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Depression in Children and Adolescents: Clinical Considerations

President’s Message

by Mark Patterson, Ph.D.

 

Greetings!  This is the first Newsletter to come out in our new and improved website.  Our new website was launched just a few weeks ago, and many of our colleagues made significant contributions to make that happen.  Special thanks to the Website Committee, Annette Taylor, Lea Goldstein, Glory Denkers, Charlotte Ormond, and past and present Board members. 

 

As we all become more familiar with our website, improvements will be made through member feedback.  Please feel free to offer suggestions! 

 

Our goal is that the website be a useful and dynamic resource for members.  In particular, if you haven’t done so already, I encourage you to check out the Forums tool.  It’s a great way to communicate with colleagues.  The Calendar will also keep you up to date on upcoming events, and now you can register for events online by clicking on that event.

 

As you may recall from our 2012 Spring Newsletter, social media connections were established for SMCPA.  Since then, we have decided to “regroup” (i.e., suspend our connections) with respect to those media in order to better understand the pros and cons of being “connected” as an association.  We plan to tap into resources from APA, CPA, and other CPA chapters who have already established professional guidelines for how to best use these resources.

 

The theme for this edition of our newsletter is depression among children and adolescents.  Thanks very much to the contributors to this edition.

 

Best regards,

 

Mark

 

 

Summary of Practice Parameters for the Assessment and Treatment of Children and Adolescents with Depressive Disorders

by Cynthia Medina, Ph.D.

 

In 2007, the American Academy of Child and Adolescent Psychiatry (AACAP) released an article documenting its practice parameters for the assessment and treatment of children and adolescents with depressive disorders. Please refer to the original publication (listed at the end of this article) for full details regarding the parameters, as well as other factors related to the study such as methodology and limitations. Although the AACAP’s study was geared towards medical doctors, many of the parameters apply to our work with children and adolescents.

 

With regards to both assessment and treatment, AACAP highlights the importance of establishing and maintaining an appropriate level of confidentiality when working with children and adolescents. Particularly, it is important to establish a safe therapeutic environment for the minor client, while also developing collaborative relationships with the child’s parents. For instance, parents should expect to be informed of the treatment plan, progress towards goals, and any situations involving risk or harm, and the minor client should be made aware that this type of information will be shared with his or her parents/ guardians.

 

In terms of assessment, clinicians should screen all child/adolescent clients for depressive symptomatology; typically, self-report and parent questionnaires such as behavioral rating forms or forms geared specifically towards depressive symptoms are appropriate. If this initial screening indicates the presence of depressive symptomatology, clinicians must then take the next step of conducting a more thorough evaluation to determine if the child/ adolescent meets criteria for depression or another psychiatric disorder. Such an evaluation should involve direct interviews with the child/adolescent as well as his or her parents, and possibly teachers and other providers. Screening for a history of manic/hypomanic symptoms should also be included. Furthermore, the evaluation should involve an assessment for suicidal and/or homicidal risk, assessment for the presence of exposure to negative environmental events or situations, and any pertinent family psychiatric history.

 

AACAP documents several parameters with regards to the treatment of depressive disorders in children and adolescents. Three phases of treatment are described: acute, continuation, and maintenance. The goal of the acute phase of treatment is to decrease or eliminate depressive symptoms. The goal of continuation treatment is to avoid relapse (a relapse is characterized as a depressive episode that occurs within two months of the initial improvement of symptoms). The goal of maintenance treatment is to avoid recurrence in those children and adolescents with more severe or chronic depression (recurrence is characterized as a depressive episode that occurs two or more months after the initial improvement). AACAP suggests that all depressed children and adolescents should participate in the acute and continuation phases of treatment. The acute phase may last for just a few weeks, with the continuation phase lasting between 6-12 months. AACAP notes that it is not clear who will need maintenance treatment; however, a good rule of thumb is that individuals that take longer to recover or who experience a greater number of recurrences are likely to need maintenance for a year or longer.

 

All treatment should include a psychoeducational aspect (educating the client and his/her family about depression), supportive psychotherapy (assistance with problem-solving and coping skills), and should involve the family and possibly the school. AACAP’s review of studies indicates that education, supportive therapy and case management appear to be sufficient treatment for children and adolescents who are experiencing uncomplicated or brief depression with mild impairment. In cases where the depression is more severe, chronic, or complicated, cognitive behavioral therapy (CBT) and interpersonal therapy (IPT) have been shown to be more effective. A medication trial may be indicated if there is no response to psychotherapy. Please refer to the original AACAP article for more detailed information regarding outcome studies of various treatments ranging from psychotherapy, medication, to combination treatments.

 

Other recommendations outlined in AACAP’s practice parameters with regards to treatment include the need for different types of treatments for individuals with comorbid conditions or more complex depressive disorders, and establishing regular and frequent follow-up contacts to monitor the child/adolescent over time. In cases where the child/adolescent is not responding to treatment, clinicians are advised to consider other factors that may be contributing to the lack of response. For instance, a misdiagnosis, undetected or untreated comorbid conditions, poor treatment compliance, or simply a poor fit between client and clinician could be the reason for the lack of response.

