According to Khan, who is a psychiatric nurse and clinical specialist and serves as house chair of the Joint Committee on Children, Families and Persons with Disabilities, in 1998, NAMI (the National Alliance of Mental Illness) of Massachusetts approached her with a request to file this bill. In the ensuing years, she has continued to lobby for its passage.

“A lot of research has been done and I’ve been working with the UMass Medical Center,” says Khan. “The concept of involuntary commitment for someone who’s a danger to themselves and others is well established.”

Massachusetts currently does not have a law that would enforce commitment without the individual’s consent. “Now if a patient is dangerous by reason of mental illness, a judge can commit the person to the hospital,” says Khan. Under what is known as Section 12 commitments, a psychologist, psychiatrist or psychiatric nurse can sign commitment papers, she explains, adding that police can also commit an individual for a three-day evaluation. “If the person is still thought to be a danger, a hearing is held,” says Khan. “A judge can commit the person for more than six months. When a person is committed and uses anti-psychotic medications, he or she improves, but after two weeks can be discharged to outpatient. Some who don’t follow up or take their medications relapse and the process gets repeated.”

Rather than enforce inpatient care, Khan is seeking therapy within the less restrictive setting of community. “Under my bill, a judge could commit a person to receive care on an outpatient basis. If there is deterioration, one could go back to the hospital or jail if a crime is involved,” she says. She cites the bill as a preventative measure to keep individuals with mental illness close to home and emotionally stable. “This type of legislation is being used in many other states. It may not solve all the problems, but it keeps the person within our own community,” Khan says.

Opponents to the bill argue that imposing treatment, even though on an outpatient basis, would violate an individual’s civil liberties. Khan refutes this reasoning. “A person is less likely to lose civil liberties if they are getting treatment in the community. It’s better to be in the community with supervision,” she says. “This bill gives us another option and opportunity to give it a try. If someone has to be compliant [with medications] and is being followed by a mental health professional, it’s more likely he would comply. Folks who are non-compliant end up homeless.”

Khan emphasizes that this bill is intended for the small group of individuals with serious mental illness who need treatment, but cannot make decisions for themselves and don’t see the need for help.

Admittedly, some public education would need to take place before the bill would be implemented, should it pass. “Families should understand and be more vigilant about warning signs,” Khan says. “This is an opportunity to raise consciousness about mental health.”

Not all consumers agree in principle with the bill. “I respect their way of looking at peer support instead, which does good solid work. But this is above and beyond what [peers] can do. It applies to anyone who might lose any perspective on their mental health level. One has to step in in certain cases,” Khan says. Although similar bills have failed to always work as they should, statistics indicate a reduction in the number of possible tragedies, she adds.

The Department of Mental Health (DMH) has never supported the bill, according to Khan. Several attempts to reach DMH for comment were unsuccessful.

Cheryl Grau, LICSW, clinical services executive at Arbour-HRI Hospital in Brookline, oversees all clinical programs, including four partial programs and says the issue is “complicated.” She admits that Khan’s proposal would “in some ways be a benefit.” However, for those who suffer with psychosis, the problem is cyclical. “When these folks go on and off medication, they never reach a higher functioning baseline. They are always a step below,” she says. “Psychotic patients are vulnerable in the community.”

Donald Davidoff, Ph.D., assistant professor of psychology at Harvard Medical School and chief of the department of neurology at McLean Hospital, points out that judicial order may not be as important as the intensity and availability of services along with a commitment from the community to provide those services. But he adds that monetary issues sometimes present a stumbling block. “Mental health services have not been robustly funded in the last few years. If legislation around judicial commitment to outpatient treatment would enhance funding, it would indeed decrease the incidence of re-hospitalization,” he says. “Back in the 60s with deinstitutionalization, the great dream was that with medication and community mental health centers, individuals could be adequately maintained outside constrictive institutions. If this legislation creates a mental health court, if you will, and, in turn, links to increased services, it might be a really good thing and might actually fulfill the dream of deinstitutionalization. Without enhancing services, you are not doing anything but adding another bureaucratic logjam.”

For those who cite the loss of civil rights, Davidoff emphasizes the importance of having a psychiatric advance directive (PAD), which invites patients to take an active role in their care. “There are better outcomes when an individual feels they participate in decision-making,” he says. “Having a PAD is a way of dealing with the abrogation of an individual’s rights.”

Davidoff says, “Like everything else today, this speaks to a societal problem. There is a lack of acknowledgement of mental illness being a true illness, something treatable and manageable.”

According to Khan, hundreds of people have called her in support of the bill. “It’s about protecting people including the individual who is severely mentally ill, the family and the public,” she says. “I’m doing this to be helpful, not hurtful.”

Since flooding from Tropical Storm Irene forced the closure of the 54-bed Vermont State Hospital (VHS) last August, community care facilities have stepped up to fill the void. Staff members are gamely coping with their new reality, while hoping for quick action from the state.

Among facilities that have stepped up are the Brattleboro Retreat, which originally took in 15 state hospital patients and Fletcher Allen Health Care, which took in seven.

Both facilities are now admitting patients who in the past would have been sent to the state hospital, meaning they are seeing patients with higher acuity and in a more crowded environment.

Fletcher Allen had to lock a previously unlocked unit. “Since the emergency, we have had a different kind of patient on that floor than we would have had historically,” says Robert Pierattini, M.D., Fletcher Allen’s physician leader of psychiatry.

“We have a level of aggression and violence that we would not have accepted before because we can’t. It’s disruptive to the other patients to have people like this on the unit. It wasn’t that kind of unit.”

