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Couples are often surprised just how much a baby changes their relationship and their lives. In fact, “A baby will change virtually every component of your life: physical, sexual, emotional, psychological, relational, social, financial, logistical and spiritual,” according to Joyce Marter, LCPC, psychotherapist and owner of Urban Balance, LLC, which offers a Pre & Post Baby Couples Counseling Program.
Whether it’s your first or fourth child, your relationship still sees a jolt. As Marter said, “The first child most often brings about the greatest life and relationship change, but each subsequent child affects a couple almost exponentially, widening the scope of responsibilities and compounding family and relationship dynamics.”
Having children can bring couples closer. But it also can chip away at a relationship if you’re unprepared for the potential pitfalls. Take this surprising statistic: Within three years of their child’s birth, about 70 percent of couples experience a significant slump in their relationship quality, according to the Gottman Relationship Institute.
The key in keeping a relationship happy and fulfilling is knowing what these pitfalls are, having realistic expectations and staying committed to each other. Below are three of the most common pitfalls and pointers to help.
Pitfall 1: Sleep deprivation
Everyone knows that having kids is exhausting. But you might not fully appreciate the fatigue. According to Marter, “the chronic and cumulative nature of sleep deprivation during the newborn phase is perhaps one of the most commonly underestimated challenges of new parenthood.”
Sleep deprivation sinks your mood, makes it harder to cope effectively with stress and exacerbates mood swings and anxiety. And that’s just what it does to each person.
Lack of sleep strains the relationship in various ways: Couples may fight about who’s doing more and sleeping less. Because couples are extra agitated and stressed, they might squabble more in general. And the primary caregiver may feel unsupported and alone and eventually resent their spouse, Marter said.
Pointers: Sleep when your baby sleeps, Marter said. “This may mean letting the laundry or scrapbooks wait and forcing yourself to nap. It might mean going to bed at 8 p.m., so that you can sleep during your baby’s longest stretch.”
What if your baby isn’t really sleeping? Marter suggested working with your pediatrician and reading other resources such as Healthy Sleep Habits, Healthy Child by Dr. Marc Weissbluth. If feedings are the reason your family isn’t getting much sleep, she also suggested checking out the La Leche League, and figuring out a feeding schedule that works best.
Ask loved ones for support and, if it’s financially feasible, hire help for household chores, a babysitter so you can take daytime naps or a night nanny, Marter said.
And work as a team. For instance, moms who are breastfeeding can pump so their partners or loved ones take turns doing the feedings.
Pitfall 2: Lack of intimacy
Sexual intimacy declines after having a baby, and not surprisingly, this can negatively affect your relationship. “Because sexuality is intensely personal and sexual connection is a major component of romantic relationships, sexual dysfunction or disconnection can become a significant problem for many couples,” Marter said.
The decline happens for many reasons. Physicians typically suggest that women abstain from intercourse for 4 to 6 weeks after childbirth. Even after that time, “women may experience or fear pain from intercourse due to the effects of delivery, an episiotomy, perineal tearing, and/or vaginal dryness due to hormone fluctuations,” Marter said. Couples also experience a decline in desire because of busy schedules, body image issues, fatigue and other concerns.
Pointers: Expect that intimacy will decline after childbirth. This is normal considering the sleep deprivation, new responsibilities and need for the woman’s body to heal, Marter said. Avoid viewing lack of sex as rejection or a sign of trouble in your relationship.
Be close and intimate in other ways, such as kissing, touching, snuggling or spooning, Marter said. Make time to physically connect with each other. Staying home and watching a movie is one way, she said.
“Good sex requires good communication.” Marter suggested talking openly about your needs, preferences and fantasies with your partner. These are some questions she suggested raising: “What is good about [your sex life]? When was it the best and why? What do you each desire? What schedule seems to work best for you? What gets in the way of having more sex?”
Also, work on your emotional connection. For instance, “Create at least 20 minutes per day to connect and talk about things other than the responsibilities with household and baby,” Marter said.
Pitfall 3: Responsibilities
In Marter’s practice, the most prevalent problem for couples is division of labor. Resentments inevitably peak when one partner feels like they’re tackling more tasks and working harder. “They may compare and become competitive or defensive about their responsibilities, schedules or the pros and cons of their work or role,” she said.
They also might glorify each other’s positions, Marter said. A stay-at-home dad might think his wife’s day at work is filled with swanky business lunches, interesting projects and a quiet commute, while he’s dealing with temper tantrums and dirty diapers. His wife might imagine him playing, cuddling and connecting with their child, while she deals with a difficult boss, endless deadlines and concerns over job security. “Then, when an issue like who is going to do the laundry comes up, the misunderstandings have created an environment ripe for conflict,” she said.
One of the problems is that couples usually don’t have a plan for how they’re going to divvy up responsibilities. Marter finds that many couples make assumptions about who’ll do what — often based on how their parents did things — which typically leads to confusion and conflict.
Pointers: Map out what your routine and responsibilities will look like, Marter said. And make sure it’s fair to both partners. Again, couples get into trouble when responsibilities are vague. One of Marter’s clients wanted her husband to help out in the mornings, but the couple ended up bickering instead. “By sitting down and reviewing the mornings tasks, the husband was able to select several items that his wife agreed would be helpful for him to manage,” she said.
When you’re figuring out fairness, remember that a relationship requires give and take. “For example, the husband of a client who is a teacher really steps it up during her grading periods and she picks up the slack when he travels for work,” Marter said.
Also, lower your standards, and let some things go. Another client of Marter’s, who was super stressed and worn out, used to iron all her baby’s clothes. Of course, getting enough sleep supersedes ironing. “Focus on the big things and let the small stuff go,” Marter said.
“The transition to family is simultaneously joyous, miraculous and wondrous and one of the most challenging life experiences and opportunities for growth,” Marter said. It helps for couples to have realistic expectations about parenthood and their relationship and to remain committed to working as a team.
The Sunk Cost Fallacy Is Ruining Your Decisions. Here's How
I f you’ve ever let unworn clothes clutter your closet just because they were expensive, or followed through on plans you were dreading because you already bought tickets, you’re familiar with the sunk cost fallacy.
