Theoretical Rationale for Understanding

“Quantitative Justification”

The Arizona Community Clinical Psychology Training Group (ACCPT.G): An organization of experienced Clinical Psychologists devoted to training Clinical Psychology Interns and Clinical Psychology Postdoctoral Residents to provide psychology services to underprivileged and underserved children in our community

By

Catherin M. Snyder, M.A.

Psychology Intern, ACCPT.G.

and

Felix Salomon, Ph.D.

Director of Clinical Training, ACCPT.G.

The population of greatest concern: Victimized Children under Arizona State Guardianship: (State and National Forensic and Academic Evidence Indicating a Need for Government Funded Intensive Psychotherapy Service and Treatment Outcome Data)

Our past placements represent active efforts toward the improvement of the mental health of the females residing in group homes. These efforts are greatly needed and perfectly timed in response to recent findings of the National Alliance on Mental Illness's (NAMI) (2006) state-by-state analysis of mental health care services in the United States. Results of NAMI's analysis reveal a D+ grade for the state of mental health in Arizona's health care system and a D for our nation as a whole. ACCPT.G directly responds to NAMI's (2006) needs analysis by securing intensive, psychoanalytically-oriented psychotherapy services for youth residing in residential care facilities.

Arizona's mental health care system, one of the first states to create pre- and post- doctoral clinical experience through the Arizona Psychology Training Consortium, utilizied very experienced Clinical Psychologists in the private sector, e.g., ACCPT.G, an approved member of the Arizona Psychological Association – Arizona Training Consortium (the Consortium). Felix Salomon, Ph.D. is the Director of Clinical Training, as well as a supervisor, Jon Masters, Psy.D. is a secondary Supervisor;

ACCPT.G, consistent with empirical data provided by the National Institute of Justice (NIJ) (1997) and the Bureau of Justice Statistics (BJS) (1997), emphasizes the need for more consistent, frequent, and in-depth assessment and psychotherapy services for the treatment of trauma-related psychopathology such as Post Traumatic Stress Disorder (PTSD), Dual Diagnoses, and Borderline Personality: characteristics exhibited by many of the adolescents in group homes. In fact, significant evidence exists indicating that child victims or witnesses of unexpected violent crime resulting in the injury of one family member by another family member (National Center for Injury Prevention and Control) are very likely to suffer from PTSD. Research also suggests that psychological traumatic disability results from both actual and possible assault, with both having the potential for seriously debilitating the victim (National Victims Assistance Academy, 2005; Meichenbaum, 1995).

ACCPT.G appreciates the traumatic histories experienced by the female youth residing in state funded group homes and are, therefore, particularly vigilant in their efforts to provide effective treatment. These females residing in group homes are child victims. Child victimization is a common reason child protective services becomes involved in the lives of youth that are particularly vulnerable to the debilitating effects of PTSD. These children, like Vietnam War Veterans, face lifetime challenges of overcoming and reconciling tragic life experience that, for now, manifests in the form of psychopathology (i.e., abnormal behavior and personality problems). Left untreated, many youth will continue to suffer from problems in behavioral control and personality characteristics that many “normal” people find disturbing (i.e., extreme hatred for others; distrust; manipulation; lying; stealing; sexual, verbal, physical, and many passive forms of victimization or perpetration; and continued dependence on “the system”: The Arizona Department of Economic Security).

Typical post trauma symptoms exhibited by displaced youth presents in the form of sleep disturbance, anxiety, sadness, and anger. Some residents exhibit problems in fundamental bodily functions, such as encopresis and enuresis. Some report that they have a feeling that something or someone is out to get them, following them, watching them. Psychoanalysts would refer to this as pervasive paranoid ideation. For these children paranoia often manifests in acting out behaviors such as physical attacks.

A frequent and easily recognized sign of trauma is the exaggerated startle reflexes: many of these young victims experience the startle reflex when someone enters a room unexpectedly. They startle very easily! This is important information because research evidence exists that indicates that special attention should be given to the startle reflex because of the physiological effects on the child's nervous system, which, over time, affects their immunity. This is one reason an early group therapy session may involve psycho-education for the residents on the nervous system, including strategies such as deep breathing and resources in the form of books and videos, to help them learn to shift their body from sympathetic/fight or flight response to parasympathetic/relaxation response activity.

