Tuesday, November 22, 2011

More Structural Family Therapy Notes

While my professor took a phone call, I glanced over at his bookshelf and my eyes fell on his copy of Families & Family Therapy by Salvador Minuchin.  Sometimes the articles or books I need fall into my lap serendipitously.  So I asked him if I could borrow his book.  He graciously agreed.  Here are some notes I have taken (since I cannot highlight or underline or write in the book as I am used to doing!):
Structural family therapy is a body of theory and techniques that approaches the individual in his social context. 

Therapy based on this framework is directed toward changing the organization of the family.

It shifts the focus from the individual to the person within their family.

When the structure of the family group is transformed, the positions of members in that group are altered accordingly.  As a result each individual's experiences change.

The theory of family therapy is predicated on the fact that man (sic) is not an isolate.  He is an acting and reacting member of social groups.  What he experiences as real depends on both internal and external components.  Man's (sic) experience is determined by his interaction with his environment.
The traditional techniques of mental health grew out of a fascination with individual dynamics.  Of necessity, the resulting treatment techniques focused exclusively on the individual, apart from his surroundings. A therapist oriented to individual therapy still tends to see the individual as the site of pathology and to gather only the data that can be obtained from or about the individual.

A therapist working within an individual framework can be compared to a technician using a magnifying glass.  The details of the field are clear, but the field is severely circumscribed.  A therapist working within the framework of structural family therapy, however, can be compared to a technician with a zoom lens.  He can zoom in for a closeup whenever he wishes to study the intrapsychic field, but he can also observe with a broader focus.

Personal Statement for PhD Application

One of my mentors, a social work professor, asked me for a copy of my PhD application in order to share it with her student, who is interested in applying.  I dug up my personal statement and smile at who I was three years ago - same and different than who I am today.  This is what I said back then:

In recent years, my own desire and encouragement from colleagues to pursue a doctoral education has been steadily building.

In 12 years of post-master’s work experience, I have had the opportunity to practice micro to macro-level social work, particularly in the school setting.

In addition, I have taught courses in the undergraduate social work program at CSULA and the School Work Services in Schools course for masters and post-masters level students interested in earning the Pupil Personnel Services credential at UCLA.

I have presented in various graduate-level courses at UCLA, CSULA and CSULB, as well as at state and national professional social work conferences.

In both my post-bachelor’s and post-master’s work experience, I have had numerous opportunities to participate in evaluation research.

All of these experiences provide me with confirmation that I want to dedicate the remainder of my career to teaching, writing and research.

I am currently a team leader for the South Los Angeles Resiliency (SOLAR) Project. I have been involved with this counseling demonstration grant and its program evaluation activities from conceptualization, proposal writing, program start-up and implementation to now our third and final year of federal funding. The SOLAR Project provides a full range of school social work services - universal, targeted and intensive interventions - at four South Los Angeles elementary schools. We collaborate with Dr. Brown and Dr. Agbayani from CSULA to conduct program evaluation looking at both mental health and academic outcomes for all levels of intervention.

This involvement in evaluation research, in addition to my experiences conducting research for the MSW degree at UC Berkeley and evaluating health education programs as an administrator, has not only increased my capacity for program evaluation research – it has fueled a deeper interest and passion.

My educational objective while in the doctoral program in social welfare is to develop knowledge and skills in social research. Specifically, I would like to engage in research related to evidence-based mental health interventions in school settings.

Also, my recent practice and research in resiliency has increased my interest in examining the role that our expectations, implicit or explicit, play in our own behavior and that of others. I wonder how adult expectations may be influenced, shaped or examined in order to consistently lead to positive results for students?

Teaching undergraduate and post-master’s level courses at CSULA and UCLA since 2001 and 2007 respectively, has expanded my interest in an academic career as a social work educator.

After completing my doctorate, I will seek an academic position as a professor of social work. I look forward to educating the next generation of social workers and would like to have a positive influence on the knowledge, skills and values that they develop in graduate school as emerging professionals.

