Sunday, January 30, 2011

Support & Resilience for the Whole Family

Abstract:

A non-experimental pilot study examined child, mother and family outcomes of a 10-session multi-family group intervention designed to reduce risk and promote resilience for mothers with depression and their families.

Positive changes following the Keeping Families Strong intervention included:
  • mother-reported decreases in child behaviour and emotional problems
  • mother-reported improvements in the quality of family interactions and routine
  • mother-reported improvements in their own well-being and support from others
  • children (9–16 years) reported decreased internalizing symptoms
  • children reported improved coping
  • children reported increased maternal warmth and acceptance and decreased stressful family events
  • attendance and mother-reported satisfaction were high, indicating the perceived value of the intervention

Valdez, C. R., Mills, C. L., Barrueco, S., Leis, J. and Riley, A. W. (2011), A pilot study of a family-focused intervention for children and families affected by maternal depression. Journal of Family Therapy, 33, 3–19.

Saturday, January 29, 2011

Open Communication in Grieving Families

Article Abstract:

The nature of surviving parent-child communication in bereaved Israeli families is examined in terms of the culture of Israeli society. Concern is with the way the culture frames the parent-child relationship in the period shortly after the death.

Twenty-three surviving parents and their forty-three children between ages of six and sixteen were interviewed four months after the death. Both parents and children seemed concerned with protecting each other from the pain and sadness associated with the loss.

Two types of families were identified.  
  1. In the open family, language is used to console and inform. Parents see themselves as able to respond to their child(ren)'s needs. 
  2. Less open families used language to influence the child to avoid their feelings and confronting the death. These surviving parents often saw the deceased as the competent family caregiver.
Silverman, P.R., Weiner. A., Nava, E.A. (1995). Parent-Child Communication in Bereaved Israeli Families. OMEGA--Journal of Death and Dying, 31(4), 275 - 293.

Integrating Family Therapy in Adolescent Depression Treatment

Abstract:

"Adolescent depression, particularly where suicidal behaviour is involved, is a complex and pressing mental health problem and demanding for families, therapists and services alike. This article reviews the evidence-based literature for adolescent depression including family therapy approaches. It suggests an integrative treatment approach that includes individual psychological treatment like CBT, medication where required and a family therapy intervention is supported by the literature. The focus of the latter is psychoeducation, building resilience and hope, enhancing communication, reducing relational conflict between parents and adolescents and addressing attachment and relationship issues. A systemic framework for integrating family therapy in the evidence- based treatment of adolescent depression is described. This is based on an ethic of hospitality towards different languages of therapy, which is illustrated by a detailed example from family therapy practice."

Larner, G. (2009), Integrating family therapy in adolescent depression: an ethical stance. Journal of Family Therapy, 31, 213–232.

Can I get a Hallelujah! and Amen!  CBT and medication (if necessary) and family therapy. Incorporating hope, resilience, communication, relationships and attachment into the family therapy treatment plan - integration. Can you dig it?!

A SAMHSA (2003) nationwide survey of school mental health services found that at the high school level, the two most common presenting problems were depression and substance abuse. Both of which, the research shows, are effectively treated with family interventions.  The same survey showed that family support services were most challenging to provide - as reported by the study respondents.

We are not there yet.  What's the best path from here to there?

Promoting Family Therapy

Article Excerpt:

"...take into account the growing evidence base that family therapy makes a difference to the lives of many families and individuals who are suffering (Carr, 2009a, 2009b; Crane, 2008). We also have to note that current evidence suggests that qualified family therapists seem to get better results than other professionals (Moore et al., in press). Such evidence...contributes more widely to the promotion of family therapy."

Rivett, M. (2010), Family therapy and family therapists: ambiguous and ambivalent relationships. Journal of Family Therapy, 32, 91–93.

Reflection and Supervision

Article Excerpt:

"The paradigm shift in family therapy that took place in the late 1970s to early 1980s was a shift towards a second order perspective (Hoffman, 1985). It embodied the view that we could no longer play the role of detached observers; the act of observation influences that which is observed (Heisenberg, 1962; Von Foerster, 1990). This shift implied that we needed to start asking questions of ourselves, and to consider our place in the therapy, in addition to the ideas and questions we may have about, and discuss with, our clients."

Mason, B. (2010), Six aspects of supervision and the training of supervisors. Journal of Family Therapy, 32, 436–439.

The Metamorphasis of Family Therapy

Abstract:

This paper reviews the current state of the theory and practice of family therapy. It proposes that the field is undergoing a radical metamorphosis in which its theory base is becoming characterised by less ideological "purity", more attention to an evidence base and an integration within other treatment modalities. Like all such metamorphoses, this transformation of family therapy is not without its difficulties. In many ways, professional contexts, professional institutions and training programmes, at least in the UK, do not appear to have made the adjustment to this change. The paper will therefore highlight these contextual issues as a counter-point to the metamorphosis that is in process.

Key Practitioner Message:
• Family therapy is changing into an evidenced based intervention
• Family therapy is integrating aspects of other therapies into its approach
• Guidelines exist which describe the content of family therapy for particular child and adolescent difficulties

Article Excerpt:

"Family therapy is now constantly seeking to connect rather than divide with the phrase 'both/and' more common than that of 'either/or' (Goldner et al., 1990)."

Rivett, M. (2008), Towards a Metamorphosis: Current Developments in the Theory and Practice of Family Therapy. Child and Adolescent Mental Health, 13, 102–106.

