Winter 2019 – Vol. 78 Issue 1 psychologistpsychologistT E X A S

Leveraging TPA’s Evaluating Malingering 7 Strategic Plan 11 in Civil Cases Texas Psychologist Beyond the PHQ-9: 9 Honored by APA 14 Free Screening Tools

PUBLISHED BY THE TEXAS PSYCHOLOGICAL ASSOCIATION WWW.TEXASPSYC.ORG Their need for care doesn’t stop when they leave your office.

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when they leave your office. a note from the president a note from the foundation Staff TPA’s Neural Network An Exciting Year in Review David White, CAE, Executive Director Sherry Reisman, Assistant Executive Director Alice Ann Holland, Ph.D., ABPP Heyward L. Green, Psy.D. Sarah Bann, Membership Coordinator 4 When your patients need extra 2 2019 TPA Board of Trustees Executive Committee support for their health conditions, President lobbyist update MEDICAL DENTAL BEHAVIORAL SCHOOL SOCIAL HEALTH SERVICES SERVICES refer them to case management Alice Ann Holland, Ph.D., ABPP From the Editor’s Desk Sunset on 2018 Case managers help patients navigate the health system by Jennifer Rockett, Ph.D. Kevin Stewart services, a Medicaid President-Elect coordinating access to care related to their health conditions. Megan Mooney, Ph.D. benefit for children birth 5 President-Elect Designate through age 20 and CASE Fran Douglas, Ph.D. 6 MANAGEMENT high-risk pregnant women. Past President Children enrolled in Medicaid Cheryl L. Hall, Ph.D. TPA’s Strategic Plan: Social Bonny Gardner, Ph.D., M.P.H., (Traditional Fee-for-Service and STAR) Trustees Justice, Science, and ACCESS Named APA Citizen Judith Andrews, Ph.D. Brian H. Stagner, Ph.D. Psychologist in 2018 may be eligible. Patients enrolled in James Bray, Ph.D. 7 9 Andrew Griffin, Ph.D. STAR Kids and STAR Health should Lillie N. Haynes, Ph.D. first be referred to their health plan. Elisabeth Middleton, Ph.D. Bret Moore, Psy.D., ABPP

Kimberly Roatan, Ph.D. forensic issues independent practice Jennifer Rockett, Ph.D. Malingering as a Non-Unitary Moving Beyond the PHQ-9: Brian H. Stagner, Ph.D. (APA Council Rep) Construct: Implications for Free Screening Tools for To refer your patient, Jeff Temple, Ph.D. Forensic Assessment Integrated Care 11 MaryKatherine14 Clemons, call Texas Health Steps Amanda Venta, Ph.D. of Psychological Injuries Katherine A. Fox, M.A., & John P. M.S., Elizabeth Cottrell, M.A., 877-THSteps Student Affiliate Group Co-Directors Vincent, Ph.D., ABPP Daniel Friedman, M.S., Karina & Ex-Officio Board Members Gutman, M.A., BCB, Elise Kotin, M.A., or visit Jennifer Boland & Blake Martin Rebecca Sewell, M.A., Emma Smith, dshs.texas.gov/caseman M.A., & Joseph Whitehouse, M.A. Editor Jennifer Rockett, Ph.D.

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1464 E. Whitestone Blvd., Suite 401 Texas Health Steps is health care for children birth through age 20 who have Medicaid. Cedar Park, TX 78613 facebook.com/ linkedin.com/ twitter.com/ Case Management can help find services for families of children with special needs and (888) 872-3435 / (888) 511-1305 fax TPAFans company/ TXPsychAssoc pregnant women who have a high-risk condition. www.texaspsyc.org texas-psychological-association

STEPS-0922_Ad_CM_TxPsy_8n625x11n125_Dec_v1-R1.indd 1 11/19/18 2:51 PM A NOTE FROM THE PRESIDENT TPA’s Neural Network ALICE ANN HOLLAND, PH.D., ABPP Children’s Medical Center Dallas / UT Southwestern Medical Center, Dallas, TX

ell, we have hit the ground I am now a board-certified clinical way the brain orchestrates even the most running this legislative neuropsychologist specializing in children, basic behaviors through complex algorithms session, but before looking adolescents, and young adults. I have a that precisely activate neurons with perfect forward, I want to look back faculty appointment at UT Southwestern timing and synchronization across the Wand thank those who laid the groundwork and see clinical patients at Children’s brain’s vast neural network. for this important legislative year. While Medical Center Dallas, where I specialize in serving as President last year, Dr. Cheryl oncology and rare brain diseases. Psychology is facing some enormous Hall also served as Chair of the Legislative challenges in 2019 and beyond. We need Committee. In that role, Dr. Hall led TPA in I also serve as the Research Director of the to work together in that same way if we’re setting our legislative agenda for the current Neuropsychology Service at Children’s. My going to be successful. This coming year has year. You can read more about that agenda in own research focuses on investigating genetic to be about connectivity. I truly believe that this issue’s “From the Lobbyists” column. and intrapersonal factors influencing neu- if we work together, we will be successful in rocognitive outcomes in medically complex navigating what lies ahead. I’d also like to thank the TPA Board of Trustees children, adolescents, and young adults. members whose terms concluded in 2018—Dr. STRATEGIC PLAN Michael Flynn, Dr. Alfonso Mercado, and Dr. CONNECTIVITY On that note, I want to thank Drs. Rick Charles Walker—for their service to TPA the As I prepared for my 2019 Presidential year, McGraw and Brian Stagner and the past three years. All of them are continuing to I wrote out a list of names of people who members of their Strategic Planning Task support in TPA in other capacities, for which have encouraged, mentored, and supported Force for the incredible effort they put we are very grateful. me in my academic and professional career. into developing a long-term strategic plan More generally, I want to thank all our past My goal in doing so was to force myself to for TPA. They produced a 43-page report TPA leaders—you all have done amazing reflect on how much I’ve learned from and with many excellent recommendations for work to promote the profession of psy- been encouraged by each person on that list. improving TPA’s efficacy in serving our chology and advocate for improved mental Watching the list grow longer and longer members and promoting mental health in healthcare policies in Texas. I’m honored to really highlighted the fact that none of us get Texas. I encourage you all to read that report, be following in your footsteps. anywhere or accomplish anything without which is available on the TPA website. It is a a lot of help. I’m sure you all could write five-year Strategic Plan, so certainly not all of MEET YOUR PRESIDENT similarly long lists. the recommendations will be accomplished this year, but I will be working hard to lay the For those of you who were not able to We can think of these people in our foundations for long-term success in all areas attend my Presidential Address at our 2018 lives—and ourselves—like neurons in the identified in that report. Convention, I will briefly introduce myself. brain. To put it simply, on my own, I can do I am a native Texan who briefly ventured a few things. When connected with a bunch Many of the primary recommendations out to California to study psychology and of other people, I can do a lot more. And of that report relate directly to my goal neuroscience at Stanford as an under- when all our connections are in synch, we of improved connectivity for TPA. For graduate. I then returned home to Dallas can accomplish amazing things. example, I was distressed to see the Strategic to get my Ph.D. at the University of Texas Planning Task Force’s report that many Southwestern Medical Center. I completed a As an undergrad, I did research in diffusion TPA members feel distant or disengaged two-year postdoctoral fellowship in pediatric tensor imaging, or DTI. It was very new from TPA—that you are not aware how neuropsychology at Children’s Medical technology at the time, and it was an decisions are made or how you can become Center Dallas. incredibly exciting time to be doing that more involved. Distressing as that is to hear, research. Conducting research with DTI I also very much understand it, because I gave me an incredible appreciation for the

2 | Texas Psychological Association have been there myself, even at times as a Board member. So, I will be working hard On my own, I can do a few things. When connected with a bunch of other people, to improve communications both within I can do a lot more. And when all our connections are in synch, we can accomplish TPA leadership and between leadership and amazing things. membership.

