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So you’ve been married for many years, maybe you’ve had children, one or both of you work full-time, life is busy, schedules are hectic…where in the world do you find time for romantic sex? Maybe one of you is ready and willing to have sex at the drop of a hat but the other of you has become resistant to sexual intimacy and possibly even resents sexual advances. Maybe one of you thinks sex is a human need and insists on having sex or being sexual even though your partner is not interested. Maybe one of you sees sex as an obligation and puts up with it even though it’s not enjoyable. All of these are unwelcome but fairly common conditions in many long-term relationships and marriages. If your long-term marriage or relationship suffers from a lack of sexual intimacy right now, it doesn’t have to stay that way!

Having a great sex life over the long-term is certainly not a given. Like other aspects of a working and satisfying relationship, a happy and fulfilling sex life usually requires two ingredients: interest and a willingness to take care of this aspect of your relationship. If you’re avoiding sex and becoming tense just at the thought of working on your sex life, you’re probably wondering: how am I going to work on my sex life when I’m not even interested in sex? Here’s a suggestion if this is the case: rather than focusing directly on improving your sexual relationship, your energy might be better off focused on the overall quality of your relationship. When both members of a couple value a healthy and satisfying partnership, the sexual aspect of the relationship comes into perspective. The intimate connection two people have in a committed, long-term relationship fosters a happy sex life when it’s good and hinders it when it’s not so good. That much is fairly obvious, but what’s less obvious is the importance of sexual intimacy in creating a healthy and satisfying relationship. Especially when one person does not feel the need or desire to nurture this aspect of the relationship, the sexual nature of the connection gets lost and a good sex life doesn’t seem that important. So here’s a reminder: no matter whether you’ve been married 20 months or 20 years, sexual intimacy is an important aspect of a healthy and satisfying partnership.

If your long-term marriage or relationship suffers from a lack of passion and sexual intimacy, you and your mate are likely experiencing a less-than satisfying partnership. When this is the case, it may or may not be related to other issues in the relationship; but if there are other issues hindering your interest in sex and these issues are not being addressed, both members of the couple miss out on the opportunity for a great relationship. The overall quality of the relationship affects sexual intimacy and sexual intimacy affects the quality of the relationship.

The first step, then, in addressing this is determining whether you are actually interested in cultivating a better connection with one another as well as having a better sex life. When you are clear that you value these, moving forward in your efforts to take care of this aspect of your relationship becomes easier. Arranging to work with a couples therapist can be a great way to start the process because it gives you the opportunity to dedicate time each week to working on the relationship. Without that structure it is very easy to let time pass and continue with the status quo. If couples therapy is not an option, there are other venues to pursue such as services offered through churches or books that guide you in your thinking and actions you can take to move forward and enjoy yourself and your life partner.

For more specific advice on bringing more sex into your relationship, read 7 Ways To Get More Sex.

In high-conflict divorce it can be difficult for parents to make joint decisions regarding their children. When parents seem more invested in winning the conflict than in finding resolution for the sake of the child, it’s time to consider a Parenting Coordinator (PC). The PC is appointed by a judge who believes that a trained professional is needed to minimize conflict in a particular case. This helps protect the child and keep courtrooms clear of parental battles. It also means that attorneys do not have to participate in hostile disputes over parenting conflicts, and can focus on their job while letting the PC handle the tasks involved in helping the clients make certain decisions. The role of the PC is to identify disputed issues, reduce misunderstandings, clarify priorities, and help the parents develop skills around communication, negotiation, and compromise. If the parents are unable to come to an agreement about an issue then the PC has the legal authority to make the decision for them. The court document appointing the PC makes it clear to all parties in what areas the PC is allowed to make decisions. PCs must comply with the court’s decision about custody, visitation, and guardianship, and they may not make financial decisions. PCs are licensed mental health professionals and attorneys with at least a master’s degree and several years of post-degree experience in their fields, have undergone PC training (which involves education about pertinent legal and psychological components of high-conflict divorce), and are involved in ongoing PC education and peer supervision.

Though the PC role was created back in the early ‘90s, many but not all states, and many but not all NC counties, make use of PCs. Why? There are some understandable concerns involved with appointing a stranger to function as an arm of the judge. First – why would a stranger be better able to make decisions for the child than the parents? PCs are appointed only when the level of conflict is so high that decisions are not getting made and the child is suffering. It is reasonable to think that a third party with some expertise in the area of child development, negotiation, and decision-making, whose only investment is to decrease hostility and do what is best for the child, will be a competent arbiter if they end up having to make the decision. While parents may sometimes be concerned about loss of control, using a PC effectively can actually help parents have more control. A PC is brought in when the situation is already out of control. They work with the parents to identify problems, communicate about them in healthy and effective ways that decrease hostility, and problem-solve. Parents who are using PCs effectively will learn skills so that they can work problems out together in the future, without the help of a PC. Or, if one or both parties don’t learn these skills, they have the PC who can make a decision and bring resolution to topics. Sometimes parents are worried that using a PC will be inconvenient and that they will have to have regular meetings with their ex-spouse. In reality, PCs are able to do the work mostly over the phone and email on an as-needed basis, so actually PCs make the process far more convenient than arguing with each other ad nauseam or going to court to have the judge make a ruling. This brings us to another concern that sometimes prevents courts from utilizing PCs – cost. Parents pay for PCs and it is not reimbursed by insurance. However, the cost of a PC still is far less than the cost of engaging attorneys to battle over the minutia of daily parenting, or going to court when you factor in attorney fees, legal fees, and time taken off work.

The benefits of using a PC are significant. First of all, it keeps the child in focus and not only gets big and small decisions made for the child to keep their life keep running as smoothly as possible, but also helps create an emotionally healthy family environment for the child. Far too often in high-conflict divorces the child gets caught in the middle. Low parental conflict is one of the primary determinants of a positive outcome for a child, meaning it contributes to the likelihood that the divorce will not be a damaging factor in their mental and emotional development. Decreasing hostility improves the parents’ lives too. Feeling provoked, dreading interactions, anticipating angrily or with fear – all these contribute negatively to a person’s mental and physical health and interfere with people being the parent they want to be. In addition to teaching communication and negotiation skills, the PC acts as a buffer so parents don’t antagonize each other as much and can more easily get to a place where they start to feel peace in their lives.

