Certification and Licensure Issues Related to the Treatment of Co-occurring Disorders.SAMHSA’S Co-Occurring Center for Excellence (COCE)
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Overview• Purpose of licensure and certification for professionals is to protect the public and ensure that practitioners have meet standards for practice.• Purpose of licensure and accreditation of programs is to ensure that they meet state regulations and/or national operating standards and also protect the public.
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Licensure and Certification of Professionals – Key Definitions• Licensure: A license is a property right of an individual and as a property right a license is backed by the laws of the State in which it is granted. (Shimberg &Roederer, 1994) “…it is illegal for a person to practice a profession without meeting standards imposed by the State.” (Schoon & Smith, 2000)
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Licensure and Certification of Professionals - Key Definitions• Certification: A process established by a private sector body that defines standards for professional practice. It may prohibit the use of a title or designation but often does not restrict someone from practicing a profession. (Schoon & Smith 2000)
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Page 5
Licensure and Certification of Professionals – Key Definitions• Difference between licensure and certification is that certification is voluntary, not overseen by a governmental body and usually does not prohibit someone from practicing• Some states use the term “certified to indicate a license-e.g. “certified independent social worker” instead of “licensed independent social worker
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Purpose of Licensure and Certification• Provides assurance that practitioners– have met standards of practice – Can perform scope of practice established for the profession– Have demonstrated knowledge and skill to practice• Provides protection from incompetent and unscrupulous professionals
--------------------------------------------------------------------------------
Page 7
Current Scopes of Practice and Core Competencies• Scopes of Practice for social workers, psychologists and psychiatrists include assessment, diagnosis, treatment of mental, emotional and behavioral disorders • The scopes of practice for psychiatrists, psychologists, social workers, mental health counselors, and marriage and family therapists also include addiction treatment • However, pre-service education for these disciplines contains little content on addictions
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Specialty Credentials• Specialty credentials in addictions exist for psychiatrists, psychologists, social workers and licensed professional counselors• Fewer than 7 percent of practitioners hold these national credentials (Harwood, et al, in press)• Some States (e.g.CT, IL, PA) have developed or are in the process of developing specialty credentials in COD but they are generally for addiction counselors
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Specialty Credentials Requirements• Mental Health Practitioners need to know the Transdisciplinary Foundations as described in the Addiction Counseling Competencies (CSAT 1998)– Understanding Addictions (models & theories; behavioral, psychological, physical health and social effects of psychoactive substances)– Treatment knowledge (continuum of care; importance of social, family and other support systems; understanding and application of research; interdisciplinary approach to treatment– Application to Practice (Understanding of diagnostic and placement criteria; understanding of variety of helping strategies– Professional Readiness (Understanding of diverse cultures; disabilities
MFT and LCSW Continuing Education Requirements --------------------------------------------------------------------------------
Page 10
Specialty Credentials• For addiction counselors providing COD treatment the domains that have been identified include:– Assessment/evaluation/diagnosis– Clinical Competence– Case Management– Pharmacology and medical issues– Systems Integration– Professional Responsibility (IAODAPCA 2002)
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Benefits and Risks Related to Specialty Credentials• Enhance competencies of practitioners in providing services to clients with COD • Integrates COD services into practice• Specialty credentials are voluntary and not required for those providing COD services• Lack of pre-service education in COD may preclude effective screening, assessment, intervention and referrals for COD clients
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Page 12
Elements of a COD Certification• Need comprehensive understanding of substance abuse & mental disorders– Remission– Recovery– Resilience• Competencies should include integrated assessment, engagement, integrated treatment planning and treatment, and long term integrated treatment methods (CSAT 2005)
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Page 13
Benefits and Risks of a COD Credential• Currently a specialty credential for COD practice exists mainly for substance abuse professionals in several states• Other disciplines have an addiction certification• Advantage of developing a national COD credential is the creation of a scope of practice and competencies specifically designed for working with COD clients• Risk is further splintering of the field and concerns that all patients would be perceived as needing COD treatment
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Page 14
Program Accreditation and Licensure• Accreditation is a voluntary performance-based process used to assess an organization or institution based on established quality and safety standards. Surveyors are carefully trained to conduct the evaluation; funders and third party payors usually require accreditation of institutions and agencies
--------------------------------------------------------------------------------
Page 15
Program Accreditation and Licensure• Licensure is a right or permission granted by the state to engage in a business, perform an act or engage in a transaction that would be unlawful with such a right or permission (Merriam-Webster 1996) • States regulate the licensing of programs & hospitals; regulations may include policies, procedures, types of staff, facility safety standards and types of care specific programs can offer
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Core Capabilities for Programs Serving COD Clients• Following services are needed:– Integrated screening and assessment– Staged interventions– Assertive Outreach– Motivational interventions– Simultaneous Interventions– Risk Reduction– Tailored mental health and substance abuse treatment– Counseling– Social Support Interventions– Longitudinal view of remission and recovery– Cultural sensitivity and competence (CSAT 2005)
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Current Issues Regarding State Licensure of Programs• COD programs need to have appropriately trained & certified/licensed staff; comprehensive services including a full array of mental health and substance abuse treatment; supportive services; and implementation of evidence-based practices• Most programs are licensed by State mental health and substance abuse agencies respectively: funding streams are separate; different data collection systems; different staffing patterns; distinct service requirements
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Page 18
Models of Licensure Standards for COD Programs • Comprehensive Continuous Integrated System of Care (CCISC) model is being implemented in several states (CSAT 2005)• CCISC integrates mental health and substance abuse systems to provide a comprehensive system of care including policies, financing, programs, clinical practices and basic clinician competencies (Minkoff 2003; CSAT 2005)
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Benefits of Licensure and Accreditation for COD Programs• Elimination of many obstacles that currently exist• Programs would be able to screen and assess for COD and some could be designated as programs to provide enhanced services• Programs that wish to specialize in COD treatment could be recognized• National accreditation would create consistent standards for programs including administrative, staffing and programmatic
--------------------------------------------------------------------------------
Page 20
Issues and Future Direction• Little research exists on whether licensed/certified clinicians have better outcomes than those not certified• Though competencies in substance abuse are being added to practice standards few curricula provide adequate education or training• Evidence-based practices for COD treatment need to be incorporated into education and training standards• State program licensure practices still make programs providing COD treatment jump through a maze of regulations• JCAHO has not yet established national standards for dual diagnosis programs
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Page 21
References• American Association for Marriage and Family Therapy Core Competency Taskforce. (2004) The MFT Core Competencies, Alexandria, VA: AAMFT• Association of Social Work Boards. Model social work practice act. www.aswb.org/Model_law.pdf• Association of State and Provincial Psychology Boards. The practice of psychology. www.asppb.org/exam/practice.asp• Center for Substance Abuse Treatment. 2005. Substance Abuse Treatment for Persons with Co- occurring Disorders. Treatment Improvement Protocol (TIP) Series 42. DHHS Publication No (SMA) 05-3992. Rockville, MD: SAMHSA
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Page 22
References• Center for Substance Abuse Treatment (1998). Addiction Counseling Competencies: The Knowledge, Skills and Attitudes of Professional Practice. Technical Assistance Publication Series No. 21. DHHS Publication No. (SMA) 98-3171. Rockville, MD: SAMHSA• Harwood, H.J., Kowalski, J., and Ameen, A. (In press). Training on substance abuse of behavioral health professionals. Falls Church, VA: The Lewin Group• Illinois Alcohol and Other Drug Abuse Professional Certification Association. (2002). Mental Illness/Substance Abuse Professional Role Delineation Study. www.iaodapca.org.• Merriwam-Webster. (1996) Merriam-Webster’s Dictionary of Law. Springfield MA: Merriam-Webster.
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References• Minkoff, K. (2003). Comprehensive, continuous, integrated system of care model description. http://www.zialogic.org/CCISC.htm.• Schoon, C.G. & Smith, I.L. (2000). The licensure and certification mission. In C.G. Schoon and I.L. Smith (Eds.) The licensure and certification mission: Legal, social and political foundations (pp1-3). New York: Professional Examination Services.• Shimberg, B. & Roederer, (1994). Questions a legislator should ask. Lexington, KY: The Council on Licensure, Enforcement and Regulation.• Substance Abuse and Mental Health Services Administration (2003).Strategies for developing treatment programs for people with co- occurring substance abuse and mental disorders.DHHS Publication No. (SMA) 03-3782. Rockville, MD: SAMHSA• Substance Abuse and Mental Health Services Administration. (2002) Report to Congress on the prevention and treatment of co-occurring substance abuse disorders and mental disorders. http://als.samshsa.gov/reports/congress2002/CoOccurringRPT.pdf.SAMHSA’S Co-Occurring Center for Excellence (COCE)
--------------------------------------------------------------------------------
Page 2
Overview• Purpose of licensure and certification for professionals is to protect the public and ensure that practitioners have meet standards for practice.• Purpose of licensure and accreditation of programs is to ensure that they meet state regulations and/or national operating standards and also protect the public.
--------------------------------------------------------------------------------
Page 3
Licensure and Certification of Professionals – Key Definitions• Licensure: A license is a property right of an individual and as a property right a license is backed by the laws of the State in which it is granted. (Shimberg &Roederer, 1994) “…it is illegal for a person to practice a profession without meeting standards imposed by the State.” (Schoon & Smith, 2000)
--------------------------------------------------------------------------------
Page 4
Licensure and Certification of Professionals - Key Definitions• Certification: A process established by a private sector body that defines standards for professional practice. It may prohibit the use of a title or designation but often does not restrict someone from practicing a profession. (Schoon & Smith 2000)
--------------------------------------------------------------------------------
Page 5
Licensure and Certification of Professionals – Key Definitions• Difference between licensure and certification is that certification is voluntary, not overseen by a governmental body and usually does not prohibit someone from practicing• Some states use the term “certified to indicate a license-e.g. “certified independent social worker” instead of “licensed independent social worker
--------------------------------------------------------------------------------
Page 6
Purpose of Licensure and Certification• Provides assurance that practitioners– have met standards of practice – Can perform scope of practice established for the profession– Have demonstrated knowledge and skill to practice• Provides protection from incompetent and unscrupulous professionals
--------------------------------------------------------------------------------
Page 7
Current Scopes of Practice and Core Competencies• Scopes of Practice for social workers, psychologists and psychiatrists include assessment, diagnosis, treatment of mental, emotional and behavioral disorders • The scopes of practice for psychiatrists, psychologists, social workers, mental health counselors, and marriage and family therapists also include addiction treatment • However, pre-service education for these disciplines contains little content on addictions
--------------------------------------------------------------------------------
Page 8
Specialty Credentials• Specialty credentials in addictions exist for psychiatrists, psychologists, social workers and licensed professional counselors• Fewer than 7 percent of practitioners hold these national credentials (Harwood, et al, in press)• Some States (e.g.CT, IL, PA) have developed or are in the process of developing specialty credentials in COD but they are generally for addiction counselors
--------------------------------------------------------------------------------
Page 9
Specialty Credentials Requirements• Mental Health Practitioners need to know the Transdisciplinary Foundations as described in the Addiction Counseling Competencies (CSAT 1998)– Understanding Addictions (models & theories; behavioral, psychological, physical health and social effects of psychoactive substances)– Treatment knowledge (continuum of care; importance of social, family and other support systems; understanding and application of research; interdisciplinary approach to treatment– Application to Practice (Understanding of diagnostic and placement criteria; understanding of variety of helping strategies– Professional Readiness (Understanding of diverse cultures; disabilities
--------------------------------------------------------------------------------
Page 10
Specialty Credentials• For addiction counselors providing COD treatment the domains that have been identified include:– Assessment/evaluation/diagnosis– Clinical Competence– Case Management– Pharmacology and medical issues– Systems Integration– Professional Responsibility (IAODAPCA 2002)
--------------------------------------------------------------------------------
Page 11
Benefits and Risks Related to Specialty Credentials• Enhance competencies of practitioners in providing services to clients with COD • Integrates COD services into practice• Specialty credentials are voluntary and not required for those providing COD services• Lack of pre-service education in COD may preclude effective screening, assessment, intervention and referrals for COD clients
--------------------------------------------------------------------------------
Page 12
Elements of a COD Certification• Need comprehensive understanding of substance abuse & mental disorders– Remission– Recovery– Resilience• Competencies should include integrated assessment, engagement, integrated treatment planning and treatment, and long term integrated treatment methods (CSAT 2005)
--------------------------------------------------------------------------------
Page 13
Benefits and Risks of a COD Credential• Currently a specialty credential for COD practice exists mainly for substance abuse professionals in several states• Other disciplines have an addiction certification• Advantage of developing a national COD credential is the creation of a scope of practice and competencies specifically designed for working with COD clients• Risk is further splintering of the field and concerns that all patients would be perceived as needing COD treatment
--------------------------------------------------------------------------------
Page 14
Program Accreditation and Licensure• Accreditation is a voluntary performance-based process used to assess an organization or institution based on established quality and safety standards. Surveyors are carefully trained to conduct the evaluation; funders and third party payors usually require accreditation of institutions and agencies
--------------------------------------------------------------------------------
Page 15
Program Accreditation and Licensure• Licensure is a right or permission granted by the state to engage in a business, perform an act or engage in a transaction that would be unlawful with such a right or permission (Merriam-Webster 1996) • States regulate the licensing of programs & hospitals; regulations may include policies, procedures, types of staff, facility safety standards and types of care specific programs can offer
--------------------------------------------------------------------------------
Page 16
Core Capabilities for Programs Serving COD Clients• Following services are needed:– Integrated screening and assessment– Staged interventions– Assertive Outreach– Motivational interventions– Simultaneous Interventions– Risk Reduction– Tailored mental health and substance abuse treatment– Counseling– Social Support Interventions– Longitudinal view of remission and recovery– Cultural sensitivity and competence (CSAT 2005)
--------------------------------------------------------------------------------
Page 17
Current Issues Regarding State Licensure of Programs• COD programs need to have appropriately trained & certified/licensed staff; comprehensive services including a full array of mental health and substance abuse treatment; supportive services; and implementation of evidence-based practices• Most programs are licensed by State mental health and substance abuse agencies respectively: funding streams are separate; different data collection systems; different staffing patterns; distinct service requirements
--------------------------------------------------------------------------------
Page 18
Models of Licensure Standards for COD Programs • Comprehensive Continuous Integrated System of Care (CCISC) model is being implemented in several states (CSAT 2005)• CCISC integrates mental health and substance abuse systems to provide a comprehensive system of care including policies, financing, programs, clinical practices and basic clinician competencies (Minkoff 2003; CSAT 2005)
--------------------------------------------------------------------------------
Page 19
Benefits of Licensure and Accreditation for COD Programs• Elimination of many obstacles that currently exist• Programs would be able to screen and assess for COD and some could be designated as programs to provide enhanced services• Programs that wish to specialize in COD treatment could be recognized• National accreditation would create consistent standards for programs including administrative, staffing and programmatic
--------------------------------------------------------------------------------
Page 20
Issues and Future Direction• Little research exists on whether licensed/certified clinicians have better outcomes than those not certified• Though competencies in substance abuse are being added to practice standards few curricula provide adequate education or training• Evidence-based practices for COD treatment need to be incorporated into education and training standards• State program licensure practices still make programs providing COD treatment jump through a maze of regulations• JCAHO has not yet established national standards for dual diagnosis programs
--------------------------------------------------------------------------------
Page 21
References• American Association for Marriage and Family Therapy Core Competency Taskforce. (2004) The MFT Core Competencies, Alexandria, VA: AAMFT• Association of Social Work Boards. Model social work practice act. www.aswb.org/Model_law.pdf• Association of State and Provincial Psychology Boards. The practice of psychology. www.asppb.org/exam/practice.asp• Center for Substance Abuse Treatment. 2005. Substance Abuse Treatment for Persons with Co- occurring Disorders. Treatment Improvement Protocol (TIP) Series 42. DHHS Publication No (SMA) 05-3992. Rockville, MD: SAMHSA
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Page 22
References• Center for Substance Abuse Treatment (1998). Addiction Counseling Competencies: The Knowledge, Skills and Attitudes of Professional Practice. Technical Assistance Publication Series No. 21. DHHS Publication No. (SMA) 98-3171. Rockville, MD: SAMHSA• Harwood, H.J., Kowalski, J., and Ameen, A. (In press). Training on substance abuse of behavioral health professionals. Falls Church, VA: The Lewin Group• Illinois Alcohol and Other Drug Abuse Professional Certification Association. (2002). Mental Illness/Substance Abuse Professional Role Delineation Study. www.iaodapca.org.• Merriwam-Webster. (1996) Merriam-Webster’s Dictionary of Law. Springfield MA: Merriam-Webster.
--------------------------------------------------------------------------------
Page 23
References• Minkoff, K. (2003). Comprehensive, continuous, integrated system of care model description. http://www.zialogic.org/CCISC.htm.• Schoon, C.G. & Smith, I.L. (2000). The licensure and certification mission. In C.G. Schoon and I.L. Smith (Eds.) The licensure and certification mission: Legal, social and political foundations (pp1-3). New York: Professional Examination Services.• Shimberg, B. & Roederer, (1994). Questions a legislator should ask. Lexington, KY: The Council on Licensure, Enforcement and Regulation.• Substance Abuse and Mental Health Services Administration (2003).Strategies for developing treatment programs for people with co- occurring substance abuse and mental disorders.DHHS Publication No. (SMA) 03-3782. Rockville, MD: SAMHSA• Substance Abuse and Mental Health Services Administration. (2002) Report to Congress on the prevention and treatment of co-occurring substance abuse disorders and mental disorders. http://als.samshsa.gov/reports/congress2002/CoOccurringRPT.pdf.
Showing posts with label continuing education lcsw. Show all posts
Showing posts with label continuing education lcsw. Show all posts
November 10, 2010
November 08, 2010
Older Adults and Mental Health CEUs
Older Adults and Mental Health CEU Continuing Education--------------------------------------------------------------------------------
The past century has witnessed a remarkable lengthening of the average life span in the United States, from 47 years in 1900 to more than 75 years in the mid-1990s (National Center for Health Statistics [NCHS], 1993). Equally noteworthy has been the increase in the number of persons ages 85 and older (Figure 5-1). These trends will continue well into the next century and be magnified as the numbers of older Americans increase with the aging of the post–World War II baby boom generation.
Millions of older Americans—indeed, the majority—cope constructively with the physical limitations, cognitive changes, and various losses, such as bereavement, that frequently are associated with late life. Research has contributed immensely to our understanding of developmental processes that continue to unfold as we age. Drawing on new scientific information and acting on clinical common sense, mental health and general health care providers are increasingly able to suggest mental health strategies and skills that older adults can hone to make this stage of the life span satisfying and rewarding.