Staff assaults skyrocketed. Pierattini reports 14 in September (previously, a typical month would have zero or one). “There were also assaults on other patients,” he says.

Also, instances of patient restraint and seclusion rose – as many in the first three months following the storm as in the previous 12-months.

Programs and staffing have had to change. “It’s changed everything,” he says.

“We don’t have enough beds to take care of everybody who needs to be admitted. There are people who are waiting for a long time to get into a hospital; there are people who are doing without hospital care. We are turning people away we normally would have admitted, so we are patching together programs to try to manage because we don’t have any beds.

“We are worried that bad things are happening that we may not even know about. People who can’t get access to hospital care are doing without appropriate care,” Pierattini says.

Despite the added stress, Pierattini praises staff. “People are doing what they need to do and they are doing it cheerfully. They are managing just fine. The attitudes are amazing.”

Still, he worries that if the situation doesn’t look like it has an end, staff will leave.

“People have choices and I don’t think they’ll stay if they don’t have confidence in the system.”

The state has since presented a plan to the legislature, which resumed Jan. 3. The governor’s plan would replace VSH with a new 15-bed facility in central Vermont, a refurbished 14-bed unit at the Brattleboro Retreat and a six-bed expansion at Rutland Regional Medical Center. It would also enhance community services and specialized programs throughout the state, such as step down beds, improved emergency and individualized services and housing vouchers and peer services.

After the closing of VSH, the influx of new patients at Brattleboro Retreat required the temporary suspension of admission to its Lesbian, Gay, Bisexual and Transgender Inpatient Program.

“It wasn’t what we planned to do, but given the emergency, everybody stepped up,” says Brattleboro Retreat’s President and CEO Robert E. Simpson, Jr., MPH, DSW. He notes a new LGBT unit will re-open in February.

The governor’s plan would provide funding for Brattleboro Retreat to renovate space for the high-acuity patients, who typically have a longer stay.

“The renovation dollars would allow us to go back into that unit and create a space that would be more vibrant for that population,” and would also create an outdoor secure space contiguous to the building, according to Simpson.

Since the flooding, on any given day, the facility has 25 patients who might have normally been admitted to VSH. Because they are higher acuity, many resist medication and treatment. “It just changes the composition of the unit and it changes the way you do care,” he says.

Simpson feels things are going well although stress has increased. “The Retreat has been here 177 years so we’ve been in the business a long time. Many of our staff has been here 20, 30 years. I would say overall it’s gone well, but it’s not without adjustment.”

He says the state doesn’t have enough capacity bed-wise and the governor’s plan would create residential programs in a more rapid way, so that people can get out of hospitals more quickly. He’s supportive of that solution but emphasizes that it needs to happen quickly.

After the governor’s plan was announced, Rep. Anne Donahue, (R-Washington 2), chairwoman of the Legislature’s Mental Health Oversight Committee, says she would like to see some revisions.

She says the committee wants to see the new psychiatric hospital not only centrally located, but also integrated with a medical center or hospital and located on the same campus.

“It’s one thing if you’ve got a 200-bed program that can sustain its own full medical complement, but when you are talking about 15 or even 25-30 beds, if it’s not sufficiently connected to a medical hospital you’re really going to have a big gap of care, with the degree of recognition of co morbidity of medical and psychiatric issues and all of the crossover needs,” she says.

Donahue adds that the plan includes a majority of beds in the southern part of the state – when a majority of the population lives in the north.

“I think there’s some massaging of the numbers that needs to happen,” she says. “There are a lot of creative ways to do that and really stay with the same basic elements of the plan but remedy some of that disparity in access.”

She said she is enthusiastic about what she sees as a rapid planning and response in terms of enhancing community services. “Given the extreme shortage of inpatient beds right now, it’s sort of the next best thing we can do is really get community resources out there and in some cases provide alternatives to inpatient care.”

Donahue adds the urgency caused by the flood should help the legislation move quickly. “We just have to be careful that the tradeoff of moving faster isn’t that we end up with a loss in quality, because it is a very long-term outcome.”

Of the changes to healthcare budgets across the country since 2009, New England is among the regions most in flux, according to a report issued by the National Alliance for Mental Illness. And though some New England states have actually seen an increase in their mental health budgets, Massachusetts has cut care by $55 million, more than any state in the region.

In NAMI’s report “State Mental Health Cuts: The Continuing Crisis,” Mass. is listed as losing 8.1 percent of its operating costs, which has resulted in cutting or shuttering programs offered by the Department of Mental Health. Three specific day services no longer supported by the state include Support, Education and Employment program; Day Treatment Programs and Social Clubs; and two PACT teams (Program for Assertive Community Treatment). Further, more than 150 hospital beds were lost when Westborough State Hospital closed in 2009, as well as a handful at Quincy Mental Health Center.

But while Mass. has suffered, some New England states have seen modest increases: Maine’s budget rose by 15.4 percent and R.I.’s by 10.6 percent. Vt. and N.H. weren’t as lucky, with increases of only 1 and 1.3 percents, respectively. According to Laurie Martinelli, executive director of NAMI Massachusetts, it’s hard to know exactly why some states see bumps while others endure losses.

“We’re like the poor stepchild,” says Martinelli, who has held her office since 2007. “Massachusetts touts itself as a leader of health reform, yet we give crumbs to mental health.”

Mass. isn’t the only state to suffer significantly. NAMI National’s report says that 28 states and D.C. have cut approximately $1.7 billion from their budgets, and among the nation’s 22 remaining states, mental health budgets increased about $487 million. The discrepancy in cutting versus increasing, says NAMI, was due to states cutting Medicaid, the country’s largest public payer of mental health care.