Along those lines, please don’t hesitate to from TPA attorney Kevin Stewart, that Your membership is essential to keeping our contact me at any point during the year committee will be working to improve clarity Government Relations positions funded. And with feedback, suggestions, or questions: in how these documents are written, with that’s just one example. Just think what we [email protected]. Especially the ultimate goal of enhanced accountability, could do if each of you would convince just if you want to get more involved in TPA, transparency, and continuity in advancing one colleague to join TPA for the first time! please email me. TPA is your professional the Strategic Plan as a whole. I am incredibly honored to have the oppor- organization. Make it yours! It is easier to get tunity to serve as your 2019 TPA President. involved in TPA than you might think, and IN CLOSING Ultimately, however, I’m just a single neuron I am going to be working hard to improve Thank you for being a TPA member. in the TPA neural network. Please join me communication of those opportunities, start- Every single membership helps, and the however you can this year—whether that ing right now. I would be happy to talk with more members, the more we’re capable be simply renewing your membership, you about what opportunities are available. of. For example, last year, TPA hired two becoming a Platinum Advocate, responding Government Relations consultants—Jerry The Strategic Plan also identified a need to action alerts, or even getting involved Philips and Kevin Stewart—whose legislative for improved communications from in Committee or Division leadership. Like expertise and nuanced understanding of TPA to the public, including media and neurons in the brain, we’re capable of so Austin politics truly has been invaluable. legislators. I am pleased to announce that much more when we’re connected and working together. two members of the Strategic Planning Jerry played a key role in stopping Task Force have accepted key leadership consolidation when we first faced Sunset in roles in TPA focused on implementing that 2017, and both he and Kevin are deep in the REFERENCES report’s recommendations on these issues. trenches working for you again this session. Stocking, G. (2018). Digital news fact sheet. Dr. Alfonso Mercado is our new Chair of In addition to fighting for TPA’s legislative Pew Research Center. Retrieved from http:// the Public Education Committee, and Dr. agenda, Kevin also is doing an incredible www.journalism.org/fact-sheet/digital-news/ Darryl Johnson is serving as Chair of a job of identifying and monitoring other newly created Marketing Task Force. The bills being filed that we need to be aware Lu, K. (2017). Growth in mobile news use latter group is already at work addressing of—please read his column to learn more driven by older adults. Pew Research Center. the strategic plan’s recommendations for about some of those! Retrieved from http://www.pewresearch. hiring a dedicated media/marketing staffer org/fact-tank/2017/06/12/growth-in-mobile- and improving TPA’s online presence, given news-use-driven-by-older-adults/ that 93% of Americans seek information online (Stocking, 2018). In fact, even among Americans ages 65 and older, 67% used mobile devices to get news as of two years Our annual convention’s theme was ago, and that percentage was on pace to Resiliency. We were honored to hear increase dramatically (Lu, 2017). TPA’s from Rosie Phillips Davis, Ph.D., ABPP, website currently is not even mobile-friendly. the incoming APA President (far left), TPA has to modernize and improve how we communicate information online in order to who inspired us to make a positive be effective in this increasingly digital world. impact on deep poverty. Beth Rom-Ry- mer, Ph.D. (second from right) was also Finally, as we all know, neurons in the a keynote speaker who discussed the brain can’t communicate and work together battles and triumphs in the prescription effectively unless they are properly orga- nized. Thus, based on both Strategic Plan privilege movement in Illinois and recommendations as well as the recom- across the country. Pictured here with mendation of an attorney highly familiar them is Cheryl. L. Hall, Ph.D., MS with TPA’s current bylaws and policies and PsyPharm, 2018 TPA President (second procedures, I have directed the Governance from left) and past TPA President Carol & Staff Committee to thoroughly examine Grothues, Ph.D. (far right). the organizational structure and governing documents of TPA. With legal guidance

Texas Psychologist | Winter 2019 | 3 A NOTE FROM THE FOUNDATION An Exciting Year in Review HEYWARD L. GREEN, PSY.D. Texas A&M Health Science Center and Baylor Scott & White Health

he Texas Psychological Foundation First Place Award for Poster Presentation sonally exploitive behaviors on emotion has continued to work diligently in of Research. Their work, entitled Resilience regulation and experiential avoidance among service to its mission. As we reflect Following Traumatic Loss examined the roles psychiatric inpatients. on the past year, we can focus on of social support, self-compassion, and sense Tsome highlights that exemplify the purpose of coherence in predicting resilience after In addition to the focus on research, and goals of TPF. First, let us focus on traumatic loss. TPF was in the spotlight at other times those who were recognized at the TPA 2018 as well. Participants in TPF’s fundraiser Convention in Frisco for their contributions SECOND PLACE AWARD FOR during the convention—Painting With a to the science of psychology. POSTER PRESENTATION Purpose—enjoyed food and beverage while OF RESEARCH socializing with colleagues and creating JENNIFER ANN CRECENTE memorable works of art to take home. The Emerging Adults’ Values: Does Parental MEMORIAL GRANT diligent effort of the “artists” in the room Financial Involvement Hinder Development? that evening was counterbalanced by a good Alexis Humenik, M.A., a student in the received the Second Place Award. Its deal of camaraderie and laughter. Arguably, Psy.D. Program in the Department of authors—Amy Page, Teresa Hulsey, an objective assessment of the paintings Psychology and Neuroscience at Baylor M.S., Amy Murrell, Ph.D., also from the completed during that evening suggests that University, is the recipient of the Jennifer Department of Psychology at the University none of those persons who were present are Ann Crecente Memorial Grant for 2018. of North Texas—investigated the impact likely to leave our field to pursue a career in Named for a young woman whose plans of the trait feeling in-between on values the arts. to enter the study of psychology ended consistency in the developmental period of when she became a victim of homicide at emerging adulthood and considered the role There were moments of recognition and age 18, this grant supports research aimed parental financial involvement as a potential good memories at the TPA Convention at understanding potential causes and/or moderator in that relationship. Awards Luncheon as we celebrated the prevention of violence against women. Ms. contribution of two colleagues with whom Humenik’s proposed research, entitled The THIRD PLACE AWARD FOR there are distinct connections with TPF. Role of Executive Dysfunction and Substance POSTER PRESENTATION Dr. Rick McGraw was honored with TPA’s Use in Intimate Partner Violent Offenders, OF RESEARCH Lifetime Achievement Award for his will examine the level of impaired executive numerous accomplishments to psychology The Third Place Award was given to cognitive function relative to substance use on both state and national levels. Among Narcissistic Personality Disorder and Emotion among offenders whose violent actions are Dr. McGraw’s many contributions during Regulation: An Inpatient Peer Comparison directed toward intimate partners. his career is the key role he played in the Study by Ryan Smith, M.A., Christopher founding of TPF. The person named TPA Frazier, Katrina Rufino, Ph.D., Bella FIRST PLACE AWARD FOR Psychologist of the Year for 2018 was Dr. Schanzer, M.D., and Michelle Patriquin, POSTER PRESENTATION Betty Richeson. Her history with TPF Ph.D. at Baylor College of Medicine. Their OF RESEARCH includes a term as its president in the past, work explored the impact of narcissistic as well as long time service on its Board of Dalena Le, Laura Captari, M.A., Amanda personality disorder traits such as arrogance, Trustees. As the generous benefactor of the Flachs, M.A., Ashley Geerts, M.S., and lack of empathy, entitlement, and interper- Lina Rodriguez from the Department of Psychology at the University of North Texas are the authors of the study achieving the If you have interest in becoming involved with the Texas Psychological Foundation, please reach out to one of our board members who can be found on the Foundation page on the TPA website.

4 | Texas Psychological Association Jennifer Ann Crecente Memorial Grant, member, and especially for her time and not only your financial support, but also which is named for her granddaughter, she service as its president for two years. We your patronage through volunteering and by joined me on the dais for the presentation of offer our best wishes as she moves forward sharing of ideas about the better fulfillment the grant. into other endeavors. of our mission.

