Confessions of a Dancing Bear
Thursday, April 22, 2004
The Passing of Dancing Bear...
Before the last class of the semester, I wanted to take a second and reflect back on my experience of the class. When looking back at how an unnamed classmate and I first joked about taking a second ethics course, calling it "More Reasons Why Not to Have Sex with Your Clients", I realize how far I have come. I want to thank Dr. Combs for providing a safe forum to discuss ethical issues. I think that our candid discussions, sometime surreal in their presentation, have all showed us how being open and honest in a doctoral level program can provide additional learning opportunities for everyone involved. From testing to sex, from feedback to dangerousness, from Internet psychology to death row executions, we have covered many important and critical topics. I have been reminded that it is every individuals responsibility to be on-guard for the famed "slippery slope" of ethical violations, for al of us to not only police ourselves, but help our colleagues. I have been challenged by my classmates and the professor to question my own assumptions, thoughts, emotions and reactions, to take a moment to pause and think before acting. I feel the experience has been a beneficial one and that the willingness of so many of us to actively contribute to each discussion has made the class both intellectually stimulating and an exciting educational opportunity. So, in short, I enjoyed and learned from the class experience and just wanted to take a minute to thank everyone involved.
With that said, this is Dancing Bear signing off... Goodnight.
Thursday, April 15, 2004
Ummm. Tuskegee. 1932 is a long time ago. It’s 72 years ago. The technology wasn’t there to treat the subjects. It was an era of racial distrust. Who can be surprised that an event like this occurred? It was 72 years ago, practically the dark ages in terms of ethics and racial equality.
What was that?
It ended when?
Did you just say 1972?
Did I just hear that the study didn’t end until October, 1972?
You mean the scientists let these men go untreated for over 40 years?
How could this have continued for that long? Didn’t someone try to stop it?
1) Doctors in 1936 criticized the study for the possibility that subjects of research were not being treated.
2) 1936: Doctors in the area agreed not to treat the subject!
3) 1940: Deliberate efforts made to assure subjects not treated by being drafted.
4) 1947-1962 African American medical students are rotated through the unit doing the study, during training
5) 1968: Some people question the ethics of the study.
6) 1969: CDC argues to continue the study.
7) 1972: Study ends.
I’m looking at medical students, local doctors, CDC officials, individuals in the government associated with the efforts to assure that these men were not treated, and the researchers themselves all had opportunities to decide that this research was grossly unethical. None off then did until 1968. This is the most terrible aspect of this entirely terrible event. Not only did researchers violate the entire moral structure that underlies all research, but that so many of the others associated with Tuskegee also did. They maintained their silence through 40 years, allowing men and their families to remain untreated from a potentially fatal disease. The impact of this is so great that it cannot be said enough: When something unethical is happening it is the responsibility of those who see, hear and partake in it to act. Not to allow responsibility to be diffuse, but to tolerate the discomfort of being the whistle blower and make the ethical violation be known. It’s no wonder that so many ethical violations pervade our profession. How easy is it to avoid confronting an unethical coworker or “accidentally” have sex with a client, when the Government and everyone involved with this event simply repeated, “It’s for the good of medical knowledge.” “It’s not really unethical, because the ends justify the means.” We must make a stand, individually and as a profession to be responsible for policing our own so that a psychological Tuskegee can never occur.
Thursday, April 08, 2004
Quiz answers: A, A, D, C, D
After reading Pope’s article on the responsibility of a testing clinician to provide feedback to a client, I find myself questioning my practicum. I am using the WISC-IV and the Rorschach to test juvenile sex offenders for a residential program. I’ve conducted 14 of these assessments and provided feedback on 0 of them. I administer the test with a brief explanation of the tests used and the fact that my results go to their primary therapist for the purpose of treatment planning. I agree that the therapists are the primary users of this information. If a client, as the one I have just finished scoring, has a verbal IQ of 75 and a Rorschach Lambda that indicates a tendency to narrow his perceptions to the point of perceptual distortion the therapist needs to know this in order to tailor his treatment plan to meet his needs. I shiver at trying to figure out how to express this to the client, a 14-year-old sex offender with clearly limited verbal intelligence. I think that if I could convey this knowledge to him in such a way that he understands and is able to participate in changes in his treatment plan, it would be beneficial. So again Doctor Combs, I challenge you! What does the ethical way to give feed back on “abnormal” or “below average” (or very low average) scores look like? What about unethical? How much do we hold back based on the client’s limitations? Suggestions are appreciated!