In fact, “peaceful” is one of the most-used words we hear our PC clients use to describe life after having an effective PC in place. It’s not all rosy all the time after a PC, but the landscape changes significantly from daily or weekly negative interactions between parties, to a primary state of calm. This comes about by having a trained professional  – the PC – who keeps the child in focus while having everyone’s best interests in mind, teaches co-parenting skills, and is able to make neutral decisions if needed.

It is a challenge understanding every aspect of one’s own culture and background, let alone someone else’s. Yet it behooves couples to understand how each other’s upbringing has shaped their lifestyle, worldview, and decision-making. While it is more obvious that partners from different cultures have cross-cultural differences, even with couples of the same culture there is no assumption that their internalized cultural systems are the same, since one’s culture includes the total of the inherited ideas, beliefs, values, and knowledge of one’s environment. Thus, far beyond country, which people often think of when identifying a person’s culture, our internalized cultural systems are influenced by region, socioeconomic status, race, religion, education, work, and even our own parents internalized systems. Additionally, with the internet and mass media, cultural influence is no longer limited by distance and cultural boundaries are hazy, permeable, and complex. Through discussion and reflection, couples can be become mindful of all aspects of the world they grew up in, the systems that influenced them, and how they bring that into their relationships. The following exercise can help couples be more mindful of all the ways their cultural systems influence their relationship:

There are several cultural systems that influence all of us: geographic location, socioeconomic status, religious/spiritual influences, family (ancestral influences, current family dynamics), media, educational opportunities, and historical/current events/politics.

For each of the cultural systems (geographic location, SES, etc.), ask yourself these five questions about each area and then have a discussion with your partner:

• What do I believe about myself?
• What do I believe about others?
• How is my behavior influenced by this?
• What judgments do I have about myself and others?
• How does this particular cultural system influence my relationship?

For example, what do I believe about myself based on the type of media I’ve been exposed to? Perhaps you realize you are heavily influenced by the standards of beauty represented in magazines and that your confidence is closely tied to physical appearance. Now how do you think that could be influencing your relationship?

Some of these may be tough to answer, especially because you may learn something about yourself you never knew. But that doesn’t have to be a negative experience. Self-awareness is healthy, even if it may be painful. You can even have fun with this exercise and make it into a game with your partner and reward each other for the new things you learn.

Over the past few years, we’ve noticed an influx of people coming for therapy or evaluations that have undergone recent immigration experiences. Most are recent refugees forced to flee their homes, lives and loved ones due to overt persecution. Some have chosen to come to the States in order to work towards an improvement in life quality. There are significant challenges that many of these people face, and our being sensitive to these challenges can help foster a more supportive, transformational relationship during such a critical time in their lives. These sensitivities can be shared by therapists, evaluators, attorneys, medical professionals, and others looking to assist recent immigrants. What follows are ways in which I prepare for meeting with immigrant clients in order to best serve them. We generally see a lot of clients looking for an evaluation that supports their asylum or residence status, the most common example being someone who has come to the states seeking asylum due to persecution in their home country. An evaluation of their trauma symptoms and diagnosis, and resultantly the anticipated effects should they be denied asylum, can be of great benefit to the court in understanding the complexities of the case.

Probably the most important factor in working with this population is to strive towards what I call “cultural humility,” or the sense that this person’s heritage informs their experience (and experience of me) in a way that I can’t really understand without hearing from them. This involves acknowledging that their experiences of our society and our interactions are grounded in assumptions that I likely don’t fully grasp. My intention then is to humbly acknowledge this lack of understanding, and attempt to get a sense of these assumptions through them. My hope is to be informed enough about their culture prior to the first meeting to ask the proper questions of them to get an understanding of what it might be like for them to sit with me. By exploring their assumptions about helping relationships, gender roles, vulnerability, etc., I’m more able to accurately assess where they are. This also allows me to see them as an individual rather than a stereotyped personification of their culture of origin.

Another salient issue, especially with recent refugees or those who have witnessed heinous traumas, is the effect the trauma can have in their telling of their story. Many people have come into my office too flooded with emotion to share the violence they’ve witnessed, instead deferring to loved ones or translators. My approach in these cases is to ground them in the present moment, either by having them explore their environment (i.e., “find me 3 blue things in this room”) or their breath. The best breathing technique I’ve found is the 3-6-9 breathing space in which I ask them to slowly count to 18 while inhaling for the first 3 counts, holding the air in their lungs for a count of 6, and using the final 9 counts to slowly exhale. This regulates the nervous system while giving them something to gently focus on (the counting).

I also like to encourage clients to maintain as much contact as is possible with their country of origin. There can be a tendency to want to create an artificial boundary between life here and the one they left behind as processing both the feelings of leaving behind a home country as well as thinking about cultivating a life here can be overwhelming. However, I often encourage people to maintain their network of support, even if those people are across an ocean.

Finally, I do my best to find resources for people. They may need help in finding a translator, food, a therapist who speaks their native language, transportation, etc. Helping people discover the resources potentially available to them will help them feel empowered in a situation in which they generally have very little power.

An immigration experience, especially one precipitated by persecution or trauma, is a jarring, life- and identity-altering experience. Being in a helping relationship with someone in such a critical and sensitive life period can be a powerful experience. To do so requires sensitivity, humility, and a heightened empathy towards the specific situation of the individual. This ideally fosters an environment in which I can readily and quickly provide information which will be helpful to the court.

Cooperative Parenting and Divorce:
Part I: Why and How to Keep the Child in Focus

Nobody gets married thinking they’re going to divorce even though the statistics are fairly well-known: in the United States forty percent of all first marriages, sixty percent of all second marriages, and seventy-three percent of all third marriages end in divorce. Half of all children living in the U.S. will experience their parents’ divorce; half of those will witness a second one. Studies on children of divorce show that they tend to have lower grades and a higher school dropout rate than children whose parents are still together, they struggle more with peer relationships, are much more likely to need psychological and substance abuse services, and as adults are almost twice as likely to attempt suicide. It is important to note that the divorce itself is not the sole contributor to these statistics, and rather it has been found it is high conflict co-parenting and loss of attachment to a parent as a result of divorce that causes these grim statistics.

