Wednesday, March 24, 2010

Spring Break

Taking a break feels great. Reading inspires most of my posts so I will probably start writing again next week. In the meantime - there will be lots more naps, long walks and lunches all over town. Thanks for checking out the blog and coming back. Writing has been good for me and your comments - in person and electronically - have meant a lot to me. Enjoy the long days to do more of what you love.


Saturday, March 20, 2010

10 Reasons to Love Evidence-Based Practice

1. Reviewing the evidence about what works means that our work may get easier. Instead of working hard but only spinning our wheels (like a hamster that gets nowhere, which by the way, I have done, have you?), we can start by using an intervention that has already been shown to work with a similar population and setting.

2. If professional resiliency (that is, bouncing back despite all the stressors and challenges and demands and painful stories that we hear can fill in the rest) is maintained through optimism, collaboration and mastery, then doing what works and monitoring the progress of our clients while we do it, can't help but make us be/feel more competent. It means getting consistently and predictably good progress and outcomes in treatment. Starting with interventions that have empirical evidence of effectiveness can't help but make us more optimistic at the outset. Then sharing our experiences of progress and learning from each other, well that closes the loop and is one example of potential collaboration.

3. How confident will you be when you tell a client at the outset that there is solid research evidence that the intervention you are proposing in the treatment plan is effective and that treatment goals are achievable? It's like both you and the client will be standing on the shoulders of giants instead of muddling together in the dark, hopeful but uncertain. Our own confidence at the beginning of treatment is connected to client outcomes. Initially, clients may borrow on our hope when they can't muster the imagination to see a better future. Our beliefs about whether things can/will get better may also influence the choices we make in treatment. Our beliefs send a message whether we are aware of them or not. Doesn't it make sense to be aware?

4. It lends our profession and work some amount of credibility. The stories of our experiences with clients are indeed compelling. Anecdotal evidence makes for great case examples. However, some people only give credence or at least greater weight to numbers, especially in a climate of reduced budgets and increasing demand for accountability. The good news is that numbers can tell a story that is just as compelling and descriptive of the path to growth, healing and resilience. I love showing the graphs. The stories behind them make them look beautiful. Looking at them makes me happy. I also share them with parents, teachers, colleagues, administrators and anyone with a stake in the well-being our our students.

5. Journal articles about intervention research are like my dearest mentors. They summarize everything we know about a particular problem and population (literature review) and then describe exactly what they did and why and what happened (methods and results). It's like a short cut to the hundreds or thousands of trial and errors that I need to log to reach mastery. The book, Outliers, by Malcolm Gladwell talks about having to put in 10,000 hours to become expert at anything (think the Beatles, Bill Gates, concert pianists). I don't see why learning from what others have done and then doing it myself can't get me there sooner.

6. Just like we are thinking and feeling human beings, our practice can learn to integrate evidence and clinical judgment. There are no inherent either/or dilemmas in this process. If we can think and feel, then we can use evidence and clinical judgment.

7. Some detractors of evidence-based practice imply that intervention research ignores minority populations, when in fact 27% of the children's mental health research included Latino subjects. The real question becomes, have we read all the research or do we just assume it doesn't exist?

8. Okay, I'm running out of steam here. Can you help me out with your ideas? And in order to balance this discussion, I will post the 10 Concerns about EBP soon.

Friday, March 19, 2010

Flourishing Abstract

It is when individuals are being tested that much becomes known about human strengths--what they are, how they come about, how they are nurtured or undermined. In this chapter, the authors briefly examine previous research on resilience--how the construct has been defined and measured and what have been identified as key protective factors and resources to account for such resilience. They consider these questions with a brief focus on studies of children as well as more lengthy consideration of research on adults and elderly individuals. The authors then compare studies of resilience conducted at early and later periods of the life course. The chapter is concluded with a discussion of targeted research priorities designed to extend and apply knowledge of positive human functioning in the face of challenge--in other words, the capacity to flourish under fire.

Flourishing under fire: Resilience as a prototype of challenged thriving.
Ryff, Carol D.; Singer, Burton; Keyes, Corey L. M. (Ed); Haidt, Jonathan (Ed). (2003).