The capacity for sound mental health among older adults notwithstanding, a substantial proportion of the population 55 and older—almost 20 percent of this age group—experience specific mental disorders that are not part of “normal” aging (see Table 5-1). Research that has helped differentiate mental disorders from “normal” aging has been one of the more important achievements of recent decades in the field of geriatric health. Unrecognized or untreated, however, depression, Alzheimer’s disease, alcohol and drug misuse and abuse, anxiety, late-life schizophrenia, and other conditions can be severely impairing, even fatal; in the United States, the rate of suicide, which is frequently a consequence of depression, is highest among older adults relative to all other age groups (Hoyert et al., 1999).
Figure 5-1. Increases in the percent of the U.S. Population over age 65 years and over 85 years (Malmgren, 1994).
Click to enlarge
Table 5-1. Best estimate 1-year prevalence rates based on Epidemiologic Catchment Area, age 55+
Prevalence (%)
Any Anxiety Disorder 11.4
Simple Phobia 7.3
Social Phobia 1.0
Agoraphobia 4.1
Panic Disorder 0.5
Obsessive-Compulsive Disorder 1.5
Any Mood Disorder 4.4
Major Depressive Episode 3.8
Unipolar Major Depression 3.7
Dysthymia 1.6
Bipolar I 0.2
Bipolar II 0.1
Schizophrenia 0.6
Somatization 0.3
Antisocial Personality Disorder 0.0
Anorexia Nervosa 0.0
Severe Cognitive Impairment 6.6
Any Disorder 19.8
Source: D. Regier & W. Narrow, personal communication, 1999.
The clinical challenges such conditions present may be exacerbated, moreover, by the manner in which they both affect and are affected by general medical conditions or by changes in cognitive capacities. Another complicating factor is that many older people, disabled by or at risk for mental disorders, find it difficult to afford and obtain needed medical and related health care services. Late-life mental disorders also can pose difficulties for the burgeoning numbers of family members who assist in caretaking tasks for their loved ones (Light & Lebowitz, 1991).
Chapter Overview
Fortunately, the past 15 to 20 years have been marked by rapid growth in the number of clinical, research, and training centers dedicated to the mental illness- and mental health-related needs of older people. As evident in this chapter, much has been learned. The chapter reviews, first, normal developmental milestones of aging, highlighting the adaptive capacities that enable many older people to change, cope with loss, and pursue productive and fulfilling activities. The chapter then considers mental disorders in older people—their diagnosis and treatment, and the various risk factors that may complicate the course or outcome of treatment. Risk factors include co-occurring, or comorbid, general medical conditions, the high numbers of medications many older individuals take, and psychosocial stressors such as bereavement or isolation. These are cause for concern, but, as the chapter notes, they also point the way to possible new preventive interventions. The goal of such prevention strategies may be to limit disability or to postpone or even eliminate the need to institutionalize an ill person (Lebowitz & Pearson, in press). The chapter reviews gains that have been realized in making appropriate mental health services available to older people and the challenges associated with the delivery of services to this population. The advantages of a decisive shift away from mental hospitals and nursing homes to treatment in community-based settings today are in jeopardy of being undermined by fragmentation and insufficient availability of such services (Gatz & Smyer, 1992; Cohen & Cairl, 1996). The chapter examines obstacles and opportunities in the service delivery sphere, in part through the lens of public and private sector financing policies and managed care.
Finally, the chapter reviews the supports for older persons that extend beyond traditional, formal treatment settings. Through support networks, self-help groups, and other means, consumers, families, and communities are assuming an increasingly important role in treating and preventing mental health problems and disorders among older persons.
Normal Life-Cycle Tasks
With improved diet, physical fitness, public health, and health care, more adults are reaching age 65 in better physical and mental health than in the past. Trends show that the prevalence of chronic disability among older people is declining: from 1982 to 1994, the prevalence of chronic disability diminished significantly, from 24.9 to 21.3 percent of the older population (Manton et al., 1997). While some disability is the result of more general losses of physiological functions with aging (i.e., normal aging), extreme disability in older persons, including that which stems from mental disorders, is not an inevitable part of aging (Cohen, 1988; Rowe & Kahn, 1997).
Normal aging is a gradual process that ushers in some physical decline, such as decreased sensory abilities (e.g., vision and hearing) and decreased pulmonary and immune function (Miller, 1996; Carman, 1997). With aging come certain changes in mental functioning, but very few of these changes match commonly held negative stereotypes about aging (Cohen, 1988; Rowe & Kahn, 1997). In normal aging, important aspects of mental health include stable intellectual functioning, capacity for change, and productive engagement with life.
Cognitive Capacity With Aging
Cognition subsumes intelligence, language, learning, and memory. With advancing years, cognitive capacity with aging undergoes some loss, yet important functions are spared. Moreover, there is much variability between individuals, variability that is dependent upon lifestyle and psychosocial factors (Gottlieb, 1995). Most important, accumulating evidence from human and animal research finds that lifestyle modifies genetic risk in influencing the outcomes of aging (Finch & Tanzi, 1997). This line of research is beginning to dispel the pejorative stereotypes of older people as rigidly shaped by heredity and incapable of broadening their pursuits and acquiring new skills.
A large body of research, including both cross-sectional studies and longitudinal studies, has investigated changes in cognitive function with aging. Studies have found that working memory declines with aging, as does long-term memory (Siegler et al., 1996), with decrements more apparent in recall than in recognition capacities. Slowing or some loss of other cognitive functions takes place, most notably in information processing, selective attention, and problem-solving ability, yet findings are variable (Siegler et al., 1996). These cognitive changes translate into a slower pace of learning and greater need for repetition of new information. Vocabulary increases slightly until the mid-70s, after which it declines (Carman, 1997). In older people whose IQ declines, somatic illness is implicated in some cases (Cohen, 1988). Fluid intelligence, a form of intelligence defined as the ability to solve novel problems, declines over time, yet research finds that fluid intelligence can be enhanced through training in cognitive skills and problem-solving strategies (Baltes et al., 1989).
Memory complaints are exceedingly common in older people, with 50 to 80 percent reporting subjective memory complaints (cited in Levy-Cushman & Abeles, in press). However, subjective memory complaints do not correspond with actual performance. In fact, some who complain about memory display performance superior to those who do not complain (Collins & Abeles, 1996). Memory complaints in older people, according to several studies, are thought to be more a product of depression than of decline in memory performance (cited in Levy-Cushman & Abeles, in press). (The importance of proper diagnosis and treatment of depression is emphasized in subsequent sections of this chapter.) Studies attempting to treat memory complaints associated with normal aging—using either pharmacological or psychosocial means—have been, with few exceptions, unsuccessful (Crook, 1993). In one of these exceptions, a recent study demonstrated a significant reduction in memory complaints with training workshops for healthy older people. The workshops stressed not only memory promotion strategies, but also ways of dealing with expectations and perceptions about memory loss (Levy-Cushman & Abeles, in press).
One large, ongoing longitudinal study found high cognitive performance to be dependent on four factors, ranked here in decreasing order of importance: education, strenuous activity in the home, peak pulmonary flow rate, and “self-efficacy,” which is a personality measure defined by the ability to organize and execute actions required to deal with situations likely to happen in the future (Albert et al., 1995). Education, as assessed by years of schooling, is the strongest predictor of high cognitive functioning. This finding suggests that education not only has salutary effects on brain function earlier in life, but also foreshadows sustained productive behavior in later life, such as reading and performing crossword puzzles (Rowe & Kahn, 1997).
The coexistence of mental and somatic disorders (i.e., comorbidity) is common (Kramer et al., 1992). Some disorders with primarily somatic symptoms can cause cognitive, emotional, and behavioral symptoms as well, some of which rise to the level of mental disorders. At that point, the mental disorder may result from an effect of the underlying disorder on the central nervous system (e.g., dementia due to a medical condition such as hypothyroidism) or an effect of treatment (e.g., delirium due to a prescribed medication). Likewise, mental problems or disorders can lead to or exacerbate other physical conditions by decreasing the ability of older adults to care for themselves, by impairing their capacity to rally social support, or by impairing physiological functions. For example, stress increases the risk of coronary heart disease and can suppress cellular immunity (McEwen, 1998). Depression can lead to increased mortality from heart disease and possibly cancer (Frasure-Smith et al., 1993, 1995; Penninx et al., 1998).
A new model postulates that successful aging is contingent upon three elements: avoiding disease and disability, sustaining high cognitive and physical function, and engaging with life (Rowe & Kahn, 1997). The latter encompasses the maintenance of interpersonal relationships and productive activities, as defined by paid or unpaid activities that generate goods or services of economic value. The three major elements are considered to act in concert, for none is deemed sufficient by itself for successful aging. This new model broadens the reach of health promotion in aging to entail more than just disease prevention.
Change, Human Potential, and Creativity
Descriptive research reveals evidence of the capacity for constructive change in later life (Cohen, 1988). The capacity to change can occur even in the face of mental illness, adversity, and chronic mental health problems. Older persons display flexibility in behavior and attitudes and the ability to grow intellectually and emotionally. Time plays a key role. Externally imposed demands upon one’s time may diminish, and the amount of time left at this stage in life can be significant. In the United States in the late 20th century, late-life expectancy approaches another 20 years at the age of 65. In other words, average longevity from age 65 today approaches what had been the average longevity from birth some 2,000 years ago. This leaves plenty of time to embark upon new social, psychological, educational, and recreational pathways, as long as the individual retains good health and material resources.
In his classic developmental model, Erik Erikson characterized the final stage of human development as a tension between “ego integrity and despair” (Erikson, 1950). Erikson saw the period beginning at age 65 years as highly variable. Ideally, individuals at this stage witness the flowering of seeds planted earlier in the prior seven stages of development. When they achieve a sense of integrity in life, they garner pride from their children, students and protégés, and past accomplishments. With contentment comes a greater tolerance and acceptance of the decline that naturally accompanies the aging process. Failure to achieve a satisfying degree of ego integrity can be accompanied by despair.
Cohen (in press) has proposed that with increased longevity and health, particularly for people with adequate resources, aging is characterized by two human potential phases. These phases, which emphasize the positive aspects of the final stages of the life cycle, are termed Retirement/Liberation and Summing Up/Swan Song.
Retirement often is viewed as the most important life event prior to death. Retirement frequently is associated with negative myths and stereotypes (Sheldon et al., 1975; Bass, 1995). Cohen points out, however, that most people fare well in retirement. They have the opportunity to explore new interests, activities, and relationships due to retirement’s liberating qualities. In the Retirement/Liberation phase, new feelings of freedom, courage, and confidence are experienced. Those at risk for faring poorly are individuals who typically do not want to retire, who are compelled to retire because of poor health, or who experience a significant decline in their standard of living (Cohen, 1988). In short, the liberating experience of having more time and an increased sense of freedom can be the springboard for creativity in later life. Creative achievement by older people can change the course of an individual, family, community, or culture.
In the late-life Summing Up/Swan Song phase, there is a tendency to appraise one’s life work, ideas, and discoveries and to share them with family or society. The desire to sum up late in life is driven by varied feelings, such as the desire to complete one’s life work, the desire to give back after receiving much in life, or the fear of time evaporating. Important opportunities for creative sharing and expression ensue. There is a natural tendency with aging to reminisce and elaborate stories that has propelled the development of reminiscence therapy for health promotion and disease prevention. The swan song, the final part of this phase, connotes the last act or final creative work of a person before retirement or death.
There is much misunderstanding about thoughts of death in later life. Depression, serious loss, and terminal illness trigger the sense of mortality, regardless of age. Contrary to popular stereotypes, studies on aging reveal that most older people generally do not have a fear or dread of death in the absence of being depressed, encountering serious loss, or having been recently diagnosed with a terminal illness (Kastenbaum, 1985). Periodic thoughts of death—not in the form of dread or angst—do occur. But these are usually associated with the death of a friend or family member. When actual dread of death does occur, it should not be dismissed as accompanying aging, but rather as a signal of underlying distress (e.g., depression). This is particularly important in light of the high risk of suicide among depressed older adults, which is discussed later in this chapter.
Coping With Loss and Bereavement
Many older adults experience loss with aging—loss of social status and self-esteem, loss of physical capacities, and death of friends and loved ones. But in the face of loss, many older people have the capacity to develop new adaptive strategies, even creative expression (Cohen, 1988, 1990). Those experiencing loss may be able to move in a positive direction, either on their own, with the benefit of informal support from family and friends, or with formal support from mental health professionals.
The life and work of William Carlos Williams are illustrative. Williams was a great poet as well as a respected physician. In his 60s, he suffered a stroke that prevented him from practicing medicine. The stroke did not affect his intellectual abilities, but he became so severely depressed that he needed psychiatric hospitalization. Nonetheless, Williams, with the help of treatment for a year, surmounted the depression and for the next 10 years wrote luminous poetry, including the Pulitzer Prize-winning Pictures From Bruegel, which was published when he was 79. In his later life, Williams wrote about “old age that adds as it takes away.” What Williams and his poetry epitomize is that age can be the catalyst for tapping into creative potential (Cohen, 1998a).
Loss of a spouse is common in late life. About 800,000 older Americans are widowed each year. Bereavement is a natural response to death of a loved one. Its features, almost universally recognized, include crying and sorrow, anxiety and agitation, insomnia, and loss of appetite (Institute of Medicine [IOM], 1984). This constellation of symptoms, while overlapping somewhat with major depression, does not by itself constitute a mental disorder. Only when symptoms persist for 2 months and longer after the loss does the DSM-IV permit a diagnosis of either adjustment disorder or major depressive disorder. Even though bereavement of less than 2 months’ duration is not considered a mental disorder, it still warrants clinical attention (DSM-IV). The justification for clinical attention is that bereavement, as a highly stressful event, increases the probability of, and may cause or exacerbate, mental and somatic disorders.
Bereavement is an important and well-established risk factor for depression. At least 10 to 20 percent of widows and widowers develop clinically significant depression during the first year of bereavement. Without treatment, such depressions tend to persist, become chronic, and lead to further disability and impairments in general health, including alterations in endocrine and immune function (Zisook & Shuchter, 1993; Zisook et al., 1994). Several preventive interventions, including participation in self-help groups, have been shown to prevent depression among widows and widowers, although one study suggested that self-help groups can exacerbate depressive symptoms in certain individuals (Levy et al., 1993). These are described later in this chapter.
Bereavement-associated depression often coexists with another type of emotional distress, which has been termed traumatic grief (Prigerson et al., in press). The symptoms of traumatic grief, although not formalized as a mental disorder in DSM-IV, appear to be a mixture of symptoms of both pathological grief and post-traumatic stress disorder (Frank et al., 1997a). Such symptoms are extremely disabling, associated with functional and health impairment and with persistent suicidal thoughts, and may well respond to pharmacotherapy (Zygmont et al., 1998). Increased illness and mortality from suicide are the most serious consequences of late-life depression.
The dynamics around loss in later life need greater clarification. One pivotal question is why some, in confronting loss with aging, succumb to depression and suicide—which, as noted earlier, has its highest frequency after age 65—while others respond with new adaptive strategies. Research on health promotion also needs to identify ways to prevent adverse reactions and to promote positive responses to loss in later life. Meanwhile, despite cultural attitudes that older persons can handle bereavement by themselves or with support from family and friends, it is imperative that those who are unable to cope be encouraged to access mental health services. Bereavement is not a mental disorder but, if unattended to, has serious mental health and other health consequences.
The past century has witnessed a remarkable lengthening of the average life span in the United States, from 47 years in 1900 to more than 75 years in the mid-1990s (National Center for Health Statistics [NCHS], 1993). Equally noteworthy has been the increase in the number of persons ages 85 and older (Figure 5-1). These trends will continue well into the next century and be magnified as the numbers of older Americans increase with the aging of the post–World War II baby boom generation.
Millions of older Americans—indeed, the majority—cope constructively with the physical limitations, cognitive changes, and various losses, such as bereavement, that frequently are associated with late life. Research has contributed immensely to our understanding of developmental processes that continue to unfold as we age. Drawing on new scientific information and acting on clinical common sense, mental health and general health care providers are increasingly able to suggest mental health strategies and skills that older adults can hone to make this stage of the life span satisfying and rewarding.
The capacity for sound mental health among older adults notwithstanding, a substantial proportion of the population 55 and older—almost 20 percent of this age group—experience specific mental disorders that are not part of “normal” aging (see Table 5-1). Research that has helped differentiate mental disorders from “normal” aging has been one of the more important achievements of recent decades in the field of geriatric health. Unrecognized or untreated, however, depression, Alzheimer’s disease, alcohol and drug misuse and abuse, anxiety, late-life schizophrenia, and other conditions can be severely impairing, even fatal; in the United States, the rate of suicide, which is frequently a consequence of depression, is highest among older adults relative to all other age groups (Hoyert et al., 1999).
Figure 5-1. Increases in the percent of the U.S. Population over age 65 years and over 85 years (Malmgren, 1994).
Click to enlarge
Table 5-1. Best estimate 1-year prevalence rates based on Epidemiologic Catchment Area, age 55+
Prevalence (%)
Any Anxiety Disorder 11.4
Simple Phobia 7.3
Social Phobia 1.0
Agoraphobia 4.1
Panic Disorder 0.5
Obsessive-Compulsive Disorder 1.5
Any Mood Disorder 4.4
Major Depressive Episode 3.8
Unipolar Major Depression 3.7
Dysthymia 1.6
Bipolar I 0.2
Bipolar II 0.1
Schizophrenia 0.6
Somatization 0.3
Antisocial Personality Disorder 0.0
Anorexia Nervosa 0.0
Severe Cognitive Impairment 6.6
Any Disorder 19.8
Source: D. Regier & W. Narrow, personal communication, 1999.
The clinical challenges such conditions present may be exacerbated, moreover, by the manner in which they both affect and are affected by general medical conditions or by changes in cognitive capacities. Another complicating factor is that many older people, disabled by or at risk for mental disorders, find it difficult to afford and obtain needed medical and related health care services. Late-life mental disorders also can pose difficulties for the burgeoning numbers of family members who assist in caretaking tasks for their loved ones (Light & Lebowitz, 1991).
Chapter Overview
Fortunately, the past 15 to 20 years have been marked by rapid growth in the number of clinical, research, and training centers dedicated to the mental illness- and mental health-related needs of older people. As evident in this chapter, much has been learned. The chapter reviews, first, normal developmental milestones of aging, highlighting the adaptive capacities that enable many older people to change, cope with loss, and pursue productive and fulfilling activities. The chapter then considers mental disorders in older people—their diagnosis and treatment, and the various risk factors that may complicate the course or outcome of treatment. Risk factors include co-occurring, or comorbid, general medical conditions, the high numbers of medications many older individuals take, and psychosocial stressors such as bereavement or isolation. These are cause for concern, but, as the chapter notes, they also point the way to possible new preventive interventions. The goal of such prevention strategies may be to limit disability or to postpone or even eliminate the need to institutionalize an ill person (Lebowitz & Pearson, in press). The chapter reviews gains that have been realized in making appropriate mental health services available to older people and the challenges associated with the delivery of services to this population. The advantages of a decisive shift away from mental hospitals and nursing homes to treatment in community-based settings today are in jeopardy of being undermined by fragmentation and insufficient availability of such services (Gatz & Smyer, 1992; Cohen & Cairl, 1996). The chapter examines obstacles and opportunities in the service delivery sphere, in part through the lens of public and private sector financing policies and managed care.
