Debating prescription privileges
THE ACHILLES' heel of APA President Robert Sternberg's well reasoned arguments for prescription privileges ("President's column," June Monitor ) is his remedy that psychologists, "[like other doctors]...refer patients to specialists when the problems the patient face go beyond their expertise...."
His thesis minimizes the risks inherent in managing critical incidents (sudden and/or severe adverse reactions). I am sure that for 90 percent, or even 95 percent, of medication issues a psychologist or a well-trained paraprofessional could arrive at a proper match between prescription and symptoms. It is that 5 percent to 10 percent of patients in which there could occur grave situations that a nonmedical prescriber would not be prepared to treat.
Furthermore, there is a compelling argument that patients should have a recent physical exam or at least a thorough screening before starting medications. We would certainly want to know about a yet-to-be diagnosed problem with blood pressure, kidney disorder, etc., before initiating medication.
If a psychiatrist is not accessible, the better level of care would be in the form of a collaboration with the patient's internist who is familiar with the patient's body and could deftly handle any physical crisis. Remember, the one small oversight of Achilles' body lead to his death.
IRA MOSES, PHD
New York, N.Y.
To report or not to report
WHETHER OR NOT RESEARCHERS (or anyone else) "should" be mandated to report suspicion of child abuse makes for a fascinating debate ("The mandated reporting debate," June Monitor ).
But the reality is that state legislatures have already debated the matter and enacted laws requiring such reporting by professionals.
Dr. David Uttal's point that researchers should not report because they do not have the expertise to make the relevant judgments makes sense in the abstract, but that would miss the point intended by the lawmakers in my state, for example, where 28 professions are listed as mandated reporters, including not only physicians and psychologists but also municipal code enforcement officials and fire inspectors.
Dr. Uttal's comment that an institutional review board (IRB) "might legitimately decide that a researcher is mandated to report abuse" (page 29) erroneously elevates IRBs to the status of legislative bodies, which of course they are not.
If a psychologist is unaware of the applicability of mandatory reporting laws in his or her jurisdiction, surely such questions are best directed to competent legal counsel.
GEOFFREY L. THORPE, PHD
University of Maine
As a clinical researcher, faculty member and member of a university IRB, I read the point counterpoint on mandated reporting requirements for psychologists with great interest. As psychologists, we are bound by a common set of ethical guidelines and code of conduct that requires us to promote and protect the public welfare. Recent HIPAA guidelines require potential subjects to be advised as to the limits of confidentiality and possible disclosure of sensitive information (including abuse). The possible chilling effect on research participation does not, in my opinion, equate with the real harm done in failing to report good faith suspicions of abuse. Following Dr. Uttal's recommendation that such decisions be left to the IRB makes it likely that even less qualified individuals will decide whether mandated reporting is necessary.
DAVID CASTRO-BLANCO, PHD
Long Island University Brooklyn, NY
Dr. Uttal wrote that the "purpose of mandated reporting is to ensure those professionals who have specific training or experiences in detecting child abuse are able to report it...." This is grossly inaccurate, deserves correction and weakens the remaining points made in the position paper. The purpose of mandated reporting has little to do with whether or not an individual has training or experience in "detecting" child abuse. Rather, the purpose of mandated reporting is to protect children (and society) from child maltreatment, an insidious crime and tremendous social tragedy. In fact, a high percentage of adult substance abusers, inmates incarcerated for violent as well as nonviolent crimes, depressed adults, individuals attempting suicide, prostitutes and inpatient populations have experienced some form of maltreatment.
Both research and practicing psychologists are in a unique position to protect children from this insidious condition through recognizing and then reporting maltreatment when it has been reasonably suspected.
Psychologists should not attempt to substantiate or "detect" (as Uttal asserts) abuse by assuming an investigative role. The attempt to "detect" abuse would be considered a trespass of professional boundaries that could jeopardize professional licensure or certification. If a psychologist becomes confused over whether a reasonable suspicion threshold has been met, the psychologist is advised to contact CPS and request procedural clarity. Psychologists of any genre have an ethical responsibility to report maltreatment when it has been reasonably suspected.
STEFAN C. DOMBROWSKI, PHD
Rider University, Lawrenceville
SHANNON A. DICKSON, PSYD
California State University at Sacramento
APA PRESIDENT Sternberg has made an excellent plea to improve education through the worthy promotion of the "other three Rs" ("President's column," March, April, and May Monitor issues). He also skillfully presents many criticisms of our educational system (i.e., accountability measures are too narrow, blaming the victims [kids] is rampant, school memories are often painful, etc.). However, Sternberg omitted reference to possibly the largest database of what actually happens in school and to what improves both sets of three Rs, regardless of ethnicity, class, age, experience, or geographic region.
Though largely unknown today, there is an abundance of strong research on person-centered education. I am currently working on a meta-analysis to organize this information and make it more available to professionals. Aspy and Roebuck are the preeminent American researchers in this area. They coordinated the categorization of over 48 million units of classroom time at all levels from at least 42 states and seven countries.
Simplistically, the robust findings show that students need to be encouraged to feel, think and talk. Teachers need to respect, empathize and be real with students. Unfortunately, eight-to-one ratios exist for teacher talk/student talk and for memory behavior/thinking behavior. Less than 1 percent of time is spent on students' feelings.
Moreover, training in interpersonal skills works. Teacher/professional interpersonal behavior predicts achievement, attendance, elementary school IQ, self-concept and pro-social behavior. The person-centered approach is the phoenix of both empirically supported therapy teaching relationships.
JEFF CORNELIUS-WHITE, PSYD
Texas A&M International University Laredo, Texas
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