Articles: Deconstructing competitive commitments & 
COVID-19 brings change to behavioral health for older adults {Below}

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Deconstructing competitive commitments

By Bruce Wilson, Ph.D.
July 28, 2020

In the human psyche, competitive commitments occur when the individual is having difficulty committing due to their commitment being in two or more directions at the same time. These commitments are competing due to the reality that they are in direct opposition to one another (i.e., freedom versus security).

In most cases, the competing commitment is stronger than the commitment to change, creating immunity to change unless the underlying assumptions are uncovered and acknowledged as not working.

Competitive commitments are one example of a seemingly unhealthy desire, at the core of a need to maintain an ambivalent situation, which creates havoc but appears to have no solution for the client. Uncovering the false assumptions of the client becomes critical to resolution.

A typical competitive commitment in couple’s therapy is the love affair outside the marriage/relationship. The client is stuck in the competitive commitment to both his wife and the other woman (obviously, the gender could be husband and the other man or same-sex partners that are permanent versus casual).

Understanding the client’s protective frames in their struggle to resolve their competitive commitment is suggested as a possible treatment strategy. Protective frames are self-created views about reality (B. Wilson and L. Wilson, 1999) a concept originally conceived by Michael Apter, the founder of reversal theory. Apter’s book The Dangerous Edge (1992) proposed three protective frames: a confidence frame, a safety frame and a detachment frame.

A confidence frame allows one to approach the edge of danger while experiencing feelings of both high arousal and feelings of protection simultaneously. The individual pushes and has no limits. They seek excitement and look for the exhilaration of danger.

The confidence frame can be appropriate or inappropriate and needs to be tested carefully for accuracy. This frame is not only relevant to people who work in physical danger but also to anyone who puts themselves at emotional or mental risk as well.

A safety frame allows the individual to feel there is no danger and no immediate possibility

of slipping into danger. The individual seeks security, avoids anxiety and feels free from stress

and strain. The safety frame can also be inaccurate and this sometimes leads to catastrophe.

Date rape, home invasion and unexpected redundancy are examples.

A detachment frame allows the individual to participate in what is going on, but only as an observer. The detachment can manifest physically, mentally or emotionally. The detachment frame features putting others at risk while standing back, a self-substitution, fantasy or make-believe, and retrospection or being stuck in the past. Although detachment may be positive at times, switching off at the end of a hard workday, this frame can also lead to ruminating and unrealistic fantasies.

The Deconstructing Competitive Commitments Model (B. Wilson, 2019) suggests Apter’s protective frames concept can be applied to clients who are dealing with the indecisiveness of a competitive commitment. The model provides a structural basis to explore, with the client, potential protective frames that may be contributing to the client’s distorted view of reality. As the model displays, clients are stuck between two opposition commitments that their inappropriate protective frames are constantly reinforced.

These frames have the potential to keep the client in a state of ambivalence for as long as the client is willing to resist the need for change. The effective therapist will work with the client to help identify any inappropriate protective frames that might be contributing to the competitive commitment at hand. This process has the potential to be a catalyst to the client’s insight and personal agency.

The next step would be for the client to make a positive commitment to change, possibly a self-contract witnessed by someone who would hold them to the commitment. During this phase, the therapist could assist the client in identifying what the client is doing or not doing to create change. The therapist would also help the client identify any false assumptions that contributed to the competitive commitment. Finally, some hidden competitive commitments might surface in the unveiling of the client’s ambivalence, and these also need to be addressed.

Competitive commitments happen in therapy all the time, and clients are constantly presenting with issues that are permeated with ambivalence and indecisiveness. “Should I do this or that?” “I want both” or “I want neither.” Could Deconstructing Competitive Commitments provide a productive alternative method of treating ambivalence in clients?

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Bruce Wilson, Ph.D., is a psychologist with Mind Health Care, a group of therapy providers in Geelong, Australia. He may be reached by email at: drwilsonpsychologist@gmail.com.

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COVID-19 brings change to behavioral health for older adults

By Paula Hartman-Stein, Ph.D.
July 28, 2020

The Centers for Disease Control and Prevention (CDC) says eight out of 10 U.S. deaths from the novel coronavirus have been in adults age 65 and older.

Nursing homes and assisted living facilities have become hotspots for the virus, accounting for 42 percent of COVID-19 deaths, according to the Foundation for Research on Equal Opportunities (FREOPP).

As a result, public health officials have recommended that older adults stay at home as much as possible during the pandemic.

In response, the Center for Medicare and Medicaid Services (CMS) began easing barriers to virtual medical care in early March, allowing Medicare to temporarily reimburse telehealth appointments at the same rate as in-office visits, relaxing HIPAA privacy law requirements, and psychological services to be reimbursed for audio-only visits. Some states granted waivers so providers licensed in one state could provide services to patients in another.

Information about states' requirements for temporary practice laws is on the Association of State and Provincial Psychology Boards (ASPPB) website.

Fear of contracting the virus has warmed older adults to telehealth. Almost 1.3 million members received medical services through telehealth in the week ending April 18, compared to 11,000 in the week ending March 7. Recent Medicare claims data shows this is a whopping increase of about 12,000 percent in just a month and a half.

Psychologists treating patients in nursing homes have had to adapt.

"I'm doing telehealth using the platform doxy.me with many clients in long-term care facilities, but some do not want to do any telehealth and some nursing homes prefer I don't come in, so I just check in via phone and ensure they're ok," said psychologist Mary Lewis, Ph.D., of Columbus, Ohio. "I have done phone therapy when the technology failed, and I had to resort to FaceTime when Internet connections failed." In one facility, she plans to do phone therapy by looking at the patient through the window.

