Sunday, January 31, 2010

Mental Health Characteristics of SW Students: Implications for SW Education

Abstract: No studies have examined to date the mental health and substance use characteristics of social work students. Therefore, this study was undertaken to describe and identify these characteristics among a sample of social work students located in a Florida school of social work. Results indicated that approximately 34% of the participants reported high levels of depressive symptoms, 12% had a history of suicidal ideation, and 4% reported having thought about suicide recently. Six percent reported high levels of post-traumatic stress disorder symptomatology, and 3% were highly likely to have a dissociative disorder. High proportions of the students reported having multiple traumatic experiences. Students in this sample were less likely to report lifetime or current alcohol or marijuana use than national college student samples, but more likely to report lifetime or current use of illicit substances other than marijuana.

From: Horton, E. Gail (2009). Mental health characteristics of social work students: Implications for social work education. Social Work in Mental Health, 7(5), 458-475.

Personal Experiences with Exposure

My own girl is anxious. Whenever I sign her up for anything new, she cries, a lot.

The walk from our car to whatever class I have signed her up for (art, Spanish, coping skills, etc.) is long and arduous for everyone within earshot. Her crying can be described as howling with mild exaggeration, although it has significantly lessened over time. Suffice it to say that people turn and look and wonder what torture I am inflicting on my girl. It becomes like my walk of shame. Only I am not ashamed. Not ashamed of exposing my girl to new experiences. Making sure that my girl does not miss out on opportunities because of her fears and worries. That is my job as her adult and I take it on, proudly.

Sitting in the darkened and cavernous Pantages theater right before the beginning of the Lion King musical, my 5-year old girl whispered in my ear, "I don't like this, I don't want to be here, why do you make me come to things like this?" Before the spectacular opening number was over, she again whispered in my ear, "when can we see this again?"

Exposure by Chorpita and Foa


From Modular Cognitive-Behavior Therapy for Childhood Anxiety Disorders by Bruce Chorpita:

Every anxious child is different. Some have families who encourage the child to confront his or her fears and overcome them, and others do not. Although Bruce Chorpita points out, "nobody likes exposure," some move smoothly through it, whereas others have depressive symptoms or oppositional behaviors or other problems that interfere with the treatment. Chorpita views exposure as the heart and soul of an effective treatment of anxiety, exposure, both imaginal and in vivo.

From Prolonged Exposure Therapy for Adolescents with PTSD: Emotional Processing of Traumatic Experiences by Edna B. Foa et al.:

The overall aim of Prolonged Exposure (PE) is to help trauma survivors emotionally process their traumatic experiences in order to diminish PTSD and other trauma-related symptoms. The name “prolonged exposure” reflects the fact that the treatment program emerged from the long tradition of exposure therapy for anxiety disorders, in which clients are helped to confront safe but anxiety-evoking situations in order to overcome their excessive fear and anxiety. At the same time, PE has emerged from the emotional processing theory of PTSD, which emphasizes the central role of successful processing of the traumatic memory in the amelioration of PTSD symptoms. Emotional processing is the mechanism underlying successful reduction of PTSD symptoms.

Saturday, January 30, 2010

Comprehensive Biopsychosocial Assessments in the Schools

Lorena, Deyanira, Joyce and Lauren routinely conduct comprehensive biopsychosocial assessment interviews with parents in elementary schools.

Linda has routinely conducted biopsychosocial assessments at various middle schools in E.L.A, Pico-Union and South L.A., as well as in the expulsion unit.

Doing this from the start pays off big in the long run. Getting a better picture of what is going on and how to respond comprehensively minimizes feeling lost and confused.

For instance, if we know that we are dealing with an adjustment disorder versus a more serious disorder like bipolar disorder or conduct disorder, then we can plan and prioritize our work accordingly.

Prioritizing the presenting problems and developing a diagnostic formulation can inform treatment goals and associated interventions. We can use the literature to identify tried and true interventions. If we are using more effective interventions, will that save us some wear and tear too? After all, getting the most ideal interventions for bipolar or conduct disorder means the difference between putting out the same fires all year or getting better outcomes (for everybody involved).