If you have chosen to divorce it’s normal to feel anxiety, guilt, and sadness as a part of your parental grief process. Your children will be grieving too, and arming yourself with some information to guide your decisions in this process is critical. The information in this article is intended to help you improve the possibility of positive outcomes for your child if you have decided that divorce is what you need to do.

Knowing some basic concepts about children and divorce can help you navigate this time in your life during which you might feel like you have to figure out how to do everything differently. There are a few factors that contribute to how well a child fares after a divorce. The best predictor for long term injury to a child in divorce is the intensity and length of hostility between the parents. Fortunately, this is the one variable you can control – with cooperative parenting skills.

First we must understand why parental conflict is so destructive to a child’s foundation. They see us as their protectors who have total control. If we are out of control during conflict and unable to do our job of protecting them, the child will feel overly vulnerable and alone. This is frightening for a child, for as much as they want to prove their independence they understand they can’t actually fend for themselves and they need their parents to survive. A deep fear of abandonment will likely be heightened when parental conflict includes putting down the other parent in front of the child. Children see themselves as half of each parent, so when one parent vilifies the other, the child can feel vilified as well. If they hear the message that the other parent is not worthy of love or respect, they will fear that they themselves aren’t either. This can be especially damaging if the vilified parent is the one they identify with the most (usually the same-sex parent but not always). Anything that threatens their relationship with the two people whose job it is to protect and provide for them weakens their foundation and chance to build a strong self-concept and self-esteem. Additionally, children learn the skills modeled for them at home so as much as possible you want to model healthy and effective communication skills with their other parent.

Cooperative parenting during and after divorce can be challenging. You’re dealing with a lot of changes within your own relationship to your child’s other parent, there may be changes to some of the relationships with friends and family, you’re trying to forge a new life for yourself… all while striving to maintain a stable and happy environment for your child. Since you love your child and want to make decisions that give them the best chance for a healthy experience with your divorce, this guiding question can be a good start to helping you decide what to do at any given point: Is this choice I’m making right now keeping my child in focus (i.e. aimed at creating stability for them, modeling skills I want them to develop, decreasing the hostility between me and their other parent, and increasing healthy relationships with both of us?). So whether that choice is to yell at the other parent or stay calm, speak poorly or well of them to your child, or agree to change next week’s schedule or not, take a pause and a breath and ask yourself that question before taking action.

As an attorney there may be times you have to interview a child. Understanding some general helpful strategies as well as basic developmental tendencies about different age groups can help you decide how to conduct an interview with a child.

No matter the age or developmental stage, kids often are not forthcoming when it comes to talking about themselves, especially difficult things. Compounding this normal reticence, they may clam up because they don’t want to hurt one of their parents or get someone in trouble. Or they may fear getting in trouble themselves. You can improve their willingness to be forthcoming by how they are prepped for the interview. Give the adult who will bring them to the interview these instructions: “Please do not coach the child to say certain things during the interview; coached children sound coached. Also, coaching tends to make children experience anxiety about the interview as they worry if they will remember what the “right” thing to say is, and coached children often experience anxiety, fear and/or depression after the interview as they question if they “performed correctly” in the interview. The best way to prepare a child for the interview is to say, “A team of professionals are helping me/us to make decisions and come to agreements; these people have helped lots of people who go to court. You are an important part of this family (or this issue), and so one day you are going to go and talk to one of the people on the team. All you have to do is be honest and say whatever you know, think or feel, and there are no right or wrong answers.”

How you introduce yourself and the interview is important as well, and being forthcoming yourself is a good start as it engenders trust. Explain to the child that while it is important to be open and honest, what he/she says will not be kept confidential, however, honesty is important as this is an opportunity for the adults to hear what the child knows, thinks and feels. Assure the child there are no right or wrong answers. Environment is key as well. Make the interview environment neutral, reassuring, and child-friendly. They are more likely to open up when things feel safe and casual. This may be a difficult situation to arrange when you have a formal meeting time in a formal setting and it’s your first (or only) time meeting them, but your attitude can go a long way. Without being disingenuous, try to create a relaxed atmosphere. If possible, engage the child in an age-appropriate activity to decrease the pressure and allow them to relax and open up. Different activities will appeal to different children so it’s a good idea to have a few choices on hand – crayons, cards, dolls or action figures, and carefully selected board games that allow conversation to occur are good materials to have when interviewing a child. The child’s parent can generally bring something that the child is typically happy and comfortable doing. For young children, having their comfort-related stuffed animal or blanket to hold is a good idea.

Remember your goals. It isn’t to resolve a problem, make the child feel better, or even provide answers for the child. Your goal is to get information from them – facts and subjective experience – and this will entail allowing them to show difficult emotions without you trying to quell them. Let them have and share their feelings. Along these lines, empathize with the child if you notice he or she is feeling anxious about the interview. It can help the child feel safe and understood and set the stage for good rapport. A nonjudgmental attitude is critical to the interview process, no matter the age of the child or the situation. Children can often have allegiances that are unexpected for the layperson, and perceived negative judgment from an interviewer toward the person they are protecting can quickly curtail an interview. Or, if you show positive judgment there is the inherent threat of negative judgment, and it might influence the child to try to give the “right” answers to continue to please you. Staying neutrally supportive is a no-fail strategy. Along these lines, avoid starting questions with “why” as the connotation is one of negative judgment (“Why did you/didn’t you, or why did or didn’t someone else…” = [you/they screwed up]). Try replacing “why” with “what made you/led you to -” and “what kept you from -.” Have an attitude of respect and genuine curiosity, as this will prevent judgment and be evident to the child in your nonverbals.