Thursday, March 18, 2010

Interpersonal Flourishing Abstract

Quality ties to others are universally endorsed as central to optimal living. Social scientists have extensively studied the relational world, but in somewhat separate literatures (e.g., attachment, close relationships, marital and family ties, social support). Studies of intimacy and close connection are infrequently connected to health, whereas studies of health and social support rarely intersect with literatures on relational flourishing. Efforts to probe underlying physiological processes have been disproportionately concerned with the negative (e.g., adverse effects of relational conflict). A worthy goal for the new millennium is promoting greater cross talk between these realms via a focus on the positive health implications of interpersonal flourishing. Vital venues for the future include mapping the emotional configurations of quality social relationships and elaborating their physiological substrates.

Abstract from Interpersonal Flourishing: A Positive Health Agenda for the New Millennium
Carol D. Ryff, Department of Psychology University of Wisconsin-Madison
Burton Singer, Office of Population Research Princeton University

Woohoo! Woohoo!

I am done !!!!!!!!!!!!!

Second quarter was even harder than the first, albeit in a different way.

This is about endurance, baby.

I struggled with internal temper tantrums and self-doubt. Last week, when I tried to soothe myself about the stress of finals week and said, out loud to myself, "It will get done." I didn't really believe myself. I kind of thought I was lying, "Sure, yeah right, como?"

And now? I am done (!) with second quarter, that is.

Spring quarter classes start in two weeks: 1) SW Policy Implementation and Analysis, 2) Independent Study course to prepare for comprehensive exams in June, and 3) Conceptual and Methodological Issues in Community Intervention (in the Psychology department).

But right now, right now, I just want to celebrate that I am done, that I didn't quit (I have thought about it so many times, but when you're in, you're in).

Thank you, Yesus! And Thank You to my husband and daughter and friends and family and FB and co-workers and neighbors and people who say encouraging things and buy me lunch and give me massages and walk with me and keep me going in this horribly beautiful and transforming experience that I have taken on. It reminds me that we don't do anything worth doing without support from others. I owe you big.

What Are You Reading and Thinking About?

Okay, I feel like I am doing most of the talking here. How about posting a comment about your collection of thoughts and what you are reading. I am interested in what people in different parts of the city, state, country and world are thinking. Let me know. Write it down.

Wednesday, March 17, 2010


To flourish means to live within an optimal range of human functioning, one that connotes goodness, generativity, growth, and resilience.

This definition builds on path-breaking work that measures mental health in positive terms rather than by the absence of mental illness (Keyes, 2002).

Flourishing contrasts not just with pathology but also with languishing: a disorder intermediate along the mental health continuum experienced by people who describe their lives as “hollow” or “empty.”

Epidemiological work suggests that fewer than 20% of U.S. adults flourish and that the costs of languishing are high; relative to flourishing (and comparable to depression), languishing brings more emotional distress, psychosocial impairment, limitations in daily activities, and lost work days (Keyes, 2002).

Straight out of the article, Positive Affect and the Complex Dynamics of Human Flourishing by
Barbara L. Fredrickson & Marcial F. Losada

Secretly, one of the main reasons I went back to school was to be able to access and read journal articles like this at my whim. Nerdy and proud! One more final and this quarter is over. woohoo.

Parenting Soundbytes

In a meta-analysis of 30 studies of behavioural parenting training, and 41 studies of individual therapy, effect sizes of .45 for parent training and .23 for individual therapy were found (Carr, 2009). That means the effect of parent training was bigger than the effect of individual therapy in reducing behavior problems. Which approach to reduce behavior problems is used most commonly by school-based mental health practitioners and why?

Longitudinal studies indicate inconsistent, coercive parenting in elementary school and poor monitoring and supervision in middle school exacerbate early conduct problems (CPPRG, 2007). Based on this research, an intervention (like Parents in Control) addressing disruptive behavior would do well to promote consistency and adequate supervision in parenting through middle school.

Disruptive behavior problems in young children are the number one reason for referral to mental health agencies (Breitenstein, 2009). On an individual level, unidentified and untreated, disruptive behavior problems can lead to more serious conduct problems.

On a school level, disruptive behavior problems create a general lack of student discipline and an atmosphere that produces fear in students that is not conducive to learning. Researchers have found that a positive disciplinary climate is directly linked to high achievement (Barton, 2003).

Fourth graders were asked how much they agreed or disagreed with the following statement: “Disruptions by other students get in the way of my learning.” Forty-three percent of White students agreed or strongly agreed, compared to 56% of Black students and 52% of Hispanic students (Barton, 2003). This tells us that the learning opportunities of minority students are disproportionately impacted by disruptive behavior. This lack of equality of opportunity in learning might be among the contributing factors of the academic achievement gap.