Thursday, April 01, 2004
I realize, of course, that I am writing this Blog 25 minutes before class begins. Why wait so late? I'd like to offer an explanation by looking to the chapter that we read for this week, challenging us to examine the ability of psychologists and other social scientists to make predictions about mental illness, as well as our client's specific behaviors, what ever those behavior be. I found myself at Practicum today, i.e. at M. House, a residential treatment center for adolescent sex offenders, listening to a conversation between a probation officer, Bob, and the assistant director of the program, David. (I remained listening to their conversation long past my normal time to leave because of its specific relevance to today’s article). The discussion was over the JSOP, a sex offender risk assessment that the program is discussing integrating into their treatment protocols and for specific measures for the D/C summaries. David was commenting that JSOP could lend great empirical support to their claims when a client is discharged from M. House, it would give the court hard numbers to examine when making discussions about a client’s residence at discharge. I found myself thinking about this article stance on actuarial prediction versus clinical prediction and my very first conversation with the psychologist at my practicum site, Dr. S. I had come to M. House for testing experience and he had agreed to let me use the Rorschach and the WISC-IV for testing and I had asked about specific sex offender risk scales. At that time he had said to me, “We don’t use those. I find they tie us down to a risk level that might be at odds to our clinical opinion of a child, and then we have to explain ourselves to the court and fight against our own data.” He also mentioned that the scales available were primarily built of static risk factors and couldn’t change in tx or the client may actually have a higher score by the end of treatment because he had admitted to previously unknown offenses that may elevate his score from his admission score. Also static factors don’t decrease with treatment! The scales that do include “dynamic factors”, which are an operationally defined clinical risk factor, can change throughout treatment, but many scales have a minority of dynamic factors and a predominance of static factors (the JSOP has 16 static factors and 5-6 dynamic factors usable for M. House’s clients). The ethical question that I pose is, despite what we know about actuarial prediction and clinical prediction, is the opinion of M. House’s psychologist an ethical one or not? Does the measure have limited usefulness in a treatment setting in which your hoping to measure changes in risk, or is it unethical to not test when it might be a better estimation of risk than the normal non-empirical clinical judgment used in discharge summaries?
Tuesday, March 16, 2004
I’d like, if I may, to take you on a slight tangent. To preface my tangent I ask you to remember our discussion of 3-11-2004. We were discussing prescription privileges as a possible means that psychologists assure that they have a future career and that the degree will have some meaning in an uncertain future. The idea that psychologists feel the need to rearrange the system so that we can make sure that we still will be needed in 20 years, is key to this argument. It’s not necessarily about the science or the appropriateness of the decision, instead it becomes about the profession trying to assure it’s future. Well, worry no longer! I see where the future is and it isn’t prescription privileges!!!
In The Clinical Psychologist vol 57, issues 1 &2, winter/spring 2004, on pages 18-24, Dr. Widiger discusses the possible direction of DSM-V. Within this brief opinion piece the author discusses a possible vision of the dimensional system for the diagnosis of mental illness. He first compares the process of diagnosing mental retardation to the future diagnostic style of DMS-V. He discusses the use of assessment as a necessary component of the decision to diagnosis an individual with a mental illness. He sites a proposed system for diagnosing personality disorders: 1) Multifactorial description of functioning, 2) social and occupational impairments associated with symptoms, 3) determine level of impairment (i.e. clinically relevant symptoms?), 4) quantitative matching to a specific disorder or the use of scores to determine placement with specific diagnostic categories. This would mean that a test, i.e. a psychologist only administered and scored and interpreted test, would become a fundamental aspect of diagnosing any mental illness. It would be like the necessity of a WISC or WAIS for MR! What does this mean? It means that should a system like this be used, it makes the future landscape safe for the professional psychologist. We’ll make ourselves invaluable to those pesky psychiatrists and other professionals who have been making “off-the-cuff” diagnoses. I can see us working at the disability office doing official diagnostic interviews and testing. At medical offices helping those doctors before they prescribe psych meds, working where ever diagnoses must be made. I know that we diagnosis a large number of the population’s psychological problems anyway, but the important thing to note is that we are tying in out specialized testing experience and expertise into a necessary part of the process of mental health treatment. I see us securing ourselves a place in the future through testing and diagnostic work, no need to bother with all those medical classes!