If time allows you should start with more casual questions unrelated to the (possibly traumatic) event for which you”re meeting with the child. A few get-to-know-you questions that allow you to share some light information about yourself to join with the child can be helpful in building rapport and creating a comfortable, safe atmosphere (“What’s your favorite television show? That’s one of my favorites too. Which character do you like the best?”). It can also be a casual jumping off point for conversation more directly related to the precipitating issue (“Oh, you like the dad in the show. How is he like/different from your dad?”). Ask nonsuggestive questions (“What happened next?” instead of “Then did she hit him?”) to avoid leading the child into making inaccurate statements. Generally, use open-ended questions to explore who, what, where, when, and how. Open-ended questions or statements (“What’s a typical day like for you?” and “Tell me more about…”) can be less intimidating and elicit more information than closed questions (“Do you always eat dinner?” and “Does Mommy ever leave you alone at home?”). If the child continues to be reticent with such questions you could try to increase their comfort level by asking questions that are still open-ended but require less of an answer from them (“What’s your favorite food?” “Tell me something you like about going to your friend’s house.”).

Sometimes open-ended questions can result in eliciting vague or little information. Structuring statements can help with this (“You said that your dad was mean to you. Can you tell me more about how he was mean?”) as well as prompts and probes (“Did something happen in the store? Tell me everything that happened there.”).

Letting children know that they are allowed to say they don’t know an answer or don’t understand a question can decrease the possibility of eliciting inaccurate information. Beware of yes/no questions, especially in the beginning of an interview – they are not only restrictive but can establish a culture of brevity within the interview. Also, young children are likely to answer affirmatively in an effort to please the interviewer. Avoid compound questions that ask two things at once (“How do you feel about your mother and your father?” and “How did you get to the party and what did you do when you got there?”). In general, ask succinct questions to decrease the chance of confusing or intimidating the child. Also avoid coercive questions (“Are you sure?”), which implies that the chil’’s first answer was faulty. Similarly, questions like “Is that all?” suggest to the child that they didn’t give you enough and they might feel compelled to give more, even if it’s not true. Pay attention to silences – what they mean from the child and what they might imply to him. Is the child being silent because he’s done talking or because he’s thinking? Is she feeling anxious in this silence? Asking the child if she wants to think more about the question or come back to that topic can be helpful. You could also elicit important information by asking about an anxious silence without forcing him to answer the question: “Can you help me understand why school is so hard to talk about?” or “I wonder what you’re feeling now?” Reflective statements (checking in about emotion), paraphrasing (checking in about brief content) and summaries (checking in about larger pieces of content) can help keep everyone focused and clarify information.

Sometimes children seem to contradict themselves and it might feel hard to address this in a way that doesn’t sound judgmental or chastising. Gentle, curious language here is key: “Earlier you said you love your mom but then you said you didn’t want to visit her. Help me understand/tell me more about that.”

Allow for flexibility in the interview. Know the basic pieces of information you want to explore and then as much as possible go where the child goes in the conversation. If you have fifty specific questions you want to get answered in one meeting you may end up sitting with a clammed-up kid and a blank notepad.

Regardless of age, children want to feel respected, valued, and heard. No matter what tips or techniques you follow, a child will know through your nonverbals if you are coming from a place of interest, caring, and respect. Pay attention to what your body language and facial expressions are conveying and avoid distracting mannerisms.

The above general guidelines sometimes need to be refined for a particular developmental level. For instance, you are more likely to suggest a game of Go-Fish to a five year-old than to a sixteen year-old. In fact, for a mature adolescent you may choose to forego the games completely and find another way to create a safe, comfortable atmosphere – perhaps just through honest conversation and treating them as an adult. In general, the younger the child the more they communicate through their bodies, play, and art.

Three to five year-olds tend to be the most suggestible and most likely to try to comply with adult requests, so avoid leading questions. They are likely to have trouble sequencing events and can confuse fantasy with reality. Their tendency towards black-and-white thinking affects their view of events as they are more likely to see people as all-good or all-bad. Their egocentric minds might assume others know what they’re thinking so you may need to encourage elaboration with this age group. Use short, concrete, probing questions to help them expound upon their account and internal experience. Engage the child in play or art.

Six to eleven year-olds are more able to verbally share their internal and external experience and show some more logical thinking about it. They understand cause and effect better. They are more able to see the greys in life and understand social inconsistencies. However, they also are more aware of social norms and mores and tend towards rule-bound reasoning. This gives rise to strong feelings and beliefs around fairness. In addition to the general suggestions above, engaging the school-age child in a structured game may help build rapport.

Teenagers are even more capable of complex thinking around relationships and cause-and-effect. They can provide more accurate information about their thoughts, feelings, and experiences than younger children. As adolescents move closer to adulthood they may have a greater need for feedback that what they say is important to the interviewer. They are also more likely to have a greater need for privacy, so being clear about confidentiality (including limits) is important.

Studies show that using culturally appropriate eye contact, minimal encouragers (uh huh, go on), demonstrating appropriate empathy, and not interrupting the child help them open up more. And of course after helping them open up you want to appropriately close the interview so that they’re not left feeling vulnerable and alone. At the end of the interview, give them age-appropriate information about what happens next, ask them to share questions or concerns, and thank them for talking with you.

Ever look at the list of tests used in a psychological evaluation, risk assessment, or custody evaluation and wonder what exactly these tests are supposed to test for? When thinking that a psychological evaluation of your client, or the other party, may be helpful to your case, ever wish you knew more about what tests might be given? While many if not most evaluations do not include a description of tests used, at Lepage Associates we think it is helpful for the readers to understand more about the tests used and thus we include a description of all tests used on every evaluation we do. Read on to find a description of some of the most common tests used in evaluations. You will find a sampling of some of the most common cognitive, self-report, and projective tests. (This is just a sample; other tests are available. We are always happy to chat with you on the phone to help determine what could be beneficial to your case.)

Cognitive tests are assessments of capabilities. Examples include IQ tests, achievement tests, and tests of executive functioning. In addition projective tests may provide information on a person’s cognitive processes.

Self-report tests are a useful adjunct to interviews alone. Such measures are widely recognized among clinicians and evaluators as a means to collect information that may not be openly admitted except through a self-report method, as people can sometimes be more hesitant to be open in a face-to-face interview format. Self-report measures are also an efficient and organized way to ask questions and elicit answers regarding one’s perception of their own psychological and interpersonal functioning. Validity scales in the more sophisticated self-report tests also serve to provide information on whether a person is trying to fake good or fake bad in testing.