“The sunk cost effect is the general tendency for people to continue an endeavor, or continue consuming or pursuing an option, if they’ve invested time or money or some resource in it,” says Christopher Olivola, an assistant professor of marketing at Carnegie Mellon’s Tepper School of Business and the author of a 2018 paper on the topic published in the journal Psychological Science. “That effect becomes a fallacy if it’s pushing you to do things that are making you unhappy or worse off.”
This idea often applies to money, but invested time, energy or pain can also influence behavior. “Romantic relationships are a classic one,” Olivola says. “The longer you’ve been together, the harder it is to break up.”
Humans get caught in this psychological trap for several possible reasons, Olivola says. Sticking with the plan, even when it no longer serves you, could be an attempt to correct cognitive dissonance: the mental disconnect between paying for something and not getting the expected return on investment. It could also be a knee-jerk reaction to regret. Or, Olivola says, it could be an attempt to convince others, and ourselves, that we’re not wasteful.
“All of these things are irrational, in the sense that you should realize the money is gone,” Olivola says. “But I do think people do these things because they want to convince themselves that they’ve managed to recapture the loss.”
You still feel the guilt of “wasting” money even when it’s not your own. Olivola’s paper found that we “feel that need to honor other people’s sunk cost in the same way that you feel the need to honor your own” &mdash even if the person who paid the cost isn’t a close friend or family member. If you got sick on the day of a concert, Olivola’s research suggests you’d be just as likely to force yourself to go if a coworker gifted you pricey tickets as if you had bought them yourself.
To reach that finding, Olivola designed a series of experiments constructed to measure the extent to which the sunk cost effect would sway people to make hypothetical decisions. Nearly across the board, the results affirmed the existence and strength of the phenomenon, both as it applies to individuals and others.
In one scenario, people were asked to imagine that they were accidentally scheduled to take two trips &mdash one to Montreal, and one to Cancun &mdash during the same weekend, forcing them to choose one. When they were told one flight cost $200 and the other cost $800, people were significantly more likely to opt for the pricey trip &mdash even if they would have preferred the cheaper destination. This effect held true whether people imagined that they had booked the flights, or that friends had given them the tickets as gifts.
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Family therapy or family counseling is a form of treatment that is designed to address specific issues affecting the health and functioning of a family. It can be used to help a family through a difficult period, a major transition, or mental or behavioral health problems in family members (“Family Therapy”, 2014).
As Dr. Michael Herkov explains, family therapy views individuals’ problems in the context of the larger unit: the family (2016). The assumption of this type of therapy is that problems cannot be successfully addressed or solved without understanding the dynamics of the group.
The way the family operates influences how the client’s problems formed and how they are encouraged or enabled by other members of their family.
Family therapy can employ techniques and exercises from cognitive therapy, behavior therapy, interpersonal therapy, or other types of individual therapy. Like with other types of treatment, the techniques employed will depend on the specific problems the client or clients present with.
Behavioral or emotional problems in children are common reasons to visit a family therapist. A child’s problems do not exist in a vacuum they exist, and will likely need to be addressed, within the context of the family (Herkov, 2016).
It should be noted that in family therapy or counseling, the term “family” does not necessarily mean blood relatives. In this context, “family” is anyone who “plays a long-term supportive role in one’s life, which may not mean blood relations or family members in the same household” (King, 2017).
According to Licensed Clinical Social Worker Laney Cline King, these are the most common types of family therapy:
- Bowenian: this form of family therapy is best suited for situations in which individuals cannot or do not want to involve other family members in the treatment. Bowenian therapy is built on two core concepts: triangulation (the natural tendency to vent or distress by talking to a third party) and differentiation (learning to become less emotionally reactive in family relationships)
The 5 Biggest Mistakes Career Changers Make
As a career coach and a career reinventer myself, I can confidently say that changing your career to something that is more suited to your values, needs, skills, and interests, is doable today, even in these tough economic times. But to switch careers effectively and achieve a positive outcome, you need four things: clarity, courage, confidence, and competence. Without these, you’ll most likely struggle hard and fail. Further, there are core steps you must take to ensure you are emotionally, financially, and professionally ready for this next step and for the eight important stages that you’ll undergo.
Step one to successful career change is to take off your rose-colored glasses, and get hip to your own trip about what you’ve created so far, and how you’ve potentially contributed to the challenges you face. Start to hold yourself more accountable than ever before for what’s in front of you. If chucking your career is appealing, certainly explore career change, but make sure you take concrete steps necessary to avoid the five top blunders many experience. These missteps will wreak havoc on your life, relationships, health, your check book, and your future.
The 5 biggest mistakes career changers make are:
1) “The Pendulum Effect” – Running from your career because you've broken down in it
If you're struggling and you’ve waited too long to make change in your current situation, you’ve most likely grown to hate your job, or your colleagues, the work you do and skills you use, and you want to run as far away as possible. This was me 10 years ago – I really couldn’t stand what I was doing or who I was doing it for, so I ran to the farthest corner of the professional world I could find – marriage and family therapy. In hindsight, my training as a therapist was a fabulous endeavor for me (it gave me life-changing skills and experience that I use every day). But living the professional “identity” of a therapist as a career – and dealing as I did with the many dark sides of human experience -- was in the end not what I wanted. I needed a second reinvention to land on what truly worked.
The way out of this blunder is this: Don’t wait until you are desperately unhappy in your current situation to make change. And definitely don’t leap before you’ve improved your situation. Wherever you are today, reclaim your power in it. Make your situation better by repairing broken relationships, building more respect, finding your voice, growing our skills, and becoming more competent. Then, when you do leave, you’ll be able to achieve the next level of success and you’ll have made clear, rational decisions that will move you forward successfully. Running away will not solve your problems – they’ll just be repeated in the next career.
2) Not developing a sound a financial plan that will support your transition
Folks come to me wanting a career change, but have no available money – either in the bank or accessible through other avenues – to make change. They simply don’t know or haven’t researched how long their transition will take, and they don’t have funds to support them during the change. You can’t go from making $75,000 in one career to replicating that salary in a completely new career, without it taking time and effort. And you need outside help to make career change. Do solid research and explore your desired change with your accountant and financial consultant and experts in that career to understand clearly – without emotion and without a “build it and they will come” mentality – the financial requirements necessary to support you through what can be years of transition. If there’s no money available, wait until you can access some (earn more, borrow, use your bonus, etc.) or lower your expenses to sock away what you’ll need.