To close I just want to note that they mention personality disorders moving to axis I and part of that may have to do with 3rd party billing (ethical quandary there!!!) and I challenge us all to look at the above possible change in diagnostic procedure and ask ourselves: Is this for the benefit of the client or is it to assure that I have a profession in 20 years?
Thank you and goodnight.
Thursday, February 19, 2004
Quiz: D, B, D, A, C, B, A, B, A, C
As I read and look over the article for this week and find myself wondering about my own training here at the university. We have discussed, both in Ethics class and in clinic team/practicum seminar the dangers of being sexually attracted to a client. However, I find myself wondering how I might answer the following paraphrased question asked of the research participants, "How well did your graduate program educate you in terms of sexual attraction to clients?" Outside of being assured that it is a terrible thing and to be avoided at all costs, or maybe at best to utilize it in terms of helping us see and notice how the client's appearance, attitude, etc may influence those around him or her, I question what have we learned? Prior to starting the course, Casey and I joked that our second Ethics class should be dubbed "More reasons why not to have sex with your client.", now I wonder how my program has helped me prepare for the day that I am sexually attracted to a client. The cognitive-behavioral model of the program seems to offer no overt suggestions, such as the psychoanalytic paradigm offers in the article. I know that seeking supervision and support are my recommended courses of actions, but more specific suggestions or ways to conceptualize the attraction have never been discussed. Now I find myself wondering what education could the program offer me? They tell me not to take action on my desires, they tell me why not to do it, they tell me the repercussions of doing it, they tell me to be very aware of my own “stuff” when dealing with this issue, and to avoid acting without careful consideration and supervision. What more can be taught? What more can our program offer us to help us be the best professionals we can be? Now I see what this blog is all about, it’s a call to the program (read: Dr. Combs) to tell me what more I can know and how this program can better help me prepare. Thus if we ever expect to answer the question asked of other graduate students with more than a “some” I need to know what more I can learn.
Friday, February 13, 2004
Quiz: D, A, B, C, A, B, B, B
I just looked up both the NJ and PA specific child-abuse reporting laws, and find myself in a bit of a quandary. I work full time as a manager of a crisis unit in NJ. In that role I am responsible for assisting the staff in doing evaluations, making difficult decisions and offering the best possible disposition for anyone we evaluate. Last week we interviewed a very young boy who came to us after throttling a young girl at school until she passed out. His history included stabbing a teacher, fighting, cruelty to animals and tiring to set his infant sister on fire. The crisis clinician felt that DYFS (Division of Youth and Family Services) should be notified as the client posed an direct risk toward his sister and that the family was neglecting her or that the client’s parents “create or allows to be created a substantial or ongoing risk” for child abuse, neglect, etc. In this case the mother told us what the client had done a few months ago and while minimizing it, was assessed to be failing at her duty as a parent in protecting her daughter from her own son. I should state that the only reason the client was at Crisis was the schools requirement. When looking at the law I think that we acted in the best interest of the client’s family. However now that I read the PA law, I realize that I could have been not following the law. PA states that we report “when (we) have reasonable cause to suspect, on the basis of their medical, professional or other training and experience, that a child coming before (us) in their professional or official capacity is an abused child.” Note this would require the client’s sister to be present and for her to have told us (impossible due to her age) or have some kind of physical evidence of abuse (not that any would be there from her brother trying to set her on fire!). It strikes me that in NJ it might be better. Yes, your alpha error (false positives) might be somewhat higher, but in this case isn’t it better than false negatives!