An interesting study was conducted on some school age children several years ago examining their startle reflexes. All the children developed PTSD after witnessing a shooting or some other trauma. All the children revealed regressed physiological startle patterns, exaggerated startle reflexes, such that the responses of a ten-year-old child resembled those of a five-year-old (National Victims Assistance Academy, 2002). This activity was regressive in nature. Why? One sign of healthy development is enhanced regulatory capacity exhibited by an individual over his or her physiological arousal throughout the lifespan.

This pattern is revealed in recent data collected by ACCPT.G during group psychotherapy, as well as a myriad of reported and tracked physiological, cognitive, behavioral, and emotional symptoms consistent with PTSD. In the previous study about the school age children and in ACCPT-G's recent data collection, the affected children experienced immediate psychic regression and overreacted to environmental cues as if they were responding to perceived danger (National Victims Assistance Academy, 2002).

Experimental data also indicates that childhood trauma impairs "normal neuron-to-neuron synaptic development in the cerebral cortex of the brain's frontal lobe leading to deficits in attention, planning, reasoning, and behavior control" (National Victims Assistance Academy, 2002). Deficiencies in attention, concentration, anticipation of consequences, planning, reasoning, perceptual processing, and behavioral control often results in academic failure or achievement problems commonly attributed to ADHD, which could be more correctly viewed as a secondary symptom of pre-existing trauma.

Observational and report data on many of the residential youth living in group homes served by ACCPT-G interns has indicated underachievement in school performance and behavioral problems in the homes that require ongoing attention. Deficits in attention and hyper-arousal behaviors caused by previous trauma are easily misinterpreted by staff and teachers as rebellion. This is a problem. The solution involves competency in assessment and treatment for the residents and psycho-education for both the residents and the staff regarding possible relationships between trauma and learning disabilities. Left untreated and misunderstood, many of the youth at risk will continue to have increasing academic problems that could possibly lead to even greater vulnerabilities and more feelings of failures related to them in life.

ACCPT.G has been proactive in recognizing the myriad of care-providing needs of the youth residing in group homes. The transition is difficult; it has only been two years since the inauguration of ACCPT.G. During the last two years, many youth have received group psychotherapy and individual psychotherapy. Staff was invited to attend monthly ACCPT.G Colloquia trainings. The goals of the pre-doctoral intern program enables the provision of in-house psychotherapy, assessment, and training services for all residents and staff as well as training opportunities for the interns. Community-based services such as this are a rarity in our community. A past intern, Catherin Snyder, M.A. is collected data to empirically document the progress that has been made through the services of ACCPT-G. Our data as well as the experience of the interns has made more salient the need for psycho-education regarding mental health issues in the home and the need for increased continuity between home, academic/school, and mental health care environments and providers. ACCPT.G is working on a model to address these issues at multiple systemic levels.

Regardless of the reality of the daily hassles and frustration involved, this type of care is unprecedented with this population in the State of Arizona and basically the nation as a whole. A growing feeling of accomplishment and well-being for this most deserving population is shared more and more by all those involved with and supporting ACCPT.G. This is a cutting edge program in providing long-term, intensive quality mental health care to victimized children who are wards of the state.

The models of treatment followed by ACCPT.G began in New York and California with similar community-based programs. ACCPT.G operates within the context of Contemporary Psychoanalytic Theory, which recognizes the needs for and benefits of constant, consistent, longer-term treatment. ACCPT.G follows guidelines of empirically validated treatment standards and is currently collecting data and revising collection methods at the relevant sites of service. The goal of the data collection is to provide empirical evidence that supports the provision of a minimum of twice weekly, 45 minute, individual psychotherapy sessions and weekly 1½-hour group psychotherapy sessions (This is the core of what Dr. Salomon likes to refer to as “the true intensive model of Contemporary Psychoanalytic Psychotherapy” for group home residents).