Finally, the chapter reviews the supports for older persons that extend beyond traditional, formal treatment settings. Through support networks, self-help groups, and other means, consumers, families, and communities are assuming an increasingly important role in treating and preventing mental health problems and disorders among older persons.
Normal Life-Cycle Tasks
With improved diet, physical fitness, public health, and health care, more adults are reaching age 65 in better physical and mental health than in the past. Trends show that the prevalence of chronic disability among older people is declining: from 1982 to 1994, the prevalence of chronic disability diminished significantly, from 24.9 to 21.3 percent of the older population (Manton et al., 1997). While some disability is the result of more general losses of physiological functions with aging (i.e., normal aging), extreme disability in older persons, including that which stems from mental disorders, is not an inevitable part of aging (Cohen, 1988; Rowe & Kahn, 1997).
Normal aging is a gradual process that ushers in some physical decline, such as decreased sensory abilities (e.g., vision and hearing) and decreased pulmonary and immune function (Miller, 1996; Carman, 1997). With aging come certain changes in mental functioning, but very few of these changes match commonly held negative stereotypes about aging (Cohen, 1988; Rowe & Kahn, 1997). In normal aging, important aspects of mental health include stable intellectual functioning, capacity for change, and productive engagement with life.
Cognitive Capacity With Aging
Cognition subsumes intelligence, language, learning, and memory. With advancing years, cognitive capacity with aging undergoes some loss, yet important functions are spared. Moreover, there is much variability between individuals, variability that is dependent upon lifestyle and psychosocial factors (Gottlieb, 1995). Most important, accumulating evidence from human and animal research finds that lifestyle modifies genetic risk in influencing the outcomes of aging (Finch & Tanzi, 1997). This line of research is beginning to dispel the pejorative stereotypes of older people as rigidly shaped by heredity and incapable of broadening their pursuits and acquiring new skills.
A large body of research, including both cross-sectional studies and longitudinal studies, has investigated changes in cognitive function with aging. Studies have found that working memory declines with aging, as does long-term memory (Siegler et al., 1996), with decrements more apparent in recall than in recognition capacities. Slowing or some loss of other cognitive functions takes place, most notably in information processing, selective attention, and problem-solving ability, yet findings are variable (Siegler et al., 1996). These cognitive changes translate into a slower pace of learning and greater need for repetition of new information. Vocabulary increases slightly until the mid-70s, after which it declines (Carman, 1997). In older people whose IQ declines, somatic illness is implicated in some cases (Cohen, 1988). Fluid intelligence, a form of intelligence defined as the ability to solve novel problems, declines over time, yet research finds that fluid intelligence can be enhanced through training in cognitive skills and problem-solving strategies (Baltes et al., 1989).
Memory complaints are exceedingly common in older people, with 50 to 80 percent reporting subjective memory complaints (cited in Levy-Cushman & Abeles, in press). However, subjective memory complaints do not correspond with actual performance. In fact, some who complain about memory display performance superior to those who do not complain (Collins & Abeles, 1996). Memory complaints in older people, according to several studies, are thought to be more a product of depression than of decline in memory performance (cited in Levy-Cushman & Abeles, in press). (The importance of proper diagnosis and treatment of depression is emphasized in subsequent sections of this chapter.) Studies attempting to treat memory complaints associated with normal aging—using either pharmacological or psychosocial means—have been, with few exceptions, unsuccessful (Crook, 1993). In one of these exceptions, a recent study demonstrated a significant reduction in memory complaints with training workshops for healthy older people. The workshops stressed not only memory promotion strategies, but also ways of dealing with expectations and perceptions about memory loss (Levy-Cushman & Abeles, in press).
One large, ongoing longitudinal study found high cognitive performance to be dependent on four factors, ranked here in decreasing order of importance: education, strenuous activity in the home, peak pulmonary flow rate, and “self-efficacy,” which is a personality measure defined by the ability to organize and execute actions required to deal with situations likely to happen in the future (Albert et al., 1995). Education, as assessed by years of schooling, is the strongest predictor of high cognitive functioning. This finding suggests that education not only has salutary effects on brain function earlier in life, but also foreshadows sustained productive behavior in later life, such as reading and performing crossword puzzles (Rowe & Kahn, 1997).
The coexistence of mental and somatic disorders (i.e., comorbidity) is common (Kramer et al., 1992). Some disorders with primarily somatic symptoms can cause cognitive, emotional, and behavioral symptoms as well, some of which rise to the level of mental disorders. At that point, the mental disorder may result from an effect of the underlying disorder on the central nervous system (e.g., dementia due to a medical condition such as hypothyroidism) or an effect of treatment (e.g., delirium due to a prescribed medication). Likewise, mental problems or disorders can lead to or exacerbate other physical conditions by decreasing the ability of older adults to care for themselves, by impairing their capacity to rally social support, or by impairing physiological functions. For example, stress increases the risk of coronary heart disease and can suppress cellular immunity (McEwen, 1998). Depression can lead to increased mortality from heart disease and possibly cancer (Frasure-Smith et al., 1993, 1995; Penninx et al., 1998).
A new model postulates that successful aging is contingent upon three elements: avoiding disease and disability, sustaining high cognitive and physical function, and engaging with life (Rowe & Kahn, 1997). The latter encompasses the maintenance of interpersonal relationships and productive activities, as defined by paid or unpaid activities that generate goods or services of economic value. The three major elements are considered to act in concert, for none is deemed sufficient by itself for successful aging. This new model broadens the reach of health promotion in aging to entail more than just disease prevention.
Change, Human Potential, and Creativity
Descriptive research reveals evidence of the capacity for constructive change in later life (Cohen, 1988). The capacity to change can occur even in the face of mental illness, adversity, and chronic mental health problems. Older persons display flexibility in behavior and attitudes and the ability to grow intellectually and emotionally. Time plays a key role. Externally imposed demands upon one’s time may diminish, and the amount of time left at this stage in life can be significant. In the United States in the late 20th century, late-life expectancy approaches another 20 years at the age of 65. In other words, average longevity from age 65 today approaches what had been the average longevity from birth some 2,000 years ago. This leaves plenty of time to embark upon new social, psychological, educational, and recreational pathways, as long as the individual retains good health and material resources.
In his classic developmental model, Erik Erikson characterized the final stage of human development as a tension between “ego integrity and despair” (Erikson, 1950). Erikson saw the period beginning at age 65 years as highly variable. Ideally, individuals at this stage witness the flowering of seeds planted earlier in the prior seven stages of development. When they achieve a sense of integrity in life, they garner pride from their children, students and protégés, and past accomplishments. With contentment comes a greater tolerance and acceptance of the decline that naturally accompanies the aging process. Failure to achieve a satisfying degree of ego integrity can be accompanied by despair.
Cohen (in press) has proposed that with increased longevity and health, particularly for people with adequate resources, aging is characterized by two human potential phases. These phases, which emphasize the positive aspects of the final stages of the life cycle, are termed Retirement/Liberation and Summing Up/Swan Song.
Retirement often is viewed as the most important life event prior to death. Retirement frequently is associated with negative myths and stereotypes (Sheldon et al., 1975; Bass, 1995). Cohen points out, however, that most people fare well in retirement. They have the opportunity to explore new interests, activities, and relationships due to retirement’s liberating qualities. In the Retirement/Liberation phase, new feelings of freedom, courage, and confidence are experienced. Those at risk for faring poorly are individuals who typically do not want to retire, who are compelled to retire because of poor health, or who experience a significant decline in their standard of living (Cohen, 1988). In short, the liberating experience of having more time and an increased sense of freedom can be the springboard for creativity in later life. Creative achievement by older people can change the course of an individual, family, community, or culture.
In the late-life Summing Up/Swan Song phase, there is a tendency to appraise one’s life work, ideas, and discoveries and to share them with family or society. The desire to sum up late in life is driven by varied feelings, such as the desire to complete one’s life work, the desire to give back after receiving much in life, or the fear of time evaporating. Important opportunities for creative sharing and expression ensue. There is a natural tendency with aging to reminisce and elaborate stories that has propelled the development of reminiscence therapy for health promotion and disease prevention. The swan song, the final part of this phase, connotes the last act or final creative work of a person before retirement or death.
There is much misunderstanding about thoughts of death in later life. Depression, serious loss, and terminal illness trigger the sense of mortality, regardless of age. Contrary to popular stereotypes, studies on aging reveal that most older people generally do not have a fear or dread of death in the absence of being depressed, encountering serious loss, or having been recently diagnosed with a terminal illness (Kastenbaum, 1985). Periodic thoughts of death—not in the form of dread or angst—do occur. But these are usually associated with the death of a friend or family member. When actual dread of death does occur, it should not be dismissed as accompanying aging, but rather as a signal of underlying distress (e.g., depression). This is particularly important in light of the high risk of suicide among depressed older adults, which is discussed later in this chapter.
Coping With Loss and Bereavement
Many older adults experience loss with aging—loss of social status and self-esteem, loss of physical capacities, and death of friends and loved ones. But in the face of loss, many older people have the capacity to develop new adaptive strategies, even creative expression (Cohen, 1988, 1990). Those experiencing loss may be able to move in a positive direction, either on their own, with the benefit of informal support from family and friends, or with formal support from mental health professionals.
The life and work of William Carlos Williams are illustrative. Williams was a great poet as well as a respected physician. In his 60s, he suffered a stroke that prevented him from practicing medicine. The stroke did not affect his intellectual abilities, but he became so severely depressed that he needed psychiatric hospitalization. Nonetheless, Williams, with the help of treatment for a year, surmounted the depression and for the next 10 years wrote luminous poetry, including the Pulitzer Prize-winning Pictures From Bruegel, which was published when he was 79. In his later life, Williams wrote about “old age that adds as it takes away.” What Williams and his poetry epitomize is that age can be the catalyst for tapping into creative potential (Cohen, 1998a).
Loss of a spouse is common in late life. About 800,000 older Americans are widowed each year. Bereavement is a natural response to death of a loved one. Its features, almost universally recognized, include crying and sorrow, anxiety and agitation, insomnia, and loss of appetite (Institute of Medicine [IOM], 1984). This constellation of symptoms, while overlapping somewhat with major depression, does not by itself constitute a mental disorder. Only when symptoms persist for 2 months and longer after the loss does the DSM-IV permit a diagnosis of either adjustment disorder or major depressive disorder. Even though bereavement of less than 2 months’ duration is not considered a mental disorder, it still warrants clinical attention (DSM-IV). The justification for clinical attention is that bereavement, as a highly stressful event, increases the probability of, and may cause or exacerbate, mental and somatic disorders.
Bereavement is an important and well-established risk factor for depression. At least 10 to 20 percent of widows and widowers develop clinically significant depression during the first year of bereavement. Without treatment, such depressions tend to persist, become chronic, and lead to further disability and impairments in general health, including alterations in endocrine and immune function (Zisook & Shuchter, 1993; Zisook et al., 1994). Several preventive interventions, including participation in self-help groups, have been shown to prevent depression among widows and widowers, although one study suggested that self-help groups can exacerbate depressive symptoms in certain individuals (Levy et al., 1993). These are described later in this chapter.
Bereavement-associated depression often coexists with another type of emotional distress, which has been termed traumatic grief (Prigerson et al., in press). The symptoms of traumatic grief, although not formalized as a mental disorder in DSM-IV, appear to be a mixture of symptoms of both pathological grief and post-traumatic stress disorder (Frank et al., 1997a). Such symptoms are extremely disabling, associated with functional and health impairment and with persistent suicidal thoughts, and may well respond to pharmacotherapy (Zygmont et al., 1998). Increased illness and mortality from suicide are the most serious consequences of late-life depression.
The dynamics around loss in later life need greater clarification. One pivotal question is why some, in confronting loss with aging, succumb to depression and suicide—which, as noted earlier, has its highest frequency after age 65—while others respond with new adaptive strategies. Research on health promotion also needs to identify ways to prevent adverse reactions and to promote positive responses to loss in later life. Meanwhile, despite cultural attitudes that older persons can handle bereavement by themselves or with support from family and friends, it is imperative that those who are unable to cope be encouraged to access mental health services. Bereavement is not a mental disorder but, if unattended to, has serious mental health and other health consequences.
November 01, 2010
Mental Health Screenings and Trauma-Related Counseling in Substance Abuse Treatment Facilities
Mental Health Screenings and Trauma-Related Counseling in Substance Abuse Treatment FacilitiesIn Brief •In 2009, more than half (62 percent) of all substance abuse treatment facilities provided brief mental health screenings that could be used to identify clients in need of trauma services; less than half (42 percent) provided full diagnostic mental health assessments
•Facilities that primarily focused on a mix of mental health and substance abuse treatment services were more likely than facilities with other primary focuses to report using trauma counseling "always or often" (30 vs. 16 to 26 percent)
•Facilities that were operated by tribal governments (55 percent) were more likely than facilities that were operated by the Federal Government (37 percent), private for-profit organizations (36 percent), private non-profit organizations (35 percent), or State or local, county, or community governments (32 percent each) to offer domestic violence services
Research shows that the experience of traumatic events and the possible sequelae of posttraumatic stress disorder (PTSD) often co-occur with a substance abuse disorder1 and are present among many substance abuse treatment clients.2 Common types of trauma include being exposed to a natural disaster or violence in combat or noncombat situations and experiencing physical assault or domestic violence. Because of the relationship between substance use and trauma-related mental health problems, it is recommended that substance abuse treatment facilities offer mental health screenings and assessments to determine whether or not a client is suffering from a trauma-related illness3 and/or has been involved in domestic violence.4
This report explores the extent to which mental health screenings, mental health assessments, trauma-related counseling, and domestic violence services are provided in substance abuse treatment facilities. The provision of these services in treatment facilities is captured by the 2009 National Survey of Substance Abuse Treatment Services (N-SSATS).
Mental Health Screenings and Assessments
Mental health screenings and assessments can be used in treatment facilities to identify clients who have been exposed to one or more traumatic events and who have problematic symptoms associated with such exposure. The Center for Substance Abuse Treatment (CSAT) guidelines for best practice with substance abuse treatment clients differentiate between mental health screenings and mental health assessments. Screenings assist in identifying substance abuse clients that show signs of mental health problems by asking questions that elicit a yes or no response; assessments define the nature of the mental health problem and gather more detailed information that may be used to develop treatment plans for clients with co-occurring mental health and substance abuse problems.5
More than half (62 percent) of the 13,513 treatment facilities that responded to N-SSATS provided brief mental health screenings for clients, but less than half (42 percent) provided full diagnostic mental health assessments. Facilities with a primary focus on mental health services, a mix of mental health and substance abuse treatment services, or general health care were more likely than facilities that primarily focused only on substance abuse treatment services to provide mental health screenings or mental health assessments (Figure 1).
Figure 1. Facilities Providing Mental Health Screenings or Assessments, by Primary Focus of Treatment Facility: 2009
Source: 2009 SAMHSA National Survey of Substance Abuse Treatment Services (N-SSATS).
Figure 1 Table. Facilities Providing Mental Health Screenings or Assessments, by Primary Focus of Treatment Facility: 2009 Primary Focus Mental Health Screenings Mental Health Assessments
Substance Abuse Treatment Services 45% 20%
Mental Health Services 94% 89%
Mix of Mental Health and Substance Abuse Treatment Services 90% 76%
General Health Care 85% 75%
Other/Unknown 53% 21%
Source: 2009 SAMHSA National Survey of Substance Abuse Treatment Services (N-SSATS).
Treatment facilities that were operated by the Federal Government (68 percent) were more likely than facilities operated by State governments (52 percent); local, county, or community governments (50 percent); private non-profit organizations (43 percent); tribal governments (40 percent); or private for-profit organizations (36 percent) to provide mental health assessments (Figure 2). Additionally, facilities that were operated by the Federal Government (79 percent) were more likely than those operated by other types of governments or organizations to provide mental health screenings.
It is recommended that substance abuse treatment providers screen all clients in substance abuse treatment for exposure to domestic violence in order to identify batterers and survivors. After substance abuse treatment providers identify those clients who have been involved in domestic violence, the provider may then determine what services the clients may need.4 Domestic violence services may include, for example, specialized counseling, medical services, or legal services.
N-SSATS provides information regarding whether or not treatment facilities offer domestic violence services. In 2009, less than half (35 percent) of treatment facilities offered domestic violence services. Facilities that primarily focused on a mix of mental health and substance abuse treatment services (46 percent) or general health care (44 percent) were more likely than those that focused on mental health services (37 percent) or substance abuse treatment services (30 percent) to offer domestic violence services.
Discussion
Mental health problems, specifically those related to trauma and/or domestic violence, often co-occur with substance abuse. Mental health screenings Mental health problems, specifically those related to trauma and/or domestic violence, often co-occur with substance abuse. Mental health screenings and assessments may be used by substance abuse treatment facilities to identify clients who are suffering from mental health problems related to trauma. By first identifying these clients, treatment providers may then develop a comprehensive treatment plan and assist clients with gaining access to trauma-related services. Treatment plans for clients with these co-occurring problems should address their substance abuse and incorporate evidenced-based interventions that aim to reduce the biological, psychological, and behavioral symptoms associated with trauma.6
The data in this report provide a snapshot of the extent to which the treatment system is identifying and providing certain services to clients suffering from co-occurring substance abuse and trauma-related mental health problems. This information may be used to increase public health awareness about substance abuse and trauma-related mental health problems, and inform behavioral health care reform initiatives that increase the treatment system’s capacity to provide needed trauma-related services to substance abuse clients.
End Notes
1 Kessler, R. C., Sonnega, A., Bromet, E., Hughes, M., & Nelson, C. B. (1995). Posttraumatic stress disorder in the National Comorbidity Survey. Archives of General Psychiatry, 52, 1048-1060.
2 Nanjavits, L. M. (2002). Clinicians’ views on treating posttraumatic stress disorder and substance use disorder. Journal of Substance Abuse Treatment, 22, 79-85.
3 Center for Substance Abuse Treatment. (1995). Anxiety disorders. In Assessment and treatment of patients with coexisting mental illness and alcohol and other drug abuse (Treatment Improvement Protocol [TIP] Series 9, DHHS Publication No. SMA 95-3061). Rockville, MD: Substance Abuse and Mental Health Services. (Original work published 1994) Retrieved from http://www.ncbi.nlm.nih.gov/bookshelf/br.fcgi?book=hssamhsatip&part=A30236
4 Fazzone, P. A., Holton, J. K., & Reed, B. G. (Consensus Panel Co-Chairs); Center for Substance Abuse Treatment. (1997). Substance abuse treatment and domestic violence (Treatment Improvement Protocol [TIP] Series 25, DHHS Publication No. SMA 97-3163). Rockville, MD: Substance Abuse and Mental Health Services Administration. Retrieved from http://www.ncbi.nlm.nih.gov/bookshelf/br.fcgi?book=hssamhsatip&part=A46712
5Sacks, S., & Ries, R. K. (Consensus Panel Co-Chairs); Center for Substance Abuse Treatment. (2005). Substance abuse treatment for persons with co-occurring disorders (Treatment Improvement Protocol [TIP] Series 42, DHHS Publication No. SMA 05-3922). Rockville, MD: Substance Abuse and Mental Health Services Administration. Retrieved from http://www.ncbi.nlm.nih.gov/bookshelf/br.fcgi?book=hssamhsatip&part=A74073
6 Shalev, A., Bonne, O., & Eth, S. (1996). Treatment of post traumatic stress disorder: A review. Psychosomatic Medicine, 58, 165-182.