With the closing of 2018, we bid a heartfelt If you have interest in becoming involved We express our thanks to all who helped to farewell to Dr. Jo Vendl as she completes her with the Texas Psychological Foundation, make 2018 a successful year for TPF. We look term with the TPF Board of Trustees. We are please reach out to one of our board forward to having your support in 2019. most sincerely grateful for her faithful and members who can be found on the Foun- dedicated commitment to TPF as a Board dation page on the TPA website. We invite

From the Editor’s Desk JENNIFER ROCKETT, PH.D. Private Practice, Bryan, TX

olleagues, have provided feedback on the content of the review of screening measures for practicing TP, I hope writers continue to provide you clinicians in the Practice column. I’ve also Welcome to a new year! First, let with good things to digest. asked Dr. Brian Stagner to write an article me take a moment to thank Dr. that discusses our Strategic Plan. Please CCheryl Hall for her leadership New to the TP this year is the Lobbyist have a read and provide Dr. Holland and Dr. this past year. Many of you may not know column which will be written by Mr. Kevin Stagner with your feedback. how much time and energy Dr. Hall has Stewart. In each issue this year, Mr. Stewart spent in the last year working for us; her will provide readers with a synopsis of Finally, thank you to those of you who have effort is greatly appreciated. As we head into legislative issues affecting psychologists. In provided feedback on the content of the TP, 2019, Dr. Alice Ann Holland will be taking this issue, Mr. Stewart gives us a glance at Thank you to all the writers in 2018; your the lead, and I can assure you under her what is ahead in this 86th legislative session work has been greatly appreciated. Keep the leadership, it will be another very productive (January 8–May 3, 2019). Thank you, Mr. articles coming, your colleagues want to read year. TPA has plenty to look forward to Stewart, for agreeing to write this column and hear the good things that psychologists in this coming year, and I look forward for us. In addition to Mr. Stewart’s column, are up to in Texas. to serving as your Texas Psychologist (TP) we have articles addressing the evaluation of Editor again. Thank you to those of you who malingering in the Forensic column and a —Jennifer

Call for submissions

The Texas Psychologist is seeking submissions for upcoming issues.

We are seeking content in the following areas: Independent Practice; Ethics; Multicultural Diversity; Forensic Issues; and Student and Early Career. Collaborations with students are encouraged. 1000–2000 word count; APA Style.

Send to [email protected] by 3/15 for the spring issue.

Texas Psychologist | Winter 2019 | 5 LOBBYIST UPDATE Sunset on 2018 KEVIN STEWART TPA Government Relations Consultant

hings at the Texas Legislature are Therapists. TPA maintains its position that TSBEP board members’ fear of being sued already heating up, so we wanted consolidation is both unnecessary and should not overcome good public policy to provide our members with potentially harmful to the progress the state decisions. We hope that the legislature will a quick update. In the House, has made in mental health. We will continue pass a law to reinstate supervision and take TSpeaker Joe Straus has retired, so House our fight this session to keep TSBEP such important decisions out of the hands of members have been hard at work finding a independent. T SB E P. new Speaker. While it won’t be official until the members vote during session, Represen- We are again working on a bill that would Finally, TPA is again asking the legislature to tative Dennis Bonnen (R-Angleton) has the protect mental health providers from allow psychologists with specialized training endorsements needed to become the next liability if they report a patient believed to prescribe mental health medications. Speaker. He was first elected to the House in to be a risk to themselves or others. Rep. The shortage of prescribing mental health 1996, and last session he served as the Chair Senfronia Thompson filed our bill, HB 461, providers is palpable, especially in rural and of the House Ways & Means Committee. on December 4. Last session, this bill made underserved areas. it through the House with unanimous votes, At the time of this writing, the healthcare but it died in its Senate Committee due OTHER RELEVANT LEGISLATION committees in each chamber are also to deadlines. We are going to get this bill In addition to TPA’s agenda items, there have in flux. In House Public Health, many moving as quickly as possible this session to been about 900 bills filed so far. We are still expert Chair Four Price to move to a more ensure passage. very early on, so we expect that number to coveted position. It is also likely, given the increase dramatically as time goes by. TPA new Speaker, that the membership of that We are also working on a bill that would is currently tracking about ten percent of committee will be reshuffled. On the Senate exempt psychiatrists and psychologists the bills currently filed—those relevant side, the University of Texas concluded its from the licensure laws of Licensed Sex to mental health and/or the practice of investigation into the alleged sexting of a UT Offender Treatment Providers (LSOTPs). psychology—and we expect that number to student by Charles Schwertner, Chair of the Many psychologists are trained to treat this increase as well. The state legislature’s interest Health and Human Services Committee. It population, yet state laws have had the effect in mental health has never been higher, and will now be up to the Lieutenant Governor of prohibiting these qualified providers from TPA’s Government Relations consultants to decide whether Schwertner will keep treating them. We have been working hard (myself and Jerry Philips) are ensuring his chair, and we expect Dan Patrick to to remedy this issue, and we expect a bill to that psychologists are well represented as announce committee membership early on be filed shortly. stakeholder meetings commence. With that in the session. In addition to our current legal action being said, there are a few bills that we would against TSBEP, challenging their rules that like to bring to your attention immediately. TPA’S 2018 LEGISLATIVE granted independent practice authority to AGENDA Licensed Psychological Associates (LPAs), Senator Jane Nelson, Chair of the powerful As you know, the Texas State Board of TPA will also be pursuing legislative action Senate Finance Committee, has filed SB Examiners of Psychologists (TSBEP) is on this issue. TSBEP has stated repeatedly 63. The bill would create what is called the going through the Sunset process again. that they changed their rules out of fear of Texas Mental Health Care Consortium. Last session, the Sunset Commission a lawsuit by LPAs. We feel that individual The Consortium would be charged with recommended consolidating TSBEP with other mental health boards, including the Texas State Board of Social Worker Exam- iners, the Texas State Board of Examiners of TPA maintains its position that consolidation is both unnecessary and potentially Professional Counselors, and the Texas State harmful to the progress the state has made in mental health. We will continue our Board of Examiners of Marriage and Family fight this session to keep TSBEP independent.

6 | Texas Psychological Association coordinating the expansion and delivery need a unanimous vote from committee Finally, suicide prevention has been a of mental healthcare services, with a focus members; if the vote were not unanimous, focus for many legislators, and some of on telemedicine. It would be composed the rule would go to the entire house for a the bills filed on the subject would impact of higher-education institutions, agency vote. psychologists. For example, HB 471, by representatives, community center repre- Representative Shawn Thierry, would require sentatives, and representatives of nonprofit There has also been a great deal of suicide prevention training for all healthcare organizations. discussion about Extreme Risk Protective providers, including psychologists. Psychol- Orders (ERPOs). ERPOs allow courts, ogists would need to complete six hours of The legislature is also looking into a after providing due process, to temporarily suicide prevention training every six years. statewide fix for the problem created by the prohibit a person from having a gun under We are watching this bill closely to see if it Supreme Court’s North Carolina Board of certain circumstances. Representative Joe moves, and we will act on it if needed. Dental Examiners decision. In that case, the Moody, currently the Chair of the House Supreme Court declared that state boards Criminal Jurisprudence Committee, has We hope that you will follow along with with a majority of active market participants filed HB 131. If it were to pass, mental health us as the session progresses. We will be are only immune from antitrust suits if their providers would not be one of the parties sending out calls for action when we need rules are reviewed by the state. HB 112, by that could seek an ERPO, but courts could psychologists to make their voices heard. It Representative Valoree Swanson, would order a person to submit to an examination is imperative to TPA’s success that legislators create a legislative review process for rules. by a mental health provider to determine see how passionate we are about mental Essentially, all rules would pass through the whether that person suffers from a serious health and the practice of psychology. Thank legislative committee that has jurisdiction mental illness. you for taking the time to read this, and stay over the proposing agency. The rule would tuned for more updates.

TPA’s Strategic Plan: Social Justice, Science, and access BRIAN H. STAGNER, PH.D. TPA Past President & Current Director for Professional Affairs

ennifer Rockett has asked me to write and a timeline for achieving numerous goals The first task faced by the SPTF was to about TPA’s Strategic Plan; I want to that are operationalized in the report. The get a read on how TPA is perceived today paint a picture of how that plan might BoT agreed to use these recommendations and on the problems psychology will face Jbe implemented to position TPA to be and timeline as guidelines for its actions in the future. Many who responded to an stronger in the face of coming challenges. in the coming year and to re-evaluate the online survey or who participated in an strategic plan at its meeting next August. I interview had very positive things to say First, some history (bear with me). The TPA encourage you to access the report and keep about TPA. Of course, that’s good news, but Board of Trustees (BoT) met in November it in mind as we move through the coming doesn’t really steer us forward. The negative during our annual convention and agreed legislative year and beyond. Read it and hold comments from psychologists were about to receive the final report of the Strategic your association accountable for pursuing a perceived lack of transparency between Planning Task Force (SPTF). The report the goals it establishes. TPA governance and the members and (which can be found on the members major disappointments regarding specific page of the TPA website) describes the I’m writing now to elaborate on some of the policy positions that TPA has taken over background for the SPTF, its composition, specific findings from the task force and to the past couple of years (e.g., on prescriptive its process and the results of extensive data articulate some ideas that are implicit in the authority, social justice issues, and our efforts gathering conducted last summer and fall report and, in my opinion, foundational to to take the TSBEP to court). My point here is from members, nonmember psychologists, where TPA needs to grow. I’ll conclude with not to criticize or defend any of these policies and community stakeholders. The report a call for a particular policy position that but to highlight the fact that we are a big includes a summary of findings from this may help unify the process. tent, we will inevitably take positions that are process, a list of specific recommendations, unpopular to one or another segment of our