Projective tests are  tests in which the test taker ‘projects’ his or her personality onto provided stimuli, and as such are a useful adjunct to interviewing and self-report tests. Designed to let a person respond to ambiguous stimuli, the person has to organize the situation, and must utilize their characteristic disposition, i.e., their personality, to respond. Projective tests are widely recognized among clinicians and evaluators as a means to learn information about a person’s personality patterns that may not be openly provided as direct information by the client.

The Wechsler Memory Scale, Fourth Edition (WMS-IV) is an individually administered battery designed to assess various memory and working memory abilities in individuals ages 16-90. In addition to the assessment of memory functioning, the WMS-IV contains a brief evaluation of cognitive status. The WMS-IV provides a detailed assessment of clinically-relevant aspects of memory functioning commonly reported in individuals with suspected memory deficits or diagnosed with a wide range of neurological, psychiatric, and developmental disorders.

The Wechsler Adult Intelligence Scale, Fourth Edition (WAIS-IV) is used to assess the general thinking and reasoning skills of persons aged 16 years and older. This test has five main scores:  Verbal Comprehension score, Perceptual Reasoning score, Working Memory score, Processing Speed score, and Full Scale score. The Verbal Comprehension score indicates the level of skill in understanding verbal information, thinking and reasoning with words, and expressing thoughts as words. The Perceptual Reasoning score indicates the level of skills in solving nonverbal problems, sometimes using eye-hand coordination, and working quickly and efficiently with visual information. The Working Memory score indicates the level of skill with attention, concentration, and mental reasoning. This skill is closely related to learning and achievement. The Processing Speed score is a measure of skill with speed of mental problem-solving, attention, and eye-hand coordination. This skill is important for reading, and being able to think quickly in general. The Full Scale score is derived from the combination of the Verbal Comprehension, Perceptual Reasoning, Working Memory, and Processing Speed scores. The WAIS–IV Full Scale score is a measure of overall thinking and reasoning skills.

The Wechsler Intelligence Scale for Children (WISC-IV) is a self-report test which assesses the same constructs and dimensions as the WAIS-IV; however, it is normed for persons ages 6 to 16. The WISC-IV provides the same composite scores as the WAIS-IV (Verbal Comprehension, Perceptual Reasoning, Working Memory, Processing Speed, and a Full Scale IQ score), though the subtests are slightly different. The WISC-IV is generally utilized to get a nuanced understanding of a child’s cognitive abilities and can inform treatment plans. In the fall of 2014, an updated version, the WISC-V, will be released and considered the current test.

The Wechsler Preschool and Primary Scale of Intelligence, Fourth Edition (WPPSI-IV) is used to assess the general thinking and reasoning skills of persons aged 2 years, 6 months to 7 years, 7 months. This test has four main scores: Verbal Comprehension, Visual Spatial, Working Memory, and Full Scale score. The Verbal Comprehension score indicates the level of skill in verbal concept formation, verbal reasoning, and knowledge acquired from the environment. The Visual Spatial score indicates the level of skill in organizing visual information, part-whole relationships, attending to visual detail, and visual motor integration. The Working Memory score indicates the level of skill with attention, concentration, and mental reasoning. This skill is closely related to learning and achievement. The Full Scale score is derived from the combination of the other three scores. The WPPSI–IV Full Scale score is a measure of overall thinking and reasoning skills. In addition to these four scores, three ancillary indexes are provided. These include Verbal Acquisition, Nonverbal Index, and General Ability. These scores further analyze various skills while accounting for other areas of functioning to provide a more comprehensive picture.

The Adult AD/HD Self-Report Scale (ASRS-v1.1) is a Symptom Checklist consisting of the eighteen DSM criteria. Six of the eighteen questions were found to be the most predictive of symptoms consistent with AD/HD. These six questions are the basis for the ASRS v1.1 Screener and are also Part A of the Symptom Checklist. Part B of the Symptom Checklist contains the remaining twelve questions.

The Adaptive Behavior Assessment System (ABAS-II) is a caretaker report assessing numerous skills and behaviors contributing to an individual’s functioning across a variety of areas which impact day to day living. The assessment provides four composite scores: Conceptual Composite, Social Composite, Practical Composite, and General Adaptive Composite. The assessment measure is used to identify life and self-care skill deficits that may need to be addressed to improve overall functioning.

The MMSE-2 (Mini-Mental State Examination) is the most widely used cognitive status exam. The MMSE-2 is a brief assessment of cognitive impairment that can be used to track patients’ progress over time, to screen large populations for cognitive impairment, and to select patients for clinical trials research in dementia treatment.

The Psychiatric Diagnostic Screening Questionnaire (PDSQ) is a brief self-report instrument that screens for the DSM Axis I clinical disorders most commonly encountered among individuals 18 years of age and older (Major Depressive Disorder, Generalized Anxiety Disorder, Panic Disorder, Posttraumatic Stress Disorder, Alcohol Abuse/Dependence, Drug Abuse/Dependence, Psychosis, Bulimia/Binge-Eating Disorder, Somatization Disorder, Obsessive-Compulsive Disorder, Social Phobia, Hypochondriasis, and Agoraphobia). In addition it provides a Total Score which functions as a global indicator of psychopathology.

The Minnesota Multiphasic Personality Inventory, Second Edition (MMPI-2) is a written psychological assessment used to diagnose mental disorders; it is the most widely used and widely researched test of adult psychopathology. It is a self-report measure used to screen for clinical and psychosocial disorders. The questions asked on the MMPI-2 are designed to evaluate the thoughts, emotions, attitudes, and behavioral traits that comprise personality. The results of the test reflect an individual’s personality strengths and weaknesses, and can identify certain disturbances of personality (that is, psychopathologies). The validity scales of the MMPI-2 (the L-Scale, F-Scale, and K-Scale) assess the response set of the subject taking the inventory. In particular, these scales assess whether a subject put forth an inordinate effort to: (1) portray oneself in excessively socially desirable terms, (2) claim an unusual frequency of problems and distress, and/or (3) persistently deny any problems or distress.

The Minnesota Multiphasic Personality Inventory, Adolescent Version (MMPI-A) is a self-report test which is a version of the MMPI-2 designed to assess the functioning of adolescents aged 14-18. It includes the same clinical and validity scales as the MMPI-2, and provides the same robust information. The MMPI-A is one of the most commonly utilized assessments of adolescent personality functioning.

