Wednesday, August 25, 2010

Book Review: Tattoos on the Heart

"...our common call to delight in one another."

I just finished reading Father Greg Boyle's recent book, Tattoos on the Heart, in three summer evenings. Some of my colleagues read it too and we've all had similar reactions to it - we love it and it makes us cry.

It is nothing short of a love letter to humanity. It's about...
...the power of unconditional love (the "no-matter-whatness" of love) and self-worth
...compassion instead of judgment
...the truth that we belong to each other and our loving relationships bring us back to ourselves and the truth of ourselves - we all matter, just as we are.

Reading it is like going to church - or at least, what going to church could be - inspiring, connecting, validating, loving, motivating, accepting, inclusive, living grace.

Boy, have I got a long way to go - and yet - I am exactly where I am supposed to be. It reminds me of a sermon I heard a long time ago that freed me - I can't do anything to make God love me any less (or more).

The parts that made me cry were not what you might expect. The parts that made me cry were when homies finally experienced feeling felt - when they saw themselves with the proud love and attentive gaze of a parent looking at their newborn for the first time - noticing a perfect and wonderful and fragile human being.

It is about homies coming home. It is also about us - homie, ex-homie or not - coming home to ourselves. In the end, we are all on the same journey to love, to belonging, to God.

In the last 20 years, G-Dog has come a long way, baby, and shares some lessons learned about working with gangs. He is honest and reflective about this, which his critics may appreciate (or not).

Father Greg Boyle is one of my heroes, but I disagree with him on one point - that is the role of evidence-based outcomes. He talks about this toward the end of the book. He represents it as almost a sin-like endeavor - he calls us to be faithful to the process and not fret over outcomes. I imagine that he feels the pressure of funders breathing down his back and demanding accountability. It's easy to conclude something is impossible or horrible if we can't imagine how to do it. Unfortunately, Father Greg hasn't met the right evidence-based practice consultant or evaluation researcher (allow me to introduce myself, Father Greg...). There is no this or that, process or outcome, either-or dilemma here. Both science and faith can live side by side - informing each other - bringing out the best in each other - integrated even.

So much to love here, but I will leave you with this...

"But in this place of which you say it is a waste, there will be heard again the voice of mirth and the voice of gladness...the voices of those who sing."
"And so the voices at the margins get heard and the circle of compassion widens. Souls feeling their worth, refusing to forget that we belong to each other. No bullet can pierce this. The vision still has its time, and, yes, it presses on to fulfillment. It will not disappoint. And yet, if it delays, we can surely wait for it."

Amen. Thank You, Yesus.

Friday, August 20, 2010

Parenting Abstract with Commentary

Clinical Psychology Review 27 (2007) 739–749
Adopting a population-level approach to parenting and family support interventions
Ronald J. Prinz, Matthew R. Sanders

Evidence-based treatments and preventive interventions in the child and family area have not met with widespread adoption by practitioners.

(What is this about, do you think? What makes change, even for the better, so hard for us? What's it going to take to rationally choose methods with better evidence and outcomes over traditional and less effective ones?)

Despite the high prevalence of child behavioral and emotional problems, many parents and families in need are not receiving or participating in services, and when they do, the most efficacious interventions are not what is usually provided.

(Is this a clinical and ethical issue or what? When parents overcome all the barriers to access that exist, including stigma and discrimination, don't they deserve the very best in the most efficient manner?)

Simultaneously addressing the issues of low penetration and insufficient dissemination of evidence-based programming requires a population approach to parenting and family support and intervention. Process issues are important, particularly in relation to engagement of stakeholders, recruitment of practitioners, consideration of organizational factors, and use of media and communication strategies. This article discusses why there is a need for a population-based approach, provides a framework of how to conceptualize such an approach, and describes an example from our own work of a recently initiated prevention trial that illustrates a population-based approach in action. The rationale, structure, and goals of the Triple P System Population Trial are described in the context of the aforementioned population framework.

(Working with large populations - school-wide, city-wide and district-wide - it makes sense to use a "population approach to parenting and family support and intervention" instead of primarily trying to serve students and their families one by one. This is especially true considering the shrinking resources and increased demands!)

Applying a public health perspective to child and family intervention, a relatively new, innovative, and potentially paradigm-shifting approach is to adopt population-wide strategies that seek to optimize impact and reach larger segments of the child/family population.

(This is so exciting, let's usher in a revolution in the way we do business.)

Surveys of parents indicate that as much as a quarter to a third of children in the general population exhibit behavioral and emotional problems that present parenting challenges and risk for subsequent adverse outcomes. Unfortunately, a high proportion of children with behavioral or emotional problems never receive either preventive or treatment services, and those who do typically do not receive empirically supported parenting interventions.

(We can do better than this, simply by doing things differently. We don't have to work harder, although change seems always to be harder initially. This becomes less true for me when I focus on the ultimate goal, which is very motivating and gives me juice to overcome the hurdle of inertia.)