Texas Psychologist | Winter 2019 | 7 cumbersome) process for making a decision TPA cannot thrive on its own. We have adversaries at all corners, from physician about when/how to take a public stand on an groups, allied mental health professionals, regulatory forces, and market pressures. issue that (usually) has political overtones. We are a small organization. We must leverage our voice. The result is that we have, from time to time, taken a stand on a hot issue. Most recently, with the leadership of Jeff Temple, Alfonso members, but we need to be much clearer face some of the same battles. TSBEP’s board Mercado, and others TPA made a strong about communicating with our members chair has written about the backdrop to this statement on the psychological science that about these activities. For example, some fight in the National Psychologist (Branaman, (unequivocally) demonstrated the risks of member and nonmember psychologists are 2018). Whether you agree with his analysis, the child separation policy at the border. under the impression that TPA has put a it is clear that his arguments are neither lot of its resources into pursuing RxP, but frivolous nor easily dismissed. I think the social justice agenda should not this is inaccurate (money for this was raised be driven by events. We can wait for a school As we have engaged these battles in the independently). The take-home message shooting or an instance of elder abuse in a legislature (e.g., over Sunset, which is a is that we need much better engagement state facility and then express our dismay whole ‘nother long story) and the master’s between governance and membership; I’ll and cite some research. I doubt we have issue, we have made enemies. Some groups return to this issue in a minute. much impact that way. So, I will be pushing that are our natural allies view us as self-in- the BoT and the Association as a whole to We likewise need to repair our relationships terested and not reliable collaborators. Some integrate these two threads that are import- with erstwhile allies. TPA cannot thrive on legislators see us as having a limited interest ant to our members in a way that will build its own. We have adversaries at all corners, – protecting private practice (The future of our association and increase our credibility from physician groups, allied mental health solo practice in the face of integrated care footprint for our members and the public. professionals, regulatory forces, and market is an additional whole ’nother saga that we Specifically, we should first identify a single pressures. We are a small organization. need to discuss another time). social justice issue as the core problem to We must leverage our voice. We need to work on for, say, the next three years. We increase the public’s awareness of all the Thus, our association has lots of work to can still issue position papers but most of good psychologists do, and we have not done do if we are to meet the challenges of the our activity should be focused on that single enough here. Media representatives would next decade. The strategic plan outlines a issue. We should be promoting that issue welcome more input when critical issues foundation for that work and details specific with guest editorials in the paper, we should arise and yet they are not turning to TPA operations that will be needed from various be pressing for changes to regulations and for expertise. Legislators have a generally committees and divisions in TPA. But the agency policies, and we should be building favorable view of psychology, but again we overarching goal is to increase TPA’s credibil- alliances in the legislature around that issue. need a stronger presence—not the presence ity and visibility on all fronts: members, non-members, the public, and policymakers. that lobbies for our interests but the presence What issue would have appeal to the that lends expertise and highly skilled There are two areas that seemed very import- majority of psychologists and would avoid manpower to help the State of Texas provide ant to psychologists who were surveyed. the politicization of our efforts? access. for its citizens. Many state agencies have high The first was a clear wish for TPA to be an praise for what we could do to help them TPA should define access as its core social advocate for the science in psychology. That’s but lament that it is difficult to locate experts justice concern and then blow that trumpet how we differentiate ourselves from other when they are needed. In these areas, people whenever and wherever possible. We need groups—WE produce the science. It is not feel good about psychology but we are too to ensure access to the best psychological too fanciful to imagine that every statement difficult to access and they don’t see TPA as services everywhere. Kids in detention tents coming out of TPA or in our newsletter the go-to resource for mental health science. in El Paso. Prisoners in solitary. The poor. or at our convention should begin with a Cancer patients. Kids with LD/ED issues. discussion of the psychological science that Our relations with allied health professions The severely mentally ill. Virtually all social is settled and a reasoned discussion of the are in worse shape. Nationally some groups justice issues that I can imagine will have quality of evidence when it is not settled. By are attacking psychology directly—CACREP an aspect of access to care, to services, to advocating for our science, we increase our has made substantial inroads into accredit- opportunity, to safety. And equality of access credibility and become the go-to source for ing all counseling training programs and has is an unqualified social good around which future policy and public understanding. stated that they will be the go-to resource members should easily rally. for mental health. In Texas we have the The second area that was very important to long-festering fight over the credentialing And how do we make this case? With our respondents was social justice. This was of master’s level providers. That story is a science. We have the tools to define the important but controversial. Some individu- prolonged one that has preoccupied TPA a problems, to outline the need and to suggest als want TPA to be more active in advocating great deal but thus far we have struggled to solutions that will and will not be worth for social justice issues while others are make headway. This is not a local Lone Star spending money on. We wouldn’t have to quite opposed to this. Most respondents fight—other jurisdictions are or will soon ask for anything for psychologists only, were unaware that TPA has a (somewhat

8 | Texas Psychological Association though some of us would probably benefit. Ok, I think this is a great idea. I’ll be pressing TPA is all of us! What allied group would reject an offer to for it in the coming months. But maybe it’s collaborate on “increased access to services flawed. If you have a different vision. we REFERENCES for XXX population”? What agency manager, need you! The plan (on the member page at legislator, or media influencer could resist texaspsyc.org) has lots of tasks and roles. We Branaman, T. (2018). Court cases, market listening when we back up our initiatives need troops to get involved, so go read the forces reshaping psychology. National with “Psychological Science for the Good of plan and then contact Sherry Reisman to be Psychologist. https://nationalpsychologist. the People.” put in touch with the appropriate committee com/2018/11/court-cases-market-forces- or division or workgroup that gets your reshaping-psychology/105177.html interest up.

Bonny Gardner, Ph.D., M.P.H. Named APA Citizen Psychologist in 2018

PA member Margaret Ann Dr. Gardner also served on the Executive (Bonny) Gardner Ph.D. of Austin, Committee of the Texas Suicide Prevention Texas, has been recognized with Coalition. an American Psychological TAssociation Citizen Psychologist Presidential Since her formal service on these com- Citation for her leadership and sustained mittees, Dr. Gardner has continued to be commitment to social justice through the involved in promoting increased access to dissemination of knowledge, advocacy, and and improved resources for public mental leadership in the Austin, Texas, community. health. For example, in addition to other Dr. Gardner currently chairs the TPA local officials, Dr. Gardner has consulted Business of Practice Committee and has with the Sheriff of Austin on issues relating served on the TPA Board of Trustees in to the intersection of criminal justice and the previous years. mental health system, including diversion of people suffering from substance use “Dr. Gardner exemplifies the definition of disorders and people with non-violent a Citizen Psychologist by using psychology offenses and mental health problems to reha- to make her community a better place,” said bilitation programs rather than jail or prison. APA President Jessica Henderson Daniel, This has presented a unique opportunity for Ph.D. “Helping to improve lives in one psychology to cross traditional disciplinary community at a time is how we can change From 2006 to 2013, Dr. Gardner served lines and encourage greater interagency the world.” Launched by Dr. Henderson on the Austin Mayor’s Mental Health Task cooperation for the solution of common Daniel, the Citizen Psychologist Initiative Force and Mayor’s Mental Health Task Force problems, according to the APA citation. recognizes APA members who engage Monitoring Committee. The mission of these their communities through public service, groups was to identify problems and needs For over 25 years Dr. Gardner has also been volunteerism, and board membership. within the mental health service delivery an active member of the Public Affairs Representing every branch of psychology, system and then to make recommendations Forum of the First Unitarian Universalist Citizen Psychologists serve as long-term for improving access and resources within Church of Austin. The Public Affairs volunteers for service organizations, partic- the system. One of Dr. Gardner’s major Forum has featured expert speakers on ipate in church ministries, and volunteer as concerns was ensuring effective public access social, economic, and political issues, as expert speakers for non-profit organizations, to psychological and emergency psychi- well as presentations on matters of health among other roles. atric services in the community. Another policy, human rights, and social justice. Dr. objective was developing better coordination Gardner chaired the Forum from 2009 to within existing networks of care to create 2016. The weekly programs were featured a safety network and continuum of care. on Austin Public Access TV and also on