3) Glomming onto the wrong “form” of work
In deciding to make career change, you must first identify the “essence” of what you want. Questions you need to answer are:
- What skills and talents do I want to utilize?
- What business outcomes do I want to support?
- What type of people, environments and cultures do I thrive best with/in?
- Which values, standards of integrity and needs must be supported through this work?
- What types of challenges do I want to face in my work?
- What financial compensation and benefits are non-negotiable for me?
Once you’ve dimensionalized the “essence” of what you want, then you have to find the right “form” of work that fits you, your lifestyle and your needs. This is where folks trip up the most. Because you want independence, for instance, you might assume that running your own business is right for you. For thousands, it isn’t (read The E-Myth Revisited: Why Most Small Businesses Don’t Work and What To Do About It, by Michael Gerber, for more). Figure out exactly what living that career will demand, and make sure it’s what you want.
4) Not digging deep enough
Let’s say you’ve been in TV production for 10 years and you are hankering to move into teaching English. I’d ask you to explore deeply all the reasons behind your wish to teach. These may include wanting to bring your language skills forward, helping young adults become more successful, mentoring people to communicate more effectively, leaving toxic corporate politics behind, etc. Is a switch to teaching English truly going to bring you satisfaction, or can you fulfill these longings in a way that suits your needs without changing careers? Are you sure you’ll be happy with all the other professional dimensions involved with being a teacher? Make sure you’re not throwing the baby out with the bathwater.
Do as much research and exploration and dig as deeply as you can to determine what you want, and what you really want from this career change. Perhaps you don’t want a different career at all, but long to bring forward new aspects of yourself, your talents and skills. The question is: What professional identity will make you the happiest?
5) Giving up too quickly
Finally, failed career changes often involve throwing in the towel too quickly. You can’t make life or career change without significant effort, time, commitment, and usually some substantial money. I’m stunned when people expect major change to happen overnight – or within a few months. They’re so eager (or desperate) to leave behind what’s made them miserable, that they simply can’t tough it out long enough to get to the destination they want.
If recent studies are right, more than 80% of workers today want out of their jobs. It’s a phenomenon of epidemic proportion. If you want career change, get on a path to exploring it, but please do yourself a favor and avoid these top mistakes.
In the end, address your life and career change with eyes wide open, and with the seriousness, rigor and commitment it – and you -- deserve.
What burning questions do you have about making the career change you're considering? Share them here.
The issue: You have sex half as often, and it's twice the hassle.
"I like sex, I really do," sighs Allison Nelson of Portland, Oregon. "I just like sleeping more." You&aposre tired, you&aposre covered in slobber, and your spouse has suddenly transformed from Sexy Stud to Superparent.
Of course you&aposre in love, you&aposre just not in the mood for getting naked under the covers. Step one, says Lindquist, is to get in the mood. And the best way is to plan time for having sex. Sure, people joke about making dates for sex, but "remember, when you were dating, you did plan when you were going to have sex. You got ready for a night out and thought about it beforehand."
Just because you&aposre married doesn&apost mean you can&apost make a hot date. Get a sitter, shave your legs, and flirt a little.
As for increasing the frequency of sex on nondate nights, experienced parents recommend making sure your bedroom is baby-free at bedtime. "There&aposs nothing like rolling on top of a toy caterpillar that starts to play &aposTwinkle, Twinkle, Little Star&apos to kill the mood," points out Nelson.
How to Use Modern Psychology to Understand Romantic Love
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Romantic love is part ancient attachment system, part caregiving system, and part modified mating system. But it is much more than the sum of its parts. It is an extraordinary psychological state that launched the Trojan War, inspired much of the world's best (and worst) music and literature, and gave many of us the most perfect days of our lives. But romantic love is widely misunderstood, and looking at its psychological subcomponents can clear out some puzzles, and guide the way around love's pitfalls.  X Research source Haidt, J. (2006). The happiness hypothesis: Finding modern truth in ancient wisdom. New York: Basic Books.
The case study approach is particularly useful to employ when there is a need to obtain an in-depth appreciation of an issue, event or phenomenon of interest, in its natural real-life context. Our aim in writing this piece is to provide insights into when to consider employing this approach and an overview of key methodological considerations in relation to the design, planning, analysis, interpretation and reporting of case studies.
The illustrative 'grand round', 'case report' and 'case series' have a long tradition in clinical practice and research. Presenting detailed critiques, typically of one or more patients, aims to provide insights into aspects of the clinical case and, in doing so, illustrate broader lessons that may be learnt. In research, the conceptually-related case study approach can be used, for example, to describe in detail a patient's episode of care, explore professional attitudes to and experiences of a new policy initiative or service development or more generally to 'investigate contemporary phenomena within its real-life context'. Based on our experiences of conducting a range of case studies, we reflect on when to consider using this approach, discuss the key steps involved and illustrate, with examples, some of the practical challenges of attaining an in-depth understanding of a 'case' as an integrated whole. In keeping with previously published work, we acknowledge the importance of theory to underpin the design, selection, conduct and interpretation of case studies. In so doing, we make passing reference to the different epistemological approaches used in case study research by key theoreticians and methodologists in this field of enquiry.
This paper is structured around the following main questions: What is a case study? What are case studies used for? How are case studies conducted? What are the potential pitfalls and how can these be avoided? We draw in particular on four of our own recently published examples of case studies (see Tables Tables1, 1 , ,2, 2 , ,3 3 and and4) 4 ) and those of others to illustrate our discussion[3-7].