The Therapist's Experience in Family Therapy

Article Excerpt:

"A consistent finding in psychotherapy research is that the quality of the therapeutic alliance is one of the best predictors of psychotherapy outcome (e.g. Bachelor and Horvath, 1999; Martin et al., 2000; Orlinsky et al., 2004): ‘Positive therapeutic outcomes are robustly predicted when therapists are experienced as being personally engaged rather than detached, collaborative rather than directive, empathic, and warmly affirming’ (Orlinsky and Ronnestad, 2005, p.179). This seems to be true for psychotherapy in general, and for family therapy in particular (Blow et al., 2007; Carr, 2005; Sprenkle and Blow, 2004).

The question I want to pose in this article, however, is how therapists should deal with strong emotions which they might experience during sessions, especially if at first sight these emotions do not seem to contribute to a positive working alliance. What should therapists do when they experience emotions such as irritation, hopelessness, sadness and fear during the session?

I will propose some ideas that address these questions. They deal with the complexity of the therapists’ experiencing and their vulnerability during sessions, in such a way that some of the therapists’ difficult or ambivalent experiences in therapy can become useful in promoting a collaborative therapeutic dialogue."

Rober, P. (2010) The therapist's experiencing in family therapy practice. Journal of Family Therapy, 1-23.


The therapeutic alliance that predicts positive therapeutic outcomes sounds a lot like the dance of attachment. 

Tuesday, January 25, 2011

Open Communication

Previous posts have stressed the benefits of open communication in families for coping with trauma and other stressful events.

When school social workers meet with students who say that they "don't want to talk to their parents about their problems," do we collude with family separation and secrecy or do we explore the ambivalence in an effort to promote parent-child communication?  This is why I tend to meet with parents first.  I don't want to get caught in a position where I am being asked to "swear to secrecy" (suspected child abuse, suicidal and homicidal ideation notwithstanding) and feel pressured to triangulate with a student against a parent.

The dance of attachment security (also addressed in previous posts) involves a caregivers attuned responses to a child.  That is, providing proximity, soothing and support to a child in distress.  Support that is well-matched to the child's needs.  This is no easy dance.

What we know is that attachment security (fluid and elegant dancing) mediates and moderates the development of PTSD and other psychopathology.  Studies have examined the relationship between attachment security and PTSD symptom development among war veterans, holocaust survivors, targets of domestic violence, and victims of child abuse.  It significantly mediates and/or moderates every time.

If a child (or adult) does not have a partner in this dance, then what soothes the distress?  Substance abuse, self-mutilation, isolation?  There are studies about this too.

If attachment security is so powerful, then when students say, "I don't want my parents to know," do we leave it at that?  Or do we explore and engage in an effort to bring the child back into a dance with a willing caregiver that protects and soothes in times of distress? 

The Substance Abuse and Mental Health Services Administration (SAMHSA) conducted a national survey of school mental health services in 2002-03.  The most common types of services, reported by more than 80% of schools, included assessment, behavior management consultation, crisis intervention and referrals.  More than 70% of schools also reported individual counseling, case management and group counseling as common services provided.  Schools reported that among the most difficult services to deliver were family support services (Sopko, 2006).

What is the disconnect between school mental health services and families?  How do we bridge the gap system-wide?

Saturday, January 22, 2011

Social Worker as Facilitator or Fixer?

In an observation exercise assigned to Masters-level Social Work students, Urdang provided these directives:  “It is your task not to advise, not to change, not to tell, but to inquire. As you inquire, clarify, and reflect, you will gain an appreciation of the client’s ability to think, to reason, to plan and to problem-solve" (Urdang, 1999).

My clinical supervisor, Reevah, used to say to me, "telling is not therapy" and "explore the client's ambivalence."  That is, ask about what is standing in the way between what they say they want and where they are.  Usually, there are thoughts, feelings, fears and justifications standing in the way.

When reviewing process recordings, I used to tell my interns that they did not have to change, fix, deny, or rescue clients from their feelings - listen and validate the feelings first, especially before moving on to engage in problem-solving.  I wish I remembered to do this more often in my personal life.

A renowned psychiatrist remarked that psychoanalysts allow clients to figure it out (I sense that some Social Workers perceive this as cruel), while Social Workers fix it for their clients (I believe psychoanalysts see this as infantilizing).

Where are you on the continuum?  What is the balance?  There must be some truth to both sides?  Where do the "sides" converge?

Tuesday, January 18, 2011

Therapeutic Attachments

Excerpt from article:
"Hoagwood (1997) reminds us that “smaller, interpersonal, and uniquely human exchanges. . .are the marrow of effective services” (p. 549). In adult mental health treatment, relationship factors such as attention, positive regard, and empathy have been shown to account for nearly a third of the variance in treatment outcomes: in contrast, specific therapeutic techniques account for just 15% of the outcome variance (Lambert & Barley, 2002)."

Kemp, S.P., Marcenko, M.O. Hoagwood, K. & Vesneski, W.  (2009) Engaging Parents in Child Welfare Services: Bridging Family Needs and Child Welfare Mandates. CHILD WELFARE, 88, 101-126.

Engaging Families in Substance Abuse Treatment

Article excerpt:
"Family therapy enabled the drug abuser to separate and individuate from the family of origin by disengaging the symbiotic relationship with the maternal figure and strengthening the disengaged relationship with the paternal figure."
Weidman, A.A. (1985). Engaging the Families of Substance Abusing Adolescents in Family Therapy. Journal of Substance Abuse Treatment, 2, 91-105.

Saturday, January 15, 2011

Attachment Style and Emotional Expression

Abstract

Pennebaker’s disclosure paradigm is a powerful manipulation: writing or talking about emotional experiences has positive effects on health. Nevertheless, the effect does not work for all people and some studies, including those of the highly emotional event of bereavement, have failed to demonstrate any effect at all.

