or False for questions 1 through 5 and mark them on the answer sheet found on page 85 or complete your test online at Psychology.EliteCME.com. 1. EFT stands for ____________. a. Emotionally focused therapy. b. Efficient family therapy. c. Essential focused therapy. d. Effective functional therapy. 2. Which model of therapy is often spontaneous and even can appear irrational in its approach to a problem? a. Communications model. b. Psychodynamic model. c. Intergenerational therapy. d. Experiential therapy. 3. The family life cycle approach theorizes that all families pass through predictable life stages, a classification table lists _______. a. Four stages of the family life cycle. b. Five stages of the family life cycle. c. Six stages of the family life cycle. d. Seven stages of the family life cycle.
4. Reuben Hill was the originator of “family stress theory, ” the basic component of his model was the ____________. a. “ABCD model.” b. “ABCX model.” c. “ABCY model.” d. “ABCZ model.” 5. Steinglass uses a family system approach to substance abuse. The typical course of therapy involves how many stages? a. 6. b. 4. c. 3. d. 7.
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Elderly Mental Health: Depression and Dementia
Chapter 2:
7 CE Hours By: Leah Kulakowski, LMFT with Wade T. Lijewski, Ph.D. and Kathryn Brohl, MA, LMFT
Learning objectives This workshop is designed to help you: Describe the most common types of mental health conditions and issues related to the diagnosis of mental illness in the elderly. Analyze the different forms and elements related to dementia / neurocognitive disorders. Assess the psychosocial factors that affect the elderly, such as living arrangements and cultural influences.
Describe the influence of mental illness in the elderly on both the afflicted person and the caregiver, such as depression, and different prevention strategies. Facilitate different treatments of mental illness in the elderly and prevention, both through therapy and medications. Analyze issues regarding the different services available to assist the elderly mentally ill.
Elder mental health – Case examples Lillian is an 84-year-old widow who lives with her married daughter. She is often unable to sleep and often stays awake at night with racing thoughts about her future, the health of her daughter, fears of moving to a nursing home and money. She frequently jokes about these racing thoughts with her friends, and knows they are not logical. However, she finds herself unable to control them. On occasion, she is frozen by panic during the day as well. Lillian is somewhat ashamed of these self-termed “silly thoughts,” and she often relies on prayer to stop them. However, they are becoming more and more difficult for her to control. During her last panic attack, she was sure she was having a heart attack and called 911. She is reluctant to leave the house for fear of having another panic attack in public and being embarrassed. Margaret is a 69-year-old married woman who always amazed friends with her zeal for life. She traveled extensively and was active in a number of social groups and organizations. Nine months ago, Margaret fell and broke her pelvis. While recuperating in a nursing home, she and her husband made the decision to move in with their son and his wife following her release. But Margaret feels she cannot get back into her former pace even though she feels fine physically. For the last two months, she’s lost her appetite, sleeps excessively and has refused to meet friends for lunch or to attend her social groups. Although she is not sure why, she feels like “giving up” and dying. Her daughter-in-law is very concerned and wants Margaret to see a psychiatrist as she feels her mother-in-law is depressed. Embarrassed at the prospect of receiving psychiatric intervention, Margaret refuses and her husband agrees, both saying that psychiatrists are for crazy or weak people. William is a 73-year-old married man who is often confused about his daily activities. He is having trouble remembering how to proceed with some tasks because he loses track of the sequencing of events. A retired carpenter, he now has problems remembering how to complete simple household repairs. In addition, he cannot always remember the names of people he frequently sees. His wife is very worried and urges him to see a doctor for a physical examination, but William is terrified he will be diagnosed with Alzheimer’s disease. His wife has also noticed that his decline began three months ago and has been very rapid. She also knows that William began taking sleeping pills around that time as well, but is doubtful that a sleep aid could lead to his current daytime problems.
The above cases examples illustrate mental health issues typical to the elderly. The most commonly diagnosed forms of mental illness in the elderly include depression, bipolar disorder, anxiety and nonAlzheimer’s dementia. In the previous examples it appears that: ●● Lillian is suffering with anxiety. ●● Margaret is probably struggling with depression. ●● William may be either developing non-Alzheimer’s dementia, or suffering from severe side effects from taking medication. While not uncommon, these examples are not normal, and need to be addressed and treated. Yet, many elderly people grew up during an era when mental health intervention was unacceptable. Consequently, persuading an elderly person to seek and accept psychotherapy and/or medication intervention is often very difficult. The elder population is growing in large numbers in the United States, mainly due to aging Baby Boomers. Dr. Dipal Jeste, M.D., professor of psychiatry and neuroscience at the University of California, San Diego, notes that this population, born between 1946 and 1964, will turn 65 in 2011, resulting in 69 million persons over the age of 65. He also notes that there will be an estimated 15 million mentally ill senior citizens by 2030, compared to only 4 million in 1970 (Jeste, et al, 1999). The numbers of persons 65 and older will be unprecedented in our cultural history in the United States. Part of the reason for the growing number of elderly persons with a mental illness is that so many more people are living much longer, due to innovations in prevention and health care. Consequently, for the first time in U.S. history, persons over 65 will soon outnumber those aged 30-44. Therefore, social services communities will be largely unprepared to handle large numbers of elderly persons with mental illness. The previous lack of large numbers of elderly persons with mental illness has also left researchers with few studies that are comprehensive enough to establish “best practices” for treating mental illness in this population (Jeste, Alexopolous, Bartels, et al., 1999). Alzheimer’s disease has received a good bit of attention in past years, and most lay people would identify Alzheimer’s disease as a prominent issue confronting the elder population. However, while it is frequently diagnosed in the elderly, other mental illnesses such as depression and bipolar disorder receive little to no attention from the popular press and relatively little interest from researchers. Yet some mental health professionals, including researchers, have now recognized the increasing numbers of elderly persons with mental illness and are calling for more research, as well as establishment of best practices.
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In the September 1999 issue of the Archives of General Psychiatry, researchers warned of an impending mental health crisis among the elderly because there are virtually no geriatric mental health specialists in this country who can handle the impending need for treating mentally ill elderly persons. The authors of this paper (Jeste, Alexopoulos, Bartels, et al.) noted that ageism also plays a role in under-diagnosing mental illness in the elderly due to the fact that many doctors dismiss depression and anxiety, simply because it is expected in this population. The author also alleges that the population in general and doctors in particular, have lowered expectations for the
quality of life for the elderly and see little point in trying to improve their mental states. This negative attitude toward elder mental health was also found in a more recent study of physicians who were found to be knowledgeable about depression in the elderly, but saw it as an inevitable outcome of old age, and not necessarily a condition that should and could be successfully treated (Zylestra and Steitz, 2001). However, with recent changes in our society surrounding Medicaid coverage and Health Care Reform, the ability to adequately provide mental health services to the elderly remains to be seen.
How is “elderly” defined? When we begin a discussion about the elderly, we need to determine what we mean when we say “elderly.” In general, we consider those adults over the age of 65 to be elderly. However, this age cut-off does not begin to explain differences between cohorts of elderly persons. Some elderly persons are disabled by the age of 65 while many others are active and working at their professions into the 80s or 90s. The Administration on Aging, the federal agency designated to serve the elderly, writes on its website that the elderly are defined as those who are a member of the aging populations comprised of people who are at least 60. The Administration on Aging (2009) notes several key issues related to the demographics of the elderly: ●● Elderly persons comprise about 12.9 percent of the U.S. population. ●● Elderly persons over the age of 85 make up 10 percent of the elderly.
●● Elderly women far outnumber elderly men (20 million versus 14 million). ●● About one-third of the elderly live alone. ●● Poverty rises with increased age. About 16 percent of adults over 75 live in poverty. As people grow older they naturally accumulate more losses, not only coping with losses of loved ones, but also simultaneously coping with physical and often financial problems. In addition, the elderly are somewhat devalued in society in general (Butler, Lewis and Sutherland, 1991). The American Geriatrics Society (AGS) has developed a summary regarding the elderly and mental health and has written a position statement regarding mental health and the elderly at www. americangeriatrics.org.
Background Mental illness is an important contributing factor to the disease burdens of the elderly. While the elderly do not appear to suffer a disproportionate share of most classifiable mental illnesses (depression or schizophrenia, for example), they do have a much higher prevalence of dementing illnesses such as Alzheimer’s disease and are subject to high rates of interpersonal losses. Despite substantial rates of morbidity, the proportion of elderly persons recognized as impaired and who actually receive adequate treatment is markedly lower than in younger groups. This under-provision of services persists despite the fact that treatment of mental illnesses such as depression or paranoia in the elderly has been shown to be as effective as treatment in younger groups. Under-treatment of mental illness in the elderly appears to be a significant factor in the high suicide rate among elderly men, as well as in the premature or inappropriate placement of elderly persons in nursing homes. According to Institute for Health Metrics and Evaluation (2010), over 20 percent of adults aged 60 and over suffer from a mental or
neurological disorder (excluding headache disorders) and 6.6 percent of all disability (disability adjusted life years-DALYs) among over 60s is attributed to neurological and mental disorders. The most common neuropsychiatric disorders in this age group are dementia and depression. Anxiety disorders affect 3.8 percent of the elderly population, substance use problems affect almost 1 percent and around a quarter of deaths from self-harm are among those aged 60 or above. Additionally, substance abuse problems among the elderly are often overlooked or misdiagnosed. Research on mental illness in the elderly has been ignored and neglected until very recently. Even with the attention that has been given to the existence of large numbers of patients with Alzheimer’s disease, funding for research in comparison to the frequency and devastating nature of mental illness in the elderly remains inadequate.
Assessments of elder mental health It is important to consider how mental health symptoms may present quite differently in elderly persons. Older adults tend to acquire psychosomatic complaints in the form of sleep disorders, poor appetite and multiple physical complaints. Their primary care physicians are often the professionals most likely to come in contact with elderly persons and need to be alert to potential depression (Chew-Graham, et al., 2008). Historically in the United States, our society has treated the elderly population differently. For example, society has viewed and treated this group as less capable and has lowered its expectations for their quality of life (Clark, 1996). These cultural attitudes are undoubtedly an influence
Psychology.EliteCME.com
on the well-being of the elderly and could be a contributing factor in depression, but this has not yet been researched to any great degree. In addition, it has been noted for decades that the elderly grapple with different issues due to their life-stage development. To paraphrase the Eriksonian psychosocial life stage theory, persons in the last stages of life are in the midst of a struggle to determine whether their life had meaning, if they contributed in some way to the world, and whether their life was truly worthwhile. Erikson noted that some elderly persons are in a great state of despair in which they are not certain life meant anything, are wracked with feelings of regret, unsure that they made a difference, and are frightened that they were failures, with little time left to make changes. These persons are in a state of anxiety as they struggle to accept that their death is imminent, clinging to and trying to make sense of their lives before dying (Erikson, 1966).
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Commonly diagnosed mental health disorders in the elderly Depression has been the most widely researched mental illness in the elderly, and consequently, there is much more information available regarding depression than for other elder mental health disorders
such as anxiety, bipolar disorder and dementia. Researchers have also focused on substance abuse.
Depression The American Psychiatric Association has identified depression as the most commonly diagnosed mental disorder in the elderly, affecting about 5 percent of those individuals ages 65 and over. However, experts suspect that this number is a low estimate. Persons with the highest suicide rate in the United States are over the age of 65, and presumably, many of these suicides can be attributed to undiagnosed depression and lack of appropriate treatment. Over half of those elderly persons who could be classified as depressed receive no treatment for the condition, and only about 10 percent receive appropriate treatment (Katon, et al., 1992). Diagnosing elder depression can be more difficult due to the existence of their physical problems. Feeling tired, loss of appetite and other physical complaints are all hallmarks of depression. However, in older persons these symptoms can have a physiological basis and may not be signs of depression. Consequently, doctors might dismiss the signs of depression as merely physiological. Depressed elderly persons do tend to have more physical than mental health complaints, and this often makes it difficult to determine whether a physical ailment or depression is the cause of their problems (Landefield, et al, 2006). Assessment of the elderly can utilize tools specifically designed to provide insight into the particular aspects of an elderly person’s mental state. The Geriatric Depression Scale asks such questions as “are you happy most of the time,” and “do you feel pretty worthless the way you are now?” and offers yes and no answer options. Answers are assigned a value of “1” or “0,” and an overall score of greater than “5” indicates depression (Sheikh and Yesavage, 1986). According to the American Psychiatric Association (2013), the DSM-5 outlines a few changes to the “what” and “how” depression is diagnosed: Major Depressive Disorder (MDD) is a medical illness that affects how you feel, think and behave causing persistent feelings of sadness and loss of interest in previously enjoyed activities. Depression can lead to a variety of emotional and physical problems. It is a chronic illness that usually requires long-term treatment. Using DSM-IV, clinicians were advised to refrain from diagnosing major depression in individuals within the first two months following the death of a loved one in what has been referred to as the “bereavement exclusion.” By advising clinicians not to diagnose depression in recently bereaved individuals, the DSM-IV bereavement exclusion suggested that grief somehow protected someone from major depression. As part of the ongoing study of major depression, the bereavement exclusion has been removed from DSM. This change from DSMIV, would be replaced by notes in the criteria and text that caution clinicians to differentiate between normal grieving associated with a significant loss and a diagnosis of a mental disorder. Removing the bereavement exclusion helps prevent major depression from being overlooked and facilitates the possibility of appropriate treatment including therapy or other interventions. While the grieving process is natural and unique to each individual and shares some of the same features of depression like intense sadness and withdrawal from customary activities, grief and depression are also different in important aspects: ○○ In grief, painful feelings come in waves, often intermixed with positive memories of the deceased; in depression, mood and ideation are almost constantly negative.
○○ In grief, self-esteem is usually preserved; in MDD, corrosive feelings of worthlessness and self-loathing are common. ○○ While many believe that some form of depression is a normal consequence of bereavement, MDD should not be diagnosed in the context of bereavement since diagnosis would incorrectly label a normal process as a disorder. Research and clinical evidence have demonstrated that, for some people, the death of a loved one can precipitate major depression, as can other stressors, like losing a job or being a victim of a physical assault or a major disaster. However, unlike those stressors, bereavement is the only life event and stressor specifically excluded from a diagnosis of major depression in DSM-IV. While bereavement may precipitate major depression in people who are especially vulnerable (i.e. they have already suffered a significant loss or have other mental disorders), when grief and depression co-exist, the grief is more severe and prolonged than grief without major depression. Despite some overlap between grief and MDD, they are different in important ways, and therefore they should be distinguished separately to enable people to benefit from the most appropriate treatment. Changes to the Bereavement Exclusion The diagnostic criteria proposed for the manual’s next edition includes language in the criteria for Major Depressive Disorder (MDD) to help differentiate between normal bereavement associated with Major Depressive Disorder and the “Bereavement Exclusion” a significant loss and a diagnosis of a mental disorder, which characterizes bereavement as a severe psychological stressor that can incite a major depressive episode even shortly after the loss of a loved one. In DSM-IV, there was an exclusion criterion for a major depressive episode that was applied to depressive symptoms lasting less than 2 months following the death of a loved one (i.e., the bereavement exclusion). This exclusion is omitted in DSM-5 for several reasons. The first is to remove the implication that bereavement typically lasts only 2 months when both physicians and grief counselors recognize that the duration is more commonly 1–2 years. Second, bereavement is recognized as a severe psychosocial stressor that can precipitate a major depressive episode in a vulnerable individual, generally beginning soon after the loss. When major depressive disorder occurs in the context of bereavement, it adds an additional risk for suffering, feelings of worthlessness, suicidal ideation, poorer somatic health, worse interpersonal and work functioning, and an increased risk for persistent complex bereavement disorder, which is now described with explicit criteria in Conditions for Further Study in DSM-5 Section III. Thirdly, bereavement-related major depression is most likely to occur in individuals with past personal and family histories of major depressive episodes. It is genetically influenced and is associated with similar personality characteristics, patterns of comorbidity, and risks of chronicity and/or recurrence as non– bereavement-related major depressive episodes. Finally, the depressive symptoms associated with bereavementrelated depression respond to the same psychosocial and medication treatments as non–bereavement-related depression.
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Causal factors The causes of depression vary. The National Institute on Aging (2014) notes that depression can be preceded by a single event such as the death of a spouse or a serious illness. Strokes, heart disease, Parkinson’s disease or diabetes can also lead to depression because older people might be more physically worn down or worried that an illness will force them to undergo significant lifestyle changes. There is no one cause of depression. For some people, a single event can bring on the illness. Depression often strikes people who felt fine but who suddenly find they are dealing with a death in the family. For some people, changes in the brain can affect mood and cause depression. Sometimes, those under a lot of stress, like caregivers, can feel depressed. Others become depressed for no clear reason. People faced with life-changing health problems, such as cancer, diabetes, heart disease, stroke, or Parkinson’s disease, may become depressed. They may worry about how the illness will change their lives. They might be tired and unable to cope with things that make them sad. Treatment can help people manage their symptoms and improve their quality of life. Genetics can also play a role. Studies show that depression may run in families. Children of depressed parents may be at a higher risk for depression. Also, depression tends to be a disorder that occurs more than once. Many older people who have been depressed in the past will be at an increased risk for becoming depressed again. What to look for: ●● An “empty” feeling, ongoing sadness, and anxiety. ●● Tiredness, lack of energy. ●● Loss of interest or pleasure in everyday activities, including sex. ●● Sleep problems, including trouble getting to sleep, very early morning waking, and sleeping too much.
●● ●● ●● ●● ●● ●● ●●
Eating more or less than usual. Crying too often or too much. Aches and pains that don’t go away when treated. A hard time focusing, remembering, or making decisions. Feeling guilty, helpless, worthless, or hopeless. Being irritable. Thoughts of death or suicide.
Newton (1992) notes that bereavement is harder on elderly persons because friends that die are not replaced as readily as when a person is younger. The resulting deterioration of a social support system takes away protective factors that help people get through these types of situations. Consequently, older adults may have few people to lean on when a spouse dies, whereas a younger person may have multiple friends to rely on. It is not uncommon for older people to note that they may be the last of a generation, which can lead to a profound sense of loss, prompting feelings of loneliness and isolation that can be difficult for younger people to comprehend. In addition, the National Strategy for Suicide Prevention also notes on its website, http://mentalhealth.samhsa.gov/SuicidePrevention, that older persons are more likely to be socially isolated through being widowed and thus more inclined to be depressed. A lack of social support among the elderly is also cited by the National Alliance for the Mentally Ill (NAMI) as a factor that often leads to depression in the elderly. Statistically, the elderly are more likely to go through major life changes, such as moving from their homes, losing their spouses, or having major health crises. All of these events are associated with increased risk of depression. Emory University has developed a program focused on depression and the elderly. The Fuqua Center for Late-Life Depression offers clinical mental health services specializing in the elderly through outpatient counseling, group therapy and psychiatric services.
Elder depression statistics According to the Geriatric Mental Health Foundation (2014), an estimated 6 percent of people ages 65 and older in a given year, or approximately 2 million individuals in this age group, have a diagnosable depressive illness. Depression affects approximately 25 percent of those with chronic illness and is particularly common in patients with ischemic heart disease, stroke, cancer, chronic lung disease, arthritis, Alzheimer’s disease, and Parkinson’s disease. Most disturbing among depression statistics is the fact that depression affects upwards of 50 percent of nursing home residents.
In 2002, the annual suicide rate for persons over the age of 65 was over 15 per 100,000 individuals; this number increases for those aged 75 to 84, with over 17 suicide deaths per every 100,000. The number rises even higher for those over age 85. Further, elder suicide may be underreported by 40 percent or more. Not counted are “silent suicides,” like deaths from overdoses, self-starvation or dehydration, and “accidents.” The elderly have a high rate of completing suicide because they use firearms, hanging, and drowning. Double suicides involving spouses or partners occur most frequently among the aged. In 2010, the highest suicide rate (18.6) was among people 45 to 64 years old. The second highest rate (17.6) occurred in those 85 years or older.
Anxiety Anxiety is a mental health condition characterized by muscle tension, irritability and insomnia. Previously referred to as social phobia in the DSM-IV, it has been renamed social anxiety disorder in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). This change reflects a new and broader understanding of the condition in a variety of social situations. In the past, social phobia primarily was diagnosed if an individual felt extreme discomfort or fear when performing in front of others. Research has shown that this definition is too narrow. With DSM-5, social anxiety can be diagnosed because of an individual’s response in a variety of social situations. According to the American Psychiatry Association (2013), social anxiety disorder is about more than just shyness and can be considerably disabling. A diagnosis requires that a person’s fear or anxiety be out of proportion—in frequency and/or duration—to Psychology.EliteCME.com
the actual situation. The symptoms must be persistent, lasting six months or longer. In DSM-IV, the timeframe was required only for children; DSM-5 expands this criterion to include adults as well. The minimum symptom period reduces the possibility that an individual is experiencing only transient or temporary fear. To be diagnosed with social anxiety disorder, the person must suffer significant distress or impairment that interferes with his or her ordinary routine in social settings, at work or school, or during other everyday activities. Unlike in DSM-IV, which requires that the individual recognize that his or her response is excessive or unreasonable, the DSM-5 criteria shift that judgment to the clinician. The clinician also will work to determine whether the person’s reaction might be explained by such reasons as a more general anxiety or an adverse response to certain medications. If the person suffers from another medical condition—for instance, stuttering or obesity—the fear or anxiety experienced must be unrelated to the other condition or out of proportion to what would normally be felt. Page 21
It is noted by Salzmann (2004) that while clinical rates of anxiety in the elderly are lower overall than rates of anxiety in younger persons, many older adults experience anxiety that does not actually meet clinical diagnostic criteria, but is still troublesome to their overall well-being. He also noted that mixed presentations of anxiety and depression are the most common co-occurring mood disorder diagnoses among the elderly. Other researchers note similar findings. It has been shown that only 2 percent of the elderly fit the criteria for a diagnosis of anxiety, but 40 percent of those diagnosed with depression also presented with anxiety (Cassel, 2004). In addition, many elderly persons with dementia also have concurrent anxiety (Merck Manual, 2005). It is, however, quite difficult to diagnose anxiety in the elderly. Beck and Stanley (1997) note that the nature of anxiety may change over the lifespan and may be quantified differently for the elderly. Whereas, in younger persons anxiety is characterized as actually facilitating performance, this has not been the case in studies of older persons. This difference in the outcomes of anxiety indicates that anxiety may have different characteristics in the elderly. In the elderly, anxiety most often takes the form of worry. Furthermore, there tend to be five areas of worry in the elderly: ●● Family. ●● Health. ●● Money. ●● Work. ●● Miscellaneous. Worries about health tended to be the most common in the elderly.
Harem et al. (2002) noted that the number of elderly persons visiting their doctors seeking treatment for anxiety disorders increased dramatically from 1985 to 1998. Furthermore, they determined that while a number of elderly persons utilized psychiatrists, a large number of elderly persons went to their primary care physicians for treatment and the primary care physicians were far less likely than psychiatrists to offer medication and/or psychotherapy. Consequently,
it appears that under-recognition and under-treatment are continuing problems with anxiety disorders in the elderly. Researchers argue that anxiety is highly prevalent yet gets little attention from researchers compared to depression (Lenze, et al., 2000). Beck and Stanley (1997) also noted that anxiety disorders tended to be much more common than affective disorders and major depression. The Penn State Worry Questionnaire has been utilized in the assessment and diagnosis of worry in younger adults and was recently assessed as a screening instrument for elderly persons. The instrument did require some modifications to fit well with the diagnosis of anxiety in the elderly. The items that were removed were primarily reverse items (i.e., the question “I never worry about anything,” required a higher level of cognitive processing than the non-reversed item, “My worry overwhelms me,” which is a basic agree or disagree question). The cognitive abilities required to answer a reversed item may be harder for an elderly person with some cognitive impairments and lead to answers that did not reflect the true feelings of the elderly person being assessed (Hopko, et al., 2003). In addition, the Beck Anxiety Inventory (BAI) has also been found to be effective in the assessment of generalized anxiety disorder in the elderly (Wetherell and Gatz, 2005). It is important to note that anxiety symptoms in the elderly are often the result of medical conditions as well. For example, cardiac problems can lead to shortness of breath and heart palpitations. Hyperthyroidism can also cause agitation and anxiety (Merck Manual, 2005). Of all of the anxiety disorders studied in the elderly, generalized anxiety disorder has been the most widely researched. There has been very little systematic investigation of other forms of anxiety disorders, such as post-traumatic stress disorder (PTSD), or phobic disorders. In reviewing past studies of PTSD, researchers noted that the symptoms are similar in the elderly and younger persons that include: ●● Reliving of the trauma. ●● Avoidance of situations that remind a person of the trauma. ●● Hyper-vigilance. PTSD in the elderly can run a chronic course over a lifetime, with intermittent reappearances, or can start in later years as the result of such events as natural disasters, or being victimized by crime. There has been very little study of PTSD in the elderly, regardless of the course or cause of the disorder (Weintraub and Ruskin, 1999). In a similar fashion, there are very few studies of phobias in the elderly. The small amount of research in this area indicates that the elderly do sometimes present with phobias such as traveling, being alone, insects and close spaces (Lindesay, Briggs and Murphy, 1989).
Bipolar disorder While bipolar disorders are typically thought to emerge relatively early in life, it is estimated by the University of Pittsburg Medical Center that 10 percent of elderly persons with bipolar disorder develop the disorder for the first time after the age of 50 (www.latelifedepression. org). There is a paucity of research on late-onset bipolar disorder, but the early research has indicated that those with late-onset bipolar have a history of major depression. In the manic episodes, elderly persons can present with increased activity, suspiciousness of others, irritability, trouble sleeping and grandiose thoughts. Manic episodes can then rapidly cycle into depression and pose a strong risk of suicide during these abrupt shifts. In the elderly, bipolar disorder often presents with symptoms of mental confusion and disorientation, and is often misdiagnosed, as it is mistaken for dementia (Medscape, 1998). Oftentimes, elderly persons show less grandiosity and more depressive symptoms, which can also make the disorder more difficult to correctly diagnose (Finn, 2006). Bipolar disorder in persons over the age of 65 is thought to be relatively rare, occurring in less than 1 percent of the population.
However, it is suspected that the disorder is under-diagnosed (Sajatovic and Kales, 2006). Although it is less prevalent than depression, the overall impact of a person with a bipolar disorder is far greater on the mental health system. A study that compared the hospitalization rates and mental health utilization rates of those elderly persons with bipolar disorder as compared to those with depression demonstrated that elderly persons with a bipolar disorder were four times as likely to be hospitalized and to use mental health services (Bartel, Forester, Miles and Joyce, 2000). To enhance the accuracy of diagnosis and facilitate earlier detection in clinical settings, the DSM-5 revised Criterion A for manic and hypomanic episodes, which now includes an emphasis on changes in activity and energy as well as mood. The DSM-IV diagnosis of bipolar I disorder, mixed episode, requiring that the individual simultaneously meet full criteria for both mania and major depressive episode, has been removed. Instead, a new specifier, “with mixed features,” has been added that can be applied to episodes of mania or hypomania when depressive features are present and to episodes of depression
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in the context of major depressive disorder or bipolar disorder when features of mania/hypomania are present (APA, 2013). Other Specified Bipolar and Related Disorder DSM-5 allows the specification of particular conditions for other specified bipolar and related disorder, including categorization for
individuals with a past history of a major depressive disorder who meet all criteria for hypomania except the duration criterion (i.e., at least 4 consecutive days). A second condition constituting another specified bipolar and related disorder is that too few symptoms of hypomania are present to meet criteria for the full bipolar II syndrome, although the duration is sufficient at 4 or more days.
Substance abuse Overall, the aging Baby Boomer population has historically used alcohol and drugs much more freely than previous generations, and higher numbers of them are entering their senior years with longstanding alcohol and drug abuse issues. The numbers of elderly substance abusers will only increase over the next few years. Consequently, there will be unprecedented numbers of elderly persons who need treatment for alcohol and drug abuse (NHSDA, 2000). However, substance abuse is one of the most under-diagnosed disorders in the elderly. Elderly persons are often retired and consequently do not have accountability to an employer who might notice their overuse of chemical substances. The Hazelden Treatment Center notes on its website www.hazelden.org that about 17 percent of persons in this country who are over the age of 60 have issues with substance abuse, including the misuse of prescription drugs. The center notes that some of these persons are chronic abusers who have had lifelong problems, but others develop problems later in life, particularly with painkillers and other prescription medications. Just as risk factors are different for elderly persons with substance abuse issues, so are the issues with diagnosis of substance abuse. Liberto and Oslin (1995) indicate in their research that late-onset substance abusers tend to respond fairly well to treatment, but are more likely to go undiagnosed, as physicians are not well trained to look for lateonset substance abuse. Substance abuse in the elderly can be hidden by physical illnesses, dementia or depression (Reid and Anderson, 1997). O’Connell, et al., (2003), notes that screening instruments for substance
abuse have been designed for younger people and fail to take into account many life-stage differences between younger and older people. The recently updated DSM-5 outlines diagnosis criteria that differs slightly from the previous DSM-IV. Substance use disorder in DSM-5 combines the DSM-IV categories of substance abuse and substance dependence into a single disorder measured on a continuum from mild to severe (APA, 2013). Each specific substance (other than caffeine, which cannot be diagnosed as a substance use disorder) is addressed as a separate use disorder (e.g., alcohol use disorder, stimulant use disorder, etc.), but nearly all substances are diagnosed based on the same overarching criteria. In this overarching disorder, the criteria have not only been combined, but strengthened. Whereas a diagnosis of substance abuse previously required only one symptom, mild substance use disorder in DSM-5 requires two to three symptoms from a list of 11. Drug craving will be added to the list, and problems with law enforcement will be eliminated because of cultural considerations that make the criteria difficult to apply internationally. In DSM-IV, the distinction between abuse and dependence was based on the concept of abuse as a mild or early phase and dependence as the more severe manifestation. In practice, the abuse criteria were sometimes quite severe. The revised substance use disorder, a single diagnosis, will better match the symptoms that patients experience. Additionally, the diagnosis of dependence caused much confusion. Most people link dependence with “addiction” when in fact dependence can be a normal body response to a substance.
Prescription drugs and the elderly The abuse and misuse of prescriptions drugs among elderly persons is a legitimate concern for mental health practitioners. Psychotropic medications are often times inappropriate for elderly persons to consume because they tend to increase confusion, sleep disorders and falls, and yet 50 percent of all psychotropic drug prescriptions are given to seniors. Elderly persons also have problems understanding instructions on taking
medications properly, and it has been demonstrated that doctors do not spend adequate time explaining medication issues to their elderly patients. Even when they understand the instructions, elderly people often fail to take their medications appropriately, partly because they lack the money to buy prescriptions and they attempt to save money by cutting back on their medications (Brazeau, 2001; Carlson, 1994).
Alcohol abuse in the elderly There are also further distinctions with types of problem drinkers in the elder population. In general, problem drinkers are divided into two types: early-onset and late-onset. Given their much shorter alcoholproblem history, late-onset alcoholics are further differentiated from their early-onset counterparts as less likely to have alcohol-related health problems or to experience physical withdrawal, with a lower frequency of intoxication and with more stable emotional, financial, and social situations (Schonfeld and Dupree 1991). One primary distinguishing feature of late-onset alcoholism is its apparent development in response to stress, particularly stress connected with aging (Akers and La Greca 1991). Consequently, late-onset alcoholics are also known as “reactive” drinkers (Gomberg, 1990). Stressors associated with aging also have been linked to heavier
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drinking among early-onset alcoholics and reduced drinking by the elderly with a long-standing alcohol problem (Atkinson, 1984). As Blazer and his colleagues (1986) point out, the primary distinguishing feature in late-onset alcoholics is their initiation of problem drinking as seniors. This particular feature identifies earlier onset elderly alcoholics from late-onset alcoholics. Mulford and Fitzgerald (1992) found that the late-onset problem drinkers included in their study of DWI offenders would not meet DSM-II or other clinical diagnostic criteria for alcoholism, a factor that may make them easier to treat but also less likely to be identified as in need of treatment. The lowered alcohol tolerance of the aging body may play a role here, making drinking a problem for persons whose consumption levels may be unchanged or relatively moderate.
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Risk factors for substance abuse in the elderly According to O’Connell, Chin, Cunningham and Lawler (2003), bereavement, (as elderly persons lose friends and family members) as well as the difficulty in adjusting to a loss of role identity upon retirement, are risk factors in substance abuse. Menninger (2002) also notes that economic difficulties from living on a fixed income and medical problems are all risk factors for substance abuse. These risk factors are quite different than for younger people who are facing different life-cycle issues. Those most likely to abuse alcohol in the elderly population are males who are under 75 years of age, from lower socioeconomic backgrounds with less education and are widowed or divorced. Interestingly, widowhood was not cited as a risk factor for women (Carlson, 1994). Atkinson (2008) gives a comprehensive outline of risk factors for substance abuse: ●● Predisposing factors: ○○ Family history (alcohol). ○○ Previous substance abuse. ○○ Previous pattern of substance consumption (individual and cohort). ○○ Personality traits (sedative-hypnotics, anxiolytics).
●● Factors that may increase substance exposure and consumption level: ○○ Gender (men: alcohol, illicit drugs; women: sedativehypnotics, anxiolytics). ○○ Chronic illness associated with pain (opioid analgesics), insomnia (hypnotic drugs), or anxiety (anxiolytics). ○○ Long-term prescribing (sedative-hypnotics, anxiolytics). ○○ Caregiver overuse of “as needed” medication (institutionalized elderly). ○○ Life stress, loss, social isolation. ○○ Negative effects (depression, grief, demoralization, anger, alcohol). ○○ Family collusion and drinking partners (alcohol). ○○ Discretionary time, money (alcohol). ●● Factors that may increase the effects and abuse potential of substances: ○○ Age-associated drug sensitivity.(pharmacokinetic, pharmacodynamic factors). ○○ Chronic medical illness. ○○ Other medications (alcohol-drug; drug-drug interactions).
Dementia What is dementia? According to the recently published DSM-5, dementia is a neurocognitive disorder. In fact, the term “dementia” has been eliminated and replaced with major or minor neurocognitive disorder. It was believed that the word dementia was stigmatizing toward older individuals and not well accepted by younger individuals with HIV dementia. The new term focuses on the decline from a previous level of functioning as opposed to a deficit (APA, 2013). Further, the dementia chapter in DSM-5 is titled “Neurocognitive Disorders,” whereas in DSM-IV it was titled “Delirium, Dementia, Amnestic, and Other Cognitive Disorders.” According to DSM-5, changes for delirium include the following: 1. Disturbance in attention (i.e., reduced ability to direct, focus, sustain, and shift attention) and orientation to the environment. 2. Disturbance develops over a short period of time (usually hours to a few days) and represents an acute change from baseline that is not solely attributable to another neurocognitive disorder and tends to fluctuate in severity during the course of a day. 3. A change in an additional cognitive domain, such as memory deficit, disorientation, or language disturbance, or perceptual disturbance that is not better accounted for by a preexisting, established, or evolving other neurocognitive disorder. 4. Disturbances in No. 1 and 3 must not occur in the context of a severely reduced level of arousal, such as coma. The old dementia terminology required the presence of memory impairment for all of the various dementias. It has been recognized that memory impairment is not the first domain to be affected in all of the other diseases that cause a neurocognitive disorder. For instance, in frontal temporal disorder, language could be affected first. This change in terminology will require that all diagnosing healthcare professionals first establish the presence of a neurocognitive disorder and then determine whether the neurocognitive disorder is minor or major. In DSM-5, a minor neurocognitive disorder is defined by the following: ●● There is evidence of modest cognitive decline from a previous level of performance in one or more of the domains outlined above based on the concerns of the individual, a knowledgeable informant, or the clinician; and a decline in neurocognitive performance, typically involving test performance in the range of one and two standard deviations below appropriate norms
(i.e., between the third and 16th percentiles) on formal testing or equivalent clinical evaluation. ●● The cognitive deficits are insufficient to interfere with independence (e.g., instrumental activities of daily living, like more complex tasks such as paying bills or managing medications, are preserved), but greater effort, compensatory strategies, or accommodation may be required to maintain independence. ●● The cognitive deficits do not occur exclusively in the context of a delirium. ●● The cognitive deficits are not primarily attributable to another mental disorder (e.g., major depressive disorder, schizophrenia). In DSM-5, a major neurocognitive disorder is defined by the following: ●● There is evidence of substantial cognitive decline from a previous level of performance in one or more of the domains outlined above based on the concerns of the individual, a knowledgeable informant, or the clinician; and a decline in neurocognitive performance, typically involving test performance in the range of two or more standard deviations below appropriate norms (i.e., below the third percentile) on formal testing or equivalent clinical evaluation. ●● The cognitive deficits are sufficient to interfere with independence (i.e., requiring minimal assistance with instrumental activities of daily living). ●● The cognitive deficits do not occur exclusively in the context of a delirium. ●● The cognitive deficits are not primarily attributable to another mental disorder (e.g., major depressive disorder, schizophrenia). When diagnosing a minor neurocognitive disorder, one and two standard deviations below appropriate norms are required. In diagnosing a major neurocognitive disorder, two or more standard deviations below appropriate norms are required. This need for cognitive testing will add to patient cost since neither the Mini Mental State Examination nor the Montreal Cognitive Assessment, the common screening tools utilized by many clinicians, yields results in standard deviations. In addition, the requirement that the cognitive deficits are insufficient to interfere with independence is subjective and will cause additional confusion for both clinicians and patients. Having determined whether a patient has a major or minor neurocognitive disorder, the healthcare professional making the diagnosis must then decide on the etiological subtype of the major or minor neurocognitive disorder. The subtypes that have been listed are neurocognitive disorder due to Alzheimer’s disease; vascular
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neurocognitive disorder; frontotemporal neurocognitive disorder; neurocognitive disorder due to traumatic brain injury, Lewy body dementia, Parkinson’s disease, or HIV infection; substance-induced
neurocognitive disorder; neurocognitive disorder due to Huntington’s disease, Prion disease, or to another medical condition; and neurocognitive disorder not elsewhere classified.