 

Finally, AACAP suggests that children who are at risk of developing depressive disorders may benefit from having access to early interventions. Children who are considered to be at risk are those who are presenting subsyndromal symptoms, those who have either a personal or family history of depression, and those whose mothers are struggling with depression. In particular, some studies have suggested that children whose depressed mothers received treatment tend to have a lower rate of psychiatric diagnosis themselves (and a higher remission rate for those who do demonstrate symptoms). Other suggested early interventions include education and guidance around lifestyle modifications such as good sleep hygiene, physical exercise, and coping strategies (meditation, yoga, social activities). It is also important to educate caregivers, school personnel, and the child/adolescent about the warning signs of depression and ways to get help.

 

Most of us are likely employing many of these recommendations already in our work with children and adolescents. However, AACAP’s practice parameters serve as a useful reminder of the steps we can and should be taking to appropriately identify and treat children and adolescents with depression and those who may be at risk of developing depression.

 

Cynthia Medina, Ph.D., is a licensed psychologist in private practice in San Mateo. She specializes in evaluations for children and adolescents experiencing difficulties with attention, learning, executive functioning, and mental health/behavioral issues such as anxiety and depression.

 

Reference:

Birmaher, B., Brent, D., & AACAP Work Group on Quality Issues (November 2007). Practice Parameters for the Assessment and Treatment of Children and Adolescents with Depressive Disorders. Journal of the American Academy of Child and Adolescent Psychiatry.

 

 

DSM-5 Proposed Changes to Depression

by Patty Bardina, Ph.D.

 

The new DSM comes out in May, and there will be significant changes that could affect our diagnostic conceptualization of cases.  The goal for the development of the DSM-5 “was to examine our current knowledge regarding diagnostic boundaries. This included examinations of: i) support for current and alternative diagnostic groupings, along with an updating of Robins and Guze validators to take into account advances in research knowledge and technology; ii) comorbidity patterns and the potential role of dimensional assessments of symptoms that cross diagnostic boundaries; and iii) the role of symptom severity and disability in setting diagnostic thresholds and methods for assessing them (Guidelines for Making Changes to DSM-V).”  While the DSM-5 will not revamp the diagnostic criteria currently used by clinicians, it aims to have clinicians start to think about disorders in terms of how they present themselves realistically and as validated by research. 

 

One major shift that the DSM-5 is hoping to achieve is a shift toward thinking about disorders dimensionally rather than categorically. Research on depression consistently shows a linear relationship between number of symptoms and level of functioning and does not indicate a significant threshold when 5 criteria are met (Andrews et al, 2007).  Thus, it has been recommended that the DSM include a severity rating that allows clinicians to assess symptom severity on a continuum, as symptom severity more highly correlates with outcome.

 

A second shift is greater consideration of the comorbidity between disorders versus distinct conditions that suggest separate disorders. In the case of depression, a Mixed Anxiety/Depression category will be included in a section that discusses disorders that require further research (Recent Updates to Proposed Revisions for DSM-5).  The research also shows overlap in the pattern of depression due to bereavement versus depression due to other life stressors. Therefore, the bereavement exclusion criterion will be eliminated (Kendler, 2010).

 

Depression in children and adolescents differs from depression in adults in that irritability often occurs instead of depressed mood. Thus, it is critical to understand the difference between depression in children/adolescents versus depression as it presents in adults and to distinguish between “typical” irritability from underlying depression.  The inclusion of a new suicide assessment tool with two scales, one for adolescents and one for adults, has been proposed to provide a consistent tool that closely aligns with evidenced risk factors.

 

The proposed changes to the DSM add another consideration to the diagnosis of depression in children and adolescents: Temper Dysregulation with Dysphoria (TDD), or likely, Disruptive Mood Dysregulation Disorder (both names have been made public).  “Criteria for the proposed diagnosis of TDD include severe, recurrent outbursts of temper occurring three or more times a week that are grossly out of proportion to the situation or provocation and that interfere significantly with functioning. Criteria also include extreme verbal and physical displays of aggression when faced with a common minor demand or stress. In between these outbursts, the individual’s mood is persistently negative: irritable, angry and/or sad. To be considered TDD, the symptoms must have begun before the age of ten. Only children over the age of six will be assigned the diagnosis, and children with the distinct manic episodes found in bipolar disorder will be excluded (DSM-5 Proposed Revisions Include New Diagnostic Category of Temper Dysregulation with Dysphoria (TDD)).”

 

Children with the symptoms described under TDD have historically been diagnosed with Major Depression, Oppositional-Defiant Disorder, and Bipolar Disorder.  Longitudinal research finds that children and adolescents with these symptoms most often develop depression or anxiety. Therefore, the specific diagnosis of TDD or Disruptive Mood Dysregulation Disorder will fall under the Mood Disorders category, and the goal is to help identify and treat these kids appropriately and distinguish them from people who develop Bipolar Disorder.