States with the largest funding cuts were Ill. (31.7 percent), Nev. (28.1 percent) and Calif. (21.2 percent).

Martinelli only surmised that when a state governor has no money, the first place to look is big-ticket items. In Mass., when the FY 2012 budget was released last year in mid-January, several DMH programs were on the chopping block. Between January and May, Martinelli says that an outcry from people who rely on the services helped put back at least $1 million.

“I feel optimistic about NAMI rallying the troops,” she says; but with the report by NAMI National saying that Mass. already has seen a $500 million decline in MassHealth, “I wish I could say I’m optimistic going forward.”

Martinelli does believe that active involvement by practitioners who treat patients suffering most from the cuts is a strong part of the solution. The relapse of clients recovering from mental illness – clients who have had their regular programs cut – appears to be the largest result from the Bay State’s budget woes.

“I think the first step is psychologists getting involved,” says Martinelli. Questioning how many practitioners actually know who their representatives are, she says there is power in psychologists, families and even clients themselves sharing in their own words about their experiences with cut programs or lacking services.

“People really underestimate the power of the personal story and what these cuts mean to practitioners.”

According to Brewer, lead researcher on a study published in the Proceedings of the National Academy of Sciences, during meditation certain regions of the brain are deactivated, specifically the “default mode network,” which deals with “self referential processing.” He explains that these areas are related to a number of cognitive disorders.

Brewer did not intentionally apply his study to autism and other neurological conditions, but functional magnetic resonance imaging (fMRI) indicated increased density in cortical density in parts of the brain associated with attention and emotion. During the study, subjects manifested an activated “task positive network” while meditating. This area of the brain is responsible for cognitive control. Brewer notes that the “task is not to be concerned with self,” but to become more mindful in general.

Brewer points out that most people don’t notice how much the mind jumps from one thought to another, a condition he calls “monkey mind.” He says that regular meditation induces a pleasant sensation and reduces the “restless vibe,” enhancing awareness and mindfulness.

Robert M. DuWors, Ph.D., neuroscientist and neuropsychologist in Vermont, Rhode Island and Massachusetts who is also an instructor in psychiatry at Harvard Medical School, was so impressed with the research on meditation, he underwent the eight-week mindfulness program at UMass Medical School to become certified in the technique. He reasons that having this certification enables him to more adequately treat homeless and early recovery patients who come to his mental health clinic on Cape Cod. “These two groups traditionally do not respond well to talk therapy. I was looking at developing a treatment intervention to enhance potential and increase insight [for patients] to allow more self-observation and understanding and to better be able to make choices,” he says.

DuWors reiterates the effectiveness of meditation for those with difficulty controlling behavior. He explains that attentional measures are subsumed under executive functioning, which is located in the prefrontal lobes. “We are finding that meditation is helpful with ADHD. People become less instantly reactive. It’s a way to get more in touch with triggers. And preliminary data shows less relapse in ADHD patients,” says DuWors. “This therapy might be better for those with impulse control, including substance abusers and those with violent tendencies. Meditation makes a connection between the brain or mind and the body. It’s a great way to jumpstart and nurture the concept of observing ego.”

Brewer has submitted a grant to conduct prospective studies that look at whether the regions of the brain change over time. “If we can teach novices to meditate using real-time feedback, we’ll get a sense of whether they are deactivating regions of the brain or not,” he says. “We’ve already seen remarkable anecdotal results with novices in just nine minutes.”

Randy Auerbach, Ph.D., directs McLean Hospital’s Child and Adolescent Mood Disorders Laboratory and is an instructor at Harvard Medical School’s Department of Psychiatry. “I think [the WHO] raised an important issue, and underscored the wide prevalence of youth mental illness. I view it as a way to raise awareness – a push in developing the trajectory of adolescent lives. I commend them for having the courage to put it out there.”

According to the National Alliance on Mental Illness (NAMI), which reported about the WHO’s study, researchers used data from the 2004 Global Burden of Disease and determined the percentage of disease burden by employing cause-specific DALYs (disability-adjusted life years). DALYs examine estimates of years of life that are lost due to premature deaths, as well as years lost to a specific disability such as depression.

According to Auerbach, as many as 50 percent of today’s youth are dealing with some degree of mental illness symptoms and some 20 percent of all adolescents will experience a major depressive issue before age 18. That 45 percent of all youth are suffering varying degrees of mental illness that are highly co-occurring and co-morbid was no surprise.

“There tends to be a spillover of parental stressors,” he says, noting that for kids, environmental influences and how vulnerable certain youth can be are factors that lead to their own diagnosis of depression.

Auerbach is a part of two group programs at McLean that are examining the causes of childhood depression. One, Project STAR (Stress, Trauma and Adolescent Resilience), is investigating how early childhood sexual abuse impacts young girls’ behavioral and neural differences, thereby affecting the early onset of depression in 13- to 19-year-old girls. Another program, Project ADAPT (Addressing Depression in Adolescent and Parent Treatment) is described as an “investigatory group treatment program for adolescent depression, which includes a concurrent but not combined parent group.”

“Depression is more than just being sad,” says Auerbach, and is so heterogeneous that the two McLean programs are trying to pinpoint the subtle shades of differences between diagnoses. If they do, psychologists may learn to tailor treatment accordingly and possibly earlier.

Noting that every study has its limits, Auerbach says the WHO was taking the pulse of this issue the way polls do in an election. He likes to think that it will confirm what he really expects, which is that the statistics will get people talking and help at-risk youth be targeted earlier rather than at the apex of their disorders.