The Minnesota Multiphasic Personality Inventory-Second Edition-Restructured Format (MMPI-2-RF) is the most recent version of the MMPI-2 and much more brief than the MMPI-2. No new norms were collected for this shortened version of the MMPI-2.

The Millon Clinical Multiaxial Inventory, Third Edition (MCMI-III) is a standardized, self-report questionnaire used to diagnose mental disorders that assesses a wide range of information related to a person’s personality, emotional adjustment, interpersonal style, and attitude toward test taking. The MCMI-III is a nice complement to the MMPI-2, as a strength of the MCMI is that it is designed to evaluate personality disorders in addition to psychopathology. These are enduring and pervasive personality traits that underlie a person’s emotional, cognitive, and interpersonal difficulties. Thus rather than focus solely on the largely transitory symptoms that make up Axis I clinical syndromes, this test also concentrates on one’s more habitual and maladaptive methods of relating, behaving, thinking, and feeling. These personality characteristics likely reflect long-term or chronic traits that have persisted for several years prior to the present assessment. Validity subscales of the MCMI-III (Disclosure-X, Desirability–Y, and Debasement-Z) assess whether someone put forth an inordinate effort to: (1) portray oneself in excessively socially desirable terms, (2) claim an unusual frequency of problems and distress, and/or (3) persistently deny any problems or distress.

The Millon Adolescent Clinical Inventory (MACI) is the adolescent version of the MCMI-III and assesses the same domains as the MCMI-III. The MACI produces the same validity scales as the MCMI-III, enabling one to assess the responding style of the adolescent. The MACI is appropriate for ages 13-19, and requires a sixth grade reading level.

The Millon Pre-Adolescent Clinical Inventory (M-PACI) self-report tool is designed to identify psychological problems in children ages 9–12. The M-PACI assessment provides an integrated view that synthesizes the child’s emerging personality styles and clinical syndromes. It identifies emerging personality styles such as emotional instability, oppositional unruliness, and sensitive inhibitions. It addresses clinical problems such as AD/HD, depression, anxiety, conduct disorder, and reality distortions. It is based on up-to-date national norms with children in court settings, school psychology evaluations, residential treatment programs, and other settings.

The Behavior Assessment System for Children, Second Edition (BASC-2) is a self-report/other-report system used to evaluate the perceptions of others and self of the behavior of children and young adults aged ages 2-25 years. It was designed to facilitate the differential diagnosis and educational classification of a variety of emotional and behavioral disorders of children and to aid in the design of a treatment plan. It is a multi-method, multidimensional tool in that it can use parent, teacher, and/or individual descriptions of observable behavior in a variety of settings such as home and school. It also evaluates the child’s emotions, personality, and perception of self of children age eight and above. Finally, it provides important background information that is useful when making clinical diagnoses or educational classifications.

The Personality Assessment Inventory (PAI) is a self-administered, objective test of personality. It is a multi-scale inventory designed for the clinical assessment of adults, ages 18 years and older. The PAI provides information relevant to clinical diagnosis, treatment planning, and screening for psychopathology. The Clinical scales of the PAI provide information about critical diagnostic features of psychopathology. The treatment consideration scales provide indicators of potential complications in treatment. The Validity scales assess the potential influence of certain response tendencies on PAI test performance such as careless or random responding, confusion, reading difficulties, or unusual item interpretation by the respondent. The interpersonal scales assess the interpersonal style of the respondent.

The Symptom Checklist-90-Revised (SCL-90-R) is a brief self-report measure designed to provide an overview of a patient’s symptoms and their intensity at a specific point in time. It that screens for nine primary symptom dimensions (Somatization, Obsessive-Compulsive, Interpersonal Sensitivity, Depression, Anxiety, Hostility, Phobic Anxiety, Paranoid Ideation, and Psychoticism). There are also three global indices. The Global Severity Index (GSI) is designed to measure overall psychological distress and can be used as a summary of the test. The Positive Symptom Distress Index (PSDI) is designed to measure the intensity of symptoms, and the Positive Symptom Total (PST) reports the number of self-reported symptoms.

The Rotter Incomplete Sentences Blank (RISB) is a projective test where the client is given a series of incomplete sentences that he or she is supposed to finish. Assessment of the client is based on what he or she projects onto the sentences, and sentence quality can also provide information on thinking. The RISB is a semi-structured projective technique used as a measure and indication of psychological adjustment or maladjustment. Responses on this type of test typically reflect the individual’s wishes, desires, fears, and attitudes. For the purposes of the RISB, adjustment is defined as freedom from prolonged unhappy emotions, the ability to cope with frustration, the ability to initiate and maintain constructive activity, and the ability to initiate and maintain constructive activity. Maladjustment is the presence of prolonged unhappy emotions, inability to cope or difficulty coping with frustration, a lack of constructive activity or interference in initiating or maintaining such activity, or the inability to establish and maintain satisfying interpersonal relationships.

The Rorschach Test test is a projective test used to examine a person’s personality characteristics and emotional functioning. The examinee’s perceptions of inkblots are recorded and then analyzed using psychological interpretation and complex algorithms. The results describe how the examinee pays attention to surroundings, thinks about experiences, expresses feelings, manages stress, self-perception, and how the examinee relates to other people.

The Thematic Apperception Test (TAT) is a projective test in that its assessment of the client is based on what he or she projects onto ambiguous images to explore the underlying dynamics of personality, such as internal conflicts, dominant drives, interests, and motives; it is also used in a psychiatric context to assess disordered thinking. There are 31 pictures total in the TAT that depict a variety of social and interpersonal situations, but a standard administration often includes a series of 10 pictures, about which the subject is asked to tell a story about each picture to the examiner. Clients are given standard instructions to tell a story with a beginning, middle, and end, to include what the characters were thinking, feeling, and doing. The CAT is the child version of the TAT.

The Substance Abuse Subtle Screening Inventory, Third Edition (SASSI-3) is a brief self-report instrument that assesses one’s current substance use. It evaluates one’s reported usage, in addition to underlying factors which are typically associated with substance use and dependence.

