Saturday, September 25, 2010

What do you want to do about this?

"There are clear indications that the most vulnerable client populations, particularly poor, minority children and families are less likely to be met by responsive service providers and relevant intervention modalities."

From "Addressing the Barriers to Mental Health Services for Inner City Children and Their Caretakers" by Mary McKay et al, 1996.

Wednesday, September 15, 2010

Pearls of Wisdom from Supervision with Reevah Simon

I have been very lucky to be mentored by amazing professionals. One of them is Reevah Simon, LCSW-extraordinaire. Here are some pearls that have stayed with me like mantras:

Ongoing conflict implies underlying agreement.
What people say about or do to us is only a continual problem if in fact we secretly agree with it. Otherwise, we'd put a stop to it right away.

The Goal of Therapy
The goal of therapy is to help clients achieve their goals (not our goals).
The goal of therapy is the integration of good & bad feelings – integration and wholeness - connect the pieces – universality (Accepting and integrating instead of rejecting and defending against our dark side, because we all have a dark side and we all feel ambivalent about everything).

Did you want to raise your kids differently than you were raised?
This question gets to the heart of the matter, in terms of the emotional reasons that we parent the way we do. We usually make parenting choices in strong reaction, usually opposition, to how we were raised. If our parents were too strict, then we tend to become too lenient. If our parents were too permissive and we suffered because of it - experienced all the dangers of the lack of supervision - then we might become suffocatingly strict. If we liked our parents work just fine, we might become flummoxed when it doesn't work on one of our own.

Anger
Parents are afraid of their own anger or their child’s anger or their spouse’s anger because anger means being or becoming out of control. But someone has to hold the anger, because systems always equal 100%. If mom holds 0%, then dad or child end up holding 100%.

Parents and Children
Kids see the world the way their parents do.
If children are suicidal, parents may be depressed.
If parents don’t change, children are not likely to change.
Parents treat children as parents wish they would have been treated thereby recreating abusive relationships and now children are abusive to parents. In order to avoid being the victimizer, parents are willing to be the victim (of their own children).
Parents were good kids and wanted to please their parents. Now, as parents, they want to please their kids and their kids become abusive toward parents.
What is the goal of parent -- to have their child love them or to raise their child to be a productive adult in the world?
Ambivalence – parents as helpless (not angry at own parents) vs. parents can change (have to be angry at their own parents).

Parents & Discipline
Good parent = not overwhelmed by feelings, container (calm, consistent)
Parents only have problems with children’s behaviors they feel ambivalent about.
Every event (child & parent interaction) ends in one of two ways:
(1) Parent succeeds or (2) Parent gives up
Appropriate discipline is a form of love. It is abusive to set up a child to fail. Children who don’t obey rules have problems in life.
Parents are waiting for their own parent’s discipline techniques to work with their children – why should they do anything differently?
Parents wait to get angry to be determined (about demands, rules and discipline).
It is very unpleasant and powerful when someone you love is angry at you.
Kids do 100% of what their parents want (vs. what their parents say).
There cannot be ongoing conflict unless there is underlying agreement or else they would put a stop to it.
Kids see parents and teachers in alliance. Common ground = future rules. Parent gives child rules in front of the teacher.
Work on home behavior before school behavior.
Opposing parent won’t give equal and opposite rule - don’t listen to your mother, don’t do your HW.
Kids have a right to their thoughts and feelings, parents have control over their child’s behavior.
Parents are doing to you (SW) what their kids are doing to them. Call them on it and be a firm parent that doesn’t give in.

Good stuff, no? There is so much more but that is enough for tonight. Sleep well friends.

Tuesday, September 14, 2010

Learning Collaborative Example

Abstract:

This study examined the impact of a learning collaborative composed of five child mental health agencies which was conducted from November 2005 to November 2006 in a suburban community adjacent to New York City.

The following data submitted by each agency were retrospectively analyzed:

1) initial show-rates for first intake appointments for all new evaluations of children and adolescents, and/or;
2) attendance at any scheduled clinic appointment subsequent to the first kept intake appointment.

Agencies reported an increase in kept initial appointments ranging from 5% to 21% over the previous year, while kept subsequent appointments evidenced an increase between 2% and 16%. In contrast, one site that did not administer the engagement strategies noted a decrease in both engagement and subsequent appointment rates during the course of the collaborative between 9% and 13% respectively.