The more intensive longer term psychotherapy is needed in the treatment of these young people rather than shorter term counseling because of the level and type of problems exhibited due to serious psychopathology resulting from previous severe trauma. We note that counseling is able to provide much needed support for them in dealing with current stresses such as living with strangers, not knowing where they will live next, etc., but psychotherapy is the treatment of choice to explore and treat the effects of the trauma that led to their placement in group homes. Psychoanalytic psychotherapy will accomplish this, and life-long beneficial personality change (attitude and behavioral change) and emotional change is the ultimate goal.

Many people wonder, "What is the difference between counseling and psychotherapy?" The following is a rather lengthy explanation: Counseling and clinical psychologists perform similar work as researchers and/or practitioners in a number of settings, including academic institutions, hospitals, community mental health centers, independent practice, and college counseling centers. The differences between counseling and psychotherapy stem from the history of each specialty, which has, over time, influenced the focus and emphasis of the type of training each specialty currently receives (Roger & Stone, 2006). The traditions and orientations of counseling and psychotherapy are different and can best be understood by considering the etymology of each term. Clinical derives from the Greek, "kline," which means bed, (and is also found in the root of the word "recline"). Clinical practice follows the medical model and was traditionally referred to as care provided at the bedside of an ill patient. The term counsel stems from the Latin word "consulere," which means to consult, advise, or deliberate. These conceptual differences reflect early differences in foci of each field and should be currently be considered in the type of treatment a person or group is seeking.

Clinical psychologists study disturbances in mental health using the medical model. Counselors do not typically follow the medical model because their role was originally to provide vocational guidance and advice people struggling with everyday problems. The counseling field's historical and current focus continues to be on treating a ‘normal' client population; that is, the research conducted and published in the professional literature is oriented toward people without serious or persistent mental illnesses (Rogers & Stone, 2006). Again, differences residing in the historical origins of the terms help us to understand the role of psychotherapist as offering assessment and treatment services to clients/patients that were not necessarily ‘normal'. This partly explains the reasons for the differing levels of training between counselors and psychologists, with psychologists receiving training in clinical issues that had previously been provided for by psychiatrists, who hold a medical degree (i.e., M.D.) (Roger & Stone, 2006). The dissimilarity between counselors and psychologists became most evident after World War II (WWII). WWII veterans suffered poor mental health after combat and many returning soldiers required special assistance to help them reintegrate into the work force. Many were unable to do so as a result of emotional disability, which was then labeled ‘shell shock'. Today, ‘shell shock' has been relabeled ‘PTSD' to better capture the essence of the underlying psychological complications war had on the psyche. The Veterans Administration hospital chose to be proactive in their efforts to treat trauma symptoms and employment difficulties. The Veterans Administration employed Clinical Psychologists to treat ‘shell shock' and vocational counselors to assist with re-entry into the work force. Again, the clinical psychologist's role was to treat the veterans' more serious psychiatric problems (Rogers & Stone, 2006). A lot has happened to the field of clinical psychology since WWII. Psychotherapy as a method of treatment is regulated (in Western countries) by the laws concerning patients their rights (Wikipedia, 2006). The American Psychological Association (APA) compiled the APA Code of Ethics. Psychotherapy involves a very high responsibility service that is usually provided by a doctoral level (Ph.D. or Psy.D.) psychologist. There are many different types of psychologists, e.g., organizational, school, academic, etc. The Clinical Psychologist is a doctoral level psychologist who is specifically trained to deliver psychotherapy and psycho-diagnostic services following legal and ethical codes with respect for the patient's confidentiality. This is the reason why Clinical Psychologists insist on a confidential space to work in to ensure that they have properly assessed each patient and this can only occur in an atmosphere of privacy, trust, and safety. As such, psychologists, like medical doctors, cannot disclose or discuss a great deal of patient information. Exceptions to the code are followed with caution when working with minors and adults specifically regarding suspicions or information that child abuse or neglect is occurring, imminent serious harm to the patient or another person is likely, or specific and informed consent is given by the patient, or the patient's guardian, for disclosure (Fisher, 2003). It should be noted, however, that disclosure of confidential information, regardless of reason, influences the level of trust and disclosure of most patients.