Family Involvement in Secondary Schools

Is it possible to work with parents at the secondary level?

Maria and Aracely run parenting classes at middle schools in South LA.

Myrna runs parenting classes at a high school in ELA.

Lorna worked with up to 8 parents a day at a high school in the Valley.

At a Southeast LA high school, Gloria developed a model for working with parents and their reunified children, when parents had immigrated to the US before their young children.

Linda teaches parenting skills at an Adult Education & Work Center.

What else is going on out there?

What are the stories? What is the impact?

Dan Siegel on Mindsight

I have over 20 pages of notes from a recent workshop by Dan Siegel. I will post a few notes at a time. Here is the first installment. I encourage you to read the book!

Mindsight lens = empathy and self-understanding.

It really is about starting with ourselves to change the world, to be the change we want to see. Personal transformation leads to us feeling interconnected.

Dan likes to dance because of how it feels versus how it looks from the outside (according to reports, apparently not very good).

In his medical training, he encountered doctors who were not given the tools to know their own mind and then went on to obliterate the mind of others. When he began to do this in order to conform and succeed in medical school, he felt dead inside.

Most of us have never been given a definition of the mind. Mind philosophers say the mind is not definable. It is made up of elements, such as: thoughts, emotions, cognitions, etc. Mind scientists refused to define the mind and stated, "that is why we're studying it." "Mind" was a placeholder for the unknown.

Mindsight lens can be developed (hope!) and turned off and on (as in the case of doctors in training).

When confronted with fear, brain increases assessment of people in front of you as "in-group" (similar) or "out-group" (not like you). This is a form of terror management. Our brain activates a fear response without our knowledge. Mindsight circuits get challenged by fear. Fear decreases compassion.

Cultural practices change synaptic connections. We have the capacity to intentionally shape cultural evolution!

Self-Determination

We, including clients, have the right to make choices - to have a say over our own lives AND to deal with the consequences of those choices.

Tackling Avoidant Coping Head On

Avoiding what is emotionally painful gives us a temporary reprieve. It works in the short-term.

But what are the costs?

Avoiding what we fear gives it power to continue to intimidate.

How do we uncover and nurture courage, strength and power to face the fears head on and overcome them?

Thursday, January 28, 2010

Have you been to the sculpture garden at UCLA? It is one of my favorite spots on campus for eating or reading. Some people nap right on the lawn.

Wednesday, January 27, 2010

Bruce Chorpita on Evidence Based Practice

These are my notes from Grand Rounds (Feb. 27, 2009) with a special presentation by Bruce Chorpita, UCLA Professor of Psychology. I had to use all my strength to keep myself from shooting right through the roof! (lots of brain popcorn activity)...

Evidence Based Practice (EBP) in Children's Mental Health Services
How can we get more from what we already have?

In EBP, there is a knowledge management problem:
--One of his psychology graduate students entered the program wanting to become an evidence-based clinician, but after reading all the research, the proliferation of treatment protocols and EBP manuals, he wound up a professor!
--Community-based, Master's-level practitioners need to be generalists and yet read studies conducted at specialty research settings.
--There are 333 to 350 evidence-based protocols!
--Dissemination as usual is inadequate. Assuming a replacement approach is inefficient and may be insulting (what you are doing is wrong, now do this...)
--Assumes unlimited resources and learning capacity (this is not the case in community settings).
--Institutionalizes services -- when there is new information, then there will be a need to de-institutionalize services

Positive client outcomes is the goal (vs. fidelity).

Rather than merely install new programs in a system, improve the practices that are already there.

See evidence base as a source of knowledge and not a list of products (manuals).

There have been 413 to 450 randomized control trials (RCTs) to date. (RCTs are the gold standard in intervention research for making causal inferences).

Chorpita developed an automated/computerized review of child RCTs (see link below) - "cliff notes" of RCTs for kids where you may enter characteristics like presenting problem, age, setting (for example, school) and strength of evidence and get an aggregated list of EBPs, that is, the most common procedures. Individual procedures like cognitive coping, which is one of the most successful treatments for any age and problem!

What do the best treatments have in common?