Also, I plan to engage in intervention research to expand knowledge of evidence-based practice with children, youth and families in a research clinic or school setting. More specifically, I would like to teach and conduct research about effective practices in family therapy, working with immigrants and refugees, strengths-based approaches, social marketing strategies and community organizing. I am interested in using participatory action, qualitative and quantitative research methods.

I want to take what I’ve learned about clinical and community work, over the last 12 and 19 years respectively, and integrate that with a deeper knowledge of evaluation and research. I want to work at the intersection and dynamic relationship that exists between practice and research. This includes exploring what particular interventions and approaches seem to benefit particular problems in specific populations and why. This is especially critical for minority and underserved communities where resources are so limited that the need for clinical and cost-effective interventions is acute. As an example: what other approaches for prevention and treatment besides specialized and expensive psychotherapy are imaginable, much less available, to monolingual immigrant uninsured teens who are presenting with anorexia and/or self-injurious behaviors?

I have a particular interest in developing life-long learning opportunities for professional social workers, moving beyond simply offering continuing education units, to providing opportunities for seasoned and mid-career social workers to continue to have access to the latest research about effective practice. There seems to be a lag in the application of knowledge that the latest research produces. This does a disservice to our profession, practitioners and clients. I’d like to take what the latest science is learning about what works and make it more accessible to front-line practitioners via newsletters, podcasts, blogs, and formal or informal community-academic communication and partnerships.

Conversely, I would like to explore strategies and innovations to create a stronger connection between research and practice including what practitioners are discovering as a result of their practice and what gets published and disseminated. I’d like to take what practitioners learn over time and systematically record it so that it can be scientifically-tested and replicated in order to elevate practice wisdom to the level of evidence-based practice where applicable.

In social work, we are increasingly asked to incorporate evaluation measures by funding sources, policymakers and other interested stakeholders for sound ethical, financial and practice reasons. For many practitioners, these skills were not taught in their clinical tracks in graduate school. I plan to work toward creating practical strategies for social work practitioners to hone these advanced generalist practice skills and respond to shifts and new demands placed on them in a dynamic and changing world and profession.

Friday, November 18, 2011

Basis for Shamanistic Therapies

Chapter 5:  Shamanistic Therapies
Altering Consciousness as a Basis for Shamanistic Therapies
"The biological basis of the IMC allowed shamanistic healing practices to emerge spontaneously from a wide variety of circumstances that alter consciousness and provide both general and specific adaptive consequences.
Understanding the therapeutic effects derived from altering consciousness requires recognition that a variety of drug and nondrug induction procedures engage the same endogenous physiological processes and induce common physiological changes that produce healing responses.

These general physiological dynamics of the IMC - parasympathetic dominance, interhemispheric synchronization, and limbic-frontal integration - have inherent therapeutic effects.  The effects reflect activation of aspects of the paleomammalian brain, specifically the hippocampal-septal region, the hypothalamus, and related areas that regulate emotions,  self, and other perceptions, and the balance between the sympathetic and parasympathetic divisions of the autonomic nervous system (ANS) (p. 186)."
Winkelman, Michael M. (2010).  Shamanism:  A Biopsychosocial Paradigm of Consciousness and Healing.  Santa Barbara: Praeger. 

Integrative Mode of Consciousness (IMC)

"The existence of a universal drive among humans for altering consciousness is strongly supported by cross-cultural research. 
Institutionalized procedures for ritually altering consciousness have been documented in virtually all societies of the world, reflecting a commonality of culture and religion. 
Bourguignon (1968) reported evidence that approximately 90 percent of the societies in a worldwide sample had institutionalized rituals for altering consciousness, suggesting it was likely a cultural universal.
In another cross-cultural study, Winkelman (1986, 1992) found that communal ritual involving ASC (altered states of consciousness) were a cultural universal; all societies have magico-religious practictioners who have their professional roles based in powers derived from the modification of consciousness . . .
Even when there is cultural repression of the IMC, experiences of this realm of consciousness nonetheless manifest spontaneously and idiosyncratically because they reflect a biological basis.

