“Critical Issues in Rural Practice” was the subject of the 8^th Annual Rural Behavioral Health Practice Conference on Friday, October 21.  The conference was webcast to individuals and group webcast sites across the United States.  Minnesota sites were at Mankato, Marshall, UM-Morris, St. Cloud, and Willmar.

The conference was very well received by participants, with comments such as:  “This has been an absolutely wonderful day/experience.”  “The presentations were excellent and very relevant to our practice.”  A group webcast coordinator said, “Thanks again for a great conference, and we look forward to hosting again next year!”

The fame and glory of being a mandate reporter is not all it’s cracked up to be.  The massive mess and confusion of what and how to report can be daunting, even to the established therapist.  As one author stated, many clinicians feel that; “There is no way to do no harm” (1) when facing a potential child abuse report.  Further, sometimes what is best for the child (a child abuse report) is not what is best for the parent.  In addition, since treating mental illness decreases the risk for child abuse, clinicians certainly don’t want to derail the treatment of mental illness due to the mandated reporting of child abuse.  Nevertheless, therapists are mandated reporters and must report all child abuse regardless of the ramifications. 

The major conundrums fall into one of these four categories: 

Psst! What’s the best kept secret in town?

It’s this: Any person who needs mental health counseling right away, with no appointment necessary, for free, can get services in Minneapolis and Saint Paul every weekday. Walk-In Counseling Center is the place to go for services provided by mental health professionals during walk-in clinic hours. There are no barriers to service here – no fees, no copays, no sliding scale. Clients can even remain anonymous if they wish.  

On January 1, 2016, the Disaster Response Network changed its name to Disaster Resource Network. The advisory committee as well as APA staff believe that the name more accurately reflects the breadth of the program. What follows is that announcement.

Twenty-five years ago, the Disaster Response Network of licensed, disaster-trained psychologists across the United States was created to offer onsite mental health services to Red Cross workers and victims of disaster. Over the years, psychologists have responded to more than a thousand disasters of various types. Their work is frequently featured in APA publications.

When my 18-month-old son was speaking in sentences, our part time nanny asked if she could bring him to one of her graduate classes at the U of MN Institute of Child Development.  Her professor said it was not possible for children to have such advanced language skills.  While I initially found the situation humorous, I realized it meant that child development experts knew very little about precocious kids.  I looked through graduate school textbooks and notes and did not find much information.  I knew what to expect for those on the lower end of the intellectual bell curve, with an IQ of 70 or below, and that it was not ethical for me to work with those clients without proper training. However, I knew little about what it meant to be on the high end of that curve, those with an IQ of 130 or above and yet I worked with very bright kids in my practice every day.   Hence began my quest to understand the gifted population.  That was 12 years ago and what I learned drastically changed the way I saw kids in my practice and what I do to help them.

High Intelligence is Neuroatypical. The ability to read at age three, have academic skills six years above their age level, and wrestle with existential concerns by age four is a result of unique neurological wiring.  Gifted brains have distinct brain structures-- they have double the glial cells, burn glucose more rapidly, and have faster, more efficient connections (1).  They think about things in elaborate creative ways, often looking lost in thought. The cortex thickens more rapidly with the ‘use it’ phase of developing high level circuits starting earlier and lasting longer (2).  There is also a delay in the ‘lose it’ or pruning phase that creates a lag in the development of executive functioning skills for as much as two to four years compared to average peers. Given academic success is largely dependent on ability to organize and get work turned in, this often results in underachievement and a misdiagnosis of ADHD.

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

I have both a Masters and a doctoral degree in Counseling Psychology from the University of St. Thomas.  My undergraduate degree was in French and Philosophy. I didn’t come to my love of psychology until after my undergraduate education.

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

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

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

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

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

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

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

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

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

The North Carolina Psychologist Vol 65(3), 2013 

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

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

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

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

Hang around me long enough, and you learn that I am a complete and total APA Practice Organization (APAPO) geek.  As Alan Nessman (Senior Special Counsel at the American Psychological Association) once said to me, “You drank the Kool-Aid, Robin!”  That’s right…I am a true believer in the mission of APAPO, which is “…to advance, protect and defend the professional practice of psychology.”  You read that right!  APA exists to promote the interests of psychology.  APAPO exists to promote the interests of psychologists. 

In the early years of my professional career as a psychologist, like many early career psychologists, I was very focused on building my practice at the same time that I was building a family life.  I didn't look beyond my own small world in those years.  Honestly, and somewhat humbly, I have to say that I really didn't even realize that there was so much more going on in the world of professional practice; that is how turned inward that I was in those early years.  Realizing, however, that it was important to belong to our professional associations during those years, I continued to pay annual dues to both APA and MPA.  I recall thinking that someday I would get involved in these organizations, but at the time chose to focus on what was immediately in front of me.  With hindsight, I often wish that someone would have tried to shake me up a little and help me realize that the practice of psychology goes far beyond the small business I was trying to build.  I think if someone I respected had sat me down and explained that all of what I was building really was even possible because of the political advocacy that comes from our professional associations, specifically from APAPO and MPA, I might have looked up long enough to have realized that if I could not contribute my time, I could at least contribute money towards those efforts.

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

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

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

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

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

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

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

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

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

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

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

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

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