ACCPT.G must follow particular guidelines when working with the children in their care. Why chose to work with psychoanalytically oriented psychologists, when there are other mental health providers to choose from? What are the options in Arizona? Well, different types of mental health services are available in Arizona. A total of 5,545 mental health professionals are currently listed as providers in the state of Arizona. Of those, 1,670 are psychologists who obtained a Philosophy Doctorate (Ph.D.) or Psychology Doctorate ( sy. D.). Only 1,105 psychologists, however, actually live in the state. There are 557 psychiatrists, 1,957 masters level counselors, 2,109 masters level social workers, 1,179 substance abuse counselors, and 300 marriage and family therapists (SAMHSA, 2004). Of the 1,670 psychologists licensed in Arizona, only 411 are members of the Arizona Psychological Association, (Dr. Cox, Personal Communication, 2006).

Why choose to secure doctoral level psychotherapy services rather than counseling for this population? Because the nature of disturbance underlying the problems exhibited by many youth residing in state facilities calls for the expertise of doctoral level Clinical Psychologists. These children do not fall within the ‘normal' spectrum. They have suffered attempted homicide (some of it against them), homicide of a parent or sibling, attempted suicide (self), rape, incest, beatings, emotional neglect, substance abuse, and much, much more. Every child has experienced disrupted or broken attachments from their parents and siblings that is inherent in the premature separation from biological (or adoptive) parents.

It is extremely important to note that, at the end of psychotherapy, the average treated patient is better off than 80% of untreated patients. In fact, researchers Gabbard and Lazaar (2006) claimed that, “the magnitude of effect of psychotherapy is equivalent to a level that justifies the interruption of clinical trials on the grounds that it would be unethical to withhold such a highly effective treatment from patients.” Additional evidence also indicates that for children with anxiety and depressive disorders and those with severe or multiple pathologies, intensive psychoanalytic treatment at 4-5 times per week is recommended because it proves to be more efficacious than 1-3 times per week. When thinking about the relational component to treatment, it makes sense to presume that sometimes, for some people, treatment length and frequency can be positively correlated with better outcomes (Gabbard & Lazaar, 2006).

Additional reasons for supporting the services ACCPT-G can provide comes from a Consumer Reports survey (Consumer Reports, 1995) of 2,900 readers who received psychotherapy (also reported by Gabbard and Lazaar, 2006), showed that longer length of treatment was associated with better outcomes and worse outcomes were linked to insurance or managed care plans that limited the frequency and length of the psychotherapy. ACCPT.G is determined to provide a quality alternative in our home State of Arizona. ACCPT.G is attempting to fill some of the gaps in care, providing in-depth learning experiences such as psycho-educational trainings and consistent, constant, predictable psychotherapy services. These services are essential in promoting psychological growth, resolving serious mental, emotional, and psychological problems. There is no substitute for these services, that is, if these services would not be provided, there would be a tremendous gap in what these children need to grow up with a reasonable chance of a healthy productive life.

It is also quite certain that shorter-term treatments or infrequent treatments would be grossly inadequate for this population, especially due to the very serious nature of their psychopathology. Although no one can predict the future, evidence exists that support ACCPT-G's claim that, “Over time, longer-term psychotherapy will save the State of Arizona money.” Why? First, the type of pathology exhibited by theseyouth indicates the need for more intensive treatment and there exists an inordinately high prevalence rate of later delinquent behavior in untreated abused children. For example, a survey published by the Bureau of Justice Statistics (1997) revealed such significant rates of childhood physical and sexual abuse histories in incarcerated adults that the correlation between childhood abuse and delinquent behavior could not be denied. Mental health treatment began shortly thereafter and focused on PTSD and childhood abuse rather than on delinquent behavior.