Eliciting the IMC may be achieved in numerous ways, including pushing psychological functions beyond their limits, disrupting subsystems by sensory overload or deprivation, manipulating the autonomic nervous system balance, or focusing or withdrawing attention . . .
There are widespread biases against some forms of altered consciousness in Western society and cultures.  Historically, such manifestations were persecuted through witchcraft accusations.  Western psychology has tended to consider shamanic-type experiences to be pathological or 'primitive,' manifested in the perspectives that meditative states are regressions to infantile levels . . .
A contrastive approach is found in the many cultures that have viewed hallucinogens as entheogens, sacred plants that produce a contact with the divine.  Meditative traditions indicate that altering consciousness provides a variety of adaptive advantages through the development of a more objective perception of the external world . . .
The desire to alter consciousness is an innate, biologically based human drive with adaptive significance, a manifestation of a fundamental homeostatic dynamic of the nervous system . . .

This intensification of the linkages of the lower brain structures, paleo-mammalian brain, and frontal brain structures produces a synthesis of behavior, emotion, and thought . . .
The wide range of procedures used cross-culturally to induce these conditions reflects the ability of diverse agents and conditions to evoke this natural potential of the human brain-mind.  The IMC is a physiologically based mode of organismic functioning and integration that produces a condition of homeostatic balance . . .

The shaman is a technician of consciousness who uses these potentials for acquiring information, healing and personal and social transformation (p. 4-5)." 
Winkelman, Michael M. (2010).  Shamanism:  A Biopsychosocial Paradigm of Consciousness and Healing.  Santa Barbara: Praeger.

The Community & Healing

"...even societies that are disintegrating (e.g., the Siriono) and lack shamanistic healers still carried out collective ceremonial activities involving healing."

Winkelman, Michael M. (2010).  Shamanism:  A Biopsychosocial Paradigm of Consciousness and Healing.  Santa Barbara: Praeger.

Thursday, November 17, 2011

Being Mama

Sometimes I feel like I got an MSW and LCSW (and started working on a PhD) just to be my girl's mama.  Lord knows I draw upon every skill and resource I can scrounge up in the dark and difficult moments of motherhood.

My girl is sensitive, so when I dropped her off at school yesterday I said to her:
When you know who you are, no one can tell you otherwise.
Kids can be mean, so be grateful when someone is kind to you.
I don't always know how to handle my girl's BIG feelings.  She said I am "wasteful" with her feelings sometimes.  I love my girl and all that she teaches me - I feel so lucky to raise such a precious soul.

Wednesday, November 16, 2011

Religion and Self-Healing

"Valle and Prince (1989) proposed that religion elicits self-healing mechanisms through giving people a sense of belongingness that engages feelings of euphoria and omnipotence produced by the body's own morphine-like substances, the endorphins.  Religious healing involves a dynamic function of the psyche that broadens the individual's repertoire of coping abilities.  Valle and Prince characterized religious healing experiences in terms of activations of the non-dominant-hemisphere processes that elicit endogenous healing mechanisms by experiences that reduce uncertainty, anxiety, and depression."
Winkelman, Michael M. (2010).  Shamanism:  A Biopsychosocial Paradigm of Consciousness and Healing.  Santa Barbara: Praeger.

Mechanisms of Shamanistic Therapies

For the last two and a half years, I have been posting reading notes on this blog.  It is my annotated bibliography.  When I am writing a paper, most of the information and references I need are either in my head or on this blog.

These excerpts come from a cool book that I requested from UC Berkeley, so I have to return it soon. The author earned an MPH and PhD and spent most of his career studying the biological bases for traditional healing practices, especially shamanism.  He is a retired professor of Arizona State University and lives in Brazil.  His website is at www.michaelwinkelman.com.