Example of a case study investigating the reasons for differences in recruitment rates of minority ethnic people in asthma research
|Context:Minority ethnic people experience considerably greater morbidity from asthma than the White majority population. Research has shown however that these minority ethnic populations are likely to be under-represented in research undertaken in the UK there is comparatively less marginalisation in the US.|
|Objective:To investigate approaches to bolster recruitment of South Asians into UK asthma studies through qualitative research with US and UK researchers, and UK community leaders.|
|Study design:Single intrinsic case study|
|The case:Centred on the issue of recruitment of South Asian people with asthma.|
|Data collection:In-depth interviews were conducted with asthma researchers from the UK and US. A supplementary questionnaire was also provided to researchers.|
|Key findings:Barriers to ethnic minority recruitment were found to centre around:|
|𠀱. The attitudes of the researchers' towards inclusion: The majority of UK researchers interviewed were generally supportive of the idea of recruiting ethnically diverse participants but expressed major concerns about the practicalities of achieving this in contrast, the US researchers appeared much more committed to the policy of inclusion.|
|𠀲. Stereotypes and prejudices: We found that some of the UK researchers' perceptions of ethnic minorities may have influenced their decisions on whether to approach individuals from particular ethnic groups. These stereotypes centred on issues to do with, amongst others, language barriers and lack of altruism.|
|𠀳. Demographic, political and socioeconomic contexts of the two countries: Researchers suggested that the demographic profile of ethnic minorities, their political engagement and the different configuration of the health services in the UK and the US may have contributed to differential rates.|
|𠀴. Above all, however, it appeared that the overriding importance of the US National Institute of Health's policy to mandate the inclusion of minority ethnic people (and women) had a major impact on shaping the attitudes and in turn the experiences of US researchers' the absence of any similar mandate in the UK meant that UK-based researchers had not been forced to challenge their existing practices and they were hence unable to overcome any stereotypical/prejudicial attitudes through experiential learning.|
Example of a case study investigating the process of planning and implementing a service in Primary Care Organisations
|Context:Health work forces globally are needing to reorganise and reconfigure in order to meet the challenges posed by the increased numbers of people living with long-term conditions in an efficient and sustainable manner. Through studying the introduction of General Practitioners with a Special Interest in respiratory disorders, this study aimed to provide insights into this important issue by focusing on community respiratory service development.|
|Objective:To understand and compare the process of workforce change in respiratory services and the impact on patient experience (specifically in relation to the role of general practitioners with special interests) in a theoretically selected sample of Primary Care Organisations (PCOs), in order to derive models of good practice in planning and the implementation of a broad range of workforce issues.|
|Study design:Multiple-case design of respiratory services in health regions in England and Wales.|
|The cases:Four PCOs.|
|Data collection:Face-to-face and telephone interviews, e-mail discussions, local documents, patient diaries, news items identified from local and national websites, national workshop.|
|Analysis:Reading, coding and comparison progressed iteratively.|
|𠀱. In the screening phase of this study (which involved semi-structured telephone interviews with the person responsible for driving the reconfiguration of respiratory services in 30 PCOs), the barriers of financial deficit, organisational uncertainty, disengaged clinicians and contradictory policies proved insurmountable for many PCOs to developing sustainable services. A key rationale for PCO re-organisation in 2006 was to strengthen their commissioning function and those of clinicians through Practice-Based Commissioning. However, the turbulence, which surrounded reorganisation was found to have the opposite desired effect.|
|𠀲. Implementing workforce reconfiguration was strongly influenced by the negotiation and contest among local clinicians and managers about "ownership" of work and income.|
|𠀳. Despite the intention to make the commissioning system more transparent, personal relationships based on common professional interests, past work history, friendships and collegiality, remained as key drivers for sustainable innovation in service development.|
|Main limitations:It was only possible to undertake in-depth work in a selective number of PCOs and, even within these selected PCOs, it was not possible to interview all informants of potential interest and/or obtain all relevant documents. This work was conducted in the early stages of a major NHS reorganisation in England and Wales and thus, events are likely to have continued to evolve beyond the study period we therefore cannot claim to have seen any of the stories through to their conclusion.|
Example of a case study investigating the introduction of the electronic health records
|Context:Healthcare systems globally are moving from paper-based record systems to electronic health record systems. In 2002, the NHS in England embarked on the most ambitious and expensive IT-based transformation in healthcare in history seeking to introduce electronic health records into all hospitals in England by 2010.|
|Objectives:To describe and evaluate the implementation and adoption of detailed electronic health records in secondary care in England and thereby provide formative feedback for local and national rollout of the NHS Care Records Service.|
|Study design:A mixed methods, longitudinal, multi-site, socio-technical collective case study.|
|The cases:Five NHS acute hospital and mental health Trusts that have been the focus of early implementation efforts.|
|Data collection:Semi-structured interviews, documentary data and field notes, observations and quantitative data.|
|Analysis:Qualitative data were analysed thematically using a socio-technical coding matrix, combined with additional themes that emerged from the data.|
|𠀱. Hospital electronic health record systems have developed and been implemented far more slowly than was originally envisioned.|
|𠀲. The top-down, government-led standardised approach needed to evolve to admit more variation and greater local choice for hospitals in order to support local service delivery.|
|𠀳. A range of adverse consequences were associated with the centrally negotiated contracts, which excluded the hospitals in question.|
|𠀴. The unrealistic, politically driven, timeline (implementation over 10 years) was found to be a major source of frustration for developers, implementers and healthcare managers and professionals alike.|
|Main limitations:We were unable to access details of the contracts between government departments and the Local Service Providers responsible for delivering and implementing the software systems. This, in turn, made it difficult to develop a holistic understanding of some key issues impacting on the overall slow roll-out of the NHS Care Record Service. Early adopters may also have differed in important ways from NHS hospitals that planned to join the National Programme for Information Technology and implement the NHS Care Records Service at a later point in time.|
Example of a case study investigating the formal and informal ways students learn about patient safety
|Context:There is a need to reduce the disease burden associated with iatrogenic harm and considering that healthcare education represents perhaps the most sustained patient safety initiative ever undertaken, it is important to develop a better appreciation of the ways in which undergraduate and newly qualified professionals receive and make sense of the education they receive.|
