Morgan T. Sammons, PhD, ABPP
Welcome to the third issue of the Journal of Health Service Psychology. As always, our goal is to provide the reader with high quality, data-driven, information-dense content that is of immediate clinical applicability. Put succinctly, if a submission is not immediately translatable into clinical practice, we’re not going to publish it. We, and our authors, have worked hard to adhere to this guidance as we have steered this publication from a biannual trade publication to a peer reviewed translational clinical journal.
Many academic journals aspire to be of direct clinical applicability, but few actually achieve this goal. Publishing high quality clinical information is surprisingly difficult. The language of the academy is distinct from the language of the clinic, and what is of importance to a scholar-researcher is not necessarily what is sought by scientist-practitioners. Finding academics who are fluent in both dialects is challenging, but we have again in this issue brought together a group of scholars and scholar-practitioners whose insights can directly improve aspects of practice.
Overall, the clinical problems presented in this issue share key similarities: they are often difficult to assess precisely, accurate diagnostic measures are frequently lacking, and the consequences of a failure to accurately diagnose and intervene can be severe. Each of our authors, however, also caution us that it is not sufficient to rely only on evidence-based diagnostic and treatment rubrics. As essential as these are, if the clinician does not take the time to accurately assess the meaning the patient attaches to his or her symptoms, treatment is not likely to be effective. Psychological intervention is neither an art nor a science—it is both—and wisdom, as well as empiricism, is essential in producing effective treatment.
Intimate partner violence (IPV) is sadly an all-too-common clinical presentation. Although numerous legal and ethical standards govern the clinician’s response to IPV, skillful therapeutic maneuvering is required to both elicit accurate information and establish a successful treatment alliance. Sarah Bannon and Dr. Jessica Salwen-Deremer explore the sensitive topic of intimate partner violence (IPV) and how to approach and assess its possibility with reluctant patients. Acknowledging such violence can elicit feelings of shame and guilt, and it may have real world consequences such as family break-up and legal difficulties. The identification, assessment, and treatment of IPV in community settings requires empathy, kindness, and gentle understanding and support.
We see desperation and exhaustion in the case of chronic childhood anxiety and insomnia presented by Drs. Anna Swan and Johanna Carpenter, in which well-intended parents have unintendedly established a system of reinforcing an anxious child’s dysfunctional sleep patterns. Parental distress, relationship problems, and occupational dysfunction are real consequences of the inability to instill appropriate sleeping behaviors in an anxious child. With the exquisite sensitivity that comes from understanding that anxious children are often begotten of anxious parents, Drs. Swan and Carpenter provide a detailed but challenging behavioral regimen to instill healthier sleeping habits in a worrying child.
Diagnostic precision in assessing tinnitus is difficult. While many individuals experience tinnitus, for some it becomes a problem that interferes with occupational and personal functioning, especially military personnel. As Drs. Caroline Schmidt and James Henry write, tinnitus is one of the most common disorders for which veterans seek compensation. Its accurate assessment, then, has both economic and personal consequences. The authors provide a framework for diagnosis and treatment that is informed by their extensive experience in the VA system.
Patients do dissemble in order to gain access to prescription narcotics. In such cases, our treatment focus needs to change from pain management to management of a substance abuse problem. In like fashion, patients may intentionally underperform on standardized neuropsychological measures for a variety of reasons. As Drs. Rachel Ellison and Monica Stika observe, communicating the results of invalid testing to patients poses a significant clinical challenge. While in some circumstances the motivation to perform badly is clear, such as the disability compensation system in the Veteran’s Healthcare Administration, patients who perform suboptimally may do so simply to ensure that a provider understands their distress. In situations like mild traumatic brain injury, where symptoms are protean and diagnostic precision difficult, contextualizing invalid results as a reflection of a patient’s need to ensure that providers understand their distress can lead to the formation of effective therapeutic alliances.