Clearly, disruptive behaviors have short-term and long-term negative effects for children, families and schools. When occurring among poor and minority students, then the long term effects can have implications for national security when we consider that current projections show that the minority population will be the majority by 2050. Will low-income and minority students of today be adequately equipped to lead in the future? What will we need to do now to close the gap and turn things around?

Students with parents who are involved in their school tend to have fewer behavioral problems and better academic performance, and are more likely to complete secondary school than students whose parents are not involved in their schools. Parental involvement allows parents to monitor school and classroom activities, and to coordinate their efforts with teachers. In addition, parent involvement in school is related to fewer student suspensions and expulsions and higher levels of student participation in extracurricular activities. Data also suggest that schools that welcome parental involvement are likely to have highly involved parents (Barton, 2003).

Among personal factors, a disruptive behavioral profile has repeatedly been shown to predict early withdrawal from school, even after controlling for familial and socioeconomic factors. For example, one study showed that aggressive behaviors and low grades as early as first grade predicted later school dropout. This link was stronger for children living in poor neighborhoods. A follow-up study confirmed that, for boys, math grades and aggressive behavior in the first grade predicted the number of years of schooling. Yet another study showed that disruptiveness rated as early as kindergarten was related to dropping out of school, even after controlling for sociodemographic variables and IQ. Disruptiveness may lead to early withdrawal from school because it contributes to school problems that are conducive to grade retention or special classroom placement (Vitaro, 1999).

A parenting program for preschool children demonstrated that the establishment of a predictable, consistent family environment with clear rules for child behavior lead to enhancement in parent’s contingent responding and reduced parental coerciveness (Bor, et al, 2002). Coerciveness has been correlated with negative outcomes for children with disruptive behaviors (CPPRG, 2007).

Owing to difficulties differentiating clinically significant disruptive behaviors from typical development, a significant proportion of young children with disruptive behavior problems go unidentified and untreated. Research supports the existence of disruptive behavior disorders in young children, and early identification and treatment are critical to interrupt the trajectory of early problems to more significant and impairing difficulties (Breitenstein, 2009).

Quality schools with high levels of student learning may have an accompanying high level of orderliness and discipline throughout the school as students are actively engaged in educationally productive activities. The issues that school discipline policies are designed to address are well known and range from the disconcerting to the dangerous. They include student disrespect for teachers, absenteeism, tardiness, use of alcohol and controlled substances, fighting, and possession of firearms (Barton, 2003).

Teachers of students with highly involved parents tend to give greater attention to those students, and they tend to identify problems that might inhibit student learning at earlier stages. Research has found that students perform better in school if their fathers as well as their mothers are involved, regardless of whether the father lives with the student (Barton, 2003).

A poll conducted in New Jersey found that urban and minority parents are far more likely to feel unwelcome in their children’s schools; 20 percent of suburban parents feel unwelcome, compared to 44 percent of urban parents (Barton, 2003). Do parents feel welcome at our schools? What implications does this have on the academic achievement, graduation rates and future of our students?

Sunday, March 14, 2010

What Do Barriers Mean?

Do barriers mean - stop trying? give up? it's too hard?

Or do barriers mean - let's figure it out?

Friday, March 12, 2010

The Informed Consent Process

Is evidence of informed consent more than just a signature on a page?

I contend that informed consent is a complex process beginning at engagement and important at every step of the social work process - assessment, diagnosis, treatment planning, intervention, evaluation and termination.

When I work with a student of any age, I make it a point to engage the parent/guardian early on. Otherwise, I feel that I am treating a disembodied student. Does a student exist or survive outside of the family system, no matter what the age? Unless they are orphans living in an institution or emancipated and living on the streets, they have a "family" with all the corresponding responsibility, relationship capacity and love that makes healing, transformation and growth possible - even if it is not obvious at first glance.

Sometimes when we go to the supermarket, my daughter runs into the parent of a classmate who says to her, "Hi, Paolina!" - while completely ignoring me! At this point, rather than feel like an invisible victim, I might be empowered to introduce myself, "Hi, I'm Paolina's mom, Alejandra."

Not engaging parents/guardians in child treatment feels disrespectful and shortsighted to me. Disrespectful because it is acting like parents/guardians are wallflowers (o pintados en la pared), invisible, not taken into account (no tomados en cuenta), irrelevent, unimportant. Shortsighted because parents/guardians and family members generally love and care about their kids more than anyone else on the planet, including dedicated social workers. It's like saying: I will direct my conversation and intervention to the child, the person with the least amount of power in the family system. I will ignore the parents and their love, commitment, responsibility and role in their child's life.