The Buss-Perry Aggression Questionnaire is a 29-item self-report questionnaire where clients rank certain statements along a five-point continuum from “extremely uncharacteristic of me” to “extremely characteristic of me.” The questionnaire returns scores for four dimensions of aggression: Physical Aggression, Verbal Aggression, Anger, and Hostility.

The Parenting Stress Index (PSI) is a screening and diagnostic self-report instrument that identifies areas of stress in parent-child interactions as perceived by the parent for children ages birth to 12. It allows a clinician or researcher to examine the relationship of parenting stress as reported by the parent to child characteristics, parent characteristics, the quality of the child-parent interactions, and stressful life circumstances. As such it provides information on the course of the developing parent-child relationship.

The Stress Index for Parents of Adolescents (SIPA) is a screening and diagnostic self-report instrument that identifies areas of stress in parent-adolescent interactions as perceived by the parent, and is appropriate for parents of adolescents ages 11-19 years. It allows a clinician or researcher to examine the relationship of parenting stress as reported by the parent to adolescent characteristics, parent characteristics, the quality of the adolescent-parent interactions, and stressful life circumstances. As such it provides information on the course of the developing parent-child relationship.

The Parenting Alliance Measure (PAM) is a self-report assessment which measures the perceived strength of the bond or “alliance” between the parents of children ages 1 to 19 years. Responses on the twenty-item PAM questionnaire reflect one parent’s ability to willfully cooperate with the other parent in order to fully meet the needs of the child. Parenting alliance has been shown to be an accurate indicator of a couple’s success at raising a child, independent of their success as simply a couple. For instance, couples with strong parenting alliance often remain invested in the parenting of their children even after separation or divorce. The PAM total score reveals to what extent parents perceive themselves to be in a cooperative, communicative, and mutually respectful alliance for the care of their children; higher scores are equated with stronger degrees of perceived parenting alliance. Factors that can affect PAM scores include divorce or recent separation, as well as child adjustment issues (e.g. delinquent acts). In addition, specific mother factors (such as communication and perception of respect) and specific father factors (teamwork and level of respect for other parent) may also have an impact.

The Early Assessment Risk List for Boys (EARL-20B) for for Girls (EARL-21G) is a structured early assessment risk list for under age 12 thought to be at risk of engaging in future antisocial behavior. Research on the EARL-20B and 21G has found the tools to be reliable and a statistically significant predictor of future antisocial conduct, that is, a better predictor of future antisocial behavior than unstructured clinical opinion. As such, they can be used as a decision-enhancing tool for assessing risk for violence. Risk items included fall under three categories: Family, Child, and Responsivity. Family Items include: household circumstances, caregiver continuity, supports, stressors within the family, parenting style, and antisocial values and conduct of family members. Child Items include: developmental problems, onset of behavioral difficulties, abuse/neglct/trauma, attention and/or hyperactivity, likeability, peer socialization, academic performance, neighborhood, authority contact, antisocial attitudes, antisocial behavior, and coping abilities. Responsivity is related to family and child responsivity to treatment.

The Juvenile Adjudicative Competence Interview (JACI) is currently the only structured competence interview designed for use with juveniles. It provides a structured set of questions to help assess the youth’s Understanding, Appreciation, and Reasoning. The JACI provides interview questions for 12 content areas carefully selected in accordance with long-standing definitions of the abilities associated with the legal standard for competence to stand trial, using wording structured to be more understandable to juveniles. Areas include: nature and seriousness of the offense, nature and purpose of the juvenile court trial, possible pleas, guilt and punishment/penalties, role of the prosecutor, role of the juvenile defense lawyer, role of the probation officer, role of the juvenile court judge, assisting the defense attorney, plea bargains/ agreements, reasoning and decision making, and participating at juvenile court hearing.

The MacArthur Competence Assessment Tool – Criminal Adjudication (MacCat-CA) is a competence-to-proceed measure which provides simple judicially-based scenarios to the examinee and then asks his or her understanding of the scenario. If the examinee does not respond correctly, he/she is given the correct answers and then asked to convey understanding. An examinee’s competence is assessed within three distinct domains: Understanding, Reasoning, and Appreciation. The Understanding subscore assesses the examinee’s capacity for factual understanding of the legal system and the process of adjudication. The Reasoning subscore assesses one’s ability to weigh alternatives and make decisions regarding legal proceedings. The Appreciation subscore reflects one’s capacity to appreciate one’s specific legal situation and circumstances.

The Test of Memory Malingering (TOMM) is a visual recognition test designed to help psychologists and psychiatrists distinguish between malingered and true memory impairments. Research has found the TOMM to be sensitive to malingering and insensitive to a wide variety of neurological impairments, which makes it very reliable. The TOMM consists of two learning trials and an optional retention trial. Results are based on two cut off scores: 1) below chance and 2) criteria based on head injured and cognitively impaired clients.

The Trauma Symptom Checklist for Young Children (TSCYC) is a caretaker report assessing various behaviors consistent with exposure to trauma in children ages 3 to 12. When completing this assessment, the caretaker evaluates the child’s behavior over the previous month. In addition to looking at various clinical presentations, this measure can also assist in the diagnosis of posttraumatic stress disorder.

The Child Sexual Behavior Inventory (CSBI) is a questionnaire used to assess sexual behaviors in children ages 2 to 12 utilizing the report of the mother or primary female caregiver. It is used to evaluate children who have been sexually abused or who are suspected of having been sexually abused. This assessment measures various domains including boundary problems, exhibitionism, gender role behavior, self-stimulation, sexual anxiety, sexual interest, sexual intrusiveness, sexual knowledge, and voyeuristic behavior.

The Multiphasic Sex Inventory, Second Edition (MSI-II) is a self-report psychosexual assessment. It measures what an individual knows about his sexual problems and what he still does not recognize or cannot (or will not) acknowledge. The MSI-II scales range from an assessment of how well the client is learning to be honest and forthright with his treatment program to an assessment of whether he still blames others and situations to avoid taking responsibility for his past assaultive or deviant behaviors and interests. The test has been designed to assess the complete range of paraphilic disorders, from child molest to transvestism, as identified in the Diagnostic and Statistical Manual. To assess how well progress is occurring, the MSI-II subscales assess underlying features of paraphilia disorders which include “recurrent and intense” a) sexually arousing fantasies, b) sexual urges, or c) sexual behaviors (DSM). A client who is making good progress should be able to recognize and acknowledge his paraphilia features (a, b, c) so that the treatment strategies he learned can be employed to help control deviant fantasies and urges before they again become recurrent and intense.