Texas Psychologist | Winter 2019 | 9 an Austin public radio thereby creating a of his jobs was to implement Brown v. Board social justice concerns within a larger larger platform through media to reach of Education in five Mid-Atlantic states, the religious context. Right after graduating a wider audience. The programs, which Virgin Islands, and Puerto Rico. In effect, from University of Texas undergraduate were free and open to the public, gave an he oversaw the desegregation of public school, I had an opportunity to go to the opportunity to ordinary citizens to interact schools, health facilities, and transportation Lower Rio Grande Valley of Texas to observe directly with experts and public officials. As systems when this was a groundbreaking and be involved in the work of the United a psychologist, Dr. Gardner provided insight development. There was some resistance, Farm Workers as they began establishing and leadership within the team framework including shutdowns of some public schools legal and social services, health clinics, and of the committee and demonstrated the in Virginia and Maryland for a while and community centers for the farmworker importance of psychology in framing public Dr. Gardner remembers going to school population. Despite providing food for our policy. in a makeshift classroom in a neighbor’s nation, arguably the most important job of basement. She said, “These were turbulent all, the farmworkers were socially and eco- Dr. Gardner’s work as a citizen psychologist times, but most schools desegregated nomically marginalized, denied basic rights, specifically on behalf of older adults has gradually without incident. I grew up and struggled to maintain a basic standard of also been exemplary. For nearly 23 years watching TV coverage of the local resistance living. These experiences led to a long-term she served on the Steering Committee of and protests to desegregation, with some of interest in social change and community the Austin Gray Panthers, an affiliate of the incidents not too far removed from what service which has made my life much the national network. Her role within that went on in Arkansas and Alabama later. My richer and more exciting. I encourage other committee included promotion of improved father also oversaw the emergence of the psychologists to get involved in community health care policy at the national and local federal Medicare and Medicaid programs as work. On days when I’m struggling with the level and advocacy on other social justice well as other federal programs designed to more mundane aspects of the practice of issues, including preserving the Social Secu- improve public health and reduce social and psychology, I can still remember why I went rity system and increasing community and economic inequality. into this field and the potential good that police awareness of the need for improved psychologists can do.” services for persons with mental illness. “All of this made a deep impression on me, and I saw it as important work,” she Dr. Gardner expresses deep appreciation to Dr. Gardner said she became interested in continued. “My high school, the National Dr. Cynthia de la Fuentes for nominating her social justice issues as a child. Her father was Cathedral School for Girls, was affiliated for this award and to Andrew Griffin, Ph.D., a federal executive with the Department of with the Episcopal Church and promoted for his work on the application process. Health, Education, and Welfare (HEW). One

On January 18, 2019, Drs. Alfonso Mercado, Amanda Venta, Jeff Temple, Megan Mooney, and Shannon-Guillot-Wright participated in a Symposium at the University of Texas Rio Grande Valley in Edin- burg, Texas, on Migration and Mental Health: Trauma, Health, and Evidence from the Texas/Mexico Border. They also visited a border wall and the Texas Human- itarian Respite Center in McAllen, Texas, run by Sister Norma Pimental.

10 | Texas Psychological Association MULTICULTURAL DIVERSITY FORENSIC ISSUES

Malingering as a Non-Unitary Construct: Implications for Forensic Assessment of Psychological Injuries

Katherine A. Fox, M.A. & John P. Vincent, Ph.D., ABPP University of Houston

hrough civil litigation, individuals The opportunity for financial gain provides consequences inherent in a litigation context can claim monetary damages on substantial incentive for individuals to necessitate the need for a clear understanding the basis of a civil wrong, or tort. exaggerate or falsify psychological symptoms of the underlying construct of malingering For example, tort law allows for or conditions (Peace & Masliuk, 2011). and how best to approach testing when Tfinancial recovery following a motor vehicle As such, when conducting evaluations in dishonest responding is suspected. accident, in which a defendant’s negligent cases involving alleged emotional injuries, or reckless driving had an adverse psycho- mental health practitioners must be attuned Identifying exaggerated claims of psycholog- logical impact on the other driver. Damages to forms of negative response bias in ical injuries is one of the most challenging in such cases can cover pain and suffering, which symptom reports are exaggerated or tasks for clinicians, independent of legal mental anguish, and associated healthcare completely fabricated. Feigning describes the context. Psychological disorders, by nature, expenses, including psychological services fabrication or exaggeration of psychological are heterogeneous, comorbid, and largely deemed necessary to remediate symptoms of or physical symptoms where the specific diagnosed based on subjective report, due to psychological injury. Psychological injuries reasons for the exaggeration are unknown an absence of biological markers of mental sustained as the result of a tort can range or unintentional. Conversely, malingering disorder. Each of these features contributes from mild, transient experiences, such as is the deliberate fabrication or exaggeration to the challenge associated with parsing embarrassment, to severe, chronic condi- of symptoms in order to achieve an external genuine illness or injury from a falsified or tions such as depression and psychological goal, such as financial compensation. exaggerated presentation. As such, estimat- trauma (Vallano, 2013). Critically, it must be noted that malingering ing the prevalence of malingering in clinical is not a diagnosis (American Psychiatric and forensic populations is difficult. Some A majority of U.S. jurisdictions permit Association, 2013; Rogers & Bender, 2013). estimates suggest that malingering occurs in damages for emotional distress or mental Rather, it is a condition of interest (V65.2), up to 40% of civil litigation cases involving injury, whether or not physical injuries were which should be considered when evaluating neuropsychological assessment (Larrabee, sustained, and it is estimated that 50% of alleged psychological injuries. 2003), while other studies have found that civil injury awards involve the experience of 20-30% of results from psychological testing psychological pain and suffering. However, In practice, a revelation of a specific motive on personal injury plaintiffs suggest that claims of psychological injury or emotional or intent rarely occurs and there is no direct malingering had taken place (Taylor, Frueh, harm are often disputed. As such, the law test of either. Thus, mental health profes- & Asmundson, 2007). requires “objective indicia of mental injury,” sionals can rarely definitively conclude an typically in the form of an official diagnosis or individual is malingering and should exercise In general, there are two main types of professional opinion (Melton, Petrila, Poyth- caution in using this term. Instead, practi- malingering measures, symptom validity ress, & Slobogin, 2007). This necessity places tioners may speak to the relative likelihood or tests (SVTs) and performance validity tests mental health practitioners at the forefront probability that an individual is exaggerating (PVTs). Symptom validity tests (SVTs) of many psychological injury cases, as they or faking symptoms, noting the degree to are used to detect the exaggeration or are tasked with evaluating the presence and which evidence is consistent with some fabrication of psychiatric symptoms based on degree of impact of those injuries. form of negative response bias. Thus, it is self-report, by utilizing detection methods important for clinicians working in this field that capitalize on the relative infrequency, to understand malingering on a conceptual odd combination, or unusual severity of level. The legal, financial, and psycho-social psychological symptoms. SVTs exist in two