Example - Parent Training EBPs and their Practice Elements:

Incredible Years: Commands*, Time Out, Rewards

Parent-Child Interaction Therapy (PCIT): Attending, Commands*

Defiant Children: Commands*, Time Out

(*"commands" refers to teaching parents not to say "let's" or "why don't you..." and to make eye contact and use proximity when making commands. Sounds like some of the elements of Parents in Control!)

What's common among all elements of research?
80% of EBP studies on anxiety use exposure (70 RCTs).
In their Hawaii study, only 6% of community-based Master's-level clinicians use exposure.

There are 31 practice elements needed to cover the maximum number of coverable CAMHD youth (address specific problems, age groups, ethnicity, and setting issues).

Only 12 practice elements are sufficient to cover 85% of the coverable youth.

Manuals can't be the only way of doing business. A coordinated library of 33 evidence-based procedures are available online and trained online.

Practitioner Guides available, one pagers (2-sided) per practice (for example, relaxation)

Clinical Dashboard (computer program) monitors client progress and practice elements being used by clinician and answers the all important question: Is the child your treating now getting better? There is something changing and what is helping to make that happen?

Chorpita did a study in Hawaii with community-based clinicians (no exclusion/inclusion criteria - all interested clinicians participated and those that initially refused were taken to lunch to get them to agree) and 203 youth ages 7 to 13 with anxiety, depression and conduct problems. Youth were part of the public mental health system and some were referred with IEP's and identified as SED (seriously emotionally disturbed). 50% had disruptive behavior disorders (ADHD, ODD, CD), 30% had anxiety disorders, and 20% had depressive disorders.

Clinicians were divided into 3 groups: 1) MATCH (clinicians were taught 33 EB procedures that they could use with flexibility - that is choose which elements to use and repeat elements as needed), 2) clinicians that provided the usual care, and 3) clinicians that were trained in using 3 EB manuals.

Clinicians were then asked about their satisfaction with training. The first group (modular) had the highest satisfaction. After tracking weekly total child problems, the modular group clients showed the least problems.

If they use it, it might work.

This study used the CAFAS (Child & Adolescent Functioning Assessment Score) - 8 scale total and the Achenbach to frequently monitor client progress (like periodic assessments). It took 10 months to decrease 10 points on the CAFAS, 20 months to decrease 20 points.

There is more in the evidence base than we are using (ignored/forgotten) :(

Exposure studies date back to the 70's and 80's! and are still not used widely.

We need to focus on how gold standard programs can inform all care, not just specialty care.

Inspect every case for outcomes (client improvements) and dig deeper when you're not getting them!

With modular treatment you can repeat certain practice elements or skip others depending on specific client needs. With manualized treatment, there is a set sequence and elements.

Flexibility in treatment vs. fidelity in manualized treatment.

Check out Chorpita's website http://www.practicewise.com/ for more information.

Sunday, January 24, 2010

The Pursuit of Happiness

No other country has a constitutional guarantee about Happiness.

Martin Seligman describes flourishing as what you choose to do when you are not oppressed.

Because we are such good students of family, culture and social rules - even if those ideas do not serve us - we hold on to limiting beliefs (internalized oppression).

What would we choose to do if we cast off all the unhelpful thoughts we were taught?

Formal structures like laws have changed (right to vote for Black men and then 50 years later, right to vote for all women; civil rights legislation, etc.) but their traces remain in the restrictions we impose on ourselves.

What do you choose to do now?

Self-Esteem Controversy

Is building self-esteem a counseling goal or a by-product of mastery and competence?

California (of course) created the California Task Force to Promote Self Esteem and Personal and Social Responsibility. Who doesn't like self-esteem?

But in his book, the Optimistic Child, Martin Seligman describes self-esteem as a result of being good at something (i.e., mastery, competence or achievement) and not counseling. Emmy Werner echoes this in her suggestion to focus on reading skills for resiliency over "self-esteem" counseling.

No matter what counseling curriculum is used to promote self-esteem, what is Juanito going to believe when he goes back to class and he knows he can't read?