|Objectives:To investigate the formal and informal ways pre-registration students from a range of healthcare professions (medicine, nursing, physiotherapy and pharmacy) learn about patient safety in order to become safe practitioners.|
|Study design:Multi-site, mixed method collective case study.|
|The cases: Eight case studies (two for each professional group) were carried out in educational provider sites considering different programmes, practice environments and models of teaching and learning.|
|Data collection and analysis:Structured in phases relevant to the three knowledge contexts:|
|Phase 1: Academic context||Documentary evidence (including undergraduate curricula, handbooks and module outlines), complemented with a range of views (from course leads, tutors and students) and observations in a range of academic settings.|
|Phase 2a: Organisational context||Policy and management views of patient safety and influences on patient safety education and practice. NHS policies included, for example, implementation of the National Patient Safety Agency's Seven Steps to Patient Safety, which encourages organisations to develop an organisational safety culture in which staff members feel comfortable identifying dangers and reporting hazards.|
|Phase 2b: Practice context||The cultures to which students are exposed i.e. patient safety in relation to day-to-day working. NHS initiatives included, for example, a hand washing initiative or introduction of infection control measures.|
|𠀱. Practical, informal, learning opportunities were valued by students. On the whole, however, students were not exposed to nor engaged with important NHS initiatives such as risk management activities and incident reporting schemes.|
|𠀲. NHS policy appeared to have been taken seriously by course leaders. Patient safety materials were incorporated into both formal and informal curricula, albeit largely implicit rather than explicit.|
|𠀳. Resource issues and peer pressure were found to influence safe practice. Variations were also found to exist in students' experiences and the quality of the supervision available.|
|Main limitations:The curriculum and organisational documents collected differed between sites, which possibly reflected gatekeeper influences at each site. The recruitment of participants for focus group discussions proved difficult, so interviews or paired discussions were used as a substitute.|
Telepsychiatry: Practical Pointers and Potential Pitfalls
During the present COVID-19 pandemic, mental-health practitioners of all disciplines are becoming accustomed to a variety of telemedicine-enabled modalities for treatment and evaluation. A growing variety of telemedicine platforms are now in use. This development has produced an explosion of articles and other documents describing theoretical advantages and disadvantages of teletherapy in psychiatry and how it can best be carried out. 1-5 For more than a decade we have practiced with the assistance of telecommunication technology for patient and examinee accessibility. Based on our own and our colleagues experience with clinical and forensic telepsychiatry, what follows are some practical pointers and potential pitfalls for clinical and forensic practitioners.
The Practice Context of Telemedicine
Over the past several decades, rural health care delivery, the courts, and prisons have increasingly relied on telemedicine to accomplish their work. This modality has increased access to examinations and improved care by medical professionals in remote geographic communities. However, it took the pandemic of 2020—and the suspension of some governmental regulations until an emergency no longer exists—to increase significantly the use of telemedicine. In forensic settings, telelinks are now used even by judges conducting trials, as well as in forensic competency evaluations, independent medical examinations, and tribunal hearings for evaluating claims of physician liability.
It is clear by now that telelink-enabled clinical and forensic evaluations are here to stay, given their evident convenience and cost savings. This is especially true in the forensic context, where the examiner and examinee, having no ongoing local treatment relationship, may be located in different regions of the country, or the examinee may be incarcerated or otherwise immobile. Moreover, elimination of the costs of travel allows for more frequent (virtual) meetings with patients, who can more easily maintain attention and concentration in shorter sessions. These may include persons suffering from psychosis, severe anxiety, depression, dissociation, fatigue, and/or lack of self-integration. Such meetings may routinely be preferred because the absence of travel, parking, and security requirements allows for more flexible scheduling and time- and cost-effectiveness.
Nonetheless, the authors believe that insufficient attention has been paid to concrete structural and behavioral details of this form of psychiatric work. There are practical issues to keep in mind that can increase the efficacy of clinical and forensic telepsychiatry, and steer clear of common pitfalls. (Except where otherwise specified, the term “interview” is meant to apply to both clinical and forensic interactions.)
Setting and Structure
It is important to establish appropriate video and audio platforms and to allow time to ensure that the preparatory technological setup for the interviews is working adequately. (When the interview is on the court premises, the setting and technical apparatus are predetermined.) As to what technological complaints need to be addressed, some evaluators have noted that poor lighting is a concern. Dark shadows, for example, can interfere with clarity of the visual image. In addition, disruptions in the video feed may interfere with accurate evaluation of the patient for abnormal involuntary movements (the AIMS test) used to monitor long-term effects of neuroleptics. On another sensory dimension, the sense of smell obviously cannot be utilized on video calls. For example, the odor of alcohol may go undetected—a significant potential omission. This limitation may necessitate alternative means of gathering otherwise olfactory-dependent data.
In the current COVID-19 emergency, free video platform setups, which have received HIPPA-compliant waivers from the federal government, may be used. However, the manufacturers may set time limits for the sessions that can compromise the needed length of an interview. Additionally, technical difficulties such as bandwidth and the absence of timely technical assistance may interrupt the flow of the interview. Such interruptions, if not adequately prepared for, may compromise the interview and affect the process of therapy or the findings of a forensic examination.
In forensic evaluations, problems may arise with connectivity for the attorney and/or the judge. The greater the number of persons on the video link, the greater the opportunities for technical interruptions, particularly when trying to connect with WIFI and cell phones. Allow time at the beginning of sessions to test and correct any audio or visual problems and plan for augmented bandwidth.
For a clinical interview, all participants have a role in establishing the appropriate guidelines. To begin with, it is important to establish who will schedule the sessions and provide the formal invitation. Some parties may prefer to originate the telecall interview to feel more in control of the session process. Generally, it is the party that initiates the link that is responsible for whether or not that link is HIPAA-compliant. Some patients who initiate telecommunication will wish to waive any applicable HIPAA-compliance requirement for the comfort of using a more familiar telecommunication pathway of their choice.
The Visual Field
The visual environments of both parties can be expected to influence the dynamics of the interaction. While many interviewers practice in home offices, those are usually curated to some degree, with attention paid to the furnishings according to some concept of a professional space. 6 By contrast, when practitioners who have not already set up home offices find themselves unexpectedly working from home in the pandemic, they may be working in their lived-in home. Both information and misinformation may emerge from this reality.