What conditions can cause neurocognitive disorders? Doctors have identified many other conditions that can cause dementia or dementia-like symptoms. Many of these conditions are reversible with appropriate treatment. Reactions to medications – Medications can sometimes lead to reactions or side effects that mimic dementia. These dementia-like effects can occur in reactions to just one drug, or they can result from drug interactions. They may have a rapid onset, or they may develop slowly over time. Metabolic problems and endocrine abnormalities – Thyroid problems can lead to apathy, depression or dementia. Hypoglycemia, a condition in which there is not enough sugar in the bloodstream, can cause confusion or personality changes. Too little or too much sodium or calcium can also trigger mental changes. Some people have an impaired ability to absorb vitamin B12, which creates a condition called pernicious anemia that can cause personality changes, irritability or depression. Tests can determine whether any of these problems are present. Nutritional deficiencies – Deficiencies of thiamine (vitamin B1) frequently result from chronic alcoholism and can seriously impair mental abilities, in particular memories of recent events. Severe deficiency of vitamin B6 can cause a neurological illness called pellagra that may include dementia. Deficiencies of vitamin B12 also have been linked to dementia in some cases. Dehydration can also cause mental impairment that can resemble dementia. Infections – Many infections can cause neurological symptoms, including confusion or delirium, due to fever or other side effects of the body’s fight to overcome the infection. Meningitis and encephalitis, which are infections of the brain or the membrane that covers it, can cause confusion, sudden severe dementia, withdrawal from social interaction, impaired judgment or memory loss. Untreated syphilis also can damage the nervous system and cause dementia. In rare cases, Lyme disease can cause memory or thinking difficulties. People in the advanced stages of AIDS also may develop a form of dementia (see HIV-associated dementia, in this chapter). People with compromised immune systems, such as those with leukemia and AIDS, may also develop an infection called progressive multifocal
leukoencephalopathy (PML). PML is caused by a common human polyomavirus, JC virus, and leads to damage or destruction of the myelin sheath that covers nerve cells. PML can lead to confusion, difficulty with thinking or speaking, and other mental problems. Subdural hematomas – Subdural hematomas, or bleeding between the brain’s surface and its outer covering (the dura), can cause dementia-like symptoms and changes in mental function. Poisoning – Exposure to lead, other heavy metals or other poisonous substances can lead to symptoms of dementia. These symptoms may or may not resolve after treatment, depending on how badly the brain is damaged. People who have abused substances such as alcohol and recreational drugs sometimes display signs of dementia even after the substance abuse has ended. This condition is known as substanceinduced persisting dementia. Brain tumors – In rare cases, people with brain tumors may develop dementia because of damage to their brains. Symptoms may include changes in personality, psychotic episodes or problems with speech, language, thinking and memory. Anoxia – Anoxia and a related term, hypoxia, are often used interchangeably to describe a state in which there is a diminished supply of oxygen to an organ’s tissues. Anoxia may be caused by many different problems, including heart attack, heart surgery, severe asthma, smoke or carbon monoxide inhalation, high-altitude exposure, strangulation, or an overdose of anesthesia. In severe cases of anoxia, the patient may be in a stupor or a coma for periods ranging from hours to days, weeks or months. Recovery depends on the severity of the oxygen deprivation. As recovery proceeds, a variety of psychological and neurological abnormalities, such as dementia or psychosis, may occur. The person also may experience confusion, personality changes, hallucinations or memory loss. Heart and lung problems – The brain requires a high level of oxygen in order to carry out its normal functions. Therefore, problems such as chronic lung disease or heart problems that prevent the brain from receiving adequate oxygen can starve brain cells and lead to the symptoms of dementia.
What are the risk factors for neurocognitive disorder? Researchers have identified several risk factors that affect the likelihood of developing one or more kinds of dementia. Some of these factors are modifiable, while others are not. ●● Age – The risk of AD, vascular dementia and several other dementias goes up significantly with advancing age. ●● Genetics/family history – As described in the section “What causes dementia?” researchers have discovered a number of genes that increase the risk of developing AD. Although people with a family history of AD are generally considered to be at heightened risk of developing the disease themselves, many people with a family history never develop the disease and many without a family history of the disease do get it. In most cases, it is still impossible to predict a specific person’s risk of the disorder based on family history alone. Some families with CJD, GSS, or fatal familial insomnia have mutations in the prion protein gene, although these disorders can also occur in people without the gene mutation. Individuals with these mutations are at significantly higher risk of developing these forms of dementia. Abnormal genes are also clearly implicated as risk factors in Huntington’s disease, FTDP-17, and several other kinds of dementia. These
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dementias are described in the section, “What are the different kinds of dementia?” ●● Smoking and alcohol use – Several recent studies have found that smoking significantly increases the risk of mental decline and dementia. People who smoke have a higher risk of atherosclerosis and other types of vascular disease, which may be the underlying causes for the increased dementia risk. Studies also have found that drinking large amounts of alcohol appears to increase the risk of dementia. However, other studies have suggested that people who drink moderately have a lower risk of dementia than either those who drink heavily or those who completely abstain from drinking. ●● Atherosclerosis – Atherosclerosis is the buildup of plaque – deposits in fatty substances, cholesterol and other matter – in the inner lining of an artery. Atherosclerosis is a significant risk factor for vascular dementia because it interferes with the delivery of blood to the brain and can lead to stroke. Studies have also found a possible link between atherosclerosis and AD. ●● Cholesterol – High levels of low-density lipoprotein (LDL), the so-called bad form of cholesterol, appear to significantly increase a person’s risk of developing vascular dementia. Some research has also linked high cholesterol to an increased risk of AD. Page 25
●● Plasma homocysteine – Research has shown that a higher-thanaverage blood level of homocysteine – a type of amino acid – is a strong risk factor for the development of AD and vascular dementia. ●● Diabetes – Diabetes is a risk factor for both AD and vascular dementia. It is also a known risk factor for atherosclerosis and stroke, both of which contribute to vascular dementia. ●● Mild cognitive impairment – While not all people with mild cognitive impairment develop dementia, people with this condition
do have a significantly increased risk of dementia compared to the rest of the population. One study found that approximately 40 percent of people over age 65 who were diagnosed with mild cognitive impairment developed dementia within three years. ●● Down syndrome – Studies have found that most people with Down syndrome develop characteristic AD plaques and neurofibrillary tangles by the time they reach middle age. Many, but not all, of these individuals also develop symptoms of dementia.
How are neurocognitive disorders diagnosed? Doctors employ a number of strategies to diagnose dementia. It is important that they rule out any treatable conditions, such as depression, normal pressure hydrocephalus or vitamin B12 deficiency, which can cause similar symptoms. Early, accurate diagnosis of dementia is important for patients and their families because it allows early treatment of symptoms. For people with AD or other progressive dementias, early diagnosis may allow them to plan for the future while they can still help to make decisions. These people also may benefit from drug treatment. The “gold standard” for diagnosing dementia, autopsy, does not help the patient or caregivers. Therefore, doctors have devised a number of techniques to help identify dementia with reasonable accuracy while the patient is still alive. Patient history Doctors often begin their examination of a patient suspected of having dementia by asking questions about the patient’s history. For example, they may ask how and when symptoms developed and about the patient’s overall medical condition. They also may try to evaluate the patient’s emotional state, although patients with dementia often may be unaware of or in denial about how their disease is affecting them. Family members also may deny the existence of the disease because they do not want to accept the diagnosis and because, at least in the beginning, AD and other forms of dementia can resemble normal aging. Therefore, additional steps are necessary to confirm or rule out a diagnosis of dementia. Physical examination A physical examination can help rule out treatable causes of dementia and identify signs of stroke or other disorders that can contribute to dementia. It can also identify signs of other illnesses, such as heart disease or kidney failure, that can overlap with dementia. If a patient is taking medications that may be causing or contributing to his or her symptoms, the doctor may suggest stopping or replacing some medications to see if the symptoms go away. Neurological evaluations Doctors will perform a neurological examination, looking at balance, sensory function, reflexes, and other functions, to identify signs of conditions – for example, movement disorders or stroke – that may affect the patient’s diagnosis or are treatable with drugs. Cognitive and neuropsychological tests Doctors use tests that measure memory, language skills, math skills and other abilities related to mental functioning to help them diagnose a patient’s condition accurately. For example, people with AD often show changes in so-called executive functions (such as problemsolving), memory and the ability to perform once automatic tasks. Doctors often use a test called the Mini-Mental State Examination (MMSE) to assess cognitive skills in people with suspected dementia. This test examines orientation, memory and attention as well as the ability to name objects, follow verbal and written commands, write a sentence spontaneously and copy a complex shape. Doctors also use a variety of other tests and rating scales to identify specific types of cognitive problems and abilities.
Brain scans Doctors may use brain scans to identify strokes, tumors or other problems that can cause dementia. Also, cortical atrophy – degeneration of the brain’s cortex (outer layer) – is common in many forms of dementia and may be visible on a brain scan. The brain’s cortex normally appears very wrinkled, with ridges of tissue (called gyri) separated by “valleys” called sulci. In individuals with cortical atrophy, the progressive loss of neurons causes the ridges to become thinner and the sulci to grow wider. As brain cells die, the ventricles (or fluid-filled cavities in the middle of the brain) expand to fill the available space, becoming much larger than normal. Brain scans also can identify changes in the brain’s structure and function that suggest AD. The most common types of brain scans are computed tomographic (CT) scans and magnetic resonance imaging (MRI). Doctors frequently request a CT scan of the brain when they are examining a patient with suspected dementia. These scans, which use X-rays to detect brain structures, can show evidence of brain atrophy, strokes and transient ischemic attacks (TIAs), changes to the blood vessels and other problems such as hydrocephalus and subdural hematomas. MRI scans use magnetic fields and focused radio waves to detect hydrogen atoms in tissues within the body. They can detect the same problems as CT scans, but they are better for identifying certain conditions, such as brain atrophy and damage from small TIAs. Doctors also may use electroencephalograms (EEGs) in people with suspected dementia. In an EEG, electrodes are placed on the scalp over several parts of the brain in order to detect and record patterns of electrical activity and check for abnormalities. This electrical activity can indicate cognitive dysfunction in part or all of the brain. Many patients with moderately severe to severe AD have abnormal EEGs. An EEG may also be used to detect seizures, which occur in about 10 percent of AD patients, as well as in many other disorders. EEGs also can help diagnose CJD. Several other types of brain scans allow researchers to watch the brain as it functions. These scans, called functional brain imaging, are not often used as diagnostic tools but are important in research, and they may ultimately help identify people with dementia earlier than is currently possible. Functional brain scans include functional MRI (FMRI), single photon-emission computed technology (SPECT), positron emission tomography (PET), and magnetoencephalography (MEG). FMRI uses radio waves and a strong magnetic field to measure the metabolic changes that take place in active parts of the brain. SPECT shows the distribution of blood in the brain, which generally increases with brain activity. PET scans can detect changes in glucose metabolism, oxygen metabolism and blood flow, all of which can reveal abnormalities of brain function. MEG shows the electromagnetic fields produced by the brain’s neuronal activity. Laboratory tests Doctors may use a variety of laboratory tests to help diagnose dementia and/or rule out other conditions, such as kidney failure, that can contribute to symptoms. A partial list of these tests includes a complete blood count, blood glucose test, urinalysis, drug and alcohol tests (toxicology screen), cerebrospinal fluid analysis (to rule out specific infections that can affect the brain), and analysis of thyroid and thyroid-stimulating hormone levels. A doctor will order only
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the tests that he or she feels are necessary or likely to improve the accuracy of a diagnosis. Psychiatric evaluation A psychiatric evaluation may be obtained to determine whether depression or another psychiatric disorder may be causing or contributing to a person’s symptoms. Pre-symptomatic testing Testing people before symptoms begin to determine whether they will develop dementia is not possible in most cases. However, in disorders such as Huntington’s where a known gene defect is clearly linked to
the risk of the disease, a genetic test can help identify people who are likely to develop the disease. Since this type of genetic information can be devastating, people should carefully consider whether they want to undergo such testing. Researchers are examining whether a series of simple cognitive tests, such as matching words with pictures, can predict who will develop dementia. One study suggested that a combination of a verbal learning test and an odor-identification test can help identify AD before symptoms become obvious. Other studies are looking at whether memory tests and brain scans can be useful indicators of future dementia.
Is there any treatment? While treatments to reverse or halt disease progression are not available for most of the dementias, patients can benefit to some extent from treatment with available medications and other measures, such as cognitive training. Drugs to specifically treat AD and some other progressive dementias are now available and are prescribed for many patients. Although these drugs do not halt the disease or reverse existing brain damage, they can improve symptoms and slow the progression of the disease. This may improve the patient’s quality of life, ease the burden on caregivers or delay admission to a nursing home. Many researchers are also
examining whether these drugs may be useful for treating other types of dementia. Many people with dementia, particularly those in the early stages, may benefit from practicing tasks designed to improve performances in specific aspects of cognitive functioning. For example, people can sometimes be taught to use memory aids, such as mnemonics, computerized recall devices or note taking. Behavior modification – rewarding appropriate or positive behavior and ignoring inappropriate behavior – also may help control unacceptable or dangerous behaviors.
Alzheimer’s disease Alzheimer’s disease falls within the category of neurocognitive disorders, as it is considered a form of dementia. In the early stages, the most common symptom is difficulty in remembering recent events, known as short term memory loss. When AD is suspected, the diagnosis is usually confirmed with tests that evaluate behavior and thinking abilities, often followed by a brain scan if available; however, examination of brain tissue is required for a definitive diagnosis. As the disease advances, symptoms can include confusion, irritability, aggression, mood swings, trouble with language, and long-term memory loss. DSM-5 now recognizes a less severe level of cognitive impairment, mild NCD, which is a new disorder that permits the diagnosis of less disabling syndromes that may nonetheless be the focus of concern and treatment (APA, 2013). Diagnostic criteria are provided for both major NCD and mild NCD, followed by diagnostic criteria for the different etiological subtypes. An updated listing of neurocognitive domains is also provided in DSM-5, as these are necessary for establishing the presence of NCD, distinguishing between the major and mild levels of impairment, and differentiating among etiological subtypes. Although the threshold between mild NCD and major NCD is inherently arbitrary, there are important reasons to consider these two levels of impairment separately. The major NCD syndrome provides consistency with the rest of medicine and with prior DSM editions and necessarily remains distinct to capture the care needs for this group. Although the mild NCD syndrome is new to DSM-5, its presence is consistent with its use in other fields of medicine, where it is a significant focus of care and research, notably in individuals with Alzheimer’s disease, cerebrovascular disorders, HIV, and traumatic brain injury. Most of the drugs currently approved by the U.S. Food and Drug Administration (FDA) for AD fall into a category called cholinesterase inhibitors. These drugs slow the breakdown of the neurotransmitter
acetylcholine, which is reduced in the brains of people with AD. Acetylcholine is important for the formation of memories, and it is used in the hippocampus and the cerebral cortex, two brain regions that are affected by AD. There are currently four cholinesterase inhibitors approved for use in the United States: tacrine (Cognex), donepezil (Aricept), rivastigmine (Exelon), and galantamine (Reminyl). These drugs temporarily improve or stabilize memory and thinking skills in some individuals. Many studies have shown that cholinesterase inhibitors help to slow the decline in mental functions associated with AD, and that they can help reduce behavioral problems and improve the ability to perform everyday tasks. However, none of these drugs can stop or reverse the course of AD. A fifth drug, memantine, (Namenda) is also approved for use in the United States, Unlike other drugs for AD, which affect acetylcholine levels, memantine works by regulating the activity of a neurotransmitter called glutamate that plays a role in learning and memory. Glutamate activity is often disrupted in AD. Because this drug works differently from cholinesterase inhibitors, combining memantine with other AD drugs may be more effective than any single therapy. One controlled clinical trial found that patients receiving donepezil plus memantine had better cognition and other functions than patients receiving donepezil alone. Doctors may also prescribe other drugs, such as anticonvulsants, sedatives and antidepressants, to treat seizures, depression, agitation, sleep disorders and other specific problems that can be associated with dementia. In 2005, research showed that use of “atypical” antipsychotic drugs such as olanzapine and risperidone, to treat behavioral problems in elderly people with dementia was associated with an elevated risk of death in these patients. Most of the deaths were caused by heart problems or infections. The FDA has issued a public health advisory to alert patients and their caregivers to this safety issue.
Vascular dementia There is no standard drug treatment for vascular dementia, although some of the symptoms, such as depression, can be treated. Most other treatments aim to reduce the risk factors for further brain damage. However, some studies have found that cholinesterase inhibitors, such
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as galantamine and other AD drugs, can improve cognitive function and behavioral symptoms in patients with early vascular dementia. The progression of vascular dementia can often be slowed significantly or halted if the underlying vascular risk factors for the disease are treated. To prevent strokes and TIAs, doctors may prescribe medicines to Page 27
control high blood pressure, high cholesterol, heart disease and diabetes. Doctors also sometimes prescribe aspirin, warfarin or other drugs to prevent clots from forming in small blood vessels. When patients have blockages in blood vessels, doctors may recommend surgical
procedures, such as carotid endarterectomy, stenting or angioplasty, to restore the normal blood supply. Medications to relieve restlessness or depression or to help patients sleep better may also be prescribed.
Other dementias Some studies have suggested that cholinesterase inhibitors, such as donepezil (Aricept), can reduce behavioral symptoms in some patients with Parkinson’s dementia. At present, no medications are approved specifically to treat or prevent FTD and most other types of progressive dementia. However, sedatives, antidepressants and other medications may be useful in treating specific symptoms and behavioral problems associated with these diseases. Scientists continue to search for specific treatments to help people with Lewy body dementia. Current treatment is symptomatic, often involving the use of medication to control the Parkinson’s and psychiatric symptoms. Although anti-Parkinsonian medication may help reduce tremor and loss of muscle movement, it may worsen
symptoms such as hallucinations and delusions. Also, drugs prescribed for psychiatric symptoms may make the movement problems worse. Several studies have suggested that cholinesterase inhibitors may be able to improve cognitive function and behavioral symptoms in patients with Lewy body disease. There is no known treatment that can cure or control CJD. Current treatment is aimed at alleviating symptoms and making the patient as comfortable as possible. Opiate drugs can help relieve pain and the drugs clonazepam and sodium valproate may help relieve myoclonus. During later stages of the disease, treatment focuses on supportive care, such as administering intravenous fluids and changing the person’s position frequently to prevent bedsores.
Can dementia be prevented? Research has revealed a number of factors that may be able to prevent or delay the onset of dementia in some people. For example, studies have shown that people who maintain tight control over their glucose levels tend to score better on tests of cognitive function than those with poorly controlled diabetes. Several studies also have suggested that people who engage in intellectually stimulating activities, such as social interactions, chess, crossword puzzles and playing a musical instrument, significantly lower their risk of developing AD and other forms of dementia. Scientists believe mental activities may stimulate the brain in a way that increases the person’s “cognitive reserve” – the ability to cope with or compensate for the pathologic changes associated with dementia. Researchers are studying other steps people can take that may help prevent AD in some cases. So far, none of these factors has been definitively proven to make a difference in the risk of developing the disease. Moreover, most of the studies addressed only AD, and the results may or may not apply to other forms of dementia. Nevertheless, scientists are encouraged by the results of these early studies and may believe it will eventually become possible to prevent forms of dementia. Possible preventive actions include: ●● Lowering homocysteine – In one study, elevated blood levels of the amino acid homocysteine were associated with a 2.9 times greater risk of AD and a 4.9 times greater risk of vascular dementia. A preliminary study has shown that high doses of three B vitamins that help lower homocysteine levels – folic acid, B12 and B6 – appear to slow the progression of AD. Researchers are conducting a multicenter clinical trial to test this effect in a larger group of patients. ●● Lowering cholesterol levels – Research has suggested that people with high cholesterol levels have an increased risk of developing AD. Cholesterol is involved in formation of amyloid plaques in the brain. Mutations in a gene called CYP46 and the apoE E4 gene variant, both of which have been linked to an increased risk of AD, are also involved in cholesterol metabolism. Several studies have also found that the use of drugs called statins, which lower cholesterol levels, is associated with a lower likelihood of cognitive impairment. ●● Lowering blood pressure – Several studies have shown that antihypertensive medicine reduces the odds of cognitive impairment in elderly people with high blood pressure. One large European study found a 55 percent lower risk of dementia in people over 60 who received drug treatment for hypertension. These people had a reduced risk of both AD and vascular dementia. ●● Exercise – Regular exercise stimulates production of chemicals called growth factors that help neurons survive and adapt to new situations. These gains may help to delay the onset of dementia
symptoms. Exercise also may reduce the risk of brain damage from atherosclerosis. ●● Education – Researchers have found evidence that formal education may help protect people against the effects of AD. In one study, researchers found that people with more years of formal education had relatively less mental decline than people with less schooling, regardless of the number of amyloid plaques and neurofibrillary tangles each person had in his or her brain. The researchers think education may cause the brain to develop robust nerve cell networks that can help compensate for the cell damage caused by AD. ●● Controlling inflammation – Many studies have suggested that inflammation may contribute to AD. Moreover, autopsies of people who die with AD have shown widespread inflammation in the brain that appeared to be caused by the accumulation of beta amyloid. Another study found that men with high levels of C-reactive protein, a general marker of inflammation, had a significantly increased risk of AD and other kinds of dementia. ●● Non-steroidal anti-inflammatory drugs (NSAIDs) – Research indicated that long-term use of NSAIDs, ibuprofen, naproxen, and similar drugs, may prevent or delay the onset of AD. Researchers are not sure how these drugs may protect against the disease, but some or all of the effect may be due to reduced inflammation. A 2003 study showed that these drugs also bind to amyloid plaques and may help to dissolve them and prevent formation of new plaques. The risk of vascular dementia is strongly correlated with risk factors for stroke, including high blood pressure, diabetes, elevated cholesterol levels and smoking. This type of dementia may be prevented in many cases by changing lifestyle factors, such as excessive weight and high blood pressure, which are associated with an increased risk of cerebrovascular disease. One European study found that treating isolated systolic hypertension (high blood pressure in which only the systolic or top number is high) in people age 60 and older reduced the risk of dementia by 50 percent. These studies strongly suggest that effective use of current treatments may prevent future cases of vascular dementia. A study published in 2005 found that people with mild cognitive impairment who took 10mg/day of the drug donepezil had a significantly reduced risk of developing AD during the first two years of treatment, compared to people who received vitamin E or placebo. By the end of the third year, however, the rate of AD was just as high in the people treated with donepezil as it was in the other two groups.
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What kind of care do people with dementia need? People with moderate and advanced dementia typically need round the clock care and supervision to prevent them from harming themselves or others. They also may need assistance with daily activities such as eating, bathing and dressing. Meeting these needs takes patience, understanding and careful thought by the person’s caregivers. A typical home environment can present many dangers and obstacles to a person with dementia, but simple changes can overcome many of these problems. For example, sharp knives, dangerous chemicals, tools and other hazards should be removed or locked away. Other safety measures include installing bed and bathroom safety rails, removing locks from bedroom and bathroom doors and lowering the hot water temperature to 120F (48.9C) or less to reduce the risk of accidental scalding. People with dementia also should wear some form of identification at all times in case they wander away or become lost. Caregivers can help prevent unsupervised wandering by adding locks or alarms to outside doors. People with dementia often develop behavior problems because of frustration with specific situations. Understanding and modifying or preventing the situations that trigger these behaviors may help to make life more pleasant for the person with dementia as well as his or her caregivers. For instance, the person may be confused or frustrated by the level of activity or noise in the surrounding environment. Reducing unnecessary activity and noise (such as limiting the number of visitors and turning off the television when it’s not in use) may make it easier for the person to understand requests and perform simple tasks. Confusion also may be reduced by simplifying home decorations, removing clutter, keeping familiar objects nearby and following a predictable routine throughout the day. Calendars and clocks also may help patients orient themselves.
People with dementia should be encouraged to continue their normal leisure activities as long as they are safe and do not cause frustration. Activities such as crafts, games and music can provide important mental stimulation and improve mood. Some studies have suggested that participating in exercise and intellectually stimulating activities may slow the decline of cognitive function in some people. Many studies have found that driving is unsafe for people with dementia. They often get lost and they may have problems remembering or following rules of the road. They also may have difficulty processing information quickly and dealing with unexpected circumstances. Even a second of confusion while driving can lead to an accident. Driving with impaired cognitive functions can also endanger others. Some experts have suggested that regular screening for changes in cognition might help to reduce the number of driving accidents among elderly people, and some states now require that doctors report people with AD to their state motor vehicle department. However, in many cases, it is up to the person’s family and friends to ensure that the person does not drive. The emotional and physical burden of caring for someone with dementia can be overwhelming. Support groups can often help caregivers deal with these demands, and they can also offer helpful information about the disease and its treatment. It is important that caregivers occasionally have time off from round-the-clock nursing demands. Some communities provide respite facilities or adult day care centers that will care for dementia patients for a period of time, giving the primary caregivers a break. Eventually, many patients with dementia require the services of a full-time nursing home.
What research is being done? Current research focuses on many different aspects of neurocognitive disorders. This research promises to improve the lives of people
affected by the dementia and may eventually lead to ways of preventing or curing these disorders.
Causes and prevention Research on the causes of AD and other dementias includes studies of genetic factors, neurotransmitters, inflammation; factors that influence programmed cell death in the brain and the roles of tau, beta amyloid and the associated neurofibrillary tangles and plaques in AD. Some other researchers are trying to determine the possible roles of cholesterol metabolism, oxidative stress (chemical reactions that can damage proteins, DNA and lipids inside cells) and microglia in the development of AD. Scientists also are investigating the role of the enzyme telomerase. Since many dementias and other neurodegenerative diseases have been linked to abnormal clumps of proteins in cells, researchers are trying to learn how these clumps develop, how they affect cells and how the clumping can be prevented. Some studies are examining whether changes in white matter, nerve fibers lines with myelin, may play a role in the onset of AD. Myelin may erode in AD patients before other changes occur. This may be due to a problem with oligodendrocytes, the cells that produce myelin. Researchers are searching for additional genes that may contribute to AD, and they have identified a number of gene regions that may be involved. Some researchers suggest that people will eventually be screened for a number of genes that contribute to AD and that they will
be able to receive treatments that specifically address their individual genetic risks. However, such individualized screening and treatment is still years away. Insulin resistance is common in people with AD, but it is not clear whether the insulin resistance contributes to the development of the disease or if it is merely a side effect. Several studies have found a reduced risk of dementia in people who take cholesterol-lowering drugs called statins. However, it is not yet clear if the apparent effect is due to the drugs or to other factors. Early studies of estrogen suggested that it might help prevent AD in older women. However, a clinical study of several thousand postmenopausal women aged 65 or older found that combination therapy with estrogen and progestin substantially increased the risk of AD. Estrogen alone also appeared to slightly increase the risk of dementia in this study. A 2003 study found that people with HIV-associated dementia have different levels of activity for more than 30 different proteins, compared to people who have HIV but no signs of dementia. The study suggests a possible way to screen HIV patients for the first signs of cognitive impairment, and it may lead to ways of intervening to prevent this form of dementia.
Diagnosis Improving early diagnosis of AD and other types of dementia is important not only for patients and families but also for researchers who seek to better understand the causes of dementing diseases and find ways to reverse or halt them at early stages. Improved diagnosis can also reduce the risk that people will receive inappropriate treatments. Psychology.EliteCME.com
Some researchers are investigating whether three-dimensional computer models of PET and MRI images can identify brain changes typical of early AD before any symptoms appear. This research may lead to ways of preventing the symptoms of the disease. Page 29
One study found that levels of beta amyloid and tau in spinal fluid can be used to diagnose AD with a sensitivity of 92 percent. If other studies confirm the validity of this test, it may also help doctors to identify people who are beginning to develop the disorder before they start to show symptoms. This would allow treatment at very
early stages of the disorder and may help in testing new treatments to prevent or delay symptoms of the disease. Other researchers have identified factors in the skin and blood of AD patients that are different from those in healthy people. They are trying to determine whether these factors can be used to diagnose the disease.
Treatment Researchers are continually working to develop new drugs for AD and other types of dementia. Many researchers believe a vaccine that reduces the number of amyloid plaques in the brain might ultimately prove to be the most effective treatment for AD. In 2001, researchers began one clinical trial of a vaccine called AN-1792. The study was halted after a number of people developed inflammation of the brain and spinal cord. Despite these problems, one patient appeared to have reduced numbers of amyloid plaques in the brain. Other patients showed little or no cognitive decline during the course of the study, suggesting that the vaccine may slow or halt the disease. Researchers are now trying to find safer and more effective vaccines for AD. Researchers are also investigating possible methods of gene therapy for AD. In one case, researchers used cells genetically engineered to produce nerve growth factor and transplanted them into monkey’s forebrains. The transplanted cells boosted the amount of nerve growth factors in the brain and seemed to prevent degeneration of acetylcholine-producing neurons in the animals. This suggests that gene therapy might help to reduce or delay symptoms of the disease. Researchers are now testing a similar therapy in a small number of patients. Other researchers have experimented with gene therapy that adds a gene called neprilysin in a mouse model that produces human beta amyloid. They found that increasing the level of neprilysin
greatly reduced the amount of beta amyloid in the mice and halted the amyloid-related brain degeneration. They are now trying to determine whether neprilysin gene therapy can improve cognition in mice. A clinical trial called the Vitamins to Slow Alzheimer’s Disease (VITAL) study is testing whether high doses of three common B vitamins, folic acid, B12, and B6, can reduce homocysteine levels and slow the rate of cognitive decline in AD. Since many studies have found evidence of brain inflammation in AD, some researchers have proposed that drugs that control inflammation, such as NSAIDs, might prevent the disease or slow its progression. Studies in mice have suggested that these drugs can limit production of amyloid plaques in the brain. Early studies of these drugs in humans have shown promising results. However, a large NIH funded clinical trial of two NSAIDs (naproxen and celecoxib) to prevent AD was stopped in late 2004 because of an increase in stroke and heart attack in people taking naproxen, and an unrelated study that linked celecoxib to an increased risk of heart attack. Some studies have suggested that two drugs, pentoxifylline and propentofylline, may be useful in treating vascular dementia. Pentoxifylline improves blood flow, while propentofylline appears to interfere with some of the processes that cause cell death in the brain (Medicine Net, 2014).
Psychosocial factors of disorders on the elderly Factors such as where an elderly person lives and who cares for that person do have an impact on the overall well-being of the elder person. Studies have demonstrated that those elderly persons who live alone do tend to have more symptoms of depression (Dean, Kolody, Wood and Matt, 1992). Other studies have similar findings. One recent study of elderly Europeans indicated that marital partners tend to be the most important factor in preventing depression in the elderly, but frequent contact with children also predicts less depressive symptoms. Those elderly persons who lived alone experienced the highest levels of depression (Buber and Engelhardt, 2008).
Furthermore, many elderly persons are also caregivers to other elderly persons, usually their spouses, thus causing another psychosocial factor that greatly affects the mental health of many of the elderly. Not only is an elderly person affected by who they live with, he or she is also affected by the setting in which they live. The setting in which an elderly person resides can affect his or her access to care and the quality of the care received. In addition, the cultural influences in the life of an elderly person also exert a profound impact upon their view of mental illness, their coping mechanisms, and their resistance to treatment.
Nursing homes and assisted living For many reasons, both physical and mental, it is not appropriate for some seniors to live on their own. However, that an elderly person lives in a residential facility does not ensure that mental health needs are being met. It has been estimated that two-thirds of nursing home residents have some form of emotional or behavioral disturbances, and one-half are taking psychotropic medications. However, the medical staff often failed to look at the clients holistically and focused on the behavioral issues only, ignoring the underlying medical causes, such as untreated infections and chronic pain as conditions that added to the mental health issues (Gruber-Baldini, et al., 2004). Chapin, Reed and Dobbs (2004) also found that depression was underdiagnosed in those elderly persons living in assisted living facilities, and residents had little understanding of mental health resources or how to access those services. Other studies have similar findings, in that many of the assisted living home residents had symptoms of mental illness (Gottsman, Peskin, Kennedy and Mossey, 1991). A survey of assisted living facility administrators indicated that while many of them were aware of mental health issues, many of their staff members who dealt directly with residents had no mental health training, and only about half of the facilities had a mental health
professional to provide a mental health assessment at intake. When the facility personnel were aware of unmet mental health needs, they did make referrals, but most often the referrals were made to general practitioners rather than mental health specialists. The author noted that assisted care facilities overall needed more training for staff to assess for mental health issues and to learn about resources and referrals in the community (Cummings, 2003). Despite the higher level of medical care provided to residents, nursing homes still overall lack effective strategies and systems of care for mentally ill residents. Carlson and Snowden (2007) noted that it has been estimated that 12 percent to 21 percent of residents in nursing homes suffer from depression. In addition, anywhere from 35 percent to 60 percent of nursing home residents take antidepressants. But about 20 percent of those getting treatment still showed significant signs of depression, which is indicative that the treatment received was inadequate and not well-monitored overall. Some nursing homes have incorporated the use of care managers who educate the family and patient about medication and other forms of treatment, create treatment plans that incorporate the appropriate forms
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of treatment and monitor the patient’s progress. According to Carolson and Snowden, effective programs have several common elements: ●● Screening tools, such as the DSM-IV structured clinical interview, which remains in place despite revisions of DSM-5. ●● Antidepressants, closely monitored by the nurse who serves as care manager and who has the authority to adjust medications as needed. ●● Psychotherapy, which is most often problem-solving therapy or interpersonal therapy. ●● Supervision of case managers by a psychiatrist, who may be on staff or contracted. After extensive review of the published literature on the treatment of nursing home patients for dementia and depression, the two most common diagnoses seen in this population, there were not a sufficient number of studies to determine what the best practices were for care of the elderly with these diagnoses. The authors determined that neither medication nor therapy totally eliminated symptoms, but interventions can lessen symptoms. Furthermore, there were not enough studies to determine whether therapy or medication was more effective. A good deal of evidence existed in the studies reviewed to support the use of antipsychotic medication, but there was less support for the use of antidepressants or benzodiazepines. The authors further recommended that there was a need for more accurate screening tools for mental illness and a need for more studies on the efficacy of medication to treat dementia and depression. An expert interdisciplinary panel led by the American Geriatrics Society (AGS) and the American Association for Geriatric Psychiatry (AAGP) and including representatives from numerous stakeholder organizations has issued a new consensus statement calling for significant revisions to the standards of care for nursing home residents with depression and behavioral symptoms associated with dementia. The AGS and AAGP have also issued health policy recommendations that address implementation of the expert panel’s clinical recommendations. Approximately 1.5 million older adults currently reside in nursing homes across the United States, and about one-fifth of those residents have symptoms of depression. Up to 40 percent of residents with dementia have both behavioral and psychiatric symptoms that could be alleviated by proper care and treatment. According to the panel, “the current protocols for the screening and management of these problems are inadequate.” Joseph G. Ouslander, MD, former AGS president and co-chair of the expert panel, states, “The current system does not provide enough specific recommendations for nursing home staff to
develop optimal, individualized care plans based on their assessment of depression and behavioral symptoms.” Among its recommendations, the panel calls for routine and regular screening for depression in every nursing home resident. They also call for improved screening instruments and first-line treatment of major depression with antidepressant medications in combination with nonpharmacologic interventions. The consensus statement also outlines numerous approaches for nursing home administrators and staff to improve the environment for residents, thus enhancing their independence, sense of well-being and quality of life. The panel states that better assessment tools for residents with dementiarelated behavioral symptoms are required, as well as careful and regular evaluation to determine whether a resident’s symptoms may be the result of adverse drug interactions or other medical conditions. The panel also states that barriers to using effective drug therapies such as restrictive formularies and attitudes about using psychotropic drugs as “chemical restraints” should be reassessed in order to provide the best care for residents. “Most importantly, we need to take advantage of the large body of research on effective interventions by ensuring that evidencebased mental health treatments are provided in nursing homes,” says Stephen J. Bartels, MD, former AAGP president and expert panel co-chair. “Improving the quality of care for residents with mental health problems will require enhanced training and staffing in nursing home needs, complimented by greater availability of mental health consultation services.” The AGS and AAGP policy recommendations include: ●● Making mental health services more available to nursing homes, particularly in rural areas and those that are publicly financed. ●● Including coverage for mental health services and health medications in public and private insurance plans that cover nursing home residents. ●● Rewarding facilities that provide appropriate pharmacologic and non-pharmacologic treatment for residents with mental illness. ●● Encouraging staff training to identify residents with mental illness. ●● Promoting research to identify the best practices in meeting the mental health care needs of nursing home residents. The consensus statement and policy recommendations are intended to assist regulators at the Centers for Medicare and Medicaid Services (CMS) and other agencies as they make revisions to the current guidelines and quality measures for nursing homes.
In-home care While many elderly persons enter long-term care settings, many more are cared for at home by family members. A recent interview with Dr, Stephen Golant, an expert on elderly housing at the University of Florida, notes than the elderly are moving more towards home-based care, in part due to concerns about the cost of assisted living facilities and nursing homes. In addition, seniors tend to prefer to live in their own homes (AARP, 2014). He stated that this does create burdens for caregivers that are becoming more difficult to reconcile given that many women now work outside the home. Many caregivers of older people are themselves older adults. Of those caring for someone aged 65 or older, the average age of caregivers is 63, with a third of these caregivers in fair to poor health themselves (Administration on Aging, 2004). One survey found that 58 percent of caregivers were over the age of 65, and that more than 10 percent were over the age of 80. There are two primary aspects to the roles of caregivers: relationship between caregivers and the identified patient, and caregiver’s mental well-being. The Family Caregiver Alliance (FCA), a national nonprofit organization that provides information and referral for caregivers as well as medical and social service personnel, notes that the average caregiver is a
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married woman between the ages of 45-55 who works full time and also devotes an average of 20 hours per week to care giving. The Family Caregiver Alliance also notes the following statistics concerning caregivers in the United States on its website: www.caregiver.org: ●● By the year 2007, the number of care-giving households in the U.S. for persons aged 50-plus could reach 39 million. ●● Over three-quarters (78 percent) of adults living in the community and in need of long-term care depend on family and friends (i.e., informal caregivers) as their only source of help; 14 percent receive a combination of informal and formal care (i.e., paid help); only 8 percent used formal care or paid help only. ●● Even among the most severely disabled older persons living in the community, about two-thirds rely solely on family members and other informal help, often resulting in great strain for the family caregivers. The use of informal care as the only type of assistance by older Americans aged 65 and over increased from 57 percent in 1994 to 66 percent in 1999. The growth in reliance upon informal care between 1994 and 1999 is accompanied by a decline in the use of a combination of informal and formal care from 36 percent in 1994 to 26 percent in 1999.
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●● Thirty percent of persons caring for elderly long-term care users were themselves aged 65 or over; another 15 percent were between the ages of 45-54.
●● For the family caregiver forced to give up work to care for a family member or friend, the cost in lost wages and benefits is estimated to be $109 per day.
Elderly caregivers Those elderly persons who care for others are themselves at high risk for developing a mental illness. The Family Caregiver Alliance notes that: ●● Women experience depression at a higher rate than men. Women, primarily wives and daughters, provide the majority of care giving. In the United States, approximately 12 million women experience clinical depression each year, at approximately twice the rate of men. A National Mental Health Association survey on the public’s attitude and beliefs about clinical depression found that more than one-half of women surveyed still believe it is “normal” for a woman to be depressed during menopause. ●● Men who are caregivers deal with depression differently. Men are less likely to admit to depression and doctors are less likely to diagnose depression in men. Men will more often “self-treat” their depressive symptoms of anger, irritability or powerlessness with alcohol or overwork. Although male caregivers tend to be more willing than female caregivers to hire outside help for assistance with home care duties, they tend to have fewer friends to confide in or positive activities outside the home. The assumption that depressive symptoms are a sign of weakness can make it especially difficult for men to seek help. ●● Lack of sleep contributes to depression. While sleep needs vary, most people need eight hours a day. Loss of sleep as a result of caring for a loved one can lead to serious depression. The important thing to remember is that even though you may not be able to get your loved one to rest throughout the night, you can arrange to get much needed sleep. Hiring a respite worker to be with your loved one while you take a nap or finding a care center or scheduling a stay-over with another family member for a few nights are ways to keep your care-giving commitment while getting the sleep you need. ●● Depression can persist after placement in a care facility. Making the decision to move a loved one to a care center is very stressful. While many caregivers are finally able to catch up on much needed rest, loneliness, guilt and monitoring the care a loved one receives in this new location can add new stress. Many caregivers feel depressed at the time of placement, and some continue to feel depressed for a long time after. One well-known study by Schulz, et al., (1995), looked at depression in caregivers of Alzheimer’s patients over a four-year period and concluded that female caregivers overall experience more depressive symptoms, but if men stay in a long-term care-giving role, they begin to become increasingly depressed as time goes on. For men and women, the more difficult a person was to care for in terms of behavior, the higher the levels of associated stress in the caregivers. Furthermore, the authors also noted that perceived levels of high social support tended to buffer caregivers against depression. Overall, in another study, depression was found to be the most commonly reported mental health problem for caregivers (Bergman-Evans, 1994). Other studies have shown that the major risk factor for the development of depression in caregivers is loss of social contacts and support that a caregiver often experiences when devoting so much time to the person in care. In one recent study it was determined that elderly caregivers typically report an extra 30 days per year of depression than do elderly persons who do not have care-giving responsibilities (Thompson, Fan, Unutzer, and Katon, 2007).