One of Seligman's criticisms is that "the self esteem movement cares more for feeling good than for doing well." He also connects self-esteem to feeling worthless, helpless and passive when depressed. (try googling Martin Seligman and self-esteem)

This makes me think about how core beliefs about self are influenced by level of attachment security. Those early caregiving relationships instill internal working models (or core beliefs) that shape expectations about the helpfulness of others, our ability to rally support and our worthiness to receive help.

Core beliefs about self can also be changed by exposure to trauma. Temporarily feeling helpless in a traumatic event can lead to a generalized belief that "I am incompetent."

Is it time to shift our emphasis to produce lasting effects on self-esteem?

Saturday, January 23, 2010

Informed Consent

The process of giving clients the information they need to make an informed choice about whether to consent and participate in treatment given its risks and benefits.

Given X presenting problem(s) or diagnosis, I recommend the following intervention(s) or treatment(s): ____________. I understand the risks of treatment and pulling your child out of class to be ________ and the benefits are ____________ based on current research and my own experience working with children in similar circumstances.

"Possibly the most intriguing part of Werner's resiliency research are her findings about reading skills. She found that fourth grade reading skills were a key indicator of resilience - the higher the reading score, the more resilient the child.

She encourages parents, teachers and schools to put their resources into improving reading skills. It appears to be a more effective way of fostering resilience in children than putting money into "self-esteem" programs that emphasize "feeling good," rather than academic success and life skills."

How do we make sure our interventions match or beat the effect of what students are getting in class?

Thursday, January 21, 2010

I am so grateful to friends and family members who read my blog - and the resultant hugs and comments and feedback and support. Most of the time, I feel like a passionate/angry/inspired woman and wonder where all these thoughts come from. They show up (like brain popcorn) when I read or study or drive or sit or they are thoughts that linger after conversations. I seem to sleep better at night now that these words have a place to reside. My husband is my editor and #1 supporter. Thank God for him.

Good night, friends, travelers, and seekers. Sweet dreams, Glo.

Tuesday, January 19, 2010

Tirade on Fear

We all get scared. Trying new things is scary. We may respond differently to fear and new things, but WE ALL GET SCARED. The thing is, there's no way around it, no short cuts; the only way to mastery, competence or achievement (and farther away from "new scary thing") is to do it. DO IT, DO IT, DO IT. It takes hundreds of trials and errors. That is thee process. For everyone. Why are you so special that you want to be perfect from the start, or (with hands on the hips) "I won't even try to do it" (all stubborn). Nobody gets to be perfect. Ever. Especially not at the beginning of anything. Grab onto your ovarios or cojones - whatever the good Lord gave you - both if you've got them and dare to do it. If for no other reason than to spite the Evil One that tells you that you can't or that it's impossible.

Hmm. Don't you just want to show 'em?

Saturday, January 16, 2010

Reminder: If you have a voice, then use it.

The only thing I’m afraid of is - not doing what I came here to do.

One of my cherished mentors calls me a woman with cojones.

I tend to cry when I speak out. It's a little embarrasing sometimes - more for the audience, I think, than for me. Before an important speech, I often pray that I don't cry. My husband suggests, if it makes me feel better, that I warn the audience that I am very passionate and might cry. It's just that I do care so much about what I am doing and what I am saying that my heart opens really wide and I start to feel it heating up my whole body and the whole room. I don't even care if I come off as weak or naive or whatever. It's being cynical, jaded, despairing or apathetic that I want to keep at bay.

Columnist Connie Schultz reminds us...

"A lot of them are mighty nervous -- at least at first. They remind me of what I always told my children when they were scared: Act brave even if you're not, and the courage will come. Turns out it works at any age.

So often, a woman will approach me before I give a talk and tell me she could never get up in front of all those people. Whenever that happens, I remind her of what Gray Panthers founder Maggie Kuhn said: Speak your mind even if your voice shakes.

If you've never heard Kuhn's words before, you might have the same response I had the first time I heard it. It hits you, doesn't it? Right there. Suddenly, you have permission not to be perfect or polished or even particularly brave. It's not who hears you that matters. It's the speaking up that'll save you every time.