This paper reviews empirical evidence and proposes an integrative model to help explain discrepant findings and assess individual differences in the manipulation’s effectiveness. Taking bereavement as exemplary of an attachment-related loss experience, it examines the relationship between styles of attachment, internal representations of the self and other, and patterns of disclosure in the coping process.

Research has shown disturbances in disclosure among insecurely attached persons. We argue that secure persons are less likely to benefit from the disclosure paradigm, since they are better able to disclose in ways that further the adjustment process in their everyday lives. Targeting persons with
insecure attachment styles and providing attachment-style-specific disclosure instructions are likely to increase the power of the manipulation.

Our examination of these individual difference patterns is compatible with recent cognitive and linguistic analyses underlying the disclosure paradigm’s impact on health.

Keywords: Self-disclosure; Attachment style; Bereavement; Coping; Well-being; Health

Stroebe, M., Schut, H., Stroebe, W.  (2005). Who benefits from disclosure? Exploration of attachment style differences in the effects of expressing emotions. Clinical Psychology Review, 26, 66– 85.

Reexperiencing Painful Emotions

ABSTRACT

Recently, a great deal of attention has been focused on the health promoting benefits that can accrue from revisiting painful emotion. The rationales for revisiting painful emotions include those that assume reexperiencing emotion per se can be health-promoting.
 

Another view stipulates that revisiting painful emotion will only yield benefit if there is some
recasting/restructuring of the emotional memory. Research pertinent to the various rationales is
discussed. Then research on the impact of emotional expression and outcomes studies of therapies designed to enhance emotional experience are reviewed.


Good supporting evidence is found for the effectiveness of behavioral exposure therapies where the duration of emotional exposure is carefully controlled, as well as for the salutary impact of talking or writing about trauma by normally functioning individual. 

On the other hand, studies evaluating the impact of experiencing and expressing painful emotion in an unstructured fashion with clinical samples suggest that the process can be harmful. 

lncorporating findings from the behavioral exposure literature and from the Pennebaker writing-about-trauma studies, the case for evoking emotional memories for the purpose of developing new responses is advanced. The dangers of encouraging emotional expression in absence of acquisition of a new response to the emotion-evoking material are discussed. 

Litrell, J. (1998). Is the Reexperience of Painful Emotion Therapeutic?  Clinical Psychology Review, 18(1), 71–102.

Benefits of Expressing Life Goals

Abstract

This study employed a 2 (writing vs. talking) x 2 (life goals vs. daily schedule) fully crossed, factorial design to examine whether health benefits might accrue for talking and/or writing about life goals.

Participants assigned the life goals topic had fewer illness-related health center visits, regardless of mode of expression, compared to participants assigned the non-emotional topic.

Counter to expectation, optimism did not moderate the effect of topic on illness-related health center visits.

Participants in talking groups rated post-intervention mood as less negative than those in writing groups and participants rated talking about life goals as more diYcult than writing about life goals.

Keywords: Expressive writing; Expressive talking; Life goals; Health; Disclosure

Harrist, S., Carlozzi, B.L., McGovern, A.R., Harrist, A.W. (2007). Benefits of expressive writing and expressive talking about life goals. Journal of Research in Personality, 41, 923–930

Pennebaker Essay on the Healing Properties of Writing

Summary of Essay

When individuals are asked to write or talk about personally upsetting experiences, significant improvements in physical health are found.

Analyses of subjects’ writing about traumas indicate that those whose health improves most tend to use a higher proportion of negative emotion words than positive emotion words.

Independent of verbal emotion expression, the increasing use of insight, causal, and associated cognitive words over several days of writing is linked to health improvement. That is, the construction of a coherent story together with the expression of negative emotions work together in therapeutic writing.

Evidence of these processes are also seen in specific links between word production and immediate autonomic nervous system activity. Implications for therapy and for considering the mind and body as fluid, dynamic systems are discussed.

Excerpt from the Essay
"It is widely acknowledged in our culture that putting upsetting experiences into words can be healthy. Research from several domains indicates that talking with friends, confiding in a therapist, praying, and even writing out one’s thoughts and feelings can all be beneficial. The purpose of this paper is to explore why writing and talking about personal experiences can promote psychological and physical health. Specifically, to what degree are the words that we choose linked to our physical and psychological health?"
Pennebaker's Summary of Implications

Emotions and cognitive work

Across studies, both emotional and cognitive factors independently predict improvements in health. Ironically, these findings suggest that many of the classic battles between catharsis or emotion-based therapies and the more recent cognitive movements are unnecessary. That is, both catharsis and insight appear to be at work, but in different ways.

Some narratives are better than others

Holding a coherent narrative to explain a traumatic or upsetting experience may not always be healthy at the beginning of therapeutic writing sessions. Movement towards the development of a narrative is far more predictive of health than having a coherent story per se. The construction of a story rather than having a constructed story, then, may be the desired endpoint of writing and, by extension, some therapy.

No pain, no gain

Openly expressing negative emotions results in increases in skin conductance levels (SCL)--an
autonomic index linked to behavioral inhibition. The expression of positive emotions is linked to a letting-go or form of relaxation. In the short run, confronting upsetting experiences may be psychologically painful and physiologically arousing. In the long run, however, the act of psychologically confronting emotionally upsetting events is associated with improved physical and psychological health.