 

Overall, the changes proposed to the DSM aim to solve current clinical problems and improve accuracy. “Thus, the revision process has also included consideration of changes in criteria and adding new specifiers, subtypes, and diagnoses (Guidelines for Making Changes to DSM-V).” However, it seems that these changes will be minimal initially as the hope is to have clinicians and researchers shift their thinking without causing too great a disruption.

 

Patricia Bardina, Ph.D., is a licensed psychologist in private practice in San Mateo. She specializes in the treatment of children and adolescents with anxiety, depression, ADHD, and/or behavior problems.

 

References:

Andrews, G, Brugha, T, Thase, ME, Duffy, FF, Rucci, P, & Slade, T (2007). Dimensionality and the category of major depressive episodeInternational Journal of Methods in Psychiatric Research, Supp 16:S41-S51.

http://www.dsm5.org/Research/Documents/Andrews_MDE.pdf

 

Brown, TA & Barlow, DH (2005). Dimensional Versus Categorical Classification of Mental Disorders in the Fifth Edition of the Diagnostic and Statistical Manual of Mental Disorders and Beyond: Comment on the Special Section. Journal of Abnormal Psychology, 114(4), 551–556.

http://www.addiction.umd.edu/Psyc434/Brown%20and%20Barlow%202005.pdf

 

DSM-5 Proposed Revisions Include New Diagnostic Category of Temper Dysregulation with Dysphoria (TDD)

http://www.dsm5.org/Newsroom/Documents/TDD%20release%202.05%20(1).pdf

 

DSM-5 Proposed Revisions Includes New Risk Syndromes and Suicide Risk Assessment Tool

http://www.dsm5.org/Newsroom/Documents/Suicide%20Scale-Risk%20Syndrome%20release%20FINAL%202.05.pdf

 

Guidelines for Making Changes to DSM-V

http://www.dsm5.org/ProgressReports/Documents/Guidelines-for-Making-Changes-to-DSM_1.pdf

 

Kendler, K. (2010). A Statement from Kenneth S. Kendler, M.D., on the proposal to eliminate the grief exclusion criterion from Major Depression.  http://www.dsm5.org/about/Documents/grief%20exclusion_Kendler.pdf

 

Recent Updates to Proposed Revisions for DSM-5 

http://www.dsm5.org/Pages/RecentUpdates.aspx

 

 

When to Consider Pharmacotherapy for Management of Depression in Children and Adolescents

by Dina Frid, M.D.

 

In this commentary, I intend to discuss considerations for the use of medications in children and adolescents with symptoms of depression.  Even though much of this discussion also applies to adults, adult pharmacological management will not be included here.  In addition, specific medications will not be discussed; however, there is a link to AACAP’s (American Academy of Child and Adolescent Psychiatry) facts for families which provides guidance for families seeking medication treatment.  Whenever there are any questions or concerns, a psychiatric referral is recommended.  This does not suggest that medications will be or need to be prescribed; yet, it allows for a discussion of the advantages and disadvantages of possible treatments, including medication management.  It can also serve as a baseline for future comparisons and for monitoring of symptoms over time. 

 

In considering medications, some key aspects to contemplate include severity, intensity and duration of depressive symptoms.  Evidence of suicidal ideation is an instance for which seeking a medication consultation is suggested.  Furthermore, presence of psychotic symptoms would be another situation warranting a medication evaluation. Other psychiatric co-morbidities interfering with basic functioning, such as severe anxiety, can benefit from medication management.  Clients incapacitated by severe anxiety or depression may not be able to fully utilize the skills they learn in therapy, and their symptoms may even prevent them from coming to therapy.  Sometimes medication can lessen this debilitating depression or anxiety, allowing the client to participate and thereby furthering the therapeutic process. 

 

It is important to take into account a child’s age, stage of development, and cognitive ability.  For example, a co-morbid diagnosis of developmental delay or mental retardation may limit psychotherapy options and influence one’s decision to refer for a medication evaluation.  In addition, examining lifestyle is crucial since changes to diet, sleep, and exercise affect symptoms of depression.  Interventions for treating disrupted sleep, for instance, may significantly alleviate other symptoms of depression and may improve therapeutic engagement.  Other factors to examine include home and school environments, family psychiatric history, past suicide attempts and past treatment.  Some questions to ponder include: has therapy been tried?  If so, was it helpful?  What were the road blocks?  Are there clear triggers that have been explored and addressed (for example: issues of loss, life transitions, trauma, etc.)?  Are there limited psychotherapy resources?  Is there substance abuse?  Is there a depressed caregiver?  Studies have shown that treatment of a depressed caregiver may improve outcomes for depressed children.

