Articles: We are all victims of the ‘attention economy’ &
‘Please don’t tell my surgeon’: Managing privacy, confidentiality in integrated healthcare settings 
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We are all victims of the ‘attention economy’

By Larry Rosen, Ph.D.
July 27, 2020

Scenario 1: You are stopped at a red light, waiting up to 45 seconds for it to change and rather than simply sit with your thoughts, you grab your phone and start tapping icons. Inevitably, the light changes, and the driver behind you honks his horn. Since

your eyes are facing down at your phone, you don't notice the light has changed.

Scenario 2: You and your significant other are watching the news. Instead of focusing your attention on the screen, you constantly check your phone even though you checked your email and social media a few minutes earlier. You have to keep asking what the reporter was saying.

Scenario 3: Your 14-year-old son has his own smartphone. You have discussed rules about phone use, including when it has to be put away for the night. You awaken at 3 a.m. only to see a light emanating from his room and he is on his phone hopping from one social media platform to another and messaging several friends.

The data from numerous studies of students, employees, families and others show that half of the time you check your phone is due to an alert or notification. In the other half, your phone has not vibrated, beeped or played a tune.

I have been studying why we persist in checking in so often even when we know we are in a situation where it is unproductive at best and often downright rude.

Part of the answer can be summed up nicely in a letter sent by the Children's Screen Time Action Network to the APA. Although the letter is directed at the impact of certain practices on children, it is equally relevant to adults.

Here is a quote from the letter, which was signed by dozens of psychologists, many of whom are experts in the field:

"We are writing to the American Psychological Association to call attention to the unethical practice of psychologists using hidden manipulation techniques to hook children on social media and video games. These techniques – employed without children's or their parent's knowledge or consent – increase kids' overuse of digital devices, resulting in risks to their health and well-being."

(The full letter can be found at screentimenetwork.org/apa)

We are all part of the "attention economy." Since our attention is a "scarce commodity," businesses strive to capture and keep it as much as they can, as their business model requires our eyeballs and brains in order to sell their products. The "product" can be as simple as buying something or as subtle as clicking on a link to pursue an advertisement for which they get paid.

The key to the attention economy business model is that the longer they can

keep your attention, the more likely it is that you will keep returning and the

more likely you will provide them with some form of compensation. In the online

world, these tools can be hidden and very insidious.

Take color, for example. Why do the circles showing how many emails or social media posts you have awaiting show white numbers on a red background? Because behavioral scientists have determined that this combination is most likely to attract your attention. That's why this color scheme is used on stop signs.

Why do Snapchat and Words With Friends encourage "streaks?" To keep people snapping or playing daily.

Why are those tiny bubbles rippling on your iMessage screen after you send a text? To keep you waiting for a return text.

Why do apps use a spinning object to show that you are "pulling to refresh"? To keep you wanting more.

Why do some social media sites withhold likes or favorites until they can send you a bunch at a time? Because intermittent reinforcement is a strong behavior modifier.

Why do YouTube and Netflix autoplay the next video with a countdown?

I could give dozens of other examples, but I hope you get the idea of how our attentional resources are being hijacked. Now add in vibrations and beeps and these are all tools to get and hold your attention.
I think that Nir Eyal, author of Hooked: How to Build Habit-Forming Products, has summed it up perfectly:

"The technologies we use have turned into compulsions, if not full-fledged addictions. It's the impulse to check a message notification. It's the pull to visit YouTube, Facebook, or Twitter for just a few minutes, only to find yourself still tapping and scrolling an hour later.

"None of this is an accident. It is all just as their designers intended using subtle psychological tricks to make people develop habits, such as varying the rewards people receive to create 'a craving,' or exploiting negative emotions that can act as 'triggers.'"

My research focus has now turned to how to help us reduce the pull of the attention economy. Apple and Google have given us a small assist by providing Screen Time and Digital Wellbeing apps that tell us how we spend our daily and weekly smartphone time.

We need to pay attention to those data, but that is not enough. We need to apply countermeasures to avoid attentional manipulation.

As my research progresses, I hope to keep you informed on what you can do to take back control.

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Larry Rosen, Ph.D., is professor emeritus of psychology at California State University, Dominguez Hills and the author of seven books on the psychological impact of technology. His latest book, The Distracted Mind: Ancient Brains in a High-Tech World (co-authored with Adam Gazzely, MD, Ph.D., and published by MIT Press) won the 2017 PROSE Award for Biomedicine and Neuroscience.