“Our emotions are our tools,” he says. “Much like any tool, they need adjustment. Kids often look over symptoms of anxiety and depression, but we need to fine-tune. [Diagnoses] shouldn’t be something people are too scared of; just something people need to address.”

In creating a new theater company, Boston’s Psych Drama, clinical psychologist Wendy Lippe, Ph.D., decided to use the theater as a way to both take a closer look at the psychology behind these classic and classical plays and to give audiences insight into their own psyches. Starting with a modern take on Shakespeare’s “Hamlet” this past November, the company plans to re-interpret these ancient and well-loved texts for a modern audience, from a psychological viewpoint. In addition, each performance will be followed with a talk for the general public given by a local psychologist on the themes of each show.

Lippe, who runs a private practice in Cambridge and Brookline and is currently an adjunct assistant professor at Boston University, has also had an extensive career in theater, having played a female Hamlet in several professional productions as well as other lead roles. She spoke with New England Psychologist’s Catherine Robertson Souter about the start-up company and their first production, in which she took on the title role.

 Q: What was the impetus for starting the theatre company?

A: few years ago, I auditioned for role of Gertrude with Sporadic Evolution Theatre in Bridgewater and ended up being given the role of Hamlet. That led to a series of portrayals of female Hamlets in which I started to think about the psychology of the piece when you are doing Hamlet as a woman.

One of my colleagues invited me to this wonderful conference in the ancient part of Sicily, “Psychoanalysis in Greek Tragedy” – right up my alley. We saw this wonderful company in an old Greek amphitheater in Ortegia put on two plays and then several psychologists presented papers and we studied them in some very interesting ways.

But there was no connection between the psychologists and the actors and directors. I thought it would be interesting if you had a theater company that integrated psychologists with the artistic team and if there was some kind of reciprocal influence. My mind just started spinning.

Q: Your first show was a reinterpretation of “Hamlet” set in modern times with you as the lead character. Was that a success?

A: It was terrific and interesting and fun and an important production for us to start with. “Hamlet” obviously has so much psychology in it and there are so many different ways one can go with it. We focused on creating essentially a family tragedy.

We worked a lot with subtext and aspects of the relationships between the characters that are not usually examined. We slowed the soliloquies and monologues down so that you could really study and think about the psychology behind the relationships and the dysfunction as well as the intrapsychic conflict.

Q: Did you add text to the original play?

A: We mostly edited because it is a huge text; the full “Hamlet” is over five hours. There were some pieces of text we changed like references to gender. We changed a small piece of text because the end of our show was a little different than the typical fencing duel that happens between Laertes and Hamlet.

 Q: But it was still the same result at the end, everyone dies except for Horatio?

A: Yes, but instead of a poisoned foil it was a poisoned king piece in a chess match.

Q: How does a female Hamlet change the play?

A: I had to think about that a lot. What does it mean when you have a woman in this role – and specifically what happens to the Oedipal dynamics between Hamlet and Gertrude? That was the first question psychologists asked me when I said I was playing Hamlet.

I realized that [a female] Hamlet has to be gay so you can keep all that wonderful dynamic going where she is so preoccupied with Gertrude’s sexuality. It is what we call the negative Oedipal.

In terms of her own gender identity – when Hamlet says “frailty thy name is woman,” she is now referring to herself and to Gertrude and Ophelia. It says a lot about Hamlet’s own self-loathing and struggle to deal with her rage and hatred at her mother for behaving in this way and jumping so quickly from her father’s to her uncle’s bed.

It becomes this interesting study in gender identity, sexual identity, self loathing and so on.

Q: Your goals for these productions are to help audiences to see themselves through the lens of these ancient texts?

A: We are trying to increase psychological mindedness and help people be more reflective in their lives.

We want to reach people you don’t usually reach. These plays speak to human and relational dilemmas that all of us can relate to because they transcend time. Everyone can relate to lust, love, greed, envy, revenge.

But it has to start with an exciting, invigorating performance. If it is old and stuffy and done in the way it’s been done forever, no one is going to want to see it. I wouldn’t want to see it.

Q: You had a number of different presenters after each of the 14 performances. Were you able to have them all become involved in a reciprocal relationship with the production?

A: In this inaugural production, because some came in from New York and some from New Hampshire, we gave our presenters the option to work with our artistic team or to work in isolation. My vision moving forward is to have people more involved to engage the audience in self-reflection through characters and the plays.

Q: Were the talk-backs a success?

A: We did have a number of people come see the show two to three times and several just come to additional talk-backs. The theater needed the public to leave by 11:30 p.m. and we were kicked out every single night. People wanted to keep talking. There is a desire for this out in the community.

Certainly every theater invites psychologists during the run of a show to give a talk-back but nothing exists where every single night we have a psychologically driven talk-back based on a psychologically driven interpretation of a Shakespearean or Greek tragedy.

Q: What is the timeline for your next production?

A: We have started brainstorming an original play based on parallel process issues that came up around the reinterpretation of “Hamlet.” We are thinking of doing a traveling show that explores what happens to the personal relationships between the actors, not the characters, when you take a classic piece of work and do a modern day reinterpretation.

Our next big project will likely be a Greek tragedy, possibly “Medea” at the end of the year. 

Connecticut

Legislators in Hartford last year approved the establishment of a quasi-public agency to develop a health insurance exchange, making Connecticut one of 14 states to set up marketplaces for consumers to shop for health insurance either online or by telephone. The move meets a requirement of federal healthcare reform.

