Spring 2003 Newsletter Section 7

Ralph Waldo Emerson once remarked that „All of my greatest ideas were stolen by the ancients‰. The message in this first column, the need for our graduate training programs and internships to provide essential required training in clinical emergencies and crises has certainly been well articulated by my illustrious predecessors (Phil Kleespies, Bob Yufit and Dale McNeal). It does appear that our internship programs do provide some of this essential training - thanks again to Phil Kleespies and his students, we now have listings of many internships that provide specific coursework and supervised clinical experience in the assessment, management, and treatment of behavioral emergencies. Our psychiatric colleagues, as part of their formal residency, require their residents to have a specific number of psychiatric emergency cases as part of their residency training. In addition, the board certification process in psychiatry requires knowledge of (and testing in) the handling of emergencies and crises. The leadership of Section VII has worked diligently with CUDCP and NCSPP to initiate a dialogue on this subject - yet in 2003 such basic training in handling emergency situations in clinical practice is still not mandatory.

Why then has professional psychology lagged behind our psychiatric counterparts? Discussions with the leadership of graduate training programs in professional psychology (i.e., NCSPP and CUDCP) have shown that these organizations are supportive of the efforts of Section VII to advance training in emergency psychology. However, from these same leaders we hear a familiar litany. Namely, that training in clinical emergencies and crisis management is like „the flag and apple pie‰ - all are in favor of such training. But these same leaders in the field also tell us that currently there are so many requirements for APA accreditation that few elective units remain available in which to implement such training. Thus, there is a natural systemic resistance to implementing any more „required‰ modules that require specialized faculty training and supervisory expertise.

While such systemic roadblocks are understandable, I am reminded of a time many years ago when I served as an expert witness for the defense side in a malpractice action where a psychologist had a patient under her care commit suicide. Upon direct questioning by the plaintiff attorney, I was asked what required training was mandated for psychologists in handling patients who were dangerous to themselves or to others. Under oath, I had to testify that our accreditation process did not require our graduate training programs to provide specialized coursework in assessing and treating dangerous patients. In the dramaturgy of the adversarial cross examination process, the plaintiff attorney loudly exclaimed "if you psychologists can't handle people who are homicidal or suicidal...then what good are you anyway!" Over the years, in speaking both with members of the defense and plaintiff bar, judges and even those lay individuals who have served on juries in malpractice actions involving mental health care, there is wide spread surprise and often consternation that all professional psychologists are not required to know how to handle emergencies - that mandatory specialized routine coursework on emergencies is not required in all of our doctoral training. While I am not suggesting that lawsuits are the way to change our graduate curriculum, it is interesting to note that the current APA accreditation process is "outcome" driven (i.e., programs must show outcome data on what they purport to train students to do).

In our own doctor of psychology graduate program in clinical psychology between Stanford University School of Medicine's Department of the Psychiatry and the Pacific Graduate School (the PGSP-STANFORD Psy.D. Consortium), all students in the fall quarter of their second year, as they begin their practicum experience, are required to have an 11 week course in assessing, managing, and treating clinical emergencies and crises. As president of Section VII, I would like to hear directly from other graduate program directors of training who require a quarter long or semester long course on this topic (email: bongar@stanford.edu). The hope would be to accumulate syllabi, reading lists, supervisory guidelines and so forth that could be provided on a voluntary basis to all CUDCP and NCSPP programs. Perhaps by voluntarily encouraging such formal training, a critical mass of doctoral programs can be achieved.

The fear of being sued probably has more widespread and deleterious effects on clinicians than do actual lawsuits. There is no specific set of clinical practices that can absolutely guarantee a psychologist that she or he will be immune from being sued (or even from a judgment for the plaintiff). High quality well trained psychologists ethically are mandated to practice within the scope of their training, education and experience. Hopefully only a few years from now, the current president of Section VII will be able to report to our members that training in clinical emergencies and crises have now voluntarily become a routine part of the scope of practice of clinical psychology.