 

One of the most significant concerns with medication use is the potential for side effects.  Both families and physicians need to be aware of possible adverse events and weigh the risks versus benefits. In particular, for children and adolescents, anti-depressants have a black box warning, thereby requiring careful safety assessments and monitoring of anti-depressant treatment. There is a careful balance between understanding the seriousness of the potential side effects, while remembering that often clients do not experience many of these possible adverse events.  Even when taking Tylenol or Aspirin, the list of potential side effects is ominous.  A clinician needs to bear in mind the reasons why the client is seeking treatment, the impairments that the client struggles with and impact on his or her quality of life.  All of these reasons are weighed against the possible benefits of medications versus potential harmful side effects.  Since there are not as many studies in children as there are in adults, many medications are prescribed off-label.  In youth, there are only a few FDA approved medications.  Fluoxetine, more commonly known as Prozac, is FDA approved for both adolescent and pre-adolescent depression, and Escitalopram, or Lexapro, is approved for adolescent depression. 

 

Medication costs can play a role, as well as cultural factors and stigma associated with taking medications.  Taking a medication can affect the client’s own self view.  For example, a client may think that he or she is “broken” or worthless if prescribed medications.  On the other hand, sometimes taking a medication may provide a newfound sense of hopefulness about the future.  The way that caregivers and families perceive medications has a strong influence on the child, who then internalizes these views.  During a medication assessment, the family’s and child’s beliefs ought to be addressed. 

 

Many studies have been done that highlight the benefits of combined therapy and medication management for depression.  Conclusions from a recent overview of child and adolescent depression states:

 

Acute treatments of MDD that have shown superiority over placebo or “nondirective usual care” as monotherapies include selective serotonin reuptake inhibitors (SSRIs), CBT, and IPT. Combination treatment of medication and CBT has also demonstrated superiority over monotherapies as evidenced by some but not all clinical trials.  (Maalouf, et al)

 

Further, to conclude, listed below are several recommendations from AACAP’s practice parameters for treating children and adolescents with depression (Birmaher et al):

 

Recommendation 7: Each Phase of Treatment Should Include Psychoeducation, Supportive Management, and Family and School Involvement.

 

Recommendation 8. Education, Support, and Case Management Appear to Be Sufficient Treatment for the Management of Depressed Children and Adolescents With an Uncomplicated or Brief Depression or With Mild Psychosocial Impairment.

 

Recommendation 9. For Children and Adolescents Who Do Not Respond to Supportive Psychotherapy or Who Have More Complicated Depressions, a Trial With Specific Types of Psychotherapy and/or Antidepressants Is Indicated.

 

In children and adolescents with moderate to severe depression, chronic or recurrent depression, considerable psychosocial impairment, suicidality, agitation, and psychosis, supportive psychotherapy and case management are usually not adequate. For these children and adolescents interventions with more specific types of psychotherapies or pharmacological treatments for depressive disorders are indicated.

 

Dina Frid, M.D., is a child, adolescent and adult psychiatrist, with community-based training and certifications by the American Board of Psychiatry and Neurology in both adult and child psychiatry.  She has a part-time private practice in San Mateo and also work for Seneca Center, a non-profit organization which helps families and children.

 

References:




Birmaher B, Brent D, Bernet W, et al. (2007). Practice parameters for the assessment and treatment of children and adolescents with depressive disorders. Journal of the American Academy of Child and Adolescent Psychiatry, 46(11):1503–26.

Maalouf F, Brent D. (April 2012).  Child and adolescent depression intervention overview: what works, for whom and how well? Child and Adolescent Psychiatric Clinics of North America, vol 21 (2).

 

 

Minding the Body: The Place of Psychology within Functional Medicine

by Stephen J. Ducat, ND, PhD

 

It is much more important to know what sort of person has a disease, than what sort of disease a person has.

-- Sir William Osler, MD 1892

 

When you’re sitting on a tack it takes a lot of aspirin to make the pain go away.

-- Sidney Baker, MD circa 2000

 

Paradigms in health care exhibit their own version of natural selection. The limitations of the dominant medical model catalyzed the evolution of more integrative approaches, which have become widely embraced among clinicians and patients alike. Functional medicine, while a less familiar rubric, is the most coherent and developed expression of the integrative health care model. It is even beginning to take hold in a few medical schools and residency programs across the country. Psychologists, I argue, will be best served by positioning themselves within this new framework, and as equals to physicians.

 

For centuries health care has been constrained by the fictitious dichotomy between mind and body. In recent decades, psychology and psychiatry resolved their long-standing turf battle by carving up the psyche into the falsely distinct territories of mind and brain.

 

Clearly, many practitioners in both disciplines have bravely defied this split. But to a great extent psychology as a profession has been blind to the fact that psychotherapy is as much of a physiological, i.e. medical intervention, as is psychopharmacology (though arguably the former demonstrates greater efficacy and a lower relapse rate than the latter).

 

In spite of the growing body of neuroplasticity research, psychologists have not taken seriously enough the fact that the mind is a property of the brain. We easily forget that when one brain converses with and conveys understanding to another – the proverbial “talking cure” – there is a biological impact, in particular, a profound alteration of neural circuitry. By losing sight of this we have allowed ourselves to be relegated to an “allied health care” profession. Various unjust disparities have come along with this subordinate status, most notably unequal pay.