The Connecticut Health Insurance Exchange would serve individuals not enrolled in an employer-sponsored insurance program, Medicare or Medicaid and small businesses with up to 50 employees and must be operational beginning Jan. 1, 2014. Its 14-person board of directors has a lot of work to do before then and is currently in the process of hiring an executive director. The Obama administration has declined to identify a uniform set of essential benefits, allowing individual states to specify benefits within four tiers of coverage.

The Connecticut Psychological Association sees itself as a stakeholder in the exchange’s development, says President Barbara S. Bunk, Ph.D. That’s why the association pledges to keep a close watch on the exchange board’s progress and make itself available to the board and legislators to provide information on mental health treatment and its importance to overall physical health.

“Mental health is frequently in danger,” Bunk explains. “We run the risk of being thought of as a carve-out or nonessential service.”

Connecticut ranked fourth in the nation in 2009 after the District of Columbia, Massachusetts and Alaska in healthcare expenditures per capita ($8,654 compared to the U.S. average of $6,815), according to data from the Kaiser Family Foundation.

The economy continues to challenge association members who must balance serving clients and the administrative demands of maintaining their practices, Bunk says. The association is planning a traveling speaker series responding to member feedback for more information on managing the business end of their practices, such as marketing.

Janine Weisman

Maine

Since 2012 is a short session year of 50 days, the Maine legislature will not be addressing any bills with a significant impact on the practice of psychology. Still, the Maine Psychological Association will have its hands full on two other fronts.

First, the MePA plans to direct energies towards an increased relationship with the Maine Primary Care Association, holding workshops to help link individual psychologists and primary care practices throughout the state.

“We would like to work more closely with the people providing health care especially in rural centers,” says MePA Executive Director Sheila Comerford.

Secondly, a most pressing concern for the Association will be cuts proposed by Gov. Paul LePage – $221 million from MaineCare (Maine’s version of Medicaid).

The cuts will eliminate coverage for 54,000 Maine residents including some working parents, young adults and childless adults.

Additional proposals will eliminate chiropractic, dental, occupational and physical therapy, podiatry and sexually transmitted disease clinics. Generic drug use would be increased and payments for hospital services reduced. Sixty million would be cut by eliminating the use of Medicaid funds to pay for housing.

Although there are no cuts directly to mental health care, with fewer clients covered, there will be a reduction in the need for mental health services.

“It will be grim for a lot of people and there will be ripple effects,” says Comerford. “A lot of health care providers will lose their jobs.”

Hearings on the budget were held in early January and the issue has been sent to the Appropriations Committee for discussion.

“I’m hopeful that not all the cuts will go through,” Comerford says, “but I think a  fair amount will.”

Catherine Robertson Souter

Massachusetts

Elena J. Eisman, Ed.D., ABPP, executive director/director of professional affairs, Massachusetts Psychological Association, says the MPA has two main legislative priorities; both are sponsored by Rep. Ruth D. Balser (D-Newton).

“One of our priorities has been to deal with transparency legislation which would require the medical necessity authorization criteria be made public,” Eisman says.

In addition to requiring health insurance entities to make the criteria public, the legislation would allow the criteria to be challenged and reviewed as to evidence basis and clinical appropriateness. “(The criteria) could be challenged if they aren’t consistent with the scientific literature,” Eisman says.

The other piece of legislation that Eisman lists as a priority involves licensure for behavioral analysts. Balser’s legislation would establish a committee on behavior analysts and applied behavior analysis within the board of registration of psychologists. The board of registration of psychologists would appoint the committee and the committee would develop criteria for the licensure of licensed behavior analysts, including both academic qualification and supervised experience. Rules created by the committee would be subject to approval by the board of registration of psychologists.

“We want to make sure there are criteria where licensing them individually, as we believe it’s important to keep behavioral analysts linked to psychology, which is where the science started,” Eisman says.

Eisman adds the major practice issues facing psychologists in Massachusetts are healthcare reform and payment reform. “We are working very hard to make sure psychologists have a role in whatever new systems are created.”

She says the MPA wants to ensure there are reimbursements for technical assistance to connect to electronic systems; that practices can connect to the super highway of information and those psychologists not part of larger health systems can connect to it in a meaningful way; and that confidentiality issues are addressed in these information super highways.

Eisman says there are a lot of changes taking place and everyone’s more at risk and the MPA could use more help and participation from Massachusetts psychologists.

“It’s important (for psychologists) to understand that they need to support both advocacy at the federal level, as well as the state level, because we do different things that impact their practice.”

Pamela Berard

New Hampshire

In New Hampshire, psychology currently falls under the jurisdiction of the Board of Mental Health Practitioner (BMHP), which also oversees the regulation of independent clinical social workers, clinical mental health counselors and marriage and family therapists.

Feeling that the profession of psychology would be better served by an independent board, the New Hampshire Psychological Association worked together with several state representatives to introduce a bill in 2011 to create one.

That bill is currently being held in subcommittee in order to give newly appointed BMHP board members a chance to address the proposed changes.

While waiting for that decision, the NHPA chose to work to introduce a similar bill in the Senate. This way, by the time the bill works its way through the Senate procedure, it should be ready for a vote on the House side as well.

The main concern with the existing board, says NHPA’s Executive Director Kathryn Saylor, Psy.D., is that an omnibus board with only one psychologist cannot be representative of the entire realm of psychological practice.

A new board would not increase costs for the state since all New Hampshire boards must show a 25 percent profit, which is put back into the state budget.