Now I realize that working with parents is not easy and generally speaking, does not come naturally to most of us. While all the literature explicitly points to parent and family involvement as one of the most powerful factors for academic achievement and social-emotional-behavioral health and resiliency, not all school personnel feel adequately trained, confident or competent to reach out.

I was thinking about all the things that fell into place for me to be able to confidently and skillfully reach out to parents.

Unless an administrator, school counselor, teacher or dean walks the parent over to my office for our first introduction or meeting (which I encourage), I am usually calling the parent on the phone soon after receiving the written or verbal referral. Doing cold-call telemarketing to earn money while I was in college really helped me to overcome the fear of meeting someone on the phone and communicating persuasively. In order to remove the "cold-call" barrier, I try get someone that the parent trusts to broker the introduction. Also, I ask the teacher or administrator to share their concerns for referral with the parent before I contact them.

Second, it helps to have a script. My "script" has evolved over time. In my second year MSW field placement at an elementary school, my field instructor had us role play how to talk to parents on the first day. In my first professional school-based assignment, I regularly called parents because this was part of my graduate school training and because my clinical supervisor for licensure hours was very family therapy-focused, also. Back then, I only got about a 50% parent/guardian engagement rate. I thought this was very bad and complained to my mentor, Reevah, about this. She taught me that parents get very easily put on the defensive when they get a call from school (sadly, it is rarely good news). They either feel that they are in trouble with the Principal (flashbacks) and come out fighting or are overwhelmed by the child's behavior too and don't know what else to do. In the latter scenario, parents will either ask for help or "fight back" as a defense against feeling incompetent or blamed as parents. It is sometimes easier to blame others first and slip into denial than to take responsibility and ask for help. This is true for all of us, let's not kid ourselves.

So my rap to parents evolved. Now it goes something like this:
"Hi, my name is...I am a school social worker and my role at the school is to make sure that every student is successful. I understand your son/daughter has had some challenges at school...I would like to meet with you to talk about how we can work together as a team to make sure that your son/daughter is doing well at school. You are the most important person in your child's life and I can't imagine being able to do this without you. I noticed that your child is really good at..."

I try to talk to the teacher and other school staff, review the cum, etc. to identify the child's strengths before I make the call. Every kid has got them and highlighting these strengths in my conversation with the parent let's them know - I get your child - I know how wonderful and important they are to you - I don't see your child as solely a checklist of risk factors or a problem student - you've done a lot of good things as a parent before I ever picked up the phone to call you.

My parent/guardian engagment rate went from 50% in a South LA elementary school to 90% at two different high schools (East LA and the Valley) and finally, nearly 99% at another South LA elementary school. I became skillful which increased my confidence, expectation and hope, which in turn gave me the encouragement I needed to continue practicing which made me more skillful, etc.

My first meeting with parents is usually at the school (most prefer this to a home visit, although I've done those too). This is when I begin conducting the biopsychosocial (BPS) assessment. Ironically, I did not learn how to do this until August, 1998 - two years post-Masters! I didn't know that I didn't know until I participated in a back-to-work training about time-limited assessments. The social worker sitting next to me in the training complained that it was so basic but I vigorously took notes because it was literally the first time that I was exposed to this type of training. No wonder my field instructor wondered why I didn't conduct developmental assessments! Suddenly I was embarrassed by a write-up I had done for a fellow CPS (child protective services) worker who requested that I interview his client. She would only speak to a female spanish-speaking social worker and I fit the bill. It was a lovely home visit and she really opened up. But after this BPS assessment training, I realized that for all my prose and inquiry - I had not delivered an assessment report! Oh well, you live and learn.

I remember the BPS trainer saying how after the longest part of the interview (presenting problem), you should be able to develop a "short list" of potential diagnoses. Subsequent interview questions help to rule things out. With a clear, objective, behavioral list of problems, it is easier to determine priorities - what to work on first. This leads into treatment planning rather smoothly. That is, taking prioritized presenting problems and developing goals - what do you want your child to be doing instead? Finally, how will we get there? What works to accomplish these goals? What's it going to take? Who will do what? Planful, thoughtful and clear - a road map making it more likely to get there sooner and less likely to get lost and confused along the way.