"A basic mechanism in shamanistic healing involves symbolic healing, particularly the use of natural metaphors that represent intrapsychic dynamics and provide a means of producing psychosocial and emotional integration." (p. 184)

"...use of spirit beliefs as representations that provide psychosocial, psychocognitive, emotional and projective mechanisms." (p. 183)

"Neuropeptides and neuroreceptors function as an information network that links body and mind through emotions." (p. 183)

Opioid release stimulates emotional experience and emotional experience stimulates opioid release. (p. 183)

"A biopsychosocial dynamic...produces symbolically induced biological changes by eliciting endogenous healing responses and other recuperative potentials." (p. 183)

"Socialization links symbols and physiological processes, providing a mechanism for ritual therapies to manipulate physiological processes through their relationships with symbols that were established through socialization; this relationship enables them to entrain physiological processes and to produce affective responses. (183-4)

"Spirit manipulation and the mind-body interface play a central role in the management of emotion states particularly anxiety, fear and attachment." (p. 183)
"The community ritual dynamics of shamanic healing also elicit endogenous healing responses. The symbolic and ritual aspects of shamanistic healing practices provide therapeutic mechanisms that elicit the opioid systems and produce psychological and sociophysiological effects related to attachment and bonding.  A neurological basis for ritual structure is illustrated by the cross-cultural similarities in the characteristics of ritual and their homologies with obsessive-compulsive disorder.  This illustrates that one basis for shamanistic healing lies in manipulation of the processes of the R-complex (reptilian brain) and the paleomammalian brain." (p. 184)

Winkelman, Michael M. (2010).  Shamanism:  A Biopsychosocial Paradigm of Consciousness and Healing.  Santa Barbara: Praeger.

Tuesday, November 15, 2011

Check-In

I was born an old lady.  So 43 years later, I am practically ancient.  I'm grateful for that gift.

Sometimes social, emotional and intellectual development are asynchronous.  This can be troubling and require work toward integration.  Sometimes mind, body, spirit and soul are not aligned and requires work toward integration.

This is all part of my journey.  I stop repeatedly to give thanks to all my helpers - in this realm and the next:
  • All my parents - biological and adopted
  • My family of origin
  • My extended family
  • My current nuclear family
  • My family of choice
  • My true friends and supportive acquaintances
  • My healers (massage therapists, acupressure and acupuncture practitioners, chiropractor, energy healers, shamanic practitioner, doctors, orthodontist, dentist & dental hygienists, psychologists and psychiatrist)
  • My mentors (Jesus, Jolene Swain, Rose Monteiro, Jane Addams, Irvin Yalom, Carl Rogers, Reevah Simon, Iyanla Vanzant, Oprah Winfrey, Roberto Gutierrez, Norman V. Peale, Napolean Hill, Robert Cordova, Albert Einstein, Steve Jobs, Buddha, Jeff Koob, Emmy Werner, Karen Sorensen, Karin Elliott Brown, Pauline Agbayani, Pia Escudero, Sheryl Kataoka, Stuart Kirk, Hector Myers, Deborah Glik, Todd Franke, Aurora Jackson).  Some of my mentors I have never met, but their writing has profoundly shaped my thinking.
  • My ancestors
  • My spirit animal helpers
  • My guardian angels
  • My personal trainers, yoga and dance class teachers
  • Books
  • Art
  • Nature
  • Music
  • Dance
  • Laughter and humor
  • Drumming
  • and nourishing food.
When moments become dark and difficult, I call on my helpers to figure things out.  I am all the time adding to my bag of tricks.  I am always willing to ask for help.  It is how I got here from way over there.

Sunday, November 13, 2011

Compassion Fatigue

"Compassion fatigue refers to a gradual decline in a provider's capacity for compassion, and is a relatively common phenomenon among those who work directly with surviving victims of disaster and trauma.  It encompasses a breaking down of our physical, psychological, and even spiritual resources.