The hearing for the Senate bill was held on Jan. 12 and a vote was expected after New England Psychologist’s press time.

Two other bills before the House include one to change wording in the procedures for the BMHP and another to limit the ability of the BMHP to consider certain complaints against psychologists. “It will prohibit BMHP from considering complaints against judicially appointed and forensic psychologists unless the originating court has substantiated the basis of the complaints,” says Saylor.

Both of these bills have been assigned to committee but no hearing dates have been set.

Catherine Robertson Souter

Rhode Island

Autism insurance reform advocates applauded last summer when Gov. Lincoln Chafee signed legislation making Rhode Island the 27th state to require private health insurance companies to cover the diagnosis, testing and treatment of autism spectrum disorder. But language in the law could end up disrupting treatment for the children it was designed to help.

That led the Rhode Island Psychological Association’s legislative committee to meet with lawmakers, advocates and state officials last fall in hopes of changing provisions governing client eligibility and credentials of therapists providing treatment. The issues are at the top of RIPA’s 2012 legislative agenda, says President Lisa M. Rocchio, Ph.D.

Under the new law, therapists must be both licensed health care professionals and certified in applied behavior analysis. But only about a half dozen of the state’s 719 licensed psychologists are ABA certified, Rocchio says. ABA certification is obtained after completing 225 hours of graduate coursework through the nonprofit Behavior Analyst Certification Board. Many association members, however, are already qualified based on their training and within the scope of their practices.

Another problem: a $32,000 cap on benefits per year and an age limit cutting off services at age 15.6. However, Medicaid currently provides services to these clients and would likely cover them after they use their allotted private insurance benefits.

RIPA is proposing language to ensure treatment is performed or supervised by a licensed health care professional under rules for providers consistent with Medicaid requirements.

RIPA’s schedule of 2012 workshops will cover a variety of topics to assist members with ethical, clinical and practical matters. A growing number of inquiries from members concerned about using email, Skype and social media sites like Facebook prompted a full-day session scheduled for October with risk management and ethics expert Eric Harris, Ed.D, J.D.

Janine Weisman

Vermont

Rick Barnett, Psy.D., LADC, M.S. Clinical Psychopharmacology and president of the Vermont Psychological Association, says the VPA is focused on three overlapping legislative priorities in 2012.

One is Act. 48 (passed in 2011), healthcare reform legislation that initiates a path toward a single-payer system in Vermont. “However, several steps must be taken to reach that goal,” Barnett says. “In 2012, VPA wants to continue to position itself as a key player in this process to preserve mental health as a core component in the overall healthcare system.”

“Along these lines, our legislative committee is working hard to assure that parity is truly enacted during the reform efforts,” Barnett says. “Although Vermont has some of the strongest parity laws in the country, there are loopholes that undermine the nature of parity. VPA wants to make sure that parity and integrated care are central to the process of moving towards a single payer.”

Additionally, as a result of Tropical Storm Irene last August, the Vermont State Hospital was closed. “Since that time, the state has been scrambling to find suitable arrangements for the most psychiatrically vulnerable patients,” Barnett says. “VPA is concerned about how intensive inpatient psychiatric treatment services are developed in 2012 not only for the displacement caused by closing VSH, but also for the broader population seeking outpatient services or those possibly referred for inpatient care. In arriving at solutions to this significant problem, VPA is certain to let legislators know how their decisions may affect mental health services as a whole, across the state.”

Barnett adds the major practice issues psychologists are facing are: stable or falling reimbursement rates for psychological services (i.e., cuts in Medicare and Medicaid funding); and workforce retention and development.

“VPA is actively involved in insurance issues through our insurance committee. VPA works closely with other mental health associations (NASW-VT, Counselor’s Association, VT Psychiatric Association) to address all the aforementioned issues in addition to workforce retention and development. It’s a very proactive, collaborative time to be a member of VPA,” Barnett says.

Pamela Berard 

While much of the wrangling over the casino issue has taken place on the political stage, some community-minded agencies have been working diligently to prevent repercussions associated with gambling addiction. According to Margo Cahoon, communications director at the Massachusetts Council on Compulsive Gambling (Mass. Council), her organization has been closely involved in talks revolving around the casino issue.

In fact, a collaborative effort has helped to ensure that the issue of gambling addiction and problems associated with excessive gambling are addressed. “People from all the gambling industries joined forces to talk about responsible public policy and to offer suggestions,” she says. In addition to the Mass. Council, representatives from Mohegan Sun, Suffolk Downs, the Massachusetts State Lottery Commission, Wonderland Greyhound Park and the State Racing Commission combined to form The Massachusetts Partnership for Responsible Gambling in Sept. 2009, Cahoon notes.

To drive home the importance of preventative measures, the Partnership invited individuals with gambling problems to share their stories with the lawmakers before the bill came up for a vote, according to Cahoon. “We wanted legislators to look at this issue from the human angle, not just the dollar angle,” she says. “We are not anti-gambling. But we see the devastation first hand.”

This group also held leadership forums to examine the best practices across the country and in Canada before compiling a list of recommendations, which it presented to the legislature. Cahoon is happy to report that most of the suggestions were included in the final bill. Two of the provisions include on-site counseling and an exclusion list. “This will allow families and the individual to propose exclusion and prevent entry to the casino,” says Cahoon. “They will have a hearing, which doesn’t usually happen elsewhere in the U.S. It’s a positive step.”

The casinos will dedicate on-site space for compulsive gambling and substance abuse services where individuals can get information. “Casino workers will be trained to recognize problem behavior and they can refer people to treatment,” says Cahoon.