Texas Psychologist | Winter 2019 | 1 1 single malingering measure. It is, however, Mental health professionals can rarely definitively conclude an individual is unusual for individuals to fail more than one malingering and should exercise caution in using this term. measure, and rarer for someone to fail more than two. Thus, administering more than main forms: large, multi-scale inventories sufficiently engaged or putting in sub-optimal one measure of response bias reduces the and brief, domain-specific measures. Larger, effort in the task. Examples of PVTs include likelihood of a false positive error. multi-scale inventories typically use validity the Test of Memory Malingering (TOMM; Difficulty in detecting malingering is scales embedded within self-report question- Tombaugh, 1996) and the Morel Emotional impacted by the shifting nature, or insta- naires of personality and psychopathology, Numbing Test (MENT, Morel, 1998). The bility, of malingering behavior itself. Often like the Minnesota Multiphasic Personality TOMM was the most frequently used erroneously deemed a “monolithic,” or stable Inventory–2 (MMPI–2; Butcher, Dahlstrom, measure to detect poor effort or malingering and enduring, construct, individuals who Graham, Tellegen, & Kreammer, 1989) and among a sample of 188 neuropsychologists malinger may be inconsistent in their false the Personality Assessment Inventory (PAI; (Sharland & Gfeller, 2007). responding across tests, time, or symptom- Morey, 2007). In both, embedded validity ology, be that psychiatric, physical/somatic, scales serve to assess inconsistent responding, Despite extensive research, no standardized or cognitive/neuropsychological (Berry & defensive responding, and symptom exagger- protocol for detecting malingering has Nelson, 2010). It cannot be assumed that ation. Other measures, such as the Trauma been developed, and there is substantial known feigners will always falsify responses Symptom Inventory–2, have a narrower focus variability in the ways that mental health in assessment, or that individuals who feign on symptoms and experiences common to practitioners approach this problem. In a one type of symptom will also feign others. trauma survivors and include embedded survey of 80 emotional injury evaluators, Similarly, responding is influenced by factors validity scales that can prove valuable in who had conducted a career sum of 10,500 such as fatigue, cognitive capabilities, and personal injury cases where PTSD or trauma evaluations, no two evaluators used the exact distractions, which may result in suboptimal is alleged (Briere, 2011). same set of psychological tests (Boccaccini & Brodsky, 1999). A more recent survey of test or invalidated performances that are not Domain-specific, standalone SVTs attempt usage found that in an international sample necessarily reflective of a willful fabrication to discern symptom exaggeration more of 868 assessment cases conducted by 434 of symptoms. Lastly, it is valuable to note directly. Some examples include the clinicians, the top ten most used measures that these estimates of presumed malinger- Structured Interview of Reported Symptoms in civil tort cases focused on the domains ing may not take into account that faking or (SIRS; Rogers, Bagby, & Dickens, 1992); the of trauma, intelligence (e.g., WAIS), and exaggerating symptoms does not rule out the Miller Forensic Assessment of Symptoms general psychopathology (e.g. MMPI–2, possibility that the individual is experiencing Test (M-FAST; Miller, 2001); and the PAI, and symptom inventories), with no some form of genuine psychopathology. Structured Inventory of Malingered Symp- specific measures of malingering represented Research in the field of malingering tomatology (SIMS; Widows & Smith, 2005). (Neal & Grisso, 2014). Rather, measures detection has focused on developing a greater Domain-specific measures such as these of malingering were only represented in understanding of the degree to which various boast strong psychometric properties and are insanity and competency to stand trial cases. measures of malingering and peripheral used frequently in forensic practice. Many The psychologists who conducted these factors (e.g., cognitive functioning, memory, of these measures are structured interviews evaluations reported using, on average, 4.6 genuine psychiatric symptoms) operate which take advantage of the supposition measures, with some cases requiring up to interdependently. One method of examining that malingerers will find it more difficult to eighteen different measures. this interdependence is via correlational exaggerate or fabricate symptoms face-to- studies. Much of the extant literature focuses face, as opposed to on paper. There are several reasons for this variability. First, all psychological measures, including on collecting validity evidence across SVT Performance validity tests (PVTs) are tests that target malingering, have individual measures, such as examining convergence designed to corroborate symptoms by look- strengths and weaknesses. Mental health between an abbreviated version of the SIRS ing at an individual’s performance, typically professionals must weigh these test qualities with MMPI validity scales (Story, 2000). on neurocognitive tasks. Similar to SVTs, when selecting and combining tests to use. Alternatively, another body of literature has PVTs utilize a variety of detection methods, For example, one must consider minimum highlighted the importance of using both including identifying uncommon or unlikely reading level, difficulty and length of PVTs and SVTs in the evaluation of malin- performance presentations, when compared administration, cost, and comprehensive- gered neurocognitive impairment, specifically to a genuinely impaired normative sample. ness. Secondly, mental health professionals traumatic brain injury (TBI; Larrabee, 2012). Other methods make use of the floor effect, are able to assess response bias by evaluating Some authors have extended this recom- operating under the principle that malinger- inconsistencies and inaccuracies across mendation to include feigned posttraumatic ers will exaggerate substantial impairment subjective reports, testing data, medical stress disorder, which can co-occur with TBI. on tasks which even genuine patients are records and other case documents. Thirdly, Two studies have examined the relationship able to pass. PVTs may also be used to gauge as noted by Boone (2011), it is not atypical between PVT and SVT malingering indices effort, capturing whether an examinee was for honestly-responding individuals to fail a across affective and neurocognitive domains.

12 | Texas Psychological Association Demakis, Gervais, and Rohling (2008) found presentations is a difficult task, which is Larrabee, G., & Berry, D. T. (2007). Diagnos- that elevated psychological symptoms were made more challenging by the natural tic Classification Statistics and Diagnostic not associated with PVT failure, nor were variability inherent in psychological condi- Validity of Malingering Assessment. In G. poorer performances on measures of neu- tions. As there are substantial consequences Larrabee, Assessment of Malingered Neuro- ropsychological functioning associated with associated with the misidentification of psychological Deficits (pp. 14–26). New York: SVT failure. Similarly, Grieffenstien, Gola, malingered symptoms, it is recommended Oxford University Press. and Baker (1995) found that, in a sample to utilize more than one measure of Melton, G. B., Petrila, J., Poythress, N. of TBI patients involved in personal injury malingering in order to improve assessment G., & Slobogin, C. (2007). Psychological cases, scores on PVTs and SVTs were not validity. Based on extant research, variation Evaluations for the Courts (Third Edition). significantly related. Factor analyses did not in sub-construct, method, and approach will New York: The Guilford Press. support a unitary construct of malingering, allow for a more comprehensive assessment leading to the conclusion that malingering of malingering, and thus yield more valid Miller, H. A. (2001). M-FAST: Miller Forensic should be approached as a multifaceted and reliable results. Assessment of Symptoms Test Professional construct consisting of both performance Manual. Odessa, FL: Psychological Assess- ment Resources, Inc. and symptom-endorsement factors, and that REFERENCES each contributed unique information. These Morel, K. R. (1998). Manual for the Morel findings support recommendations to use American Psychiatric Association. (2013). Emotional Numbing Test for Posttraumatic a variety of measures, which tap different Diagnostic and Statistical Manual of Mental Stress Disorder (MENT). Printed in USA. constructs via different methods, when Disorders (Fifth ed.). Washington, D.C.: Morey, L. (2007). Personality Assessment conducting a comprehensive evaluation of Author. Inventory (PAI): Professional Manual. PAR psychological injury. Berry, D. R., & Nelson, N. (2010). DSM-5 (Psychological Assessment Resources). and Malingering: A Modest Proposal. Using a between-subjects design, Fox and Psychological Injury and Law. Neal, T., & Grisso, T. (2014). Assessment Vincent (in preparation) evaluated bivariate Practices and Expert Judgment Methods correlations amongst the TOMM, TSI-2 Boccaccini, M., & Brodsky, S. (1999). in Forensic Psychology and Psychiatry. Atypical Responding Scale, SIMS, and Diagnostic Test Usage by Forensic Psycholo- Criminal Justice and Behavior, 1406–1421. M-FAST, in a simulated personal injury gists in Emotional Injury Cases. Professional Peace, K. A., & Masliuk, K. A. (2011). Do paradigm, in which psychological, but Psychology: Research and Practice, 253–259. Motivations for Malingering Matter? Symp- not neurocognitive or physical symptoms Boone, K. (2011). Clarification or confusion? toms of Malingered PTSD as a Function of were alleged. Consistent with assumptions A Review of Rogers, Bender, and Johnson’s Motivation and Trauma Type. Psychological of a multi-trait, multi-method (MTMM) a critical analysis of the MND criteria. Injury and Law, 44–55. approach, participant scores were expected Psychological Injury and Law, 157–162. to correlate according to measurement of Rogers, R., & Bender, S. (2013). Evaluation underlying traits and methods. Convergent Briere, J. (2011). 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PVT measure of performance or effort (i.e., (2008). The effect of failure on cognitive TOMM). In this study, we found evidence Sharland, M., & Gfeller, J. (2007). A survey and psychological symptom validity tests in of neuropsychologists’ beliefs and practices consistent with the conceptualization of litigants with symptoms of post-traumatic malingering as a non-unitary construct with respect to the assessment of effort. stress disorder. Clinical Neuropsychology, Archives of Clinical Neuropsychology, 213–223. comprised of both performance and 879–895. symptom-endorsement factors. Likewise, Story, D. L. (2000). Validation of a Short these findings support clinical recommenda- Greiffenstein, M., Gola, T., & Baker, W. Form of the Structured Interview of Reported tions to administer a variety of malingering (1995). MMPI–2 validity scales versus Symptoms (SIRS). domain specific measures in detection of measures when conducting evaluations of Taylor, S., Frueh, B., & Asmundson, G. psychological injury in civil tort cases. factitious traumatic brain injury. The Clinical Neuropsychologist, 230–240. (2007). Detection and management of In summary, current research supports malingering in people presenting for Larrabee, G. (2011). Performance Validity treatment of posttraumatic stress disorder: the conceptualization of malingering as and Symptom Validity in Neuropsychologi- a non-unitary or multifaceted construct. Methods, obstacles, and recommendations. cal Assessment. Journal of the International Journal of Anxiety Disorders, 22–41. Detecting falsified or exaggerated symptom Neuropsychological Society, 18, 625–631.