At this stage, parents are truly informed to consent to treatment. You can confidently say - this is what we will work on and why. This is how we will work on it and why. Now parents enter this agreement with their eyes open and with a fuller understanding - informed. They were part of the process and the conversation every step of the way. They know what, when, where, why and how and the risks and benefits - full disclosure. Would you, as a parent, want or expect any less?

I also realize that my training as an HIV Pre/Post Test Counselor and then as a Trainer of HIV Test Counselors emphasized the concept and process of informed consent. Clients did not sign the informed consent form to take the HIV test until we had discussed: What is HIV? What does the HIV antibody test look for? What do the results mean? What are the risks and benefits of taking the test? and more. If a client doesn't get his blood drawn for the test until both counselor and client are confidently clear about what the client is about to do, then how do we reach the same level of clarity when working with parents and their children as they consent for mental health treatment?

Sometimes we don't have a plan. We don't know where we are going and we hope they don't ask. Even if they don't ask, we ought to know and we ought to tell them. Don't you think? I didn't always know how to plan. I have learned everything along the way - reading, training, practice. When I worked for Sonoma County, doing child protective services work, I attended a training about child welfare risk assessment and case planning. I loved how the professor encouraged us to write individualized case plans. That is, rather than recycle boilerplate language so that every client has the exact same case plan, he taught us to think about - what puts a singular child at risk exactly? and what do parents need to do differently so the child is no longer at risk? He talked about writing goals in positive terms - what to do instead of what not to do. For instance, when climbing, is it a better idea to say "look up" or "don't look down" - which is more likely to get the desired response?

When training social work interns, I was committed to making sure that they did not graduate with the gaps in practice knowledge that I experienced in mine. To that end, I sought out information, books, training, consultation and practice in BPS assessment, diagnosis and treatment planning. In the process of teaching them, I learned a lot myself. I am so grateful for that process now.

Sunday, March 7, 2010

Week 10

My groaning with classmates has lead to these "insights":

The quarter system is brutal. It is my first time on this schedule as a student. You are behind when the quarter begins, there is no time for things to stick or sink in, and you have less time to read the same amount of material - insanity!

The energy level coming into Fall quarter, after the delicious summer break, is different than the one coming into Winter and Spring Quarters. I am working on replicating the rejuvenating effects of summer in the cold or rainy weeks of Winter after giving Fall quarter my all. That means intense doses of self-care to counter all the energy depleted last quarter.

This quarter has also been hard because the classes have been more technical and abstract with a review of more reference-like material. That explains some of my feeling unmotivated. I need to tap into some juicy passion to fuel me through.

Anyway, coming up on week 10 - two assignments and lots of reading due this week. Then, finals week - two papers, a presentation and a take-home final. It sounds like a lot to me right now, but it will get done. I left perfectionism behind long ago. Now I strive to be excellent when it really matters and to get it done when that is what is sufficient.

Spring Break is in view.

Sir Ken Robinson on Creativity and Schools

I found this video clip on my nephew's website, It is funny, inspiring and enlightening (sounds like fun, no?)...

Short Film on the Nature and Power of Resiliency

Recommended to me by my colleague, Gloria, I pass it on to you. Enjoy!

Martin Seligman Video and Podcast

If you are interested in what Martin Seligman has to say about positive psychology and optimism first hand, then check out the following...

I was talking about Seligman in class and one of my SSW students looked him up and sent me this link to his video:

Here's a link to a podcast/transcript:

More Yalom, the Here-and-Now and Authentic Relationship

Reading Yalom revolutionized my thinking. His unblinking self-awareness and honesty inspired me to be – to discover – who I am as person and professional in the therapeutic relationship. It is very intimate, powerful, rewarding and ultimately, integrating and liberating.

The following passage from the same book quoted in the previous post, Momma and the Meaning of Life, describes his counter-transference notes about a fictional patient. He uses these notes for discussion in a counter-transference group he is in with peers/colleagues. It opened my eyes to hear him say these things out loud to peers, to us (his readers) and due to some unintended high jinx, to his patient. The power of this self-awareness and revelation in his work (grounded in the here-and-now approach) with the patient reminds me of the power of process recordings. Most interns report hating them, but I don’t know any other tool that is as effective in cutting to the core of what we, as therapists, do, say and feel in therapy and why (rationale/purpose based on theoretical orientation or lack thereof). Each step is a skill that takes time. What do I think and feel in the moment that I am in with this client in the here-and-now, no matter how deep, superficial, ugly or beautiful? Most interns tend to report what they think the client is feeling instead or guard against revealing unpleasant thoughts and feelings because they sound “unprofessional.” Then, how can I take this thought or feeling and turn it into an intervention – a statement or question to the client in real time? Finally, (most don’t get here but a few have) daring the genuine exchange and authentic relationship.