Physically, those experiencing compassion fatigue often struggle with a chronic sense of exhaustion and fatigue, insomnia, headaches, stomach aches, and frequent bouts of sickness (e.g. colds, sore throats).

Psychologically, they may feel irritable or overwhelmed.  Their baseline capacities for empathy dissolve into numbness to others' pain, and they can become cynical regarding surviving victims' ability to change and/or even perceive them as being responsible for many of their problems.

Responders experiencing compassion fatigue often report a sense of feeling scattered and being unable to meet their professional (e.g. paperwork) and personal (e.g. calling home) obligations."
"Systems thinking requires that we, as providers, understand our role(s) with the patient and family systems with whom we work.  Our own personal health (psychological and physical) is as important to attend to as those we serve."
Mendenhall, T.J., & Berge, J.M. (2010).  Family therapists in trauma-response teams:  bringing systems thinking into interdisciplinary fieldwork.  Journal of Family Therapy, 32, 43-57. 

Despite being a common and universal phenomenon in the face of trauma work, professionals perceive stigma associated to compassion fatigue.  How many of us would raise our hands and say, "I am experiencing compassion fatigue" and then seek help and support?

When I read the reports of "feeling scattered" due to compassion fatigue, I can't help but be reminded of soul loss.  Many indigenous and shamanic cultures believe that traumatic events may result in soul loss - when parts of our soul check-out for self-protection. There is no need to continue to walk around with a maimed soul.  The soul parts can return home safely with proper intervention - you need only ask, believe and accept this healing.

For more information about soul retrieval and finding a shamanic practitioner, check out Sandra Ingerman's website.

Systems Thinking in Trauma Response

"Systems thinking brings an overt sensitivity to both intrapersonal and interpersonal family processes that are related to increased stress in the contexts of disaster and trauma, and this fosters and elicits positive individual, relational and family growth in both the acute and long-term phases of support.  It promotes an appreciation for respective family members' unique perceptions of meaning, and facilitates members' co-creation of new meanings in the evolution of healing and post-trauma growth.  It pushes us to consider our own role in the helping process and how the contribution of our training and background fits withing the larger efforts of our team's mission.  Finally, systems thinking commands attention to our own functioning, and highlights our obligation to self-care."

Mendenhall, T.J., & Berge, J.M. (2010).  Family therapists in trauma-response teams:  bringing systems thinking into interdisciplinary fieldwork.  Journal of Family Therapy, 32, 43-57. 

More Family Systems Theory

Sometimes you don't have time or interest in reading the whole article.  Fortunately, I do, so here are some excerpts I've pulled out just for you . . .
1.     "Family systems theory - or 'systems thinking' - represents a hallmark of family therapy and the many clinical approaches that it encompasses.  Key theoretical underpinnings including:
  • attention to relational factors,
  • interaction sequences,
  • social and political contexts, and
  • extra-therapeutic factors
guide everything we do."
2.     "Moving beyond primarily individual-oriented intervention strategies (and those focused on groups of individuals) in conventional approaches to psychological first aid and trauma responding, family therapy commands explicit attention to individual, relational and family systems as bounded sets of interrelated elements.  Family therapists bring an overt sensitivity to inter-member processes that are related to increased stress in the contexts of disaster (e.g. family conflict, over-functioning/under-functioning patterns) and trauma work, as well as opportunities to foster and push positive relational and family dynamics in both acute and long-term phases of support."
3.     "Family therapists...readily conceptualize 'systems' in accord with the biopsychosocial family systems model...to consider multiple and interconnected systems, including patients'. . .
  • anatomical and physiological make-up (e.g. brain structure, somatic symptoms), 
  • psychological functioning (e.g. PTSD, depression, anger, sense of hope and/or hopelessness),
  • relational and family systems (e.g. attachment, communication, boundaries, cohesion, adaptability), 
  • and larger social and ecosystemic structures (e.g. supportive peer and friendship networks, contemporary political milieux, neighbourhood wealth/poverty).
4.     "...we must honour the complexities of these multiple and interconnected systems, as they are all relevant and influence each other."

