Does U.S. federal policy support employment and recovery for people with psychiatric disabilities?

Evidence suggests that a high percentage of people with a psychiatric disability can recover--find meaningful work, develop positive relationships, and participate fully in their communities. Evidence also suggests that work is an essential component of recovery. However, few people with a serious psychiatric disability are actually employed and most of those who are employed work only part-time at barely minimum wages.To assess the impact of federal programs such as Social Security Disability Insurance, vocational rehabilitation, medical insurance, and psychiatric services upon employment, we conducted a qualitative study of 16 employed and 16 unemployed individuals with psychiatric disabilities. All of our participants had disabilities severe enough to qualify them for Social Security Disability benefits.They told us that current federal policies and practices encouraged employment and integration of only a few participants, in a particular stage of their recovery, and placed significant barriers in the employment path of others.     

Impact of cognitive-behavioral therapy for panic disorder on comorbidity: a controlled investigation

This study examined the effects of cognitive-behavioral therapy (CBT) for principal panic disorder with or without agoraphobia, on comorbidity in 30 individuals (16 female). To test the hypothesis that improvements in co-existing conditions were not due to spontaneous fluctuations across time, patients receiving immediate CBT were compared to those assigned to wait list (n = 11). Results indicated clinician-rated severity of comorbid specific phobia declined significantly following immediate CBT compared to no change after wait list. The number of patients without comorbidity of any severity increased after immediate CBT, with no such increase following wait list. However, the groups did not differ in the frequency of additional diagnoses or overall severity of comorbidity. In the total sample, results indicated reductions in comorbidity by 9-month follow-up, with marked declines in the severity of comorbid generalized anxiety disorder (GAD), social and specific phobia. Our findings suggest that targeted CBT for panic disorder has beneficial effects on comorbidity over the longer term and that some of its immediate effects exceed those due to the passage of time alone.     

In the belly of the beast: traumatic countertransference

The authors discuss their work together in a consultation process. One author led many groups that were created to facilitate recovery for persons directly impacted by the terrorist attacks on September 11, 2001; the other acted as consultant to the therapist/leader. The leader was a resident of New York City at the time of the attacks; the consultant lived in a distant Midwestern city and the two had never met prior to the work. They describe their experience of working together and the role of this collaboration in the lives of the leader and the groups. Well aware that little exists in the literature about groups led by leaders having experienced the same trauma as group members, the authors pay special attention to the countertransference that each underwent and raise questions about the effects of that on the group process.     

An Investigation of Genetic Counselors' Discussions of Genetic Discrimination with Cancer Risk Patients

Twenty-five genetic counselors who see familial cancer risk patients were interviewed about their definitions of genetic discrimination, perceptions of patient risk for discrimination, frequency and type of discrimination experienced by their patients, sources of information about discrimination, and what they tell patients about genetic discrimination. There was variability in participant definitions and content of discussions of genetic discrimination. Although 82% regarded risk to be low to theoretical, 40% reported possible instances of genetic discrimination, including insurance companies requiring results to cover procedures, denial of life/health insurance, social discrimination, and employment discrimination. Ninety-six percent of the sample reported always or almost always discussing genetic discrimination, and one or more of the following: insurance discrimination risks, protective legislation, no known cases positively documenting discrimination, strategies to avoid discrimination, and uncertainty of protective measures. The majority use current literature and research as information sources. Practice, policy, and research implications are discussed.     

The effects of slowed speech on auditory comprehension in aphasia

The present study investigates the effects of slowed speech on auditory comprehension in aphasia. Specifically, an attempt was made to isolate the effects of added time on comprehension at the language processing stages of auditory perception, by increasing the duration of the vowel segments in each word; word recognition and semantic analysis, by adding silences between words; and syntactic analysis, by adding silences at constituent phrase boundaries. Sentences were also read at a slow rate to see the effects of naturally slowed speech on sentence comprehension. Test sentences consisted of simple active and passive declarative sentences, and complex sentences with embedded medial and final relative clauses. Sentences were either semantically reversible or nonreversible. Thirty-four aphasic patients who varied in both severity and type of aphasia were tested on a picture verification task. Results indicated that slowing facilitated language comprehension significantly only in the syntactic condition. Neither syntactic complexity nor semantic reversibility interacted with slowed speech to facilitate auditory language comprehension. Further, it was only the Wernicke's aphasics who showed significant improvement with time added at constituent boundaries. These results suggest that time alone does not facilitate language comprehension in aphasia, but that rather it is the interaction of time with syntactic processing which improves comprehension.     