And here's the thing about that shaky voice. People will listen anyway. I see it time and time again as I travel the state and meet women who just can't be silent any longer. One woman in particular has wedged her way into my memory. She is a middle-aged mother whose son recently returned safely from Iraq. But he came home to a different mother. It isn't enough that her son survived. She wants all the troops to come home. And so she wears a T-shirt that identifies her as the mother of an Iraq War veteran, and she shows up at event after event, forcing herself to talk to rooms full of people she knows won't all agree with her.

"My voice is not real strong, and it usually shakes," she said softly as she grabbed my hand before speaking. "But sometimes. Sometimes, I think if I don't speak out? Well, I'm afraid I will lose my mind."

A few minutes later, she took the stage. Her voice shook that night, just as she feared, and she stumbled over her words a few times as she shifted from side to side.

But for the entire time that she spoke, her soft, trembling voice was the only sound in the room."

Friday, January 15, 2010

Leaning Into It

At the beginning of this week, I was having a temper tantrum about the math part of statistics class. Then I decided to double my efforts (flash cards! and diving into Stats Support class). The rollercoaster loops are becoming more manageable. I'm leaning into it.

When things get hard, rather than resist, it helps me to lean into it. Like when I did a summer family retreat and we had to walk, in the unrelenting heat, up and down the chaparral mountains for meals, dharma talks and mindful walking hikes. No point in complaining for 5 days. So I leaned into it -I did it - and I felt good.

Sunday, January 10, 2010

Here comes the next train...

I loooooove breaks. Detaching, disengaging and disconnecting to the intensity of work. The brain and body relax, oh so deeply.

Now it's time to get back in the game and my brain is responding ever so slowly.

I still want to play with family and friends, be slothful and unencumbered.

Deep breath. I like the way my body feels on break. Any chance of holding on to that feeling for the next 10 weeks? And to distributing my time and energy to family, self-care, school, work, friends, fun, fun, fun.

Evidence-Based Practice (EBP)

"You work twice as hard with a less than ideal treatment. "

"Be transparent with clients about the strength of the evidence for a particular intervention. Informed consent requires providing information to the client."

--Jim Raines

Are we doing what works and being transparent about it?

Are we doing what we know because that is what we feel comfortable/confident doing, regardless of whether it works for our client in their particular situation? And if so, how do we explain this to clients?

When we think about changing what we do and learning something new - what thoughts, feelings or bodily sensations come up? Can we notice without judgment and proceed anyway?

What will it feel like when we are being even more effective in our work and clients are accomplishing their goals? Can you picture it?

"Create and preserve the image of your choice."
--Ghandi

PTSD, Children & their Parents

…it is not surprising that PTSD in young children develops more often if the trauma involves threat to the caregiver (Scheeringa & Zeanah, 1995), and that the caregiver’s ability to cope with trauma is the strongest predictor of child’s outcomes (Benedek, 1985).

So what can we do to boost the caregiver's ability to cope?

Chicana Activists - Rebels or Good Girls?

In the article, Using a Chicana Feminist Epistemology in Educational Research, Dolores Delgado Bernal "provides a forum in which Chicanas speak and analyze their stories of school resistance and grassroots leadership," in this case referring specifically to women who participated and organized the 1968 East L.A. School Blowouts.

She "asked the women how the social, cultural, and sexual realities of their lives manifested in the duality of 'good schoolgirl' and 'bad activist student.' "

"Their good schoolgirl behavior of speaking up in class, asking questions, and offering leadership to sanctioned student organizations was acceptable behavior (and even encouraged). However, when they practiced these same behaviors during the school boycotts, they were perceived as deviant. Their behavior had not changed -- others' interpretation of their behavior had. In other words, they helped me to see that their 'good schoolgirl' behavior that was so openly rewarded by good grades, student council positions, and respect from teachers was the exact same behavior that was unfairly punished when they used it to protest the inferior quality of their education."

If you have a voice, then use it.

Thursday, January 7, 2010

Stories about the Math in Social Work - Interns & Family Therapy for Effectiveness

The Student to SSW Ratio & SW Interns

The recommended student to school social worker ratio is 800 to 1. That is, one full-time school social worker for every 800 students. This still sounds like a lot to some professionals! NASW actually recommends a ratio of 350 to 1 in the types of schools that most of us work in at LAUSD.