 

Correspondingly, some clinicians, and even the general public to a certain extent, have tended to view the blunt instrument of psychopharmacology as the solution to a “chemical imbalance.” This is not to say that drugs do not have utility for certain patients. But this view seems to be embedded in a fundamental logical fallacy – that the cause of a condition can be simply extrapolated from the mechanism of action of a symptom-suppressing drug. Obviously, depression is no more a fluoxetine deficiency than backaches are an aspirin deficiency (whether or not one is impaled on a tack). And when pharmacology is regarded as the only real medicine, psychotherapy can be readily dismissed as harmless handholding.

The mind/brain split has only deepened during the last three or four decades in which managed care has gained hegemony over the business and practice of health care. Both psychology and medicine have become increasingly fragmented into blinkered silos of specialization. And, correspondingly, third party payers have burdened both professions with the mandate to treat ICD9 or DSM IV codes instead of patients. As such, psychologists and physicians often end up treating effects instead of causes.

 

The good news is that a paradigm is emerging that challenges the dichotomies described above, and one that opens up new opportunities for psychologists. That framework, functional medicine, is a more systemized and cogent version of the more familiar but less theorized concept known as integrative medicine. The founding practitioners and scientists at the Institute of Functional Medicine sought to add more depth and substance to that vague descriptor “integrative” by considering two fundamental questions: 1.) What is integration? and 2.) Just what is being integrated?

 

Borrowing from psychiatrist and mindfulness teacher, Daniel Siegel, we can think of integration as the linking of differentiated parts of a system. This can encompass many domains of integration including the body, the mind, social relations, and health care.

 

Bodily integration refers to links between tissues, organs, structures, regions, and functions. This is called systems biology, and is the foundation of functional medicine. One of my favorite metaphors is a spider web. Imagine the system of the body as a large web in which every nodal point, while distinct, is yoked to every other point. If you pull on the web over here, there will be traction exerted every place else.

 

Consuming a high carbohydrate diet, for example, will over time likely affect function in multiple parts of the body, producing changes in pancreatic function, immune response, intestinal and blood-brain barrier function, gut microbial balance, inflammation, neurotransmitter and hormone levels, cognitive capacity, and cardiovascular function.

 

Mental integration includes links between our memories, thoughts, beliefs, emotions, and components of our identity. The breakdown of integration can be manifested as impairments of differentiation, or failures to link. In the realm of memory there may be an intrusion of a traumatic history, amnesia, or simple expressions of motivated forgetting.  Thoughts and beliefs can be marked by the distortions of denial, projection, or the black and white cognition of fundamentalism. Emotions can be subject to explosive disinhibition and impulsive acting out, or disavowal and alexithymia. Identity can be dissociatively fragmented, unstable, or rigidly impervious to influence.

 

Social integration refers to the web of connection that links us with others – members of a couple, extended families, communities, and larger societies. Pathologies in this domain, as with others, can manifest as failures to link or to differentiate. We can lead the life of a disconnected monad, being unable to give to, take from, feel a responsibility toward, or experience a kinship with others with whom we are interdependent. Or, we can be rigidly overly identified with our tribe, assuming that individuation would come at the real or imagined cost of ostracism.

 

Functional medicine is the most developed framework for integration in health care. In this paradigm, an integrative model of the basic medical sciences (the systems view of how the body-mind functions described above) is married to an integrative approach to treatment. The aim of therapeutic intervention, especially of chronic disease, is to assess and treat the upstream causes of downstream symptoms. A clinically useful diagnosis requires that clinicians identify the antecedents, triggers and mediators that eventuate in the “disease.”

 

Another central precept of functional medicine is the notion of biochemical individuality. Twenty patients presenting with depression may be responding to twenty different causes – variable combinations of etiological factors that could include early attachment trauma, recent losses, marital discord, the physical limitations imposed by orthopedic conditions, genetic polymorphisms affecting folate metabolism, environmental toxin exposure, nutritional deficiencies, stealth infection, autoimmunity, protein maldigestion, or gluten sensitivity, to name a few.

 

On the other hand, each of twenty people exposed to the same cause could end up with a different “disease.” It is not surprising, then, that treating diagnostic codes produces such poor results, especially when working with patients suffering from complex chronic conditions.

 

Treatment from a functional medicine perspective involves more than the integration of modalities but also means an integration of providers, an appreciation of the value of collaboration among all members of treatment team. This could be a team comprised of individual practitioners who may occasionally communicate with one another about a shared patient. Or, it could involve the collaborative wellness model of a company like Mevident, for whom I work as a clinical advisor. They offer a free IT platform for integrative health care providers that facilitates communication between patients and their treatment team, and among members of that team – all in a way that maintains confidentiality and holds a place for the agency of patients.