•Facilities that primarily focused on a mix of mental health and substance abuse treatment services were more likely than facilities with other primary focuses to report using trauma counseling "always or often" (30 vs. 16 to 26 percent)
•Facilities that were operated by tribal governments (55 percent) were more likely than facilities that were operated by the Federal Government (37 percent), private for-profit organizations (36 percent), private non-profit organizations (35 percent), or State or local, county, or community governments (32 percent each) to offer domestic violence services
Research shows that the experience of traumatic events and the possible sequelae of posttraumatic stress disorder (PTSD) often co-occur with a substance abuse disorder1 and are present among many substance abuse treatment clients.2 Common types of trauma include being exposed to a natural disaster or violence in combat or noncombat situations and experiencing physical assault or domestic violence. Because of the relationship between substance use and trauma-related mental health problems, it is recommended that substance abuse treatment facilities offer mental health screenings and assessments to determine whether or not a client is suffering from a trauma-related illness3 and/or has been involved in domestic violence.4
This report explores the extent to which mental health screenings, mental health assessments, trauma-related counseling, and domestic violence services are provided in substance abuse treatment facilities. The provision of these services in treatment facilities is captured by the 2009 National Survey of Substance Abuse Treatment Services (N-SSATS).
Mental Health Screenings and Assessments
Mental health screenings and assessments can be used in treatment facilities to identify clients who have been exposed to one or more traumatic events and who have problematic symptoms associated with such exposure. The Center for Substance Abuse Treatment (CSAT) guidelines for best practice with substance abuse treatment clients differentiate between mental health screenings and mental health assessments. Screenings assist in identifying substance abuse clients that show signs of mental health problems by asking questions that elicit a yes or no response; assessments define the nature of the mental health problem and gather more detailed information that may be used to develop treatment plans for clients with co-occurring mental health and substance abuse problems.5
More than half (62 percent) of the 13,513 treatment facilities that responded to N-SSATS provided brief mental health screenings for clients, but less than half (42 percent) provided full diagnostic mental health assessments. Facilities with a primary focus on mental health services, a mix of mental health and substance abuse treatment services, or general health care were more likely than facilities that primarily focused only on substance abuse treatment services to provide mental health screenings or mental health assessments (Figure 1).
Figure 1. Facilities Providing Mental Health Screenings or Assessments, by Primary Focus of Treatment Facility: 2009
Source: 2009 SAMHSA National Survey of Substance Abuse Treatment Services (N-SSATS).
Figure 1 Table. Facilities Providing Mental Health Screenings or Assessments, by Primary Focus of Treatment Facility: 2009 Primary Focus Mental Health Screenings Mental Health Assessments
Substance Abuse Treatment Services 45% 20%
Mental Health Services 94% 89%
Mix of Mental Health and Substance Abuse Treatment Services 90% 76%
General Health Care 85% 75%
Other/Unknown 53% 21%
Source: 2009 SAMHSA National Survey of Substance Abuse Treatment Services (N-SSATS).
Treatment facilities that were operated by the Federal Government (68 percent) were more likely than facilities operated by State governments (52 percent); local, county, or community governments (50 percent); private non-profit organizations (43 percent); tribal governments (40 percent); or private for-profit organizations (36 percent) to provide mental health assessments (Figure 2). Additionally, facilities that were operated by the Federal Government (79 percent) were more likely than those operated by other types of governments or organizations to provide mental health screenings.
It is recommended that substance abuse treatment providers screen all clients in substance abuse treatment for exposure to domestic violence in order to identify batterers and survivors. After substance abuse treatment providers identify those clients who have been involved in domestic violence, the provider may then determine what services the clients may need.4 Domestic violence services may include, for example, specialized counseling, medical services, or legal services.
N-SSATS provides information regarding whether or not treatment facilities offer domestic violence services. In 2009, less than half (35 percent) of treatment facilities offered domestic violence services. Facilities that primarily focused on a mix of mental health and substance abuse treatment services (46 percent) or general health care (44 percent) were more likely than those that focused on mental health services (37 percent) or substance abuse treatment services (30 percent) to offer domestic violence services.
Discussion
Mental health problems, specifically those related to trauma and/or domestic violence, often co-occur with substance abuse. Mental health screenings Mental health problems, specifically those related to trauma and/or domestic violence, often co-occur with substance abuse. Mental health screenings and assessments may be used by substance abuse treatment facilities to identify clients who are suffering from mental health problems related to trauma. By first identifying these clients, treatment providers may then develop a comprehensive treatment plan and assist clients with gaining access to trauma-related services. Treatment plans for clients with these co-occurring problems should address their substance abuse and incorporate evidenced-based interventions that aim to reduce the biological, psychological, and behavioral symptoms associated with trauma.6
The data in this report provide a snapshot of the extent to which the treatment system is identifying and providing certain services to clients suffering from co-occurring substance abuse and trauma-related mental health problems. This information may be used to increase public health awareness about substance abuse and trauma-related mental health problems, and inform behavioral health care reform initiatives that increase the treatment system’s capacity to provide needed trauma-related services to substance abuse clients.
End Notes
1 Kessler, R. C., Sonnega, A., Bromet, E., Hughes, M., & Nelson, C. B. (1995). Posttraumatic stress disorder in the National Comorbidity Survey. Archives of General Psychiatry, 52, 1048-1060.
2 Nanjavits, L. M. (2002). Clinicians’ views on treating posttraumatic stress disorder and substance use disorder. Journal of Substance Abuse Treatment, 22, 79-85.
3 Center for Substance Abuse Treatment. (1995). Anxiety disorders. In Assessment and treatment of patients with coexisting mental illness and alcohol and other drug abuse (Treatment Improvement Protocol [TIP] Series 9, DHHS Publication No. SMA 95-3061). Rockville, MD: Substance Abuse and Mental Health Services. (Original work published 1994) Retrieved from http://www.ncbi.nlm.nih.gov/bookshelf/br.fcgi?book=hssamhsatip&part=A30236
4 Fazzone, P. A., Holton, J. K., & Reed, B. G. (Consensus Panel Co-Chairs); Center for Substance Abuse Treatment. (1997). Substance abuse treatment and domestic violence (Treatment Improvement Protocol [TIP] Series 25, DHHS Publication No. SMA 97-3163). Rockville, MD: Substance Abuse and Mental Health Services Administration. Retrieved from http://www.ncbi.nlm.nih.gov/bookshelf/br.fcgi?book=hssamhsatip&part=A46712
5Sacks, S., & Ries, R. K. (Consensus Panel Co-Chairs); Center for Substance Abuse Treatment. (2005). Substance abuse treatment for persons with co-occurring disorders (Treatment Improvement Protocol [TIP] Series 42, DHHS Publication No. SMA 05-3922). Rockville, MD: Substance Abuse and Mental Health Services Administration. Retrieved from http://www.ncbi.nlm.nih.gov/bookshelf/br.fcgi?book=hssamhsatip&part=A74073
6 Shalev, A., Bonne, O., & Eth, S. (1996). Treatment of post traumatic stress disorder: A review. Psychosomatic Medicine, 58, 165-182.
October 29, 2010
Genetic attribution for schizophrenia, depression, and skin cancer: impact on social distance.
Genetic attribution for schizophrenia, depression, and skin cancer: impact on social distance.
New Zealand Journal of Psychology| November 01, 2007 | Breheny, Mary | COPYRIGHT 1998New Zealand Psychological Society. This material is published under license from the publisher through the Gale Group, Farmington Hills, Michigan. All inquiries regarding rights should be directed to the Gale Group. (Hide copyright information)Copyright
Genetic explanations for mental and physical illness are increasingly common in both scientific research and in media reports generated from such research, however, the social impact of these explanations are less well understood. In this study it was predicted that both genetic attribution for illness and type of illness would be related to a desire for social distance. Participants were provided with a description of Jamie, who suffered from skin cancer, major depression, or schizophrenia. This illness was described as either having a strongly genetic basis, no genetic basis, or no causal explanation was provided. Participants then indicated their willingness to interact with Jamie using the Social Distance Scale. Type of illness described did significantly influence social distance score, with participants more willing to interact with Jamie when he was described as having skin cancer than schizophrenia or major depression. There was a significant interaction between illness type and genetic attribution for illness, with an increase in willingness to interact when schizophrenia was described as genetically caused and a decrease in willingness to interact when major depression was described as genetically caused. Genetic explanations may be suggested to reduce the stigma associated with mental illnesses, however, these explanations work in complex ways and may not uniformly reduce illness related stigma.
**********
The role o f genetics in determining health and wellbeing is increasingly discussed in scientific research (de Jong, 2000) and in media reports of such research (Conrad, 2001). The genetic component of complex traits is often investigated (de Jong, 2000), including the contribution of genetics to criminality (see Lowenstein, 2003; Martens, 2002; Retz, Retz-Junginger, Supprian, Thome & Rosler, 2004), and mental illness (see Thompson, Watson, Steinhauer, Goldstein & Pogue-Geile, 2005). Media representations contribute to lay explanations, and genetic factors are commonly identified as causing mental illness. Around two thirds of an Australian community sample attributed schizophrenia and depression to genetic causes (Jorm, Christensen & Griffiths, 2005). However, the impact of a claim of a genetic basis for complex psychological traits has received relatively little attention (Lemke, 2004), and may be a useful framework for understanding public attitudes towards those with mental illnesses (Zissi, 2006).
Genetic Attribution
Genetic explanations may influence understandings of human behaviour and the stigma associated with these behaviours (Phelan, 2005). Reframing mental illness as a brain disease with a genetic component has been suggested to reduce the stigma associated with mental illness; however, conversely, this may exacerbate experience of stigma (Bag, Yilmaz, Kirpinar, 2006; Corrigan & Watson, 2004). In support of this, Dietrich, Matschinger and Angermeyer (2006) found that biological or genetic causes of schizophrenia were associated with greater fear and reduced willingness to interact with people with schizophrenia. Phelan (2005) also found that genetic causes were associated with greater seriousness, persistence, and transmissibility of deviance. Research has found less blame attributed to those with genetically caused schizophrenia (Phelan, 2002), and less stigma associated with causes beyond the patients control, including genetic transmission (Martin, Pescosolido & Tuch, 2000; van't Veer, Kraan, Drosseart, & Modde, 2006). Phelan (2005) found some participants reported both reduced blame and increased associative stigma for genetically caused mental illnesses. Genetic causes for mental illness may have complex effects, ameliorating the blame associated with mental illness, bur increasing stigma.
Social Distance
Stigma is an attribute that discredits an individual, reducing them from a whole person to a discounted person in the eyes of others (Major & O'Brien, 2005). The evaluations of stigmatised others are widely shared, and are used as the basis for excluding or avoiding members of the discredited category (Major & O'Brien, 2005). Social distance is a way to assess attitudes towards those with a stigmatised identity, and is defined as the relative willingness to participate in relationships of varying intimacy with those who have a devalued social identity (Lauber, Nordt, Falcato & Rossler, 2004). Measures of social distance are widely used to assess attitudes to mental illness (Reinke, Corrigan, Leonhard, Lundin & Kubiak, 2004), by measuring participants' reported willingness to engage in relationships with a person described as having a particular illness (Lauber et al., 2004).
New Zealand Journal of Psychology| November 01, 2007 | Breheny, Mary | COPYRIGHT 1998New Zealand Psychological Society. This material is published under license from the publisher through the Gale Group, Farmington Hills, Michigan. All inquiries regarding rights should be directed to the Gale Group. (Hide copyright information)Copyright
Genetic explanations for mental and physical illness are increasingly common in both scientific research and in media reports generated from such research, however, the social impact of these explanations are less well understood. In this study it was predicted that both genetic attribution for illness and type of illness would be related to a desire for social distance. Participants were provided with a description of Jamie, who suffered from skin cancer, major depression, or schizophrenia. This illness was described as either having a strongly genetic basis, no genetic basis, or no causal explanation was provided. Participants then indicated their willingness to interact with Jamie using the Social Distance Scale. Type of illness described did significantly influence social distance score, with participants more willing to interact with Jamie when he was described as having skin cancer than schizophrenia or major depression. There was a significant interaction between illness type and genetic attribution for illness, with an increase in willingness to interact when schizophrenia was described as genetically caused and a decrease in willingness to interact when major depression was described as genetically caused. Genetic explanations may be suggested to reduce the stigma associated with mental illnesses, however, these explanations work in complex ways and may not uniformly reduce illness related stigma.
**********
The role o f genetics in determining health and wellbeing is increasingly discussed in scientific research (de Jong, 2000) and in media reports of such research (Conrad, 2001). The genetic component of complex traits is often investigated (de Jong, 2000), including the contribution of genetics to criminality (see Lowenstein, 2003; Martens, 2002; Retz, Retz-Junginger, Supprian, Thome & Rosler, 2004), and mental illness (see Thompson, Watson, Steinhauer, Goldstein & Pogue-Geile, 2005). Media representations contribute to lay explanations, and genetic factors are commonly identified as causing mental illness. Around two thirds of an Australian community sample attributed schizophrenia and depression to genetic causes (Jorm, Christensen & Griffiths, 2005). However, the impact of a claim of a genetic basis for complex psychological traits has received relatively little attention (Lemke, 2004), and may be a useful framework for understanding public attitudes towards those with mental illnesses (Zissi, 2006).
Genetic Attribution
Genetic explanations may influence understandings of human behaviour and the stigma associated with these behaviours (Phelan, 2005). Reframing mental illness as a brain disease with a genetic component has been suggested to reduce the stigma associated with mental illness; however, conversely, this may exacerbate experience of stigma (Bag, Yilmaz, Kirpinar, 2006; Corrigan & Watson, 2004). In support of this, Dietrich, Matschinger and Angermeyer (2006) found that biological or genetic causes of schizophrenia were associated with greater fear and reduced willingness to interact with people with schizophrenia. Phelan (2005) also found that genetic causes were associated with greater seriousness, persistence, and transmissibility of deviance. Research has found less blame attributed to those with genetically caused schizophrenia (Phelan, 2002), and less stigma associated with causes beyond the patients control, including genetic transmission (Martin, Pescosolido & Tuch, 2000; van't Veer, Kraan, Drosseart, & Modde, 2006). Phelan (2005) found some participants reported both reduced blame and increased associative stigma for genetically caused mental illnesses. Genetic causes for mental illness may have complex effects, ameliorating the blame associated with mental illness, bur increasing stigma.
Social Distance
Stigma is an attribute that discredits an individual, reducing them from a whole person to a discounted person in the eyes of others (Major & O'Brien, 2005). The evaluations of stigmatised others are widely shared, and are used as the basis for excluding or avoiding members of the discredited category (Major & O'Brien, 2005). Social distance is a way to assess attitudes towards those with a stigmatised identity, and is defined as the relative willingness to participate in relationships of varying intimacy with those who have a devalued social identity (Lauber, Nordt, Falcato & Rossler, 2004). Measures of social distance are widely used to assess attitudes to mental illness (Reinke, Corrigan, Leonhard, Lundin & Kubiak, 2004), by measuring participants' reported willingness to engage in relationships with a person described as having a particular illness (Lauber et al., 2004).
October 18, 2010
Marijuana Treatment Project
The Center for Substance Abuse Treatment (CSAT), part of the Substance Abuse and Mental Health Services Administration, funded three clinical sites and a Coordinating Center (CC) to design and implement the Marijuana Treatment Project (MTP) in the late 1990s. A major focus of CSAT is rigorous testing of approaches to treat marijuana dependence in both adults and adolescents. MTP studied the efficacy of treatments for adults who are dependent on marijuana. At the time of funding, MTP was one of the largest Knowledge Development and Applications initiatives funded by CSAT. Another was the Cannabis Youth Treatment (CYT) Study, which resulted
in the CYT Series, a five-volume resource that provides unique perspectives on treating adolescents for marijuana use (Godley et al. 2001; Hamilton et al. 2001; Liddle 2002; Sampl and Kadden 2001; Webb et al. 2002). This manual for Brief Marijuana Dependence Counseling (BMDC) is based on the research
protocol used by counselors in MTP. The manual provides guidelines for counselors, social workers, and psychologists in both public and private settings who treat adults dependent on marijuana.
The 10 weekly one-on-one sessions in the BMDC manual offer examples of how a counselor can help a client understand certain topics, keep his or her determination to change, learn new skills, and access needed community supports (exhibit I-1). Stephens and colleagues (2002) describe the MTP rationale, design, and participant characteristics. Findings from MTP are presented in supplemental reading B of section VII.
Me? Hooked on Pot?
Many individuals for whom this intervention was designed often have difficulty accepting that they are dependent on marijuana. The topic is controversial, even for those who walk through a counselor’s door to talk about their marijuana use.
People who become clients in BMDC may have
• Put off actions and decisions to the point of being a burden on family and friends
• Given up personal aspirations
• Had nagging health concerns, such as worries about lung damage
• Made excuses for unfinished tasks or broken promises
• Experienced disapproval from family and friends
• Been involved in the criminal justice system.
Current Findings About Marijuana Use
Marijuana is the most commonly used illicit substance in the United States (Clark et al. 2002; Substance Abuse and Mental Health Services Administration 2003). According to the 2003 National Survey on Drug Use and Health, 14.6 million people ages 12 and older had smoked marijuana in the preceding month (Substance Abuse and Mental Health Services Administration 2004). It is estimated that approximately 4.3 million people used marijuana at levels consistent with abuse or dependence in the past year. Given that it is an illicit substance, any use of marijuana carries with it some significant risks. However, this document focuses on people who use marijuana heavily or are dependent on it. This treatment manual is directed primarily at these
persons but may be useful for other persons with substance abuse or substance use disorders. Studies have demonstrated that tolerance and withdrawal develop with daily use of large doses of marijuana or THC (Haney et al. 1999a; Jones and Benowitz 1976; Kouri and Pope 2000). About 15 percent of people who acknowledge moderate-to-heavy use reported a withdrawal syndrome with symptoms of nervousness, sleep disturbance, and appetite change (Wiesbeck et al. 1996). Many adults who are marijuana dependent report affective (i.e., mood) symptoms and craving
during periods of abstinence when they present for treatment (Budney et al. 1999). The contribution of physical dependence to chronic marijuana use is not yet clear, but the existence of a dependence syndrome is fairly certain. An Epidemiological Catchment Area study conducted in Baltimore found that 6 percent of people who used marijuana met Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) (American Psychiatric Association 1994), criteria for dependence and 7 percent met DSM-IV criteria for substance abuse (Rosenberg and Anthony 2001). Coffey and colleagues (2002) found that persons who use marijuana more than
once a week are at significant risk for dependence. In the 1990s, the number of people who sought treatment for marijuana dependence more than doubled (Budney et al. 2001). Therefore, a large group of adults who smoke marijuana is dependent and may need and benefit from treatment. Surveys of people using marijuana who are not in treatment consistently show that a majority report impairment of memory, concentration, motivation, self-esteem, interpersonal relationships,
health, employment, or finances related to their heavy marijuana use (Haas and Hendin 1987;
Section I. Introduction
Rainone et al. 1987; Roffman and Barnhart 1987; Solowij 1998). Similar marijuana-related consequences are seen among those seeking treatment for their marijuana use (Budney et al. 1998; Stephens et al. 1994b, 2000). People using marijuana who participated in previous treatment studies averaged more than 10 years of near-daily use and more than six serious attempts to quit (Stephens et al. 1994b, 2000). These individuals had persisted in their use despite multiple forms of impairment (i.e., social, psychological, physical), and most perceived themselves as unable to stop.