For this reason, some clinicians and evaluators, especially those who are novices to home office practice, prefer a blank screen that will not show personal effects in the office space or provide any indications of the geographic area of the assessment. Such details may expose clues to the whereabouts of secure locations needed in domestic violence or custody cases. Other practitioners use a virtual background, which, while reflecting an aspiration to neutrality, may also contribute to an aura of unreality. An inauthentic background can reinforce an interviewee’s predisposition to view Shakespeare’s metaphor of “All the world is a stage” (in “As You Like It”) in concrete terms. By contrast, appropriate objects visible in the office, such as works of art, can prompt helpful associations in psychotherapy or psychodynamically informed forensic examination. Regardless of the distinctive features of an interviewer’s office, it is often better that the background be the interviewer’s own authentic office.
The visual field of online practice has a number of potentially limiting factors. Awareness of these potential pitfalls is a vital step in increasing the efficacy of such practice.
For example, while video makes it easy to observe facial expressions and register tone of voice, the lower body, sometimes from the neck down, often is not visible. Some body language and aspects of dress are thus unavailable. This potential limitation may be particularly problematic in custody evaluations, where full body choreography in family evaluations is sometimes essential. The presence of the family can be a positive part of an online evaluation. 7 However, if the interviewee is told to place him/herself far enough from the lens to permit such full viewing, facial expressions may be harder to see and the voice harder to hear. Varying the patient’s distance from the camera in the course of the interview is a potential remedial option when necessary.
Telepsychiatry may not be the ideal or exclusive modality for young children, especially when they are overactive to the extent it is difficult to keep their attention or capture their interactions within the screen. However, evaluations for attention deficit disorders may be successfully accomplished using telehealth. 8 The mindful observer may need to pay closer attention to information that may be more telepsychiatry-accessible, such as variation in eye movement, facial expression, and speech rhythm or tone, as well as to integrate this information into analysis of corroborative data.
In family evaluations or domestic violence screenings, it may help to visually take in the entire clinical gestalt of the family. Without an additional party running the cameras, many camera settings do not permit a full view of all parties at the same time. In such instances, more attention needs to be paid to the rhythm, timing, and tone of the family speech patterns. The visual gestalt may need to be further complemented by the auditory gestalt and corroborative data (eg, medical and school records, structured interviews, and psychological testing).
Time may also be a relevant consideration, especially if clinician and patient are in different time zones. Some patients, uncertain about their appointment time, may be confused if placed in a digital waiting area until the doctor is available. Because of the recognized intensity of such meetings and the need for particular focus and attention, the session may need to be divided into 2 or more such meetings to allow breaks for either party.
In working with developmentally disabled individuals, some evaluators find that the lag in digital savvy can be a major holdup in the evaluation process, particularly with a deficit in WIFI and the staff’s inability to correct deficiencies. At times, the video feedback may be so distorted that the evaluator cannot get enough of the expressive language clues to understand the problem. This is made even more difficult when the staff is new and unfamiliar with the parties being assessed. The collegial relationship and teamwork between staff and evaluator are critical factors deciding the quality of the examination, particularly in agencies with increased staff turnover. With these patients, it is best to have a team in place, including a behavioral clinician, a nurse, and family members. However, be aware that some family members will not agree to participate in video sessions.
Some of the problems that emerge from online observations can be grouped under the rubric of potential distractions for both interviewer and interviewee.
Recording the session, as well as providing a record of the interview, may increase performance anxiety and attempts to manage one’s impression, especially in forensic examinations or adversarial proceedings, in which the examinee and others (family, attorney) have a stake in the outcome. The same applies to having a third party (such as an attorney) present. The distorting effect of recording or third-party presence in both the clinical and forensic contexts has been well studied. 9-12 If such distortion is unavoidable (eg, by court order), special consideration needs to be given to minimizing it. In some states, such as Massachusetts, the recording of clinical interviews without permission of all parties is prohibited by law. 13
Some patients of all ages are more comfortable with audio transmission alone, as they are then less distracted by the close-up of the therapist’s face as well as their own. As in all therapy and evaluation, being aware and respectful of the wide range of individual variability, as well as of one’s own countertransference, is vital.
By contrast, the absence of the interviewer’s picture or the substitution of a photo for a live image may be experienced by some interviewees as inattentiveness or lack of interest on the part of the interviewer, much like analytic patients who cannot tolerate being unable to see the analyst. When an interviewer is aware of such a risk, asking the interviewee to describe their experience of the interview can be helpful.
The picture-in-picture effect may have several valences, pro and con. For some interviewees it is a potent distraction. For others it may convey the reassuring presence of the examiner and/or an intrusive pressure to influence behavior. Not using picture-in-picture, especially in forensic contexts, may decrease some interviewees’ less authentic tendency to play to an audience. Clinicians and forensic examiners likewise may be distracted by their own faces or facial reactions, splitting attention from the interviewee. Alternatively, some interviewers find it helpful to see themselves as the process evolves, perhaps detecting their own countertransference reactions (eg, blind spots) and distractions. An interviewer’s awareness of these effects can help support the therapeutic alliance or the validity of a forensic examination.
How Therapeutic Issues Can Manifest in Telepsychiatry
Sometimes it is difficult to distinguish between interruptions or distractions attributable to technical imperfections or mishaps and those that have a deeper dynamic origin.
Awareness of a potential distraction can turn a potential video call pitfall into a therapeutic insight. Exploring the meaning of telelink-enabled communications in the course of treatment can be helpful not only for avoiding telelink-related pitfalls, but also for furthering the therapeutic process itself.
Emergency Backups and Privacy
When the patient is present in one’s office, one always knows what local emergency services to call in, which is not the case when the individual is a distance away. In virtual sessions, it is still sometimes necessary to have an appropriate emergency support network and backup plan at the patient’s site. In the rush to adapt to telehealth, there is a risk of omitting this step. Thus, for new patients, for some ongoing patients when indicated, and in high-risk populations of forensic examinees, a risk assessment should be completed at the beginning of every session, along with the standard brief technical check-in (“How’s the WIFI? Can you see me, hear me okay?”). Since interviews may occur at some distance from the practitioner’s location, and may even cross state lines, the practitioner should obtain phone numbers of local emergency services, police, family members, or significant others to assist in times of crisis. When indicated, the availability of such resources should be assessed and documented.