 

So, for example, a depressed patient, like those described above, might benefit from a team of practitioners. It could be comprised of a psychologist to provide psychotherapy, a naturopathic doctor to assess and treat metabolic imbalances, a chiropractor to address orthopedic limitations to exercise, a nutritionist to create a sustainable healthy eating plan, and/or a health coach to teach mindfulness-based stress reduction techniques.

 

Given the explosion of interest in functional medicine across the country among clinicians of all disciplines, educational institutions, and patients, this new paradigm is likely to be the future model of health care. It is one in which psychologists should and can have a central role.

 

Stephen Ducat, N.D., Ph.D., is a naturopathic doctor and clinical psychologist whose practice in San Francisco and Marin joins science-based natural medicine, nutrition, and psychotherapy. He is also a clinical advisor for Mevident (www.mevident.com). You can learn more about his work at themindbodyclinic.com.

 

 

Results of the On-line Survey of the Colleagues Assistance and Support Program (CLASP) of San Mateo

by June Martin, Ph.D., SMCPA CLASP Chair

 

Note: The complete document is available to SMCPA members under About Us: Documents.

 

The purpose of this online survey was threefold: (a) to explore the health and wellness strategies that our SMCPA members use as working psychologists facing the demands of our profession; (b) to ask how CLASP resources could be used to support our chapter members; and (c) to identify chapter members’ interest in attending a local support/consultation group. The survey was opened on July 29, 2011, and closed on August 31, 2011. The results of the survey are presented here to inform all of SMCPA’s members.

 

The general findings of this survey were: (a) participants’ coping strategies included a number of health and wellness approaches that they themselves adapted to their needs as working psychologists facing what they identified as the top three stressors in our profession—namely, Overwork, Professional Isolation, and Not Prioritizing Self-Care; (b) the majority of the participants did not know about or use CLASP resources; and (c) almost half 45.5% (N = 22) of the participants indicated that they were interested in attending a local support/consultation group. A copy of the survey results appears in the Appendix, to be found under About Us: Documents for SMCPA members.

 

Survey Format

 

The survey consisted of 14 questions, which called for: (a) closed-ended, single select or multiple choice answers (e.g., age, gender, yes/no); (b) closed-ended, multiple choice answers (select all that apply); and (c) open-ended text answers (for suggestions).

 

Demographics of the Survey Sample

 

The sample was self-selected from a total population of 105 SMCPA members and yielded a final survey response rate of 21%. Of the 22 participants who started the survey, 95.5% (n = 21) filled it out completely. The sample consisted of 19 women (N = 22; 86.4%), 2 men (N = 22; 9.1%), and 1 individual (N = 22; 4.5%) who did not indicate gender. The mean age range was between 56 and 65 (n = 11). Twenty respondents (90.9%) were between 46 and 75. Also, 20 respondents (90.9%) worked in a clinical private practice setting, with the majority (n = 14; 63.6%) in business between 16 and 30 hours per week. Over half of the respondents (n = 13; 59.1%) were experienced psychologists with 16 to 30 years in their current professional settings. In general, the sample consisted of experienced, middle-aged female clinicians who worked part-time in private practice.

 

Some Interesting Findings

The participants (N = 22) identified the following top three occupationally related stressors: Overwork, 11 (50%); Professional Isolation, 10 (45.5%) and Not Prioritizing Self-Care, 8 (36.4%).

 

The top three stress symptoms that the participants reported they would self-manage include: Feeling uninspired or a Loss of Pleasure in Work, 15 (n = 18, 83.3%); Inability to Focus or Concentrate, Forgetfulness, 14 (n = 17, 82.4%); and Anxiety, 12 (n = 17, 70.6%). It appears that psychologists may prefer to not formally divulge to their peers that they are uninspired or lack focus at their work, which may involve stressors that arise from personal problems (see Bortell, 2011).

 

The top three stress symptoms that psychologists reported would activate their seeking help from others include: Increased Negative Countertransference, 15 (n = 18, 83.3%); Depression, 11 (n = 16, 68.8%); and Substance Use/Abuse or Other Compulsive Behavior, 8 (n = 11, 72.7%). All these are symptoms that the APA has identified as dangerous indicators for psychologists; in fact, the ethics code and its commentators, recommends psychologists to seek help for these problems (ACCA, 2006; Bridgeman, 2009, 2010; Bridgeman & Galper, 2010; Fisher, 2012).

 

The top three barriers to maintaining wellness, self-care, or use of CLASP include: Lack of Time, 13 (n = 20; 65.0%); Privacy or Confidentiality Concerns, 11 (n = 20; 55.0%); and Cannot Afford It (Financial Constraints), 8 (n = 20; 40.0%). The lack of time is partly explained by the additional demands of the profession, such as those imposed by HIPPA and Managed Care in the form of unpaid paperwork that psychologists have to engage (for an extensive discussion, see Bridgeman & Galper, 2010; Clay, 2011; Lee, Lim, Yang, & Lee, 2011).