The bill also requires that payback statistics be displayed prominently on slot machines. “This is a good educational tool. It’s a reminder that the statistics are stacked against the gambler,” Cahoon says. Additionally, the casino bill will establish a public health trust fund that will provide services and programs for problems directly related to gambling. This initiative will supply research related to problem gambling. “There is currently not a lot of data available to inform policy,” says Cahoon. “This is a strong start.”

While gambling in and of itself may pose a problem to the individual, the family, community and greater society, the issue of dual diagnoses complicates the picture. According to Cahoon, approximately 75 percent of problem gamblers also have another health problem, such as anxiety, depression, bipolar disorder, alcohol or substance abuse. The National Comorbidity Survey Replication reports that pathological gamblers are significantly more likely to have mental health disorders and/or substance use disorders compared to those without gambling problems.

Several towns in the Commonwealth are lobbying to have a casino built in its community, none more strenuously than Palmer in the western part of the state. Christopher E. Overtree, Ph.D., director of The Psychological Services Center at the University of Massachusetts Amherst, points out that residents in western Massachusetts currently have several casinos in close proximity. “For hardcore gamblers, having a casino in western Massachusetts won’t change their behavior,” he says. “It’s a matter of impulse control. Closer access might increase the chance of becoming addicted for some individuals. It’s a good idea to anticipate an increase in this type of behavior.”

Overtree explains that a person addicted to gambling does not usually self-identify until a secondary problem arises. “One would hope that when evaluating the true cost and benefits of casinos, which are obviously designed to increase revenue for the Commonwealth and create jobs, [legislators] would factor in the true cost of fallback on taxpayers. The people who access mental health care for gambling problems are most likely in financial trouble due to foreclosures and other economic catastrophes. People who fall into this condition may not be able to afford co-pays,” he says. “Those costs shouldn’t be hidden; they should be on the table. This is the true picture of what the pros and cons are. Gambling addiction can have a disproportionately negative impact on publicly funded support services. This differentiates it from other mental health problems.”

“We should buttress available mental health resources, both specialty programs and for addiction and addiction counselors as well as mental health programs. In western Massachusetts, certain segments struggle to access mental health care now,” says Overtree. “It’s a problem of an adequate supply of competent clinicians and institutions that can accept people quickly. Expanding available services should be a priority.”

However, Overtree admits that creating such programs poses a dilemma. “There is not a lot of financial incentive to do this, unless there is a clear process for getting reimbursement. This may require state funds or fast-tracking payment through insurance companies,” he says.

The Mass. Council offers a special certificate program that qualifies social workers and psychologists to work with problem gamblers. “We want to have more people in certain areas of the state. We don’t feel we have enough coverage, particularly in western Massachusetts,” Cahoon says. She notes that discussions with R.I. and N.Y. after those states instituted gambling revealed an increase in problem behavior, particularly with slot machine use. “We expect to see an increase in problem gambling, especially in the first two years,” she says.

For 10 years, James Greenblatt, M.D. has fought a near-daily occupational hazard. It has followed him from his last job to his current one and has robbed him of hours he’ll never get back while highlighting unfairness in the country’s managed care system – case by upsetting case.

As the new medical director of the Cambridge Eating Disorder Center in Massachusetts, instead of spending more time with patients who need CEDC’s aggressive residential care, Greenblatt is often subsumed with arguing the severity of their cases to prove that their diagnosis of having an acute eating disorder warrants a bed at the center. He also argues that not only will the bed probably save the patient’s life, it deserves to be covered by insurance. Often, it’s not.

“It’s been a major part of my career,” says Greenblatt, who joined CEDC in November after seven years in the same position at Walden Behavioral Care in Waltham, Mass.

“Insurance companies have done a very aggressive job of limiting treatment based on parameters they have that sometimes are not always looking at the patient’s best interest,” he says. “Outpatient doctors are trying to get patients in hospitals; insurance will say no, almost on a daily basis.”

The media has publicized the battle to secure coverage for eating disorder patients across the country whose acute disease has wreaked havoc on their internal organs. Articles have relayed cases about claims being accepted or denied for stays in residential programs that some experts deem necessary and some managed care organizations don’t.

In October, The New York Times reported on a California case that ultimately forced the state to pay for residential treatment of eating disorders and other serious mental illnesses under the state’s mental health parity law. It was a win for eating disorder advocates that the parity law required companies to cover expenses for mental and behavioral disorders as they would any other illness.

“The parity piece is such a big issue,” says Patrice D. Lockhart, M.D., medical director of the New England Eating Disorder Program at Mercy Hospital in Portland, Maine. “We’ve seen this swing back and forth several times. Especially for [eating disorder] residential treatment, it falls in a grey zone about determining who residential care is most useful for.”

These experts argue that in some cases, that grey zone is decidedly black and white. With a chronic diagnosis of anorexia nervosa, for example, Lockhart says a patient who has suffered for years can be so malnourished, the strain on the heart, kidney and liver functions requires intense help to break the cycle. Consistent purging can drop electrolytes low enough to cause death. Many patients can’t heal alone and can relapse after treatment if not properly supported at home or during further treatment.

“I think all of the articles I’ve read, the cases are both striking and horrifying; but I don’t think people understand the magnitude of the problem,” says Greenblatt. “This is the most life threatening set of diseases we have in psychiatry.”

While eating disorders don’t always lead to suicide or mortality, they can. Yet sometimes the sole criteria insurance companies use to determine whether they will cover a residential stay – often needed to provide around-the-clock care to regulate a patient’s medical condition, food intake or mental state during healing – is their weight.

