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American AcademY OF CLINICAL PSYCHOLOGY

PROFESSIONAL ARTICLES

  • 12 Sep 2019 7:09 PM | Anonymous

    Researchers at the Indian Institute of Science (IISc) have identified how a key midbrain region plays a vital role in attention in humans, using advanced imaging and modelling techniques.


    The human brain is constantly bombarded with information. It is through attention that it makes decisions efficiently: it processes relevant information and tunes out distractions. Understanding how attention works in the brain and how it controls behaviour can help scientists understand disorders such as Attention-Deficit Hyperactivity Disorder (ADHD), according to Devarajan Sridharan, Assistant Professor at IISc's Centre for Neuroscience and his Ph.D. student Varsha Sreenivasan, who recently published their findings in the Proceedings of the National Academy of Sciences.

    Attention is widely associated with the outermost layer of the brain tissue called the cerebral cortex, which is also linked to awareness, thoughts, memory, language, and consciousness. It is only recently that scientists began linking a midbrain region called the superior colliculus (SC) with attention.

    "SC is an evolutionarily conserved midbrain structure that can be found in all vertebrates, including fish, lizards, birds and mammals. It is usually studied for its role in controlling eye movements," explains Sreenivasan.

    To demonstrate its role in attention, scientists had in recent years studied behaviour in monkeys during attention-demanding tasks. They observed that the monkeys were attentive when the SC was stimulated and distracted when this part of the brain was silenced.

    But scientists were not sure how exactly SC promotes attention in humans: Was it focusing on the target visual stimulus over several others for decisions (increased choice bias) or was it enhancing the visual clarity of the target stimulus (increased visual sensitivity)? Bias- or sensitivity-mediated attention plays out in situations that require rapid and selective decision making, for instance, at a traffic signal.

    Consider this example: you are driving on a foggy morning and you stop at a signal. The signal appears green, but you are unsure. As you are in a hurry, your brain decides that it is green and you drive away. In this case, your choice bias towards the green signal is guiding your decision. In an alternate scenario, you see that the fog is lifting gently. You detect a flicker of the green light and you drive away. Here, your visual sensitivity towards the green signal increases, which then helps your decision-making process. While a few recent studies have made the case for SC's role in controlling choice bias, others have leaned towards visual sensitivity.

    To address this debate, in the current study, Sreenivasan and Sridharan conducted two sets of experiments in human participants, using non-invasive techniques. In one, they conducted a behaviour test on 22 participants, where they tracked changes in bias and sensitivity during attention-demanding tasks. In the second experiment, they studied the anatomy of SC in 82 participants, including the 22 tested earlier. Using an imaging technique called diffusion Magnetic Resonance Imaging (dMRI), and a 3-D modelling technique called tractography, they tracked white matter fibres in the brain connecting the SC with other regions, including the cortex.

    When they compared the results of the two experiments, they found that SC strongly connects with a part of the cerebral cortex called the parietal cortex, which has previously been associated with attention. They also show that the strength of SC-cortex connectivity can predict individuals' bias, but not sensitivity.

    "We also show that choice bias is stronger, on average, towards the right side of our visual field. Interestingly, SC connections in the cortex also mirror this asymmetry for bias, which further underscores the relationship between SC and bias," explains Sridharan.

    In the future, the team plans to study the activity of SC using a different imaging technique called functional MRI (fMRI) that can identify increased blood oxygen levels in areas of the brain that are activated during tasks. Sreenivasan adds, "Through fMRI, we will investigate if SC's activity correlates with behavioural measures of sensitivity and bias. Our approach can also help understand if SC-cortex connection asymmetries are predictive of certain kinds of attention disorders such as ADHD."

    https://medicalxpress.com/news/2019-09-midbrain-region-attention.html


  • 22 Aug 2019 7:22 PM | Anonymous

    The Centers for Medicare and Medicaid Services’ 2020 physician fee schedule proposed rule increases values and improves the coding structure for Health and Behavior Services.

    Practicing psychologists who help Medicare patients cope with or manage a physical health condition should see an increase in their 2020 payments for these services when billing health and behavior assessment and intervention (H&B) CPT codes.

    In a proposal released July 29, the Centers for Medicare and Medicaid Services (CMS) indicated that the agency has accepted recommendations presented by APA Services to increase the relative value units (RVUs) for H&B services. The proposal would raise reimbursement rates for H&B services to a level that is comparable to payments for psychotherapy services.

    This rate increase and other proposed payment policy and billing changes for health care services are included in the agency’s 2020 Medicare Physician Fee Schedule proposed rule.