According to Lisa Lind, Ph.D., chief of quality assurance for Deer Oaks, a behavioral healthcare group with over 400 clinicians across 29 states, some facilities are allowing in-person services, with varying restrictions. Most require clinicians to go through a screening process that involves answering questions about symptoms and having their temperature taken. Wearing a mask is mandatory and some facilities require gowns, gloves, shoe coverings, and face shields.

Acquiring personal protective equipment (PPE) in a timely fashion, particularly at the onset of the pandemic, and its cost, have kept some clinicians from working in facilities that require PPE but don't provide it to consultants.

Lind said telehealth waivers have been beneficial in potentially opening up opportunities to continue psychological services, but facilities have encountered difficulties providing facilitators to assist with telehealth delivery even though facilities can bill CMS an originating facility fee to coordinate the session.

"When eight to 10 patients would normally be seen in a usual workday prior to COVID-19, now maybe three to four patients are seen on average due to facilitator schedule limitations," Lind said. "The allowance for audio-only telehealth services by CMS increased the ability to reach patients who have access to a telephone without relying on facility staff to assist, although this is limited to those residents who have access to a telephone and providers having access to their phone number."

Many psychologists agree that everyone is not an ideal candidate for telehealth, including those with hearing deficits and certain levels of cognitive impairment. Some individuals with mild-to-moderate levels of dementia can participate in, and benefit from, telehealth services. But in-person psychological services appear preferable for those with dementia with behavioral issues, individuals with psychotic symptoms, and those with hearing/vision/motor impairment.

Virtual outpatient groups extend access

John Merladet, Ph.D. a psychologist in the Homebase Primary Care Program at the Orlando Florida Veteran's Administration hospital, recently began a group for Vietnam vets with a focus on the late-life onset of post-traumatic stress.

Robert Matthew Wachen, Ph.D. a psychologist at the Bedford VA hospital in Bedford, Mass., said that after the COVID crisis hit he transitioned a caregiver-support group first to telephone and then to video, with weekly meetings of the four-to eight-person group.

"The covid crisis has nudged us into territory that would have been wise to have been in all along,

" he said. "We plan to continue to provide the virtual service to those who cannot come to us."
One group member and that person's spouse both contracted COVID-19. 
The spouse died of the virus

and the caregiver recovered and continued to attend the group.

"I very strongly suspect the caregiver would have stopped attending in person during the spouse's final weeks and after the death. Instead, not only the caregiver but the group at large benefitted to process this chapter of transitioning out of caregiving after many years. It's been a deeply moving and meaningful experience for all involved," said Wachen.

According to Rachael Falk, PsyD, the Center for Memory Health at Hebrew SeniorLife in Boston provides a virtual therapy group for caregivers that is billed to Medicare and other third-party payers.

Cathee Stegall, community services director for the nonprofit Memory Matters in Hilton Head Island, S. C., which offers adult day services, early memory loss clubs and caregiver support, began to offer virtual programs to replace in-person programs after its doors closed in mid-March. Although the facility plans to re-open in July, Stegall anticipates some families may not send loved ones, preferring the online programs.

Using a Zoom platform Stegall and a co-facilitator conduct three support groups that have as many as 20 people in the virtual meeting at a time. She also conducts telehealth programs for the early memory loss (EML) club that include suggested cognitive stimulation activities delivered to the EML students' homes via email.

Stegall also helped develop a program through Zoom for participants with mild to moderate dementia who live at home. Family members set up the Zoom call and watch loved ones participate in activities involving music, art, physical exercise, meditation and short stories. She said one unexpected benefit is that family members can see what their loved ones can do and the memories they share with the group.

Adaptations for neuropsychological evaluations

Psychologist Sheri Gibson, Ph.D., of Colorado Springs, has opted not to use telehealth when assessing older adults' capacity.

"My decision is based on the nature of those assessments because I draw important conclusions and offer expert opinions involving the possibility of removing a person's rights to make decisions around their health care, finances, or living situation," she said. "And in most cases, I will be expected to testify in court on my findings. In consulting with my neuropsychology colleagues on this dilemma, they have agreed that capacity evaluations should be conducted in person if possible."

During the height of the quarantine mandate, she put evaluations on hold, but began conducting them in May in her office and a hospital setting. In her private practice office, she has clients complete a COVID-19 screening questionnaire and takes their temperature. She and the client wear masks, except in extraordinary cases.

Gibson sanitizes her office and testing space, opens the windows to allow ventilation, and offers hand sanitizer in the lobby and her office.

Future of telehealth for Medicare patients

CMS Administrator Seema Verma told reporters on June 2 her department is evaluating telehealth waivers to determine if they should be extended and is creating additional rules around the issue. APA is advocating that telehealth continue to be reimbursed for 12 months after the pandemic ends.

Healthcare analysts say virtual care is likely to remain popular for services such as chronic disease management, behavioral healthcare and evaluation visits. These visits can easily be conducted through a telehealth modality, mainly if CMS retains telehealth payment parity for Medicare's 44 million beneficiaries.

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Paula Hartman-Stein, Ph.D. is an independent consultant in Asheville, N.C., and editor of Enhancing Cognitive Fitness in Adults: A guide to the use and development of community-based programs. Since the pandemic she offers virtual meditation and expressive writing programs. Her websites are www.centerforhealthyaging.com and www.TheInspiredWriter.com.

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