“This is Dr. Lash dictating notes for countertransference seminar. Notes on Myrna, Thursday, 28 March. Typical, predictable, frustrating hour. She spent most of the session whining as usual about the lack of single available men. I get more and more impatient…irritable – lost it for a moment and made an inappropriate remark: ‘Do you see Dating Bureau on my T-shirt?’ Really hostile thing for me to do – very unlike me – can’t remember the last time I’ve been so disrespectful to a patient. Am I trying to drive her away? I never say anything supportive or positive to her. I try, but she makes it hard. She gets to me…so boring, rasping, crass, narrow. All she ever thinks about is making her two million in stock options and finding a man. Nothing else…narrow, narrow, narrow…no dreams, no fantasies, no imagination. No depth. Has she ever read a good novel? Ever said something beautiful? Or interesting…just one interesting thought? God, I’d love to see her write a poem – or try to write a poem. Now, that would be therapeutic change. She drains me. I feel like a big tit. Over and over the same material. Over and over hitting me over the head about my fee. Week after week I end up doing the same thing – I bore myself.
Today, as usual, I urged her to examine her role in her predicament, how she contributes to her own isolation. It’s not such a difficult concept, but I might as well be speaking Aramaic. She just can’t get it. Instead she accuses me of not believing that the singles scene is bad for women. And then, as she often does, she threw in a crack about wishing she could date me. But when I try to focus on that, how she feels toward me or how she makes herself lonely right here in this room with me, things get even worse. She refuses to get it; she will not relate to me, and she will not acknowledge that she doesn’t – and insists it’s not relevant anyway. She can’t be stupid. Wellesly graduate – high-level graphics work – huge salary, hell of a lot bigger than mine – half the software companies in Silicon Valley competing for her – but I feel I’m talking to a dumb person. How many goddamn times do I have to explain why it’s important to look at our relationship? And all those cracks about not getting her money’s worth – I feel demeaned. She is a vulgar lady. Does everything possible to eliminate any shred of closeness between us. Nothing I do is good enough for her. Presses so many of my buttons that there’s got to be something of my mother in this. Every time I ask her about our therapy relationship, she gives me that wary look as though I’m coming on to her. Am I? Not a whisper of it when I check into my feelings. Would I if she weren’t my patient? Not a bad-looking woman – I like her hair, gleaming – carries herself well – great-looking chest, popping those buttons – that’s definitely a plus. I worry about staring at those breasts but I don’t think I do – thanks to Alice! In high school once, I was talking to a girl named Alice and hadn’t any idea that I was staring at her tits until she put her hand under my chin and tilted my face up and said, ‘Yoo-hoo, you-hoo, I’m up here!’ I never forgot. That Alice did me a big favor.
Myrna’s hands are too big; that’s a turnoff. But I do like that great slick, sexy swish of her stockings as she crosses her legs. Yeah, I guess there are some sexual feelings there. If I had run into her when I was still single, would I have hit on her? Probably yes, I’d be attracted to her physically, until she opened her mouth and started whining or demanding. Then I’d want to get away fast. There’s no tenderness, no softness to her. She’s too self-focused, all sharp angles – elbows, knees, ungiving – [a click as the tape came to an end]”

Wow. That’s very (sometimes uncomfortably) revealing. Courageous? Pretty or not, it’s the honest-to-goodness truth and it stands between therapist and client whether we choose to look at it or not. If we look at it then we can act consciously. If we don’t look at it – because it is too disturbing – then how does it come out in ways that we are not aware?

Friday, March 5, 2010

Listening & Connecting

Reading Yalom taught me to be a psychotherapist using a humanistic-existentialist approach. Carl Rogers, master therapist and theorist, also described himself as humanistic and existentialist. I learned skills for connecting using his person-centered approach (active listening skills).

When we listen to clients and their stories and witness their pain, we have an urge to change, fix, minimize or deny their feelings (don't feel that way, look on the bright side, don't cry, it's not so bad). Empathic listening is powerful and leaves clients feeling understood - ultimately very healing.