When patients are at risk for emergencies, interviewers should know whether other parties are in the home or within earshot, and whether the session is being recorded. The use of HIPAA-compliant or -noncompliant telecommunications should also be identified. It is important to establish behavior limits, ensuring that the meeting is a safe time for communication without domination, bullying, or intimidation.
Clearly, family privacy rules need to be set early in treatment. The patient may wish to bring others into the session ideally, this would be discussed in advance. However, since the patient is already there, the opportunity for this step may be missed or scanted.
In addition, telepsychiatry poses some questions that the clinician or examiner needs to reflect upon, since a single size does not fit all patients or examinees nor is telepsychiatry any more of a rote diagnostic-checklist exercise than in-person psychiatry. How does the new remote distancing process affect people of diverse cultures? How is rapport established between parties to encourage truthful disclosure? These are questions that need to be considered early in the process. Clinicians should inquire about the patient’s or examinee’s comfort during the process.
Whenever possible, encourage patients to decide how and where the virtual interview will occur and proceed only with their agreement. They may have concerns about allowing someone into their home space for example, an interviewee may be self-conscious about the appearance of their home environment. Inquire about what other options may be available for the interview: is there private space in a library or other accessible public building? For individuals needing an interpreter, how is this use accounted for in the responses to questions? How does this affect the interview process?
It is essential to maintain a professional environment when working from home while connecting with the interviewee’s home space. Doing so requires an appropriate setting and attire, even if one is not fully visible to the patient. For example, interviewing from a bedroom or while wearing pajama bottoms is unwise.
It is the authors’ view that in some instances the casualness of the setting does present potential obstacles for maintaining appropriate boundaries, even when online. A messy environment in either the clinician’s or patient’s room may generate an atmosphere of laxity about the clinical work, leading to a loss of focus. On the other hand, with increased self-awareness and experience, a casual atmosphere can have the advantage of freeing all concerned from rigid formulations or habitual preconceptions.
Telemedicine is not the same as in-person visits. Some patients feel that some things have been lost, such as empathy and respect. The shift to a virtual environment has shocked some patients, and some claim that physicians are seemingly less available and less empathic about patients’ concerns. One person complained that physicians seemed to be keeping their distance—even when the office was back up and running with appropriate personal protective equipment. Another patient, who had undergone major surgery for cancer, recalled that when they arrived for a follow-up visit, the treating physician spoke from the doorway and never came into the examining room.
Has the patient-physician relationship suffered from this imposed distancing? Historically, it has been recognized that an emotionally vital and mutually respectful professional relationship between physician and patient offers some protection from lawsuits. The physician’s commitment to caring for the patient, even within the safe distancing of this pandemic, must be maintained.
Practitioners should pay attention to their own wellness. Clinicians have complained of increased eye strain, body stiffness, and fatigue during long stretches of time in front of monitors. It is prudent to build in time periods and techniques for recovery and replenishment. In addition, the telehealth mode can feel isolating compared to pre-pandemic, in-person practice. Clinicians should coordinate periodic consultation with colleagues and participate in clinical rounds so as to remain part of a professional community and maintain clinical and/or forensic acumen. Making one’s home office artfully and authentically comfortable can be beneficial as well.
During the COVID-19 emergency, usual restrictions regarding payment for services across state lines, regardless of licensure, have been relaxed. 14 However, this reimbursement process may change after the pandemic, as some private insurers indicate plans to limit coverage for virtual visits. 15 Therefore, it is important for all parties to be fully aware of their financial responsibilities for these arrangements going forward and to negotiate the finances thoughtfully. For Medicare and Medicaid patients, updated guidance is available on the website of the Centers for Medicare & Medicaid Services (CMS.gov). Patients who rely on third-party reimbursement should be advised to check with their insurance companies before proceeding with consultation.
Risk Management in Telepsychiatry
In 2011, Cash 16 wrote: “Telepsychiatry, if done well, can benefit patients. It also presents significant risks for the unwary.” Telling practitioners that a current practice modality is both non-uniform and actively evolving is not reassuring, but telepsychiatry has checked both boxes. Nonetheless, under pressure of the pandemic, telehealth is rapidly gaining greater acceptance and legitimacy, with consequent revisions in legal and regulatory frameworks. Although the subject is now extensively covered elsewhere, 17 a useful brief summary can be attempted here.
1. Standard of care. The issue of standard of care, a touchstone of malpractice claims, is surprisingly straightforward and broadly accepted. The standard for a telepsychiatric treatment or forensic evaluation is identical to that for the in-person equivalent. Documentation should note the limitations of this medium and what is done to minimize them.
2. Informed consent. Informed consent has acquired 2 different dimensions: the patient must consent to the use of telepsychiatry in the first place and further consent should be negotiated if either party wishes to record the session or have third parties present (with consideration of the problematic consequences of recording and third-party presence discussed above).
3. Interstate licensure. Up to now, at least, it has been good risk management for the clinician to know whether they need to be licensed, even temporarily, in the patient’s jurisdiction. For a patient in the same state, no matter how remote, this is not a problem, although one should inquire with one’s local licensing board as to any specific requirements for telepsychiatric practice. For a patient in a different state, that state’s licensing board needs to be contacted directly to establish 1) whether a local license is required or, in some cases, a temporary one and 2) whether any local regulations differ from those of the practitioner’s home state (eg, whether the Tarasoff warning is required). Seeing that state licensure requirements for forensic evaluations are met is the responsibility of the retaining attorney. In addition, the practitioner’s malpractice insurer should be asked whether coverage extends to such interstate practice.
In December 2020, the US Department of Health and Human Services (HHS) allowed health-care professionals to provide telehealth services across state lines, regardless of state and local prohibitions, both to ease access and to expand the range of telehealth services Medicare pays for during the COVID-19 emergency. Practitioners need to stay informed of developments in this area. In practical terms, however, with 43 out of 50 states having explicitly waived the state licensure requirement for telehealth practice in the current pandemic, 14 a few states’ medical boards’ delay in updating their regulations to accommodate the increasingly common practice of telepsychiatry will likely no longer be recognized as a legal prohibition.