5.     "...integrating psychoanalytic ideas with systemic practices can contextualize individuals' respective functioning within families - and thereby synthesize competing perspectives in healing and growth..."
6.     "...argues for integrating such approaches, highlighting how attention to family members' unique attachment histories influences the manners in which they experience trauma - thereby informing therapists' effective intervening and care."
7.     "Finally, systems thinking commands that we recognize and honour our own roles in the process of helping.  For example, attention to our personal emotional processes, self-care, and preventing burnout and compassion fatigue are not only important for our own and other team members' sake, but for the safety and well-being of the people and families we serve."
8.     "A 25-year-old woman who lost her colleague to suicide stated that she will tell her other colleagues daily what she appreciates about them so that they never feel unappreciated and lonely."
9.     "Regardless of what discipline ultimately brought us to it, providers of mental health entered this business to ease the suffering of those who are hurting, and to empower their growth and resolve in the face of hardshipWe can do this from a variety of professional platforms, in collaboration and synchrony with each other.
10.     "Common systems themes such as appropriate hierarchies (e.g. executive power), subsystems (e.g. parents, children/siblings), and interpersonal boundaries (e.g. as they relate to sexual behaviour or self-disclosure) are valuable concepts with which to inform teams' decision-making processes, overall structure and ongoing functioning.  In our own work, we have learned to address these challenges through straightforward and frank conversations with colleagues, supervisors and students - and maintain that these challenges call for consistent attention and diligence so that the safety of all team members is ensured and that ethical violations are not committed."

Mendenhall, T.J., & Berge, J.M. (2010).  Family therapists in trauma-response teams:  bringing systems thinking into interdisciplinary fieldwork.  Journal of Family Therapy, 32, 43-57. 

Thursday, November 10, 2011

Practice, Policy & Research Triangle


Practice should influence research and policies:
  • Practitioners and clients should give voice to their needs and strengths.  Researchers need to listen.  In this way, important research problems and questions are addressed.  That is, research is conducted that makes a difference in people's lives.  
  • Practitioners and clients should also give voice to their needs and proposed solutions by participating in the political process - at the agency level, as well as local, state and federal levels. Policymakers need to listen.
Policy dictates or influences practice and research:
  • Policies set the parameters, provide funding and regulations for how we conduct our direct practice work.
  • Policies also dictate what type of research gets funded.
Research influences or should influence policies and practice:  
  • Policies should be based on the best science available in addition to meeting the needs of constituents.
  • Practice should also be based on the best science available as well as integrating practitioner experience/wisdom and community/client values.
It is high time that the severed parts work as a whole system.

Tuesday, November 8, 2011

More Notes from Mary McKay on Family Engagement in Children's Mental Health Treatment

I heard Mary McKay speak on Family Engagement strategies in Los Angeles again.  I told her I wasn't just a fan, I was a groupie.  I heard her speak about a year ago (see notes from that workshop on this blog).

After introducing myself and her offer to help me in the program any way she could (she is an LCSW and PhD too), I handed her my recently completed manuscript about a parenting intervention in schools for her review and feedback.  She is so gracious, warm, witty and wise - reminds me of Bonnie Hunt - love her.