Caregivers of those persons with dementia are especially at a high risk of developing depression. The Family Caregiver Alliance warns caregivers of the potential consequences of providing long-term care for someone with dementia on the website www.caregiver.org: “Researchers have found that a person who provides care for someone with dementia is twice as likely to suffer from depression as a person providing care for someone without dementia. The more severe the case of dementia, such as that caused by Alzheimer’s disease, the more likely the caregiver is to experience depression. It is critical for caregivers, especially in these situations, to receive consistent and dependable support.”
Caring for a person with dementia can be all-consuming. It is different from other types of care giving. Not only do caregivers spend significantly more hours per week providing care, they report more employment problems, personal stress, mental and physical health problems, less time to do the things they enjoy, less time to spend with other family members and more family conflict than non-dementia caregivers. As stressful as the deterioration of a loved one’s mental and physical abilities may be for the caregiver, dealing with dementiarelated behavior is an even bigger contributor to developing symptoms of depression. Dementia-related symptoms such as wandering, agitation, hoarding and embarrassing conduct make every day challenging and make it harder for a caregiver to get rest or assistance in providing care. Unfortunately, many barriers exist that keep caregivers from getting the help they need for depression. According to Grey (2003), caregivers fail to get treatment due to several factors: ●● Caregivers are too focused on the needs of those they care for and do not take time to take care of themselves. ●● The financial resources of the family are often being used by the person that the caregiver takes care of, ●● And there is not enough left for the caregiver to pay for therapy and medication. ●● Few programs exist to provide outreach to caregivers and provide them with support and linkage to resources. ●● Primary care physicians tend to focus only on the patient and do not address the overall needs of the family system. ●● Primary care physicians often overlook depression and do not diagnose it in caregivers. In some areas, programs do exist to provide respite care for a few hours or even a few days, and other inventive programs are found to give support and counseling to caregivers. However, most states do not have these types of programs. The American Medical Association, as well several states including California, Wisconsin, Minnesota, Pennsylvania and Washington, have developed tools for the assessment of caregivers to identify those who are suffering from depression, anxiety, and other issues and to link these caregivers to resources.
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Cultural influences African American elderly Ethnic minority elderly persons have been understudied overall in mental health and psychiatry. However, their numbers are growing even more rapidly than the elder population in general. For example, the elderly African American population is expected to grow by at least 8 percent by the year 2050. However, African American elderly persons are very much underrepresented in studies of the elderly. Moreover, there are often barriers to mental health treatment for the elderly African American population that can make their treatment more difficult. As noted by Ahmed and Kramer (2006), there is a high level of stigma attached to seeking mental health services for elderly African Americans. Frequently, these elderly persons prefer to seek help from their pastors or other religious leaders. In addition, elderly African Americans tend to be distrustful of the mental health establishment and often feel culturally disconnected to the providers who are very often Caucasian. Furthermore, a lack of cultural understanding has historically led to misunderstanding between older African Americans and the mental health profession. For example, ethnic majority mental health professionals often overlook many of the life events that older African Americans
experienced as severe trauma as a result of segregation and racial violence. Consequently, the mental health establishment often misinterprets the reactions of elderly African Americans towards society as paranoid when these behaviors are, instead, understandable when viewed with a culturally sensitive lens. In addition, some older African Americans may also express emotional distress in ways that do not have a label in the ethnic majority culture, which are described as “culture bound syndromes.” For example, “falling out” is an emotional state that consists of dizziness and collapse and is widely recognized in the African American culture, but has no real counterpart in Caucasian culture. Some older African Americans may also believe in “rootwork,” which attributes psychological problems to someone placing a hex on an individual. In addition, African Americans may respond differently to psychoactive medications than Caucasians do. Ahmed and Kramer (2006) cite the work of Lin, et al (1997) that indicated that African Americans might metabolize medications differently than Caucasians.
Hispanic elderly persons Many Hispanics are reluctant to seek mental health treatment due to language and cultural barriers. This is particularly true among older Hispanics, who often know less English than younger Hispanics. Furthermore, due to cultural differences, treating Hispanic persons can be difficult if a clinician is unaware of some cultural influences that impact the therapeutic relationship. Ahmed and Kramer cite the work of Anez, et al (2005) and Gloria and Peregoy (1996) to describe common cultural situations: ●● Falisimo is a term that describes a cultural value among Hispanics that encourages the importance of the family over the individual and for family to be highly valued in general. Extended family tends to be very important and can serve as strength, but also a hindrance to treatment if the family disapproves of treatment for an individual. ●● Simpatia is a cultural value that emphasizes harmony over conflict. Simpatia, however, can result in Hispanics agreeing with a mental health professional about a course of treatment to avoid creating conflict. However, the person may not follow through with recommendations, but agree to avoid conflict. ●● Personalismo is the high regard for getting to know another person in a social setting. Hispanic persons may expect and desire to relate on a social level to the clinician and may feel offended if the clinician ignores this need and gets right to business with the client.
●● Respero is the respect for elders and placing great value on the advice and opinions of the elders of a family. In addition, respero includes the cultural expectation that children will take care of their parents into the elderly years. ●● Fatalismo is the belief that greater powers control life events and one’s destiny. This belief can lead to a person having a strong external locus of control. ●● Verguenza is a cultural tradition that revolves around shame. Seeking treatment may bring shame upon a family, and Hispanics will seek to avoid bringing shame if at all possible. This can be a barrier to seeking treatment. ●● Machismo and marianismo are terms that describe gender roles in Hispanic persons. Machismo refers to the traditional role of a man as a protector and provider for his family. Marianismo is the cultural expectation that a woman will be submissive to men and be a nurturing wife and mother. In addition, many Hispanics practice various religious belief systems such as Santeria, Espiritismo, and Curanderismo. These systems have some common themes regarding the placing of spells and various healing practices to heal the afflicted. Many elderly Hispanic persons have strong beliefs regarding these practices and may wish to use these instead of traditional mental health treatment.
Asian Americans elderly Asian Americans are the fastest growing minority group in the United States. Asian Americans are comprised of many ethnic groups from numerous countries, with the majority of Asian Americans being Chinese, who make up about 25 percent of all Asians in the United States. As a result of certain cultural and religious beliefs, many Asian Americans believe it is better to deal with mental illness within the family and avoid involving “outsiders.” In addition, the language barrier is often a reason why Asian Americans avoid seeking mental health services. It is also difficult, due to their cultural expectations, to value the needs of the individual over the needs of the family. For many Asian Americans, it can be difficult to understand Western-based therapy, which emphasis individual happiness and choices, often at the expense of the wants and desires of the family unit.
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Asian Americans are typically expected to care for their elderly parents and do not consider this to be burdensome. Elderly persons expect that their children will care for them and are not as concerned as Caucasians with the notion of being a burden for their children. This high level of family support can be seen as a strength for older Asian Americans. However, among many of the Asian cultures, there is a high respect shown for authority figures, which can include mental health professionals. This respect will sometimes result in the client agreeing to follow the recommendations of the therapist, but the client will not actually follow through with these recommendations. (Ahmed and Kramer, 2006).
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Pharmacological treatment for Asian Americans Some studies have indicated that Asian Americans do metabolize medications such as benzodiazepines and antipsychotic medications differently than Caucasians do, which can have adverse effects for treatment. Furthermore, many Asians take herbal supplements that can interact in adverse ways with medications (Ahmed and Kramer, 2006). Cultural issues In many Asian cultures there is a particular stigma associated with mental illness. There is a primary concern that if mental illness becomes known, other people will not want to marry into the family. Therefore, the family often conceals psychosis until it has reached the critical point, which can make it more difficult to treat. There are also several culture-bound syndromes described by Ahmed and Kramer (2006) that occur in Asian cultures but do not have a diagnosis in our culture: ●● Amok, which is most frequently noted in Southeast Asia, that describes a rampage often resulting in death.
●● Phii Pob: in Thailand, this is a possession by a spirit and most frequently occurs in females. ●● Hsieh Ping, which occurs in Thailand, is the manifestation of symptoms that include agitation, speaking in tongues and hallucinations. ●● Hwa-byung, which is found primarily in Korea and is the presentation of symptoms such as feeling pressure in the chest, fear, headaches, fatigue and suicidal thoughts; it is believed to be the result of unexpressed anger. ●● Shenjing sheuiaro, found in China, which results in insomnia, loss of appetite, problems with concentration, memory loss, headaches and sexual dysfunction. ●● Latah is a disorder mostly found in Malaysian females, which results in disassociated behaviors and extreme startle responses and is believed to be caused by possession. ●● Shin-byung is found in Koreans and results in anorexia, weakness, and insomnia and is believed to result from the possession by one’s ancestors.
Native American elderly Native Americans tend to have higher rates of substance abuse, suicide and anxiety than Caucasians or any other minority group. Native Americans have a long history of oppression and abuse from Caucasian society and have suffered many atrocities over the centuries. The resulting poverty, lack of education, grief and ongoing family conflicts have had many negative effects on Native Americans. The
cultural mistrust of “outsiders” has its basis in reality and thus, makes it difficult for many Native Americans to accept services from external resources. (It is interesting to note that among some tribes, dementia is viewed as a sign of the ability to communicate with the afterlife and is actually held in high esteem by other tribal members, rather than a negative condition that requires intervention and treatment.)
Elder mental illness prevention The key issues in preventing major mental illness in the elderly are: ●● Increasing the access of seniors to services in the community. ●● Eliminating the stigma that many older adults feel towards mental health therapy. Some research relates to the importance of removing the stigma associated with receiving treatment for mental illness. Prevention efforts to change the attitudes of elderly persons towards the access of mental health services have been studied, and the research indicated that brief
psycho-educational outreach could increase the participation of senior adults in outpatient mental health counseling (Alvidrez, Arean, and Stewart, 2005). Other studies have had similar findings, in that providing education to this population group can help remove that stigma and move them into treatment earlier, thus preventing some later problems. “Spiritual and community support have also been shown to help keep elderly persons more active and provide an overall greater sense of wellbeing. Social supports help to insulate a person against life events such as bereavement and physical illnesses,” (Boyd, 2005).
Suicide prevention Suicide prevention has received most of the attention in the area of prevention of mental illness and the elderly. There are several risk factors for suicide in the elderly that can be assessed and managed. Certain types of medications can be used in killing oneself rather easily. Therefore, in depressed persons, it is better not to prescribe amitriptyline and dosulepin (Henry et al., 1995). The increased education and training of general medical practitioners is also critical in the prevention of suicide. A large number of elderly persons who committed suicide were found to have visited their primary care doctor in the month before they killed themselves. Training that is focused on helping doctors recognize the signs of depression would help to prevent some suicides (Vassilas and Morgan 1994; Harwood et al, 2000).
In screening the elderly for suicidal intentions, there are some indications that both the Beck Hopelessness Scale and the Geriatric Depression Scale offer insight into the intent of an elderly person. Suicidal ideations in the elderly are typically preceded by problems with physical health as well as higher scores on Beck’s Hopelessness Scale (Hill, et al., 1988). Furthermore, Dennis, et al., (2005) noted that among those elderly persons who suffered from depression, the Geriatric Depression Scale showed that those who had attempted suicide were more likely to have answered yes to the question: “ Do you feel your situation is hopeless?” and to have answered no to, “is it wonderful to be alive now?” Therefore, the utilization of these screening instruments can be an effective tool in identifying those elderly persons who are at higher risk of suicide and consequently alert providers to the need for increased monitoring or more intensive interventions.
Prevention of depression There is also evidence that targeted prevention programs can help prevent the development of depression. Wilson, Mottram and Sixsmith (2007) found in their study of elderly persons between the ages of 80 to 90 that not living close to friends and family, dissatisfaction with housing and strong financial concerns were all associated with higher levels of depression. This research indicates that screening procedures that assess these types of concerns in the elderly can then lead to specific interventions to alleviate these risk factors.
It is critical for those on the “front lines” who regularly interact with elderly persons receive training to recognize depression in their clients. A recent study examined a program delivered by case managers to high-risk elderly persons. Case managers were trained to provide screening and assessment, education, referral and linkage. The authors studied levels of depression, utilization of mental health services, overall health and levels of social and physical activity. Overall, there was a modest decrease in depressive symptoms, but the participants were much more knowledgeable about services available to them
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and understood that engaging in increased levels of activity led to a better sense of well-being, and had overall less physical pain (Arean, Alexopolous, and Chu, 2007). Because many of the elderly in the United States live in nursing homes, it is essential that nursing home personnel recognize the signs of depression. A recent study of nursing home residents demonstrated that efforts to educate caregivers to recognize and respond to
depressive symptoms in the residents appeared to have a positive effect. The authors studied two groups of caregivers, providing education to recognize depression symptoms to one of the groups. They assessed depressive symptoms over a period of time for residents assigned to all of the caregivers. The residents who interacted with the trained caregivers had overall lower rates of depression than those residents whose caregivers were not trained to recognize symptoms of depression (Cuijpers and Lammeren, 2000).
Substance abuse prevention Substance abuse prevention takes on three main forms: ●● The first is primary prevention, which can range from regulating certain substances in an effort to curb their usage to consultation from a pharmacist or physician when an older adult begins taking prescription drugs with a high rate of abuse, such as narcotic painkillers. Primary prevention efforts can also involve public education campaigns to educate the public about the issues of substance abuse in an attempt to prevent people from ever beginning the use of substances. ●● Secondary prevention acknowledges that a person may have already begun to use a substance, and these prevention strategies are designed to intervene against further use of an illegal substance such as marijuana, or to warn people against developing issues with misuse of a substance, or to halt a progression towards addiction. ●● Tertiary prevention involves efforts to halt the progression of substance abuse that is rather severe, and to stop it from becoming fatal (Carlson, 1994). Substance abuse is typically underdiagnosed in the elderly population. Substance abuse in the elderly often involves prescription medications or alcohol, rather than street drugs such as marijuana, heroin or cocaine. In treating the elderly, it is critical to realize that prevention efforts against substance abuse often have further-reaching impacts on the elderly person’s health. Substance abuse of alcohol or prescription drugs can have a profound impact on the other medications that an elderly person may truly need for other health conditions. It can also be more difficult to utilize prevention methods regarding prescription medications when many doctors do not consider that the elderly are often more sensitive to medications overall. Many medications are simply inappropriate for elderly persons due to the tendency of some medications to lead to mental confusion and problems with physical coordination that result in falls and injuries (Carlson, 1994). It would seem incongruous that many physicians who treat the elderly are not aware of these issues, but studies have indicated about 25 percent of elderly persons were prescribed wrong medications (Wilcox, 1994). Complicated issues accompany elderly persons and medications, in addition to the prevention of the misuse of prescription drugs. Some studies have shown that elderly persons often withhold information from their physicians because they think many of their symptoms are a normal part of aging and not important enough to mention. Other seniors have limited incomes and do not consistently stay on their medications because they cannot afford them. In addition, many doctors do not take enough time to explain side effects and the importance of medication compliance to their patients. Better training with physicians is needed to help prevent prescription medication complications within the elder population (Carlson, 1994). Carlson goes on to note that prevention of substance abuse in the elderly should focus on general education towards preparing the elderly for life changes, financial preparation and bereavement. In addition, there needs to be more education for the elderly about the dangers of alcohol and prescription drug abuse. However, these prevention efforts need to target not just heavy drinkers, but also those who are infrequent users in order to help them understand the dangers of mixing alcohol and prescription drugs. Furthermore, moderate Psychology.EliteCME.com
drinkers need to understand how the physiological differences that accompany advancing age also change the body’s response to alcohol. The quantity of alcohol absorbed within the body at age 45 may be too great for a 75-year-old person. In addition, based on the extensive study of multistate prevention efforts, Carlson noted common factors that should be present for the successful implementation of substance abuse prevention efforts: 1. Collaboration – The plans for an elderly substance abuse and misuse prevention initiative should be developed with participation from other state-level agencies involved in services to older adults, include consultation with relevant local and regional service providers and also involve participation by representatives from the aging community. This recommendation recognizes the various services that might be appropriate entry or target points for prevention efforts and the importance they have had in prevention efforts elsewhere. Early involvement is critical for full utilization of these options in any program implementation. It also acknowledges the diverse interests such groups represent and the need for any initiative to reflect this diversity and draw on its strengths. 2. Information – Strategies for any prevention initiative should include compilation and packaging of information about the targeted problem or problems, and where and how to access additional resources and services. Such a package should make maximal use of existing materials and resources, with the primary attention directed to distribution of information rather than development of new materials. This recommendation addresses the existing availability of diverse informational and training materials and stresses the value of putting them together in such a way as to improve their accessibility through a carefully planned distribution strategy. The goal is to have them more readily and widely identified, reviewed and utilized. 3. Education – Considerations for support of education and training should include the elderly clients, their family members, senior and substance abuse services providers, other caregivers and gatekeepers, and health care providers that include physicians. Effective prevention requires the involvement of the individual at risk plus the complex network of associates and service providers likely to be in a position to perpetuate, identify or intervene in the substance abuse or misuse problem. The recommendation draws on indications that multiple points of action are most effective. It also acknowledges the central role often played by others in the health and well-being of older adults. 4. Scope-prevention initiatives for the elderly should be wide in scope and include as part of their aims not only improvement in general health behaviors other than substance abuse and misuse but also support for secondary intervention and treatment. This recommendation is consistent with the suggestions of experts in the field about the need to include a range of prevention strategies with this age group. It also attends to the often-overlapping causes and consequences of health behaviors among older adults and the advantages of intervening to prevent further health compromises.
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5. Pilot program – Pilot or demonstration programs should be considered that improve linkages between information and education efforts and individualized attention or counseling.
areas for specific changes directly influencing substance abuse and misuse and their prevention or intervention, as well as more general policies affecting quality of life and social roles.
Standard prevention approaches often fail to lead to the desired behavioral change. One solution identified to improve these outcomes is to complete more personalized follow-up, particularly with high-risk individuals. The recommendation aims to encourage the planners of elderly prevention programs to be innovative and to draw on research knowledge of what is likely to be effective. 6. Policy – Finally, prevention strategies should review state and agency policies that affect this age group, seeking to identify
This final recommendation addresses the power of policy to shape action. Policy directives have been identified elsewhere as ways to influence medication practice, improve access to substance abuse services and reduce ageism and stereotypes. Policy can lead to social change. Some part of the problems of substance abuse and misuse among the elderly would be substantially reduced with attention to the stigma, discrimination, social isolation and poverty affecting older adults.
Treatment of mental illness in the elderly The treatment of mental illness in the elderly has been the subject of numerous studies. It has been fairly well established that some form of treatment was better than no treatment at all (Socgin and McElreath, 1994).
Treatment of depression One recent study of various forms of treatment for depression in the elderly concluded that there was enough evidence of the effectiveness of cognitive behavioral treatments and psychodynamic treatments for depression to be recommended for continued usage (Fiske, et al., 1999). One model, in particular, is the IMPACT model. IMPACT is an acronym for Improving Mood, Promoting Access to Collaborative Treatment for late-life depression. IMPACT is a treatment model that studied approximately 1800 elderly persons who met DSM-IV criteria for major depression or dsythymia. A team that included a primary care physician, depression care-manager and a consulting psychiatrist implemented the model. The study compared groups of elderly persons who received only medication, only psychotherapy, or some combination of both. About 70 percent of participants received medication, 70 percent received psychotherapy and about 90 percent overall received some form of intervention. As participants began to improve, an assigned care manager facilitated creating a relapse prevention plan. The control group of elderly persons received visits with their primary care physician and referral to mental health specialists. About 50 percent of these participants received medication and another 25 percent received mental health intervention. The researchers followed the participants over a 24-month period and found that the IMPACT participants had superior outcomes overall, with
less depression than those persons who did not receive the collaborative treatment (Hunkeler, et al., 2006). However, studies that are more recent have compared the effectiveness of various treatments for depression in which the authors conducted a meta-analysis of 122 psychosocial and psychotherapeutic interventions. The studies primarily involved adults aged 55-76 diagnosed with depression. The meta-analysis looked at: ●● Cognitive-behavioral therapy. ●● Psychodynamic therapy. ●● Reminiscence, relaxation, supportive, control-enhancing treatments. ●● Psycho-educational treatments. It was demonstrated that cognitive-behavioral therapy had above-average effects on depression and overall ratings of well-being. Overall, group therapy or group interventions were less effective than individual therapy. Better outcomes were found in the subjects who received treatment from more qualified therapists, particularly for those therapists who had specialized education in geriatrics (Pinquart and Soerensen, 2001). Therefore, we can conclude from this study that therapists who have specialized training in working with the elderly and who provide cognitive-behavioral therapy on an individualized basis are likely to be the most effective with depressed elderly persons.
Pharmacological treatment for depression Due to the many physiological changes that accompany advancing age, prescribing medication for the elderly can be very challenging. Swift and Triggs, (2006) noted the following physiological changes that occur in the elderly: ●● Elevation of gastric pH. ●● Reduction of gastric emptying rate. ●● Thinning and reduction of absorptive surface. ●● Decline in total body size in advanced age. ●● Relative increase in total body fat until advanced age. ●● Decline in metabolically active tissue. ●● Decline in total body water. ●● Reduction in liver mass. ●● Redistribution of regional blood flow away from liver. ●● Reduction in renal tubular function. Antidepressant treatment is controversial, regardless of the age of the person. There are special considerations in prescribing medication to the elderly to treat depression. Elderly persons have different outcomes
associated with the use of serotonin reuptake inhibitors than do younger persons. These medications are effective in younger people, but have a tendency to cause episodes of mania in older people for reasons that are not totally understood (Pinals, 2006). Salzman, Wong and Wright (2002), concluded after their analysis of multiple studies involving the use of medication in treating the depressed elderly that antidepressants were, in general, effective. No one particular form of antidepressant was found to be superior to another. However, the authors also noted that the incidences of relapse among the elderly were quite high when medications were discontinued, so in conclusion, it was found to be very important for many elderly persons to be prepared to continue maintenance doses on a long-term basis. Another study found similar outcomes. As major depressive disorders do have a rather high chance of recurrence over the life course, it has been recommended that long-term maintenance pharmacological treatment is the best way to manage further recurrence (Flint and Rifat, 2000).
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Marriage and family therapy Marital therapy can be effective in helping older persons with depression. The use of marital (dyadic) therapy to assist a person in responding to a spouse’s depression is often helpful for couples. The elder depressed spouse can benefit when the other partner learns to communicate more effectively, reducing counterproductive negative comments (Asen, 2006).
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The use of family therapy is also considered by some authors to be an ideal intervention for an elderly person who is suicidal, as the family can give support to the elderly family member. In addition, family therapy can also be a useful intervention with the elderly who are having problems coping with their adult children, who may suffer from their own mental issues and substance abuse problems (Richman, 2004).
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In addition, family therapy can assist in maintaining the wellbeing of an elderly person. One of the keys to determining the best family therapy framework to follow is to complete a comprehensive assessment with the elder adult. The mnemonic PRACTICE (ChristieSeeley, 1984) is a model that is designed to work with the elderly in particular, and it includes the following dimensions: P - Presenting problem. R - Roles and rules. A - Affect. C - Communication. T - Time in family life cycle. I - Illness. C - Community. E - Environmental.
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●● The presenting problem can be the actual mental illness or other systemic issues within the family. It is important for the family
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therapist to gather information concerning how each family member views the problems of the elderly person. In terms of roles and rules, it is critical to assess family functioning before and after the presenting problem arose. The emergence of a mental illness can result in a shift in family roles. The father who was the patriarch and is now incapacitated with depression will often abdicate this role and place the mother into a new role that may be very uncomfortable for her. Affect involves the assessment of how the family express emotion. Communication looks to assess who does the talking for the family, which family members do not speak to each other and whether the communication is clear. Time in family lifecycle. Successful transition to different stages in life requires flexibility to accept the changes that come with different life stages. For example, it is important to assess how elderly people have accepted the change in caregiving roles as children leave home and start their own families. Elderly persons who have been unable to accept this change will have more difficulty with the changes in roles that come at different life cycle stages. Illness – This dimension of assessment explores the etiology of the mental and/or physical illnesses affecting the family. In addition, it is important to explore the issues of guilt and shame associated with the emergence of the illness. Community – The interviewer needs to assess what supports exist in the community and what needs are unmet for housing, medical care, social support, etc. The family also needs to be assessed to determine which, if any, supports they are willing to accept. Environment includes the assessment of housing, finances, employment, neighborhood and cultural context.
Electroconvulsive therapy Electroconvulsive therapy, (ECT), which is sometimes known by the slang term “shock treatment” is highly controversial. It has been shown to be effective, but is generally limited to usage in the most severe cases of depression that are unresponsive to medication and psychotherapy. The National Alliance for the Mentally Ill (NAMI) states on its website, www.nami.org, that ECT has been shown to be effective, but notes that it is very difficult to receive the treatment due to the history of the misuse of the procedure and the many myths surrounding its usage. Without specifically endorsing ECT, the organization does state that it should be considered as a treatment for only appropriately assessed individuals. There have been other studies that indicated the effectiveness of ECT for treating depression in the elderly. It was noted that 79 percent of those people receiving the treatment showed significant improvement in their depressive symptoms. However, the authors did note a significant number of side effects, including hypertension, impaired memory and
mental confusion. Consequently, it was urged that subjects for this treatment be chosen carefully (Kujala, Rosenvinge, Bekkelund, 2002). Some researchers believe strongly in ECT. Some research indicates that even one treatment of ECT can reduce depression by 21 percent (Williams, O’Brien, and Cullum, 1997). Tew (1999) reported that one-half to three-fourths of depressed elderly persons had favorable outcomes from ECT treatment. Other studies, Zorumski et al., (1988), showed that 80 percent of elderly patients received benefits from ECT. Both Zorumski and Zal (1999), suggest that ECT should be used whenever an elderly person does not respond well to medication, as well as for those who are dangerously depressed with malnutrition or psychosis. Another meta-analysis of studies of ECT with the elderly showed that 12 studies reported the effects of ECT and found that overall it was found to be effective. In one-third of the studies, ECT was actually found to be more effective than treatments with antidepressants. Overall, the studies did not find any outstanding incidents of negative side effects from the ECT (Salzman, Wong and Wright, 2002).
Problem-solving therapy In addition, many of the elderly who are diagnosed with depression are chronically physically disabled or ill. The co-morbidity of physical illness and depression sets up a vicious cycle in which the physical problems aggravate the depression, but the depression in turn makes it easier for people to give up hope and not adhere to their physical recovery as well. A strong need for integrated treatment exists. In their study of depressed elderly persons with chronic obstructive pulmonary disease (COPD), Alexopoulos, Raue, Sirey and Arean (2007) noted that the lack of energy, loss of interest in daily activities and the general apathy that accompanies depression makes it especially hard for patients with COPD to follow their physical rehabilitation. The authors identified that using a combination of therapy to help with problem-solving skills as well as techniques Psychology.EliteCME.com
to help decrease the resistance to treatment appeared to be the most effective in helping to alleviate depression and to have the participants follow their treatment regime for COPD. It appears that the therapy itself had some effect on the depression, but the adherence to the medical treatment also helped participants feel better physically, which could have also alleviated some of the depression. Similar results were found in a study of depression and arthritis in the elderly. The collaborative care approach, which utilized case managers and incorporated the problem-solving therapy approach with clients, was found to result in both decreased problems with arthritis and a decrease in depression (Lin, et al., 2003).
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Treatment of bipolar disorder Many of the medications required to treat bipolar disorders are very strong with a rather high incidence of side effects. This treatment of bipolar disorder in the elderly is made more complicated by the fact that pharmacological interventions for the elderly are different due to physiological changes that occur with advancing age. For example, lithium is the drug of choice to control bipolar disorders in younger people. However, most elderly persons have somewhat diminished renal functioning, and lithium can cause complications with renal function that can be deadly in older persons (Gutman and Gutman, 2006). Interventions which include the use of psycho-education in addition to medication have been shown to produce better outcomes than those studies in which medication alone was used (Colom, Vieta, MartinezAran, 2003; Colom, Vieta, Reinares, 2003).
Lithium and divalproex appear to be effective to treat mania in the elderly with bipolar disorder. However, the research in this area is still not very extensive. Other classifications of drugs, such as anti-depressants, have been examined in extremely few studies. There is almost no research on the ideal dosages or the length of administration of the medications. Age-related factors might attenuate benefit and increase vulnerability to side effects of pharmacotherapy (Young, et al, 2004). In examining the long-term behaviors of adults with bipolar disorder, it was also noted that persons with this diagnosis often have a hard time being compliant with medication, and this can hamper the treatment of the illness (Martire, et al., 2004).
Treatment for anxiety There have not been a large number of studies pertaining to the treatment of anxiety in the elderly. One of the few in recent years indicated that risperidone proved useful in the treatment of anxiety disorders (Morinigo, 2004). Benzodiazepines have been used to treat anxiety for decades, but are not always the best course of treatment for the elderly as they tend to cause sedation, mental confusion and lack of physical coordination, even at fairly low doses. In addition, the tolerance for benzodiazepines builds very quickly and therefore requires the use of higher and higher doses to achieve the same results (Ettinger and Kanner, 2006). In a meta-analysis of the treatment of anxiety in older persons, the average participant had suffered from anxiety for 19 years, had an average age of 69, and two-thirds were women. Behavioral interventions and medication were examined across all studies, and medication appeared to have some advantage over therapy for symptom improvement. Overall, control groups who received no treatment showed improvement in about 30 percent of cases. No particular form of therapy showed superiority over another. Nor were
any outstanding differences found between classes of drugs used to treat anxiety (Pinquart and Duberstein, 2007). Another study comparing different forms of cognitive behavioral therapy (CBT) did show that it was effective for generalized anxiety disorder. An enhanced form of cognitive behavioral therapy included learning and memory aids designed to make the therapy more effective with elderly patients. Homework reminders, troubleshooting calls and a weekly review of all concepts and techniques were compared with standard cognitive behavioral therapy. The enhanced version was found to be more effective. Cognitive behavioral therapy has shown promise as an effective treatment in the elderly who suffer from anxiety. CBT with the elderly has been studied far less than the use of CBT with younger people, but it has been shown to be effective in younger people. Therefore, it has been generally assumed that it would also work well with the elderly. However, few studies have empirically tested this theory.
Services for the elderly There is an array of services to help the elderly when they are unable to fully function, either mentally or physically. In general, case management services are not offered exclusively for mental health issues, but programs include services for the mental health needs of the elderly as part of services that are already offered. Most states do have some sort of program to serve the elderly. In Florida, for example, the Department of Elder Affairs has local offices called Area Agencies on Aging that link the elderly to a variety of programs in their county. The state level program is primarily aimed at seniors with physical impairment and offers case management, meal delivery, legal assistance, adult day care, respite services and emergency response. Fees are often charged on a sliding scale basis. In South Florida, which has a high number of senior citizens, private agencies, such as Jewish Social Services of South Florida, offer a wide and comprehensive array of services to the elderly, including in-home therapy and case management. However, for those elderly who live in rural areas or in states with low numbers of elderly persons, services are often very limited. For the rural elderly in particular, access to services is very difficult. Many elderly persons in rural areas live in poverty and have little access to transportation. However, some efforts, such as mobile teams of psychiatrists and therapists to access rural areas, have provided more help to some communities. Though even 20 years ago, telephonic therapy was heralded as a cutting-edge idea that could provide more access to therapy and other services, there were issues related to funding of these services through Medicare, and this great technological idea never really materialized (Kirchner, 1981).
that are primarily related either to persons with Alzheimer’s or caregiver support groups. Yet, “mental health” receives only one link that connects to a list of county mental health departments, with no details given about the type or availability of services. In Texas, the Department of Aging and Disability focuses on a range of services, such as housing and health care and information about adult daycare. But there is no mention of mental health services in any explicit way, and only a link is provided to a general help line for an array of services. Iowa, California and Georgia are among the states that offer a typical range of services to the elderly, including comprehensive services, meal delivery, emergency response, homemaker services and respite care. Some states, such as South Dakota, offer case management to the elderly as a way to assess needs, link families to resources in the community and hopefully avoid crisis situations before they occur. Assessment and treatment planning are utilized with the ultimate goal of preventing seniors from moving into institutional care before it is truly needed, or in some cases, prevent residential care from occurring at all. Vermont is another state that appears to have a more comprehensive approach to working with elderly persons with mental health needs, through its Elder Care program, which is a joint effort of the mental health and aging departments of the state government. This program provides a senior help line, counseling, case management and medication monitoring specifically aimed at elderly persons.
The New York State Office for the Aging lists detailed services for health care, housing, energy and transportation, and some social services Page 38 Psychology.EliteCME.com
In addition to state-run programs, many private agencies offer senior care management for private-paying individuals. These agencies typically offer a variety of services, including assessment, medical in-home care, case management and guardianship. Still, many of these agencies, both public and private, do not mention mental health needs as part of their assessment or services. There are some references to dementia and Alzheimer’s disease, but with a few notable exceptions, little reference to or focus on depression, substance abuse, anxiety and other mental disorders. There has been a small amount of research conducted on the efficacy of case management in the elderly mentally ill. Arean, Alexopoulos and Chu (2007) studied the benefits of case management for a group of lowincome, depressed seniors. Low-income seniors who received therapy for depression reported having too many life concerns that could not be adequately addressed in therapy alone, such as financial, transportation and housing problems. The authors conducted a study with control groups of seniors who received only CBT, only case management, and a combination of case management and CBT. The group who received both CBT and case management had better outcomes than those seniors who only received CBT, or only received case management.
Adult day care is another service that can help adults suffering from a variety of mental health problems. The National Adults Day Service Association has member agencies throughout the United States. Many of these programs focus on seniors with medical issues, and others only serve those individuals with dementia, Alzheimer’s disease and related memory disorders. A few of these programs do provide services that focus on adults with mental illness, but these are not very common and are typically associated with hospitals. In the state of Florida, the Department of Elder Affairs requires that adult day care must provide supervision, one meal per day, arts and crafts, and leisure time activities. Optional services include social services, health services, and occupational, physical and speech therapy. Many centers are not capable of handling adults with persistent mental illness. Day-care centers that provide social and mental health services provide a great service for families. However, the average cost of such a center is $64 per day, which can be very difficult for many elderly persons and their families to pay. Most states offer some sort of subsidies based on income.
Conclusion Mental health of older adults can be improved through promoting active and healthy ageing. Mental health-specific health promotion for the older adults involves creating living conditions and environments that support wellbeing and allow people to lead healthy and integrated lifestyles. Promoting mental health depends largely on strategies which ensure the elderly have the necessary resources to meet their basic needs, such as: ●● Providing security and freedom. ●● Adequate housing through supportive housing policy. ●● Social support for elderly populations and their caregivers. ●● Health and social programs targeted at vulnerable groups such as those who live alone, rural populations or who suffer from a chronic or relapsing mental or physical illness. ●● Violence or older adults maltreatment prevention programs. ●● Community development programs. There are many elderly persons in the United States who are not receiving appropriate mental health screening, diagnosis and intervention. In addition, many areas of mental illness treatment for the elderly have a paucity of research studies that use control groups and longitudinal outcomes on which to base best practices. Much of the therapeutic and pharmacological treatments utilized for the elderly are based on studies done with much younger persons and ignore the fact that elderly persons do not have the same psychosocial needs or physiological makeup. In addition, elder clients may not respond as well to therapy interventions as would a younger person, so their medications may also affect them differently. Though many elderly persons in the United States are also from ethnic minority groups, very few social workers, therapists and psychiatrists are given
the appropriate cultural diversity training to enable them to engage their elderly clients most effectively. Many nursing homes do not have staff adequately trained to recognize mental health issues or the fact that residents may be overmedicated. Consequently, residents may be prescribed incorrect medications with the intention of regulating their behaviors. Those elderly persons who live in their homes, either alone or with family, often do not receive appropriate mental health interventions because they generally receive screening, diagnosis and treatment from their general practitioners – medical doctors who lack the expertise needed to recognize and treat mental illness. At particularly high risk for mental health problems are elderly persons who also function as caregivers. Often, these persons are underserved by social service and mental health agencies in their communities. A few states have comprehensive service networks for the elderly, and quite a few private agencies exist to help families coordinate services. Many services only focus on Alzheimer’s and/or physical problems and ignore mental health problems. Some mental health prevention services exist, but few are currently funded even though several studies have shown that case management and a problem-solving approach can help to engage elderly persons in treatment sooner and more effectively. A crisis looms on the horizon, as the lack of expertise in treating mental illness in the elderly and the scarce number of programs and resources collide with a rapidly increasing number of aging Baby Boomers. The call set forth years ago by the American Psychiatric Association has not been fully heeded, and as these needs arise without the necessary preparations in place, there will likely be a long struggle ahead and many lessons to be learned.
How can you help research on dementia? People with dementia and others who wish to help research on dementing disorders may be able to do so by participating in clinical studies designed to learn more about the disorders or to test potential new therapies. Information about many such studies is available free of charge from the federal government’s database of clinical trials, clinicaltrials.gov (http://clinicaltrials.gov). Information about clinical trials specific to AD is available from the Alzheimer’s Disease Clinical Trials Database (http://www.nia.nih.gov/ alzheimers) a joint project of the U.S. Food and Drug Administration and the National Institute of Aging (NIA) that is maintained by the NIA’s Alzheimer’s Disease Education and Referral Center. Psychology.EliteCME.com
For clinical trials taking place at the National Institutes of Health, additional information is available from the following office: Patient Recruitment and Public Liaison Office Clinical Center National Institutes of Health Building 61, 10 Cloister Court Bethesda, MD 20892-4754 800-411-1222 | 866-411-1010 (toll free) | TTY: 301-594-9774 (local) http://clinicalcenter.nih.gov/ Voluntary health organizations may be able to provide information about additional clinical studies. Page 39
Glossary of terms Acetylcholine – A neurotransmitter that is important for the formation of memories. Studies have shown that levels of acetylcholine are reduced in the brains of people with Alzheimer’s disease. Alzheimer’s disease – The most common cause of dementia in people aged 65 and older. Nearly all brain functions, including memory, movement, language-judgment, behavior and abstract thinking, are eventually affected. Amyloid plaques – Unusual clumps of material found in the tissue between nerve cells. Amyloid plaques, which consist of a protein called beta amyloid along with degenerating bits of neurons and other cells, are a hallmark of Alzheimer’s disease. Amyloid precursor protein – A normal brain protein that is a precursor for beta amyloid, the abnormal substance found in the characteristic amyloid plaques of Alzheimer’s disease patients. Apolipoprotein E – A gene that has been linked to an increased risk of Alzheimer’s disease. People with a variant form of the gene, called apoE epsilon 4, have about 10 times the risk of developing Alzheimer’s disease. Ataxia – A loss of muscle control. Atherosclerosis – A blood vessel disease characterized by the buildup of plaque, or deposits of fatty substances and other matter in the inner lining of an artery. Beta amyloid – A protein found in the characteristic clumps of tissue (called plaques) that appear in the brains of Alzheimer’s patients. Binswanger’s disease – A rare form of dementia characterized by damage to small blood vessels in the white matter of the brain. This damage leads to brain lesions, loss of memory, disordered cognition and mood changes. CADASIL – A rare hereditary disorder linked to a type of vascular dementia. It stands for cerebral autosomal dominant arteriopathy with subcortical infarct and leukoencephalopathy.
controlling sleep. The disease causes dementia and a progressive insomnia that eventually leads to a complete lack of sleep. Frontotemporal dementias – A group of dementias characterized by degeneration of nerve cells, especially those in the frontal and temporal lobes of the brain. FTDP-17 – One of the frontotemporal dementias, linked to a mutation in the tau gene. It is much like other types of the frontotemporal dementias but often includes psychiatric symptoms such as delusions and hallucinations. Gerstmann-Straussler-Schneiker disease – A rare, fatal hereditary disease that causes ataxia and progressive dementia. HIV-associated dementia – A dementia that results from infection with the human immunodeficiency virus (HIV) that causes AIDS. It can cause widespread destruction of the brain’s white matter. Huntington’s disease – A degenerative hereditary disorder caused by a faulty gene for a protein called Huntington. The disease causes degeneration in many regions of the brain and spinal cord, and patients eventually develop severe dementia. Lewy body dementia – One of the most common types of progressive dementia, characterized by the presence of abnormal structures called Lewy bodies in the brain. In many ways, the symptoms of this disease overlap with those of Alzheimer’s disease. Magnetic resonance imaging (MRI) – A diagnostic imaging technique that uses magnetic fields and radio waves to produce detailed images of body structures. Mild cognitive impairment –A condition associated with impairments in understanding and memory not severe enough to be diagnosed as dementia but more pronounced than those associated with normal aging.