The ability to guide one’s own therapeutic writing

Writing itself is a powerful therapeutic technique. Without instructions or feedback, subjects in Pennebaker's studies naturally evolve common writing styles that promote physical and psychological health. It may be possible to train people to write in certain ways in order to boost the effectiveness of writing. In a pilot study, 14 students were asked to write about their deepest thoughts and feelings each day for two weeks. On two days, students were given a list of word categories (negative emotions, insight words, causation words) that they should actively attempt to use in their writing. Although the students noted that their writings were least personal on those days (and also were most difficult to do), they also noted that those writing days were the most valuable and meaningful for them.

The mind and body as fluid, dynamic systems


The body expresses itself linguistically and biologically at the same time. In discussions with voice and movement coaches in the theater, Pennebaker says it is clear that people can talk and/or stand in either natural or unnatural ways. When people portray characters that are pompous or arrogant, there are corresponding affectations in language structure, voice tenor, posture, and, he suspects, autonomic and endocrine activity.

Invited Essay
Putting Stress into Words: Health, Linguistic, and Therapeutic Implications by James W. Pennebaker
Behav. Res. Ther. Vol. 31, No. 6, pp. 539-548, 1993

Thanks, Dr. Pennebaker your words are beautiful and hopeful. 

The information provided in the essay summary (taken directly from the article) about the number or proportion of negative emotion words in writing that is healing seems to contradict some of Pennebaker's earlier findings (listed in an earlier post). I will email him to ask him to clarify the seeming discrepancy. 

The case for the evolution of a coherent story is strengthened. It doesn't need to make sense before we begin writing.  We write so that over time, it begins to make sense.   Even if we start out overwhelmed by the mass of it, we can tinker at the edges until we get there.  I am starting to see the value of the coherent story everywhere - the arts, attachment security, social science research, physical health, trauma memory resolution...

Becoming Expert

What do you want to become expert about? 

This is the question asked of us by professors at the 1st year doctoral program orientation last fall.  The question intrigued and excited me. 

The fog is lifting and the answer is becoming clearer.   
I want to know all about attachment and risk & resilience theories.  
I want to know how to develop and test new models of family and community interventions anchored in these theories and empirical findings.

To that end, I have been reading about attachment and resilience.  What you focus on, read about, think about and write about changes you.  I am glad to be immersed in these theories.

The Heat is On Writing

This quarter is all about writing.  I am working on a publishable paper and a dissertation proposal.  Ideas and readings from the last two years are coming together to form coherent and integrated stories.  To help me put it together in this strange new format, I am, of course, consulting "my mother" - the books.

I found several books on amazon.com with friendly titles like:
  • Writing Your Dissertation in Fifteen Minutes a Day: A Guide to Starting, Revising, and Finishing Your Doctoral Thesis by Joan Bolker
  • Writing Your Journal Article in Twelve Weeks: A Guide to Academic Publishing Success by Wendy Laura Belcher
  • How to Write a Lot: A Practical Guide to Productive Academic Writing by Paul J. Silvia
  • The Literature Review: Six Steps to Success by Lawrence A. Machi
  • Writing for Social Scientists: How to Start and Finish Your Thesis, Book, or Article by Howard S. Becker 
There is a graduate student resource center at UCLA that offers workshops on writing the dissertation proposal and uses the book on this list related to that topic.  This is reassuring, otherwise I might have passed it by as too friendly and downright hokey (really? 15 minutes a day?).
    Amazon lets you browse inside some of these books so I started to read the last book on this list.  It is written by a sociology professor, Howard Becker, who tries to make the problems of writing "less problematic" and in his book proposes "finding the roots of writing problems and the possibilities of their solution in social organization."  

    Becker talks about his own observations of students struggling to write as a result of lack of confidence.  When you can't "write on demand," he argues, your confidence goes down the next time you approach a writing task and "before you know it, you can't see your way out."  

    He notes the difference in writing by scholars and grad students from undergrad papers.  There is more at stake for the former group than the latter.  Scholars and grad students care more about the subject and are writing for others that care likely as much.  Our future rests on how peers and superiors will judge our writing.  Yikes!  I wasn't thinking about my writing in quite those terms, but now that he mentions it...

    He goes on to say that "problems of style and diction invariably involve matters of substance."  With a year and a half (+) of reading journal articles in my areas of interest and writing papers incorporating all those interests under my belt, I have much better stories to tell.  

    He aims to demystify the writing process because he says most students are unaware of the multiple drafts involved before publishing anything.

    This book was written as a result of teaching a writing course for sociology graduate students which invariably drew in students from other disciplines who were struggling with the same concerns.  He had been reading the Paris Review Interviews with Writers so he was inspired to ask the class about their writing habits:  "Louise, how do you write?"  She described the type of paper (yellow legal pad) and type of writing instrument (green felt tip pen) and how she had to clean the house before sitting down to write (oh, sister! I let that go a long time ago but apparently this is pretty common among women).  He asked others to describe their particular and peculiar writing rituals too.  He didn't allow anyone to pass.  It was clear that "shameful" disclosure was causing "great tension" in the classroom but by the end, he reports they were all "relieved" and "relaxed" - happy in the knowledge that they were all "crazy" when it came to writing.  He interpreted their "neurotic" writing symptoms sociologically as "magical rituals and charms" to dispel anxiety.

    So he asked them, "What are you so afraid of not being able to control rationally that you have to use all these magical spells and rituals?"  They feared two things:
    • They were afraid that they would not be able to organize their thoughts, that writing would be a big, confusing chaos that would drive them mad.
    • They were afraid that what they wrote would be wrong and that people would laugh at them.
    He pointed out to the class that they had shared "shameful" things in class and no one had died.  Interestingly, he writes, "I am no Freudian..." and he's right - sounds like he's using Cognitive Behavior Therapy (which is more Aaron Beck-ian).  He structured the class so that everyone had to bring in a paper for discussion and re-writing (exposure therapy?).  But first he brought in a colleague's "methods section" from a working paper and they ruthlessly edited and rewrote it in class for three hours - asking, "Does this need to be here?  If not, I am taking it out."