 

The respondents agree that the most effective way to deal with stress is to talk about it. However, over half of the respondents indicated that talking about stress involves dealing with issues of privacy, confidentiality, and shame-guilt-embarrassment, which likely represent barriers to formally obtaining help through CLASP resources. It is interesting that 40% indicated that they cannot afford professional help. Perhaps the respondents dealing with Managed Care encounter re-imbursement difficulties. Alternatively, these respondents may experience additional stress as part-time clinicians in private practice. It is a limitation that income status was not asked as one of the demographic questions in this survey.

 

The top three ways of responding to stress include: Attend to Physical, Emotional, Psychological Health, 21 (n = 21, 100.0%); Talk to a Colleague, 20 (n = 20, 100.0%); and Seek Family or Social Support, 20 (n = 20, 100.0%). Although psychologists are reluctant to admit their problems to colleagues formally, they appear to have no such hesitation around informal conversations with peers, family members, and friends.

 

According to the 22 participants who responded, the top three preventative self-care models include: Practice Adequate Sleep, Healthy Diet, and Regular Exercise, 21 (95.5%); Seek Consultation with Peers or Experts When Professionally or Personally Challenged, 21 (95.5%); and Seek Family or Social Support, 18 (81.8%). In their responses to this question, the participants indicated that they are fully aware of what to do to prevent stress, even though they may be reluctant to do it.

 

Additional Comments

 

While on the surface it may seem that most of the respondents were working less than full-time, half of the respondents (n = 11; 50%) reported that being overworked increases their level of stress. Yet, only 5 respondents (22.7%) are working more than 31 hours in their current professional setting. The nature of our work can be emotionally exhausting, yet 90% of the respondents have never visited the CLASP website (see Bridgeman, 2003). It is also interesting that close to half (45.5%) would like to receive help via our local case consultation peer support group idea.

 

Recommendations

Based on the findings and on suggestions made by the participants in this survey, June Martin and Lyn Pock have established an ongoing monthly case consultation and peer support group to meet the survey’s objective of using CLASP resources for SMCPA members. This group was specifically structured to eliminate the barriers to using CLASP resources—namely, the group is free of charge, respectful of confidentiality, inclusive, and meets monthly at a convenient San Mateo location.

 

If you are interested in joining this monthly group, please contact June Martin at (650)703-9986 or phdjm@pacbell.net. For additional support on health, wellness, and stress management, I also recommend that members visit our CPA CLASP webpage (Bridgeman, 2003, 2007). Some of the resources you may like to (re)visit include:

 

CLASP articles: http://www.cpapsych.org/goto.cfm?page=http://www.cpaclasp.org/

 

CLASP brochure: http://www.cpapsych.org/goto.cfm?page=http://www.cpaclasp.org/

 

CLASP Information and Referral Line 1-888-262-8293

 

CLASP Providers for psychologists: CLASP Information & Referral Provider Roster

 

 

June Martin, Ph.D., is a clinical psychologist with a private practice in San Mateo. She has over 20 years of experience in sex therapy and psychotherapy and specializes in addressing relationship, sexuality, and intimacy concerns.

 

References:

ACCA (2006). Monograph Advancing Colleague Assistance in Professional Psychology, reviews licensing board responsibilities, the disciplinary process, grounds for disciplinary actions, guiding principles, assessment, interventions, liability.

 

Bortell, L. (2011). CLASP means self-care: CPA means self-care. The California Psychologist, 44(3), 33. 

 

Bridgeman, D. (2003). CLASP: www.cpapsych.org/goto.cfm?page=http://www.cpaclasp.org.

 

Bridgeman, D. (2007). Positive peer partnering for psychologists. Available from the California Psychological Association’s Colleague Assistance and Support Program (CLASP) website: http://www.cpapsych.org/ (articles).

 

Bridgeman, D. (2009). Balance, boundaries and benevolence: The complexities of psychologists’ self-care, coping, and wellness. An informal assessment, available from the California Psychological Association’s Colleague Assistance and Support Program (CLASP) website: http://www.cpaclasp.org.

 

Bridgeman, D. (2010).  The ACCA toolkit with strategies of engagement for psychologists for support in developing and maintaining a colleague assistance program.

 

Bridgeman, D. & Galper, D. (2010). Listening to our colleagues-2009 APA practice survey results: Worries, wellness, and wisdom.  Presentation at the 118th Annual Convention of the American Psychological Association, San Diego, CA.

 

Clay, R. A. (2011). Is stress getting to you?  Monitor on Psychology, 42(1), 59–63.

 

Fisher, C. B. (2012). Decoding the ethics code: A practical guide for psychologists (2nd. ed.). Thousand Oaks: Sage.

 

Lee, J., Lim, N., Yang, E., & Lee, S. M. (2011). Antecedents and consequences of three dimensions of burnout in psychotherapists: A meta-analysis. Professional Psychology: Research and Practice, 42(3), 252–258.

 

 

Highlights from the Santa Clara County and San Mateo County Book Club

by Nancy Wesson, Ph.D.