Cholinesterase training – Drugs that slow the breakdown of the neurotransmitter acetylcholine.
Mini-Mental State Examination – A test used to assess cognitive skills in people with suspected dementia. The test examines orientation, memory and attention as well as the ability to name objects, follow verbal and written commands, write a sentence spontaneously and copy a complex shape.
Cognitive training – A type of training in which patients practice tasks designed to improve mental performance. Examples include memory aids, such as mnemonics, and computerized recall devices.
Multi-infarct dementia – A type of vascular dementia caused by numerous small strokes in the brain. Myelin – A fatty substance that coats and insulates nerve cells.
Computed tomographic (CT) scans – A type of brain scan that uses X-rays to detect brain structures.
Neurofibrillary tangles – Bundles of twisted filaments found within neurons and a characteristic feature found in the brains of Alzheimer’s patients. These tangles are largely made up of a protein called tau.
Cortical atrophy – Degeneration of the brain’s cortex (outer layer). Cortical atrophy is common in many forms of dementia and may be visible on a brain scan. Cortical dementia –A type of dementia in which the damage primarily occurs in the brain’s cortex, or outer layer. Corticobasal degeneration – A progressive disorder characterized by nerve cell loss and atrophy in multiple areas of the brain. Creutzfeldt-Jakob disease – A rare, degenerative, fatal brain disorder believed to be linked to an abnormal form of a protein called a prion. Dementia – A term for a collection of symptoms that significantly impair thinking and normal activities and relationships. Dementia pugilistica – A form of dementia caused by head trauma such as that experienced by boxers. It is also called chronic traumatic encephalopathy or boxer’s syndrome. Electroencephalogram (EEG) – A medical procedure that records patterns of electrical activity in the brain. Fatal familial insomnia – An inherited disease that affects a brain region called the thalamus, which is partially responsible for
Neurotransmitter – A type of chemical, such as acetylcholine, that transmits signals from one neuron to another. People with Alzheimer’s disease have reduced supplies of acetylcholine. Organic brain syndrome – A term that refers to physical disorders (not psychiatric in origin) that impair mental functions. Parkinson’s dementia – A secondary dementia that sometimes occurs in people with advanced Parkinson’s disease, which is primarily a movement disorder. Many Parkinson’s patients have the characteristic amyloid plaques and neurofibrillary tangles found in Alzheimer’s disease, but it is not yet clear whether the diseases are linked. Pick’s disease – A type of frontotemporal dementia where certain nerve cells become abnormal and swollen before they die. The brains of people with Pick’s disease have abnormal structures, called Pick bodies, inside the neurons. The symptoms are very similar to those of Alzheimer’s disease. Plaques – Unusual clumps of material found between the tissues of the brain in Alzheimer’s disease. See also amyloid plaques.
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Post-traumatic dementia – A dementia brought on by a single traumatic brain injury. It is much like dementia pugilistica, but usually also includes long-term memory problems.
substances throughout the cell. In Alzheimer’s disease, tau is changed in a way that causes it to twist into pairs of helical filaments that collect into tangles.
Presenilin 1 and 2 – Proteins produced by genes that influence susceptibility to early-onset Alzheimer’s disease.
Transmissible spongiform encephalopathies – Part of a family of human and animal diseases in which brains become filled with holes resembling sponges when examined under a microscope.
Primary dementia – A dementia, such as Alzheimer’s disease, that is not the result of another disease. Primary progressive aphasia – A type of frontotemporal dementia resulting in deficits in language functions. Many, but not all, people with this type of aphasia eventually develop symptoms of dementia. Progressive dementia – A dementia that gets worse over time, gradually interfering with more and more cognitive abilities.
CJD is the most common of the known transmissible spongiform encephalopathies. Vascular dementia – A type of dementia caused by brain damage from cerebrovascular or cardiovascular problem, usually strokes. It accounts for up to 20 percent of all dementia. “Dementia: Hope Through Research,” NINDS. Prepared by: Office of Communications and Public Liaison National Institute of Neurological Disorders and Stroke National Institutes of Health Bethesda, MD 20892
Secondary dementia – A dementia that occurs as a consequence of another disease or an injury. Senile dementia – An outdated term that reflects the formerly widespread belief that dementia was a normal part of aging. The word senile is derived from a Latin term that means, roughly, “old age.” Sub-cortical dementia – Dementia that affects parts of the brain below the outer brain layer, or cortex. Substance-induced persisting dementia – Dementia caused by abuse of substances such as alcohol and recreational drugs that persists even after the substance abuse has ended. Tau protein – A protein that helps the functioning of microtubules, which are part of the cell’s structural support and help to deliver
NINDS health-related material is provided for information purposes only and does not necessarily represent endorsement by or an official position of the National Institute of Neurological Disorders and Stroke or any other federal agency. Advice on the treatment or care of an individual patient should be obtained through consultation with a physician who has examined that patient or is familiar with that patient’s medical history.
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Hopko, D.R., Stanley, M.A., Reas, D.L. , Wetherell, J.L.,Beck, J.G., Novy, D.M., & Averill, P.M. (2003). Assessing worry in older adults: confirmatory factor analysis of the Penn State Worry Questionnaire and psychometric properties of an abbreviated model. Psychological Assessment, 15, 173–183. Hunkeler, E.M., Katon, W., Tang, L., Williams, Jr, J.W., Kroenke, K., Lin, E., Harpole, L.H., Arean, P., Levine, S., Grypma, L.M., Hargreaves, W.A., Unützer, J. (2006). Long term outcomes from the IMPACT randomised trial for depressed elderly patients in primary care. British Medical Journal, 332, 259-263. Institute for health metrics and evaluation. (2010). Global burden of disease study. Retrieved from http://ghdx.healthdata.org/global-burden-disease-study-2010-gbd-2010-data-downloads Long term outcomes from the IMPACT randomised trial for depressed elderly patients in primary care. British Medical Journal, 332, 259-263. Jeste, D.V., Alexopoulos, G.S., Bartels, S.J., et al. (1999). Consensus statement on the upcoming crisis in geriatric mental health. Archives of General Psychiatry, 56, 848-853. Jeste, D.V., Blazer, D., First, M. (2005). Aging-related diagnostic variations: need for diagnostic criteria appropriate for elderly psychiatric patients. Biological Psychiatry, 58, 265-271. Katon, W., Schulberg, H.C. (1992). Epidemiology of depression in primary care. General Hospital Psychiatry, 14, 237-247. Kirchner, J.H. (1981). Rural mental health service delivery to the elderly. Journal of Rural Community Psychology, 2, 31-38. Koenig, H.G., & Blazer, D.G. (2003). In Cassel, C.K., Leipzig, R.M., Cohen, H.J.Eds. Geriatric Medicine: an evidence based approach. Springer. Koenig, H.G., & Blazer, D.G. (2003). Depression, anxiety, and other mood disorders. Pp. 11631184. In Cassel, C.K., Leipzig, R.M., Cohen, H.J. (Eds.), Geriatric medicine: an evidence based approach. New York: Springer. Kujala, I., Rosenvinge, B., Bekkelund, S.I., (2002). Clinical outcome and adverse effects of electroconvulsive therapy in elderly psychiatric patients. Journal of Geriatric Psychology and Neurology, 15, 73-76. Landfield, C.S., Palmer, R., Johnson, M.A., Johnston, C.B., Lyons, W. (2006). Current Geriatric Diagnosis and Treatment. McGraw-Hill: New York. Leff, J. Vearnals, S., Wolff, G., Alexander, B., Chisholm, D., Everett, B., Asen, E., Jones, E., Brewin, C.R., and Dayson, D. (2000). The London depression intervention trial: randomised controlled trial of antidepressants v. couple therapy in the treatment and maintenance of people with depression living with a partner: clinical outcome and costs. The British Journal of Psychiatry, 177, 95 - 100. Lenze, E.J. ,Mulsant, B.H, Shear, M.K., Schulberg, H.C., Dew, M.A., Begley, A.E., Pollock, B.G., &. Reynolds, C.F., (2000). Comorbid anxiety disorders in depressed elderly patients. American Journal of Psychiatry, 157, 722–728. Liberto J.G., & Oslin D.W. (1995). Early versus late onset of alcoholism in the elderly. International Journal of Addiction, 30,1799-1818. Lindesay, J., Briggs, K., & Murphy, E. (1989). Phobic disorders in the elderly. British Journal of Psychiatry, 159, 531-541. Lin, K., Cheung, F., Smith, M., & Poland, R. (1997). The use of psychotropic medications in working with Asian patients. In Lee, E. (Ed.), Working with Asian Americans: A guide for clinicians. Wiley, New York (pp. 388–399). Martire LM, Schulz R, Mulsant BH, et al (2004). Family caregiver functioning in late-life bipolar disorder. American Journal of Geriatric Psychiatry, 12, 339–340. Menninger, J.L. (2002). Assessment and treatment of alcoholism and substance-related disorders in the elderly. Bulletin of the Menninger Clinic, 66. Morinigo, A., Blanco, M., Labrador, J., Martin, J., Noval, D., (2005). Risperidone for resistant anxiety in elderly persons. American Journal of Geriatric Psychiatry, 13, 81-82. Mulford, H.A., & Fitzgerald, J.L. (1992). Elderly versus younger problem drinker profiles: Do they indicate a need for special programs for the elderly? Journal on Studies of Alcohol, 53, 601-610. National Institute on Aging (2014). Health and aging: Depression. Retrieved from http://www.nia. nih.gov/health/publication/depression#causes Newton, J. (1992). Preventing Mental Illness in Practice. Routledge. P. 166. O’Connell, H., Chin, A., Cunningham, C., Lawlor, B., Norman, C. (2003). Alcohol use disorders in elderly people: redefining an age-old problem in old age. British Medical Journal, 327, 664-667. O’Connell, H., Chin, A., Hamilton, F., Cunningham, C., Walsh, J.B., Coakley, D., Lawlor, B.A. (2003). A systematic review of the utility of self-report alcohol screening instruments in the elderly. International Journal of Geriatric Psychiatry, 11, 1074-1086.
Pinals S. (2006). Treatment interventions for elderly patients with bipolar disorder. Presented at the American Psychiatric Association 159th Annual Meeting; May 20-25, 2006;Toronto, Ontario, Canada. Pinquart, M. & Duberstein, P.R. (2007). Treatment of anxiety disorders in older adults: A metaanalytic comparison of behavioral and pharmacological interventions. American Journal of Geriatric Psychiatry -15,639-651. Pinquart M, & Sörensen S., (2001), How effective are psychotherapeutic and other psychosocial interventions with older adults? Journal of Mental Health and Aging 7, 207-243. Reid, M.C., & Anderson, P.A. (1997). Geriatric substance abuse disorders. Medical Clinics of North America, 81, 999-1016. Richmond, J., (2004). The widening scope of family therapy for the elderly. In, Assessment, Treatment, and Prevention of Suicidal Behavior. R.I. Yufit & D. Lester (Eds.), New York: Wiley. Sajatovic, M and Kales, H.C., (2006). Diagnosis and management of bipolar disorder with comorbid anxiety in the elderly. Journal of Clinical Psychiatry, 67, 21-27. Salthouse, T.A., & Somberg, B.L., (1982). Isolating the age deficit in speeded performance. Journal of Gerontology, 37, 59-63. Salzman, C. (2004). Late-life anxiety disorders. Psychopharmacology Bulletin, 38, 25-31. Salzman, C., Wong, E., & Wright, B. (2002). Drug and ECT treatment of depression in the elderly, 1996-2001: a literature review. Biological Psychiatry, 52, 265-284. Schonfeld, L., and Dupree, L.W. (1991). Antecedents of drinking for early- and late-onset elderly alcohol abusers. Journal of Studies on Alcohol, 52:6. Scogin, F., & McElreath, L., (1994). Efficacy of psychosocial treatments for geriatric depression: a quantitative review. Journal of Consulting and Clinical Psychology, 63, 69-74. Schulz, R., O’Brien, A.T., Bookwals, J., & Fleissner, K. (1995). Psychiatric and physical morbidity effects of dementia caregiving: Prevalence, correlates, and causes. The Gerontologist, 35: 771-791. Sheikh J.I., Yesavage, J.A., (1986). Geriatric Depression Scale (GDS): recent evidence and development of a shorter version. Clinical Gerontology, 5, 165-172. Swift, C.G., & Triggs, E.J. (1987) Clinical pharmokenetics in the elderly. In Clinical Pharmacology in the elderly, C.G. Swift, Ed. London: InformaHealth Care Tew, J.D., Mulsant, B.H., Haskett, R.F., Prudic, J., Thase, M.E., Crowe, R.R., Dolata, D., Begley, A.E., Reynolds, C.F., & Sackheim, H.A., (1999). Acute Efficacy of ECT in the Treatment of Major Depression in the Old-Old. American Journal of Psychiatry, 156, 1865-1870. Thompson A, Fan MY, Unützer J, Katon WJ: (2008). One extra month of depression: the effects of caregiving on depression outcomes in the IMPACT trial. International Journal of Geriatric Psychiatry, 23, 511-516. Vassilas, C. A. & Morgan, H. G. (1994). Elderly suicides’ contacts with their general practitioner before death. International Journal of Geriatric Psychiatry, 9, 1008-1009. Weintraub, D., Ruskin, P.E., (1999). Post-traumatic stress in the elderly: a review. Harvard Review of Psychiatry, 7, 144-152. Wetherell, J.L., & Gatz, M. (2005). The Beck Anxiety Inventory in older adults with generalized anxiety disorder. Journal of Psychopathology Behavioral Assessment, 27, 17-24. Wilcox, S.M., Himmelstein, D.U., Woolhandler, S., (1994). Inappropriate drug prescribing for the community-dwelling elderly. Journal of the American Medical Association, 272, 292–296. Williams, J.H.G., O’Brien, J.T., Cullum, Sr. (1997). Time course of response to electroconvulsive therapy in elderly depressed subjects. International Journal of Geriatric Psychiatry 12, 563 – 566. Wilson, K., Mottram, P., & Sixsmith, A., (2007). Depressive symptoms in the very old living alone: prevalence, incidence and risk factors. International Journal of Geriatric Psychiatry, 22, 361-366. Wright B.M., & Payne R.B., (1985). Effects of aging on sex differences in psychomotor reminiscence and tracking proficiency. Journal of Gerontology, 40, 179-84. Zal, H.M., (1999). Treating depression in the elderly: remedying an undiagnosed disorder. Consultations in Primary Care, 1565-1579. Zorumski, C.F., Rubin, E.H., & Burke, W.J., (1988). Electroconvulsive therapy for the elderly: a review. Hospital Community Psychiatry 39, 643-647. Young, R.C., Gyulai, L., Musant, B., (2004). Pharmacotherapy of bipolar disorders in old age. American Journal of Geriatric Psychiatry, 12, 342-357. Zylstra, R.G., & Steitz, J.A. (2000). Knowledge of late life depression and aging among primary care physicians. Aging and Mental Health, 4, 30-35.
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Elderly Mental Health: Depression and Dementia Final Examination Questions
Choose True or False for questions 6 through 15 and mark them on the answer sheet found on page 85 or complete your test online at Psychology.EliteCME.com. 6. It is projected that there will be an estimated: a. 25 million mentally ill senior citizens by 2030. b. 100 million mentally ill senior citizens by 2030. c. 10 million mentally ill senior citizens by 2030. d. 15 million mentally ill senior citizens by 2030. 7. The DSM-5 now refers to anxiety as social anxiety disorder, however it was previously known as ___________ within the DSM-IV. a. Social isolation. b. Social phobia. c. Internal anxiety. d. Public phobia. 8. Dementia is a ____________ disorder. a. Sociological. b. Neurophonic. c. Neurocognitive. d. Sociocognitive. 9. It has been recognized that _______________ is not the first domain to be affected in all of the other diseases that cause a neurocognitive disorder. a. Physical disability. b. Memory impairment. c. Hearing impairment. d. Visual impairment. 10. Medications can sometimes lead to reactions or side effects that mimic: a. Sleep apnea. b. Strokes. c. Dementia. d. Depression.
12. __________ is a cultural tradition that revolves around shame. Seeking treatment may bring shame upon a family, and Hispanics will seek to avoid bringing shame if at all possible, which can be a barrier to seeking treatment. a. Simpatia. b. Falisimo. c. Respero. d. Verguenza. 13. Tertiary prevention involves efforts to halt the progression of substance abuse that is rather severe, and to stop it from becoming: a. A problem. b. In need of further assessment. c. Fatal. d. Habitual. 14. A type of training in which patients practice tasks designed to improve mental performance. Examples include memory aids, such as mnemonics, and computerized recall devices. a. Cognitive training. b. Behavioral training. c. Neuro training. d. Recall training. 15. Primary progressive _________ is a type of frontotemporal dementia resulting in deficits in language functions. a. Dementia. b. Aphasia. c. Syndrome. d. Disease.
11. Several studies have shown that ______________ medicine reduces the odds of cognitive impairment in elderly people with high blood pressure. a. Psychotropic. b. Antidepressant. c. Antihyperthyroid. d. Antihypertensive.
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Chapter 3:
Ethics
3 CE Hours By: Wade T. Lijewski, Ph.D. and Chad Hagans, Ph.D.
Learning objectives Summarize the importance of professional values and ethics in psychology. Distinguish between the general principles and the ethical standards of the American Psychological Association’s (APA’s) Ethical Principles of Psychologists and Code of Conduct. Describe potential ethical dilemmas.
Explore methods for analyzing ethical issues. Describe what to do when an ethical or boundary violation occurs. Review and understand recent scholarship regarding ethical standards and issues surrounding the provision of psychological services via the internet. Explore case examples of ethical standards.
Introduction Psychologists often work with vulnerable individuals in sensitive situations. An important aspect of being a mental health professional, whether you conduct research or provide therapeutic services, is being aware of the ethical issues faced by all psychologists. If you provide psychological services, you are obligated to remain informed regarding current ethical standards or issues. Ethics, also known as moral philosophy, is a branch of philosophy that involves systematizing, defending, and recommending concepts of right and wrong behavior. The American Psychological Association (APA) Ethical Principles of Psychologists and Code of Conduct (known as the Ethics Code) consist of four parts: ●● Introduction. ●● Preamble. ●● General Principles (A–E). ●● Specific Ethical Standards. The Introduction discusses the intent, organization, procedural considerations, and scope of application of the Ethics Code. The Preamble and General Principles are aspirational goals to guide psychologists toward the highest ideals of psychology. Although the General Principles are not themselves enforceable rules, they should be considered by psychologists in arriving at an ethical course of action. The Ethical Standards set forth enforceable rules for conduct as psychologists. Most of the Ethical Standards are written broadly, in order to apply to psychologists in varied roles, although the application of an Ethical Standard may vary depending on the context. The Ethical Standards are not exhaustive. The fact that an Ethical Standard does not address a given behavior specifically does not imply either ethical or unethical conduct. This Ethics Code applies only to psychologists’ activities that are part of their scientific, educational, or professional roles as psychologists. Areas covered include but are not limited to the clinical, counseling, and school practice of psychology; research; teaching; supervision of trainees; public service; policy development; social intervention; development of assessment instruments; conducting assessments; educational counseling; organizational consulting; forensic activities; program design and evaluation; and administration. It is important to note that the Ethics Code applies to these activities across a variety of situations and means of communication, such as in person, postal, telephone, Internet, and other electronic transmissions. Membership in the APA commits members and student affiliates to comply with the standards of the APA Ethics Code and to the rules and procedures used to enforce them. Lack of awareness or misunderstanding of an Ethical Standard is not itself a defense to a charge of unethical conduct. The current Rules and Procedures
of the APA Ethics Committee describe the procedures for filing, investigating, and resolving complaints of unethical conduct. APA may impose sanctions on its members for violations of the Ethics Code standards, including termination of APA membership, and may notify other bodies and individuals of its actions. Actions that violate the standards of the Ethics Code may also lead to the imposition of sanctions on psychologists or students, whether or not they are APA members, by bodies other than APA, including state psychological associations, other professional groups, psychology boards, and other state or federal agencies. In addition, APA may take action against a member after his or her conviction of a felony, expulsion or suspension from an affiliated state psychological association, or suspension or loss of licensure. The Ethics Code provides guidance and standards of professional conduct for psychologists that the APA and other bodies that choose to adopt them can apply to their members. The Ethics Code is not intended to be a basis of civil liability. Whether a psychologist has violated the Ethics Code standards does not solely determine whether the psychologist is legally liable in a court action, whether a contract is enforceable, or whether other legal consequences occur. The Ethics Code utilizes words such as reasonably, appropriate, and potentially, which: ●● Allow professional judgment on the part of psychologists. ●● Eliminate injustice or inequality that would occur without the modifier. ●● Ensure applicability across the broad range of activities conducted by psychologists. ●● Guard against a set of rigid rules that might be quickly outdated. As used in the Ethics Code, the term reasonable means the prevailing professional judgment of psychologists engaged in similar activities in similar circumstances, given the knowledge the psychologist had or should have had at the time. Psychologists commit themselves to increasing the scientific and professional knowledge of behavior, people’s understanding of themselves and others, and to the use of such knowledge to improve the condition of individuals, organizations, and society. Psychologists respect and protect civil and human rights and the central importance of freedom of inquiry and expression in research, teaching, and publication. They strive to help the public develop informed judgments and choices concerning human behavior. In doing so, psychologists perform many roles, such as researcher, educator, diagnostician, therapist, supervisor, consultant, administrator, social interventionist, and expert witness.
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History The APA first created a Committee on Ethical Standards for Psychologists in 1947. The first version of the Ethics Code was adopted in 1952 and published in 1953. The most recent version of the Ethical Principles and Code of Conduct was in force from 1992 to 2003. The newest amendments to these documents became effective June 1, 2010.
to applicable laws and psychology board regulations. In applying the Ethics Code to their professional work, psychologists may consider other materials and guidelines that have been adopted or endorsed by scientific and professional psychological organizations and the dictates of their own conscience, as well as consult with others within the field.
From its inception, the Ethics Code has provided a common set of principles and standards upon which psychologists can build their professional and scientific work. The goals of the Ethics Code are the welfare and protection of the individuals and groups with whom psychologists work and the education of members, students, and the public regarding ethical standards of the discipline.
In the event that the Ethics Code establishes a higher standard of conduct than is required by law, psychologists must meet the higher ethical standard. Situations may arise in which psychologists’ ethical responsibilities conflict with law, regulations, or other governing legal authority. In this case, psychologists must communicate their commitment to this Ethics Code and take steps to resolve the conflict in a responsible manner consistent with basic principles of human rights.
In the process of making decisions regarding their professional behavior, psychologists must consider this Ethics Code in addition
The following section outlines the general principles and ethical standards of the APA Ethics Code (APA, 2003).
General Principles of the Ethics Code General Principles, as opposed to Ethical Standards, are broader and are aspirational in nature. Their purpose is to guide and inspire psychologists toward the very highest ethical ideals of the profession. General Principles, in contrast to Ethical Standards, do not represent obligations and should not form the basis for imposing sanctions. Principle A: Beneficence and non-maleficence Psychologists strive to benefit those with whom they work and do no harm. In their professional actions, psychologists seek to safeguard the welfare and rights of those with whom they interact professionally and other affected persons and the welfare of animal subjects of research. When conflicts occur among psychologists’ obligations or concerns, they are expected to attempt to resolve these conflicts in a responsible fashion that avoids or minimizes harm. Because psychologists’ scientific and professional judgments and actions may affect the lives of others, they are alert to and should guard against personal, financial, social, organizational, or political factors that might lead to misuse of their influence. Psychologists are also expected to be aware of the possible effect of their own physical and mental health on their ability to help those with whom they work. Principle B: Fidelity and responsibility Psychologists must establish relationships of trust with those with whom they work. They are expected to be aware of their professional and scientific responsibilities to society and to the specific communities in which they work. Psychologists uphold professional standards of conduct, clarify their professional roles and obligations, accept appropriate responsibility for their behavior, and seek to manage conflicts of interest that could lead to exploitation or harm. Psychologists are expected to consult with, refer to, or cooperate with other professionals and institutions to the extent needed to serve the best interests of those with whom they work.
In situations in which deception may be ethically justifiable to maximize benefits and minimize harm, psychologists have a serious obligation to consider the need for, the possible consequences of, and their responsibility to correct any resulting mistrust or other harmful effects that arise from the use of such techniques. Principle D: Justice Psychologists must recognize that fairness and justice entitle all people to access to and benefit from the contributions of psychology and to equal quality in the processes, procedures, and services that psychologists conduct. They are to exercise reasonable judgment and take precautions to ensure that their potential biases, the boundaries of their competence, and the limitations of their expertise do not lead to or condone unjust practices. Principle E: Respect for people’s rights and dignity Psychologists should respect the dignity and worth of all people and the rights of individuals to privacy, confidentiality, and selfdetermination. Psychologists must be aware that special safeguards may be necessary to protect the rights and welfare of persons or communities whose vulnerabilities impair autonomous decision making. Psychologists should be aware of and respect cultural, individual, and role differences. These differences include those based on age, gender, gender identity, race, ethnicity, culture, national origin, religion, sexual orientation, disability, language, and socioeconomic status. Every psychologist must consider these factors when working with members of such groups. Psychologists must endeavor to eliminate the effect on their work of biases based on such factors and should not knowingly participate in or condone activities of others based upon such prejudices.
Principle C: Integrity As a concept that many people feel is synonymous with the word ethics, psychologists seek to promote integrity. Integrity is the accuracy, honesty, and truthfulness in the science, teaching, and practice of psychology. This principle addresses the expectation that psychologists will not steal, cheat, or engage in fraud, subterfuge, or intentional misrepresentation of fact. Psychologists should strive to keep their promises and avoid unwise or unclear commitments.
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Ethical Standards The ethical standards of the Ethics Code provide a more detailed look at specific situations psychologists encounter. They are currently divided into ten categories ranging from privacy and confidentiality to research, assessment, and therapy as related to their professional conduct. Each standard has additional subsections that relate to the overlying expectation. Ethical standard #1: Resolving ethical issues 1.01 Misuse of psychologists’ work If psychologists learn of misuse or misrepresentation of their work, they take reasonable steps to correct or minimize the misuse or misrepresentation. 1.02 Conflicts between ethics and law, regulations, or other governing legal authority If psychologists’ ethical responsibilities conflict with law, regulations, or other governing legal authority, psychologists clarify the nature of the conflict, make known their commitment to the Ethics Code, and take reasonable steps to resolve the conflict consistent with the General Principles and Ethical Standards of the Ethics Code. Under no circumstances may this standard be used to justify or defend violating human rights. 1.03 Conflicts between ethics and organizational demands If the demands of an organization with which psychologists are affiliated or for whom they are working are in conflict with this Ethics Code, psychologists clarify the nature of the conflict, make known their commitment to the Ethics Code, and take reasonable steps to resolve the conflict consistent with the General Principles and Ethical Standards of the Ethics Code. Under no circumstances may this standard be used to justify or defend violating human rights. 1.04 Informal resolution of ethical violations When psychologists believe that there may have been an ethical violation by another psychologist, they attempt to resolve the issue by bringing it to the attention of that individual, if an informal resolution appears appropriate and the intervention does not violate any confidentiality rights that may be involved. 1.05 Reporting ethical violations If an apparent ethical violation has substantially harmed or is likely to substantially harm a person or organization and is not appropriate for informal resolution under Standard 1.04, Informal Resolution of Ethical Violations, or is not resolved properly in that fashion, psychologists take further action appropriate to the situation. Such action might include referral to state or national committees on professional ethics, to state licensing boards, or to the appropriate institutional authorities. This standard does not apply when an intervention would violate confidentiality rights or when psychologists have been retained to review the work of another psychologist whose professional conduct is in question. 1.06 Cooperating with ethics committees Psychologists cooperate in ethics investigations, proceedings, and resulting requirements of the APA or any affiliated state psychological association to which they belong. In doing so, they address any confidentiality issues. Failure to cooperate is itself an ethics violation. However, making a request for deferment of adjudication of an ethics complaint pending the outcome of litigation does not alone constitute noncooperation.
1.07 Improper complaints Psychologists do not file or encourage the filing of ethics complaints that are made with reckless disregard for or willful ignorance of facts that would disprove the allegation. 1.08 Unfair discrimination against complainants and respondents Psychologists do not deny persons employment, advancement, admissions to academic or other programs, tenure, or promotion, based solely upon their having made or their being the subject of an ethics complaint. This does not preclude taking action based upon the outcome of such proceedings or considering other appropriate information. Ethical standard #2: Competence 2.01 Boundaries of competence Psychologists provide services, teach and conduct research with populations and in areas only within the boundaries of their competence, based on their education, training, supervised experience, consultation, study, or professional experience. Where scientific or professional knowledge in the discipline of psychology establishes that an understanding of factors associated with age, gender, gender identity, race, ethnicity, culture, national origin, religion, sexual orientation, disability, language, or socioeconomic status is essential for effective implementation of their services or research, psychologists have or obtain the training, experience, consultation, or supervision necessary to ensure the competence of their services, or they make appropriate referrals, except as provided in Standard 2.02, Providing Services in Emergencies. Psychologists planning to provide services, teach, or conduct research involving populations, areas, techniques or technologies new to them undertake relevant education, training, supervised experience, consultation, or study. When psychologists are asked to provide services to individuals for whom appropriate mental health services are not available and for which psychologists have not obtained the competence necessary, psychologists with closely related prior training or experience may provide such services in order to ensure that services are not denied if they make a reasonable effort to obtain the competence required by using relevant research, training, consultation, or study. In those emerging areas in which generally recognized standards for preparatory training do not yet exist, psychologists nevertheless take reasonable steps to ensure the competence of their work and to protect clients/patients, students, supervisees, research participants, organizational clients, and others from harm. When assuming forensic roles, psychologists are or become reasonably familiar with the judicial or administrative rules governing their roles. 2.02 Providing services in emergencies In emergencies, when psychologists provide services to individuals for whom other mental health services are not available and for which psychologists have not obtained the necessary training, psychologists may provide such services in order to ensure that services are not denied. The services are discontinued as soon as the emergency has ended or appropriate services are available.
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2.03 Maintaining competence Psychologists undertake ongoing efforts to develop and maintain their competence. 2.04 Bases for scientific and professional judgments Psychologists’ work is based upon established scientific and professional knowledge of the discipline. 2.05 Delegation of work to others Psychologists who delegate work to employees, supervisees, or research or teaching assistants or who use the services of others, such as interpreters, take reasonable steps to (1) avoid delegating such work to persons who have a multiple relationship with those being served that would likely lead to exploitation or loss of objectivity; (2) authorize only those responsibilities that such persons can be expected to perform competently on the basis of their education, training or experience, either independently or with the level of supervision being provided; and (3) see that such persons perform these services competently. 2.06 Personal problems and conflicts Psychologists refrain from initiating an activity when they know or should know that there is a substantial likelihood that their personal problems will prevent them from performing their work-related activities in a competent manner. When psychologists become aware of personal problems that may interfere with their performing work-related duties adequately, they take appropriate measures, such as obtaining professional consultation or assistance and determine whether they should limit, suspend or terminate their work-related duties. Ethical standard #3: Human relations 3.01 Unfair discrimination In their work-related activities, psychologists do not engage in unfair discrimination based on age, gender, gender identity, race, ethnicity, culture, national origin, religion, sexual orientation, disability, socioeconomic status, or any basis proscribed by law. 3.02 Sexual harassment Psychologists do not engage in sexual harassment. Sexual harassment is defined as sexual solicitation, physical advances, or verbal or nonverbal conduct that is sexual in nature, that occurs in connection with the psychologist’s activities or roles as a psychologist and that either (1) is unwelcome, is offensive or creates a hostile workplace or educational environment, and the psychologist knows or is told this or (2) is sufficiently severe or intense to be abusive to a reasonable person in the context. Sexual harassment can consist of a single intense or severe act or of multiple persistent or pervasive acts. 3.03 Other harassment Psychologists do not knowingly engage in behavior that is harassing or demeaning to persons with whom they interact in their work based on factors such as those persons’ age, gender, gender identity, race, ethnicity, culture, national origin, religion, sexual orientation, disability, language, or socioeconomic status. 3.04 Avoiding harm Psychologists take reasonable steps to avoid harming their clients/patients, students, supervisees, research participants, organizational clients, and others with whom they work, and to minimize harm where it is foreseeable and unavoidable.
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3.05 Multiple relationships A multiple relationship occurs when a psychologist is in a professional role with a person and: ○○ At the same time is in another role with the same person, ○○ At the same time is in a relationship with a person closely associated with or related to the person with whom the psychologist has the professional relationship, or ○○ Promises to enter into another relationship in the future with the person or a person closely associated with or related to the person. A psychologist refrains from entering into a multiple relationship if the multiple relationship could reasonably be expected to impair the psychologist’s objectivity, competence or effectiveness in performing his or her functions as a psychologist, or otherwise risks exploitation or harm to the person with whom the professional relationship exists. Multiple relationships that would not reasonably be expected to cause impairment or risk exploitation or harm are not unethical: ○○ If a psychologist finds that, due to unforeseen factors, a potentially harmful multiple relationship has arisen, the psychologist takes reasonable steps to resolve it with due regard for the best interests of the affected person and maximal compliance with the Ethics Code. ○○ When psychologists are required by law, institutional policy, or extraordinary circumstances to serve in more than one role in judicial or administrative proceedings, at the outset they clarify role expectations and the extent of confidentiality and thereafter as changes occur. 3.06 Conflict of interest Psychologists refrain from taking on a professional role when personal, scientific, professional, legal, financial, or other interests or relationships could reasonably be expected to impair their objectivity, competence, or effectiveness in performing their functions as psychologists or expose the person or organization with whom the professional relationship exists to harm or exploitation. 3.07 Third-party requests for services When psychologists agree to provide services to a person or entity at the request of a third party, psychologists attempt to clarify at the outset of the service the nature of the relationship with all individuals or organizations involved. This clarification includes the role of the psychologist (therapist, consultant, diagnostician, or expert witness), an identification of who is the client, the probable uses of the services provided or the information obtained, and the fact that there may be limits to confidentiality. 3.08 Exploitative relationships Psychologists do not exploit persons over whom they have supervisory, evaluative, or other authority such as clients/ patients, students, supervisees, research participants, and employees. 3.09 Cooperation with other professionals When indicated and professionally appropriate, psychologists cooperate with other professionals in order to serve their clients/patients effectively and appropriately. 3.10 Informed consent When psychologists conduct research or provide assessment, therapy, counseling, or consulting services in person or via electronic transmission or other forms of communication, they obtain the informed consent of the individual or individuals using language that is reasonably understandable to that person or persons except when conducting such activities without consent is mandated by law or governmental regulation or as otherwise provided in this Ethics Code. Page 47
For persons who are legally incapable of giving informed consent, psychologists must: ○○ Provide an appropriate explanation. ○○ Seek the individual’s assent. ○○ Consider such persons’ preferences and best interests. ○○ Obtain appropriate permission from a legally authorized person, if such substitute consent is permitted or required by law. When consent by a legally authorized person is not permitted or required by law, psychologists take reasonable steps to protect the individual’s rights and welfare. When psychological services are court ordered or otherwise mandated, psychologists inform the individual of the nature of the anticipated services, including whether the services are court ordered or mandated and any limits of confidentiality, before proceeding. Psychologists are required to appropriately document written or oral consent, permission, and assent. 3.11 Psychological services delivered to or through organizations Psychologists delivering services to or through organizations provide information beforehand to clients and when appropriate those directly affected by the services about (1) the nature and objectives of the services, (2) the intended recipients, (3) which of the individuals are clients, (4) the relationship the psychologist will have with each person and the organization, (5) the probable uses of services provided and information obtained, (6) who will have access to the information, and (7) limits of confidentiality. As soon as feasible, they provide information about the results and conclusions of such services to appropriate persons. If psychologists will be precluded by law or by organizational roles from providing such information to particular individuals or groups, they so inform those individuals or groups at the outset of the service. 3.12 Interruption of psychological services Unless otherwise covered by contract, psychologists make reasonable efforts to plan for facilitating services in the event that psychological services are interrupted by factors such as the psychologist’s illness, death, unavailability, relocation, or retirement or by the client’s/patient’s relocation or financial limitations. Ethical standard #4: Privacy and confidentiality 4.01 Maintaining confidentiality Psychologists have a primary obligation and take reasonable precautions to protect confidential information obtained through or stored in any medium, recognizing that the extent and limits of confidentiality may be regulated by law or established by institutional rules or professional or scientific relationship. 4.02 Discussing the limits of confidentiality Psychologists discuss with persons (including, to the extent feasible, persons who are legally incapable of giving informed consent and their legal representatives) and organizations with whom they establish a scientific or professional relationship (1) the relevant limits of confidentiality and (2) the foreseeable uses of the information generated through their psychological activities. Unless it is not feasible or is contraindicated, the discussion of confidentiality occurs at the outset of the relationship and thereafter as new circumstances may warrant. Psychologists who offer services, products, or information via electronic transmission inform clients/patients of the risks to privacy and limits of confidentiality.
4.03 Recording Before recording the voices or images of individuals to whom they provide services, psychologists obtain permission from all such persons or their legal representatives. 4.04 Minimizing intrusions on privacy Psychologists include in written and oral reports and consultations, only information germane to the purpose for which the communication is made. Psychologists discuss confidential information obtained in their work only for appropriate scientific or professional purposes and only with persons clearly concerned with such matters. 4.05 Disclosures Psychologists may disclose confidential information with the appropriate consent of the organizational client, the individual client/patient, or another legally authorized person on behalf of the client/patient unless prohibited by law. Psychologists disclose confidential information without the consent of the individual only as mandated by law, or where permitted by law for a valid purpose such as to: ○○ Provide needed professional services. ○○ Obtain appropriate professional consultations. ○○ Protect the client/patient, psychologist, or others from harm; or ○○ Obtain payment for services from a client/patient, in which instance disclosure is limited to the minimum that is necessary to achieve the purpose. 4.06 Consultations When consulting with colleagues, (1) psychologists do not disclose confidential information that reasonably could lead to the identification of a client/patient, research participant, or other person or organization with whom they have a confidential relationship unless they have obtained the prior consent of the person or organization or the disclosure cannot be avoided, and (2) they disclose information only to the extent necessary to achieve the purposes of the consultation. 4.07 Use of confidential information for didactic or other purposes Psychologists do not disclose in their writings, lectures, or other public media, confidential, personally identifiable information concerning their clients/patients, students, research participants, organizational clients, or other recipients of their services that they obtained during the course of their work, unless they take reasonable steps to disguise the person or organization, the person or organization has consented in writing, or there is legal authorization for doing so. Ethical standard #5: Advertising and other public statements 5.01 Avoidance of false or deceptive statements Public statements include but are not limited to paid or unpaid advertising, product endorsements, grant applications, licensing applications, other credentialing applications, brochures, printed matter, directory listings, personal resumes or curricula vitae or comments for use in media such as print or electronic transmission, statements in legal proceedings, lectures and public oral presentations, and published materials. Psychologists do not knowingly make public statements that are false, deceptive or fraudulent concerning their research, practice or other work activities, or those of persons or organizations with which they are affiliated. Psychologists do not make false, deceptive or fraudulent statements concerning (1) their training, experience or competence; (2) their academic degrees; (3) their credentials; (4) their institutional or association affiliations; (5) their services; (6) the scientific or clinical basis for or results or
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degree of success of, their services; (7) their fees; or (8) their publications or research findings.
control, whether these are written, automated or in any other medium.