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‘Please don’t tell my surgeon’: Managing privacy, confidentiality in integrated healthcare settings

By Efrat Hedges Eichenbaum, Ph.D.
July 27, 2020

Integrated care settings are treatment settings in which a psychologist is embedded in an interdisciplinary and/or medical team. Examples include primary care, intensive care units and specialty medical clinics (e.g., oncology, chronic pain). Psychologists increasingly work in integrated care settings (APA Council of Representatives, 2016).

Interdisciplinary settings present unique ethical dilemmas for psychologists (e.g., Kerkhoff & Hanson, 2015, Taylor, 2001, Darnall, Carr, & Schatman, 2016). One example of an ethical challenge in an integrated setting is mandated care consults (e.g., “The doctor said I have to come to see you so I can keep getting my medication”). In addition, differences in scopes of practice across different disciplines can present other ethical challenges (e.g., “The occupational therapist diagnosed my patient with Alzheimer’s?”). Capacity concerns present frequently in integrated settings (e.g., “Why is my patient declining to undergo dialysis when it could save her life?”), and psychologists often assist their teams in decision-making when such issues arise.

A major ethical dilemma that can arise in interdisciplinary settings is the management of privacy and confidentiality concerns. Patient privacy and confidentiality are fundamentally different in integrated settings as compared to traditional mental health clinics due to electronic record sharing and interdisciplinary consultation.

In many interdisciplinary settings, all clinical staff has full access to the psychologist’s notes. Communication with other disciplines about patient care, including mental health care, is standard on integrated teams.

One example of this type of dilemma frequently occurs in pain management clinics: Your patient, Pat, is prescribed opioids at your clinic. Pat has a significant alcohol abuse history and disclosed that she drinks alcohol four times a week and borrows opioids from a friend. She has asked you not to disclose this to the team, fearing that her opioid prescription will be discontinued and her pain will become debilitating.

This dilemma can be anxiety-provoking — it involves patient safety, disclosure

of sensitive material, legaland clinical liability to multiple providers and several

conflicting ethical principles.

Fortunately, an ethical decision-making model for psychologists working in integrated

settings (Kerkhoff & Hanson, 2013) is available. This model, which rehabilitation

psychologists developed, consists of six steps:

1. Identifying the critical incident and ethical challenge; 2. Identifying conflicting ethical principles; 3. Understanding the social context and key stakeholders; 4. Addressing organizational and legal concepts;

5. Generating and anticipating alternative solutions; 6. Evaluating disposition.

This model provides a means of reconciling opposing ethical principles in integrated settings and includes the patient and team as stakeholders in decision-making.

In Pat’s case and other situations involving sensitive disclosures, the psychologist must maintain the therapeutic relationship. The Discovery of opioid misuse is not a “gotcha” moment — it is an opportunity to discuss patient safety and revisit the patient’s care plan with the team.

It is recommended that psychologists discuss their documentation and consultation requirements during informed consent, taking care to review psychologists’ ethical duty to document and consult truthfully while maintaining patient privacy to the greatest possible extent.

It is possible to document information and consult sensitively and truthfully, and include the patient in this process. For example, the psychologist and the patient could make the disclosure to a prescribing provider together.
Alternatively, the psychologist could send the provider a secure message with the patient in the room to give the patient some input about the language used within the disclosure.

In situations involving prescription medication misuse, it can be beneficial for psychologists to emphasize the importance of patient care and safety — not punishment — and to offer additional mental health follow-up and support as needed.

For more complex disclosure situations, the psychologist should consider professional/peer consultation (e.g., contacting an ethics committee) to improve decision-making, limit risk, and increase the probability of a positive outcome.

Interdisciplinary settings offer a unique opportunity to provide mental healthcare to hard-to-reach populations with complex treatment needs.

Although integrated care settings present many ethical challenges, psychologists can successfully manage these by using an ethical decision-making model that incorporates the complex contexts and multiple stakeholders involved in these settings.

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Efrat Hedges Eichenbaum, Ph.D., is a fellowship-trained rehabilitation psychologist in Minnesota. She serves as APA Division 22’s (Rehabilitation Psychology) Practice Committee Chair and is a member of the Minnesota Psychological Association’s Ethics Committee. She can be reached by email at Efrat@DrEichenbaumCBTsheets.com

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