    In addition to increased values for H&B services, CMS has proposed: 

    • Replacing the existing CPT® codes (96150-96155) for H&B services with new codes and updated descriptors.
    • Using a single, nontimed code to report H&B assessment (similar to CPT code 90791; Psychiatric diagnostic evaluation).
    • Making structural changes to codes that describe the primary or base service, and add-on codes to describe additional work and time beyond the primary/base service.
    • Increasing the units of time for reporting the base codes from 15 minutes to 30 minutes.

    CMS will announce final changes to 2020 values and CPT codes when it releases the physician fee schedule final rule in November. Implementation of the new codes and values will begin Jan. 1, 2020.

    “We are so pleased with the proposed changes to H&B codes,” says APA Chief of Practice Jared Skillings, PhD. “The proposal not only represents success in our ramped-up advocacy for reimbursement, but it also signals that CMS recognizes the value of psychologists’ expertise with patients who have a medical condition.”  

    These changes will expand access to psychological care for patients with a medical condition without a psychological diagnosis.

    Psychologists working in hospital-based consultation services and integrated primary care, among others, will be able to more accurately document and be fairly reimbursed for their work.

    Additionally, psychologists in private practice will now have more opportunities to provide and be reimbursed for working with patients with physical health conditions.

    CMS has not reviewed the H&B code set since 2002, when they were first established to reimburse psychologists for providing psychological services that help patients manage physical health problems. In 2017, CMS tasked the American Medical Association’s (AMA) CPT® Editorial Panel and Resource Based Relative Value Update Committee with reviewing and revising the codes. APA representatives and staff have been working with the AMA committees to advocate for fair and accurate updates to these codes.

    Resources, Next Steps and How to Get Involved

    As part of the rulemaking process, APA will complete its analysis of the proposed rule and submit a comment letter to CMS addressing the agency’s changes to the H&B codes and other relevant issues. Comments to CMS on the proposed rule are due Sept. 27.

    Email us if you have questions about the proposed rule and its implications. 

    Read PracticeUpdate to stay informed about changes to billing and reimbursement.

    Visit APA Services’ Reimbursement webpage for more information and resources on Medicare, codes and billing.

    In the table below you will find the proposed coding changes and updated work RVUs for the family of H&B codes.

    Proposed Revisions to Health Behavior Assessment and Intervention Services for 2020


    CPT® Code Code Descriptor Proposed wRVU

    Assessment Services

    961X0 Health behavior assessment, including re-assessment (ie, health-focused clinical interview, behavioral observations, clinical decision making) 2.10

    Intervention Services

    Individual Intervention
    961X1 Health behavior intervention, individual, face-to-face; initial 30 minutes 1.45
    +961X2 Health behavior intervention, individual, face-to-face; each additional 15 minutes (list separately in addition to code for primary service) 0.50
    Group Intervention
    961X3 Health behavior intervention, group (two or more patients), face-to-face; initial 30 minutes 0.21
    +961X4 Health behavior intervention, group (two or more patients), face-to-face; each additional 15 minutes (list separately in addition to code for primary service) 0.10
    Family Intervention (with patient present)
    961X5 Health behavior intervention, family (with the patient present), face-to-face; initial 30 minutes 1.55
    +961X6 Health behavior intervention, family (with the patient present), face-to-face each additional 15 minutes (list separately in addition to code for primary service) 0.55
    Family Intervention (without patient present)
    961X7 Health behavior intervention, family (without the patient present), face-to-face; initial 30 minutes 1.50
    +961X8 Health behavior intervention, family (without the patient present), face-to-face; each additional 15 minutes (list separately in addition to code for primary service) 0.54

    + indicates Add-on Code

    https://www.apaservices.org/practice/reimbursement/health-codes/medicare-reimbursement-psychologists?_ga=2.244261261.900611814.1569254001-424535628.1569254001

  • 17 Jul 2019 7:19 PM | Anonymous

    Cheri Marmarosh sheds light on a topic that is often overlooked.

    By Cheri L. Marmarosh

    I will never forget the words of wisdom Jack Corazzini passed onto me: “It is not what you do; it is what you do about what you do.” In other words, no matter what you say or what happens in the group, it is more important to address the impact of what follows after. You may think your intervention is on point, but you fail to realize it offends a group member. You may think that you are being empathic when you make a group-as-a-whole intervention, only to find out you disappointed someone who felt differently in the group. You may think you are reaching out to connect to someone in the group, but your words convey a microaggression. The truth is, we never know how our interventions in group will land. We hope for the best when we take risks and inevitably, we find ourselves tangled in ruptures.