From an efficacy standpoint, family-based programming, based on social-learning, functional analysis, and cognitive-behavioral principles, is the treatment of choice particularly for early behavioral problems and conduct problems in general. Parenting and family support programs that are based on the same conceptual models have also proven efficacious for prevention.

(It is scary, as a trapeze artist, to let go of the last bar unless your other hand has a firm grip on the next bar. The next bar is better! Trust and let go, baby!)

Despite high prevalence rates for child behavior problems, only a small proportion of parents ever participate in a parenting/family intervention of any kind, and even fewer in one that is evidence based. If the delivery of programs is restricted for example to mental health clinics and private-practice clinicians, then parental access to programming is like to be quite limited. In fact, most contact points where parents routinely confer with frontline professionals (e.g., primary care, educational and daycare, public health) do not provide evidence-based information and support for effective parenting. The problem of access is multi-faceted: (1) most professionals with whom the general population of parents has contact are not prepared to provide evidence-based consultation about parenting and child behavior; (2) by and large, many parents who need assistance with child behavioral and emotional issues either cannot get adequate services or do not seek it out; and, (3) as a result, evidence-based interventions are reaching only a tiny proportion of children and families in the population.

(Let's change this, baby! Let's revolutionize the services to which the most vulnerable have access. Let's bring the best science to vulnerable communities! Revolution, baby! Access, baby! Tell me you are feeling the call!)

Empirical support for family-based treatments and preventive interventions has been well established. Practitioner adoption of evidence-based interventions for both treatment and prevention has been quite limited in a number of application areas, and the family/parenting area is no different. Much of the services in the child and family area are non-evidence based.

(Enough of this, now! Let's step out of the darkness and into the light. We know so much more now. Let's do better.)

The presumption underlying the deployment of population level interventions is that the component programs have shown evidence of efficacy and effectiveness. Going to scale at a population level, though potentially cost effective, is nonetheless a major investment that cannot be predicated on programs that have not been sufficiently validated. The field is just beginning to formulate standards of evidence necessary for broad dissemination of an intervention program. For example, the Society for Prevention Research (2004) has promulgated standards of evidence for viable preventive interventions. According to these standards, a program that is deemed ready for broad dissemination must have clear evidence for efficacy and effectiveness (described in detail in the standards), have materials and services that facilitate going to scale (e.g., manuals, training, and technical support), provide clear cost information, and have appropriate monitoring and evaluation tools. These criteria are important for understanding what is needed to conduct broad dissemination of a preventive intervention, including interventions for parents and families. However, there is an additional distinction that is relevant, namely that dissemination of parenting interventions on a broad scale and taking a population approach to parenting programming, while overlapping, are not entirely synonymous. In addition to the aforementioned dissemination criteria, a successful population approach requires evidence of flexibility, ease of accessibility, cost efficiency and practicality at a population level, and effectiveness in population-level applications.

I hope this abstract with additional article excerpts has peaked your interest. Check out the full article for more information. You too can be a nerd for social justice, efficacious and efficient interventions.

Sunday, August 15, 2010

Essential Questions

Who are you and what do you want?

These are the questions that ground me in the face of all external pressures - status, conformity, gender-role stereotypes, etc. The voice inside drowns out the external voices and is trustworthy.

We all mattered the day we were born, regardless. We don't need to strive to matter. Father Greg Boyle says that our world operates under the false assumption that some of us matter less than others. Social caste systems imply that some of us matter more than others. This is a socially-constructed delusion with very real effects and consequences. If it is socially-constructed, then new ways of thinking, mutual and widespread agreement can usher in the revolution.

My clinical supervisor, Reevah Simon, explained to me that 90% of who we are is the baby. The baby part is one of an inner triumvirate - the parent, the adult and the baby - and drives our behavior. The baby feels the pain of separation, envy and jealousy acutely. The distinction between envy and jealousy is that envy is admiration and longing for the personal qualities or material possessions of another. While jealousy refers specifically to wanting to posses the love, time and attention of a person in particular.

The pain is strong and intolerable leading to infantile rage if the need goes unmet or is frustrated. We have choices for coping with this intolerable pain. The adult in us can work to attain the quality or material object in question. This is the harder and more mature path.

Take the Taj Mahal, for example. Imagine standing before it and marveling at its beauty - design, materials, workmanship. Now you can build one of your own or with a few well-placed bombs, tear it down. Either appeases the baby and ameliorates the pain of envy. Buying stuff and talking badly about others might serve to soothe in the short term, but in the long run, it doesn't get you closer to your own version of the Taj Mahal, which will eat at you until you get around to building it. Focus on what you want, not on what you don't want. Do the work.

In your own life, what is your version of the Taj Mahal? Feel free to imagine it, build it. Why allow marketed distractions and flawed social constructions to divert you from your original masterpiece?

I like knowing who I am and what I want. I like being around people who know who they are and what they want. Acceptance is both freedom and liberating. Feeling secure in the knowledge that we matter and have nothing to prove. When you know who you are and what you truly want - you feel full. The baby stops wailing when it is full.