These findings support the effectiveness of learning collaboratives for improving service use among youth with mental health difficulties and their families.

I am smelling the seeds of a research question for my dissertation. When I was a beginning school social worker at an elementary school in South LA, my kept rate for intakes with parents was about a frustrating 50%. When I went to work at high schools in North Hollywood and East LA, it went up to 90% (thanks to consultation with my Clinical Supervisor). By the time I got to Harmony ES, it was at 99%. Parents didn't change, I did, or at least my engagement strategies did.

Learning Collaboratives - What?

So if it is the next best thing, then what is it exactly?

It is "a well-regarded methodology for disseminating practice improvements in healthcare."

1. You start with a clinical practice you want to improve - a focus area or topic (For instance, an article was published recently titled, "The effect of a learning collaborative to improve engagement in child mental health services.")

2. Then you convene experts - subject and application experts.

3. You invite interested organizations to participate voluntarily (this is key for the "collaborative" part).

4. You develop a framework and changes.

5. There are a series (usually three over the course of a year or so) of learning sessions that bring together experts and organizations to exchange ideas. Experts present the framework and changes for ideal care and later this is bolstered by the voices of practitioners who can say, "I had the same problem and this is how I solved it."

6. Each of these learning sessions are followed by action periods (usually three) for testing the changes proposed during the learning sessions. During the action periods, organizations use a scientific method -Plan-Do-Study-Act cycles (also referred to as small tests of change), to address barriers and quickly make improvements necessary to accomplish the collaborative goals.

7. Ongoing support may include email, visits, phone conferences, webinars, monthly team reports, intranet resources and dialogue, etc.

8. At the end there is celebration and publications - but most importantly, there is change, practice improvement and better care and outcomes for our clients. Everyone can learn from and celebrate that.

Learning Collaboratives - Why?

I have been a proponent of evidence-based practice because who can argue with the idea of using good science to inform clinical practice?

There is a dark side to EBP, of course. There is always a dark side. How is it compiled? Who gets the label? What research (RCTs) get funded? Politics drive a lot of these questions. Then there is the politics of implementation.

I have mainly focused on EBP as the bridge over the chasm between research and practice, but this bridge isn't clean because of the politics that drives everything.

Politics has a bad rap - I use it here to describe the reality that there are always multiple stakeholders, each with their own interests/concerns/needs/agenda, trying to form and inform what we do. Everything is political. Because of the naturally conflicting needs of various stakeholders, the process gets a bad rap. We need PeaceMakers or Conflict Mediators for adults. Conflict isn't bad, it's natural. The problem is we don't know what to do with it. We usually try to avoid it, which doesn't help or makes things worse. It is so important for every stakeholder to stand up and use their voice. This is the best way to make sure that solutions, including policy, are comprehensive and serve the greatest good.

So where is the hope for integrating research and practice? Learning Collaboratives.

It is a model devloped by the medical community (same origins of EBP). It was created expressly for the purpose of closing the "gap between what we know and what we do."

"Sound science exists on the basis of which the costs and outcomes of current health care practices can be greatly improved, but much of this science lies fallow and unused in daily work."

This model has been used to improve asthma care for children and adults, reduce cesarean section rates, reduce delays and waiting times, reduce costs and improve outcomes in adult cardiac surgery, improve care at end of life, and so on... These areas were chosen after a national survey of clinical, policy and administrative leaders and published as "Eleven Worthy Aims for Clinical Leadership of Health System Reform."

If the field of school social work or school mental health applied this model, what practice improvements would we tackle first? What topics would you put on the following list?

"Eleven Worthy Aims for Clinical Leadership of School Mental Health/School Social Work/Child Welfare Reform"

Monday, September 13, 2010

Flexibility with Fidelity

I love this abstract as it highlights an important aspect of evidence-based practice: we are not rigid or robot practictioners! We can and must tailor the essential program components to fit the client(s) sitting in front of us.

Title:
Implementing trauma-focused CBT with fidelity and flexibility: A family case study

Author:
Kerig, Patricia K.; Sink, Holli E.; Cuellar, Raven E.; Vanderzee, Karin L.; Elfstrom, Jennifer L.