Okay, this is the gist of what she said in her south side of Chicago accent ...
  • In children's mental health treatment, 50% of parents never make it to their first appointment (according to national show/no show appointment rates).  
  • 25% engage in children's mental health treatment (sadly, 75% do not).
  • She interviewed parents to find out what we did well and what we needed to develop, in terms of children's mental health treatment. 
  • Messages from therapists to parents:  
    • "Life is complicated and there are no easy answers"
    • "I don't have all the answers but I'd like to partner with you."
  • It takes a lot of hard work to get good outcomes, in terms of family engagement and retention in treatment.  
Barriers/Obstacles to Engagement
    • Concrete obstacles - schedule, transportation, language barriers, poverty.
    • Perceptual barriers - parents own previous school experiences (in school based mental health services); ambivalence about treatment (are you going to be helpful or harmful?)
  • It is good for families to come with a healthy mistrust and skepticism.  They are showing a pretty good sense - "I care about what happens to my family" and that is why they are hesitant about involving themselves in the mental health system.
  • For mental health professionals concerned about our alliance with teens vs. parents:  Young people need their families and our task is to teach them how to mend those relationships.
  • Parents may be fearful and discouraged and think, "You can't possibly be helpful."
  • Parents are suspicious of mental health providers based on previous negative experiences with helpers when they have been called "bad parents."  Parents need to be understood, supported and not judged. 
  • The variables found to be most significant when modeled (probably logistic regression) - stigma and fears of being blamed (perceptual barriers) - and not concrete barriers (transportation, child care, etc.)  Not all engagement barriers are created equal.
  • Even poor people know how to run their lives (get to appointments that they deem important).  They will overcome concrete obstacles for what's important.  If their fears and concerns are not addressed, they will not use their limited resources to attend appointments.
  • Unexpressed questions and concerns are significant barriers.  Yet, no family will say, "I won't come because I am afraid."  "Nice people" like mid-Westerners won't say, New Yorkers might say, "nice people" are strong-minded but nice.
  • If you only problem solve around concrete barriers, then you won't increase appointment show rates.
  • Some cultural values leave us less skilled/practiced at disagreeing with professionals due to respect for authority - but will go home and not do what they say.
  • Don't leave engagement to chance.  If we don't do something differently, then more families will not become engaged.  If we employ empirically supported strategies for engagement, it is more likely that families will engage in treatment.  The hard work is in systematically doing something differently.
  • Clinicians can address parental ambivalence about treatment by creating discrepancy and engaging in change talk.  
  • How do you help people who do not see they have a problem?
    • Psychoeducation - information about the disorder - depression, anxiety, etc.
    • Child can tell his father about his experiences with anxiety and depression. 
Goals for Telephone Engagement (first call to families)
  • Systematically incorporate engagement skills and tools; systematic attention to engagement
  • Clarify the need for mental health care
  • Increase caregiver investment and efficacy
  • Encouraged disagreement about reason for referral to try to build alignment
  • Working with adults:  Adult do not do things because they are told what to do, but because it's in their best interest.  
  • Being judgmental is not good customer service.  If you're thinking, "duh," then I wonder how we might come off as judgmental in more nuanced ways, especially to families that may feel reticent or suspicious (or previously burned by mental health professionals).  Parents report, "I've gone to helpers and they haven't been helpful (judged me)."
  • Clinician message: "I know you care about your child.  I care about your child too and I care about their success as a student."
Goals of 1st Interview
  • Anxiety gets in the way of listening and learning and retaining information.  
  • Achieving treatment goals requires intensive parent partnerships.
  • "I can do nothing without 'we' " - "How are we going to work together?" - "What can we change?"
  • If we see the child instead of the parent, then we can expect slow to non-existent change.  The research shows that seeing the parent is more effective.
  • We can only go as fast as the family is able to go, although this may feel as slow as a snails pace.  Important to set a spirit of real collaboration.  Send the message, "I can't go it alone with just the kids," and mean it!  Partnership is necessary for treatment change and not just "nice."
  • Parents wonder, "Can therapist offer me something that my sister or mother cannot?"
  • If parents walk away without evidence that we can be helpful, they won't come back.