"Listen to your patients; let them teach you. To grow wise you must remain a student." --Professor John Whitehorn from Momma and the Meaning of Life by Irvin Yalom.

Yalom describes the work of his mentor: "Dr. Whitehorn related to the person, rather than the pathology, of that patient. His strategy invariably enhanced both the patient's self-regard and his or her willingness to be self-revealing...There was no duplicity: Dr. Whitehorn genuinely wanted to be taught...'You and your patients both win,' he would say, 'if you let them teach you enough about their lives and interests. Learn about their lives; you will not only be edified but you will ultimately learn all you need to know about their illness.' "

Yalom asks a client at termination: "Tell me, from your perspective, what was the real center, the core of our work?"
Patient responds: "Engagement," she said at once. "You were always there, leaning forward, getting closer."
Yalom: "In your face, you mean?"
Patient: "Right! But in a good way. And not in any fancy metaphysical way. I needed just one thing: for you to stay with me and be willing to expose yourself to the lethal stuff radiating from me. That was your task. Therapists don't generally understand this. No one but you could do this. My friends couldn't stay with me. They themselves were too busy grieving for Jack, or distancing themselves from the ooze, or burying the fear of their own deaths, or demanding - and I do mean demanding - that I feel okay after the first year. That's what you really did best. You had good staying power. You hung in there close to me. More than just staying close, you kept pushing for more and more, urging me to talk about everything, no matter how macabre. And if I didn't, you were likely to guess - pretty accurately, I'll hand it to you - what I was feeling. And your actions were important - words alone wouldn't have done it. That's why one of the best single things you did was to tell me I had to see you an extra session every time I got really engaged with you."
Yalom: Other helpful things?
Patient: "Again simple things. You may not even remember, but at the end of one of our very first sessions, as I was walking out the door, you put your hand on my shoulder and said, 'I'll see this through with you.' I never forgot that statement - it was a mighty staff of support."
Yalom: "I remember, Irene."
Patient: "And it helped a lot when sometimes you'd stop trying to fix or to analyze or interpret me and you'd say something simple and straight like, 'Irene, you're going through a nightmare - one of the worst I can imagine.' And the best thing of all was when you'd add - not often enough - that you admired and respected me for my courage in persevering."

Yalom summarizes his approach using the here-and-now:
"I bridled at such simplification. Surely my approach to therapy was more complex and sophisticated! But the more I thought about it, the more I came to see that Irene had it quite right.

For sure she was right about 'engagement' - the key concept in my psychotherapy. I had decided at the very onset that engagement was the most effective thing I could offer Irene. And that did not simply mean listening well, or encouraging catharsis, or consoling her. It meant rather that I would get as close as I could to her, that I would focus on the 'space between us' (a phrase I used in virtually every hour I saw Irene), on the 'here and now': that is, on the relationship between her and me here (in this office) and now (in the immediate moment.).

Now, it is one thing to focus on the here-and-now with patients who seek therapy because of relationship problems but another matter completely for me to have asked Irene to examine the here-and-now. Think of it: Is it not both absurd and churlish to expect a woman in extremis (a woman whose husband lay dying of a brain tumor, who was also grieving for a mother, a father, a brother, a godson) to turn her attention to the most minute nuances of a relationship with a professional she hardly knows?

Nonetheless, that was just what I did. I began it in the first sessions and never relented. In every session, without fail, I inquired about some aspect of our relationship. 'How lonely do you feel in the room with me?' 'How far from, how close to me do you feel today?' If she said, as she often did, 'I feel miles away,' I was sure to address that feeling directly. 'At what precise point of our session did you first notice that today?' Or, 'What did I say or do to increase the distance?' And most of all, 'What can we do to reduce it?'

Throughout our therapy I was dogged about engagement. I refused to be pushed away. To her, 'I'm numb; I don't want to talk; I don't know why I'm here today,' I responded with some comment such as, 'But you are here. Some part of you wants to be here, and I want to talk to that part today.'

Ordinarily the here-and-now focus in psychotherapy has many advantages. It imparts a sense of immediacy to the therapy session. It provides more accurate data than relying on patients' imperfect and ever-shifting views of the past. Since one's mode of relating in the here-and-now is a social microcosm of one's mode of relating to others, both past and present, one's problems in relating are immediately revealed, in living color, as the relationship with the therapist unfurls. Furthermore, therapy becomes more intense, more electric - no individual or group session focusing on the here-and-now is ever dull. Moreover, the here-and-now provides a laboratory, a safe arena, in which a patient can experiment with new behaviors before trying them in the world outside.