Psychologists claim degrees as credentials for their health services only if those degrees were either earned from a regionally accredited educational institution or were the basis for psychology licensure by the state in which they practice.
If confidential information concerning recipients of psychological services is entered into databases or systems of records available to persons whose access has not been consented to by the recipient, psychologists use coding or other techniques to avoid the inclusion of personal identifiers.
5.02 Statements by others Psychologists who engage others to create or place public statements that promote their professional practice, products, or activities retain professional responsibility for such statements. Psychologists do not compensate employees of press, radio, television, or other communication media in return for publicity in a news item. A paid advertisement relating to psychologists’ activities must be identified or clearly recognizable as such. 5.03 Descriptions of workshops and non-degree-granting educational programs To the degree to which they exercise control, psychologists responsible for announcements, catalogs, brochures, or advertisements describing workshops, seminars, or other non-degree-granting educational programs ensure that they accurately describe the audience for which the program is intended, the educational objectives, the presenters, and the fees involved. 5.04 Media presentations When psychologists provide public advice or comment via print, Internet, or other electronic transmission, they take precautions to ensure that statements: ○○ Are based on their professional knowledge, training, or experience in accord with appropriate psychological literature and practice; ○○ Are otherwise consistent with this Ethics Code; and ○○ Do not indicate that a professional relationship has been established with the recipient. 5.05 Testimonials Psychologists do not solicit testimonials from current therapy clients/patients or other persons who because of their particular circumstances are vulnerable to undue influence. 5.06 In-person solicitation Psychologists do not engage, directly or through agents, in uninvited in-person solicitation of business from actual or potential therapy clients/patients or other persons who because of their particular circumstances are vulnerable to undue influence. However, this prohibition does not preclude attempting to implement appropriate collateral contacts for the purpose of benefiting an already engaged therapy client/patient or providing disaster or community outreach services. Ethical standard #6: Record keeping and fees 6.01 Documentation of professional and scientific work and maintenance of records Psychologists create, and to the extent the records are under their control, maintain, disseminate, store, retain, and dispose of records and data relating to their professional and scientific work in order to (1) facilitate provision of services later by them or by other professionals, (2) allow for replication of research design and analyses, (3) meet institutional requirements, (4) ensure accuracy of billing and payments, and (5) ensure compliance with law. 6.02 Maintenance, dissemination, and disposal of confidential records of professional and scientific work Psychologists maintain confidentiality in creating, storing, accessing, transferring and disposing of records under their
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Psychologists make plans in advance to facilitate the appropriate transfer and to protect the confidentiality of records and data in the event of psychologists’ withdrawal from positions or practice. 6.03 Withholding records for nonpayment Psychologists may not withhold records under their control that are requested and needed for a client’s/patient’s emergency treatment solely because payment has not been received. 6.04 Fees and financial arrangements As early as is feasible in a professional or scientific relationship, psychologists and recipients of psychological services reach an agreement specifying compensation and billing arrangements. Psychologists’ fee practices are consistent with law. Psychologists are expected to not misrepresent their fees. If limitations to services can be anticipated because of limitations in financing, this is discussed with the recipient of services as early as is feasible. If the recipient of services does not pay for services as agreed, and if psychologists intend to use collection agencies or legal measures to collect the fees, psychologists first inform the person that such measures will be taken and provide that person an opportunity to make prompt payment. 6.05 Barter with clients/patients Barter is the acceptance of goods, services, or other nonmonetary remuneration from clients/patients in return for psychological services. Psychologists may barter only if (1) it is not clinically contraindicated, and (2) the resulting arrangement is not exploitative. 6.06 Accuracy in reports to payors and funding sources In their reports to payors for services or sources of research funding, psychologists take reasonable steps to ensure the accurate reporting of the nature of the service provided or research conducted, the fees, charges or payments, and where applicable, the identity of the provider, the findings, and the diagnosis. 6.07 Referrals and fees When psychologists pay, receive payment from, or divide fees with another professional, other than in an employer-employee relationship, the payment to each is based on the services provided (clinical, consultative, administrative, or other) and is not based on the referral itself. Ethical standard #7: Education and training 7.01 Design of education and training programs Psychologists responsible for education and training programs take reasonable steps to ensure that the programs are designed to provide the appropriate knowledge and proper experiences, and to meet the requirements for licensure, certification, or other goals for which claims are made by the program. 7.02 Descriptions of education and training programs Psychologists responsible for education and training programs take reasonable steps to ensure that there is a current and accurate description of the program content (including participation in required course- or program-related counseling, Page 49
psychotherapy, experiential groups, consulting projects, or community service), training goals and objectives, stipends and benefits, and requirements that must be met for satisfactory completion of the program. This information must be made readily available to all interested parties. 7.03 Accuracy in teaching Psychologists take reasonable steps to ensure that course syllabi are accurate regarding the subject matter to be covered, bases for evaluating progress, and the nature of course experiences. This standard does not preclude an instructor from modifying course content or requirements when the instructor considers it pedagogically necessary or desirable, so long as students are made aware of these modifications in a manner that enables them to fulfill course requirements. When engaged in teaching or training, psychologists present psychological information accurately. 7.04 Student disclosure of personal information Psychologists do not require students or supervisees to disclose personal information in course either orally or in writing, regarding sexual history, history of abuse and neglect, psychological treatment, and relationships with parents, peers and spouses or significant others except if (1) the program or training facility has clearly identified this requirement in its admissions and program materials or (2) the information is necessary to evaluate or obtain assistance for students whose personal problems could reasonably be judged to be preventing them from performing their training or professionally related activities in a competent manner or posing a threat to the students or others. 7.05 Mandatory individual or group therapy When individual or group therapy is a program or course requirement, psychologists responsible for that program allow students in undergraduate and graduate programs the option of selecting such therapy from practitioners unaffiliated with the program. Faculty who are or are likely to be responsible for evaluating students’ academic performance do not themselves provide that therapy. 7.06 Assessing student and supervisee performance In academic and supervisory relationships, psychologists establish a timely and specific process for providing feedback to students and supervisees. Information regarding the process is provided to the student at the beginning of supervision. Psychologists evaluate students and supervisees on the basis of their actual performance on relevant and established program requirements. 7.07 Sexual relationships with students and supervisees Psychologists do not engage in sexual relationships with students or supervisees who are in their department, agency, or training center or over whom psychologists have or are likely to have evaluative authority. Ethical standard #8: Research and training 8.01 Institutional approval When institutional approval is required, psychologists provide accurate information about their research proposals and obtain approval prior to conducting the research. They conduct the research in accordance with the approved research protocol. 8.02 Informed consent to research When obtaining informed consent as required in Standard 3.10, Informed Consent, psychologists inform participants about: ○○ The purpose of the research, expected duration, and procedures.
○○ Their right to decline to participate and to withdraw from the research once participation has begun. ○○ The foreseeable consequences of declining or withdrawing. ○○ Reasonably foreseeable factors that may be expected to influence their willingness to participate such as potential risks, discomfort, or adverse effects. ○○ Any prospective research benefits. ○○ Limits of confidentiality. ○○ Incentives for participation. ○○ Whom to contact for questions about the research and research participants’ rights. They provide opportunity for the prospective participants to ask questions and receive answers. ○○ Psychologists conducting intervention research involving the use of experimental treatments clarify to participants at the outset of the research. ○○ The experimental nature of the treatment. ○○ The services that will or will not be available to the control group(s) if appropriate. ○○ The means by which assignment to treatment and control groups will be made. ○○ Available treatment alternatives if an individual does not wish to participate in the research or wishes to withdraw once a study has begun. ○○ Compensation for or monetary costs of participating including, if appropriate, whether reimbursement from the participant or a third-party payor will be sought. 8.03 Informed consent for recording voices and images in research Psychologists obtain informed consent from research participants prior to recording their voices or images for data collection unless (1) the research consists solely of naturalistic observations in public places and it is not anticipated that the recording will be used in a manner that could cause personal identification or harm, or (2) the research design includes deception, and consent for the use of the recording is obtained during debriefing. 8.04 Client/patient, student, and subordinate research participants When psychologists conduct research with clients/patients, students, or subordinates as participants, psychologists take steps to protect the prospective participants from adverse consequences of declining or withdrawing from participation. When research participation is a course requirement or an opportunity for extra credit, the prospective participant is given the choice of equitable alternative activities. 8.05 Dispensing with informed consent for research Psychologists may dispense with informed consent only (1) where research would not reasonably be assumed to create distress or harm and involves (a) the study of normal educational practices, curricula, or classroom management methods conducted in educational settings; (b) only anonymous questionnaires, naturalistic observations, or archival research for which disclosure of responses would not place participants at risk of criminal or civil liability or damage their financial standing, employability, or reputation, and confidentiality is protected; or (c) the study of factors related to job or organization effectiveness conducted in organizational settings for which there is no risk to participants’ employability and confidentiality is protected or (2) where otherwise permitted by law or federal or institutional regulations. 8.06 Offering inducements for research participation Psychologists make reasonable efforts to avoid offering excessive or inappropriate financial or other inducements for
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research participation when such inducements are likely to coerce participation. When offering professional services as an inducement for research participation, psychologists clarify the nature of the services, as well as the risks, obligations, and limitations. 8.07 Deception in research Psychologists do not conduct a study involving deception unless they have determined that the use of deceptive techniques is justified by the study’s significant prospective scientific, educational, or applied value and that effective nondeceptive alternative procedures are not feasible. Psychologists do not deceive prospective participants about research that is reasonably expected to cause physical pain or severe emotional distress. Psychologists explain any deception that is an integral feature of the design and conduct of an experiment to participants as early as is feasible, preferably at the conclusion of their participation, but no later than at the conclusion of the data collection, and permit participants to withdraw their data. (See also Standard 8.08, Debriefing.) 8.08 Debriefing Psychologists provide a prompt opportunity for participants to obtain appropriate information about the nature, results, and conclusions of the research, and they take reasonable steps to correct any misconceptions that participants may have of which the psychologists are aware. If scientific or humane values justify delaying or withholding this information, psychologists take reasonable measures to reduce the risk of harm. When psychologists become aware that research procedures have harmed a participant, they take reasonable steps to minimize the harm. 8.09
Humane care and use of animals in research Psychologists acquire, care for, use, and dispose of animals in compliance with current federal, state, and local laws and regulations, and with professional standards. Psychologists trained in research methods and experienced in the care of laboratory animals supervise all procedures involving animals and are responsible for ensuring appropriate consideration of their comfort, health, and humane treatment. Psychologists ensure that all individuals under their supervision who are using animals have received instruction in research methods and in the care, maintenance, and handling of the species being used, to the extent appropriate to their role. (See also Standard 2.05, Delegation of Work to Others.) Psychologists make reasonable efforts to minimize the discomfort, infection, illness, and pain of animal subjects. Psychologists use a procedure subjecting animals to pain, stress, or privation only when an alternative procedure is unavailable and the goal is justified by its prospective scientific, educational, or applied value. Psychologists perform surgical procedures under appropriate anesthesia and follow techniques to avoid infection and minimize pain during and after surgery. When it is appropriate that an animal’s life be terminated, psychologists proceed rapidly, with an effort to minimize pain and in accordance with accepted procedures.
8.10 Reporting research results Psychologists are expected to not fabricate data.
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If psychologists discover significant errors in their published data, they take reasonable steps to correct such errors in a correction, retraction, erratum, or other appropriate publication means. 8.11 Plagiarism Psychologists do not present portions of another’s work or data as their own, even if the other work or data source is cited occasionally. 8.12 Publication credit Psychologists take responsibility and credit, including authorship credit, only for work they have actually performed or to which they have substantially contributed. Principal authorship and other publication credits accurately reflect the relative scientific or professional contributions of the individuals involved, regardless of their relative status. Mere possession of an institutional position, such as department chair, does not justify authorship credit. Minor contributions to the research or to the writing for publications are acknowledged appropriately, such as in footnotes or in an introductory statement. Except under exceptional circumstances, a student is listed as principal author on any multiple-authored article that is substantially based on the student’s doctoral dissertation. Faculty advisors discuss publication credit with students as early as feasible and throughout the research and publication process as appropriate. 8.13 Duplicate publication of data Psychologists do not publish, as original data, data that have been previously published. This does not preclude republishing data when they are accompanied by proper acknowledgment. 8.14 Sharing research data for verification After research results are published, psychologists do not withhold the data on which their conclusions are based from other competent professionals who seek to verify the substantive claims through reanalysis and who intend to use such data only for that purpose, provided that the confidentiality of the participants can be protected and unless legal rights concerning proprietary data preclude their release. This does not preclude psychologists from requiring that such individuals or groups be responsible for costs associated with the provision of such information. Psychologists who request data from other psychologists to verify the substantive claims through reanalysis may use shared data only for the declared purpose. Requesting psychologists obtain prior written agreement for all other uses of the data. 8.15 Reviewers Psychologists who review material submitted for presentation, publication, grant, or research proposal review respect the confidentiality of and the proprietary rights in such information of those who submitted it. Ethical standard #9: Assessment 9.01 Bases for assessments Psychologists base the opinions contained in their recommendations, reports, and diagnostic or evaluative statements, including forensic testimony, on information and techniques sufficient to substantiate their findings. Except as noted in 9.01c, psychologists provide opinions of the psychological characteristics of individuals only after they have conducted an examination of the individuals adequate to support their statements or conclusions. When, despite reasonable efforts, such an examination is not practical, Page 51
psychologists document the efforts they made and the result of those efforts, clarify the probable impact of their limited information on the reliability and validity of their opinions and appropriately limit the nature and extent of their conclusions or recommendations. When psychologists conduct a record review or provide consultation or supervision and an individual examination is not warranted or necessary for the opinion, psychologists explain this and the sources of information on which they based their conclusions and recommendations. 9.02 Use of assessments Psychologists administer, adapt, score, interpret, or use assessment techniques, interviews, tests, or instruments in a manner and for purposes that are appropriate in light of the research on or evidence of the usefulness and proper application of the techniques. Psychologists use assessment instruments whose validity and reliability have been established for use with members of the population tested. When such validity or reliability has not been established, psychologists describe the strengths and limitations of test results and interpretation. Psychologists use assessment methods that are appropriate to an individual’s language preference and competence, unless the use of an alternative language is relevant to the assessment issues. 9.03 Informed consent in assessments Psychologists obtain informed consent for assessments, evaluations or diagnostic services, as described in Standard 3.10, Informed Consent, except when (1) testing is mandated by law or governmental regulations; (2) informed consent is implied because testing is conducted as a routine educational, institutional, or organizational activity (e.g., when participants voluntarily agree to assessment when applying for a job); or (3) one purpose of the testing is to evaluate decisional capacity. Informed consent includes an explanation of the nature and purpose of the assessment, fees, involvement of third parties and limits of confidentiality, and sufficient opportunity for the client/patient to ask questions and receive answers. Psychologists inform persons with questionable capacity to consent or for whom testing is mandated by law or governmental regulations about the nature and purpose of the proposed assessment services, using language that is reasonably understandable to the person being assessed. Psychologists using the services of an interpreter obtain informed consent from the client/patient to use that interpreter, ensure that confidentiality of test results and test security are maintained, and include in their recommendations, reports, and diagnostic or evaluative statements, including forensic testimony, discussion of any limitations on the data obtained. 9.04 Release of test data The term test data refers to raw and scaled scores, client/ patient responses to test questions or stimuli, and psychologists’ notes and recordings concerning client/patient statements and behavior during an examination. Those portions of test materials that include client/patient responses are included in the definition of test data. Pursuant to a client/patient release, psychologists provide test data to the client/patient or other persons identified in the release. Psychologists may refrain from releasing test data to protect a client/patient or others from substantial harm or misuse or misrepresentation of the data or the test, recognizing that in many instances release of confidential information under these circumstances is regulated by law.
In the absence of a client/patient release, psychologists provide test data only as required by law or court order. 9.05 Test construction Psychologists who develop tests and other assessment techniques use appropriate psychometric procedures and current scientific or professional knowledge for test design, standardization, validation, reduction or elimination of bias, and recommendations for use. 9.06 Interpreting assessment results When interpreting assessment results, including automated interpretations, psychologists take into account the purpose of the assessment as well as the various test factors, test-taking abilities, and other characteristics of the person being assessed, such as situational, personal, linguistic, and cultural differences that might affect psychologists’ judgments or reduce the accuracy of their interpretations. They indicate any significant limitations of their interpretations. 9.07 Assessment by unqualified persons Psychologists do not promote the use of psychological assessment techniques by unqualified persons, except when such use is conducted for training purposes with appropriate supervision. 9.08 Obsolete tests and outdated test results Psychologists do not base their assessment or intervention decisions or recommendations on data or test results that are outdated for the current purpose. Psychologists do not base such decisions or recommendations on tests and measures that are obsolete and not useful for the current purpose. 9.09 Test scoring and interpretation services Psychologists who offer assessment or scoring services to other professionals accurately describe the purpose, norms, validity, reliability and applications of the procedures, and any special qualifications applicable to their use. Psychologists select scoring and interpretation services (including automated services) on the basis of evidence of the validity of the program and procedures as well as on other appropriate considerations. Psychologists retain responsibility for the appropriate application, interpretation, and use of assessment instruments, whether they score and interpret such tests themselves or use automated or other services. 9.10 Explaining assessment results Regardless of whether the scoring and interpretation are done by psychologists, by employees or assistants, or by automated or other outside services, psychologists take reasonable steps to ensure that explanations of results are given to the individual or designated representative unless the nature of the relationship precludes provision of an explanation of results (such as in some organizational consulting, pre-employment or security screenings, and forensic evaluations), and this fact has been clearly explained to the person being assessed in advance. 9.11 Maintaining test security The term test materials refers to manuals, instruments, protocols, and test questions or stimuli and does not include test data as defined in Standard 9.04, Release of Test Data. Psychologists make reasonable efforts to maintain the integrity and security of test materials and other assessment techniques consistent with law and contractual obligations, and in a manner that permits adherence to this Ethics Code.
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Ethical standard #10: Therapy 10.01 Informed consent to therapy When obtaining informed consent to therapy as required in Standard 3.10, Informed Consent, psychologists inform clients/ patients as early as is feasible in the therapeutic relationship about the nature and anticipated course of therapy, fees, involvement of third parties and limits of confidentiality, and provide sufficient opportunity for the client/patient to ask questions and receive answers. When obtaining informed consent for treatment for which generally recognized techniques and procedures have not been established, psychologists inform their clients/patients of the developing nature of the treatment, the potential risks involved, alternative treatments that may be available, and the voluntary nature of their participation. When the therapist is a trainee and the legal responsibility for the treatment provided resides with the supervisor, the client/ patient, as part of the informed consent procedure, is informed that the therapist is in training and is being supervised and is given the name of the supervisor. 10.02 Therapy involving couples or families When psychologists agree to provide services to several persons who have a relationship (such as spouses, significant others, or parents and children), they take reasonable steps to clarify at the outset (1) which of the individuals are clients/patients and (2) the relationship the psychologist will have with each person. This clarification includes the psychologist’s role and the probable uses of the services provided or the information obtained. If it becomes apparent that psychologists may be called on to perform potentially conflicting roles (such as family therapist and then witness for one party in divorce proceedings), psychologists take reasonable steps to clarify and modify, or withdraw from, roles appropriately. 10.03 Group therapy When psychologists provide services to several persons in a group setting, they describe at the outset the roles and responsibilities of all parties and the limits of confidentiality. 10.04 Providing therapy to those served by others In deciding whether to offer or provide services to those already receiving mental health services elsewhere, psychologists carefully consider the treatment issues and the potential client’s/ patient’s welfare. Psychologists discuss these issues with the client/patient or another legally authorized person on behalf of the client/patient in order to minimize the risk of confusion and conflict, consult with the other service providers when appropriate, and proceed with caution and sensitivity to the therapeutic issues.
10.05 Sexual intimacies with current therapy clients/patients Psychologists do not engage in sexual intimacies with current therapy clients/patients. 10.06 Sexual intimacies with relatives or significant others of current therapy clients/patients Psychologists do not engage in sexual intimacies with individuals they know to be close relatives, guardians, or significant others of current clients/patients. Psychologists do not terminate therapy to circumvent this standard. 10.07 Therapy with former sexual partners Psychologists do not accept as therapy clients/patients persons with whom they have engaged in sexual intimacies. 10.08 Sexual intimacies with former therapy clients/patients Psychologists do not engage in sexual intimacies with former clients/patients for at least two years after cessation or termination of therapy. Psychologists do not engage in sexual intimacies with former clients/patients even after a two-year interval except in the most unusual circumstances. Psychologists who engage in such activity after the two years following cessation or termination of therapy and of having no sexual contact with the former client/patient bear the burden of demonstrating that there has been no exploitation, in light of all relevant factors, including (1) the amount of time that has passed since therapy terminated; (2) the nature, duration, and intensity of the therapy; (3) the circumstances of termination; (4) the client’s/patient’s personal history; (5) the client’s/patient’s current mental status; (6) the likelihood of adverse impact on the client/patient; and (7) any statements or actions made by the therapist during the course of therapy suggesting or inviting the possibility of a posttermination sexual or romantic relationship with the client/ patient. 10.09 Interruption of therapy When entering into employment or contractual relationships, psychologists make reasonable efforts to provide for orderly and appropriate resolution of responsibility for client/ patient care in the event that the employment or contractual relationship ends, with paramount consideration given to the welfare of the client/patient. 10.10 Terminating therapy Psychologists terminate therapy when it becomes reasonably clear that the client/patient no longer needs the service, is not likely to benefit, or is being harmed by continued service. Psychologists may terminate therapy when threatened or otherwise endangered by the client/patient or another person with whom the client/patient has a relationship. Except where precluded by the actions of clients/patients or third-party payors, prior to termination psychologists provide pretermination counseling and suggest alternative service providers as appropriate.
Psychologists and Ethical Dilemmas Psychologists deal with boundary issues every day, such as: ●● “My client seems in crisis. Should I let the session run overtime?” ●● “What should I say to my best friend who wants me to see his young daughter in psychotherapy?” ●● “Is it a good idea for me to waive the fee for a proud client who desperately needs therapy, lost his job, and is unable to find other work?” ●● “Should I attend my client’s wedding and bring a gift?” ●● “My new client is known for giving great parties and has invited me. Should I go?” Psychology.EliteCME.com
●● “I wonder what I should say to the tournament organizers. I really want to win but they’ve paired me with my therapy client as a doubles-partner.” Starting in the early 1980s, questions like these began to rise and held the field’s attention. The 1980s through the mid-1990s saw a virtual explosion of healthy controversy and thoughtful writings on dual relationships, bartering, nonsexual touch, meeting therapy clients outside the office for social visits, and other nonsexual boundary issues. Should all prohibitions be abolished? Was it possible to tell which boundary crossings were therapeutically helpful, which were Page 53
therapeutically contra-indicated as harmful, and which might be common or even unavoidable in certain communities or cultures? Research during the 80s and 90s demonstrated how theoretical orientation, size of the local community, therapist gender, client gender, profession, and other factors affected both the degree to which therapists engaged in crossing various boundaries and therapists’ beliefs about the nature and appropriateness of boundary crossings. “The Concept of Boundaries in Clinical Practice, a ground-breaking article by Gutheil and Gabbard (1993), represented a turning point for the field. It provided a useful framework for thinking through and challenging beliefs, for providing thoughtful explorations, for learning from and arguing against, for understanding the history and development of this area, and for helping to think through difficult decisions in our day-to-day clinical work. Guthiel and Gabbard (1993) organized the individual instances of boundary crossings such as Freud’s that were described in the literature, the emerging research, and the diverse viewpoints as a basis for their initial “explorations,” and developed a framework of boundary crossings and boundary violations that reflected the realities of clinical practice. Guthiel and Gabbard made judgments in light of the context and specifics. They examined crossings and violations of such diverse boundaries as role, time, place and space, money, gifts, services, clothing, language, self-disclosure, and physical contact. They emphasized that crossing boundaries “may at times be salutary, at times neutral, and at times harmful” and that the nature, clinical usefulness, and impact of a particular crossing “can only be assessed by a careful attention to the clinical context” (p. 188-189). People differ in their ability to perceive that something they might do, or are already doing, could directly or indirectly affect the welfare of others (Rest, 1982). Below are a few of the most basic assumptions we make about ethical awareness and decision-making (Koocher & KeithSpiegel, 2008; Pope & Vasquez, 2007). ●● Ethical awareness is a continuous, active process that involves constant questioning and personal responsibility. Conflicts with managed care companies, the urgency of patients’ needs, the possibility of formal complaints by patients or second-guessing by colleagues about a difficult boundary decision we make, mind-deadening routines and endless paperwork, worrying about making ends meet, fatigue, and so much else can begin to block our personal responsiveness and dull our sense of personal responsibility. They can overwhelm us, drain us, distract us, lull us into ethical sleep, and make us more vulnerable to the tendency we all share as human beings to rationalize our questionable decisions. It is crucial to practice continued alertness and mindful awareness of the ethical implications of what we choose to do and not do. ●● Awareness of ethical codes and legal standards is an essential aspect of critical thinking about ethics and of making ethical decisions. Codes and standards, however, inform rather than determine our ethical decisions. They cannot substitute for
thinking and feeling our way through ethical dilemmas, and cannot protect us from ethical struggles and uncertainty. Each new client, regardless of similarities to other clients, is unique. Each therapist is unique. Each situation is unique and constantly evolves. Our theoretical orientation, the nature of our community and the client’s community, our culture and the client’s culture, and many other contexts influence what we see and how we see it. Every ethical decision must consider these contexts. ●● Awareness of evolving research and theory in scientific and professional literature are also important aspects of ethical competence, but the claims and conclusions emerging in the literature should not be passively accepted or reflexively applied no matter how popular, authoritative, or seemingly obvious. We must greet published claims and conclusions with active, careful, informed, persistent, and comprehensive questioning. Many of us find it easier to question the ethics of others, especially in an area as difficult and controversial as boundaries, while putting our own beliefs, assumptions, and actions off limits. Questioning someone’s ethical decisions and behavior must be a reciprocal process: it is crucial to question our own decisions and behavior and to allow ourselves to be questioned at least as much as we question others. It is a warning signal if we spend more time pointing out the supposed negative aspects of others, than we spend trying to overcome our own challenges and move into more positive perspectives and possibilities. Psychologists often encounter ethical dilemmas without clear and easy answers. This is perhaps more true for boundary decisions than for any other area. We may confront overwhelming needs unmatched by adequate resources, conflicting responsibilities that seem impossible to reconcile, frustrating limits to our understanding and interventions, and countless other challenges as we seek to help people who come to us because they are hurting and in need, sometimes because they are desperate and have nowhere else to turn. Suddenly we are required to make dauntingly complex decisions about boundaries “on the spot” as a reaction to a client’s or colleague’s unexpected words or behaviors. There is no legitimate way to avoid these ethical struggles. They are part of our work. Consultation is usually helpful and sometimes crucial. Because our own issues may blind us, consulting with trusted colleagues (those not involved with the situation) can strengthen ethical decision-making (Pope & Vasquez, 2007). Colleagues may best reveal unrecognized biases and useful perspectives that we had not considered. Moreover, as we make difficult decisions under stress, we may become more concerned with how the decision affects us—this is unintentional but understandable. For example, Will it place us at risk for a malpractice suit or licensing complaint? Will it alienate a referral sources we depend on? Will it cause a managed care company to drop us as a provider? Consultation may help us consider the consequences of our decisions for all those affected by them.
Potential ethical issues Here are some suggestions for ways to analyze potential ethical issues when you encounter them. ●● Imagine what might be the “best possible outcome” and the “worst possible outcome” from either crossing or not crossing this boundary. Does either crossing or not crossing involve significant risk of negative consequences, or any real risk of serious harm, in the short or long term? If harm is a real possibility, are there ways to address it? ●● Consider the research and other published literature on this boundary crossing. If there is none, consider bringing up the topic at the next meeting of your professional association or making a professional contribution in the form of an article.
●● Familiarize yourself with, and take into account, any guidance regarding this boundary crossing offered by professional guidelines, ethics codes, legislation, case law, and other resources. ●● Identify at least one colleague you can trust for honest feedback on boundary crossing questions. ●● Pay attention to your interior uneasy feelings, doubts, or confusion, and try to determine what is causing them, in addition to what implications, if any, they may have for your decisions. ●● Describe to a new client exactly how you work and what kind of services you provide as part of your informed consent and during the initial therapy session. If the client appears to feel uncomfortable, explore further and, if warranted, refer to a colleague who may be better suited to this individual.
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●● Refer to a suitable colleague any client whom you feel incompetent to treat or with whom you do not feel you could work effectively. Reasons to refer range your insufficient training and experience to personal attributes of the client that make you extremely uncomfortable in a way that prevents you from working effectively.
●● Depend on the informed consent process for any planned and obvious boundary crossing, such as taking a phobic client for a walk in the local mall to window shop. ●● Document in writing the reasons for any planned boundary crossing, describing exactly why, in your clinical judgment, this was (or will be) helpful to the client.
Boundary crossings Some boundary crossings are unexpected: suddenly we encounter a client outside of therapy—at a friend’s dinner party or in a minor fender-bender on the street. Flustered and with no time to think, we may make a very human blunder. Other boundary crossings may be virtually inevitable or inescapable. In a small and geographically remote town, we may likely be in more than one relationship with our therapy clients, and some of these relationships may cause boundary crossings that undermine the therapy. Still other boundary crossings— despite the best of intentions, the most careful planning, and the most skillful intervention—may go wrong: therapy veers off course, the relationship unravels, growth and progress stall. The signs of trouble may be sudden and unmistakable such as when the client criticizes us for crossing a boundary or for some consequence of the crossing, abruptly terminates, or perhaps even files a formal complaint. However, signs may also be more subtle, and it may be unclear whether the boundary crossing or something else is the cause. The client may begin missing sessions or not paying on time, the clienttherapist rapport between us starts to erode, or there may be nothing specific we can point to but somehow things seem a little “off.”
self-assessment, for us as psychologists, are imperatives, given the situation. Talking over the situation with an experienced colleague who can provide honest feedback and thoughtful consultation may be very helpful. Even when we are able to be honest and non-defensive with ourselves, we may find it difficult to open up to a respected colleague about our work not going well, about the possibility that we may have made a mistake that ended up hurting a client. Will our colleague think less of us? Be critical? Question our competence and judgment? What sorts of feelings do we experience when we think of disclosing our blunders or our uncertainty over not knowing what to do? Do we feel anxious, embarrassed, ashamed, guilty, inadequate, panicked, or even afraid? Does some part of us feel like crying or running and hiding? Consultation about boundary crossings that have turned disruptive and perhaps harmful is likely to be helpful only to the extent that we can be honest with the consultant.
Whether the signs of trouble with a boundary crossing are blatant or vague, if we start to suspect that we may have made a mistake, not handled the situation well, or need to address the effects of a boundary crossing, we each face a significant question: What do I do now?
Listen carefully to the client. We may make all sorts of assumptions about how the client is reacting to the boundary crossing or the crossing’s negative consequence, but these may be completely incorrect. Too often, we may find ourselves starting to say something along the lines of “I know just how you feel,” or “I know you must just feel terrible.” Such statements are an example of guessing and can be leading for the client, when in fact we should be asking questions.
It is important to continue to monitor the situation carefully, even though paying attention to it may be uncomfortable. It may be difficult for us as psychologists to realize we have made a mistake, perhaps a big one, and assume responsibility for our error. However, denial and avoidance are usually powerful resources for turning an emerging problem into a disaster!
Try to see the matter from the client’s point of view. A client may experience a boundary crossing in a way that represents the opposite of what we intended, of what we anticipated, or of what the client anticipated. Empathizing with the client’s experience may be particularly difficult if the client is angry and accusing, has withdrawn from therapy, or has decompensated.
Be open and non-defensive, even though this may be difficult. As we consider how our crossing a boundary with a client had negative results, we may be tempted to minimize the correlation between the boundary crossing and the negative consequences. We may be tempted to downplay or trivialize the impact. We may find ourselves wanting to attribute the negative impact not to the boundary crossing, but rather to the client’s condition, to the client faking or exaggerating, or to the client’s life circumstances. However, personal self-reflection and
It is also very important to keep adequate, honest, and accurate records of this situation as it evolves. Just as we may find it difficult to disclose what happened and its implications to a respected colleague, it may be hard to make a written record of the situation, especially one that the client and others may see eventually. Aside from our responsibility to maintain adequate clinical records, therapists often find it remarkably useful to chart the events with as much clarity and honesty as possible. It helps us make sense of the situation and find ways to respond positively and constructively.
Is apologizing appropriate? If you believe that you made a mistake, however well intentioned, consider apologizing. There appears to be wide spread fear that to apologize to clients for our mistakes in handling boundaries is to take unnecessary and unwise risks by admitting guilt. Apologizing can make us feel vulnerable. What will happen now? Will the client accept our apology or will it just make things worse and enrage the individual? Will the client interpret our apology as disingenuous or inadequate? Will the client see us weak or incompetent? Will the apology plague us as admission of guilt in a formal licensing complaint or lawsuit? If the boundary crossing was inadvertent or unintended, if we acted in what we thought was the client’s best interests, we may feel that we owe no apology. The client may be angry at us, failing to realize we have done far more good than harm, going overboard in reacting to what was a relatively minor slip on our part, not being as Psychology.EliteCME.com
understanding as we’d like, or complaining in an accusatory, insistent, loud, repetitive, or whiny way. If any of these are the case, we may not believe the client deserves an apology, and wish the client would stop discussing it and move on — or drop out of therapy altogether and go bother some other practitioner. There have been many instances when a client considered an ethics complaint but never pressed it because the psychologist apologized for the concern and made it right. Every one of us has experienced the healing power of the words, “I’m really sorry.” Apologizing is a personal, intimate act. Deciding whether or not to apologize requires the same care as any clinical and ethical judgment, taking the client, the context, and the nature of the boundary crossing itself into account.
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The Internet and Clinical Practice: Ethical Standards and Issues Internet-based therapy In recent years there has been a rapid proliferation of mental health services offered via the internet (Barnett, 2011; Rochlen, Zack, & Speyer, 2004). Scholars have indicated that the delivery of such services provides the benefits of increased accessibility, reduced stigmatization, and potential reduction in the costs of service provision (Berle et al., 2015). Recent research has indicated that as many as 90% of patients in some clinical samples prefer internet-based mental health services to face-to-face service delivery (Berle et al., 2015). With early reviews indicating the clinical efficacy of internet-based services (e.g., Ivarsson et al., 2014), such services are likely to grow in popularity and utilization in the future, thus bringing the issue of ethical standards of practice of internet-based services to the forefront. In a recent study, Haberstroh et al. (2014) reviewed the state licensing boards for marriage and family therapists, professional counselors, psychologists, and social workers to determine the legal and ethical practice of internet-based therapy in the United States. The authors found no differences among the professions regarding whether they permitted internet-based therapy at the state level. Although no state licensing boards prohibited internet-based therapy, across professions, 32% of state licensing boards offered no direction for internet-based practice, and 28% of state licensing boards relied solely on national ethical codes. Given the nascence of licensure laws and ethical codes regarding internet-based therapy, it is thus more incumbent on mental health professionals to stay abreast of and be guided by the current professional literature in the area. Recent literature has examined the similarities and differences between face-to-face and internet-based therapy in the application of ethical principles and standards. For example, Hertlein, Blumer, and Mihaloliakos (2015) asked marriage and family therapists to identify ethical concerns and drawbacks of internet-based therapy.
Five themes emerged from their study: 1. Confidentiality. 2. Impact to the therapeutic relationship. 3. Licensing and liability issues. 4. Issues related to crises and risky clinical situations. 5. Training and education. Along these lines, Kostopoulou et al. (2015) highlighted the importance of the following practices when conducting internet-based therapy: 1. The informed consent (written and verbal), including the potential risks, consequences and benefits of internet-based therapy. 2. Competence to practice. 3. Confidentiality. 4. Doing no harm. 5. The discussion of terminations, interruptions of service, and payment arrangements. Additionally, the authors emphasized the importance of: 1. Conducting an initial assessment of each client to determine his or her appropriateness for internet-based therapy. 2. The provision of adequate emergency contact information in the event an internet-based client faces a crisis. 3. Ensuring that clients’ privacy and confidentiality are adequately protected by encrypting electronic transmissions and records. 4. Finally, they noted that “the APA Ethics Code applies to these activities across a variety of contexts, such as in person, postal, telephone, internet, and other electronic transmissions” (p. 1061), highlighting that current ethical standards contain language that can be applied to psychologists who provide internet-based services.
Social media in therapy A separate but related area involves the use of social media in therapy. As mental health professionals increasingly use the internet for personal and professional activities, they risk having an increasing number of incidental contacts with clients online. Kolmes and Taube (2014) for example noted that 48% of the 227 mental health professionals they sampled intentionally sought information about current clients in non-crisis situations, and 28% accidentally discovered client information on the internet. Similarly, Harris and Robinson-Kurpius (2014) found that a third of the 315 counseling and psychology graduate students sampled had used the internet to find information about a client, with the majority of them not having obtained informed consent from the client before conducting the internet search. Increased disclosure of client information was related to lower scores on ethical decision-making in the study. Along these lines, Jordan et al. (2014) offered recommendations to be integrated into the professional ethical codes for mental health professionals to ensure the ethical use of social medial in therapy. They noted for example that mental health professionals should be aware that social media in general blur boundaries, and mental health
professionals should consider how clients may perceive the often ambiguous information generated through social media. They further emphasized the following: 1. Informed consent, in that mental health professionals inform clients of their policy on the use of social media in therapy, including possible risks and communication styles. 2. Multiple relationships, in that mental health professionals become aware of the impact their self-disclosure on social media sites may have on their professional relationships. 3. Confidentiality, in that mental health professionals take additional care when utilizing social media, including the use of encryption software and a discussion of the risk of any confidentiality breach. 4. Professional competence and integrity, whereby mental health professionals receive training on the appropriate and ethical use of social media in therapy, including how social media impact individuals, couples, and families (Jordan et al., 2014). An appendix contains a sample informed consent that uses social media, taken from Jordan et al. (2014).
Case examples Let’s take a closer look at some examples from real life situations where a few ethical standards came into play. The names of the individuals involved have been changed, though the details are factual. Case study #1 A psychologist was providing research services for an organization that asked the psychologist to include interviews of employees over
six months to assess perceptions of the work environment and obtain qualitative data regarding their overall employee satisfaction. The organization provided the psychologist with a list of employees and their contact information. As participation was completely voluntary, the psychologist sent an e-mail to the employees listed describing the purpose of the study and requested volunteers to participate.