During the past decade evidence has emerged that a variety of problems are associated with chronic marijuana use. Although the severity of these problems appears to be less than that of problems caused by other drugs and alcohol, the large number of people using who may have these problems raises the possibility of a significant public health problem. Like those who use other mood-altering substances, many individuals who use marijuana chronically perceive the
problems to be severe enough to warrant treatment. The results of earlier studies on treatments for marijuana problems indicated that some adults
who used marijuana responded well to several types of interventions, such as cognitive behavioral, motivational enhancement, and voucher-based treatments (Budney et al. 2000; Stephens et al. 1994b, 2000). Relapse rates following treatment were similar to those for other drugs of abuse and, as found with other types of substance abuse treatment, improvements in drug use were accompanied by other positive gains, including improvements in dependence symptoms, problems
related to marijuana use, and anxiety symptoms. However, the generalizability of the treatment findings appeared to be limited by the predominantly white, male, and socioeconomically stable (i.e., educated and employed) characteristics of the samples. Therefore, the results of these studies may be limited to this fairly homogeneous group of people who are marijuana users.
Overview of the Marijuana Treatment Project1
CSAT funded MTP to design and conduct a study of the efficacy of treatments for marijuana
dependence, to extend this line of research, and to broaden the applicability of the approach to a
more diverse group than that used in earlier trials (Stephens et al. 1994b, 2000). The treatment
sites were the University of Connecticut School of Medicine, Department of Psychiatry,
Farmington, Connecticut; The Village South, Miami, Florida; and the University of Washington,
School of Social Work, Seattle, Washington. The CC was at the University of Connecticut,
Department of Psychiatry.
The study examined the efficacy of treatments of different durations for a diverse group of adults who
were marijuana dependent. Two treatments—one lasting two sessions, the other nine sessions—
were compared with a delayed treatment control (DTC) condition, in which subjects were offered
treatment 4 months after their baseline assessment. The same counselors delivered treatments of
both durations to avoid confounding the mode of treatment, length of treatment, and counselor
experience. A case management component was incorporated in the longer treatment to help clients
identify and overcome barriers to successful behavior change in their everyday environments. The
hypothesis was the nine-session and two-session interventions would produce outcomes superior to
the DTC in terms of higher abstinence rates and associated negative consequences.
in the CYT Series, a five-volume resource that provides unique perspectives on treating adolescents for marijuana use (Godley et al. 2001; Hamilton et al. 2001; Liddle 2002; Sampl and Kadden 2001; Webb et al. 2002). This manual for Brief Marijuana Dependence Counseling (BMDC) is based on the research
protocol used by counselors in MTP. The manual provides guidelines for counselors, social workers, and psychologists in both public and private settings who treat adults dependent on marijuana.
The 10 weekly one-on-one sessions in the BMDC manual offer examples of how a counselor can help a client understand certain topics, keep his or her determination to change, learn new skills, and access needed community supports (exhibit I-1). Stephens and colleagues (2002) describe the MTP rationale, design, and participant characteristics. Findings from MTP are presented in supplemental reading B of section VII.
Me? Hooked on Pot?
Many individuals for whom this intervention was designed often have difficulty accepting that they are dependent on marijuana. The topic is controversial, even for those who walk through a counselor’s door to talk about their marijuana use.
People who become clients in BMDC may have
• Put off actions and decisions to the point of being a burden on family and friends
• Given up personal aspirations
• Had nagging health concerns, such as worries about lung damage
• Made excuses for unfinished tasks or broken promises
• Experienced disapproval from family and friends
• Been involved in the criminal justice system.
Current Findings About Marijuana Use
Marijuana is the most commonly used illicit substance in the United States (Clark et al. 2002; Substance Abuse and Mental Health Services Administration 2003). According to the 2003 National Survey on Drug Use and Health, 14.6 million people ages 12 and older had smoked marijuana in the preceding month (Substance Abuse and Mental Health Services Administration 2004). It is estimated that approximately 4.3 million people used marijuana at levels consistent with abuse or dependence in the past year. Given that it is an illicit substance, any use of marijuana carries with it some significant risks. However, this document focuses on people who use marijuana heavily or are dependent on it. This treatment manual is directed primarily at these
persons but may be useful for other persons with substance abuse or substance use disorders. Studies have demonstrated that tolerance and withdrawal develop with daily use of large doses of marijuana or THC (Haney et al. 1999a; Jones and Benowitz 1976; Kouri and Pope 2000). About 15 percent of people who acknowledge moderate-to-heavy use reported a withdrawal syndrome with symptoms of nervousness, sleep disturbance, and appetite change (Wiesbeck et al. 1996). Many adults who are marijuana dependent report affective (i.e., mood) symptoms and craving
during periods of abstinence when they present for treatment (Budney et al. 1999). The contribution of physical dependence to chronic marijuana use is not yet clear, but the existence of a dependence syndrome is fairly certain. An Epidemiological Catchment Area study conducted in Baltimore found that 6 percent of people who used marijuana met Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) (American Psychiatric Association 1994), criteria for dependence and 7 percent met DSM-IV criteria for substance abuse (Rosenberg and Anthony 2001). Coffey and colleagues (2002) found that persons who use marijuana more than
once a week are at significant risk for dependence. In the 1990s, the number of people who sought treatment for marijuana dependence more than doubled (Budney et al. 2001). Therefore, a large group of adults who smoke marijuana is dependent and may need and benefit from treatment. Surveys of people using marijuana who are not in treatment consistently show that a majority report impairment of memory, concentration, motivation, self-esteem, interpersonal relationships,
health, employment, or finances related to their heavy marijuana use (Haas and Hendin 1987;
Section I. Introduction
Rainone et al. 1987; Roffman and Barnhart 1987; Solowij 1998). Similar marijuana-related consequences are seen among those seeking treatment for their marijuana use (Budney et al. 1998; Stephens et al. 1994b, 2000). People using marijuana who participated in previous treatment studies averaged more than 10 years of near-daily use and more than six serious attempts to quit (Stephens et al. 1994b, 2000). These individuals had persisted in their use despite multiple forms of impairment (i.e., social, psychological, physical), and most perceived themselves as unable to stop.
During the past decade evidence has emerged that a variety of problems are associated with chronic marijuana use. Although the severity of these problems appears to be less than that of problems caused by other drugs and alcohol, the large number of people using who may have these problems raises the possibility of a significant public health problem. Like those who use other mood-altering substances, many individuals who use marijuana chronically perceive the
problems to be severe enough to warrant treatment. The results of earlier studies on treatments for marijuana problems indicated that some adults
who used marijuana responded well to several types of interventions, such as cognitive behavioral, motivational enhancement, and voucher-based treatments (Budney et al. 2000; Stephens et al. 1994b, 2000). Relapse rates following treatment were similar to those for other drugs of abuse and, as found with other types of substance abuse treatment, improvements in drug use were accompanied by other positive gains, including improvements in dependence symptoms, problems
related to marijuana use, and anxiety symptoms. However, the generalizability of the treatment findings appeared to be limited by the predominantly white, male, and socioeconomically stable (i.e., educated and employed) characteristics of the samples. Therefore, the results of these studies may be limited to this fairly homogeneous group of people who are marijuana users.
Overview of the Marijuana Treatment Project1
CSAT funded MTP to design and conduct a study of the efficacy of treatments for marijuana
dependence, to extend this line of research, and to broaden the applicability of the approach to a
more diverse group than that used in earlier trials (Stephens et al. 1994b, 2000). The treatment
sites were the University of Connecticut School of Medicine, Department of Psychiatry,
Farmington, Connecticut; The Village South, Miami, Florida; and the University of Washington,
School of Social Work, Seattle, Washington. The CC was at the University of Connecticut,
Department of Psychiatry.
The study examined the efficacy of treatments of different durations for a diverse group of adults who
were marijuana dependent. Two treatments—one lasting two sessions, the other nine sessions—
were compared with a delayed treatment control (DTC) condition, in which subjects were offered
treatment 4 months after their baseline assessment. The same counselors delivered treatments of
both durations to avoid confounding the mode of treatment, length of treatment, and counselor
experience. A case management component was incorporated in the longer treatment to help clients
identify and overcome barriers to successful behavior change in their everyday environments. The
hypothesis was the nine-session and two-session interventions would produce outcomes superior to
the DTC in terms of higher abstinence rates and associated negative consequences.
May 18, 2010
National Strategy for Suicide Prevention
National Strategy for Suicide Prevention:
Goals and Objectives for Action
--------------------------------------------------------------------------------
Preface from the Surgeon General:
Suicide exacts an enormous toll from the American people. Our Nation loses 30,000 lives to this tragedy each year, another 650,000 receive emergency care after attempting to take their own lives. The devastating trauma, loss, and suffering is multiplied in the lives of family members and friends. This document, National Strategy for Suicide Prevention – Goals and Objectives for Action, lays the foundation of our Nation's strategy to confront this serious public health problem.
At this document's source are countless dedicated individuals representing every facet of our Nation's communities. They include representatives to a 1993 United Nations/World Health Organization Conference who played key roles in establishing guidelines for national suicide prevention strategies. They include the passionate grassroots activists whose work stimulated Congressional Resolutions declaring suicide prevention a national priority and calling for our own national strategy. They include dedicated public servants and private individuals who jointly organized and participated in the first National Suicide Prevention Conference in 1998 to consolidate a scientific base for this critical endeavor. These people and their efforts led directly to publication of the Surgeon General's Call to Action to Prevent Suicide - 1999 with its most important recommendation, the completion of the National Strategy for Suicide Prevention.
After listening to the concerns of the American people, Government leaders helped bring stakeholders together in a shining example of public- private collaboration to achieve this major milestone in public health. Those who have invested their hearts and minds in this effort believe it effectively points the way for organizations and individuals to curtail the tragedy of suicide and suicidal behavior. Though it does not specify all the details, it provides essential guidance and suggests the fundamental activities that must follow–activities based on the best available science.
Nearly half of the States are engaged in suicide prevention and many have already committed significant resources to implement programs. Their leadership in evaluating the effectiveness of these programs will help guide the efforts of States that follow in their paths. Most of these plans recognize that much of the work of suicide prevention must occur at the community level, where human relationships breathe life into public policy. American communities are also home to scores of faith-based and secular initiatives that help reduce risk factors and promote protective factors associated with many of our most pressing social problems, including suicide.
As you read further, keep in mind that the National Strategy for Suicide Prevention is not the Surgeon General's strategy or the Federal government's strategy; rather, it is the strategy of the American people for improving their health and well-being through the prevention of suicide. I congratulate each person who played a role in bringing it to completion. You have served your fellow Americans well.
Sincerely yours,
David Satcher, M.D., Ph.D.
Surgeon General
Goals and Objectives for Action
--------------------------------------------------------------------------------
Preface from the Surgeon General:
Suicide exacts an enormous toll from the American people. Our Nation loses 30,000 lives to this tragedy each year, another 650,000 receive emergency care after attempting to take their own lives. The devastating trauma, loss, and suffering is multiplied in the lives of family members and friends. This document, National Strategy for Suicide Prevention – Goals and Objectives for Action, lays the foundation of our Nation's strategy to confront this serious public health problem.
At this document's source are countless dedicated individuals representing every facet of our Nation's communities. They include representatives to a 1993 United Nations/World Health Organization Conference who played key roles in establishing guidelines for national suicide prevention strategies. They include the passionate grassroots activists whose work stimulated Congressional Resolutions declaring suicide prevention a national priority and calling for our own national strategy. They include dedicated public servants and private individuals who jointly organized and participated in the first National Suicide Prevention Conference in 1998 to consolidate a scientific base for this critical endeavor. These people and their efforts led directly to publication of the Surgeon General's Call to Action to Prevent Suicide - 1999 with its most important recommendation, the completion of the National Strategy for Suicide Prevention.
After listening to the concerns of the American people, Government leaders helped bring stakeholders together in a shining example of public- private collaboration to achieve this major milestone in public health. Those who have invested their hearts and minds in this effort believe it effectively points the way for organizations and individuals to curtail the tragedy of suicide and suicidal behavior. Though it does not specify all the details, it provides essential guidance and suggests the fundamental activities that must follow–activities based on the best available science.
Nearly half of the States are engaged in suicide prevention and many have already committed significant resources to implement programs. Their leadership in evaluating the effectiveness of these programs will help guide the efforts of States that follow in their paths. Most of these plans recognize that much of the work of suicide prevention must occur at the community level, where human relationships breathe life into public policy. American communities are also home to scores of faith-based and secular initiatives that help reduce risk factors and promote protective factors associated with many of our most pressing social problems, including suicide.
As you read further, keep in mind that the National Strategy for Suicide Prevention is not the Surgeon General's strategy or the Federal government's strategy; rather, it is the strategy of the American people for improving their health and well-being through the prevention of suicide. I congratulate each person who played a role in bringing it to completion. You have served your fellow Americans well.
Sincerely yours,
David Satcher, M.D., Ph.D.
Surgeon General
May 12, 2010
Depression and Mood Disorders Continuing Education CEU
Depression and Mood Disorders
The Prevalence of Major Depression and Mood Disorders in Suicide
Mental Health: A Report of the Surgeon General, states that "major depressive disorders account for about 20 to 35 percent of all deaths by suicide" (p. 244). This estimate is based on a review of psychological autopsies conducted by Angst, Angst, and Stassen (1999). This brief review is intended to address this prevalence estimate. It is important to note that this estimate refers only to the prevalence of major depressive disorder among those who commit suicide, not any other mood disorders (e.g., bipolar I & II, dysthymia, adjustment disorder with depressed mood). Prevalence estimates that include other mood disorders in addition to major depression are much higher.
Major depression in suicide
The lower bound of the 20-35% estimate of the prevalence of major depression in suicide is loosely based on one psychological autopsy study; a study where the reliability of the diagnoses are somewhat questionable. This study (Rich, Young & Fowler, 1986) of 204 subjects identified 15% of suicides as having major depressive disorder. However, an additional 30% were reported as having "atypical depression," defined in this study as having a depressive syndrome that followed the onset of substance use. If this ambiguously defined group were to be considered major depression, the estimate climbs to 45%. A number of other studies suggest that the prevalence of major depression in suicide is somewhat over 30%. The four other available psychological autopsy studies that include samples of suicides from the full age range and reliable diagnoses based on structured interviews (Arato, Demeter, Rihmer & Somogyi, 1988; Dorpat & Ripley, 1960; Foster, Gillespie, McClelland & Patterson, 1999; Henriksson et al., 1993) obtained prevalence estimates of major depression ranging from 30-34% of suicides. In addition, several psychological autopsy studies examining more specific subsamples (e.g., the elderly, adolescents, women) find even higher prevalence estimates. In three psychological autopsy studies of adolescents (Brent et al. 1988; Brent et al., 1999; Shaffer et al., 1996) 41%, 43%, and 32% of adolescent suicides were determined to have had major depression prior to death. Two studies of young adults (Lesage et al. 1994; Runeson, 1989) found a prevalence of 40% and 41%, respectively. A study of 104 women by Asgard (1990) found a 35% rate of major depression. One study of 54 older adults over age 65 found a prevalence of 54%. In summary, the available data suggest that the 20-35% estimate for the prevalence of major depressive disorder in completed suicide is probably somewhat conservative and that a 30-40% prevalence estimate is probably more accurate. This estimate includes both secondary and primary depression. Many of these individuals would also be comorbid with other disorders, especially substance abuse.
Mood disorders in suicide
Prevalence estimates for all mood disorders in suicide (including MDD, Bipolar I & II, dysthymia, and adjustment disorder with depressed mood) are much higher than for major depression alone. These rates are probably closer to 60%, although as noted below, this estimate varies because of inconsistency of the criteria used to define a "mood disorder" across investigations. Four studies examining the full age range of suicides estimate that 36%, 48%, and 66%, and 70% of suicides have some sort of "depressive disorder" or "depression" (Foster et al., 1999; Rich et al., 1986, Henriksson et al., 1993, Barraclough, Bunch, Nelson, & Sainsbury, 1974). Three studies of adolescents found prevalence estimates for "mood disorders" or "affective disorders" of 61%, 63%, and 67% respectively (Shaffer et al., 1996; Brent et al. 1988; Marttunen et al., 1992). Two studies of young adults (Lesage et al., 1994; Runeson, 1989) found estimates of 60% and 64%. A study of 104 women by Asgard (1990) found a 59% rate of "mood disorders." In a review of psychological autopsy studies that examined patterns of psychiatric diagnosis across age groups, Conwell and Brent (1995) concluded that depressive disorders increased with age. Overall estimates for the rates of mood disorders range from 36% to 70% with great interstudy variability. This variability is probably partly a combination of unreliable methods of diagnosis and different definitions of what constitutes a "mood disorder." Despite this variability, a number of studies have found a pattern for increasing mood disorders with aging.
--------------------------------------------------------------------------------
References
Angst, J., Angst, F., and Stassen, H. H. (1999). Suicide risk in patients with major depressive disorder. Journal of Clinical Psychiatry, 60(supp. 2), 57-62.
Arato, M., Demeter, E., Rihmer, Z., & Somogyi, E. (1988). Retrospective psychiatric assessment of 200 suicides in Budapest. Acta Psychiatrica Scandinavica, 77, 454-456.
Asgard, U. (1990). A psychiatric study of suicide among urban women in Sweden. Acta Psychiatrica Scandinavica, 82, 115-124.
Barraclough, B., Bunch, J., Nelson, B., & Sainsbury, P. (1974). A hundred cases of suicide: Clinical aspects. British Journal of Psychiatry, 125,355-373.
Brent, D.A., Perper, J.A., Goldstein, C.E., Kolko, D.J., Allan, M.J., Allman, C.J., & Zelenak, J.P. (1988). Risk factors for adolescent suicide: A comparison of adolescent suicide victims with suicidal inpatients. Archives of General Psychiatry, 45,581-588.