Texas Psychologist | Winter 2019 | 1 3 Tombaugh, T. (1996). TOMM: Test of Vallano, J. (2013). Psychological Injuries Widows, M., & Smith, G. (2005). SIMS: Memory Malingering. North Tonawanda: and Legal Decision Making in Civil Cases: Structured Inventory of Malingered Symptom- Multi-Health Systems, Inc. What We Know and What We Do not Know. atology. Lutz, FL: PAR, Inc. Psychological Injury and Law, 99–112.

INDEPENDENT PRACTICE

Moving Beyond the PHQ-9: Free Screening Tools for Integrated Care

MaryKatherine Clemons, M.S. (Nova Southeastern University), Elizabeth Cottrell, M.A. (Radford University), Daniel Friedman, M.S. (PGSP–Stanford University), Karina Gutman, M.A., BCB (Alliant International University–CSPP San Diego), Elise Kotin, M.A. (Alliant International University– CSPP Fresno), Rebecca Sewell, M.A. (Midwestern Univer- sity, Illinois), Emma Smith, M.A. (Midwestern University, Arizona) & Joseph Whitehouse, M.A. (William James College)

This article was written as part of our instrument used to assess adult patients for SUICIDE doctoral internship experience at the possible bipolar disorder. The MDQ includes Death by suicide is the 10th leading cause University of Texas Health Science Center questions assessing specific behaviors related of death. Within the healthcare system, at Tyler. All questions can be directed to to bipolar disorder, as well as symptom there is a need to provide effective suicide Kathryn Wortz, Ph.D., Training Director, co-occurrence and functional impairment. assessment tools. Given the imminent risk at [email protected] The MDQ has been developed only as a to individuals who experience suicidal screener for bipolar I disorder, and not a ideation, accessing measures to properly ithin the primary care diagnostic instrument; it takes approximately assess and target suicidal risk is paramount. behavioral health/integrated 5 minutes to complete. A clinical evaluation The Columbia Suicide Severity Rating care environment, most by a trained professional should follow a Scale (C-SSRS) can be completed in an professionals are intimately positive screen (Hirschfeld, 2002; Williams, interview format or as a self-report measure. Wfamiliar with the PHQ-9 brief depression 2017). It has also been found reliable and The C-SSRS has 10 categories, which include screening measure. While the PHQ-9 is valid (Hirschfeld et al, 2000). indeed a useful measure, there are many yes/no responses that indicate either the other screening tools available in the public The Depression Anxiety Stress Scales presence or absence of the behavior. The domain to assess a variety of symptomatol- (DASS) is a 42-item, self-report measure categories include a comprehensive assess- ogies, including mood, suicide ideation and used to identify experiences of depression ment of the domains of suicidal ideation and behavior, sleep, substance use, and memory (i.e., dysphoria, hopelessness, anhedonia), suicidal behavior. The C-SSRS demonstrates and cognition. Some of these options are anxiety, (i.e., arousal, anxious affect, skeletal moderate to strong internal consistency and offered below for consideration by the busy muscle effects) and stress (i.e., difficulty reliability. There are versions of the C-SSRS clinician. relaxing, nervous arousal, irritability). available for children, adolescents, and adults The questions on the DASS are answered (Posner, Brown, Stanley, Brent, et. al., 2011). MOOD on a 4-point severity scale, identifying The Reasons for Living Scale (RFLS) is the severity or frequency patients have In primary care settings, it has been found a commonly used tool that is a 72-item, experienced each emotional state over the that 30% of patients have mood disturbance, self-report questionnaire, which evaluates past week. There is also a shorter version of such as anxiety, dysthymia, and bipolar motives for individuals to continue their the DASS, containing 21 items. The use of the disorder (DHHS, 2006). Given these sta- lives. The purpose of the RFLS is to assess DASS has been widely researched and has tistics, quickly measuring mood symptoms suicidal risk as it relates to the range and been found to be reliable and valid for use in primary care settings can prove effective. strength of reasons for living. Protective among many settings. The Mood Disorder Questionnaire factors became a focus when developing the (MDQ) is a 15-item, self-report screening RFLS. There is a short form of the RFLS that

14 | Texas Psychological Association consists of 48 items, in addition to a military among patients presenting to non-psychiat- The Epworth Sleepiness Scale (ESS) is (RFL-M) and adolescent version (BRFL-A; ric medical and hospital clinics. The screener an 8-item, self-report questionnaire that Deutsch & Lande, 2017; Linehan, Goodstein, yields two subscales, the HADS-A anxiety assesses the patient’s general level of daytime Nielsen, & Chiles, 1983). subscale and HADS-D depression subscale, sleepiness, as daytime sleepiness is a key which both contain 7 items. The HADS diagnostic feature of several sleep disorders TheSuicide Behaviors Questionnaire-Revised is used with adult patients and has strong (Johns, 1991). The ESS asks patients to rate (SBQ-R) is a brief, 4-item questionnaire psychometric properties; it is considered a their usual chances of dozing off or falling that assesses previous suicidal ideation and valid tool to identify symptoms of anxiety asleep while engaged in 8 different activities suicidal behaviors. Specifically, the SBQ-R and depression in medical populations (e.g., sitting and reading, watching TV). examines patterns of previous ideation and (Bjelland et al., 2002). The item scores are summed for a total ESS attempts, recent occurrence of ideation, score, which gives an estimate of the patient’s suicide risk, and self-reported endorsement SLEEP “average sleep propensity” (Johns, 2002), of future suicidal behaviors. The SBQ-R is with ESS scores of 11–14 indicate increasing Sleep concerns among patients are common, commonly used in clinical and nonclinical levels of excessive daytime sleepiness. populations (Osman, Bagge, Gutierrez, with the prevalence of sleep disorders estimated to be approximately 40% (Colten Konick, Kopper, & Barrios, 2001). SUBSTANCE USE AND PAIN & Altevogt, 2006). The gold standard of ANXIETY AND assessment of sleep disorders is expensive, The evaluation of alcohol and drug use is an PHYSIOLOGICAL AROUSAL time-intensive, and in integrated care integral part of assessing risky health behav- settings often impractical, thus creating the iors in integrated care settings. The 10-item Using brief and validated screening tools need for brief, self-report screening tools to Alcohol Use Disorder Identification Test can be an effective way to identify anxiety guide further assessment and intervention. (AUDIT) is a self-report measure developed and other related disorders in primary care by the World Health Organization to assess settings and facilitate a referral for further TheInsomnia Severity Index (ISI) is a alcohol use (Saunders, Aasland, Babor, de la assessment and treatment. The Generalized brief self-report measure that assesses the Fuente, & Grant, 1993; Selin, 2003). Validated Anxiety Disorder Scale (GAD-7) is a patient’s perception of their insomnia, and within medical settings, total scores of eight commonly used measure that screens for can also measure treatment outcomes. The or higher suggest problematic drinking symptoms associated with generalized ISI measures the severity of sleep-onset (Bohn, Babor, & Kranzler, 1995; Conigrave, anxiety disorder, one of the most common difficulties and sleep maintenance difficulties, Hall, & Saunders, 1995). For concerns about presenting anxiety disorders in the primary satisfaction with current sleep, impact on other substances, the Drug Abuse Screening care setting, with an estimated prevalence of daily functioning, impairment observable to Test (DAST-10) is a brief, 10-item measure, 2.8–8.5% (Spitzer, et al., 2006). The GAD-7 others, and degree of distress caused by the with each question answered with a yes or is a brief self-report measure comprised sleep problems. Higher scores suggest more no response (Skinner, 1982); a score greater of 7 items inquiring about symptoms severe insomnia and established cutoff scores than 2 is suggestive of drug abuse (Maisto et experienced within the past two weeks. are provided to identify different degrees of al., 2000). Scores range from 0–21, with cutoffs of 5, 10, insomnia. The ISI appears to be a reliable and 15 indicating mild, moderate, and severe measure of perceived insomnia severity and Although a frequently utilized treatment for anxiety. This screener is appropriate for is sensitive to changes in patient’s perceptions chronic pain, prescribed opioid medications use with adults and has a strong specificity, of treatment outcomes (Bastien, Vallières, present serious risks for many patients. internal consistency, and test-retest reliability Morin, 2001; Wong et al., 2017). The Screener and Opioid Assessment for (Spitzer et al., 2006). Patients with Pain – Revised (SOAPP-R) The STOP-BANG Questionnaire is a 24-item scale that can be completed in The Nijmegen Questionnaire is a self-report was designed to be a concise, reliable, approximately ten minutes (Butler et al., measure that has been used to screen for easy-to-administer screening tool for 2008). A score greater than 18 is considered hyperventilation syndrome as well as symp- obstructive sleep apnea (OSA). The STOP- at risk for opioid misuse. Although other toms of dysfunctional breathing associated BANG screening tool consists of 8 yes/no factors should also be considered when with various medical and anxiety-based questions related to the clinical features of assessing risk of opioid misuse, the SOAPP-R disorders (van Dixhoorn & Folgering, 2015). sleep apnea: snoring, tiredness, observed is a helpful and quick addition to an opioid It is comprised of 16 symptoms rated on a apnea, high BP, BMI, age, neck circumfer- risk assessment. five-point scale. A total score of 23 or higher ence, and male gender (Chung, Abdullah, suggests the presence of hyperventilation & Liao, 2016). The total score ranges from TRAUMA AND PTSD disorder or dysfunctional breathing (Thomas 0 to 8, and is used to determine the patient’s et al., 2001). OSA risk classification. The STOP-BANG Approximately 7.7 million individuals in any Questionnaire can be administered and given year will experience posttraumatic The Hospital Anxiety and Depression Scale scored quickly, and the cutoff score of 3 has stress (PTS) symptoms, which impact (HADS) has been widely used for over 30 demonstrated high sensitivity in detecting individuals of all ages across the lifespan and years to identify anxiety and depression sleep apnea (Chung et al., 2008). individuals of all backgrounds and nation-