    The individual psychotherapy literature has emphasized the importance of these ruptures in the alliance and their repair (Safran & Muran, 2000), and meta-analyses have revealed that repairing ruptures relates to positive outcomes in individual psychotherapy (Eubanks, Muran, & Safran, 2018). There are models addressing alliance ruptures, and clinical researchers have developed measures to assess ruptures and repairs through self-report and observer coding (Eubanks, Muran, & Safran, 2015).

    Interestingly, the importance of rupture and repair has not received as much attention in group work, although I imagine the number of ruptures and the importance of their repairs are significant in group therapy. Lo Coco and colleagues (2019) reviewed the literature and found only one study that examined patterns of alliance ruptures in group treatment (Watson, Thomas & Daffern, 2017) and no study that examined the repaired-rupture event as a predictor of treatment outcome in group therapies. Watson et al. (2017) explored the ruptures in the alliance in group therapy for sexual offenders in a structured group treatment program. Thirty group members (55.6 percent) reported a rupture in the alliance, and half of them reported that the ruptures were repaired. Interestingly, group members who perceived a non-repaired rupture reported less working alliance. This is an important study that links ruptures in group therapy to other curative factors in group treatment and encourages us to continue to explore ruptures in group therapy.

    Lo Coco et al. (2019) did a wonderful job reviewing the literature and giving examples of different types of ruptures in group therapy based on the work of Safran and Muran (2000). They describe two different types of ruptures: withdrawal ruptures, where members pull back and disengage after experiencing a rupture, and confrontation ruptures, where members directly express their anger or disappointment after experiencing a rupture. In addition to providing clinical vignettes of these ruptures, they describe what it looks like when the rupture is not resolved and when it is resolved. Reading the case examples is helpful, and it illuminates how critical it is for us to pay more attention to withdrawal ruptures that can be more subtle, especially in a group where there are many people interacting.

    When it comes to research, the authors suggest that research on alliance rupture-repair in group treatment is important and the area is wide open. We need studies to validate self-report and observer ratings of ruptures in group therapy. We also need studies that link ruptures and repairs to group process and outcome. Understanding individual differences regarding the types of ruptures and openness to repair is important as is researchers that examine leader effects. In addition, the authors suggest that we should address the complexity of group therapy, and we should rely on sophisticated statistical analyses in order to tease apart individual and group variability in alliance and outcome.

    Because ruptures and repairs are so important in group therapy, I am editing special editions devoted to this topic to further research and theory to help guide us. Thus, there has been calls for papers in The International Journal of Group Psychotherapy, the journal for the American Group Psychotherapy Association (AGPA) and Group Dynamics, the journal for Div, 49, for this special edition, and the deadline for submissions is Nov. 26, 2019, for both journals.

    For Group Dynamics, the special issue is for empirical studies (PDF, 83.6KB), papers that describe statistical methods specific to group research, manuscripts that illustrate psychometric assessment particular to group contexts and evidence-based case studies that meet the journal’s guidelines. Authors are encouraged to contact myself, Cheri Marmarosh, or the journal editor, Giorgio A. Tasca, to discuss the suitability of a potential topic for submission.

    For the International Journal of Group Psychotherapy, we are interested in theoretical and clinical papers that explore how ruptures and repairs in group therapy relate to trauma work, macroaggressions, reflective functioning, subgroups, leadership, attachments, and group process and outcome. Authors are encouraged to contact myself, Cheri Marmarosh, or the journal editor, Jill Paquin, to discuss suitability of a potential topic for submission. We hope you will consider submitting your work.

    References

    Eubanks, C. F., Muran, J. C., & Safran, J. D. (2015). Rupture Resolution Rating System (3RS): Manual. Unpublished manuscript, Mount Sinai- Beth Israel Medical Center, New York.

    Eubanks, C. F., Muran, J. C., & Safran, J. D. (2018). Alliance Rupture Repair: A Meta-Analysis. Psychotherapy, 55, 508519. doi: 10.1037/pst000018

    Lo Coco, G., Tasca, G. A., Hewitt, P. L., Mikail, S.F., & Kivlighan, D . M. (2019). Ruptures and repairs in group therapy alliance: An untold story in psychotherapy research. Research in Psychotherapy: Psychopathology, Process, and Outcome, 22, 58-70.

    Safran, J. D., & Muran, J. C. (2000). Negotiating the therapeutic alliance: A relational treatment guide. New York, NY: Guilford Press.

    https://www.apadivisions.org/division-49/publications/newsletter/group-psychologist/2019/07/ruptures?_ga=2.240650251.900611814.1569254001-424535628.1569254001

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