Brent, D. A., Perper, J. A., Moritz, G., Allman, C., Friend, A., Roth, C., Schweers, J., Balach, L., & Baugher, M. (1993). Psychiatric risk factors for adolescent suicide: A case-control study. Journal of the American Academy of Child and Adolescent Psychiatry, 32,521-529.
Clark, D. C. (1991). Final Report to the AARP Adrus Foundation: Suicide Among the Elderly.
Conwell, Y. & Brent, D. (1995). Suicide and aging I: Patterns of psychiatric diagnosis. International Psychogeriatrics, 7, 149-164.
Dorpat, T. L., & Ripley, H. S. (1960). A study of suicide in the Seattle area. Comprehensive Psychiatry, 1, 349-359
Foster, T., Gillespie, K., McClelland, R., & Patterson, C. (1999). Risk factors for suicide independent of DSM-III-R Axis I disorder. British Journal of Psychiatry, 175, 175-179.
Henriksson, M. M., Aro, H. M., Marttunen, M. J., Heikkinen, M. E., Isometa, E. T., Kuoppasalmi, K. I., & Lonqvist, J. K. (1993). Mental disorders and comorbidity in suicide. American Journal of Psychiatry, 150, 935-940.
Lesage, A., Boyer, R., Grunberg, F., Vanier, C., Morissette, R., Menard-Bueeau, C., & Loyer, M. (1994). Suicide and mental disorders: A case-control study of young men. American Journal of Psychiatry, 151, 1063-1068.
Marttunen, M. J., Hillevi, M., Aro, H.M., & Lonnqvist, J. K. (1992). Adolescent suicide: Endpoint of long-term difficulties. Journal of the American Academy of Child and Adolescent Psychiatry, 34(4), 649-654.
Rich, C. L., Young, D., & Fowler, R. C. (1986). San Diego suicide study: Young vs old subjects. Archives of General Psychiatry, 43, 577-582.
Runeson, B. (1989). Mental disorder in youth suicide: DSM-III-R Axes I and II. Acta Psychiatrica Scandinavica, 79, 490-497.
Shaffer, D., Gould, M. S., Fisher, P., Trautmann, P., Moeau, D., Kleinman, M., & Flory, M. (1996). Psychiatric diagnosis in child and adolescent suicide. Archives of General Psychiatry, 53, 339-348.
The Prevalence of Major Depression and Mood Disorders in Suicide
Mental Health: A Report of the Surgeon General, states that "major depressive disorders account for about 20 to 35 percent of all deaths by suicide" (p. 244). This estimate is based on a review of psychological autopsies conducted by Angst, Angst, and Stassen (1999). This brief review is intended to address this prevalence estimate. It is important to note that this estimate refers only to the prevalence of major depressive disorder among those who commit suicide, not any other mood disorders (e.g., bipolar I & II, dysthymia, adjustment disorder with depressed mood). Prevalence estimates that include other mood disorders in addition to major depression are much higher.
Major depression in suicide
The lower bound of the 20-35% estimate of the prevalence of major depression in suicide is loosely based on one psychological autopsy study; a study where the reliability of the diagnoses are somewhat questionable. This study (Rich, Young & Fowler, 1986) of 204 subjects identified 15% of suicides as having major depressive disorder. However, an additional 30% were reported as having "atypical depression," defined in this study as having a depressive syndrome that followed the onset of substance use. If this ambiguously defined group were to be considered major depression, the estimate climbs to 45%. A number of other studies suggest that the prevalence of major depression in suicide is somewhat over 30%. The four other available psychological autopsy studies that include samples of suicides from the full age range and reliable diagnoses based on structured interviews (Arato, Demeter, Rihmer & Somogyi, 1988; Dorpat & Ripley, 1960; Foster, Gillespie, McClelland & Patterson, 1999; Henriksson et al., 1993) obtained prevalence estimates of major depression ranging from 30-34% of suicides. In addition, several psychological autopsy studies examining more specific subsamples (e.g., the elderly, adolescents, women) find even higher prevalence estimates. In three psychological autopsy studies of adolescents (Brent et al. 1988; Brent et al., 1999; Shaffer et al., 1996) 41%, 43%, and 32% of adolescent suicides were determined to have had major depression prior to death. Two studies of young adults (Lesage et al. 1994; Runeson, 1989) found a prevalence of 40% and 41%, respectively. A study of 104 women by Asgard (1990) found a 35% rate of major depression. One study of 54 older adults over age 65 found a prevalence of 54%. In summary, the available data suggest that the 20-35% estimate for the prevalence of major depressive disorder in completed suicide is probably somewhat conservative and that a 30-40% prevalence estimate is probably more accurate. This estimate includes both secondary and primary depression. Many of these individuals would also be comorbid with other disorders, especially substance abuse.
Mood disorders in suicide
Prevalence estimates for all mood disorders in suicide (including MDD, Bipolar I & II, dysthymia, and adjustment disorder with depressed mood) are much higher than for major depression alone. These rates are probably closer to 60%, although as noted below, this estimate varies because of inconsistency of the criteria used to define a "mood disorder" across investigations. Four studies examining the full age range of suicides estimate that 36%, 48%, and 66%, and 70% of suicides have some sort of "depressive disorder" or "depression" (Foster et al., 1999; Rich et al., 1986, Henriksson et al., 1993, Barraclough, Bunch, Nelson, & Sainsbury, 1974). Three studies of adolescents found prevalence estimates for "mood disorders" or "affective disorders" of 61%, 63%, and 67% respectively (Shaffer et al., 1996; Brent et al. 1988; Marttunen et al., 1992). Two studies of young adults (Lesage et al., 1994; Runeson, 1989) found estimates of 60% and 64%. A study of 104 women by Asgard (1990) found a 59% rate of "mood disorders." In a review of psychological autopsy studies that examined patterns of psychiatric diagnosis across age groups, Conwell and Brent (1995) concluded that depressive disorders increased with age. Overall estimates for the rates of mood disorders range from 36% to 70% with great interstudy variability. This variability is probably partly a combination of unreliable methods of diagnosis and different definitions of what constitutes a "mood disorder." Despite this variability, a number of studies have found a pattern for increasing mood disorders with aging.
--------------------------------------------------------------------------------
References
Angst, J., Angst, F., and Stassen, H. H. (1999). Suicide risk in patients with major depressive disorder. Journal of Clinical Psychiatry, 60(supp. 2), 57-62.
Arato, M., Demeter, E., Rihmer, Z., & Somogyi, E. (1988). Retrospective psychiatric assessment of 200 suicides in Budapest. Acta Psychiatrica Scandinavica, 77, 454-456.
Asgard, U. (1990). A psychiatric study of suicide among urban women in Sweden. Acta Psychiatrica Scandinavica, 82, 115-124.
Barraclough, B., Bunch, J., Nelson, B., & Sainsbury, P. (1974). A hundred cases of suicide: Clinical aspects. British Journal of Psychiatry, 125,355-373.
Brent, D.A., Perper, J.A., Goldstein, C.E., Kolko, D.J., Allan, M.J., Allman, C.J., & Zelenak, J.P. (1988). Risk factors for adolescent suicide: A comparison of adolescent suicide victims with suicidal inpatients. Archives of General Psychiatry, 45,581-588.
Brent, D. A., Perper, J. A., Moritz, G., Allman, C., Friend, A., Roth, C., Schweers, J., Balach, L., & Baugher, M. (1993). Psychiatric risk factors for adolescent suicide: A case-control study. Journal of the American Academy of Child and Adolescent Psychiatry, 32,521-529.
Clark, D. C. (1991). Final Report to the AARP Adrus Foundation: Suicide Among the Elderly.
Conwell, Y. & Brent, D. (1995). Suicide and aging I: Patterns of psychiatric diagnosis. International Psychogeriatrics, 7, 149-164.
Dorpat, T. L., & Ripley, H. S. (1960). A study of suicide in the Seattle area. Comprehensive Psychiatry, 1, 349-359
Foster, T., Gillespie, K., McClelland, R., & Patterson, C. (1999). Risk factors for suicide independent of DSM-III-R Axis I disorder. British Journal of Psychiatry, 175, 175-179.
Henriksson, M. M., Aro, H. M., Marttunen, M. J., Heikkinen, M. E., Isometa, E. T., Kuoppasalmi, K. I., & Lonqvist, J. K. (1993). Mental disorders and comorbidity in suicide. American Journal of Psychiatry, 150, 935-940.
Lesage, A., Boyer, R., Grunberg, F., Vanier, C., Morissette, R., Menard-Bueeau, C., & Loyer, M. (1994). Suicide and mental disorders: A case-control study of young men. American Journal of Psychiatry, 151, 1063-1068.
Marttunen, M. J., Hillevi, M., Aro, H.M., & Lonnqvist, J. K. (1992). Adolescent suicide: Endpoint of long-term difficulties. Journal of the American Academy of Child and Adolescent Psychiatry, 34(4), 649-654.
Rich, C. L., Young, D., & Fowler, R. C. (1986). San Diego suicide study: Young vs old subjects. Archives of General Psychiatry, 43, 577-582.
Runeson, B. (1989). Mental disorder in youth suicide: DSM-III-R Axes I and II. Acta Psychiatrica Scandinavica, 79, 490-497.
Shaffer, D., Gould, M. S., Fisher, P., Trautmann, P., Moeau, D., Kleinman, M., & Flory, M. (1996). Psychiatric diagnosis in child and adolescent suicide. Archives of General Psychiatry, 53, 339-348.
April 12, 2010
Common Stress Reactions Following Exposure To Trauma
Common Stress Reactions Following Exposure To Trauma
Psychological and EmotionalInitial euphoria, relief
Guilt about surviving or not having suffered as much as others
Anxiety, fear, insecurity, worry
Pervasive concern about well-being of loved ones
Feelings of helplessness, inadequacy, being overwhelmed
Vulnerability
Loss of sense of power, control, well-being, self-confidence, trust
Shame, anger over vulnerability
Irritability, restlessness, hyperexcitability, impatience, agitation, anger, blaming (anger at source, anger at those exempted, anger at those trying to help, anger “for no apparent reason”)
Outrage, resentment
Frustration
Cynicism, negativity
Mood swings
Despair, grief, sadness
Periods of crying, emotional “attacks” or “pangs”
Feelings of emptiness, loss, hopelessness, depression
Regression
Reawakening of past trauma, painful experiences
Apathy, diminished interest in usual activities
Feelings of isolation, detachment, estrangement, “no one else can understand”
Denial or constriction of feelings; numbness
“Flashbacks,” intrusive memories of the event, illusions, pseudo-hallucinations
Recurrent dreams of the event or other traumas
Cognitive
Poor concentration
Mental confusion, slowness of thinking
Forgetfulness
Amnesia (complete or partial)
Inability to make judgments and decisions
Inability to appreciate importance or meaning of stimuli
Poor judgment
Loss of appropriate sense of reality (denial of reality, fantasies to counteract reality)
Preoccupation with the event
Repetitive, obsessive thoughts and ruminations
Over-generalization, over-association with the event
Loss of objectivity
Rigidity
Confusion regarding religious beliefs/value systems; breakdown of meaning and faith
Self-criticism over things done/not done during trauma
Awareness of own and loved ones’ mortality
http://www.aspirace.com
Psychological and EmotionalInitial euphoria, relief
Guilt about surviving or not having suffered as much as others
Anxiety, fear, insecurity, worry
Pervasive concern about well-being of loved ones
Feelings of helplessness, inadequacy, being overwhelmed
Vulnerability
Loss of sense of power, control, well-being, self-confidence, trust
Shame, anger over vulnerability
Irritability, restlessness, hyperexcitability, impatience, agitation, anger, blaming (anger at source, anger at those exempted, anger at those trying to help, anger “for no apparent reason”)
Outrage, resentment
Frustration
Cynicism, negativity
Mood swings
Despair, grief, sadness
Periods of crying, emotional “attacks” or “pangs”
Feelings of emptiness, loss, hopelessness, depression
Regression
Reawakening of past trauma, painful experiences
Apathy, diminished interest in usual activities
Feelings of isolation, detachment, estrangement, “no one else can understand”
Denial or constriction of feelings; numbness
“Flashbacks,” intrusive memories of the event, illusions, pseudo-hallucinations
Recurrent dreams of the event or other traumas
Cognitive
Poor concentration
Mental confusion, slowness of thinking
Forgetfulness
Amnesia (complete or partial)
Inability to make judgments and decisions
Inability to appreciate importance or meaning of stimuli
Poor judgment
Loss of appropriate sense of reality (denial of reality, fantasies to counteract reality)
Preoccupation with the event
Repetitive, obsessive thoughts and ruminations
Over-generalization, over-association with the event
Loss of objectivity
Rigidity
Confusion regarding religious beliefs/value systems; breakdown of meaning and faith
Self-criticism over things done/not done during trauma
Awareness of own and loved ones’ mortality
http://www.aspirace.com
April 11, 2010
DISASTER COUNSELING SKILLS
For Mental Health and Human Services Workers
in Major Disasters
DISASTER COUNSELING SKILLS
Disaster counseling involves both listening and guiding. Survivors typically benefit from both talking about their disaster experiences and being assisted with problem-solving and referral to resources. The following section provides "nuts-and-bolts" suggestions for workers.
ESTABLISHING RAPPORT
Survivors respond when workers offer caring eye contact, a calm presence, and are able to listen with their hearts. Rapport refers to the feelings of interest and understanding that develop when genuine concern is shown. Conveying respect and being nonjudgmental are necessary ingredients for building rapport.
ACTIVE LISTENING
Workers listen most effectively when they take in information through their ears, eyes, and "extrasensory radar" to better understand the survivor's situation and needs. Some tips for listening are:
Allow silence - Silence gives the survivor time to reflect and become aware of feelings. Silence can prompt the survivor to elaborate. Simply "being with" the survivor and their experience is supportive.
Attend nonverbally - Eye contact, head nodding, caring facial expressions, and occasional "uh-huhs" let the survivor know that the worker is in tune with them.
Paraphrase - When the worker repeats portions of what the survivor has said, understanding, interest, and empathy are conveyed. Paraphrasing also checks for accuracy, clarifies misunderstandings, and lets the survivor know that he or she is being heard. Good lead-ins are: "So you are saying that . . . " or "I have heard you say that . . . "
Reflect feelings - The worker may notice that the survivor's tone of voice or nonverbal gestures suggests anger, sadness, or fear. Possible responses are, "You sound angry, scared etc., does that fit for you?" This helps the survivor identify and articulate his or her emotions.
Allow expression of emotions - Expressing intense emotions through tears or angry venting is an important part of healing; it often helps the survivor work through feelings so that he or she can better engage in constructive problem-solving. Workers should stay relaxed, breathe, and let the survivor know that it is OK to feel.
SOME DO'S AND DON'T'S
Do say:
These are normal reactions to a disaster.
It is understandable that you feel this way.
You are not going crazy.
It wasn't your fault, you did the best you could.
Things may never be the same, but they will get better, and you will feel better.
Don't say:
It could have been worse.
You can always get another pet/car/house.
It's best if you just stay busy.
I know just how you feel.
You need to get on with your life.
The human desire to try to fix the survivor's painful situation or make the survivor feel better often underlies the preceding "Don't say" list. However, as a result of receiving comments such as these, the survivor may feel discounted, not understood, or more alone. It is best when workers allow survivors their own experiences, feelings, and perspectives.
PROBLEM-SOLVING
Disaster stress often causes disorganized thinking and difficulty with planning. Some survivors react by feeling overwhelmed and become either immobilized or unproductively overactive. Workers can guide survivors through the following problem-solving steps to assist with prioritizing and focusing action.
Identify and define the problem
Describe the problems/challenges you are facing right now.
Selecting one problem is helpful, identify it as the most immediate, and focus on it first. The problem should be relatively solvable, as an immediate success is important in bringing back a sense of control and confidence.
Assess the survivor's functioning and coping
How have you coped with stressful life events in the past?
How are you doing now?
Through observation, asking questions, and reviewing the magnitude of the survivor's problems and losses, the worker develops an impression of the survivor's capacity to address current challenges. Based on this assessment-the worker may make referrals, point out coping strengths, and facilitate the survivor's engagement with social supports. The worker may also seek consultation from medical, psychological, psychiatric, or disaster relief resources.
Evaluate available resources
Who might be able to help you with this problem?
What resources/options might help?
Explore existing sources of assistance and support such as immediate and extended family, friends, church community, health care providers, etc. and how the survivor might obtain their help. Refer the survivor to the appropriate relief agencies and assess if the survivor is able to make the calls and complete the required applications. Assist with accessing resources when necessary.
Develop and implement a plan
What steps will you take to address this problem?
Encourage the survivor to say aloud what he or she plans to do and how. Offer to check-in with the survivor in a few days to see how it is going. If the worker has agreed to perform a task for the survivor, it is very important to follow through. Workers should promise only what they can do, not what they would like to do.
A WORD OF CAUTION
When confronted with a disaster survivor's seemingly overwhelming needs, workers can feel the understandable impulse to help in every way possible. Workers may become over involved and do too much for the survivor. This is usually not in the best interest of the survivor. When survivors are empowered to solve their own problems, they feel more capable, competent, and able to tackle the next challenge. Workers should clearly understand the scope of their role in the disaster relief effort and recognize that empowering survivors is different from doing for them.
CONFIDENTIALITY
A helping person is in a privileged position. Helping a survivor in need infers a sharing of problems, concerns, and anxieties-sometimes with intimate details. This special sharing cannot be done without a sense of trust, built upon mutual respect, and the explicit understanding that all discussions are confidential and private. No case should be discussed elsewhere without the consent of the person being helped (except in an extreme emergency when it is judged that the person will harm himself or others). It is only by maintaining the trust and respect of the survivor that the privilege of helping can continue to be exercised.
in Major Disasters
DISASTER COUNSELING SKILLS
Disaster counseling involves both listening and guiding. Survivors typically benefit from both talking about their disaster experiences and being assisted with problem-solving and referral to resources. The following section provides "nuts-and-bolts" suggestions for workers.
ESTABLISHING RAPPORT
Survivors respond when workers offer caring eye contact, a calm presence, and are able to listen with their hearts. Rapport refers to the feelings of interest and understanding that develop when genuine concern is shown. Conveying respect and being nonjudgmental are necessary ingredients for building rapport.
ACTIVE LISTENING
Workers listen most effectively when they take in information through their ears, eyes, and "extrasensory radar" to better understand the survivor's situation and needs. Some tips for listening are:
Allow silence - Silence gives the survivor time to reflect and become aware of feelings. Silence can prompt the survivor to elaborate. Simply "being with" the survivor and their experience is supportive.
Attend nonverbally - Eye contact, head nodding, caring facial expressions, and occasional "uh-huhs" let the survivor know that the worker is in tune with them.