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Since only seven employees responded with interest in participating, the sample was small but also served as a fair random sample. This group of individuals was to meet one-on-one with the psychologist in short, monthly interviews and responses would be analyzed during the six-month process. At the first employee session, the employee informed the psychologist that they knew each other. While the psychologist could not recall ever seeing or interacting with this person, the employee described how his sister went to high school with the psychologist and that they had been in similar circles of friends. The psychologist recognized that the employee’s sister was still a close friend. Another employee was eager to share his feelings about the organization during the interview. The psychologist quickly realized that this person was unhappy and very vocal about multiple issues and individuals within the organization. The psychologist also realized that the qualitative data the discussion provided could be extremely useful in identifying areas of organizational change. During a meeting to discuss how the research effort was going after the first sessions, the organization asked the psychologist about any trends or issues that initially “stood out.” The psychologist conveyed the negative information about the organization and its leadership the second employee provided. The organization considered this harsh criticism. As this was difficult for the agency representatives to hear, they demanded to know which employee had expressed such “hostile” comments. Question #1: What ethical dilemmas do you see within this situation? Answer #1: There are primarily two described here: 1. The case participant who “knew” the psychologist. This is a potential conflict of interest and could have an impact on responses provided by the employee and the data received within the study. 2. The agency representatives demanding to know who made the harsh comments. This is a potential violation of confidentiality of the research participant. Question #2: What should the psychologist do in response? Answer #2: In the first situation, the psychologist thanked the employee for being interested and wanting to participate in the study, but explained that, because of the friendship with the employee’s sister, the psychologist would not be able to have that employee continue as a participant. The psychologist reinforced that the employee’s opinions of the organization mattered and encouraged expression of employee satisfaction or concerns through avenues such as discussion with their immediate supervisor or use of the employee suggestion box. In the second situation, when asked to reveal the identity of the participant who made critical comments, the psychologist informed the agency representatives that doing so would be a violation of the APA Ethics Code. The representatives became angry and stated that they were the ones paying the psychologist for the study and if they wanted to know something, they should receive such information. After explaining the foundational principle of confidentiality of research participants and expressing appreciation for the partnership and opportunity to conduct the study, the psychologist informed the agency it would be impossible to continue to serve in this capacity if the agency expected the psychologist to violate ethical standards. In this situation, other representatives of the agency stepped in, apologized for their colleagues’ request, and the study continued as planned. Case study #2 A psychologist was conducting forensic disability evaluations for a national organization. The organization did not have policies regarding obtaining informed consent from disability claimants, or the administration of psychological tests during evaluations. Although it was not a written policy of the organization, the more informal communication from the organization’s administration to the psychologist included pressure to complete the disability evaluations Psychology.EliteCME.com
without informed consent and without psychological testing, as both were viewed as detracting from the expedience the organization valued strongly. Question #1: What ethical dilemmas do you see within this situation? Answer #1: The pressure applied to the psychologist by the organization’s administration conflicts with the first two of the following, while being related to the third: Ethical standard 3.10 (Informed Consent), which reads as follows: “When psychologists conduct research or provide assessment, therapy, counseling, or consulting services in person or via electronic transmission or other forms of communication, they obtain the informed consent of the individual or individuals using language that is reasonably understandable to that person or persons except when conducting such activities without consent is mandated by law or governmental regulation or as otherwise provided in this Ethics Code.” Ethical standard 9.01 (Bases for Assessments), which reads in part as follows: “Psychologists base the opinions contained in their recommendations, reports, and diagnostic or evaluative statements, including forensic testimony, on information and techniques sufficient to substantiate their findings.” Ethical standard 1.03 (Conflicts Between Ethics and Organizational Demands), which reads as follows: “If the demands of an organization with which psychologists are affiliated or for whom they are working are in conflict with this Ethics Code, psychologists clarify the nature of the conflict, make known their commitment to the Ethics Code, and take reasonable steps to resolve the conflict consistent with the General Principles and Ethical Standards of the Ethics Code. Under no circumstances may this standard be used to justify or defend violating human rights.” Question #2: What should the psychologist do in response? Answer #2: As ethical standard 1.03 reads, “psychologists clarify the nature of the conflict, make known their commitment to the Ethics Code, and take reasonable steps to resolve the conflict consistent with the General Principles and Ethical Standards of the Ethics Code.” In this case, the psychologist provided the above ethical standards to the organization’s administration, while noting that maintaining licensure as a psychologist was a condition of employment with the organization. It was noted that failure to uphold these ethical standards would not only be unethical and a disservice to the disability claimants and others, but could also put the psychologist’s professional license in jeopardy. Recognizing that it was incompatible for the organization to simultaneously require the psychologist to maintain a professional license, while pressuring the psychologist to practice in such a way as to endanger that license, the organization’s administration yielded and permitted the psychologist to obtain informed consent and utilize psychological testing as needed. Case study #3 A psychologist conducted a forensic psychological evaluation of an individual for a referral source. After submitting the evaluation, the psychologist learns that the individual’s treating psychologist sent an unsolicited letter the referral source, claiming that the evaluating psychologist’s evaluation should be given little or no consideration by the referral source, as it included psychological tests that were not normed on the population to which the individual belonged. The tests administered were in fact normed on the population to which the individual belonged, however. Question #1: What ethical dilemmas do you see within this situation? Answer #1: Ethical standard 1.03 (Informal Resolution of Ethical Violations) reads as follows: “When psychologists believe that there may have been an ethical violation by another psychologist, they attempt to resolve the issue by bringing it to the attention of that individual, if an informal resolution appears appropriate and the Page 57
intervention does not violate any confidentiality rights that may be involved.” Question #2: What should the psychologist do in response? Answer #2: The psychologist who conducted the evaluation should provide clarification to the referral source regarding the nature of the test instruments used, specifically that they were in fact normed on the population to which the individual belonged. As stated in the ethical standard above, he or she should also attempt to resolve the issue informally with the other psychologist by bringing it to his or her attention. Case study #4 A psychologist conducted a pre-surgical evaluation of an individual. When the psychologist communicated to the individual the psychologist’s preliminary impressions of the individual’s psychological functioning, the individual became defensive and hostile, threatening to complain to the psychologist’s licensing board. The psychologist had not yet formulated conclusions or recommendations regarding the individual’s suitability for surgery.
Question #1: What ethical dilemmas do you see within this situation? Answer #1: Principle D (Justice) of the general principles of the ethical code reads as follows: “Psychologists must recognize that fairness and justice entitle all people to access to and benefit from the contributions of psychology and to equal quality in the processes, procedures, and services that psychologists conduct. They are to exercise reasonable judgment and take precautions to ensure that their potential biases, the boundaries of their competence, and the limitations of their expertise do not lead to or condone unjust practices.” Question #2: What should the psychologist do in response? Answer #2: Given that the psychologist has received a threat of a complaint to his or her licensing board, it is reasonable to consider that the psychologist’s impartiality regarding the individual may have become impaired. The psychologist should recommend that the individual pursue a pre-surgical evaluation from another mental health professional with competence in this area.
Conclusion There are many elements related to ethics within the field of psychology. As psychologists who provide a wide variety of services, you will encounter countless different situations and relationships. To ensure professional and sound judgment within your actions and interactions, you must be familiar with the general principles and ethical standards provided in the APA Ethics Code. It is also important for you as psychologists to know what to do when you face an ethical dilemma or potential boundary issue. Failure to abide by the ethics guidelines could result in sanctions against you,
termination of your APA membership, or legal ramifications brought on by complaints or potential lawsuits from a client or former client. As a final reminder of what we all know, but sometimes forget: None of us needs to think through these questions on our own. We are part of a large and diverse community of skilled professionals who try to make the best decisions possible to help our clients. Both our decisions about boundaries and our professional conduct will benefit from these perspectives, strengths, empathy, constructive questioning, support, and caring for each other.
Appendix The following informed consent developed by a mental health professional who uses social media is extracted from Jordan et al. (2014) and is included for educational purposes consistent with the current continuing education course. It illustrates the fairly wideranging issues that mental health professionals should consider when using social media in their clinical practice. “I use e-mail for scheduling and occasional between-session contact. I will respond to e-mails within 1–7 days. Do not use e-mail to contact me about urgent matters. If you have an emergency, you should use the contacts described below (under Your Responsibilities). If you would like to schedule an appointment with me more than 1 week in advance, you will need to call me at XXX XXX XXXX. My e-mail account is secure and encrypted. However, while my e-mail is secure, yours may not be. You should be aware that third parties, including your e-mail or Internet provider, may have access to e-mails you send, meaning they are not confidential. Also, be mindful of who else may have access to your e-mail if you have a shared computer, shared e-mail account, or may leave your e-mail account open on an unattended computer. I use a professional Facebook page for the purposes of advertising my services, connecting with colleagues, and interacting with community agencies and professional organizations. I do not offer online therapy. If you post a message on my Facebook page, or send me a personal message or e-mail, I will not respond online. Instead, I will discuss such contact with you in person at our next session. Further, you should be aware that if you ‘‘Like’’ my page, others will be able to see this connection and may make assumptions about our relationship, or may ask you directly about what our relationship is. If you make a public statement about your relationship with me, I will not be able to confirm or deny that relationship due to confidentiality issues.
connection, I will ignore that request. I have this policy for two main reasons. First, I believe there is a need for healthy boundaries regarding my personal and professional life, and while LinkedIn is a professional website, there is a blurring personal and professional exchange which I would like to avoid. Second, in order to avoid compromising your confidentiality, I do not publicly link myself to my clients in any way. In addition, I do have a personal Facebook profile; however, I do not accept friend requests from clients. If you do find my personal profile and attempt to contact me, I will not respond to any information I receive from you. If we have mutual friends and happen to view each other’s information, we can discuss possible implications and how we prefer to proceed at our next session. Be aware that any information you post on social media, including Facebook or LinkedIn – even in a personal message – is not confidential, and is considered part of a public forum. This means anyone can legally access and share anything you post on these forums. Further, as in a therapy session, I am required by law to report anything I learn that leads me to believe that you are a danger to yourself or others; a child is being abused or neglected; or an elderly person is being abused or neglected.”
I also have a professional LinkedIn page in order to connect with colleagues and professional organizations. I do not accept clients as connections on my LinkedIn profile; if you try to add me as a Page 58 Psychology.EliteCME.com
References
American Psychological Association (2003). Ethical Principles of Psychologists and Code of Conduct. Barnett, J. E. (2011). Utilizing technological innovations to enhance psychotherapy supervision, training, and outcomes. Psychotherapy, 48(2), 103–108. Berle, D., Starcevic, V., Milicevic, D., Hannan, A., Dale, E., Brakoulias, & V., Viswasam, K. (2015). Do patients prefer face-to-face or internet-based therapy? Psychotherapy and Psychosomatics, 84(1), 61-62. Borys, D. S., & Pope, K. S. (1989). Dual relationships between therapist and client: A national study of psychologists, psychiatrists, and social workers. Professional Psychology: Research and Practice, 20, 283-293. Burkard, A. W., Knox, S., Groen, M., Perez, M., & Hess, S. A. (2006). European American therapist self-disclosure in cross-cultural counseling. Journal of Counseling Psychology, 53, 15-25. Farber, B. A. (2006). Self-disclosure in psychotherapy. New York: Guilford. Farber, B. A., & Sohn, A. E. (2007). Patterns of self-disclosure in psychotherapy and marriage. Psychotherapy, 44, 226-231. Graham, J. (2007, August 18). Doctors try new word: ‘Sorry’: Admitting mistakes not just right thing to do, medical community finds it may prevent malpractice suits. Chicago Tribune. Gutheil, T. G., & Gabbard, G. O. (1993). The concept of boundaries in clinical practice: Theoretical and risk-management dimensions. American Journal of Psychiatry, 150, 188-196. Gutheil, T. G., & Gabbard, G. O. (1998). Misuses and misunderstandings of boundary theory in clinical and regulatory settings. American Journal of Psychiatry, 155, 409-414. Haberstroh, S., Barney, L., Foster, N., & Duffy, T. (2014). The ethical and legal practice of online counseling and psychotherapy: A review of mental health professions. Journal of Technology in Human Services, 32, 149–157 Harris, S., & Robinson Kurpius, S. E. (2014). Social networking and professional ethics: Client searches, informed consent, and disclosure. Professional Psychology: Research and Practice, 45(1), 11-19. Henry, R. (2007). More states weigh ‘apology’ options for doctors leery of lawsuits. Hertlein, K. M., Blumer, M. L. C., Mihaloliakos, J. H. (2015). Marriage and family counselors’ perceived ethical issues related to online therapy. The Family Journal, 23(1), 5-12 Ivarsson, D., Blom, M., Hesser, H., Carlbring, P., Enderby, P., Nordberg, R., & Andersson, G. (2014). Guided internet-delivered cognitive behavior therapy for post-traumatic stress disorder: A randomized controlled trial. Internet Interventions, 1(1), 33-40. Jeffrey, A., & Austin, T. (2007). Perspectives and practices of clinician self-disclosure to clients: A pilot comparison study of two disciplines. American Journal of Family Therapy, 35, 95-108. Jordan, N. A., Russell, L., Afousi, E., Chemel, T., McVicker, M., Robertson, J., & Winek, J (2014). The ethical use of social media in marriage and family therapy: Recommendations and future directions. The Family Journal: Counseling and Therapy for Couples and Families, 22(1), 105-112.
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Kolmes, K., & Taube, D. O. (2014). Seeking and finding our clients on the internet: Boundary considerations in cyberspace. Professional Psychology: Research and Practice, 45(1), 3-10. Koocher, G. P. & Keith-Spiegel, P. (2008). Ethics in psychology and the mental health professions. New York: Oxford University Press. Kostopoulou, A., Melis, A., Koutsompou, V-I., Karasarlidou, C., (2015). E-therapy: The ethics behind the process. Procedia Computer Science, 65, 492-499. Kraman, S. S., & Hamm, J. (1999). Risk management: Extreme honesty may be the best policy. Annals of Internal Medicine, 131, 963-967. Lazare, A. (2006). Apology in medical practice: An emerging clinical skill. Journal of the American Medical Association, 296, 1401-1404. Myers, D., & Hayes, J. A. (2006). Effects of therapist general self-disclosure and countertransference disclosure on ratings of the therapist and session. Psychotherapy, 43, 173-185. Nissellee, P. (2004). Is self-disclosure a boundary violation? Journal of General Internal Medicine, 19, 984. Pope, K. S., & Vasquez, M. J. T. (2007). Ethics in psychotherapy and counseling: A practical guide (3rd edition). San Francisco, CA: Jossey-Bass/John Wiley Pope, K. S., Sonne, J .L., & Greene, B. G. (2006). What therapists don’t talk about and why: Taboos that hurt us and our clients. Washington, DC: American Psychological Association. Rachman, A. W., Reppen, J., Tucker, J., & Schulman, M. A. (2004). Beyond neutrality: The curative function of the analyst self-disclosure in the psychoanalytic situation. In Way beyond Freud: Postmodern psychoanalysis observed (pp. 218-237). London: Open Gate Press. Roberts, J. (2005). Transparency and self-disclosure in family therapy: Dangers and possibilities. Family Process, 44, 45-63. Rochlen, A. B., Zack, J. S., & Speyer, C. (2004). Online therapy: Review of relevant definitions, debates, and current empirical support. Journal of Clinical Psychology, 60(3), 269–283. Ryan, J. (2005). Medical apology law may surface. Retrieved August 16, 2007 from http://www. eastvalleytribune.com/story/34402 Sweezy, M. (2005). Not confidential: Therapist considerations in self-disclosure. Smith College Studies in Social Work, 75, 81-91 Zechmeister, J. S., Garcia, S., Romero, C., & Vas, S. N. (2004). Don’t apologize unless you mean it: A laboratory investigation of forgiveness and retaliation. Journal of Social & Clinical Psychology, 23, 532-564.
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ETHICS Final Examination Questions
Choose True or False for questions 16 through 20 and mark them on the answer sheet found on page 85 or complete your test online at Psychology.EliteCME.com. 16. The Ethics Code is intended to provide guidance for psychologists and standards of _________________. a. Therapeutic services. b. Professional conduct. c. Classroom techniques. d. Supervision. 17. In the event that the law and the standards set forth by the Ethics Code differ from one another, the psychologist is to adhere to: a. The law. b. The Ethics Code. c. The higher standard. d. The advice of a colleague. 18. The principle that requires psychologists to seek to promote accuracy, honesty, and truthfulness in the science, teaching, and practice of psychology is called: a. Justice. b. Fidelity. c. Integrity. d. Beneficence.
19. When psychologists become aware of personal problems that may interfere with their performing work-related duties adequately, they take appropriate measures, such as _________ and then determine whether they should limit, suspend, or terminate their work-related duties. a. Additional training. b. Obtaining professional consultation or assistance. c. Further research. d. Searching past practice. 20. In a very small and geographically remote town, psychologists may be more likely to: a. Conduct more research. b. Gather data on research participants from the local city hall. c. Experience multiple relationships. d. Find research assistants.
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Chapter 4:
Healthy Living Psychology 4 CE Hours
By: Wade T. Lijewski, Ph.D.
Learning objectives This course is designed to help you: Describe the importance of health psychology. Discuss the functions of various types of health psychologists. Analyze the impact of relationships and social interaction on physical health and quality of life.
Demonstrate the knowledge of early implementation techniques for healthy living concepts. Apply helpful hints to improve healthy living conditions in your own life as well as others’. Assess the impact of stress. Critique the elements of positive psychology.
Introduction People have mixed visions when they hear the term “healthy living psychology.” Some people immediately equate it only to physical health topics, such as losing weight and stopping smoking. But there are other elements in health psychology, known as the study of psychological and behavioral processes, that are linked to health, illness and health care and expand into how positive relationships and coping mechanisms can improve people’s lifestyles. In this course, we will take a look at the various elements and recommendations to help people have healthy physical as well as mental lifestyles. However, while it’s important to review the two separately, it’s also important to recognize that what impacts people’s physical health often also impacts their mental health, and vice versa. Health psychology is concerned with understanding how psychological, behavioral and cultural factors are involved in physical health and illness, in addition to the biological causes that are well understood by medical science. Psychological factors, such as stress, can affect health directly by causing the release of hormones such as cortisol, which damages the body over time, and indirectly via people’s own behavior choices. These choices, in turn, can harm or protect their personal health, such as by smoking or exercising. Health psychologists take a bio-psychosocial approach, using three primary processes: 1. Biological processes – virus, tumor and so on. 2. Psychological processes – stress, thoughts, beliefs, and behaviors such as smoking or exercise. 3. Social processes – socioeconomic status, culture and ethnicity. Recent trends in psychology have offered more emphasis on the social processes and how relationships and social interactions play into such concepts. As a result, the combination of health psychology and social psychology has resulted in what many psychologists refer to as healthy living psychology.
Whether making efforts to impress others, manage money, advance a career or other personal aspirations, there is a wealth of accumulated knowledge to help you reach your goals. However, if your ultimate goal is to lead a satisfying life, your best shot is to seek out wisdom that helps you cultivate strong relationships of all kinds. Studies indicate that people who enjoy close ties with friends and family are happier, have fewer health problems, and are more resilient to the stresses of our times. Positive social connections aren’t just important to living a fulfilling life, they’re vital to any type of healthy life at all. When people do not have stable and supportive relationships, they can experience levels of depression and anxiety. Our personal connections to others provide some of the best opportunities to grow in meaningful ways. Any relationship can be viewed as a research opportunity where we experiment with bold acts of change, and in turn, learn something about ourselves, the other person, and the possibilities between us. Health psychology is a relatively new field of applied psychology that uses psychological principles to “promote changes in people’s attitudes, behavior and thinking about health and illness” (The British Psychological Society, 2013). A simpler way to understand health psychology is that it aims to promote health and prevent illness (Lafreniere and Cramer, 2012). Key to understanding health psychology is the bio-psychosocial model. George Engel developed the bio-psychosocial model in response to the biomedical stance that all illnesses are related to biological deficiencies (Engel, 1977). Engel proposed that health was determined not only by biological factors but also by psychological and social factors. An extension of this thinking is that to help people in the physical healing process, we need to pay attention to their psychological and social needs in combination with treating their medical needs (Suls and Rothman, 2004). Current research has supported this understanding of total health treatment.
History of health psychology Recent changes in our nation’s health Overall, the nation is remarkably healthier in the current generation than any time in history; however, this improvement is not equally distributed. Infant mortality rates have dropped 75 percent since 1950 (Centers for Disease Control and Prevention, 2012). In addition, death rates among children have been reduced 50 percent over the last 50 years. Psychology.EliteCME.com
Although homicide rates of young African American and Hispanic males dropped almost 50 percent in the 1990s, homicide still remains the leading cause of death for young black men. New AIDS cases are still being reported in young people, and obesity is an increasing problem for adults and children. Page 61
To fund these improvements, the nation spent $1.3 trillion on health care in 2000, or 13.2 percent of the gross domestic product, far more than any other nation. Seventeen percent of health care costs were paid out-of-pocket by consumers, while government programs such as Medicare and Medicaid paid 43 percent of all medical bills. A survey conducted in 2002 by the Centers for Disease Control and Prevention revealed that children are significantly more likely to have health insurance in 2002 than in 1997, when the State Children’s Health Insurance Program (SCHIP) was enacted.
The survey also showed that the number of young Americans who could benefit from drug treatment is significantly larger than previously believed, and that many drug users who meet the criteria for needing treatment do not recognize that they have a problem. The survey also found that 10.8 percent of youth 12 to 17 years were current drug users in 2001, up from 9.7 percent in 2000. The measure of perceived risk in the use of marijuana among youth provides an important predictor of drug abuse, for it is widely understood to be a “gateway experience” to narcotics (Centers for Disease Control and Prevention, 2012).
Origins and development Psychological factors in health has been studied since the early 20th century by disciplines such as psychosomatic medicine and behavioral medicine, though these were primarily branches of medicine, not psychology. Health psychology began to emerge as a distinct discipline of psychology in the United States in the 1970s. In the mid-20th century, there was a growing interest and understanding in medicine on the effect of behavior on health. For example, the Alameda County Study, which began in the 1960s, showed that people who ate regular meals (e.g., breakfast), maintained a healthy weight, received adequate sleep, did not smoke, drank little alcohol and exercised regularly were in better health and lived longer. At the same time, there was a growing realization of the importance of good communication skills in medical consultations. In addition, psychologists and other scientists were discovering relationships between psychological processes and physiological ones. These included the impact of stress on the cardiovascular and immune systems of the body, and the early finding that the functioning of the immune system could be altered by learning. In 1969, William Schofield submitted a report for the American Psychological Association entitled, “The Role of Psychology in the Delivery of Health Services.” Schofield found that the psychological research of the time frequently saw mental health and physical health as entirely separate and devoted very little attention to psychology’s impact upon physical health. Of the psychologists working at the time, very few were involved with this area, and he proposed that new forms of education and training for future psychologists would be needed. The APA reacted in 1973 by setting up a task force to consider how psychologists could help people to manage their health behaviors as well as better manage physical health problems and how to train health care staff to work most effectively with patients.
This resulted in a series of events that led to the formation in 1997 of a division of the APA dedicated to health psychology. In the 1980s, similar organizations were set up in the UK as the British Psychological Society’s Division of Health Psychology in 1986, and the European Health Psychology Society that same year. Similar organizations developed in other countries, such as Australia and Japan. In hindsight, the emergence of health psychology could have been triggered by many different factors, such as the following: ●● Development of epidemiological evidence demonstrating the important relationship between health and behavior. ●● Behavioral sciences were added to medical schools’ curriculums, and were often taught by psychologists. ●● Health professionals began to receive training in communication skills, with the initial aim of improving patient satisfaction and adherence to medical treatment. ●● Primary care became an emphasis for clinical psychology, and interventions based on psychological theory were often applied. ●● Behavior modification and therapy based on theoretically based models demonstrated they could change behaviors and be useful in clinical populations. ●● An increased understanding of the interaction between psychological and physiological factors led to the emergence of psychophysiology and psychoneuroimmunology (PNI). ●● The health domain was frequently used by social psychologists for testing theoretical models, such as the links between beliefs, attitudes and behavior. ●● In the early 1980s, the diagnosis of AIDS/HIV led to an increase in funding for behavioral research and a focus on behavior change.
What is health psychology? Health psychologists conduct research to identify behaviors and experiences that promote health, give rise to illness, and influence the effectiveness of health care. They also recommend ways to improve health care and health care policy. Health psychologists have worked on developing ways to reduce smoking and improve daily nutrition to promote health and prevent illness. They have also studied the association between illness and individual characteristics. For example, health psychology has found a relationship between the personality characteristics of thrill seeking, impulsiveness, hostility and anger, emotional instability, depression, and high-risk driving.
In addition, health psychologists attempt to change health behaviors for the dual purpose of helping people stay healthy and helping patients adhere to disease treatment regimens. Health psychologists employ cognitive behavior therapy and applied behavior analysis.
Health psychology is also concerned with contextual factors, including economic, cultural, community, social, and lifestyle factors that influence health. The bio-psychosocial model can help in understanding the relationship between contextual factors and biology that affect health. Physical addiction plays an important role in smoking cessation. Some research suggests that seductive advertising also contributes to psychological dependency on tobacco, although other research has found no relationship between media and smoking in youth.
Health psychology is both a theoretical and applied field. Health psychologists employ diverse research methods. These methods include controlled randomized experiments, quasi-experiments, longitudinal studies, time-series designs, cross-sectional studies, and case-control studies, and action research. Health psychologists study a broad range of variables, including genotype, cardiovascular disease (cardiac psychology), smoking habits, religious beliefs, alcohol use, social support, living conditions, emotional state, social class, and much more. Some health psychologists treat individuals with sleep problems,
People’s physical health can be affected by the things they do, by the way they process information, their career choice, family dynamics, life troubles and the environment in which they live (MacDonald, 2013). For example, someone living in a damp, mildew infested home will probably over time develop respiratory or sinus problems, and may develop allergies.
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headaches, alcohol problems, etc. Other health psychologists work to empower community members by helping them gain control over their health and improve the quality of life of entire communities. When helping people develop a healthier lifestyle, their career choices are another area that health psychology explores. There is a direct relationship between choices of work and physical and emotional health. The more frustrating the project, the more risk people have of developing an emotional or psychological illness. Sometimes when people feel sick, tired or overrun, or when they develop certain diseases, it is not in response to a virus or bacteria infiltrating the immune system, but rather a response to what is happening within their bodies, brains and subconscious minds. Catching a cold is only one example. Of course, there is a biological component, meaning a virus has attacked a person’s weakened immune system. Health psychologists have a dual mission: 1. To help prevent mental and physical illness and disease. 2. To promote healthy living. From cancer to diabetes, health psychologists deal with a wide variety of issues underlying physical illness and chronic disease and use their knowledge to enhance the quality of life of individuals (Uyemura, 2011).
Interestingly, much of what health psychologists teach (deep breathing, mindfulness, stress reduction, and so on) works for everyone. Our fast-paced life and increased dependency on technology often results in disconnection, stress and lack of sleep, all of which wreak havoc on our health (Uyemura, 2011). Fortunately, there are simple steps people can take today to begin living a healthier life, which we will discuss further in upcoming sections of this course. Heart-related conditions, breathing conditions, muscle and joint pain conditions and various physical ailments are common among people coping with the emotional and psychological stresses of modern day life. The release of the stress chemicals in the body weakens the body’s defenses in fighting a physical illness. The more people understand the power of the mind, the more they will realize that physical well-being directly relates to thoughts, feelings and behaviors (MacDonald, 2013). Stress level is one of the key psychological factors affecting physical health. When people are under pressure, their bodies produce chemicals and hormones that the body does not require, and some may be harmful. These difficult conditions and the release of the chemicals results in a weakening of the immune system This weakened immune system means that people are more susceptible to physical and mental ailments (MacDonald, 2013).
Stress management Stress is an organism’s response to a stressor, such as an environmental condition or a stimulus. Stress is a body’s way to react to a challenge. The body’s way to respond to stress is by the sympathetic nervous system, which results in the fight-or-flight response. Stress typically describes a negative condition or a positive condition that can have an impact on an organism’s mental and physical well-being. Chronic stress is defined as a state of prolonged tension from internal or external stressors that may cause various physical manifestations, such as asthma, back pain, arrhythmias, fatigue, headaches, HTN, irritable bowel syndrome, and ulcers, and suppress the immune system. Chronic stress takes a more significant toll on the body than acute stress does. It can raise blood pressure, increase the risk of heart attack and stroke, increase vulnerability to anxiety and depression, contribute to infertility, and hasten the aging process. For example, results of one study demonstrated that individuals who reported relationship conflict lasting one month or longer have a greater risk of developing illness and show slower wound healing. Similarly, the effects that acute stressors have on the immune system may be increased when there is perceived stress and anxiety caused by other events. For example, students who are taking exams show weaker immune responses if they also report stress from daily hassles.
We may not be able to control stress, but we can manage it. Here are some stress management tips and techniques that may help people feel better and less stressed every day: ●● Seek out social support. ●● Eat healthy, well-balanced meals. ●● Avoid alcohol and recreational drugs. And don’t smoke. ●● Accept that there are events that you cannot control. ●● Maintain a positive attitude! Instead of focusing on the negatives, such as “Nothing goes right for me,” or “Bad things always happen to me,” give yourself positive messages, like “I’m doing my best,” or “I’ll ask for help if I need it.” ●● Stop stress in its tracks; if you feel overwhelmed, take a walk or drive in the slow lane to avoid getting angry at other drivers. ●● Manage your time. Give yourself time to get things done and set your watch so you have more time to prepare for an event. ●● Do things that you find enjoyable, like reading or gardening. ●● Take 15-20 minutes every day to sit quietly and reflect. Learn and practice relaxation techniques like yoga or deep breathing. ●● Exercise regularly by bicycling, walking, hiking, jogging, or working out at the gym. Your body can fight stress better when it is fit. ●● Get enough rest and sleep. Your body needs time to recover from stressful events.
A look at the types of health psychology Occupational health psychology (OHP) is a separate but related discipline and is a relatively new field that emerged from the union of health psychology, industrial/organizational psychology, and occupational health. The field is concerned with identifying psychosocial characteristics of workplaces that affect the health and well-being of people who work. OHP is also concerned with developing strategies to effect change at workplaces to improve the health of people who work.
clinical questions that may arise across the spectrum of health care. ClHP is one of many specialty practice area for clinical psychologists. It is also a major contributor to the prevention-focused field of behavioral health and the treatment-oriented field of behavioral medicine. Clinical practice includes education, the techniques of behavior change, and psychotherapy. In some countries, a clinical health psychologist with additional training can become a medical psychologist and thereby obtain prescription privileges.
Research in occupational health psychology indicates that people in jobs that combine little decision latitude with a high psychological workload are at increased risk for cardiovascular disease. Other OHP research reveals a relationship between unemployment and elevations in blood pressure. OHP research also documents a relationship between social class and cardiovascular disease.
Public health psychology (PHP) is population-oriented. A major aim of PHP is to investigate potential causal links between psychosocial factors and health at the population level. Public health psychologists present research results to educators, policy makers, and health care providers to promote better public health. PHP is allied to other public health disciplines, including epidemiology, nutrition, genetics and biostatistics. Some PHP interventions are targeted toward at-risk
Clinical health psychology (ClHP) refers to the application of scientific knowledge derived from the field of health psychology to Psychology.EliteCME.com
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population groups (e.g., undereducated, single pregnant women who smoke) and not the population as a whole (e.g., all pregnant women). Community health psychology (CoHP) investigates community factors that contribute to the health and well-being of individuals who live in communities. CoHP also develops community-level interventions that are designed to combat disease and promote physical and mental health. The community often serves as the level of analysis, and is frequently sought as a partner in health-related interventions.
Critical health psychology (CrHP) is concerned with the distribution of power and the impact of power differentials on health experience and behavior, health care systems, and health policy. CrHP prioritizes social justice and the universal right to health for people of all races, genders, ages, and socioeconomic positions. A major concern is health inequalities. The critical health psychologist is an agent of change, not simply an analyst or cataloger.
The Importance of relationships Positive, productive relationships demand the best of us. For a friendship or marriage to allow both people to flourish, each person is an active participant in helping create the other one’s positive future. Whether we are a friend, lover, daughter, or grandparent, each relationship gives us a chance to invest our energy in making another person’s reality better. Each of us needs to fully show up, be present, listen, express ourselves, and care for the other, and that requires time and attention. When it all works out well and we can see the happiness on the other’s face, it creates, at least for the author, the best feeling of satisfaction in the world. Scientific research has established both a theoretical basis and strong empirical evidence for a causal impact of social relationships on health. Prospective studies that control for baseline health status consistently show increased risk of death among persons with a low quantity and sometimes low quality of social relationships. Experimental and quasi-experimental studies of humans and animals suggest that social isolation is a major risk factor for mortality from widely varying causes. The extent and quality of social relationships experienced by individuals is also a function of broader social forces. Whether people are employed,
married, attend church, belong to organizations, or have frequent contact with friends and relatives, and the nature and quality of those relationships are all determined in part by their positions in the larger social structure that is stratified by age, race, sex, and socioeconomic status and is organized in terms of residential communities, work organizations, and larger political and economic structures. Relationships teach us about ourselves. Sometimes, for good or bad, the person standing in front of us can be a mirror showing us who we really are. If we don’t like something in them, there are chances we don’t like it in ourselves. Friendships also give us a chance to watch ourselves in action. We can, on a moment-to-moment basis, pay attention to what we are thinking, feeling, or doing in response to what is happening externally. We can plug into our life story anytime, and learn from it (Gielan, 2010). Best of all, we get a chance everyday to practice acting from love. This goes beyond doing something nice for someone. Acting from love requires us to recognize the times when fear arises within us, and work to overcome it so we don’t choose a course of action from a fearful place. That takes awareness, hard work, and courage, but in those moments, when we choose love, we grow as human beings (Gielan, 2010).
Helpful hints to healthy living Keeping a positive attitude can go further than you can imagine! There are negative vibes and there are positive vibes. Criticism sends out negative vibes. So do complaints, disagreement, blame and frowns. Love, however, involves the emanation of positive energies. Offering thanks, gratitude and appreciation along with interest in others’ lives and warm smiles all are words and actions that send forth positive energy (Heitler, 2012). These positive emanations convey a loving stance. The more positives you send others, the more others will feel loved by you, and the more they are likely to love you in return. People who emanate positive vibes are upbeat to talk with. They feel “warm.” Whether they are your boss, your employee or colleague, your friend, family members or loved ones, these folks feel safe to share with, and like sunshine, radiate good feelings. Their positivity makes you want to talk with them more because they’ve set good vibes as a relationship standard. Positive leaders consistently avoid being critical, negating what you say, being argumentative or responding dismissively to what you say. Those negative energy habits are what negative people offer. Interacting with negative individuals or being in a group that they lead induces feelings of discouragement, makes others feel insecure, and can simply be unpleasant to experience. Positive individuals and leaders, by contrast, convey interest in your perspectives and wellbeing, agreement, appreciation, humor and affection. Subconsciously, your body produces feel-good chemicals when you hear positive words and phrases or receive a smile, eye contact, or a pat on the back. Serotonin and oxytocin levels in your body rise. By contrast, serotonin levels in your body go down when you interact with someone who is negative telling you, “Stay away!” (Heitler, 2012). Every sentence you say, of course, will not radiate good vibes. Some talking is serious or just for information-sharing. At the same time, generously seasoning your interactions with positive expressions of
agreement, appreciation, affection, good humor and enthusiasm warms your relationships and brightens how people feel when they talk with you. Of course, positive words have an even more potent impact when they are accompanied by an enthusiastic tone of voice and genuine interest in the other. You can’t fix the ones you love, so focus on fixing yourself. Many people have the idea that we can fix supposed flaws in our partners, friends, parents, and children, making them behave the way we want. However, even making attempts to change others can be incredibly draining both on you and the other person. A healthier approach to improving relationships with others is to look inward to fix the problem rather than trying to change the other person. Sometimes it’s a matter of simply developing patience and acceptance. If you know your partner hates large gatherings, consider attending the next party solo so he doesn’t have to make forced conversation and you don’t have to leave early (and annoyed). Or if your son says he wants to forgo college for now, try to express enthusiasm for his specific interests rather than bombarding him with links to school rankings. Making accommodations like these involves the crucial recognition that there are some matters on which you’re never going to be on the same page and that you’re willing to accept this to preserve the other’s autonomy. It’s more harmful to over-parent than to under-parent. As parents, it’s important to be mindful of how our actions impact our children. Parents sometimes hover relentlessly over their kids to keep them safe and fulfilled. This approach or parental mentality seems logical on the surface. Parents want their children to grow up feeling loved and happy; in an uncertain world of real (or perceived) dangers and intense competition for jobs, these parents may feel compelled to intervene often to give their kids every possible advantage in life.
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However, this approach can be detrimental to the development of children and youth. It’s important to keep them safe, but it’s also important to let them explore and learn so that they develop the level of competence and independence needed to be successful in today’s society.
The higher the quantity and quality of your relationships, the longer you live. The connections that sustain us physically as well as emotionally can be hard to come by in a world where many work from home or live far from old friends (Svoboda, 2012).
Regularly stepping in to protect maturing kids from stress or assuming they need you at all times to feel secure may hurt them in the long run. Age-inappropriate over-parenting leads to depression-prone, aimless kids (and ultimately, adults) with diminished self-efficacy, lacking the ability to put a plan in place to achieve goals. By not letting kids stumble over the little things, parents prevent them from developing coping skills. Without such skills, children don’t acquire a sense of mastery and self-confidence, which in turn fosters long-term dependence on parents (Svoboda, 2012).
While cellphones and Facebook can help us feel connected, it’s worth the effort to build up our in-person network as well. Some of the strongest evidence to support this theory comes from Julianne Holt-Lunstad of Brigham Young University, who collected data from 148 previous studies looking at the relationship between health and human interaction. What she found was startling: People with active social lives were 50 percent less likely to die of any cause than their nonsocial counterparts. Low levels of social interaction have the same negative effects as smoking 15 cigarettes a day and even worse effects than being obese or not exercising.