For some, patients carrying below 75 percent of their ideal body weight are deemed critical. But where a certain percentage on one patient can look different on another, it’s nearly impossible to show how ill they are on the inside or the strain their mental disease has had on their lives.

Unlike other parts of the country, however, several New England insurance companies support this select population. Neil Minkoff, M.D., is the medical director of the Massachusetts Association of Health Plans, which is a non-profit voice representing 13 health plans across the state.

According to Minkoff, MAHP plans (which include United Healthcare, Harvard Pilgrim, Fallon Community Health Plan and others) have historically been a market that’s ahead of the curve for its widely covering residential programs for eating disorder patients when medically needed.

“I do think that some insurance companies get very aggressive. But we have always worked under the condition that this therapy is medically necessary,” says Minkoff.

Health insurance company, Anthem has praised Lockhart’s program at Mercy for its efficacy and cost-effectiveness. The New England Eating Disorder Program offers three- to six-week stays in its “partial hospitalization” program. Patients receive intensive care by day but go home at night to “practice” the eating habits and psychological tools they are learning to facilitate healing. Lockhart says Anthem named Mercy an “Institute of Excellence.”

Blue Cross Blue Shield of Massachusetts has also taken a supportive stance. “Eating disorders are complex illnesses that often require a combination of medical, nutritional, and behavioral treatments,” says Jeffrey L. Simmons, M.D., medical director for Behavioral Health at Blue Cross Blue Shield. “Based on nationally recognized clinical criteria, we provide coverage for a variety of eating disorder programs, including residential care, when a treating clinician recommends this level of care for their patient.”

In spite of their frustration, both Greenblatt and Lockhart express understanding of the between-a-rock-and-a-hard-place position managed care often finds itself. Insurance companies need research and trials to support what they cover. There are few on the books to prove or disprove the benefit of residential stays for severe eating disorder patients.

“I do understand,” says Greenblatt, who has written several books on using nutrition and depression research as ways to treat eating disorders. “The insurance companies point-number one is that there is no research that says that being in a hospital is helpful. Everyone is frustrated by the lack of knowledge base.”

Greenblatt’s work attempts to counter the lacking research. The founder and medical director of Comprehensive Psychiatric Resources, a private integrative psychiatric practice, Greenblatt published a paper with colleagues in Neuropsychiatric Disease and Treatment describing using an electroencephalograph (EEG) to determine what, if any medication could be prescribed to an eating disorder patient co morbid with depressive or bipolar disorder.

Through these referenced-EEGs, Greenblatt’s hope and others’ is to reduce inpatient, residential and partial hospitalization days for eating disorder patients by using EEG data to better treat some of the psychological diagnoses that can cause the disease.

“Care at residential facilities across the country provide very positive environments, but we still have to answer questions about how to stop the illness,” says Greenblatt. “What medical professionals are doing is just making educated guesses [about the cause of eating disorders]. Reference EEG is able to demonstrate that eating disorder patients follow a pattern over a number of years.”

Category: “Disorders Usually First Diagnosed in Infancy, Childhood or Adolescence”

Changes: The Task Force has considered adding the following five disorders: Language Impairment, Late Language Emergence, Specific Language Impairment, Social Communication Disorder and Voice Disorder. The following have been suggested for elimination: Expressive Language Disorder, Mixed Receptive-expressive Language Disorder and “Communication Disorder Not Otherwise Specified” (which is being moved to a different category).

Kupfer’s Comments: “A noteworthy change…is that of Autism Spectrum Disorder (which will exist in a chapter entitled Neurodevelopmental Disorders). This diagnosis combines the former DSM-IV diagnoses of Autistic Disorder, Asperger’s Disorder, Child Disintegrative Disorder and Pervasive Developmental Disorder Not Otherwise Specified into a single diagnosis. Although these individual diagnoses are not new to DSM, their existence as a single spectrum disorder is.”

Category: “Mood Disorders”

Changes: The Task Force has considered adding the following: Premenstrual Dysphoric Disorder, Mixed Features Specifier and Mixed Anxiety Depression.

Kupfer’s Comments: “A particularly important addition, it will provide clinicians with a more precise definition of mixed symptomatology (depression plus mania/hypomania features) and will allow them to accurately and more quickly identify patients at risk for converting from a unipolar disorder to a bipolar disorder. Premenstrual Dysphoric Disorder currently exists in DSM-IV as an Appendix condition (i.e., as a disorder requiring further research), and its elevation to a disorder in the main manual means women suffering from severe mood symptoms and impaired functioning during the menstrual cycle can receive proper treatment.”

Category: “Other Disorders”

Changes: This category comprises new disorders that were not listed in the DSM-IV. In a sub-category of “Self Injury,” non-suicidal self injury (NSSI) is being proposed in light of the growing number of self-harming patients with behavior that leads to bruising, bleeding or pain. Also proposed for the “Other Disorders” category are two types of “Factitious Disorder” – in one’s self or about another – in which patients falsely report symptoms or illness in themselves or about another.

Kupfer’s Comments: “Regarding proposals for Self Injury Disorders, these were drafted in response to the high public health need to call greater attention to matters of suicide attempt and non-suicidal self injurious behavior (e.g., ‘cutting), particularly among adolescents. In DSM-IV, discussion of such issues is generally relegated to that of Borderline Personality Disorder and Major Depressive Disorder, yet suicidal and non-suicidal behavior is widely pertinent across clinical populations and should not be considered only among patients being treated for Personality or Mood Disorders. NSSI is under investigation in the DSM-5 Field Trials.”