Paraphrase - When the worker repeats portions of what the survivor has said, understanding, interest, and empathy are conveyed. Paraphrasing also checks for accuracy, clarifies misunderstandings, and lets the survivor know that he or she is being heard. Good lead-ins are: "So you are saying that . . . " or "I have heard you say that . . . "
Reflect feelings - The worker may notice that the survivor's tone of voice or nonverbal gestures suggests anger, sadness, or fear. Possible responses are, "You sound angry, scared etc., does that fit for you?" This helps the survivor identify and articulate his or her emotions.
Allow expression of emotions - Expressing intense emotions through tears or angry venting is an important part of healing; it often helps the survivor work through feelings so that he or she can better engage in constructive problem-solving. Workers should stay relaxed, breathe, and let the survivor know that it is OK to feel.
SOME DO'S AND DON'T'S
Do say:
These are normal reactions to a disaster.
It is understandable that you feel this way.
You are not going crazy.
It wasn't your fault, you did the best you could.
Things may never be the same, but they will get better, and you will feel better.
Don't say:
It could have been worse.
You can always get another pet/car/house.
It's best if you just stay busy.
I know just how you feel.
You need to get on with your life.
The human desire to try to fix the survivor's painful situation or make the survivor feel better often underlies the preceding "Don't say" list. However, as a result of receiving comments such as these, the survivor may feel discounted, not understood, or more alone. It is best when workers allow survivors their own experiences, feelings, and perspectives.
PROBLEM-SOLVING
Disaster stress often causes disorganized thinking and difficulty with planning. Some survivors react by feeling overwhelmed and become either immobilized or unproductively overactive. Workers can guide survivors through the following problem-solving steps to assist with prioritizing and focusing action.
Identify and define the problem
Describe the problems/challenges you are facing right now.
Selecting one problem is helpful, identify it as the most immediate, and focus on it first. The problem should be relatively solvable, as an immediate success is important in bringing back a sense of control and confidence.
Assess the survivor's functioning and coping
How have you coped with stressful life events in the past?
How are you doing now?
Through observation, asking questions, and reviewing the magnitude of the survivor's problems and losses, the worker develops an impression of the survivor's capacity to address current challenges. Based on this assessment-the worker may make referrals, point out coping strengths, and facilitate the survivor's engagement with social supports. The worker may also seek consultation from medical, psychological, psychiatric, or disaster relief resources.
Evaluate available resources
Who might be able to help you with this problem?
What resources/options might help?
Explore existing sources of assistance and support such as immediate and extended family, friends, church community, health care providers, etc. and how the survivor might obtain their help. Refer the survivor to the appropriate relief agencies and assess if the survivor is able to make the calls and complete the required applications. Assist with accessing resources when necessary.
Develop and implement a plan
What steps will you take to address this problem?
Encourage the survivor to say aloud what he or she plans to do and how. Offer to check-in with the survivor in a few days to see how it is going. If the worker has agreed to perform a task for the survivor, it is very important to follow through. Workers should promise only what they can do, not what they would like to do.
A WORD OF CAUTION
When confronted with a disaster survivor's seemingly overwhelming needs, workers can feel the understandable impulse to help in every way possible. Workers may become over involved and do too much for the survivor. This is usually not in the best interest of the survivor. When survivors are empowered to solve their own problems, they feel more capable, competent, and able to tackle the next challenge. Workers should clearly understand the scope of their role in the disaster relief effort and recognize that empowering survivors is different from doing for them.
CONFIDENTIALITY
A helping person is in a privileged position. Helping a survivor in need infers a sharing of problems, concerns, and anxieties-sometimes with intimate details. This special sharing cannot be done without a sense of trust, built upon mutual respect, and the explicit understanding that all discussions are confidential and private. No case should be discussed elsewhere without the consent of the person being helped (except in an extreme emergency when it is judged that the person will harm himself or others). It is only by maintaining the trust and respect of the survivor that the privilege of helping can continue to be exercised.
April 05, 2010
Depression and Mood Disorders
Depression and Mood Disorders
The Prevalence of Major Depression and Mood Disorders in Suicide
Mental Health: A Report of the Surgeon General, states that "major depressive disorders account for about 20 to 35 percent of all deaths by suicide" (p. 244). This estimate is based on a review of psychological autopsies conducted by Angst, Angst, and Stassen (1999). This brief review is intended to address this prevalence estimate. It is important to note that this estimate refers only to the prevalence of major depressive disorder among those who commit suicide, not any other mood disorders (e.g., bipolar I & II, dysthymia, adjustment disorder with depressed mood). Prevalence estimates that include other mood disorders in addition to major depression are much higher.
Major depression in suicide
The lower bound of the 20-35% estimate of the prevalence of major depression in suicide is loosely based on one psychological autopsy study; a study where the reliability of the diagnoses are somewhat questionable. This study (Rich, Young & Fowler, 1986) of 204 subjects identified 15% of suicides as having major depressive disorder. However, an additional 30% were reported as having "atypical depression," defined in this study as having a depressive syndrome that followed the onset of substance use. If this ambiguously defined group were to be considered major depression, the estimate climbs to 45%. A number of other studies suggest that the prevalence of major depression in suicide is somewhat over 30%. The four other available psychological autopsy studies that include samples of suicides from the full age range and reliable diagnoses based on structured interviews (Arato, Demeter, Rihmer & Somogyi, 1988; Dorpat & Ripley, 1960; Foster, Gillespie, McClelland & Patterson, 1999; Henriksson et al., 1993) obtained prevalence estimates of major depression ranging from 30-34% of suicides. In addition, several psychological autopsy studies examining more specific subsamples (e.g., the elderly, adolescents, women) find even higher prevalence estimates. In three psychological autopsy studies of adolescents (Brent et al. 1988; Brent et al., 1999; Shaffer et al., 1996) 41%, 43%, and 32% of adolescent suicides were determined to have had major depression prior to death. Two studies of young adults (Lesage et al. 1994; Runeson, 1989) found a prevalence of 40% and 41%, respectively. A study of 104 women by Asgard (1990) found a 35% rate of major depression. One study of 54 older adults over age 65 found a prevalence of 54%. In summary, the available data suggest that the 20-35% estimate for the prevalence of major depressive disorder in completed suicide is probably somewhat conservative and that a 30-40% prevalence estimate is probably more accurate. This estimate includes both secondary and primary depression. Many of these individuals would also be comorbid with other disorders, especially substance abuse.
Mood disorders in suicide
Prevalence estimates for all mood disorders in suicide (including MDD, Bipolar I & II, dysthymia, and adjustment disorder with depressed mood) are much higher than for major depression alone. These rates are probably closer to 60%, although as noted below, this estimate varies because of inconsistency of the criteria used to define a "mood disorder" across investigations. Four studies examining the full age range of suicides estimate that 36%, 48%, and 66%, and 70% of suicides have some sort of "depressive disorder" or "depression" (Foster et al., 1999; Rich et al., 1986, Henriksson et al., 1993, Barraclough, Bunch, Nelson, & Sainsbury, 1974). Three studies of adolescents found prevalence estimates for "mood disorders" or "affective disorders" of 61%, 63%, and 67% respectively (Shaffer et al., 1996; Brent et al. 1988; Marttunen et al., 1992). Two studies of young adults (Lesage et al., 1994; Runeson, 1989) found estimates of 60% and 64%. A study of 104 women by Asgard (1990) found a 59% rate of "mood disorders." In a review of psychological autopsy studies that examined patterns of psychiatric diagnosis across age groups, Conwell and Brent (1995) concluded that depressive disorders increased with age. Overall estimates for the rates of mood disorders range from 36% to 70% with great interstudy variability. This variability is probably partly a combination of unreliable methods of diagnosis and different definitions of what constitutes a "mood disorder." Despite this variability, a number of studies have found a pattern for increasing mood disorders with aging.
The Prevalence of Major Depression and Mood Disorders in Suicide
Mental Health: A Report of the Surgeon General, states that "major depressive disorders account for about 20 to 35 percent of all deaths by suicide" (p. 244). This estimate is based on a review of psychological autopsies conducted by Angst, Angst, and Stassen (1999). This brief review is intended to address this prevalence estimate. It is important to note that this estimate refers only to the prevalence of major depressive disorder among those who commit suicide, not any other mood disorders (e.g., bipolar I & II, dysthymia, adjustment disorder with depressed mood). Prevalence estimates that include other mood disorders in addition to major depression are much higher.
Major depression in suicide
The lower bound of the 20-35% estimate of the prevalence of major depression in suicide is loosely based on one psychological autopsy study; a study where the reliability of the diagnoses are somewhat questionable. This study (Rich, Young & Fowler, 1986) of 204 subjects identified 15% of suicides as having major depressive disorder. However, an additional 30% were reported as having "atypical depression," defined in this study as having a depressive syndrome that followed the onset of substance use. If this ambiguously defined group were to be considered major depression, the estimate climbs to 45%. A number of other studies suggest that the prevalence of major depression in suicide is somewhat over 30%. The four other available psychological autopsy studies that include samples of suicides from the full age range and reliable diagnoses based on structured interviews (Arato, Demeter, Rihmer & Somogyi, 1988; Dorpat & Ripley, 1960; Foster, Gillespie, McClelland & Patterson, 1999; Henriksson et al., 1993) obtained prevalence estimates of major depression ranging from 30-34% of suicides. In addition, several psychological autopsy studies examining more specific subsamples (e.g., the elderly, adolescents, women) find even higher prevalence estimates. In three psychological autopsy studies of adolescents (Brent et al. 1988; Brent et al., 1999; Shaffer et al., 1996) 41%, 43%, and 32% of adolescent suicides were determined to have had major depression prior to death. Two studies of young adults (Lesage et al. 1994; Runeson, 1989) found a prevalence of 40% and 41%, respectively. A study of 104 women by Asgard (1990) found a 35% rate of major depression. One study of 54 older adults over age 65 found a prevalence of 54%. In summary, the available data suggest that the 20-35% estimate for the prevalence of major depressive disorder in completed suicide is probably somewhat conservative and that a 30-40% prevalence estimate is probably more accurate. This estimate includes both secondary and primary depression. Many of these individuals would also be comorbid with other disorders, especially substance abuse.
Mood disorders in suicide
Prevalence estimates for all mood disorders in suicide (including MDD, Bipolar I & II, dysthymia, and adjustment disorder with depressed mood) are much higher than for major depression alone. These rates are probably closer to 60%, although as noted below, this estimate varies because of inconsistency of the criteria used to define a "mood disorder" across investigations. Four studies examining the full age range of suicides estimate that 36%, 48%, and 66%, and 70% of suicides have some sort of "depressive disorder" or "depression" (Foster et al., 1999; Rich et al., 1986, Henriksson et al., 1993, Barraclough, Bunch, Nelson, & Sainsbury, 1974). Three studies of adolescents found prevalence estimates for "mood disorders" or "affective disorders" of 61%, 63%, and 67% respectively (Shaffer et al., 1996; Brent et al. 1988; Marttunen et al., 1992). Two studies of young adults (Lesage et al., 1994; Runeson, 1989) found estimates of 60% and 64%. A study of 104 women by Asgard (1990) found a 59% rate of "mood disorders." In a review of psychological autopsy studies that examined patterns of psychiatric diagnosis across age groups, Conwell and Brent (1995) concluded that depressive disorders increased with age. Overall estimates for the rates of mood disorders range from 36% to 70% with great interstudy variability. This variability is probably partly a combination of unreliable methods of diagnosis and different definitions of what constitutes a "mood disorder." Despite this variability, a number of studies have found a pattern for increasing mood disorders with aging.
March 19, 2010
California Bills Regarding MFT and LCS Licenses and CAMFT Position
Unpaid Taxes Effect on Licensees
ABX8 8 (Committee on Budget)
This bill, among other provisions, would require the Franchise Tax Board, should an individual licensee fail to pay taxes, to send a notice of suspension of license. The bill provides that the licensee who fails to satisfy the unpaid taxes by a specified date shall automatically have his/her license suspended. CAMFT has joined with a coalition to oppose this bill.
Child Custody and Visitation
AB 612 (Beall)
This bill, as introduced, would have prohibited a court from considering a nonscientific theory in making a determination regarding child custody or visitation with a child. It would also have prohibited a court from considering or receiving into evidence a report, assessment, evaluation, or investigation if it included a nonscientific theory. CAMFT’s position on the bill was “oppose unless amended.” The bill was later amended in a way that we no longer opposed, providing that a child’s expression of significant hostility toward a parent may be admitted as possible corroborating evidence that the parent has abused the child. The amendment prohibited a court from concluding that an accusation of child physical or sexual abuse against a parent is false based solely on the child’s expression of significant hostility toward the parent. But, this amendment was merely a maneuver to get it out of a committee. As soon as the bill progressed, the offensive language was restored and we are once again opposed. This bill is a two-year bill.
Medi-Cal Reimbursement for Same-Day Visits
AB 1445 (Chesbro)
This bill, sponsored by the California Primary Care Association, would provide that a MediCal patient could seek treatment on the same day from more than one health care provider and the providers’ services would be reimbursed. CAMFT is in support of this legislation. This bill is a two-year bill.
MediCal: Alcohol and Drug Screening and Brief Intervention Services
AB 1599 (Beall)
This bill would establish the MediCal Alcohol and Drug Screening and Brief intervention Services Program, which would be administered in consultation with the State Department of Alcohol and Drug Programs. Its purpose would be to increase the state’s ability to make alcohol and drug screening and brief intervention services available to MediCal beneficiaries who are pregnant or of childbearing age. This bill would provide that participating in the program would be voluntary for MediCal beneficiaries. The results of any screening under the program would be confidential. CAMFT is watching this bill at this time.
Parity for Mental Health Care Services
AB 1600 (Beall)
This bill would expand mental health care coverage for certain health care service plans and health insurance issued, amended, or renewed on or after January 1, 2011, to include mental disorders defined in the DSM IV. There has been similar legislation in the two prior years that has been vetoed by the Governor. This legislation goes hand in hand with the Federal Parity law and expands on the existing California parity law that only covers severe mental and emotional disorders of adults and children. CAMFT is in support of this legislation.
Out of State Insurance Carriers
AB 1904 (Villines)
This bill would allow an insurance carrier from out of state to offer, sell, or renew a health care service plan or a health insurance policy in California without holding a license in the state of California . This bill, if successful, would be problematic for MFTs seeking reimbursement from such plans. Due to legislation that CAMFT sponsored in the 80s, out of state insurance companies are required by law to reimburse MFTs. Because they are required, if doing business in California , to abide by California law, which means that they must be licensed to do business in California . We are opposed to this bill, but we are told that the bill is not likely to move forward. There is a companion bill in the Senate as well.
Clinical Social Worker Examinations
AB 2167 (Nava)
This bill would, on and after January 1, 2014, require the Board of Behavioral Sciences to issue a license to each applicant who successfully passes the Social Work National Exam. In other words, if this legislation passes, aspiring clinical social workers would no longer take state-developed examinations, and they would instead take the examination that is used throughout the rest of the country. This change would allow LCSW licentiates in California to compete for federal loan reimbursements, which they are not currently eligible for because of the state specific examinations. CAMFT is watching this bill.
Retired License for Licensees of the BBS
AB 2191 (Emmerson)
This bill would permit persons who are licensed by the BBS to acquire a “retired” license if they choose to. Such a person would not be permitted to engage in any activity for which a license is required. The retired license fee would be nominal at only $40 for the remainder of one’s life. It would be permissible to restore the license to active state, if eligible, by paying the required fees, completing the required mandatory continuing education, and taking the required examinations if more than five years have passed since electing the retired status. If fewer than five years have passed, examinations would not be required. (The bill currently says three years, but the BBS has committed to increase this exception to five years.) CAMFT is watching this legislation. We do have concerns about licensees electing the retired status who may at a later time return to practice. If there is such a possibility of returning to practice, we would encourage the licentiate to elect to have an inactive license during the period of inaction because examinations would not be required upon re-activation.
Repeal of Antiquated Law Regarding Research on Homosexuality
AB 2199 (Lowenthal)
CAMFT has taken a position of support on this legislation that would repeal an antiquated section of law that provided for research regarding the causes and cures of homosexuality.
Child Abuse and Neglect Reporting Act
AB 2380 (Lowenthal)
This bill, among other things, adds further clarification in the Child Abuse and Neglect Reporting Act with regard to the meaning of “reasonable suspicion.” Existing law says that “. . . ‘reasonable suspicion’ means that it is objectively reasonable for a person to entertain a suspicion, based upon facts that could cause a reasonable person in a like position, drawing, when appropriate, on his or her training and experience, to suspect child abuse or neglect.” Added to this definition would be the following: “‘Reasonable suspicion’ does not require certain knowledge that child abuse or neglect has occurred nor does it require a specific medical indication of child abuse or neglect; any ‘reasonable suspicion’ is sufficient. ‘Reasonable suspicion’ may be based on any information considered credible by the reporter, including hearsay.” CAMFT is watching this bill at this time.
Continuing Education and other Requirements with regard to Elder and Dependent Adult Abuse and Older Adults
(AB 2435) Lowenthal
CAMFT’s position on this bill is “oppose unless amended.” The bill appears to be intended to affect the professions of marriage and family therapists, clinical social workers, and psychologists, but at this time appears to be solely directed at marriage and family therapists. If such legislation is warranted, we believe it should be equally applied across all of the mental health disciplines. We further object in that there appears to be no intent to affect physicians or other health care professionals and we are curious as to why not. It is also not applicable to professional clinical counselors who will also be regulated by the effective date of the proposed implementation of this legislation.
The bill proposes that elder and dependent adult abuse be added to the seven hour requirement for continuing education in child abuse assessment and reporting. The manner in which the bill proposes to add the requirement to provide for training in elder and dependent adult abuse is confusing and will result in an inability to enforce what is intended. All persons who are already licensed, as well as many who are pursuing licensure, have already fulfilled the requirement to have had training in child abuse assessment and reporting. Placing the new requirement to get training in elder and dependent adult abuse assessment and reporting within this previously existing requirement for training in child abuse and assessment confounds the situation and professionals will not be able to interpret what it is they are supposed to do, i.e., are they to take a new seven hour training that combines the content for both child abuse and elder abuse, or are they to take a three and one-half hour course in elder and dependent adult abuse, which is half of the total requirement?
While we have expressed that we are not necessarily adverse to a requirement for professionals to be knowledgeable about the reporting of elder and dependent adult abuse, as long as equally applied across the professions, this legislation needs to be clear as to what is expected. At this point, it is not. The bill does not address persons who have already taken such courses, or taught such courses, or who have had the content adequately addressed in the content of other courses. This content is typically covered in law and ethics courses and human development courses that cover the lifespan of individuals and families.
The bill proposes changing the name of one (and only one) of the degrees that may qualify for licensure as a marriage and family therapist. Such a change would place a hardship on schools that may have difficulty rapidly changing the title of their degree programs. Adding the term “older adult” without a definition as to what is meant by such a term is also problematic. We would request that this term be removed from the degree title.