    Anyway, that is as far as the free preview would allow me to read.  What strikes me about all this is that everywhere I look - from public speaking to writing to asking for what we need to following our dreams - fear and negativity is in the air and we get in our own way.  The baby part in us tantrums and wants to quit or hide and the parent part in us can lovingly or firmly (whatever it takes, baby) wrestle us to the ground until we follow through and put in the hours of practice, however long it takes, to accomplish whatever is in front of us.

    Looking at the two most common fears about writing, I reflect on the reason I have written on this blog week after week for the last year and a half.  The purpose of writing on this blog has been precisely to organize my thoughts and digest the material I am learning. Not writing would drive me mad.  I am grateful that this medium exists and appreciate the supportive feedback that I have received.  In the last year and a half, I have been writing or reading for school.  When I got distracted while studying 10-12 hours a day, I would write on this blog.  Writing, writing, writing.  I am ready.  Fear or no fear.  It is time to put it all together.  I am writing because I have been writing.  Amen.

    Friday, January 7, 2011

    Exposure Therapy and Journal Writing

    There is an evidence-based intervention that is used in the treatment of anxiety disorders, including PTSD.  It is called "exposure therapy" and it is the most researched and empirically supported intervention there is.  Exposure studies date back to the 70s and 80s. 

    Exposure therapy, (also referred to as imaginal exposure or the trauma narrative) for the treatment of traumatic stress, involves the client telling the story of the traumatic event to a therapist, over and over, until habituation occurs.  That is, until the memory of the event is "digested" and is no longer upsetting and distressing.  Telling about what happened "there and then" in the safer "here and now."  Until then, thinking or talking about the event has produced painful emotions and physiological responses (increased heart rate, sweaty palms, etc.).  Trying not to think about it (avoidance as coping) is thought to cause and perpetuate the traumatic stress symptoms (nightmares, intrusive thoughts and memories, etc.) even though it appears to relieve the pain in the short-term. After the current fear of the old memory is faced and overcome, the client feels a "sense of relief and calm."  The memory can be filed away without the distressing emotions and physiological arousal attached to it - without the emotions and sensations that the memory was encoded with in the first place.

    Edna Foa, a trauma researcher, describes the approach in her book, Prolonged Exposure Therapy for Adolescents with PTSD: Emotional Processing of Traumatic Experiences:
    • 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.
    As a clinician,  I have conducted several sessions to review the trauma narrative with children and adolescents.  I listen and bear witness.  I ask questions only to facilitate the telling of the story with details about events, people and feelings.  I try to create a safe environment (warm and empathic) so the story can be told until the child reaches a sense of calm and relief.  I ask the student to rate their fear when telling the story now.  I watch as the ratings go up (more fear) and then go down (less fear) with each successive re-telling.  The first time I conducted a session, I felt the tension rise in my own body, my muscles ached after a few re-tellings.  I asked the student if she wanted to stretch between tellings and she said yes.  We giggled as we stretched - hands to the ceiling and hands to the floor.  I felt better after laughing and stretching.  At the end of treatment, she remembered the stretching was helpful, too.


    I train other social workers to use this technique as part of an evidence-based trauma treatment.  Social workers remark about how tired they feel after doing one to three sessions in one day.  I wonder about the transfer of energy.  I think about how one masseuse said that she sets an intention to help clients release toxins without taking them on herself.  I think about how vicarious traumatization in the course of therapy has been described:
    • As the emotional needs and distresses of people in difficulty were presented to me, I not only felt them through the process of empathy, but I also found I tended to absorb them within myself as well (English, 1976).
    • Conditions of depression and despair in one's clients (which he calls 'soul sadness') can be contagious (Chessick, 1978).
    • Research supports the notion that doing psychotherapy can be dangerous to the psyche of the therapist (Guy, 1987). 
    • The notion of vicarious traumatization...implies that much of the therapist's cognitive world will be altered by hearing traumatic client material (McCann, 1990).  
    • Secondary traumatic stress and compassion fatigue is a reaction from indirect exposure to a traumatic event...as a result of the therapist's own empathy towards a traumatized client in addition to the therapist's own secondary experience to the traumatic material (Figley, 1999).
    Then I come across Pennebaker's finding that writing stories about emotional events is healing, upsetting while doing it, but with a positive impact on physical health in the end.  Writing the stories that healed included certain elements, namely:
    • Writing about both facts and feelings surrounding the traumas - linking cognitive and affective aspects of the story.
    • Use of positive emotion words.
    • Use of a moderate number of negative emotion words.
    • Very high and very low levels of negative emotion words were related to poorer health.
    • Most important, an increase in both causal and insight words over the course of writing.  That is, people who benefited from writing began with poorly organized descriptions and progressed to coherent stories by the last day of writing.
    Now the "use of positive emotion words" and the number of negative and positive emotion words reminds me of the flourishing ratio that Friedrickson (2004) talks about in her "Broaden-and-Build Theory of Positive Emotions" and Losada’s model of team performance.   These researchers found that a ratio of positive to negative affect at or above 3 to 1 will characterize individuals in flourishing mental health.