Continuing parental over-involvement is also associated with increased entitlement. Children who are used to getting everything they need from their parents without exerting any effort may think, “I’m entitled to everything, but I don’t have the abilities to achieve what I want,” which can result in further disappointment down the line when the real world doesn’t dispense recognition on command. If kids struggle over a little adversity, they learn specific coping skills and gain the confidence that they can take whatever comes their way. Under-parenting just a bit – stepping back, giving kids the chance to recognize that you’re there for them even when you’re not hitched to their side, that they’re capable of picking themselves up when they fall down – is the only way they’ll internalize the strength of the parental bond and a sense of their own competence. We have to be comfortable about allowing our children to live with disappointment and resolve their own problems as much as possible while assuring them that their feelings are heard (even if you’re the one saying “no”) and that you’re available for moral support. Trust in their ability to tackle whatever obstacles they might encounter. Our job as parents is to help our kids become self-sufficient. Letting them grapple with disappointment is some of the best training they can get for dealing with the larger challenges life will inevitably throw their way (Svoboda, 2012). Seek a mate whose values and background echo your own. The key to a happy, healthy relationship is choosing someone who is, quite frankly, a lot like you and a person who validates your existing views and habits instead of trying to change them. This may sound politically incorrect, but the old “opposites attract” motto generally doesn’t hold up over the long haul. Studies have repeatedly underscored the role of homogamy in romantic success. The elements of the concept of homogamy are shared values, personality traits, economic background, and religion, as well as closeness in age. These can be very important in securing a long-lasting relationship. The more a couple shares a similar perspective, the less conflict there’s likely to be in their relationship. However, regardless of how well the two of you score on compatibility tests, you need to feel a spark of attraction, something that can actually come from the differences between your partner’s interests and passions and your own (e.g., you like photography and cooking, your partner likes hiking). So what’s the happiest medium? Seek out a partner whose passions differ enough to expand your experience, but with whom you are aligned on important big-picture issues, like how to show affection, what constitutes a moral life, and how to raise children. The strength of your friendships is as critical for your health as the lifestyle choices you make. We’ve all heard the usual advice for living longer: exercise more, quit smoking, and limit junk food. However, nurturing your relationships plays an important role as well. Supportive friendships may do as much to promote your physical well-being as a top-notch diet and workout regimen. Psychology.EliteCME.com
Meanwhile, research by psychologist Sheldon Cohen of Carnegie Mellon University suggests that the more social connections you have, the greater your ability to fight infection. He gave healthy subjects nasal drops containing a cold virus; those who reported the greatest diversity of social ties were four times less likely to develop colds than those reporting the fewest. He controlled for factors that could have explained the discrepancy, including age, BMI, and time of year. It’s not just how many relationships you have that’s important. The type is also key, according to Uchino’s research. He recorded the blood pressure of 88 women in a stressful situation (preparing to give a speech) and found that readings spiked less when a close friend was available to offer participants encouragement than when they were with a friend they perceived as less supportive. The finding suggests that close friendships may have protective effects on our cardiovascular systems, especially in times of anxiety. Being accustomed to your partner isn’t the same as being out of love. A slew of misconceptions exist about relationships, such as: If you’re with the right person, you’ll rarely experience conflict. The spark should stay alive all on its own. Life should be a continual state of wedded (or paired-up) bliss. Too often, couples assume a relationship is damaged beyond all repair when the period of sexual and emotional excitement ends and the arguing begins. Part of this mindset comes from the widespread cultural belief that it’s easier to cut ties than to stick it out when discord arises. The immature part of us hates confronting our limited ability to invest in someone else and loves the idea that compatible people don’t have conflicts of interest. However, it is interesting that research and real-world experience don’t support this mythology. Some studies have found that successful couples argue. It’s how they go about it that determines their continued relationship satisfaction (among other things, happy partners refrain from hurling nasty zingers or withdrawing from conflict). Airing grievances is necessary because it allows both people to speak their minds and take responsibility for their missteps (Markman, 2010). It is also normal to experience a waning of sexual desire once you’ve progressed past the giddy initial stages of a relationship. Arriving at such a point actually offers an opportunity to deepen your relationship in ways that would have been impossible at the outset (Uyemura, 2011). The only formula for fixing the frustration and stagnation you’ll both inevitably feel is to take concrete steps to resolve them, but that doesn’t mean unleashing a litany of complaints. Instead, focus on the lasting bonds that remain in the relationship. Instead of asking yourself, “Am I still in love with my partner?” try asking, “What can I do to restore our connection?” It might mean sparking some excitement in your less-than-thrilling sex life by initiating something new and unexpected, or perhaps it’s as seemingly simple as recycling that pile of basement boxes that’s annoyed her for months. Or maybe the first step is sitting down for a 20-minute Page 65
conversation about what’s been stressing him out at work, one where you resolve to hold back your opinions and really listen. Finally, remind yourself that a committed relationship requires continual efforts to progress. Avoid assumptions. We often do things for people that we would like but they might not. What’s important to us might not be what’s most important to those we’re trying to help. Make an effort to avoid making assumptions and instead ask, “How can I be of help to you?” Breathe deeply. Want to do something in the next five minutes that will change your life? Breathe deeply. Clinical health psychologist Amanda Withrow, Ph.D., suggests that unconsciously “we breathe into our chest.” The way we should be breathing, however, is diaphragmatically. “Diaphragmatic breathing is slow, deep breathing into our bellies.” It is an important stress management tool and great because it’s free and can be done anywhere and at any time. Interestingly enough, while technology has been known to increase stress levels, there are now smartphone applications that can guide you through deep breathing and help you to practice breathing properly. Give and get a hug. Some psychologists suggest that you should give and receive four hugs a day. Research shows that hugging makes you live longer. Human beings need touch. It soothes and calms us and it brings down the reactive arousal system that can get activated when we feel threatened in any way, and especially in stressful situations. Keep in mind that hugs don’t have to be just of the human type; dogs and cats count, too. Be mindful. Forget about that mounting to-do list, the fight you had with your best pal, or your Facebook update or Twitter account. Take time out to get back to the present moment. If you can learn to be mindful of your thoughts and think more objectively, it can have a positive impact on your behavior and your life. Don’t participate in negative self-talk. What’s one way you can start being kinder to yourself? Learn to be more self-compassionate. Being cruel to yourself, judgmental, and attacking yourself is believed to be something rooted in our culture and is really a problem. It is not indicative of how much money you have, the house you own or your job. People in other cultures who are not financially wealthy have more social support and are nicer to themselves and each other. Why? Because of the thoughts and beliefs they have about themselves. Negative thinking about yourself is a major contributing factor to depression and anxiety. Depression is often anger turned back onto yourself. Labeling and name-calling yourself stupid, for example, can have a negative impact on your life. Health psychologists encourage people to “stop the war with themselves” through helping individuals recognize negative self-talk when it happens and showing them the link with depressive symptoms.
Create your own family of choice. You cannot control the family you’ve been given. Longitudinal studies show people who have been humiliated, abused or neglected are at a much higher risk of dying at a younger age and developing a complex chronic condition (Uyemura, 2011). How do you reap the benefits of having a supportive family if your own family continues to be abusive or toxic? Create your own. Find friends and even older people who can act as parental figures for you. Example: Instead of encouraging you to drink to excess or use drugs, those you choose to be your “family” would actually support you in making healthier choices for yourself. Instead of holding you up for ridicule, this would actually be about doing something good for yourself. Love yourself and then love your neighbor. In their pre-flight instructions, flight attendants demonstrate how to use the oxygen mask if needed, and tell passengers to put on their own mask first before helping others with theirs. The same applies to selfcare. Realistically, you will not be able to help anyone else unless you first take care of yourself. Take care of your physical health. It is recommended that individuals participate in physical activity (including aerobic exercise and strength training) for 90 minutes each day. That might seem overwhelming for most, but the good news is that even 20 minutes three times a week or 10,000 steps a day is enough to help you increase longevity. Take back control. There are a lot of things in life that we have no control over. But the key to healthy living is focusing on your thoughts and reactions, the things you can control. Remember the Serenity Prayer? Even nonreligious folks can reap the benefits from following these words: “God grant me the serenity to accept the things I cannot change; the courage to change the things I can; and wisdom to know the difference.” It can truly be empowering to focus on what you can control and then let go of the things that you can’t. Make sleep and healthy eating priorities. Getting enough sleep is vital to your mental health and physical wellbeing. A healthy average is seven to nine hours a night. How many hours do you get on a regular basis? Eating regular, nutritious meals is also important. People are often focused on and anxious about getting ready for bathing suit season, which in many cases, leads to dieting. However, diets and restricting your food intake can sometimes trigger eating disorders in individuals. Stick with eating at the same time of day every day so that your body is less likely to enter starvation mode and you’re not restricting yourself and your body. Find someone you can confide in. You don’t need millions of Facebook friends or even hundreds of in-person ones. According to research, you just need one trustworthy friend you can confide in to live longer and recover faster from illness. Lyon said that part of the recovery program in some countries includes having someone to talk to about it. Social support is that important.
Physical health Physical health can be affected by the things that people do, by the way they process information, career choice, family dynamics, life troubles and the environment in which they live. For example, someone living in a damp, mildew infested home will probably over time develop respiratory or sinus problems, and at times may develop allergies. When helping people develop a healthier lifestyle, a person’s career choice is another area that health psychology explores. There is a direct relationship between choices of work and physical and emotional health. The more frustrating the project, the more risk people put themselves in to develop an emotional and or psychological
illness (Copeland, 2002). Stress level is one of the key factors related to psychological factors affecting physical health. When individuals are under pressure, their bodies often produce chemicals and hormones that the body does not require, and some may be harmful. These difficult conditions and the release of the chemicals result in a weakening of the immune system. This weakened immune system means that people are more susceptible to physical and mental ailments.
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When people feel sick, tired, or overrun, or when they develop certain diseases, it is not always in response to a virus or bacteria infiltrating the immune system, but instead a response to what is happening within the body, brain and subconscious mind. Catching a cold is only one example. This considered, we certainly cannot neglect the biological component, recognizing the impact when a virus attacks a weakened immune
system. Heart-related conditions, breathing conditions, muscle and joint pain conditions, and various physical ailments are common among people coping with the emotional and psychological stresses of modern day life. The release of stress chemicals in the body weakens the body’s defenses in fighting a physical illness. The more people understand the power of the mind, the more they will realize that physical well-being directly relates to thoughts, feelings, and behaviors.
Physical health and genetics People born from alcoholic parents tend to have more addictive personalities than those whose parents were not alcoholic. Some emotional and mental ailments directly relate to abuse endured in childhood; others tend to be more genetic in nature. However, psychological, social, and environmental factors all play key prominent roles in managing addictions along with this genetic tendency (MacDonald, 2013).
studies show that there is a remarkably strong probability that the individual will just start smoking again.
For example, one way to describe the basics of health psychology is by exploring the smoking addiction. Part of the smoking habit is the physical component of addiction to nicotine as withdrawal symptoms set in once the process of quitting begins. A typical physician will prescribe medicines to suppress the physical addiction symptoms of withdrawal, treating the smoking addiction as any problem. However,
There is a psychological component to the addiction because the smoker stands to gain rewards, no matter how temporary, from each cigarette. Smoking may suppress the appetite, offer an opportunity to relax and unwind, or provide a momentary distraction to current stresses. There is also a behavioral aspect to smoking, such as always lighting up when getting in the car, having a cigarette right after dinner, or using a cigarette as a stress reliever (MacDonald, 2013).
A chain smoker who uses a nicotine patch may have difficulty quitting if he or she continues to believe that smoking is not harmful or that smoking helps to relax. In these cases, even with the patch, the smoker may easily return to smoking. The average counselor or physician is only treating the physical withdrawal aspects of smoking.
Society, cultural factors and physical health Expectations and gender roles can put a large amount of pressure on people to behave and act in a distinct fashion. Racism and religious factors often are stressors in people’s lives, and over time, these stressors have an impact on overall health. For example, white, middle-class people tend to have better overall health than inner-city minorities. Health psychology explores the underlying factors that have a direct and indirect impact on people’s quality of life (MacDonald, 2013). Every year scientists are discovering new insights into how the brain, body and mind interrelate. How do they relate to each other in harmony? The human brain is one of the most intricate, mysterious, and powerful organs in the entire universe. Science has been able to conjure up ideas and concepts in mathematics that had never been considered, and some imagine worlds that do not exist. For example, telekinesis is in the infancy stages in terms of being a proven ability. However, this idea stems from people wanting to explore the unknown aspects of the brain and its seemingly limitless potential (MacDonald, 2013). There is a distinctive respect for what the brain is capable of achieving with medicine and psychology. We understand much more today than we did even 20 years ago about the interaction of emotions and pain,
the thought processes involved in healing, and the remarkable healing powers of the human body (MacDonald, 2013). Research has discovered that people whose parents suffer from certain diseases, such as diabetes, cancer, hypertension, or even addictions, are predisposed to getting these conditions. This is a genetic predisposition. Biology certainly does play a central role in the health and well-being of everyone. However, psychological, environmental and cultural factors also play key roles in any illness and the effects of biology. For example, if mothers were to be diagnosed with breast cancer when they were in their late 30s or early 40s, then most medical professionals would encourage daughters to obtain a screening regularly once they have reached a certain age. It would not matter whether they stayed indoors away from the damaging rays of the sun or that they did not smoke. They are a cancer risk because of the genetic predisposition for the disease that runs in the family history. However, there is no guarantee that daughters of mothers who had breast cancer will suffer the same. It simply means that the DNA (the genetic material that people share with their family) may include a marker that leaves people more susceptible to the disease more than someone else who does not have this marker (MacDonald, 2013).
The bio-psychosocial model and health psychology When health psychologists talk about the bio-psychosocial model, behaviors are key ingredients contributing to physical health. Do people smoke? Do they drink alcohol regularly? Do they eat junk food? Have a stressful job? Are finances tough? Do people exercise regularly? How is the family? How is the social life? These are just a few questions that a health psychologist may explore. There are behavioral and social conditions that directly or indirectly affect the state of overall physical health. Millions of people around the country and the world are under tremendous amounts of stress; the economy is suffering and unemployment remains high. People who are employed are working more hours and are taking on more responsibilities for less pay. Those who have lost their jobs worry about paying their bills, feeding their families and holding onto what they have worked so hard to achieve in the past.
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Stress derives from the instinctual nature of the desire to survive, which the psychological community labels as the “fight-or-flight” response. When the brain perceives a threat to the body, regardless of whether that threat is real or a product of the imagination, the brain responds as if in danger. The brain calls for adrenaline to be pumped throughout the body, which allows it to run faster (away from the problem) or fight with a bit more strength than it naturally possesses (face the problem). This fight-or-flight response and the adrenaline that is produced are only meant to be sustained for brief periods of time, for survival. The physical body is under constant tension adapting to the “fight-or-flight response,” especially when people are facing chronic stress at home or work (Pickren, 2007).
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As a result, people tend to feel run down and tired more often, and they may experience aching joints, muscle aches, lower back pain, headaches and increases in blood pressure – all of which are common side effects of repeated stress and increases in adrenaline. The key is how people recognize and respond to stress and how this relates to behavior. While some do not seem to think stress is abnormal, it does indeed take a heavy toll on a person, both physically and emotionally. Health psychologists work in clinical settings promoting behavioral changes linked to everyday stressors of life. They inform the public, conduct research, teach at universities, and work in the field of sports medicine. For centuries, an opinion has persisted among the general public, medical community and especially those who subscribe to the “tough love” theory that emotional makeup should not and does not have any effect on physical health. It is common for these people to say, “Just pull yourself up by the bootstraps and move on,” when faced with financial, work, relationship or personal problems. Physicians who are assessing patients’ symptoms still too frequently say, “It’s all in your mind,” or much worse, simply write a prescription. These health providers are attempting to help, but they are also unknowingly creating more complications to improving and treating their patients’ on the quality of life principle. Most health providers today will accept the principles of health psychology, yet they do not seem to use them enough in practice. This applied science has not yet been solidified in physicians’ minds so they can apply the theory in their practice, which in turn directly affects patients’ quality of life. Health psychology’s roots are in the belief that everyone deserves proper medical and psychological care, even when daily habits, career, or family life problems contribute to a decrease in physical health and psychological well-being. The bio-psychosocial model views health, wellness and illness as a result of several different interrelated factors affecting a person’s life, from biological characteristics to behavioral and social conditions. Imagine, changing the way people think and cope with aspects of life can move them towards pain-free living or help them decrease blood pressure by learning a few techniques. Applying and believing in this concept will increase people’s quality of life. While healing with “health psychology” is certainly much more complicated than simply changing a thought or behavior, most people did not believe in this concept, and until recently, it has been ignored by the medical community. Some patients and physicians view health psychology concepts as a personal affront to gaining knowledge and do not believe that pain relates to overall emotional well-being. Others fear that people working in the health psychology fields will judge them or their pain
as being “abnormal.” Some medical professionals attempt to discredit patient complaints of pain and intimidate people into believing that the problem simply does not exist and that it is all a figment of their imagination. This is not true; there is a relationship between the physical brain and pain or disease process that people experience. The problem may simply not be medically proven, or the location of pain cannot be found in the body at the time. Do not be tricked into believing that an illness is a figment of imagination; this belief can cause psychological problems and increase physical symptoms. Healing comes, in part, from the underlying psychological aspects of the mind (thoughts and feelings), behaviors and the brain. Clinical health psychologists have labeled this way of thinking as a biopsychosocial model. The model encourages a positive shift in the way people think about health, illness, and healing. Clinical health psychology attempts to provide answers to the following questions: ●● What is the relationship between emotional health, wellness and physical illness? ●● What is the connection between the body, mind and environment? ●● What role does psychology play in health and disease? ●● How should a particular illness be treated? By understanding and harnessing psychological factors, health psychologists can improve health by working directly with individual patients, indirectly in large-scale public health programs, and by training health care professionals (i.e., physicians and nurses) to take advantage of this knowledge when working with their patients. Health psychologists work in a variety of settings: alongside other medical professionals in hospitals and clinics, in public health departments that are working on large-scale behavior change and health promotion programs, and in universities and medical schools where they teach and conduct research. Although its early beginnings can be traced to the kindred field of clinical psychology, four different divisions within health psychology and one allied field have developed over time. The four divisions include clinical health psychology, public health psychology, community health psychology, and critical health psychology. The allied field is occupational health psychology. Professional organizations for the field of health psychology include Division 38 of the American Psychological Association, the Division of Health Psychology of the British Psychological Society, and the European Health Psychology Society. Advanced credentialing in the U.S. as a clinical health psychologist is provided through the American Board of Professional Psychology.
Preventing illness Many health psychologists focus on prevention research and interventions designed to promote healthier lifestyles and try to find ways to encourage people to improve their health. For example, they may help people to lose weight or stop smoking. Health psychologists also use their skills to try to improve the health care system. For example, they may advise doctors about better ways to communicate with their patients. Health psychologists work in many different settings, including the NHS, private practice, universities, communities, schools and organizations. While many health psychologists provide clinical services as part of their duties, others function in non-clinical roles, primarily involving teaching and research. Leading journals include Health Psychology, the Journal of Health Psychology, the British Journal of Health Psychology, and Applied Psychology: Health and Well-Being. Health psychologists can work with people on a one-to-one basis, in groups, as a family, or at a larger population level.
Health psychologists work toward promoting health through behavioral change, as mentioned above; however, they attempt to prevent illness in other ways as well. Health psychologists try to help people to lead a healthy life by developing and running programs that can help people make changes in their lives, such as stopping smoking, reducing the amount of alcohol they drink, eating more healthily, and participating in regular exercise. Campaigns informed by health psychology have targeted tobacco use. Those least able to afford tobacco products consume them most. Tobacco provides individuals with a way of controlling aversive emotional states accompanying daily experiences of stress that characterize the lives of deprived and vulnerable individuals. Practitioners emphasize education and effective communication as a part of illness prevention because many people do not recognize, or minimize, the risk of illness present in their lives (Sandoval, 1996). Moreover, many individuals are often unable to apply their knowledge of health practices because of everyday
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pressures and stresses. Anti-smoking campaigns are a common example of population-based attempts to motivate the smoking public to reduce its dependence on cigarettes.
people avoid risky behaviors that may affect their health and wellbeing, such as unprotected sex, and even encourage regular teeth brushing or hand-washing to prevent future ill health.
Some illnesses can be treated better if they are caught early. Health psychologists have worked to understand why some people do not go for screening or immunizations and are finding ways to encourage people to have health checks for illnesses such as cancer or heart disease. Health psychologists are also finding ways to try to help
Health psychologists also aim at educating health professionals, including physicians and nurses, in communicating effectively with patients in ways that overcome barriers to understanding, remembering, and implementing effective strategies for reducing exposures to risk factors and making health-enhancing behavior changes.
The effects of disease Health psychologists investigate how disease affects individuals’ psychological well-being. People who become seriously ill or injured faces many different practical stressors. These include problems meeting medical and other bills; problems obtaining proper care when home from the hospital; obstacles to caring for dependents; having their sense of self-reliance compromised; gaining a new, unwanted identity as a sick person; and so on. These stressors can lead to depression, reduced self-esteem and so on.
Health psychology also concerns itself with bettering the lives of individuals with terminal illness. When there is little hope of recovery, health psychologist therapists can improve the quality of life of the patient by helping the patient recover at least some of his or her psychological well-being. Health psychologists are also concerned with identifying the best ways to provide therapeutic services for the bereaved.
Critical analysis of health policy Critical health psychologists explore how health policy can influence inequities, inequalities, and social injustice. These avenues of research expand the scope of health psychology beyond the level of individual health to an examination of the social and economic determinants of
health, both within and between regions and nations. The individualism of mainstream health psychology has been critiqued and deconstructed by critical health psychologists using newer qualitative methods and frameworks for investigating health experience and behavior.
Conducting research Health psychologists have advanced skills in a variety of research methods, which enables them to conduct research, provide expert advice or collaborate on a study, such as studying the links between stress and health. Health psychologists carry out research to answer questions such as:
●● ●● ●● ●●
What influences healthy eating? How is stress linked to heart disease? What are the emotional effects of genetic testing? How can we change people’s health behavior to improve their health?
Teaching and communication Health psychologists can also be responsible for training other health professionals, for example, on how to deliver an intervention to help promote healthy eating or stopping smoking; or deliver training in communication skills, such as how to break bad news; or support behavior change. This can also enhance practitioner-patient relationships and adherence to treatment. In the United Kingdom, health psychologists are registered by the Health Professions Council (HPC) and have trained to be eligible for full membership in the Division of Health Psychology within the British Psychological Society (BPS). Registered health psychologists who are chartered with the British Psychological Society have undertaken a minimum of six years of training and have specialized in health psychology for a minimum of three years. Health psychologists in training must have completed BPS stage 1 training and be registered with the BPS Stage 2 training route or with a BPS-accredited university doctoral health psychology program. Once qualified, health psychologists can work in a range of settings, for example the NHS, universities, schools, private health care,
research and charitable organizations. A health psychologist in training might work within applied settings while working towards registration and chartered status. A health psychologist will have demonstrated competencies in all of the following areas: ●● Professional skills (including implementing ethical and legal standards, communication and team work). ●● Research skills (including designing, conducting and analyzing psychological research in numerous areas). ●● Consultancy skills (including planning and evaluation). ●● Teaching and training skills (including knowledge of designing, delivering and evaluating large and small scale training programs). ●● Intervention skills (including delivery and evaluation of behavior change interventions). All qualified health psychologists must also engage in and record their continuing professional development (CPD) for psychology.
Improving doctor-patient communication Health psychologists try to aid the process of communication between physicians and patients during medical consultations. There are many problems in this process, with patients showing a considerable lack of understanding of many medical terms, particularly anatomical terms (i.e. intestines). One main area of research on this topic involves “doctor-centered” or “patient-centered” consultations. Doctor-centered consultations are generally directive, with the patient answering questions and playing
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less of a role in decision-making. Although this style is preferred by elderly people and others, many people dislike the sense of hierarchy or ignorance that it inspires. They prefer patient-centered consultations, which focus on the patient’s needs, involve the doctor listening to the patient completely before making a decision, and involving the patient in the process of choosing treatment and finding a diagnosis.
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Improving adherence to medical advice Getting people to follow medical advice and adhere to their treatment regimens is a difficult task for health psychologists. People often forget to take their pills or consciously opt not to take their prescribed medications because of side effects. Failing to take prescribed medication is costly and wastes millions of usable medicines that could otherwise help other people. Estimated adherence rates are difficult to measure. However, there is evidence that adherence could be improved by tailoring treatment programs to individuals’ daily lives. Ways of measuring adherence Health psychologists have identified a number of ways of measuring patients’ adherence to medical regimens:
●● Counting the number of pills in the medicine bottle. This has problems with privacy and could be deemed as patronizing or showing a lack of trust in patients. ●● Using self-reports. However, patients may fail to return the selfreport or lie about their adherence. ●● Asking a doctor or health worker, though this presents problems with doctor-patient confidentiality. ●● Using “trackcap” bottles, which track the number of times the bottle is opened. However, this either raises problems of informed consent, or if informed consent is obtained, influence through demand characteristics.
Managing pain Health psychology attempts to find treatments to reduce and eliminate pain, as well as understand pain anomalies, such as episodic analgesia, causalgia, neuralgia, and phantom limb pain. Although the task of measuring and describing pain has been problematic, the development of the McGill Pain Questionnaire has helped make progress in this area.
Treatments for pain include patient-administered analgesia, acupuncture (found by Berman to be effective in reducing pain for osteoarthritis of the knee), biofeedback, and cognitive behavior therapy.
Health psychologist roles Below are some examples of the types of positions held by health psychologists within applied settings, such as the NHS and private practice: ●● Consultant health psychologist: A consultant health psychologist will take a lead for health psychology within public health, including managing tobacco control and smoking cessation services and providing professional leadership in the management of health trainers. ●● Principal health psychologist: A principal health psychologist could, for example, lead the health psychology service within one of the UK’s leading heart and lung hospitals, providing a clinical service to patients and advising all members of the multidisciplinary team. ●● Health psychologist: An example of a health psychologist’s role would be to provide health psychology input to a center for weight management. This could include psychological assessment
of treatment, development and delivery of a tailored weight management program, and advising on approaches to improve adherence to health advice and medical treatment. ●● Research psychologist: Research psychologists carry out health psychology research, for example, exploring the psychological impact of receiving a diagnosis of dementia, or evaluating ways of providing psychological support for people with burn injuries. Research can also be in the area of health promotion, for example, investigating the determinants of healthy eating or physical activity or understanding why people misuse substances. ●● Health psychologist in training/assistant health psychologist: As an assistant/in training, a health psychologist will gain experience assessing patients, delivering psychological interventions to change health behaviors and conducting research while being supervised by a qualified health psychologist.
Journal of Health Psychology Health Psychology is not just a category within the field of psychology. It is also the name of an existing scholarly journal devoted to understanding the scientific relations among psychological factors, behavior and physical health and illness. Health Psychology is the official scientific publication of APA’s Division 38 (Health Psychology). The readership is broad in discipline, background, interests, and specializations. The main emphasis of the journal is on original research, including integrative theoretical review papers, meta-analyses, treatment outcome trials, and brief scientific reports. Scholarly case studies, commentaries, and letters to the editor will also be considered. Papers should have significant theoretical or practical importance for understanding relations among behavior, psychosocial factors, and physical health, as well as their application. All papers should emphasize, whenever possible, the translation of scientific findings for practice and policy. Health Psychology publishes original scholarly articles on topics like these: ●● Contextual factors that may contribute to disease or its prevention. ●● Prevention.
●● Interfaces among biological, psychosocial, social and behavioral factors in health. ●● Assessment approaches in health. ●● Health risk and resilience behavior. ●● Health promotion. ●● Child and adolescent health. ●● Couple and family relationships and health. ●● Lifespan approaches to health, including those of older adults. ●● Evaluation and dissemination of treatment approaches that target individuals, families, groups, multicenters, or communities. ●● Ethnicity, social class, gender and sexual orientation in health. ●● Health disparities. ●● Research methodology, measurement, and statistics in health psychology. ●● Implications of research findings for health-related policy. ●● Advances in health-related theory. ●● Innovations in technology. ●● Professional issues in health psychology, including training and supervision.
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Workplace wellness There is also evidence from occupational health psychology that stress-reduction interventions at the workplace can be effective. Workplace wellness is any workplace health promotion activity or organizational policy designed to support healthy behavior in the workplace and to improve health outcomes. Generally speaking, health promotion is defined as the process of enabling people to increase control over and improve their health. Health promotion can be carried out in the workplace as well as many other settings. Known as “corporate well-being” outside the U.S., it consists of a variety of activities, such as health fairs, health education,
medical screenings, health coaching, weight management programs, wellness newsletters, on-site fitness programs and facilities and educational programs. Workplace wellness includes organizational policies designed to facilitate employee health, including allowing flex time for exercise, providing on-site kitchen and eating areas, offering healthy food options in vending machines, holding “walk and talk” meetings, and offering financial and other incentives for participation, among many other options. Workplace wellness has been expanded over the past decade to encompass the overall creation of a “culture of health” within the worksite.
Framework Worksite wellness programs including nutrition and physical activity components may occur separately or as part of a comprehensive worksite health promotion program addressing a broader range of objectives such as smoking cessation, stress management, and weight loss. A conceptual model has been developed by the Task Force for Community Preventive Services and serves as an analytic framework for workplace wellness and depicts the components of such comprehensive programs. These components include worksite interventions including: ●● Environmental changes and policy. ●● Informational messages. ●● Behavioral and social skills or approaches. Worksite environmental change and policy strategies are designed to make healthy choices easier. They target the whole workforce instead of individuals by modifying physical or organizational structures. Examples of environmental changes may include enabling access to healthy foods (i.e., through modification of cafeteria offerings or vending machine content) or enhancing opportunities to engage in physical activity (i.e., by providing onsite facilities for exercise). Policy strategies may involve changing rules and procedures for employees, such as offering health insurance benefits, reimbursement for health club memberships, or allowing time for breaks or meals at the worksite. Informational and educational strategies attempt to build the knowledge base necessary to inform optimal health practices. Information and learning experiences help bring about voluntary adaptations of behavior conducive to health. Examples include: ●● Health-related information provided on the company intranet. ●● Posters or pamphlets. ●● Nutrition education software. ●● Information about the benefits of healthy diet and exercise. Behavioral and social strategies attempt to influence behaviors indirectly by targeting individual cognition (awareness, self-efficacy, perceived support, intentions) believed to mediate behavior changes. These strategies can include structuring the social environment to provide support for people trying to initiate or maintain weight change. Such interventions may involve individual or group behavioral counseling, skill-building activities such as cue control, use of rewards or reinforcement, and inclusion of coworker or family members for support.
One particular program, Healthy People 2010, is a blueprint for a 10-year national initiative to improve the health of all Americans. Employers can use Healthy People 2010 objectives to focus businesssponsored health promotion and disease prevention efforts and measure worksite and community-wide outcomes against national benchmarks. As defined by Healthy People 2010, a comprehensive worksite health promotion program contains five program elements: ●● Health education, which focuses on skill development and lifestyle behavior change along with information dissemination and awareness building, preferably tailored to employees’ interests and needs. ●● Supportive social and physical environments. These include an organization’s expectations of healthy behaviors, and implementation of policies that promote health and reduce risk of disease. ●● Integration of the worksite program into the organization’s structure. ●● Linkage to related programs such as employee assistance programs (EAPs) and programs to help employees balance work and family. ●● Worksite screening programs ideally linked to medical care to ensure follow-up and appropriate treatment as necessary. In addition, Partnership for Prevention includes two additional components: ●● Support for individual behavioral change with follow-up interventions. ●● Evaluation and improvement processes to help enhance the program’s effectiveness and efficiency. The Centers for Disease Control’s National Institute for Occupational Safety and Health (NIOSH) through its Total Worker Health program offers an extensive list of resources to assist employers, employees, and practitioners in their efforts to implement and develop programs within their organizations that integrate employee health activities. Most of the publicly available reputable sources provides tips and tools, but are not “off-the-shelf” or “turn-key solutions.” Organizations wishing to obtain more assistance will find there are numerous private companies offering fee-based services. The Partnership for Prevention offers extensive background and programspecific information in its Healthy People 2010 and Beyond report, which is available to anyone at no charge on the Internet.
Early implementation of healthy living practices The most direct manner of promoting the concepts of healthy living may simply be through media campaigns armed with informational appeals to the benefits of health psychology (Lafreniere and Cramer, 2012). These awareness campaigns can help to reduce the stigmas surrounding mental health care and promote acceptance of psychological treatment. Even more important, primary care physicians may need to screen and promote integrating psychological treatment with medical treatment because their status as authority figures may help those resistant to Psychology.EliteCME.com
treatment because of mental health care stigmas (Loscalzo, Clark, and Holland, 2011). A combination of both the informational campaigns and the promotion by the primary care physician should ensure that patients understand what options may be most beneficial to their care. Unfortunately, this may be slow to occur. Stigmas about mental health care are still prevalent and prevent people from seeking out the help they may need (Corrigan, 2004). Fortunately, the development of sound clinical skills and scientific backing over the second half of Page 71
the 20th century has led to an increased integration of psychological courses in medical training (Pickren, 2007). It may just be that a new generation of doctors with a better understanding of how psychological processes impact physical health
is needed to really push for this change. It may be slow in coming, but through promotion of the bio-psychosocial model and awareness campaigns, the benefit of psychological treatment in combination with traditional medical treatment can become the new norm.
Importance of starting with schools Every opportunity for parents and educators to talk with children and adolescents about the dangers of drugs, alcohol and smoking is vital. Parents, educators and students must work together to keep drugs out of their schools and prevent young people from engaging in drug use. When young people do not perceive the risk, use invariably increases. There is a large and growing denial gap when it comes to drug abuse and dependency. Our responsibility as educators is to reach out to help children find ways to lead drug-free lives. Clearly, the earlier we reach substance abusers, the greater will be our likelihood of success. There has never been a time in America where the wellness of students has been more apparently at risk. Today’s students are exposed to a multitude of threats to their personal wellness, many of which were virtually unknown a generation ago. Recent incidents of school violence (however atypical they may be in absolute numbers and intensity) have refocused public attention equally on programs to identify troubled students and also on approaches to ensure a healthy school community. It appears to have been a surprise to many commentators that the very children involved in school violence were themselves previously unknown to their school’s mental health providers. The answer to the implied question of “why?” may be that the school psychologist was too busy focusing on identification and placement for special education instead reviewing the mental-health needs and culture of the entire school. The questions of what constitutes appropriate and effective health and mental health services to school-aged children and who should provide such services have entered the debate. Changes resulting from health
care reform have effectively removed as a partner one traditional line of support, the family medical practitioner. Reformed health care means that independent clinicians in private clinics and hospitals provide fewer services, and managed care’s costsaving focus has not included schools as locations for treatment or as partners in treatment. The availability of insured behavioral health care services is, at best, in short supply and rarely offered through school settings. The language and culture of health care has metamorphosed so rapidly “that the only constant in health care reform is that nothing remains constant” (Wrobel & Krieg, 2002, p. 7). Thus, traditional health care communities are no longer significant players in the provision of service to the nation’s troubled youths and certainly are insignificant in promoting wellness within schools’ populations. School psychologists are now poised to take a “key position to participate in comprehensive health care of children and adolescents … as part of an integrated system of culture-specific services, ranging from prevention to treatment directed toward health, mental health, and related needs of students and their families” (Nastasi, 2000, p. 540). There is therefore a need for a new conceptualization of a school psychologist who bridges the gap created by the removal of traditional medical care services from the health care and wellness equation. The school psychologist can directly treat a broad spectrum of “nonmedical” public health concerns, including both physical and mental health. Farley (1996) has coined a name for this movement, one that melds health and education into a single professional service; he proposes educare psychology as a replacement for school psychology.
How can a school psychologist get involved? School psychologists can first become involved on an individual level. While school personnel have traditionally provided formal intervention services, these services have not always been viewed as contributing to the general health of children and adolescents. For the most part, school psychologists have persisted in conducting traditional psychoeducational assessment as their primary function.
variables that promote or impede the expression of healthy behaviors (Power et al., 1999). Such systems interventions have traditionally been relegated to a position that lies outside the typical role and function of school psychologists (Borgelt & Conoley, 1999). However, the complexity of problems faced by today’s youth demand integrated system-wide efforts.
The analogy that comes to mind is the role of the prison guard engaged in rehabilitation. Although it is correct that the location is appropriate and the existence of personnel is indisputable, the primary orientation of the traditional guard is not that of an agent who promotes long-term change in behavior, attitude, or values. While this is an uncharitable depiction of very many school psychologists, it is the case that far too many school psychologists do not take a life-span approach when considering plans for their clients.
Schools, families, and community agencies often impact each other in an interdependent context, and as such cannot afford to be ignored (Knoff, 1996). School psychologists increasingly are being called upon to implement programs that improve the wellness climate of the school, with activities such as structuring curriculum, initiating peer mediation and conflict resolution, mentoring, counseling, and providing a growing array of school based mental health services (De Jong, 2000; Nastasi, 1998; Shafii and Shafii, 2001).
Changing behavior in others requires engaging partners, modeling appropriate behavior patterns, creating wellness circles, and generally “promoting the positive” as an appropriate lifestyle.
They can also participate actively on an organizational level. Systemwide initiatives in wellness promotion must begin with a statement of mission, goals, and purpose. It is difficult to lead a school population to a generalized sense of “wellness” when involved parties are unable adequately to define the construct. Policies and procedures that both reflect and activate the mission should be incorporated at district, building, and classroom levels. Training of all stakeholders through in-service workshops and programs will be necessary so that individual resources are not excessively taxed by the sheer amount of need present in any one locale. There will be an obvious need for delegation, and school psychologists must develop these skills.
Acting as a “wellness coach” for children and youth can be a critical catalytic role. Larson (2000), in applying the central tenets of positive psychology to the young, stressed the need to develop students’ intrinsic sense of initiative. A lack of a rigor in promoting positive youth development has resulted in child deficiencies in positive development, manifested by high rates of boredom, alienation, and disconnection from meaningful challenge. School psychologists should consider challenging themselves to shift their focus beyond individual students and examine systematic
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Positive psychology Seligman and Csikszentmihalyi (2000) defined positive psychology as a science of positive subjective experience, positive individual traits, and positive institutions on which psychologists can renew their mission to serve the well-being of their public. They lamented the exclusive
focus on pathology that has dominated the psychology literature and marginalized the positive features of the human condition. Positive psychology advocates that we change the focus from a disease model involving equal parts repair and remediation to one that emphasizes existing positive qualities and nurtures their growth.
Wellness promotion in the context of positive psychology Central to the idea of positive psychology is the promotion of wellness across society, with particular emphasis on the young. Indeed, there has been increasing emphasis on developing health-enhancing behavior early in life for this very purpose (Kehle et al., 2002; Nastasi, 2000). Wellness may be defined not simply as the absence of disease or illness, but instead as the presence of physical, mental and emotional health. Closely related to wellness promotion, health promotion has also been defined as involving a focus on the enhancement of wellbeing and competence instead of reactive interventions (Zins, Heron, & Goddard, 1999). Likewise, wellness promotion would seem best to serve target populations by de-emphasizing disease model conceptualizations and embracing the enhancements of existing positive traits. With the central theme of positive psychology acting as a guide, promoting wellness includes not only eliminating or reducing unhealthy behavior, but also increasing or strengthening children’s existing skills and competencies at generating and maintaining a positive health focus by modifying their attitudes and values about the intrinsic worth of a healthy lifestyle. Promoting wellness might also involve increasing the number and relative strength of resilience variables. Cowen, Wyman, Work, and Parker (1990) suggest enhancing these variables through the following initiatives: Increasing problem-solving skills and social competence; reducing separations from primary caregivers (particularly during formative years); developing warm and secure parent/child relationships; instituting effective discipline practices within families and schools; and increasing the availability of extra-familial adult models for identification and support. The role of education as a link between learning and health promotion seems obvious; yet, many school professionals continue to endorse a
separation between education and health care (usually evidenced as deference to medical partners). However, social workers, counselors, and school psychologists have longstanding engagement in the provision of school-based mental health services. Even though each of these groups tends to promote a different philosophy, service delivery system, and rationale for their work, each provides significant triage services to children through direct-intervention mental-health services as well as service coordination with local agencies. Consistent with the idea of positive psychology is the concept of “cultivating the positive” through the expansion of mental health service delivery in the schools (Roeser, 2001). Educational reform initiatives have expanded the mission of schools to address the needs of the whole child, including academic, social, emotional, and health issues (Power et al., 1999). This, in part, has given rise to the concept of “full-service schools,” described as “a convenient delivery system for students and their families to access needed intervention services, provide prevention programs, and facilitate learning for all students” (Bucy, Meyers, and Swerdlik, 2002, p. 281–282). Federal grant programs, such as Safe Schools/Healthy Students, continue to support collaboration between schools and communities to expand schoolbased health services (Nealis, 2001). Despite almost no governmental support for a medical-health care system that uses schools as a forum, mental health services are offered in some capacity by a growing number of school districts (Brener, Martindale, and Weist, 2001). However, there exist few structured, school-based programs that intentionally incorporate the concept or term of “wellness” (Kolbe & Berkin, 2000).