The legislation proposes that the 500 required hours of experience for marriage and family therapists in working with couples, families, and children be expanded to include older adults. Again, “older adults” is not defined. Further, while we do not object to required education in working with persons who are aging, we do not want to see the essence and focus of the profession changed. This profession was known as “marriage, family and child counselors” from 1964 until 1999 and then became “marriage and family therapists.” Working with couples, families, and children is at the core of the discipline and of course includes working with persons who are aging, as they too are a part of family systems. We therefore have requested that the focus of these hours not be changed. Additionally, if there were to be such a change in the marriage and family therapist requirements, it should be equally imposed upon the other disciplines and provide greater specificity as to what is intended by the term “older adults.”
Further, persons pursuing the MFT license are currently required to have had ten contact hours of education in working with the elderly and long term care, and those already licensed prior to the effective date of this requirement were required to gain three contact hours in working with the elderly and long term care.
Unpaid Taxes Effect on Licensees
SBX8 8 (Committee on Budget)
This bill like its Assembly companion, among other provisions, would require the Franchise Tax Board, should an individual licensee fails to pay taxes, to send a notice of suspension of license. The bill provides that the licensee who fails to satisfy the unpaid taxes by a specified date shall automatically have his/her license suspended. CAMFT has joined with a coalition to oppose this bill.
Health Care Coverage and Benefits
SB 316 (Alquist)
This bill would have required full service health care service plans and health insurers to expend on health care benefits no less than 85 percent of the fees/premiums collected for policies issued, amended, or renewed on or after January 1, 2011. CAMFT is in support of this legislation. This bill is a two-year bill.
Regulatory Boards
(SB 1111) Negrette McLeod
This is a lengthy and multi-faceted bill that has numerous objectionable provisions. We are generally opposed to the bill and will be working individually and collectively with the other disciplines to modify the objectionable provisions. The purpose of the bill, generally speaking, is to “clean up” enforcement throughout the many Boards, Bureaus, and Committees under the umbrella of the Department of Consumer Affairs. The Department and Administration, rightfully so, are concerned about the excessive amount of time it takes to investigate and prosecute disciplinary actions. These actions, on average, are taking three years to bring to fruition. Of course, both consumers and licensees have an interest in swift resolution of complaints and disciplinary actions. Further, the state’s budget likely exacerbates the delays as a result of cuts within licensing boards, the California Department of Consumer Affairs Division of Investigations (DofI), and the Attorney General’s (AG) office. This bill is seeking to improve efficiency and accountability specifically within the healing arts boards.
One of the changes being sought would require a person who is disciplined to pay to the licensing board the actual costs for the investigation, prosecution, and enforcement of the case. These costs include, but are not limited to, attorneys, expert consultants, witnesses, administrative filing and service fees, and any other fees associated with the prosecution of the case. Currently the licensee, as determined by the administrative law judge, is ordered to pay the “reasonable” costs of the investigation and enforcement of the case. Changing reasonable to actual provides no incentive to the board, the DofI, or the AG’s office to be judicious in how it handles these matters. If they drag cases on for years and years, engage in actions that violate the law or due process rights, and/or needlessly pursue wild goose chases, the licentiate should not be held responsible for such costs. These costs are generally payable 30 days after the effective date of the order and there appears to be no opportunity to challenge the costs as determined.
The bill would give additional authority to the executive officer of the licensing board in many cases. For example, the executive officer would, in some situations, be given the authority to adopt a proposed default decision or adopt a proposed settlement agreement, without such action going to the board. The bill would allow the executive officer of a board, where the licentiate has failed to comply with a request to inspect or copy records, to petition the director to issue a temporary order that the licensee cease all practice and activities that require a license. In such case, the executive officer would be required, to the extent practicable, to provide telephonic, electronic mail, message, or facsimile written notice to the licensee of a hearing on such a petition at least 24 hours prior to the hearing.
The bill seems to confuse confidentiality and privilege. The bill seems to say that the provisions of privileged communications (should be confidentiality when speaking of communications between licensees and their clients) shall not apply to investigations or proceedings conducted by a healing arts board. The board and its agents are expected to maintain confidentiality, but they would have the authority to examine records in the licensee’s office in certain circumstances, apparently without authorization. The psychotherapist-patient privilege belongs to the patient and only the patient should be able to waive the privilege—not a licensing board. The bill provides, “Any document relevant to the business operations of a licensee, and not involving medical records attributable to identifiable patients, may be inspected and copied where relevant to an investigation of a licensee.”
The bill provides that a licensee shall cooperate with the licensing board and sets forth severe financial penalties for those who are deemed to be uncooperative. In such a circumstance, it may not be in the licensee’s best interest to cooperate in order to defend oneself. Such an expectation is unreasonable.
Requirement for Healing Arts Practitioners to Wear Name Tags
(SB 1132) Negrete McLeod
This is a “spot bill” surrounding legislation that has passed in prior years. Existing law requires healing arts practitioners to wear name tags while working that disclose names and license status in at least 18-point type. This requirement is not applicable to health care practitioners working in a practice or an office where a license is prominently displayed. Existing law further provides that if a health care practitioner or a licensed clinical social worker is working in a psychiatric setting or in a setting that is not licensed by the state, the employing entity or agency shall have the discretion to make an exception from the name tag requirement for individual safety or therapeutic reasons. CAMFT is watching this legislation that could become more expansive requiring practitioners to wear name tags.
Restrictions on Advertising and Designations of Licensees
(SB 1150) Negrete McLeod
At this time this bill is not applicable to MFTs, but we are nevertheless watching the bill very closely to see what it will become. The bill, among other things, would require a number of professionals, when advertising, to list the abbreviations for the licenses held immediately after their names. Among other things, the bill would require psychologists to include the designation “Ph.D.” immediately after their names. Of course, the bill is incorrect with regard to psychologists because the supposed required designation is a degree and not a license. The purpose of this legislation may be directed, to some degree, at the potential misleading use of “Dr.” preceding the name of a professional, since such a representation is limited to use by physicians.
ABX8 8 (Committee on Budget)
This bill, among other provisions, would require the Franchise Tax Board, should an individual licensee fail to pay taxes, to send a notice of suspension of license. The bill provides that the licensee who fails to satisfy the unpaid taxes by a specified date shall automatically have his/her license suspended. CAMFT has joined with a coalition to oppose this bill.
Child Custody and Visitation
AB 612 (Beall)
This bill, as introduced, would have prohibited a court from considering a nonscientific theory in making a determination regarding child custody or visitation with a child. It would also have prohibited a court from considering or receiving into evidence a report, assessment, evaluation, or investigation if it included a nonscientific theory. CAMFT’s position on the bill was “oppose unless amended.” The bill was later amended in a way that we no longer opposed, providing that a child’s expression of significant hostility toward a parent may be admitted as possible corroborating evidence that the parent has abused the child. The amendment prohibited a court from concluding that an accusation of child physical or sexual abuse against a parent is false based solely on the child’s expression of significant hostility toward the parent. But, this amendment was merely a maneuver to get it out of a committee. As soon as the bill progressed, the offensive language was restored and we are once again opposed. This bill is a two-year bill.
Medi-Cal Reimbursement for Same-Day Visits
AB 1445 (Chesbro)
This bill, sponsored by the California Primary Care Association, would provide that a MediCal patient could seek treatment on the same day from more than one health care provider and the providers’ services would be reimbursed. CAMFT is in support of this legislation. This bill is a two-year bill.
MediCal: Alcohol and Drug Screening and Brief Intervention Services
AB 1599 (Beall)
This bill would establish the MediCal Alcohol and Drug Screening and Brief intervention Services Program, which would be administered in consultation with the State Department of Alcohol and Drug Programs. Its purpose would be to increase the state’s ability to make alcohol and drug screening and brief intervention services available to MediCal beneficiaries who are pregnant or of childbearing age. This bill would provide that participating in the program would be voluntary for MediCal beneficiaries. The results of any screening under the program would be confidential. CAMFT is watching this bill at this time.
Parity for Mental Health Care Services
AB 1600 (Beall)
This bill would expand mental health care coverage for certain health care service plans and health insurance issued, amended, or renewed on or after January 1, 2011, to include mental disorders defined in the DSM IV. There has been similar legislation in the two prior years that has been vetoed by the Governor. This legislation goes hand in hand with the Federal Parity law and expands on the existing California parity law that only covers severe mental and emotional disorders of adults and children. CAMFT is in support of this legislation.
Out of State Insurance Carriers
AB 1904 (Villines)
This bill would allow an insurance carrier from out of state to offer, sell, or renew a health care service plan or a health insurance policy in California without holding a license in the state of California . This bill, if successful, would be problematic for MFTs seeking reimbursement from such plans. Due to legislation that CAMFT sponsored in the 80s, out of state insurance companies are required by law to reimburse MFTs. Because they are required, if doing business in California , to abide by California law, which means that they must be licensed to do business in California . We are opposed to this bill, but we are told that the bill is not likely to move forward. There is a companion bill in the Senate as well.
Clinical Social Worker Examinations
AB 2167 (Nava)
This bill would, on and after January 1, 2014, require the Board of Behavioral Sciences to issue a license to each applicant who successfully passes the Social Work National Exam. In other words, if this legislation passes, aspiring clinical social workers would no longer take state-developed examinations, and they would instead take the examination that is used throughout the rest of the country. This change would allow LCSW licentiates in California to compete for federal loan reimbursements, which they are not currently eligible for because of the state specific examinations. CAMFT is watching this bill.
Retired License for Licensees of the BBS
AB 2191 (Emmerson)
This bill would permit persons who are licensed by the BBS to acquire a “retired” license if they choose to. Such a person would not be permitted to engage in any activity for which a license is required. The retired license fee would be nominal at only $40 for the remainder of one’s life. It would be permissible to restore the license to active state, if eligible, by paying the required fees, completing the required mandatory continuing education, and taking the required examinations if more than five years have passed since electing the retired status. If fewer than five years have passed, examinations would not be required. (The bill currently says three years, but the BBS has committed to increase this exception to five years.) CAMFT is watching this legislation. We do have concerns about licensees electing the retired status who may at a later time return to practice. If there is such a possibility of returning to practice, we would encourage the licentiate to elect to have an inactive license during the period of inaction because examinations would not be required upon re-activation.
Repeal of Antiquated Law Regarding Research on Homosexuality
AB 2199 (Lowenthal)
CAMFT has taken a position of support on this legislation that would repeal an antiquated section of law that provided for research regarding the causes and cures of homosexuality.
Child Abuse and Neglect Reporting Act
AB 2380 (Lowenthal)
This bill, among other things, adds further clarification in the Child Abuse and Neglect Reporting Act with regard to the meaning of “reasonable suspicion.” Existing law says that “. . . ‘reasonable suspicion’ means that it is objectively reasonable for a person to entertain a suspicion, based upon facts that could cause a reasonable person in a like position, drawing, when appropriate, on his or her training and experience, to suspect child abuse or neglect.” Added to this definition would be the following: “‘Reasonable suspicion’ does not require certain knowledge that child abuse or neglect has occurred nor does it require a specific medical indication of child abuse or neglect; any ‘reasonable suspicion’ is sufficient. ‘Reasonable suspicion’ may be based on any information considered credible by the reporter, including hearsay.” CAMFT is watching this bill at this time.
Continuing Education and other Requirements with regard to Elder and Dependent Adult Abuse and Older Adults
(AB 2435) Lowenthal
CAMFT’s position on this bill is “oppose unless amended.” The bill appears to be intended to affect the professions of marriage and family therapists, clinical social workers, and psychologists, but at this time appears to be solely directed at marriage and family therapists. If such legislation is warranted, we believe it should be equally applied across all of the mental health disciplines. We further object in that there appears to be no intent to affect physicians or other health care professionals and we are curious as to why not. It is also not applicable to professional clinical counselors who will also be regulated by the effective date of the proposed implementation of this legislation.
The bill proposes that elder and dependent adult abuse be added to the seven hour requirement for continuing education in child abuse assessment and reporting. The manner in which the bill proposes to add the requirement to provide for training in elder and dependent adult abuse is confusing and will result in an inability to enforce what is intended. All persons who are already licensed, as well as many who are pursuing licensure, have already fulfilled the requirement to have had training in child abuse assessment and reporting. Placing the new requirement to get training in elder and dependent adult abuse assessment and reporting within this previously existing requirement for training in child abuse and assessment confounds the situation and professionals will not be able to interpret what it is they are supposed to do, i.e., are they to take a new seven hour training that combines the content for both child abuse and elder abuse, or are they to take a three and one-half hour course in elder and dependent adult abuse, which is half of the total requirement?
While we have expressed that we are not necessarily adverse to a requirement for professionals to be knowledgeable about the reporting of elder and dependent adult abuse, as long as equally applied across the professions, this legislation needs to be clear as to what is expected. At this point, it is not. The bill does not address persons who have already taken such courses, or taught such courses, or who have had the content adequately addressed in the content of other courses. This content is typically covered in law and ethics courses and human development courses that cover the lifespan of individuals and families.
The bill proposes changing the name of one (and only one) of the degrees that may qualify for licensure as a marriage and family therapist. Such a change would place a hardship on schools that may have difficulty rapidly changing the title of their degree programs. Adding the term “older adult” without a definition as to what is meant by such a term is also problematic. We would request that this term be removed from the degree title.
The legislation proposes that the 500 required hours of experience for marriage and family therapists in working with couples, families, and children be expanded to include older adults. Again, “older adults” is not defined. Further, while we do not object to required education in working with persons who are aging, we do not want to see the essence and focus of the profession changed. This profession was known as “marriage, family and child counselors” from 1964 until 1999 and then became “marriage and family therapists.” Working with couples, families, and children is at the core of the discipline and of course includes working with persons who are aging, as they too are a part of family systems. We therefore have requested that the focus of these hours not be changed. Additionally, if there were to be such a change in the marriage and family therapist requirements, it should be equally imposed upon the other disciplines and provide greater specificity as to what is intended by the term “older adults.”
Further, persons pursuing the MFT license are currently required to have had ten contact hours of education in working with the elderly and long term care, and those already licensed prior to the effective date of this requirement were required to gain three contact hours in working with the elderly and long term care.
Unpaid Taxes Effect on Licensees
SBX8 8 (Committee on Budget)
This bill like its Assembly companion, among other provisions, would require the Franchise Tax Board, should an individual licensee fails to pay taxes, to send a notice of suspension of license. The bill provides that the licensee who fails to satisfy the unpaid taxes by a specified date shall automatically have his/her license suspended. CAMFT has joined with a coalition to oppose this bill.
Health Care Coverage and Benefits
SB 316 (Alquist)
This bill would have required full service health care service plans and health insurers to expend on health care benefits no less than 85 percent of the fees/premiums collected for policies issued, amended, or renewed on or after January 1, 2011. CAMFT is in support of this legislation. This bill is a two-year bill.
Regulatory Boards
(SB 1111) Negrette McLeod
This is a lengthy and multi-faceted bill that has numerous objectionable provisions. We are generally opposed to the bill and will be working individually and collectively with the other disciplines to modify the objectionable provisions. The purpose of the bill, generally speaking, is to “clean up” enforcement throughout the many Boards, Bureaus, and Committees under the umbrella of the Department of Consumer Affairs. The Department and Administration, rightfully so, are concerned about the excessive amount of time it takes to investigate and prosecute disciplinary actions. These actions, on average, are taking three years to bring to fruition. Of course, both consumers and licensees have an interest in swift resolution of complaints and disciplinary actions. Further, the state’s budget likely exacerbates the delays as a result of cuts within licensing boards, the California Department of Consumer Affairs Division of Investigations (DofI), and the Attorney General’s (AG) office. This bill is seeking to improve efficiency and accountability specifically within the healing arts boards.
One of the changes being sought would require a person who is disciplined to pay to the licensing board the actual costs for the investigation, prosecution, and enforcement of the case. These costs include, but are not limited to, attorneys, expert consultants, witnesses, administrative filing and service fees, and any other fees associated with the prosecution of the case. Currently the licensee, as determined by the administrative law judge, is ordered to pay the “reasonable” costs of the investigation and enforcement of the case. Changing reasonable to actual provides no incentive to the board, the DofI, or the AG’s office to be judicious in how it handles these matters. If they drag cases on for years and years, engage in actions that violate the law or due process rights, and/or needlessly pursue wild goose chases, the licentiate should not be held responsible for such costs. These costs are generally payable 30 days after the effective date of the order and there appears to be no opportunity to challenge the costs as determined.
The bill would give additional authority to the executive officer of the licensing board in many cases. For example, the executive officer would, in some situations, be given the authority to adopt a proposed default decision or adopt a proposed settlement agreement, without such action going to the board. The bill would allow the executive officer of a board, where the licentiate has failed to comply with a request to inspect or copy records, to petition the director to issue a temporary order that the licensee cease all practice and activities that require a license. In such case, the executive officer would be required, to the extent practicable, to provide telephonic, electronic mail, message, or facsimile written notice to the licensee of a hearing on such a petition at least 24 hours prior to the hearing.
The bill seems to confuse confidentiality and privilege. The bill seems to say that the provisions of privileged communications (should be confidentiality when speaking of communications between licensees and their clients) shall not apply to investigations or proceedings conducted by a healing arts board. The board and its agents are expected to maintain confidentiality, but they would have the authority to examine records in the licensee’s office in certain circumstances, apparently without authorization. The psychotherapist-patient privilege belongs to the patient and only the patient should be able to waive the privilege—not a licensing board. The bill provides, “Any document relevant to the business operations of a licensee, and not involving medical records attributable to identifiable patients, may be inspected and copied where relevant to an investigation of a licensee.”
The bill provides that a licensee shall cooperate with the licensing board and sets forth severe financial penalties for those who are deemed to be uncooperative. In such a circumstance, it may not be in the licensee’s best interest to cooperate in order to defend oneself. Such an expectation is unreasonable.
Requirement for Healing Arts Practitioners to Wear Name Tags
(SB 1132) Negrete McLeod
This is a “spot bill” surrounding legislation that has passed in prior years. Existing law requires healing arts practitioners to wear name tags while working that disclose names and license status in at least 18-point type. This requirement is not applicable to health care practitioners working in a practice or an office where a license is prominently displayed. Existing law further provides that if a health care practitioner or a licensed clinical social worker is working in a psychiatric setting or in a setting that is not licensed by the state, the employing entity or agency shall have the discretion to make an exception from the name tag requirement for individual safety or therapeutic reasons. CAMFT is watching this legislation that could become more expansive requiring practitioners to wear name tags.
Restrictions on Advertising and Designations of Licensees
(SB 1150) Negrete McLeod
At this time this bill is not applicable to MFTs, but we are nevertheless watching the bill very closely to see what it will become. The bill, among other things, would require a number of professionals, when advertising, to list the abbreviations for the licenses held immediately after their names. Among other things, the bill would require psychologists to include the designation “Ph.D.” immediately after their names. Of course, the bill is incorrect with regard to psychologists because the supposed required designation is a degree and not a license. The purpose of this legislation may be directed, to some degree, at the potential misleading use of “Dr.” preceding the name of a professional, since such a representation is limited to use by physicians.
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