Accurate empathy is also at the core of the case presented by Dr. Beverly Thorn, who helps us tease out the multifactorial origin of a chronically painful condition in a woman with numerous psychosocial stressors. Chronic pain patients often arouse emotions of helplessness, anger, and suspicion in providers. In spite of our professed objectivity, few of us can deny that we’ve experienced similar emotions when referred a patient who has exhausted the resources and good will of many medical providers, and the invalidation that patients experience at the hands of providers serves only to worsen pain and its consequences. Dr. Thorn provides an integrated array of evidence-based techniques that are designed not to abolish pain but to assist patients in reconceptualizing its management. She reminds us continually that progress with such patients can be slow and immediate rewards of treatment difficult to measure. With persistence, though, her approach can yield not only newfound techniques to behaviorally manage pain but new insights to help a patient adapt to a chronic condition.
Setting aside traumatic physical injury, no clinical presentation has a worse potential short-term outcome—if not properly and promptly treated—than stroke, myocardial infarction, and suicidal ideation. While numerous standard algorithms and approved medications exist for cardiovascular emergencies, the assessment of suicidal ideation is largely unstandardized. Scales that purport to classify suicidal patients as high- or low-risk are often misleading at best. At worst, a patient will be asked a question about suicide on a standardized screener and the clinician will fail to follow up. Algorithmic approaches to assessing the suicidal patient are ineffective, as Dr. John Sommers-Flanagan demonstrates, unless the clinician makes the effort to understand what has brought the patient to that critical juncture in his or her life. Dr. Sommers-Flanagan discusses various components of suicide assessment in a manner that is both clinically skillful and deeply human—providing the clinician with a means of moving beyond assessing rote symptoms so that they can be engaged in an effective course of treatment. Dr. Sommers-Flanagan’s techniques are consistent with the approach espoused by the eminent suicidologist David A. Jobes, PhD, ABPP, whose recent National Register clinical webinar (archived) can be found at CE.NationalRegister.org.
As these summaries illustrate, the Journal of Health Service Psychology delivers information-dense, clinically relevant content. The feedback so far from Registrants and other interested parties has been extremely positive.
Inspired by this success, we are rapidly expanding our career development content. In November 2017, we launched our clinical webinar series. Attendance is free for Registrants, as is the associated continuing education credit. Non-affiliated psychologists pay a small fee ($35) to attend. I’m happy to report that we are now averaging about 1,000 registrations per webinar. We have a great schedule of topics and presenters lined up for 2018, including some partner presentations with other organizations. For those of you who cannot attend the live webinar due to scheduling conflicts, they will all be available on our continuing education website (CE.NationalRegister.org) where you may view them at any time and earn CE credit.
In the same theme, we are planning to launch a “Clinical Consult” podcast series in the coming months. Hosted by an outstanding doctoral student from the University of Iowa, Daniel Elchert, these podcasts will be designed for the busy clinician and will focus exclusively on issues of immediate interest to the practitioner.
We’ve also made progress expanding licensure mobility. Vermont and New Jersey adopted our program in 2017 and members have already started applying under the expedited provisions in both states. More recently, the Florida Board of Psychology voted to accept the Register’s mobility program. This will still require positive legislative action to come into effect, but it is great news that we are making progress in a state that many of our Registrants are interested in.
Finally, I would like to share some very good news with you about the Register’s leadership. We have elected a new public member to our Board of Directors, Dr. Ron Manderscheid, who comes to us with a wealth of experience at the highest levels of public mental health research and policy. Previously the chief of mental health statistics and IT at the Center for Mental Health Services within SAMHSA, and a senior policy advisor on healthcare reform in the Department of Health and Human Services (HHS), he is a recognized national and international leader in mental health and substance use. Dr. Manderscheid is now the Executive Officer of the National Association of County Behavioral Health and Developmental Disability Directors—in other words, at the front lines of mental health and substance use service delivery in the United States. Please join me in welcoming him to our Board.