 The Psychosexual Life History is a self-report measure designed for use with persons referred for psychological or forensic evaluation following allegations of sexual abuse. The client completes the measure first and it is then reviewed during a clinical interview with the evaluator. It includes areas of physical health status, mental health issues, family background data, childhood and adolescent developmental history, adolescent behavioral history, educational history, occupational history, substance abuse history, sexual history, marital-family history, adult legal history, treatment history, and a description of the alleged sexual impropriety.

Social & Emotional Skill-Building Classes Everyone Can Benefit From:

The Broad Applicability of Dialectical Behavior Therapy

Elements of DBT are applicable for anyone interested in self-improvement because it addresses basic areas of functioning that we all sometimes feel are disrupted occasionally. These include mindfulness/focus, regulating our emotions, tolerating stress, and being effective in interpersonal relationships. What does dialectical mean? Dialectical refers to the belief that two opposing thoughts can exist at the same time. The underlying dialectic in DBT is we can accept ourselves as we are  and at the same time  we can work toward change.

The opposite of dialectical thinking is dichotomous thinking, or black-and-white thinking. Dichotomous thinking allows for there to be only two possibilities: something is good or bad, a viewpoint is right or wrong, we love or we hate someone. Dichotomous thinking is tempting because it makes life simple since we only have to decide between two categories when figuring out how to classify something. The problem is, most everything in life is either gray or black-and-white. Dialectical thinking allows for something to be good and bad at the same time, a viewpoint to be right and wrong at the same time, and to love and hate someone at the same time. Dialectical thinking sees the whole picture and hears the whole truth. It allows for many people’s ideas and opinions to exist. Engaging in dialectical thinking allows you to consider the value of someone else’s opinion without de-valuing your own, love a friend after they made a mistake or disagreed with you, or preserve and build your self-esteem without the pressure of trying to be perfect.

DBT is conducted in a group format with one or two facilitators. Several weeks are devoted to each module and they are conducted as skill-building classes, not psychotherapy sessions or support group meetings. DBT is comprised of four modules: Core Mindfulness, Emotion Regulation, Distress Tolerance, and Interpersonal Effectiveness. Core Mindfulness skills are the basis for the other skill sets and are repeated after every module.

Core Mindfulness skills allow you to focus on the present and increase awareness of what is happening right now, within and outside of you. You learn to slow down and use all the information you have to get centered so that you can make healthy and effective decisions.

Emotion Regulation skills include knowing what you feel as it happens, using emotions in a healthy way, decreasing emotional intensity when needed, changing emotions when possible, and sitting with them without acting on them.

Distress Tolerance skills enable you to reduce frequent or intense difficult emotions by changing what you can and accepting what you can’t. You learn to soothe yourself before engaging in unhealthy and ineffective emotional reactions.

Interpersonal Effectiveness skills help you understand what your needs are in relationships, get those needs met in healthy ways, communicate effectively, and repair relationships – all while maintaining or improving self-respect and the respect of others.

Dialectical Behavior Therapy, or DBT, was developed by Marsha Linehan, Ph.D. in the late 1980’s. In addition to its broad applicability for general self-improvement, several studies over the past 25+ years have shown DBT to be an empirically validated treatment, meaning that clinical trials have demonstrated its effectiveness for a number of different diagnoses. It is used to treat anxiety, depression and other mood disorders, trauma, substance dependence, eating disorders, and personality disorders.

Working in the legal profession increases the odds that you are working with a client who is struggling to cope with stress and potentially other mental health concerns. Understanding their barriers to access and how to overcome them can result in improved outcomes.

The legal foundation for mental health availability has made significant gains since the 2008 passage of the Mental Health Parity and Addiction Equity Act (MHPAEA). The act did two important things: it forced large health plans to cover mental health equally with medical benefits and it included substance abuse disorders. The Affordable Care Act (ACA) upped the ante by applying those two factors to the individual insurance market and including them as Essential Health Benefits.

But parity is not access. Several factors still affect the use of mental health services. While equality of coverage is now part of the mandate, defining equivalence of services between mental health and medical/surgical is not easy. There are many behavioral health treatments that don’t have a clear medical equivalent, such as group-based intensive outpatient programs for substance abuse. In addition, health care benefits were traditionally overseen by separate benefits administrators than medical benefits, leading to a fragmented system. Of particular concern is the availability of providers, especially in rural areas. The historical forces of limited coverage and low reimbursement rates for mental health services has concentrated providers in high-population, high-income areas.

So what now? While we have many challenges to overcome, the legal foundation for parity is a good start. It will take time for the benefits to be realized as so many changes to the healthcare and insurance marketplaces are happening at the same time. But evidence is already showing the benefits of integrated care. A 2006 FEHB study concluded that “when coupled with management of care, implementation of parity in insurance benefits for behavioral health care can improve insurance protection without increasing total costs.” Research studies are popping up to show the benefits of integrated care in reducing and preventing physical and mental symptoms, all tied to potential dollars saved as well as improved patient outcomes. As more integration is implemented through the AHRQ’s push for Patient Centered Medical Homes and the Joint Commission’s Behavioral Health Homes, we will see how the benefits pan out.

In the meantime, how do I help my clients? As we mentioned in our November 2012 newsletter, 25% of adults and 20% of children annually have mental health issues that would benefit from talk therapy. As discussed herein, insurance coverage for mental health concerns is available and improving. Talk to your clients about getting help; you are a trusted advisor to them and have the unique opportunity to help. Is stigma of receiving help or getting to the therapist a problem? Some attorneys mention therapy to all clients so the client does not feel singled out. Also, consider referring a therapist who incorporates distance therapy. And encourage your client to advocate for their healthcare integration across disciplines by listing their therapist as an approved person to communicate with their primary care provider and/or medical specialist. As a trusted advisor, you can help normalize their experience and refer valuable mental health resources to facilitate a good outcome for your clients.