    Fortunately, we can feel all our feelings - the so-called positive and negative ones - and still flourish.  Their balance just has to be 3 to 1 - three positive emotions to one negative emotion.  We don't have to be perfect or false.  Three to one will do nicely.  By the way, this turns out to be true for individual flourishing, couple relationships, and work teams.

    The idea of writing about emotional or traumatic events, even if no one provides feedback, as was done in Pennebaker's study with college students, intrigued me.  Healing for students without the risk of vicarious trauma for mental health clinicians?   Hmm.

    Storytelling

    When I teach social work courses, I often invite social workers to speak to students.  I ask the professionals to tell their stories - talk about the client or the project that made an impression.   I ask them to cover the details - who they were and what happened, the feelings that came up, the questions and self-doubt that they struggled to overcome.

    The Hero's Journey
    Students want to hear the stories of the work and be inspired.  They want to learn from the experience of seasoned clinicians. Students want to see themselves in the story - cast as the capable and flawed protagonist, who faced with a challenge, struggles with external barriers and internal feelings of self-doubt, and overcomes by using time-tested and time-honored skills competently in the context of a therapeutic relationship. 

    All the components of the social work process, including the theoretical framework and underlying rationale for interventions, are part of the story.
    • How did you meet and how did the relationship get started? - Engagement
    • What did you ask and what did they say? - Assessment
    • What did you think was going on with the client and their environment?  - Diagnostic Formulation
    • What did you decide to do and why?  Did the client agree? How did you explain this to the client? - Treatment Planning and Theoretical Rationale
    • What did you try?  - Interventions
    • How did that go? What progress did the client make?  How could you tell? Did the client accomplish their treatment goals?  Did they feel better? - Evaluation
    • How did you know you were done?  How did you say goodbye? - Termination
    Invariably, however, most guest speakers felt compelled to discuss their work broadly and abstractly, listing duties and components instead.  It seems that we believe the language of academia should be formal, abstract, detached.

    In Methods of Discovery:  Heuristics for the Social Sciences, Abbott notes that storytelling is used as a powerful explanatory method in research because...
    • ...Narration seems persuasive precisely because telling stories is how we explain most things in daily life.
    • ...Narration is the syntax of everyday understanding.
    If it is good for research in the social sciences, then it is good for the training of social workers.

    In Writing as a Sacred Path, the author notes that in ancient Celtic cultures storytelling was considered a service to the community.  Among the Dine people (Navaho), to be told a story is a great honor.

    Stories are gifts.  Write them down.  Tell the stories.  Share your insights.  Use your voice.  I bet that writing and organizing our professional stories, with details and coherence, leads to professional efficacy and resilience.  I may have stumbled on a hypothesis for testing.

    Whatever way your stories come to you is the right way.  --RL LaFevers

    Thursday, January 6, 2011

    Reading and Writing Again

    Winter Quarter, 2011 has just begun and I find myself sitting again for hours at a time.  It is a reading and sitting meditation practice. Monkey mind thoughts get in the way sometimes but the lure of ideas inspired by reading draw me into a deeper focus and concentration.  Every few hours I get up for water or to move around.

    Blogging is also a distraction and a release -  it is a place to put the thoughts and ideas piling up in my head while I read.  Blogging becomes a place to digest, organize, and make sense of what I am reading and flesh out the forming seed thoughts.  I see connections everywhere.  I want to build bridges between various theoretical frameworks, perspectives and approaches.

    My dissertation proposal seminar is taught by Zeke, my former epistemology professor.  He is old-school in the best sense of the word.  Zeke is probably in his 70s and a Michigan alum.
    • (An aside:  Michigan is the real deal, where it is too cold to do anything but study and where most grad programs are rated #1 in the country.  Dr. Brown, Director of the School of Social Work at CSULA, is also a Michigan alum and said their graduate school alumni make up the greatest percentage of graduate school deans and directors.)
    Zeke is from Israel and his native accent still comes through.  He uses braces to walk because of polio disease.  He is a scholarly heavyweight and a sociologist.  I am a dork because I find myself smiling in class a lot and giving him a thumbs up while I hang on every word he speaks and take copious notes.  It is a small seminar class - 8 students total - so it's hard to be inconspicuous with my painted-on goofy smile and hand gestures.  But I don't care because he is challenging and encouraging at the same time.  He takes my questions seriously and encourages being challenging.

    Some nuggets from yesterday's lecture:
    • Epistemology shapes the way we think about problems and dissertations.
    • By the end of Spring quarter, we will have a well-defined dissertation proposal that we are comfortable defending.
    • This is a writing seminar on substance and style, so expect to write and write and write. 
    • We will write the proposal piece by piece.  We will read each others work and discuss it in class.  We will write several drafts of each section of the proposal.
    • We will create an environment conducive to reflection and being self-critical.
    • Dissertations must be well-written, that is, everyone needs to be able to understand the language, concepts and intent.
    • Dissertation Proposal:
    1. Statement of the Problem (the heart of the dissertation)
    2. Critical Review of the Literature
    3. Own Theoretical Framework
    4. Hypotheses & Research Questions
    5. Methodology
    6. Timeline
    • If you're not passionate about your dissertation topic then you will be miserable and the work will be unbearable
    • Shoot above "run of the mill" but not too far in "left field" - get creative and add something new, your own special twist to the knowledge base - frame the problem in such a way that will make it exciting and different
    • In his research career, Zeke borrowed a concept from manufacturing and used it as an analogy:  "Human service organizations are like factories and people are raw materials."  Initially controversial, this new way of looking at things set him apart as a scholar.
    My assignment is to write the "Statement of the Problem."  He said this is the hardest part of the proposal.  Here I go...