Is early identification of children of alcoholics necessary for preventive intervention? Reaction to Havey and Dodd

Havey and Dodd (1995, this issue) address the question of how to best identify early adolescents who are at risk for later substance abuse, with a particular focus on children of alcoholics (COAs). They conclude that stressful family events are preferable to COA status as an at-risk indicator. In addition, they question the well-substantiated at-risk status of COAs, claiming support for the null hypothesis regarding individual and family differences between COAs and non-COAs. This article addresses both conceptual and methodological concerns about identification and intervention for COAs in general, and about the Havey and Dodd study in particular. I first discuss a theoretically-empirically based approach to identification and risk prevention that supports a more complex, less parsimonious, model than that suggested by Havey and Dodd. Second, I present research to support the at-risk status of COAs. Third, I discuss issues related to identification of COAs and question the validity of Havey and Dodd's identification techniques. On the basis of conceptual and methodological arguments, I contend that Havey and Dodd's conclusions are not well-founded in their own or others' research and that the at-risk status of COAs cannot be dismissed on the basis of their research. I also contend that early identification may not be necessary for intervention with COAs or other at-risk groups. Alternatively, primary prevention programs provide the context for both service delivery and identification of individuals who might not otherwise be easily identified, particularly those at risk for developing mental health problems because of family environment factors (e.g., family alcoholism or conflict), or those currently experiencing mild or internalized (e.g., depression) adjustment difficulties.     

Client Perceptions of the Impact of Genetic Counseling: An Exploratory Study

Twenty-eight former genetic counseling clients seen at a major Midwestern university were recruited to be interviewed about their genetic counseling experiences, including most and least helpful aspects, what they learned, how this information impacted their decision-making, and their perceptions of their genetic counselors' behaviors. Responses were inductively analyzed, and several themes were identified, including: Clients sought genetic counseling to obtain genetic-medical information; a majority accurately recalled this information; genetic counseling influenced decisions for about 50% of the sample; decision-making was affected by several extra-session factors; a majority experienced distress during the session; most perceived genetic counselor responses as nondirective and liked this approach; counselor behaviors regarded as directive involved discussion of pregnancy termination; participants disagreed about the need for and provision of genetic counselor support; most regarded the session as helpful and stated that they would seek genetic counseling again. Suggestions for addressing these issues in practice and research are given.     

BRCA1 Testing: Genetic Counseling Protocol Development and Counseling Issues

This article discusses the genetic counseling protocols which were developed and counseling issues that have arisen in the first 2 years of evaluating a large kindred with a BRCA1 mutation. The rationale for the development of the genetic counseling protocols and specific genetic counseling visual aids are presented and discussed. The protocols and counseling aids can serve as models for other programs offering cancer susceptibility testing. The observations of study counselors about study subject concerns and responses to genetic testing at the time of the pretest and posttest counseling sessions are presented.     

The competence of criminal defendants: A theoretical reformulation

“Competence” of criminal defendants is best viewed not as an open-textured single construct but rather as two related but separable constructs-a foundational concept of competence to assist counsel, and a contextualized concept of decisional competence. This approach has several advantages. First, it provides a useful explanatory framework for the settled features of existing law. Second, it helps to clarify the issues in areas where the law is unsettled or controversial, such as the circumstances under which incompetence bars adjudication and the abilities required for decisional competence. Third, it exposes the similarities between competencies in criminal defense and competencies in other legal contexts, and thereby helps to link what have been discrete literatures in both law and behavioral science. Fourth, because this approach is derived from a theoretical analysis of the purposes of the pertinent legal rules, it provides a framework for defining the “psycho-legal abilities” that are encompassed by each of the two competence constructs. In this respect, a relatively simple reconceptualization has surprisingly concrete implications for designing a program of empirical research and, eventually, for improving the scientific basis of competence assessments in criminal cases.     

IQ independence of measures of dysfunctional cognition

An important step in validating measures of dysfunctional cognition is to ensure that they are not confounded with general intelligence. We evaluated the Cognitions Checklist (Depression and Anxiety subscales), the Dysfunctional Attitudes Scale, and the Hopelessness Scale in a sample of 162 outpatients with depressive or anxiety disorders. These measures were not confounded with fluid or crystallized intelligence. Furthermore, correlations between the dysfunctional cognition scales and symptom severity measures were not attenuated when intelligence was statistically controlled.