Even more important than all these benefits, the here-and-now approach also accelerated the development of a deep intimacy between us. Irene's outward demeanor - frosty, forbidding, supremely competent and confident - kept others from approaching her. This was precisely what happened when I placed her in a six-month therapy group at the time that her husband was dying. Though Irene quickly won the members' respect and provided considerable support to others, she received little in return. Her air of supreme self-sufficiency told the other group members she needed nothing from them.

Only her husband had cut through her formidable demeanor; only he had challenged her and demanded a deep, intimate encounter. And it was only with him that she could weep and give voice to the young lost girl within her. And with Jack's death she lost that touchstone of intimacy. I knew it was presumptuous, but I wanted to become that touchstone for her...Gradually, very gradually, she was able to acknowledge feelings of helplessness and to turn to me for comfort."

Wednesday, March 3, 2010

Anxiety & Massage

Massage Reduces Anxiety in Child and Adolescent Psychiatric Patients

Abstract. A 30-minute back massage was given daily for a 5-day period to 52 hospitalized depressed and adjustment disorder children and adolescents. Compared with a control group who viewed relaxing videotapes, the massaged subjects were less depressed and anxious and had lower saliva cortisol levels after the massage. In addition, nurses rated the subjects as being less anxious and more cooperative on the last day of the study, and nighttime sleep increased over this period. Finally, urinary cortisol and norepinephrine levels decreased, but only for the depressed subjects. J. Am. Acad. Child Adolesc. Psychiatry, 1992,31,1:125-131. Key Words: massage, child/adolescent psychiatric patients.

Not surprising, I suppose. So if we know it, then why aren't we all doing it more? Massages for everyone! For the kids and for the caring adults who serve the kids!

Tuesday, March 2, 2010


Critical reflection on practice is a requirement of the relationship between theory and practice. Otherwise theory becomes simply “blah, blah, blah,” and practice, pure activism.

-Paulo Freire, Pedagogy of Freedom

Writing is Good for Us

How do we meditate, reflect, look inward when there are so many distractions? How do we hear the sound of our own inner voice among the noise?

I have been wanting to write for a very long time. Writing is good for us. I didn't altogether get it whenever I heard writers say that they write because they must. Now I get it.

In Writing Down the Bones: Freeing the Writer Within, Natalie Goldberg writes:

"I went home with the resolve to write what I knew and to trust my own thoughts and feeling and to not look outside myself...Trust in what you love, continue to do it, and it will take you where you need to go."

"Why do you come to sit meditation? Why don't you make writing your practice? If you go deep enough in writing, it will take you everyplace."

"This book is about writing. It is also about using writing as your practice, as a way to help you penetrate your life and become sane...really say deep down what you need to say."

In Writing as a Way of Healing: How telling our stories transforms our lives, Louise A. DeSalvo writes:

"Writing has helped me heal. Writing has changed my life. Writing has saved my life...And how often have others - acquaintances, friends, students, published writers - told me that writing has helped them heal from loss, grief, or personal tragedy, that writing gave them unimaginably plentiful spiritual and emotional advantages? That writing has changed them, has helped them come to terms with something difficult, that writing has saved their lives. Often."

DeSalvo describes James W. Pennebaker's Opening Up: The Healing Power of Confiding in Others as summarizing "ten years of scientific research into the connection between opening up about deeply troubling, emotionally difficult, or extremely traumatic events and positive changes in brain and immune funtion...Pennebaker's work on the relationship between suppressing our stories and illness, on the one hand, and telling our stories and increased health, on the other is well respected and pathbreaking in the field of psychology..."

At the Evolution of Psychotherapy Conference in Anaheim recently, Bessel van der Kolk quoted the results from Pennebaker's research. He said how important it was to keep track of our internal life and put it into words.

Write it down. Now how does that feel?


In the parable of the sower and the seeds, a sower scatters seeds on the road, near rocks and among weeds and thorns. Exposed to the sun, the seeds become scorched and die or among weeds become choked and die. When the seeds fall on good earth, they grow yielding thirty, sixty, and a hundredfold.

Are our hearts and minds open to what we can learn? Is our earth good, is the soil tilled? Are universal messages, inspiration, whispers, signs and signposts lost on us? Or are we ready? What fruit will we bear and what will be sown in the spring?