Source:
Journal of Clinical Child and Adolescent Psychology. Vol 39(5), Sep 2010, pp. 713-722

Descriptors:
Cognitive Behavior Therapy*; Family*; Grief*; Posttraumatic Stress Disorder*; Trauma*; Evidence Based Practice

Abstract:
Effective approaches for the treatment of childhood posttraumatic stress disorder and traumatic grief are needed given the prevalence of trauma and its impact on children's lives. To effectively treat posttraumatic stress disorder in children, evidence-based practices should be implemented with flexibility and responsiveness to culture, developmental level, and the specific needs of the family. This case study illustrates flexibility with fidelity in the use of a manualized treatment, describing the implementation of Trauma Focused-Cognitive Behavior Therapy with three traumatized family members: a caregiver and two children. Particular attention is paid to the use of creative strategies to tailor interventions to the individual clients while maintaining fidelity to the principles and components of this evidence-based treatment.

Symboldrama

Cool abstract about a pilot study of an innovative intervention (love this kind of stuff):

A total of 15 clinically referred adolescents who had been sexually or physically abused participated in this pilot study of the use of symboldrama psychotherapy. Symboldrama is a psychotherapeutic method that uses imagery as the major psychotherapeutic tool.

All adolescents reported to be suffering from a high level of dissociative symptoms and other symptoms such as anxiety, depression, posttraumatic stress, and anger after their traumas.

The objective of the study was to test the hypothesis that symboldrama psychotherapy in addition to psycho-education of the non-offending parent would significantly reduce the reported symptoms.

Before treatment, the participants answered three questionnaires: (a) the Life Incidence of Traumatic Events Scale, (b) the Trauma Symptom Checklist for Children, and (c) the Dissociation Questionnaire, Swedish version. After treatment, the participants once again filled out the Trauma Symptom Checklist for Children and the Dissociation Questionnaire, Swedish version. The scores from before and after treatment were compared, and the results showed that the symptoms had been statistically significantly reduced.

Title: Symboldrama, a psychotherapeutic method for adolescents with dissociative and PTSD symptoms: A pilot study.
Author: Nilsson, Doris & Wadsby, Marie
Source: Journal of Trauma & Dissociation. Vol 11(3), Jul 2010, pp. 308-321

Thursday, September 9, 2010

New School Year - Year 2

I am beginning the 2nd year of the doctoral program. I can't even believe it. One year ago I was starting the program. Two years ago I was applying. That's how it happens - increments, baby steps.

I am working on a study plan and a research internship plan. In the study plan, I have to choose a focus:

1) Substantive area in social welfare
Evidence-based practice? My advisor says this is not a substantive area, more of a method or approach. Resilience? He says this is too big. He suggested child welfare, but this sounds like DCFS work, specifically. So it will be children's mental health and well-being or something like that.

2) Social and behavioral science knowledge applicable to the substantive area
The courses I want to take for this are mostly in Community Health Sciences. Courses like, Communication-Health Promotion and Education, Health Communication-Popular Media, Communication & Media Development in Health Promotion & Education. My idea is to adopt a universal, public health approach to children's mental health and well-being in the schools.

My thinking is that there are way too many of us, parents and kids, to address children's mental health in a piece-meal, individual therapy sort of way. There are nearly 700,000 students in LAUSD alone. Schools burst with 1,000 to 3,000 students. Since social norms are powerful and predictive, then why not spend some energy shifting those? It is less stigmatizing and individual therapy. Actually, it is the opposite of stigmatizing! It is easier to do it if everyone is doing it! Also, cheaper, preventive, etc.

Then I want to take this course: Latin America-Traditional Medicine, Shamanism, and Folk Illness. Cool, right? I want to RCT that shit right there. I am curious about how people around the world have figured it out. What helps kids grow up to be healthy, happy and wise despite the risks and traumatic events? If it means traveling to find out, I am down with that, too. It also strikes me as cheaper than the fancy shit that a lot of researchers have cooking up. Do you know how expensive evidence-based family therapy interventions are? Very expensive. That doesn't seem right.

3) Research methods
I am taking two quarters of Community-Based Participatory Research with Ken Wells, brilliant mind man. The class is designed for Robert Wood Johnson Foundation Clinical Scholars (physicians who want to be researchers) but Ken let me in. I have to take at least one more Statistics class (ugh) and I want to take some qualitative research methods courses, too.