4. Confidentiality and HIPAA. Questions involving confidentiality, as indicated in some of the case vignettes above, may be complex, with unexpected intrusions into the session and other leaks of confidential material that are far less likely to occur in the professional office setting. The platform used for telepsychiatry (Zoom, Skype, etc.) must be established as HIPAA-compliant and the patient/examinee so informed. The patient does have a right to waive that requirement.
5. Handling emergencies. As noted above, practitioners using telepsychiatry should establish a method of dealing with any emergencies that occur during a session. One approach is for the practitioner to become familiar with resources in the patient’s location and to negotiate with them in advance how emergencies will be handled. Another is to establish a collegial relationship with a local physician who can handle any needed physical examination, lab work, or emergency response. Note that many prescribing contexts require an initial physical examination. 16
6. Sharing uncertainty in the therapeutic alliance. Last but far from least, the therapeutic alliance is itself a cornerstone of liability prevention. Sharing clinical uncertainty, in both its cognitive and affective dimensions, with patients (and their families, when involved) strengthens the alliance and, with it, the patient’s resources for dealing with pandemic-compounded pain, fear, and grief. 18-20 This process is as essential and can be as effective in telepsychiatry as in in-person psychiatry. Given the perennial uncertainties of practice, now compounded by ever-changing clinical and legal standards, attention to unintended clinical iatrogenesis and legal harms, or “critogenesis,” is vital. However, a hyper-focus on legalisms to the detriment of good clinical care needs to be avoided. 21-22 Just as there are hybrid forms of education now in place during the pandemic, we anticipate that the future delivery of mental health care will continue to blend telehealth and in-person office practice.
The above summary is intended to alert practitioners to areas of risk for litigation in telepsychiatry. Local regulatory boards, malpractice insurers, and personal attorneys may be further resources for case-specific questions that arise.
Dr Norris is assistant professor of Psychiatry (part-time) at Harvard Medical School. She practices clinical and forensic psychiatry in Wellesley, Massachusetts. Dr Bursztajn is associate professor of Psychiatry (part-time) at Harvard Medical School. He practices clinical and forensic psychiatry in Cambridge, Massachusetts. Dr Gutheil has been faculty and staff at the Massachusetts Mental Health Center in Boston for half a century and is professor of Psychiatry at Harvard Medical School. Mr Brodsky is a writer who has coauthored numerous books and articles in the mental-health field. Drs Bursztajn and Gutheil and Mr Brodsky are co-founders and Dr Norris is a member of the Program in Psychiatry and the Law at Harvard Medical School.
1. American Psychiatric Association. What is Telepsychiatry? American Psychiatric Publishing 2017.
2. APA Committee on Telepsychiatry & APA College Mental Health Caucus. College mental health, telepsychiatry: best practices, policy considerations & COVID-19. American Psychiatric Association. Accessed January 18, 2021. https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/Telepsychiatry/APA-College-Mental-Health-Telepsychiatry-COVID-19.pdf
3. Sales CP, McSweeney L, Saleem Y, Khalifa N. The use of telepsychiatry within forensic practice: a literature review on the use of videolink – a ten-year follow-up. J Forensic Psychiatr Psychol. 201829(3):387-402.
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14. Federation of State Medical Boards. US states and territories modifying requirements for telehealth in response to COVID-19. Updated January 13, 2021. https://www.fsmb.org/siteassets/advocacy/pdf/states-waiving-licensure-requirements-for-telehealth-in-response-to-covid-19.pdf
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20. Gutheil TG, Bursztajn HJ, Brodsky A. Malpractice prevention through the sharing of uncertainty: informed consent and the therapeutic alliance. N Engl J Med. 1984311:49–51.
21. Gutheil TG. Legal defense as ego defense: A special form of resistance to the therapeutic process. Psychiatr Quart.197951:251–256.
Set aside time to regularly look at your money
In situations where you feel highly anxious, your body thinks that it needs to react to a danger immediately, so it goes into fight, flight or freeze mode. The part of your brain that handles cognitive function and allows you to analyze options and predict consequences "literally goes offline," Clayman says.
People tend to respond to this anxiety by either avoiding their finances altogether, or becoming obsessive about "fiddling with their accounts," she says.
It's important to schedule time to look at your money, so you can approach it in a "safer, more focused setting," Clayman says.
For example, choose an evening on a random weeknight to look at money, rather than waiting for high-stakes situations when you need to make a decision or when something is threatening your financial stability.
"Make that practice really simple," Clayman says. Choose three things to do each time you check in: For instance, review how your money is coming in and out, predict what expenses you might have coming up and make adjustments to prevent being reactive, she says.
If you're only looking at your money when you're anxious, then it reinforces the idea that "money is dangerous and we should be afraid of it, because every experience we have with money is negative," she says. But having scheduled "money time" can make you feel more secure that you've made the best decisions to reduce anxiety.
In fact, research has shown that increased financial literacy is associated with decreased financial anxiety. Once you get more familiar with the way that your money ebbs and flows, you'll be less surprised and anxious when it's time to check in, she says.
Eyewitness Testimony and Human Memory
The most important foundation for eyewitness testimony is a person's memory - after all, whatever testimony is being reported is coming from what a person remembers. To evaluate the reliability of memory, it is once again instructive to look to the criminal justice system. Police and prosecutors go to great lengths to keep a person's testimony "pure" by not allowing it to be tainted by outside information or the reports of others.
If prosecutors don't make every effort to retain the integrity of such testimony, it will become an easy target for a clever defense attorney. How can the integrity of memory and testimony be undermined? Very easily, in fact - there is a popular perception of memory being something like a tape-recording of events when the truth is anything but.
As Elizabeth Loftus describes in her book "Memory: Surprising New Insights into How We Remember and Why We Forget:"
Memory is not so much a static state as it is an ongoing process - and one which never happens in quite the same way twice. This is why we should have a skeptical, critical attitude towards all eyewitness testimony and all reports from memory - even our own and no matter what the subject, however mundane.