By the year 2000, America's correctional facilities fully recognized the need for improving mental health services in their institutions. Adult incarceration data reveal that state prisons held approximately 191,000 mentally ill inmates. By midyear 2000, 70% of America's inmates were undergoing mental health screening at in-take, 65% were undergoing psychiatric assessment, 51% were under 24-hour mental health care, 71% were receiving therapy, 73% were taking psychotropic medication, and 66% were receiving assistance from the correctional facility in securing community based mental health treatment after release (U.S. Department of Justice, 2001).

Given that Arizona's 2005 arrest rate was 307,786 with 51,291 under the age of 18 (Department of Public Safety, 2005), it makes sense that ACCPT.G would seek to provide preventative mental health treatment to disenfranchised youth. The second reason for providing intensive psychotherapy services is related to ACCPT.G's claim that preventive services during childhood will save the State of Arizona money in the long run. The fact that approximately 60% of visits to primary care physicians are for medical complaints that stem from psychological disorders is just one reason, and cost offset studies show a significant decrease in total health care costs following mental health intervention. For example, in a Civilian Health and Medical Program of the Uniformed Services (CHAMPUS) study, the decision to devote an additional $22 million to outpatient care resulted in a net savings of $200 million (American Psychological Association, 1993). Therefore, it makes sense to start helping the children and adolescents with psychotherapy. It saves society hundreds of millions of dollars in later possible emotional and financial costs to society and the individual that are damaging in multiple ways. Given the above, one of psychotherapy's main benefits to society is in increasing the positive quality of each citizen's life!

Outside of ACCPT.G mental health services, dissatisfaction with other mental health services was evidenced in staff reports that the typical level of treatment is uncertain, infrequent, and not intensive enough. Counseling generally involves random visits, once or twice a month, ranging from 15 minutes to 1 ½ hours, from a case-worker assigned to a resident's case. Complaints from staff that they do not know what the counselor is focusing on in treatment helps ACCPT.G understand that developing communicational relationships between staff and treating clinicians is desirous. In addition, staff reports that many of the residents meet with a counselor only twice a month for about 15 minutes indicates the need for an additional and different approach to meeting the serious mental health needs of these children.

This population has profound needs for intensive psychotherapy. If these needs are met, they will be able to better develop into psychologically healthy, successful, and productive adults. ACCPT.G intends to collect data to document the need for long-term intensive mental health treatment because ACCPT.G looks to empirical research to guide the treatment of youth. An example of the ways in which data collected from the youth can be used in the long term is provided in a study conducted at the University of South Alabama. The study was published in the January 1999 Journal of Interpersonal Violence.Results of the study revealed a need for improved mental health in victimized females and suggested that early victimization is related to later victimization and drug use. This statement was based on the research findings of 42% of the adult women who, in the study, had histories of child abuse and experienced adult or recurrent sexual assaults. The women in the study reportedly demonstrated very poor coping strategies and were exceptionally vulnerability to re-victimization (National Victims Assistance Academy, 2002).

ACCPT.G uses findings such as this to identify the need for teaching coping strategies along with personality development. In many cases of severe trauma, the exploration of that trauma (or series of traumas) in a trusting caring relationship with a qualified psychologist often helps the patient to gain insight into the reasons for re-victimization. This insight and emotional healing serves as a good preventative measure in reference to later abnormal behavior such as turning into an abuser to deal with past abuse. Again, as stated above, the typical history of residents involves significant physical, emotional, and sexual abuse. In addition, the more devastating effects of neglect often result into what is sometimes called “The Neglected Child Syndrome”. This syndrome is seen in children who suffer from severe emotional and/or physical neglect. The neglected child often exhibits the symptoms of emotional and social withdrawal, apathy, dissociation, inattentiveness, aimless activity, and drug abuse. It makes sense to assume that a constant, consistent professional listener, trained in a graduate psychology program, with treatment skills acquired through supervision by experienced clinical psychologists. Clinical psychologists are dedicated to understanding psychopathology at a deeper level and this is why psychology students spend hundreds of thousands of dollars on education and training opportunities to ensure that they are competent to provide the type of clinical services needed for their patients.