Role and function of the school psychologist in wellness promotion As applied practitioners, school psychologists bring a commitment to use the science of psychology for the welfare of children by using skills, instrumentation, and techniques that bear on learning and behavior. The goal statements proposed by NASP (Ysseldyke et al., 1997) indicate that school psychologists must have knowledge of typical child development (and psychopathology) to develop and implement prevention and intervention programs for students with a wide range of needs. Also essential is that school psychologists recognize behaviors that serve as precursors to larger problems and know how to work with staff, families, and the general community to mobilize resources. The school psychologist must develop challenging but achievable behavioral, affective, and adaptive goals for all students, provide information about ways in which students can achieve these goals, and monitor student progress toward these goals. Wellness promotion activities have never been closely aligned with the traditional role of the school psychologist.
While there has been a proliferation of schools that offer medical, mental health, and social services, school psychologists typically have a relatively minor role in the delivery of any of these services (Reeder et al., 1997). This outdated template for school psychological service delivery has been insufficient to ameliorate an ever-expanding host of childhood problems. Sheridan and Gutkin (2000, p. 487) note, “Wherever one turns, the signs of failure are unambiguous and undeniable.” It may be time for school psychologists and school systems to redefine their role to meet the demands of stakeholders. School psychologists occupy a unique position in schools, for they bring insight into the social and emotional development of children and skills in problem prevention (Elias, 2000). Leaders in school psychology have proposed a redefinition of the field within health care delivery (i.e. Dwyer, 1996); however, this likely will necessitate a procedural shift in dayto-day job responsibilities and a thorough reconceptualization of the central purposes of the profession.
Wellness promotion practices As individual service delivery continues to dominate the schedules of most practitioners, initial efforts in promoting wellness in schools likely will occur in individualized contexts. Indeed, it may be argued that school psychologists have been deeply involved in individual wellness promotion since the inception of the profession. Psychology.EliteCME.com
The typical duties of evaluation and consultation clearly demand significant attention be directed toward the “betterment” of the individual student. Activities such as evaluating the effects of prescribed medication; counseling students who are wrestling with learning difficulties; and
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collaborating with families, school staff, and agencies on behalf of students are all directed at promoting the global well-being of students. This involvement can also take the form of advocacy and facilitation for individual students framed to their needs. Unfortunately, most schools continue to limit mental health interventions to individuals who create significant disruptions or experience serious problems (Adleman and Taylor, 1998). There is a tendency to rely on narrowly focused, short-term, cost-intensive interventions. Based on established threats to student wellness, there now exists an overwhelming need for comprehensive approaches to use resources more efficiently to better address the needs of those served while also serving greater numbers. Physical activity should not be limited to the standard concepts of exercise and team sports. Instead, it can embrace activities that appeal to teenagers’ temperaments, personalities, and interests. The goal is to increase overall activity levels. From a physical standpoint, increased physical activity results in healthier bones and joints, less fat, and leaner muscle mass and helps to prevent the development of high blood pressure. From a psychological standpoint, increased physical activity reduces feelings of depression and anxiety, heightens levels of self-esteem, and promotes social well-being.
Children who participate in higher levels of activity are also less likely to use tobacco, drugs, or alcohol. And while there is no direct link evident between physical activity and academic performance, improved mental health resulting from increased activity may improve a student’s capacity to learn. Pro-social activity is about helping children build alliances and affiliations with peer groups and conventional institutions from which they can learn positive and healthy habits. Children who are engaged in positive, goal-directed activities are less likely to engage in risky behaviors. School-sponsored clubs, Boy Scouts, Girl Scouts, age-relevant religious groups, or any formal or informal gathering for engaging in activities should be considered positive bases for pro-social activity. Increased pro-social activity among teens also creates the benefits of social connectedness, positive family relationships, futurefocus orientation, and school achievement. Strengthened social and psychological skills from being in a positive, pro-social group promotes clearer expectations for socially acceptable behavior. Teenagers involved in pro-social community groups are more likely to report having received recognition for good grades, more likely to rate their chances of graduating from high school and going to college as “very high,” and significantly more likely to report feeling good about themselves (HHS Campaign to Encourage Physical Activity and Healthy Behaviors for Children, 2002).
Conclusion It’s not only important to keep your “finger on the pulse” of medical issues that can impact your level of healthy living, but also on the pulse of existing relationships with those around you. Researchers speculate that the stress associated with low social support sets off a cascade of damaging reactions within the body, including cardiovascular dysfunction and weakened immune resistance (Svoboda, 2012).
Psychologists who strive to understand how biological, behavioral, and social factors influence health and illness are called health psychologists. Health psychologists use their knowledge of psychology and health to promote general well-being and understand physical illness. They are specially trained to help people deal with the psychological and emotional aspects of health and illness.
Studies indicate that people who enjoy close ties with friends and family are happier, have fewer health problems, and are more resilient to the stresses of our times. Positive social connections aren’t just important to living a fulfilling life, they’re vital to any type of healthy life at all. When people do not have stable and supportive relationships, they can experience levels of depression and anxiety.
The term “health psychology” is often used synonymously with the terms “behavioral medicine” and “medical psychology.”
The world of health psychology is changing lives one day at a time, and with some expert guidance and support, people can experience the healthy, vibrant life that they desire. All it takes is unlocking the secrets of the brain, body, and emotions. A simple fact of life is that human beings are extraordinarily complex, and an illness can be the result of a myriad of factors. These factors emerge from biological, psychological and environmental facets of everyday life. Most often, medications alone will not provide the positive results necessary for people to achieve maximum health. But although medicines do not fully spur recovery or reduce the pain, not all options for improvement have been exhausted. Health psychology principles clearly have not been used or recognized by conventional western medicine. Health psychology is a relatively new field of applied psychology that uses psychological principles to “promote changes in people’s attitudes, behavior and thinking about health and illness” (The British Psychological Society, 2013). A simpler way to understand health psychology is that it aims to promote health and prevent illness (Lafreniere & Cramer, 2012). Key to understanding health psychology is the bio-psychosocial model. Recent advances in psychological, medical, and physiological research have led to a new way of thinking about health and illness. This conceptualization, which has been labeled the bio-psychosocial model, views health and illness as the product of a combination of factors, including biological characteristics (i.e., genetic predisposition), behavioral factors (i.e., lifestyle, stress, health beliefs), and social conditions (i.e., cultural influences, family relationships, social support).
Health psychologists work with many different health care professionals (e.g., physicians, dentists, nurses, physician’s assistants, dietitians, social workers, pharmacists, physical and occupational therapists, and chaplains) to conduct research and provide clinical assessments and treatment services. George Engel developed the bio-psychosocial model in response to the biomedical stance that all illnesses are related to biological deficiencies (Engel, 1977). Engel proposed that health was determined not only by biological factors but also by psychological and social factors. An extension of this thinking is that to help people in the physical healing process, we need to pay attention to their psychological and social needs in combination with treating their medical needs (Suls & Rothman, 2004). Current research has supported this understanding of total health treatment. Early implementation of educational and prevention efforts in health psychology is also important. While media advertisements and campaigns cover a broader population, such efforts may be slow to implement. However, in addition to information given by primary physicians, using school psychologists to provide health psychologytype services may be a great opportunity for communicating both physical and mental health tools and techniques to the next generation. In conclusion, health psychologists use a psychological approach by exploring physical, psychological, and behavioral aspects, and consider a problem in a holistic fashion. The practice of using health psychology principles significantly improves the likelihood of successfully quitting any addiction. Health psychology can help people become more physically fit, help with decreasing chronic pain, improve the quality of life for those diagnosed with a terminal illness, prevent further complications of any
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serious physical ailment, and help people learn new ways to cope with the tensions that govern everyday life.
can help them run that marathon, or play a better game of golf or basketball or any sport.
The clinical health psychologist’s goal is to encourage people to achieve their full potential and discover new ways to manage a medical condition. They also work with people who want to improve their current physical health by learning motivational techniques that
Above all, it is important to understand and recognize the existing efforts and opportunities to share the concepts of healthy living with all individuals of all walks of life, in hopes that our society will embrace a culture of healthy living.
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Healthy Living Psychology Final Examination Questions
Choose True or False for questions 21 through 30 and mark them on the answer sheet found on page 85 or complete your test online at Psychology.EliteCME.com. 21. Health psychology is concerned with understanding which of these factors is involved in physical health and illness in addition to the biological causes that are well understood by medical science? a. Psychological. b. Behavioral. c. Cultural. d. All of the above.
26. Research has discovered that people whose parents suffer from certain diseases, such as diabetes, cancer, hypertension, or even addictions, have: a. A genetic predisposition to getting these conditions. b. Lower levels of social interaction. c. Poor support networks. d. Additional mental health disorders.
22. Recent trends in psychology have offered more emphasis on which of the following? a. Survey results. b. Mental health disorders. c. Relationships and social interactions. d. Drugs.
27. The bio-psychosocial model considers which of the following as the key ingredient contributing to physical health? a. Genetics. b. Stress. c. Relationships. d. Behaviors.
23. Which of the following can raise blood pressure, increase the risk of heart attack and stroke, increase vulnerability to anxiety and depression, contribute to infertility, and hasten the aging process? a. Diabetes. b. Acute stress. c. Chronic stress. d. Insomnia.
28. When there is little hope of recovery when treating individuals with terminal illness, health psychologist therapists can improve the quality of life of the patient by helping the patient recover at least some of his or her: a. Family connections. b. Psychological well-being. c. Financial costs. d. Dignity.
24. What kind of psychologists present research results to educators, policy makers, and health care providers? a. Public health psychologists. b. Community health psychologists. c. Critical health psychologists. d. Clinical health psychologists. 25. Levels for which of the following increase when we experience positive interactions with others and decrease when we experience negative interactions with others? a. Serotonin. b. Sodium. c. Lithium. d. Magnesium.
29. Health psychology is not just a category within the field of psychology, but is also: a. A government program. b. An APA scholarly journal. c. Its own charitable organization. d. A cultural mindset. 30. The process of enabling people to increase control over and improve their health that can be carried out in the workplace as well as many other settings is called: a. Empowerment. b. Health promotion. c. Community awareness. d. Stress management.
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Chapter 5:
Understanding Schizophrenia and Its Treatment Implications 1 CE Hour
By: National Institute of Mental Health (NIMH) Edited by: Kathryn Brohl, MA, LMFT and Wade T. Lijewski, Ph.D.
Learning objectives This workshop is designed to help you: Assess characteristics inherent in people who have schizophrenia. Discuss the causal factors attributed to schizophrenia. Analyze when the onset of schizophrenia occurs and how it affects different populations.
Describe treatment implications and the currently recognized methods of treatment for schizophrenia. Express the importance of family engagement in the care-giving of people with schizophrenia.
Defining schizophrenia What is schizophrenia? Schizoaffective disorder is a serious mental illness that has features of two different conditions: schizophrenia and an affective (mood) disorder that may be diagnosed as either major depression or bipolar disorder.
The recent 2013 update to the Diagnostic and Statistical Manual of Mental Disorders brought about changes in many areas of mental health diagnosis. Two changes were made to DSM-IV Criterion A for schizophrenia.
Schizophrenia is a brain disorder that distorts the way a person thinks, acts, expresses emotions, perceives reality, and relates to others. Depression is an illness that is marked by feelings of sadness, worthlessness, or hopelessness, as well as problems concentrating and remembering details. Bipolar disorder is characterized by cycling mood changes, including severe highs (mania) and lows (depression).
The first change is the elimination of the special attribution of bizarre delusions and Schneiderian first-rank auditory hallucinations (e.g., two or more voices conversing). In DSM-IV, only one such symptom was needed to meet the diagnostic requirement for Criterion A, instead of two of the other listed symptoms. This special attribution was removed due to the non-specificity of Schneiderian symptoms and the poor reliability in distinguishing bizarre from non-bizarre delusions. Therefore, in DSM-5, two Criterion A symptoms are required for any diagnosis of schizophrenia.
According to the National Institute of Health (2014), schizophrenia is a chronic, severe, and disabling brain disorder that has been recognized throughout recorded history and currently affects about 1 percent of Americans. People with schizophrenia may hear voices other people don’t hear or they may believe that others are reading their minds, controlling their thoughts, or plotting to harm them. These experiences are terrifying and can cause fearfulness, withdrawal, or extreme agitation. People with schizophrenia may not make much sense when they talk, may sit for hours without moving or talking much, or may seem perfectly fine until they talk about what they are really thinking. Because many people with schizophrenia have difficulty holding a job or caring for themselves, the burden on their families and society is significant as well. Available treatments can relieve many of the disorder’s symptoms, but most people who have schizophrenia must cope with some residual symptoms as long as they live. Nevertheless, this is a time of hope for people with schizophrenia and their families. Many people with the disorder now lead rewarding and meaningful lives in their communities. Researchers are developing more effective medications and using new research tools to understand the causes of schizophrenia and to find ways to prevent and treat it.
The second change is the addition of a requirement in Criterion A that the individual must have at least one of these three symptoms: delusions, hallucinations, and disorganized speech. At least one of these core “positive symptoms” is necessary for a reliable diagnosis of schizophrenia. The DSM-IV subtypes of schizophrenia (i.e., paranoid, disorganized, catatonic, undifferentiated, and residual types) are now eliminated due to their limited diagnostic stability, low reliability, and poor validity. These subtypes also have not been shown to exhibit distinctive patterns of treatment response or longitudinal course. Instead, a dimensional approach to rating severity for the core symptoms of schizophrenia is included in Section III to capture the important heterogeneity in symptom type and severity expressed across individuals with psychotic disorders. This course presents information on the symptoms of schizophrenia, when the symptoms appear, how the disease develops, current treatments, support for patients and their loved ones, and new directions in research.
Symptoms of schizophrenia What are the symptoms of schizophrenia? The symptoms of schizophrenia fall into three broad categories: ●● Positive symptoms are unusual thoughts or perceptions, including hallucinations, delusions, thought disorder, and disorders of movement. ●● Negative symptoms represent a loss or a decrease in the ability to initiate plans, speak, express emotion, or find pleasure in everyday life. These symptoms are harder to recognize as part of the disorder and can be mistaken for laziness or depression. Psychology.EliteCME.com
●● Cognitive symptoms (or cognitive deficits) are problems with attention, certain types of memory, and the executive functions that allow us to plan and organize. Cognitive deficits can also be difficult to recognize as part of the disorder but are the most disabling in terms of leading a normal life.
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Positive symptoms Positive symptoms are easy to spot behaviors not seen in healthy people and usually involve a loss of contact with reality. They include hallucinations, delusions, thought disorder and disorders of movement. Positive symptoms can come and go. Sometimes they are severe and at other times hardly noticeable, depending on whether the individual is receiving treatment.
are broadcasting their thoughts aloud to others. They may also have delusions of grandeur and think they are famous historical figures. People with paranoid schizophrenia can believe that others are deliberately cheating, harassing, poisoning, spying upon, or plotting against them or the people they care about. These beliefs are called delusions of persecution.
Hallucinations. A hallucination is something a person sees, hears, smells, or feels that no one else can see, hear, smell, or feel. “Voices” are the most common type of hallucination in schizophrenia. Many people with the disorder hear voices that may comment of their behavior, order them to do things, warn them of impending danger, or talk to each other (usually about the patient). They may hear these voices for a long time before family and friends notice that something is wrong. Other types of hallucinations include; seeing people or objects that are not there, smelling odors that no one else detects (although this can also be a symptom of certain brain tumors), and feeling things like invisible fingers touching their bodies when no one is near.
Thought disorders. People with schizophrenia often have unusual thought processes. One dramatic form is disorganized thinking, in which the person has difficulty organizing his or her thoughts or connecting them logically. Speech may be garbled or hard to understand. Another is “thought blocking,” in which the person stops abruptly in the middle of a thought. When asked why, the person may say that it felt as if the thought had been taken out of his or her head. Finally, the individual might make up unintelligible words, or “neologisms.”
Delusions. Delusions are false personal beliefs that are not part of the person’s culture and do not change, even when other people present proof that the beliefs are not true or logical. People with schizophrenia can have delusions that are quite bizarre. Such as believing that neighbors can control their behavior with magnetic waves, people on television are directing special messages to them, or radio stations
Disorders of movement. People with schizophrenia can be clumsy and uncoordinated. They may also exhibit involuntary movements and may grimace or exhibit unusual mannerisms. They may repeat certain motions over and over or, in extreme cases, may become catatonic. Catatonia is a state of immobility and unresponsiveness. It was more common when treatment for schizophrenia was not available; fortunately, it is now rare (World Health Organization, 1992).
Negative symptoms The term “negative symptoms” refers to reductions in normal emotional and behavioral states. These include the following: ●● Flat affect (immobile facial expression, monotonous voice). ●● Lack of pleasure in everyday life. ●● Diminished ability to initiate and sustain planned activity. ●● Speaking infrequently, even when forced to interact.
People with schizophrenia often neglect basic hygiene and need help with everyday activities. Because it is not as obvious that negative symptoms are part of psychiatric illness, people with schizophrenia are often perceived as lazy and unwilling to better their lives.
Cognitive symptoms Cognitive symptoms are subtle and are often detected only when neuropsychological tests are performed. They include the following: ●● Poor “executive functioning” (the ability to absorb and interpret information and make decisions based on that information). ●● Inability to sustain attention.
●● Problems with “working memory” (the ability to keep recently learned information in mind and use it right away). Cognitive impairments often interfere with the patient’s ability to lead a normal life and earn a living. They can cause great emotional distress.
Causal factors and onset When does it start and who gets it? Psychotic symptoms (such as hallucinations and delusions) usually emerge in men in their late teens and early 20’s and in women in their mid-20’s to early 30’s. They seldom occur after age 45 and only rarely before puberty, although cases of schizophrenia in children as young as 5 have been reported. In adolescents, the first signs can include a change of friends, a drop in grades, sleep problems, and irritability. Because many normal adolescents exhibit these behaviors as well, a diagnosis can be difficult to make at this stage. In young people who go on to develop the disease, this is called the “prodromal” period. Research has shown that schizophrenia affects men and women equally and occurs at similar rates in all ethnic groups around the world (Mueser & McGurk, 2004).
People with schizophrenia are not especially prone to violence and often prefer to be left alone. Studies show that if people have no record of criminal violence before they develop schizophrenia and are not substance abusers, they are unlikely to commit crimes after they become ill. Most violent crimes are not committed by people with schizophrenia and most people with schizophrenia do not commit violent crimes. Substance abuse always increases violent behavior, regardless of the presence of schizophrenia. If someone with paranoid schizophrenia becomes violent, the violence is most often directed at family members and takes place at home.
What about suicide? People with schizophrenia attempt suicide much more often than people in the general population. About 10 percent (especially young adult males) succeed (Meltzer et al, 2003). It is hard to predict which people with schizophrenia are prone to suicide, so if someone talks
about or tries to commit suicide, professional help should be sought right away.
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What about substance abuse? Some people who abuse drugs show symptoms similar to those of schizophrenia, and people with schizophrenia may be mistaken for people who are high on drugs. While most researchers do not believe that substance abuse causes schizophrenia, people who have schizophrenia abuse alcohol and/or drugs more often than the general population.
Substance abuse can reduce the effectiveness of treatment for schizophrenia. Stimulants (such as amphetamines or cocaine), PCP, and marijuana may make the symptoms of schizophrenia worse, and substance abuse also makes it more likely that patients will not follow their treatment plan.
Schizophrenia and nicotine The most common form of substance abuse in people with schizophrenia is an addiction to nicotine. People with schizophrenia are addicted to nicotine at three times the rate of the general population, which equates to 75-90 percent vs. 25-30 percent (Jones & Benowitz, 2002). Research has revealed that the relationship between smoking and schizophrenia is complex. People with schizophrenia seem to be driven to smoke, and researchers are exploring whether there is a biological basis for this need. In addition to its known health hazards, several studies have found that smoking interferes with the action of
antipsychotic drugs. People with schizophrenia who smoke may need higher doses of their medication. Quitting smoking may be especially difficult for people with schizophrenia since nicotine withdrawal may cause their psychotic symptoms to temporarily get worse. Smoking cessation strategies that include nicotine replacement methods may be better tolerated. Doctors who treat people with schizophrenia should carefully monitor their patient’s response to antipsychotic medication if the patient decides to either start or stop smoking.
What causes schizophrenia? Like many other illnesses, schizophrenia is believed to result from a combination of environmental and genetic factors. All the tools of modern science are being used to search for the causes of this disorder.
Can schizophrenia be inherited? Scientists have long known that schizophrenia runs in families. It occurs in 1 percent of the general population, but is seen in 10 percent of people with a first-degree relative (a parent, brother, or sister) with the disorder. People who have second-degree relatives (aunts, uncles, grandparents, or cousins) with the disorder also develop schizophrenia more often than the general population. The identical twin of a person with schizophrenia is most at risk, with a 40 to 65 percent chance of developing the disorder (Cardno & Gottesman, 2000). Our genes are located on 23 pairs of chromosomes that are found in each cell. We inherit two copies of each gene, one from each parent. Several of these genes are thought to be associated with an increased
risk of schizophrenia, but scientists believe that each gene has a very small effect and is not responsible for causing the disease by itself. It is still not possible to predict who will develop the disease by looking at genetic material. Although there is a genetic risk for schizophrenia, it is not likely that genes alone are sufficient to cause the disorder. Interactions between genes and the environment are thought to be necessary for schizophrenia to develop. Many environmental factors have been suggested as risk factors, such as exposure to viruses or malnutrition in the womb, problems during birth, and psychosocial factors, like stressful environmental conditions.
Schizophrenia and the brain Do people with schizophrenia have faulty brain chemistry? It is likely that an imbalance in the complex, interrelated chemical reactions of the brain involving the neurotransmitters dopamine and glutamate (and possibly others) play a role in schizophrenia.
Neurotransmitters are substances that allow brain cells to communicate with one another. Basic knowledge about brain chemistry and its link to schizophrenia is expanding rapidly and is a promising area of research.
Do the brains of people with schizophrenia look different? The brains of people with schizophrenia look a little different than the brains of healthy people, but the differences are small. Sometimes the fluid-filled cavities at the center of the brain, called ventricles, are larger in people with schizophrenia; overall gray matter volume is lower; and some areas of the brain have less or more metabolic activity. Three microscopic studies of brain tissue after death have also revealed small changes in the distribution of characteristics of brain cells in people with schizophrenia. It appears that many of these changes were prenatal because they are not accompanied by glial cells, which are always
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present when a brain injury occurs after birth. One theory suggests that problems during brain development lead to faulty connections that lie dormant until puberty. The brain undergoes major changes during puberty, and these changes could trigger psychotic symptoms. The only way to answer these questions is to conduct more research. Scientists in the United States and around the world are studying schizophrenia and trying to develop new ways to prevent and treat the disorder.
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Treatment implications How is schizophrenia treated? Because the causes of schizophrenia are still unknown, current treatments focus on eliminating the symptoms of the disease.
Antipsychotic medications Antipsychotic medications have been available since the mid 1950’s. They effectively alleviate the positive symptoms of schizophrenia. While these drugs have greatly improved the lives of many patients, they do not cure schizophrenia. Everyone responds differently to antipsychotic medication. Sometimes several different drugs must be tried before the right one is found. People with schizophrenia should work in partnership with their doctors to find the medications that control their symptoms best with the fewest side effects. The older antipsychotic medications include chlorpromazine (Thorazine), haloperidol (Haldol), perphenazine (Etrafon, Trilafon), and fluphenzine (Prolixin). The older medications can cause extrapyramidal side effects, such as rigidity, persistent muscle spasms, tremors, and restlessness. In the 1990s, new drugs, called atypical antipsychotics, were developed that rarely produced these side effects. The first of these new drugs was clozapine (Clozaril). It treats psychotic symptoms effectively even in people who do not respond to other medications, but it can produce a serious problem called agranulocytosis, a loss of the white blood cells that fight infection. Therefore, patients who take clozapine must have their white blood cell counts monitored every week or two. The inconvenience and cost of both the blood tests and the medication itself has made treatment with clozapine difficult for many people, but it is the drug of choice for those whose symptoms do not respond to the other antipsychotic medications, old or new. Some of the drugs that were developed after clozapine was introduced—such as risperidone (Risperdal), olanzapine (Zyprexa), quetiapine (Seroquel), sertindole (Serdolect), and ziprasidone (Geodon)—are effective and rarely produce extrapyramidal symptoms and do not cause agranulocytosis; but they can cause weight gain and metabolic changes associated with an increased risk of diabetes and high cholesterol (Lieberman, 2005). Aripiprazole (Abilify) is another atypical antipsychotic medication used to treat the symptoms of schizophrenia and manic or mixed (manic and depressive) episodes of bipolar I disorder. Aripiprazole is in tablet and liquid form. An injectable form is used in the treatment of symptoms of agitation in schizophrenia and manic or mixed episodes of bipolar I disorder. People respond individually to antipsychotic medication although agitation and hallucinations usually improve within days and delusions usually improve within a few weeks. Many people see substantial improvement in both types of symptoms by the sixth week of treatment. No one can tell beforehand exactly how a medication will affect a particular individual, and sometimes several medications must be tried before the right one is found. When people first start to take atypical antipsychotics, they may become drowsy, experience dizziness when they change positions, have blurred vision, develop a rapid heartbeat, menstrual problems, a sensitivity to
the sun, or skin rashes. Many of these symptoms will go away after the first days of treatment, but people who are taking atypical antipsychotics should not drive until they adjust to their new medication. If people with schizophrenia become depressed, it may be necessary to add an antidepressant to their drug regimen. A large clinical trial funded by the National Institute of Mental Health (NIMH), known as CATIE (Clinical Antipsychotic Trials of Intervention Effectiveness), compared the effectiveness and side effects of five antipsychotic medications—both new and older antipsychotics—that are used to treat people with schizophrenia. Length of treatment. Like diabetes or high blood pressure, schizophrenia is a chronic disorder that needs constant management. At the moment, it cannot be cured, but the rate of recurrence of psychotic episodes can be decreased significantly by staying on medication. Although responses vary from person to person, most people with schizophrenia need to take some type of medication for the rest of their lives, as well as use other approaches, such as supportive therapy or rehabilitation. Relapses occur most often when people with schizophrenia stop taking their antipsychotic medication because they feel better, only take it occasionally because they forget or don’t think taking it regularly is important. It is very important for people with schizophrenia to take their medication on a regular basis and for as long as their doctors recommend. If they do so, they will experience fewer psychotic symptoms. There are a variety of reasons why people with schizophrenia do not adhere to treatment. If they don’t believe they are ill, they may not think they need medication at all. If their thinking is too disorganized, they may not remember to take their medication every day. If they don’t like the side effects of one medication, they may stop taking it without trying a different medication. Substance abuse can also interfere with treatment effectiveness. Doctors should ask patients how often they take their medication and be sensitive to a patient’s request to change dosages or to try new medications to eliminate unwelcome side effects. There are many strategies to help people with schizophrenia take their drugs regularly. Some medications are available in long-acting, injectable forms, which eliminate the need to take a pill every day. Medication calendars or pillboxes labeled with the days of the week can both help patients remember to take their medications and let caregivers know whether medication has been taken. Electronic timers on clocks on watches can be programmed to beep when people need to take their pills, and pairing medication with routine daily events, like meals, can help patients adhere to dosing schedules. Medication interactions. Antipsychotic medications can produce unpleasant or dangerous side effects when taken with certain other drugs. For this reason, the doctor who prescribes the antipsychotics should be told about all medications (over-the-counter and prescription) and all vitamins, minerals, and herbal supplements the patient takes. Alcohol or other drug use should also be discussed.
Psychosocial treatment Numerous studies have found that psychosocial treatments can help patients who are already stabilized on antipsychotic medication deal with certain aspects of schizophrenia, such as difficulty with communication, motivation, self-care, work, and establishing and maintaining relationships with others. Learning and using
coping mechanisms to address these problems allows people with schizophrenia to attend school, work, and socialize. Patients who receive regular psychosocial treatment also adhere better to their medication schedule and have fewer relapses and hospitalizations. A positive relationship with a therapist or a case manager gives the
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patient a reliable source of information, sympathy, encouragement, and hope, all of which are essential for managing the disease. The therapist can help patients better understand and adjust to living with schizophrenia by educating them about the causes of the disorder, common symptoms or problems they may experience, and the importance of staying on medications. Illness management skills. People with schizophrenia can take an active role in managing their own illness. Once they learn basic facts about schizophrenia and the principles of schizophrenia treatment, they can make informed decisions about their care. If they are taught how to monitor the early warning signs of relapse and make a plan to respond to these signs, they can learn to prevent relapses. Patients can also be taught more effective coping skills to deal with persistent symptoms. Integrated treatment for co-occurring substance abuse. Substance abuse is the most common co-occurring disorder in people with schizophrenia, but ordinary substance abuse treatment programs usually do not address this population’s special needs. Integrating schizophrenia treatment programs with drug treatment programs produces better outcomes. Rehabilitation. Rehabilitation emphasizes social and vocational training to help people with schizophrenia function more effectively in their communities. Because people with schizophrenia frequently become ill during the critical career-forming years of life (ages 1835) and because the disease often interferes with normal cognitive functioning, most patients do not receive the training required for skilled work. Rehabilitation programs can include vocational counseling, job training, money management counseling, assistance in learning to use public transportation, and opportunities to practice social and workplace communication skills.
Family education. Patients with schizophrenia are often discharged from the hospital into the care of their families, so it is important that family members know as much as possible about the disease to prevent relapses. Family members should be able to use different kinds of treatment adherence programs and have an arsenal of coping strategies and problem-solving skills to manage their ill relatives effectively. Knowing where to find outpatient and family services that support people with schizophrenia and their caregivers is also valuable. Cognitive-behavioral therapy. Cognitive behavioral therapy is useful for patients with symptoms that persist even when they take medication. The cognitive therapist teaches people with schizophrenia how to test the reality of their thoughts and perceptions, how to “not listen” to their voices, and how to shake off the apathy that often immobilizes them. This treatment appears to be effective in reducing the severity of symptoms and decreasing the risk of relapses. Self-help groups. Self-help groups for people with schizophrenia and their families are becoming increasingly common. Although professional therapists are not involved, the group members are a continuing source of mutual support and comfort for each other, which is also therapeutic. People in self-help groups know that others are facing the same problems they face and no longer feel isolated by their illness or the illness of their loved one. The networking that takes place in self-help groups can also generate social action. Families working together can advocate for research and more hospital and community treatment programs, and patients acting as a group may be able to draw public attention to the discriminations many people with mental illnesses still face in today’s world. Support groups and advocacy groups are excellent resources for people with many types of mental disorders.
What is the role of the patient’s support system? Support for those with mental disorders can come from families, professional residential or day program caregivers, shelter operators, friends or roommates, professional case managers, or others in the communities or places of worship who are concerned about their welfare. There are many situations in which people with schizophrenia will need help from other people. Getting treatment. People with schizophrenia often resist treatment, believing that their delusions or hallucinations are real and psychiatric help is not required. If a crisis occurs, family and friends may need to take action to keep their loved one safe. The issue of civil rights enters into any attempt to provide treatment. Laws protecting patients from involuntary commitment have become very strict, and trying to get help for someone who is mentally ill can be frustrating. These laws vary from state to state, but, generally, when people are dangerous to themselves or others because of mental illness and refuse to seek treatment, family members or friends may have to call the police to transport them to the hospital. In the emergency room, a mental health professional will assess the patient and determine whether a voluntary or involuntary admission is needed. A person with mental illness who does not want treatment may hide strange behavior or ideas from a professional; therefore, family members and friends should ask to speak privately with the person conducting the patient’s examination and explain what has been happening at home. The professionals will then be able to question the patient and hear the patient’s distorted thinking for themselves. Professionals must personally witness bizarre behavior and hear delusional thoughts before
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they can legally recommend commitment, and family and friends can give them the information they need to do so. Caregiving. Ensuring that people with schizophrenia continue to get treatment and take their medication after they leave the hospital is also important. If patients stop taking their medication or stop going for follow-up appointments, their psychotic symptoms will return. If these symptoms become severe, they may become unable to care for their own basic needs for food, clothing, and shelter; they may neglect personal hygiene; and they may end up on the street or in jail, where they rarely receive the kind of help they need. Family and friends can also help patients set realistic goals and regain their ability to function in the world. Each step toward these goals should be small enough to be attainable, and the patient should pursue them in an atmosphere of support. People with mental illness who are pressured and criticized usually regress and their symptoms worsen. Telling them what they are doing right is the best way to help them move forward. How should you respond when someone with schizophrenia makes statements that are strange or clearly false? Because these bizarre beliefs or hallucinations are real to the patient, it will not be useful to say they are wrong or imaginary. Going along with the delusions will not be helpful, either. It is best to calmly say that you see things differently than the patient does, but that you acknowledge that everyone has the right to see things in his or her own way. Being respectful, supportive, and kind without tolerating dangerous or inappropriate behavior is the most helpful way to approach people with this disorder.
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What is the outlook for the future? The outlook for people with schizophrenia has improved over the last 30 years or so. Although there still is no cure, effective treatments have been developed, and many people with schizophrenia improve enough to lead independent, satisfying lives.
This is an interesting time in schizophrenic research. The explosion of knowledge in genetics, neuroscience, and behavioral research will enable a better understanding of the causes of the disorder, how to prevent it, and how to develop better treatments to allow those with schizophrenia to achieve their full potential.
How can a person participate in schizophrenia research? Scientists worldwide are studying schizophrenia so they will be able to develop new ways to prevent and treat the disorder. The only way it can be understood is for researchers to study the illness as it presents itself in those who suffer from it. There are many different kinds of studies. Some studies require that medication be changed; others, like genetic studies, require no change at all in medications. To receive online information about federally and privately supported schizophrenia research, visit http://clinicaltrials.gov. This site describes an extensive list of studies being conducted across the United States. The information provided should be used in conjunction with advice from a health care professional.
NIMH conducts a Schizophrenia Research Program, which is located at the National Institute of Mental Health in Bethesda, Maryland. Travel assistance and study compensation are available for some studies. A list of outpatient and inpatient studies conducted at NIMH can be found at http://patientinfo.nimh.nih.gov. In addition, NIMH staff members can speak with you and help you determine whether their current studies are suitable for you and your family member. Simply call the toll free line at 1-888-674-6464. You can also indicate your interest in research participation by sending an email to
[email protected]. All calls remain confidential.
For more information on schizophrenia For further information: National Institute of Mental Health Public Inquiries & Dissemination Branch 6001 Executive Boulevard Room 8184, MSC 9663 Bethesda, MD 20892-9663 Phone: 301-443-5413 or 1-866-615-NIMH (6464) toll-free TTY: 301-443-8431 TTY: 866-415-8051 FAX: 301-443-4279 Email:
[email protected] Web site: http://www.nimh.nih.gov
The National Library of Medicine, a service of the U.S. Library of Medicine and the National Institutes of Health, provides updated information on many health topics, including schizophrenia. It also lists mental health organizations that provide useful information. If you have Internet access, search for schizophrenia at: http://medlineplus.gov. En Espanol http://medlineplus.gov/spanish/ Information from NIMH is available in multiple formats. You can browse online, download documents in PDF, and order paper brochures through the mail. If you would like to have NIMH publications, you can order them online at www.nimh.nih.gov. If you do not have Internet access and wish to have information that supplements this publication, please contact the NIMH Information Center at the numbers listed.
References
American Psychiatric Association (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.). doi:10.1176/appi.books.9780890423349 http://dx.doi.org/10.1176/appi. books.9780890423349 American Psychiatric Association (2013). DSM-5: Diagnostic and Statistical Manual of Mental Disorders. Cardno AG, Gottesman II (2000). Twin studies of schizophrenia: from bow-and-arrow Concordances to star wars Mx and functional genomics. Ann J Med Genet. Spring; 97 (1):12-7. Jones RT & Benowitz NL. (2002). Therapeutics for Nicotine Addiction. In Davis KL, Charney D, Coyle JT & Nemeroff C (Eds), Neuropsychopharmacology: The Fifth Generation of Progress (pp1533-1544). Nashville, TN: American College of Neuropsychopharmacology. Lieberman JA, Stroup TS, McEvoy JP, Swartz MS, Rosenheck RA, Perkins DO, Keefe RS, Davis SM, Davis CE, Lebowitz BD, Severe J, Hsiao JK (2005). Clinical Antipsychotic Trials of
Intervention Effectiveness (CATIE). Effectiveness of antipsychotic drugs in patients with chronic schizophrenia. N Engl J Med. Sep 22; 353 (12):1209-23. Meltzer HY, Alphs L, Green AI, Altamura AC, Anand R, Bertoldi A, Bourgeois M, Chouinard G, Islam MZ, Kane J, Krishnan R, Lindenmayer JP, Potkin S (2003). International Suicide Prevention Trial Study Group. Clozapine treatment for suicidality in schizophrenia: International Suicide Prevention Trial (InterSePT). Arch Gen Psychiatry. Jan; 60(1):82- 91. Meltzer HY, Baldessarini RJ (2003). Reducing the risk for suicide in schizophrenia and affective disorders. J Clin Psychiatry. 2003 Sep; 64(9):1122-9. Mueser KT, McGurk SR (2004). Schizophrenia. Lancet. Jun 19; 363(9426):2063-72. World Health Organization (1992). Catatonic Schizophrenia. The ICD-10 Classification of Mental and Behavioral Disorders: Clinical descriptions and diagnostic guidelines. Geneva, Switzerland.
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UNDERSTANDING SCHIZOPHRENIA AND ITS TREATMENT IMPLICATIONS Final Examination Questions
Choose True or False for questions 31 through 40 and mark them on the answer sheet found on page 85 or complete your test online at Psychology.EliteCME.com. 31. Schizophrenia is a brain disorder that distorts the way a person thinks, acts, expresses emotions, perceives reality, and ___________. a. Learns. b. Relates to others. c. Responds to medication. d. Understands social norms. 32. An individual must have at least one of three “positive symptoms” for a reliable diagnosis of schizophrenia: delusions, hallucinations, and ______________. a. Dementia. b. Psychosis. c. Disorganized speech. d. Social phobia.
36. People with schizophrenia are addicted to ___________ at three times the rate of the general population. a. Alcohol. b. Nicotine. c. Narcotics. d. Stimulants. 37. Schizophrenia occurs in one percent of the general population, but is seen in _____ percent of people with a first-degree relative that has the disorder. a. Five. b. Ten. c. Twelve. d. Twenty-three.
33. ______________ are harder to recognize as part of the disorder and can be mistaken for laziness or depression. a. Negative symptoms. b. Positive symptoms. c. Cognitive symptoms. d. Veiled symptoms.
38. People respond individually to ______________ although agitation and hallucinations usually improve within days and delusions usually improve within a few weeks. a. Family counseling. b. Individual therapy. c. Antipsychotic medication. d. Cognitive behavioral therapy.
34. ___________ are false personal beliefs that are not part of the person’s culture and do not change, even when other people present proof that the beliefs are not true or logical. a. Hallucinations. b. Delusions. c. Thought disorders. d. Biases.
39. __________ emphasizes social and vocational training to help people with schizophrenia function more effectively in their communities. a. Rehabilitation. b. Socialization. c. Recovery. d. Restitution.
35. The ability to absorb and interpret information and make decisions based on that information is known as: a. Executive functioning. b. Working memory. c. Cognitive development. d. Neurological process.
40. The ___________ that takes place in self-help groups can also generate social action. a. Bonding. b. Attachment. c. Networking. d. Therapy.
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