Most of the schools that can afford to invest in a full-time school social worker have thousands of students. Two social work interns, each working 20 hours a week, approximate one full-time social worker. School social workers can double their efforts and help to close the ratio gap with just two social work interns.

When I first did this at a 2,000-student elementary school in South Los Angeles, I went from a caseload of 60-80 students to supervising 5-8 social work interns. Each intern, in turn, had a caseload of 5-10 students. Better math lead to better school social work.

Math Quiz for SSWs: At a school with 3,000 students, how many interns would you need to reach the recommended ratios of 800 or even 350 to 1?

Working with Parents vs. Working with Students Individually

In a recent review of the effectiveness of family therapy for child-focused problems, it was noted that "behavioral parent training is far more effective than individual therapy." In a review of 30 behavioral parent training studies and 41 studies of individual therapy, the effect size was .45 for parent training and .23 for individual therapy -nearly double the difference in effect size. Social workers can double their effectiveness moving from individual therapy to behavioral parent training. Do you want to use an intervention that is a bigger bang for your buck or do you want to work doubly hard?

Working with Families and Attendance Rates

I had lunch recently with a former SW intern who is now a PSA counselor. She told me about her experiences at a high school in the Valley where she systematically reviewed weekly computerized reports listing students with attendance problems and conducted outreach to their parents to offer concrete help, support, home visits, parenting training and mental health services including biopsychosocial assessments and family therapy. At one point, her Principal came back from a local district meeting thrilled to announce that their high school had been singled out as having the highest attendance rate - 98%.

Monday, January 4, 2010

Core Beliefs & Questions

If my core belief is, "I am incompetent," then it would makes sense that I not ask questions when I did not understand because this would invite attention to my so-called incompetence. I might also strive to be perfect (no typos) as a defense to my anxiety about my incompetence ever showing.

If my core belief is, "I am competent," then I am free to ask questions whenever I'd like because my questions merely symbolize my curiosity, or the learning process, or the lack of clarity of ideas presented, or how engaged I am in the conversation/presenter - any number of reasons, none of them pointing to any permanent incompetence on my part. Mistakes would also just be human - normal & natural - not further denigrating confirmation.

And isn't competence a dynamic concept on a continuum? How do we get stuck with a rigid and fixed idea that is clearly dependent on context and changes in time and space?

Notice, without judging

Reevah calls it the scientific approach, that is, looking objectively at your feelings. That in some ways your feelings are beyond your control - arising normally and naturally from our nature and experiences. Yet we feel ashamed or guilty about them and this causes us anxiety, so we try to cope using defense mechanisms. But what if we just noticed, without judging? It may not be thee feeling that concerns us but our feelings about thee feeling.

Noticing, without judging is also a precept of mindful awareness or Buddhist psychology. Thich Nhat Hanh talks about how we all have all the seeds (like jealousy, love, hatred, compassion, etc.) The real question is which will we allow to grow? So if we all agree that we all have all the feelings and that they are truly normal and natural, rather than judging the feelings that are deemed "socially unacceptable," what if we noticed them, without judging? What would happen then?

Back to School - Winter Quarter

SOC 210B - Statistics with Cameron Campbell (sociologist and demographer) and 10 weeks of linear regression. Weekly homework is 80% of grade and the take-home final is 20%. Woohoo!

Example of a regression coefficient statement:
"On average, an additional year of education increases income by $750/year."

Stats Support with Bridget Freisthler to review the technical aspects of the analytic techniques and discuss the findings from those analyses for write up in a paper, journal article or dissertation!


SW 245B - Intervention research with Todd Franke, focusing on research design and proposing randomized control trial and quasi-experimental designs.

"We will focus on design as separate from analysis because sophisticated statistics can't save what has been ruined by poor design or lack therof."


SW 225A - Policy course with Fernando Torres-Gil. Following universal health care policy as a class and I will probably choose to write about No Child Left Behind.

"Learning how to define a researchable question that is analytic, objective and non-ideological."
I finally checked out Powell Library - gorgeously old and refurbished. The study rooms are quiet and full of light. I will be studying there on Mondays. Feeling really good about the new quarter and being back.