    Research Study about Emotion Regulation in Anxiety Disorders

    The goal of the Emotion Regulation study is to improve upon already efficacious therapeutic strategies for all of the anxiety disorders and evaluate ways of enhancing the long term outcomes of treatment across a broad array of measures of functioning.

    The Emotion Regulation study is designed to compare two different versions of behavioral therapy for anxiety disorders.
    1. The first version involves teaching methods for slowing physiological responding, changing erroneous thoughts about anxiety inducing situations, and modifying behaviors in order to learn to overcome fears of specific objects, places, or experiences, through exposure therapy. 
    2. The second treatment version involves strategies designed to replace anxious physical responding and negative thinking with mindful and nonjudgmental observation, and shift behavior towards achieving life goals, again through exposure therapy.

    Eligibility Criteria

    Individuals who meet diagnostic criteria for any of the major anxiety disorders, Panic Disorder with or without Agoraphobia, Generalized Anxiety Disorder, Social Phobia, Obsessive Compulsive Disorder, Post-Traumatic Stress Disorder, and Specific Phobias, are eligible for the study if they are between the ages of 18 to 60, are English speaking, are not currently suffering from major medical conditions, and are either un-medicated or stabilized on medications for anxiety or depression.

    Screening Procedures

    • Interested participants call 310-206-9191 to complete a phone screener for initial eligibility. 
    • If eligible, participants are scheduled for an in-person, no-cost, diagnostic evaluation (approximately 2-3 hours) at the UCLA Psychology Clinic. 
    • Referrals are provided when the diagnostic evaluation indicates lack of eligibility for the study. 
    • Eligible participants are randomly assigned to either one of the two treatment conditions.
     Treatment Procedures

    Treatment is conducted one on one, over 12 weekly visits (at the UCLA Psychology Clinic) and is followed by phone calls once a month for the next 6 months. Assessments are conducted prior to beginning treatment, at completion of treatment, 6 months, and 12 months later. These assessments include diagnostic evaluations, a battery of self-report questionnaires, behavioral observation, and physiological recording in a laboratory.

    Fees
    • Treatment fees are on a sliding scale - based on income, for 12 sessions. 
    • There are no fees for any of the assessments (prior to treatment, at completion of treatment, and 6 months after treatment). 
    • Parking costs for each assessment are reimbursed upon request. 
    • In addition, participants receive $25 for follow-up assessments at post treatment and 6 months, and $50 for the follow-up assessment at 12 months.

    Study Personnel Contact

    For further information about this project, contact Carolyn Davies at 310-206-9191. This study is conducted in collaboration with Georg Eifert, Ph.D., Chapman University, California and John Forsyth, Ph.D., State University of New York, Albany.

    Principal Investigator: Michelle G. Craske, Ph.D.

    Internet Skills-Based Program for Child Anxiety

    If you are the mother of a 6-12 year old anxious child, you may be interested in a study being conducted by researchers at UCLA. The purpose of this study is to determine whether anxious children and their mothers can benefit from a Cognitive-Behavioral Skills-Based Program delivered over the Internet.

    If you and your child are eligible for this free study, you would be randomly assigned to one of two 12-week conditions:
    1. the Internet Program condition or 
    2. the Waitlist condition. 
    People placed in the waitlist condition will be given access to the internet program at the end of the study. You would also be asked to answer questions online and over the telephone. You do NOT need to come into the research lab. People from across the United States are welcome to join this study.

    Eligibility Criteria

    The following is a list of some of the eligibility criteria for this study. It is not exhaustive. In order to determine if you and your child are eligible to participate in this study, please call (310) 206-1128 and speak to the study's principal investigator, Melody Keller.
    • Your child must be between the ages of 6 and 12 years old.
    • In order to be in this study, you (the mother) and your child must speak English fluently.
    • You (the mother) and your child must be able to read in English.
    • Your child cannot be in this study if he or she has ever been diagnosed with Mental Retardation, Autism, Asperger's Disorder, or Pervasive Developmental Disorder (PDD).
    • If you (the mother) and/or your child are on medication, the dose(s) must be stable.
    • You (the mother) and your child cannot be in this study if either of you is currently receiving Cognitive Behavioral Therapy for any mental health problem.
    • You (the mother) cannot be taking parenting classes or receiving therapy aimed at addressing parenting skills.
    Study Personnel Contact

    For further information about this project, contact Melody Keller at (310) 206-1128.

    Principal Investigator: Melody Keller, M.A., C.Phil.

    Enroll in Social Anxiety Study at UCLA

    Anxious in social situations? 

    Fear of public speaking?

    A UCLA study offers low-cost behavioral therapy for social anxiety disorder. Please read below for more information or contact Jenny Czarlinski at 310-206-9191 or j.czarlinski@gmail.com.

    The Neural Mediators of Behavior Therapy study is funded by the National Institute of Mental Health (NIMH).  The study is designed to compare two different versions of behavioral therapy for social anxiety disorder:
    1. The first version involves teaching methods for slowing physiological responding, changing erroneous thoughts about anxiety inducing situations, and modifying behaviors in order to learn to overcome fears of specific objects, places, or experiences, through exposure therapy. 
    2. The second treatment version involves strategies designed to replace anxious physical responding and negative thinking with mindful and nonjudgmental observation, and shift behavior towards achieving life goals, again through exposure therapy. 
    Some of the participants will be assigned to a waiting period before they start one of the two behavioral treatments. The goal is to compare the neural mechanisms of each treatment approach.