Texas Psychologist | Winter 2019 | 1 5 potential anxiety and affective symptoms While the PHQ-9 is a useful measure, there are many other screening tools avail- for children ages 8–18. The RCADS yields able in the public domain to assess a variety of symptomatologies, including mood, total anxiety scores and subscale scores for suicide ideation and behavior, sleep, substance use, and memory and cognition. separation anxiety disorder, social phobia, generalized anxiety disorder, panic disorder, obsessive-compulsive disorder, and major alities (Department of Health and Human The St. Louis University Mental Status depressive disorder. It has been translated Services, 2018). Given the impact that trauma (SLUMS) exam was developed as a screening into many languages, including Spanish and can have, assessment of PTS symptoms in tool for detecting mild cognitive impairment Chinese (Chorpita et al., 2000). integrated care settings is imperative. The in a veteran population. It has since been Posttraumatic Stress Disorder Checklist extended to other populations and can be The CRAFFT Screening Tool for (PCL-5) is a 20-item, self-report measure that useful in the detection of early dementia. The Adolescent Substance Use (CRAFFT) is assesses 20 symptoms corresponding with SLUMS has 11 items and takes approximately administered by the clinician for youth ages criteria of PTSD symptoms in the DSM-5 seven minutes to administer, with scores 14–21. The first three questions ask about among adults aged 18 years and older. The ranging from 0 to 30. Scores of 27 to 30 alcohol, marijuana, or other substance use purpose of the PCL-5 is to screen for PTSD are considered normal, and scores of 26 or during the past 12 months. What follows symptoms, support a provisional diagnosis of below are suggestive of possible cognitive are questions related to the youth’s specific PTSD, and monitor PTSD symptom changes impairment or dementia. Compared to the experiences with substances in relation to during and after treatment. Completion MMSE, the SLUMS is superior in identifying Cars, Relaxation, being Alone, Forgetting, of the PCL-5 takes approximately 5 to 10 people with milder cognitive problems Family/Friends, and Trouble (CRAFFT). minutes. The PCL-5 has strong internal (Stewart et al., 2012). consistency reliability (.94) and test-retest reliability (.82) (Blevins et al., 2015). PEDIATRICS REFERENCES Specially designed measures for children Bastien, C. H., Vallières, A., & Morin, C. M. MEMORY AND COGNITION and adolescents are invaluable to proper (2001). Validation of the Insomnia Severity Cognitive screening is a first step in evaluat- screening for issues relevant to a pediatric Index as an outcome measure for insomnia ing dementia and other neuropsychological population and help bridge the gap between research. Sleep Medicine, 2(4), 297–307. disorders. The importance of brief cognitive what caregivers report and what kids Birmaher, B., Brent, D. A., Chiappetta, L., screening in integrated care cannot be experience. The Child and Adolescent Bridge, J., Monga, S., & Baugher, M. (1999). understated, especially among an aging Trauma Screen (CATS) is used to screen Psychometric properties of the Screen for patient population. The Mini Mental Status for potentially traumatic events (PTEs) Child Anxiety Related Emotional Disorders Exam (MMSE) has been widely used among and PTSD symptoms in children and (SCARED): a replication study. Journal of health care providers and researchers. The adolescents. These symptoms are based on the American Academy of Child & Adolescent MMSE has both validity and reliability for the DSM-5, therefore the CATS can act as Psychiatry, 38(10), 1230–1236. the diagnosis and longitudinal assessment a useful diagnostic aid. The CATS is also Birmaher, B., Khetarpal, S., Brent, D., Cully, of Alzheimer’s Dementia (AD), with scores available in Spanish, with both caregiver M., Balach, L., Kaufman, J., & Neer, S. M. greater than or equal to 24 points (out of 30) (ages 3–6 or 7–17) and self-report (ages 7–17) (1997). The screen for child anxiety related suggesting normal cognition. Scores below versions (Sachser et al., 2017). emotional disorders (SCARED): Scale con- 24 suggest severe (≤9 points), moderate TheScreen for Child Anxiety Related struction and psychometric characteristics. (10–18 points) or mild (19–23 points) Journal of the American Academy of Child & cognitive impairment. Emotional Disorder (SCARED) is a 41-item self-report measure of symptoms of anxiety Adolescent Psychiatry, 36(4), 545–553. The Montreal Cognitive Assessment for children aged 8–18, which yields an overall Bjelland, I., Dahl, A. A., Tangen, T., & (MoCA) is a simple, stand-alone cognitive anxiety score, as well as subscales for panic Neckelmann, D. (2002). Bjelland 2002, JoPR, screening tool validated for adults ages 55–85 disorder or significant somatic symptoms, HADS, 52, 69–77. http://doi.org/10.1016/ years old (Nasreddine et al., 2005). The generalized anxiety disorder, separation S0022-3999(01)00296-3 MoCA covers several important cognitive anxiety, social anxiety disorder, and signifi- Blevins, C.A., Weathers, F.W., Davis, M.T., domains, can be administered in 10 minutes, cant school avoidance. A 5-item version of the Witte, T.K., and Domino, T. (2015). The and fits on one page. Moreover, the data SCARED also exists, which can be useful as a posttraumatic stress disorder checklist for indicate that it has excellent test-retest brief screener in fast-paced settings, when no dsm-5 (PCL-5): Development and initial reliability, positive and negative predictive anxiety disorder is suspected, or for children psychometric evaluation. Journal of Trau- values for MCI and AD, and is more with less verbal capacity (Birmaher et al., matic Stress. Vol. 28, 489–498. sensitive than the MMSE (Nasreddine et 1999; Birmaher et al., 1997). al., 2005). Scores below 25 are suggestive of cognitive impairment. The Revised Child Anxiety and Depression Scale (RCADS) is a 47-item self report or caregiver report (RCADS-P) of

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Texas Psychologist | Winter 2019 | 1 7 PRSRT STD U.S. POSTAGE PAID PERMIT NO. 1425 AUSTIN, TX 1464 E. Whitestone Blvd., Ste. 401 Cedar Park, TX 78613

2019 Annual Convention 31 Oct.–2 Nov. 2019

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