Meeting with my advisor really set me at ease. My ideas, as grateful as I am for them, overwhelm me sometimes. I love it when professors help me to contain them - organize them, shape them into something useful.

Monday, September 6, 2010

Why?

I was recently asked, "Do you consider yourself a Christian?"

With time to think about it, I offer the following reply: "I consider myself a hardcore Christian. I'm also a hardcore Buddhist. And I'm a hardcore defender of human rights. I want to reclaim Jesus' message from the intolerant fanatics who have co-opted the Bible and the movement in order to perpetuate ignorance and hatred in the world."

This blog is about what I am learning. It is also about why I am learning. And how I get by. Because it is not easy. It is one of the hardest things I have ever taken on. Right up there with raising my daughter. I would not be here, still standing, if God did not have my back in this thing. I felt beat up last year - juggling school, work and family. But not showing up would have been worse.

Thank you, Yesus. Amen.

Saturday, September 4, 2010

Downloads

When God says to me, "Go and stand over there"

I don't want to be found standing anywhere but "over there"

no matter how scary "over there" appears to be from over here

I trust the small, still voice inside

It has never lead me astray

Amen.

There is no competition on the road to being yourself.
No one can be a better you than you.
So, again, I ask, "Who are you and what do you want?"
If your answer scares you because you fear the outside world might judge you and say, "who do you think you are to be and want that..." then remember from whom you came.
Because if God is for us, then who can be against us?
God loves you and everyone else. There is enough for all of us.
There is no competition on the road to being yourself.

The only thing I am afraid of is not doing what I came here to do.
The universe will conspire to help us.
It is our birthright to be who we are.

Evidence Based Practice "with all deliberate speed"


Recently, I went to the Museum of Tolerance with my family. We walked through an exhibit on the history of school segregation (both Brown/White and Black/White). I came across this quote from the Supreme Court ruling, Brown vs. Board of Education. Just because laws change, it doesn't mean that people will "act right" all of a sudden. Schools changed "slowly and with great resistance."

The quote made me think of research-based and evidence-informed practices in both education and mental health. Taking the best of science and applying it to standard practices and interventions in both fields makes sense - I mean, don't all students have a civil right to this? But change has been slow and has been met with great resistance.


A couple of weeks ago, I spoke to an administrator from the Department of Mental Health who said there is a growing trend of anti-intellectualism among providers. I immediately registered his remark as an epistemological concern - that is, there are Masters-level and licensed clinicians who do not privilege research as an important, albeit limited, form of knowing.


I wondered what dynamics might be at play?
  • Is this about a philosophy of knowledge?
  • A collective temper tantrum in the face of change coming from the top?
  • Are we scared to uncover that the way we have been doing things, ways that we have grown accustomed to, have become comfortable with and that we can do in our sleep, are not working or even harmful?

I don't mean harmful to life or limb. What I mean is,
if we pull students out of class and
don't offer them something that we believe (based on systematic evidence)
will reduce their specific cluster of symptoms and
accomplish their personalized and tailored academic and mental health goals and
evaluate whether this happens or not and
do something differently if not,
then we may have just wasted precious (life and instructional) time that our most vulnerable students cannot afford.


Poor and minority students of color have been lagging behind their white counterparts for far too long - on almost every important indicator in education, health, and mental health.


What our students need is the best, the very best and nothing but the best.


What we have been doing has not been good enough. We need better for every student, in every class, at every school, day-in and day-out, every year.


In the face of economic crisis and cut-backs, there is more to do with less.


So how do we make up for this slack?


Working ourselves to pieces is not an option.


This is where the research can help.


How do we do better with what we have?


Not more output - but more efficient, focused and effective output.


Giving up some old and traditional ways, in this case, will actually make things easier. And not everything needs to be thrown out with the bath water. There are some timeless practices that jibe with current research and can be integrated nicely.


Are you moving swiftly for social justice and social reform? Or is fear dragging your feet and throwing up resistance?


How do we do better with less? Let's put our hearts and brains together and figure this (s&*%) out (dammit).


This is how schools in the South managed to sit 3 students at a desk in the classroom when they only had 2 chairs.


Whatever we need to do for our students now, we can figure it out.