    Eligibility Criteria

    Individuals who meet diagnostic criteria for Social Anxiety Disorder, are eligible for the study if they are between the ages of 18 to 60, are English speaking, are not currently suffering from major medical conditions, and are either un-medicated or stabilized on medications for anxiety or depression.

    Screening Procedures

    • Interested participants leave their contact information (i.e., name, phone number, best times to call) at (310) 206-9191 (a voice answering machine). 
    • Participants are then phoned by study personnel and asked a few simple screening questions. 
    • If eligible, participants are scheduled for an in-person, no-cost, diagnostic evaluation (approximately 2-3 hours) at the UCLA Psychology Clinic and also will complete an fMRI (Functional Magnetic Resonance Imaging) assessment. 
    • Eligible participants are randomly assigned to either one of the two treatment conditions.
    Treatment Procedures

    Treatment is conducted one on one, over 12 weekly visits (at the UCLA Psychology Clinic) and is followed by phone calls once a month for the next 6 months. Assessments are conducted prior to beginning treatment, at completion of treatment and 6 months later. These assessments include diagnostic evaluations, a battery of self-report questionnaires, behavioral observation, physiological recording in a laboratory, and a repeat of the FMRI at post treatment.

    Fees

    There are no fees for any of the assessments (prior to treatment, at completion of treatment, and 6 months after treatment). Parking costs for each assessment are reimbursed upon request. In addition, participants are offered gift certificates in the value of $15 for follow-up assessments at post treatment, 6 months and 12 months, and $25 for follow-up assessments at 12 months and 24 months. Treatment fees are on a sliding scale - based on income, for 12 sessions.

    Study Personnel Contact

    For further information about this project, contact Jenny Czarlinski at 310-206-9191 or j.czarlinski@gmail.com. This study is conducted in collaboration with Matthew Lieberman, Ph.D. and Shelley Taylor, Ph.D., at UCLA.

    Principal Investigator: Michelle G. Craske, Ph.D.

    Monday, January 3, 2011

    Talking & Laughing

    In her recent documentary, Joan Rivers said the point of comedy is to face the tragedy by talking and laughing about it.  The funny lady has a serious point.

    Pennebaker (1986) found that writing about emotional experiences, both the facts and the feelings, leads to improved physical health.

    Bowlby (1988) told us that when mothers are able to talk about their happy or unhappy childhoods with detail, organization and coherence, bringing up the good and the bad, they were more likely to have secure attachments with their own children.

    Open communication in families is linked to family resilience.  Parents talking about emotions is also related to children's social interactions and relationships with peers, and children's emotional resilience and ability to cope constructively with challenging situations.  Parents who are aware of emotions, particularly negative emotions, can talk about and accept these emotions in themselves. These parents also are aware of emotions in their children and have the ability to assist their children in understanding their emotions.

    So if talking about it is so great, does timing matter?  Hobfoll (2007) writes:
    • "a major reason why psychological debriefing (such as Critical Incident Stress Debriefing) has been criticized in recent years is that it serves to enhance arousal in the immediate aftermath of trauma exposure.  It has been suggested that requiring people to ventilate in the immediate aftermath of trauma can increase arousal at the very time that they are required to calm down and restore equilibrium after the traumatic experience."  
    Referring to PTSD treatment, Hobfoll (2007) writes:  "Open communication and exposure therapy come later and end with a sense of relief and calm."

    So what helps immediately after a traumatic event?  Studies (Holbrook, 2010; Bryant, 2009) have found that the use of morphine during trauma care may reduce the risk of developing PTSD after a serious injury. Laughter is like morphine - the body produces endorphins when we laugh that act like "natural" morphine. 

    So go ahead - you have been given permission (and empirical support) to talk about it, laugh about it even.  It's not too soon to laugh about it - the sooner the better.  Cheers, to funny stories for our health in the Happy New Year - Salud!

    Bryant, R.A., Creamer, M., O’Donnell, M., Silove, D., & McFarlane, A.C. (2009) A Study of the Protective Function of Acute Morphine Administration on Subsequent Posttraumatic Stress Disorder. BIOL PSYCHIATRY, 65, 438–440.

    Hobfoll, S.E., Watson, P., Bell, C.C., Bryant, R.A., Brymer, M.J., Friedman, M.J., Friedman, M., Berthold, P.R., Gersons, J.T.V.M.J., Layne, C.M., Maguen, S., Neria, Y., Norwood, A.E., Pynoos, R.S., Reissman, D., Ruzek, J.I., Shalev, A.Y., Solomon, Z., Steinberg, A.M., Ursano, R.J. (2007).  Five Essential Elements of Immediate and Mid-Term Mass Trauma Intervention: Empirical Evidence. Psychiatry, 70(4), 283-306.

    Holbrook, T.L., Galarneau, M.R., Dye, J.L.,  Quinn, K., & Dougherty, A.L. (2010).  Morphine Use after Combat Injury in Iraq and Post-Traumatic Stress Disorder. N Engl J Med, 362, 110-117.

    Attachment Quotes

    I am starting to think that I should re-name this blog and put "attachment" somewhere in the title.  That would be cool with me...

    "...quote from John (Bowlby), at the age of 80:
    • 'My mother held the view that it was dangerous to spoil the children so her response - she was a very stable, sensible, capable person - to bids for her attention and affection were the opposite of what was required'...the only time the children could catch their mother's attention was by asking questions about nature." *
    It's no wonder Bowlby became a scientist.  Kids seem to grow in the direction of what their parent(s) pay attention to - like a flower bending toward the sun.  


    *From John Bowlby, His Early Life: A Biographical Journey Into the Roots of Attachment Theory by Suzan Van Dijken, New York, NY: Free Association Books, 1998.