 

The book club met on January 4, 2013.  We discussed the book “Sleep: A Groundbreaking Guide to the Mysteries, the Problems, and the Solutions” by Carlos Schenck, M.D. The meeting was well attended and although all the members enjoyed the book, some book club members described reading the book as more like reading fiction than science at times because of the anecdotal accounts of some of the more extreme sleep disorders. For example: Some of the parasomnia descriptions entail unusual behavior during sleep, as in the case of the woman who while still asleep would go to the airport, buy a ticket, get on a plane and wake up in a strange city.  Most members were surprised by the range of sleep disorders, and we discussed several cases where a sleep disorder might be confused with clinical symptoms.

 

The March 1st book club meeting discussed the book: “Unmasking psychological symptoms: How Therapists Can Learn to Recognize the Psychological Presentation of Medical Disorders” by Harvard psychiatrist, Barbara Schildkrout, M.D.

 

 

CPA Board Notes Oct 26-27 Meeting Highlights
by Linda Schneider, Ph.D., CPA Board of Directors

 

For a more complete report, please see Jo Linder-Crow's Board in Action email sent to CPA members, 12/5/2012, or http://files.cpapsych.org/files/Governance/bod-files/Board_in_Action_October_26_27_2012.pdf .  To receive these reports directly, please join CPA.

 
The Affordable Care Act was discussed.  California is moving ahead, at the beginning stages of developing health exchanges.  The first year (2014), it is estimated that the Affordable Care Act will cover two million people.  The second year it will cover three million, and the fourth year four million.

A  CPA Task Force on Health Care Reform will continue in 2013, under the direction of Michael Ritz.  This committee organized the first interdisciplinary Health Care Summit September 29, 2012, in L.A.  This was a beginning to ensure that psychology and psychologists in California will be a part of the changes in the future of health care delivery.


The MCEP, the program that you have mailed your CE's into every two years, died on December 31, 2012.  Starting January 1, 2013, you are responsible for keeping your own CE units.  The BOP will conduct a random audit to check compliance.  We do not know yet what lack of compliance will be met with by the Board.


Amanda Levy, Director of Government Affairs reported on CPA's legislative agenda and summarized the recent activity.  Again, please go to Jo's report for a more extensive viewing of CPA's very active legislative agenda.


The BOP (Board of Psychology) was extended for a full 4 years.  This means that we will maintain our separate identity as psychologists.... to be revisited in 4 yrs. 


SB 1172, the Sexual Orientation Change Efforts Bill (doing away with requirements and limitations on the therapist and patient), was successful .Two lawsuits have been filed and CPA is tracking these.


A Workman's Comp Bill was finagled through the legislature. CPA will work in the next legislative session to reintroduce some of the language regarding separate mental health evaluations that were removed in the passage of this bill.

       


New CPA CE BANKING
by Linda Schneider, Ph.D., CPA Board of Directors

 

Disorganized, forgetful, afraid of natural disasters...or just want more advocacy regarding your CE?  CPA has a new banking program for your CE's with two levels.  They will bank your CE's and make them available to you at any time you need them.  The Premier level will interface with the BOP on your behalf should you be audited.  The Premier level will also notify you of any changes or nuances in the CE regulations and requirements. Please go to California Psychological Association for more specifics & information.   

 

 

2013 CPA Convention Newport Beach...Fun in the Sun

by Linda Schneider, Ph.D., CPA Board of Directors

 

April 11-14, 2013, in Newport Beach.  Registration is now open.  If you haven't been to Newport recently, and even if you have, here's a chance to get away, network, and get CE's...and it's tax deductible!!!  Dean Delis, Ph.D. (Assessment of Memory and Executive Function in the Digital Age) and Fred Luskin (Forgive for Good) are among the many excellent speakers. This is a chance to earn CE’s while networking with psychologists from around the state.  To see the many topics and pre-conference workshops on telepsychology, changing our brains…through applied neuropsychology, forensics and more, see the website www.cpapsych.org. Ask for a brochure or register by March 20 for a discounted fee.  Students can volunteer to work and get the registration fee waived. And come before or stay after to enjoy surf, sand, and shopping at convention hotel discounted prices! 

 

 

Office Space

 

$550/month - Office in Quiet Building

Atherton/Redwood City - Quiet building with other professionals (mostly therapists). Ground floor, 164 sq. ft. Available 6/1. Includes carpet, heating/AC, off-street parking, janitorial service & utilities. Remodelled bathrooms. Waiting room. Requires 12 mo. lease minimum. Also offices to share. Call Tom, 650-208-8624

 

Therapeutic office in downtown Burlingame.  Share a suite with 3 other therapists. Lovely common waiting room and restroom.  The office room is approximately 200 sq. feet with private entrance and a small kitchenette attached.  Rent is approximately $865 per month. To see the suite, contact Cari Lenahan,  clenahan2@comcast.net

 

Psychotherapy office in San Mateo on North San Mateo Drive. Quiet, comfortable office in a former single family home.  Garden setting. Shared waiting room, parking in back. 169 sq. ft. $700/mo, one-year lease.  Contact Burt White, 650-579-1200.

 

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