  • Proven useful to show parents how to reduce stress, increase parenting skills, using tools created by and for parents.
  • End interview with, "how was this for you? Are you interested in returning?"
  • Big chunk don't come back because they don't want to - something went wrong in the first exchange.
How to make paperwork more engaging
  • Review paperwork - what is most essential? Remove the rest.
  • Talk to parents about approach to paperwork.  We come off as disempowered when talking about paperwork.  How can we come off as competent - show our self-efficacy?  Quit apologizing for paperwork because the research shows that this approach wasn't helpful.
  • Parents described signing consent and wishing they hadn't after they left.
  • Clinican message, "I don't want you to sign anything you don't feel good about.  I don't want you to walk out with any questions or concerns without an opportunity to discuss them."
  • Parents want to feel respected and understand process.
  • Frame sensitive assessment questions as opportunities to build trust.  Explain who will see the information and how it will be protected.  Families worry about access.
  • Need rationale for developmental history questions (such as age of developmental milestones of walking and talking) - especially when working with 16 year old pregnant teen!  If parents don't understand why we are asking certain questions, then they think we are weird or wasting their time.
  • Paperwork can be an opportunity to engage and allay fears.
  • With systematic incorporation of these strategies, rates of return often double and triple.
  • If setting for interviewing family is less than ideal, with regards to confidentiality, then encourage families to have the good sense to share only what is safe to do in such a vulnerable setting.
  • Constantly seek feedback from family.
  • If client can't articulate goals, then they aren't likely to get good outcomes.  Take out the service plan at every visit to track outcomes.
  • If parents have had a "bad" experience, they are less likely to ask for help again.
  • After one bad experience, parents are more likely to be suspicious at the next visit and likely to drop out.  Ask about and discuss past negative experiences.
  • The most engaging characteristic is authenticity.
  • Termination assessment:  "Is this a good time to end?  Has enough progress been made?"
  • Clarify the reason for referral from the parents perspective.  Parents critique:  Clinicians miss the opportunity to ask about parents perspective on referral - "Do you agree with this referral?"
  • What percentage do you think are excited about referral?  What percentage do you think are in agreement with the need for referral?  Parents usually blame the teacher (and every once in a while, the teacher is a problem).  
  • Parent:  "If this encounter is lead by my need, then I will return.  Otherwise, I'm done."
  • If parents bring up their concerns - talk about them.  If they don't bring them up, then ask and raise concerns proactively.  Explore by saying, "A lot of families have questions and concerns about...For example..."
  • Parents wonder, "how is all this talking supposed to help?"
  • Parents are as scared/nervous as we were (as clinicians) at our first intake.  Parents come in with their game face (cool and scary).  It's family's first time - they are worked up - it's our job to help them regulate and relax.  Don't get to the big Question too quickly - "How can I help you?" Talk for five minutes to allow families to take a breath and stop being nervous - so family can make an assessment of you as the clinician.  Parents only agenda at first meeting is to show up (against their good sense to stay away).  If we rush them, they'll leave out important details - "I don't know if I trust her yet.  I don't know if I'll tell her that yet."

Forgiveness Affirmation

A side effect of depression and anxiety is being too harsh - unforgiving - on ourselves and others.

The following Forgiveness Affirmation comes from Connie Domino, RN, MPH, from her book, The Law of Forgiveness.  After leading goal-setting workshops, she noticed some participants reached their goals faster than others.  She noted that a lot of it had to do with holding on to the weight of anger and bitterness - it can get in the way.  Release it and be free already.

Here is the Forgiveness Affirmation and instructions:

1. Make a list

It is helpful for some people to make a list of those they would like to forgive. It doesn’t matter if it takes you several days or weeks to work through your list. The important thing is you have begun the process. Make a list of everyone you can think of that you would like to forgive, from your present and your past. Also, make a list of people you have wronged, whose forgiveness you seek. Forgiveness works freely both ways.

2. Find a quiet space

First, set aside a quiet time when you are least likely to be interrupted. Turn off any disruptive electronic equipment. Make sure any people who live with you know not to interrupt and ensure your pets are settled. Sit or lie in a comfortable place and position.

3. Visualize the person in your mind’s eye

Bring the person you wish to forgive into your mind’s eye. As much as possible, see them happy and surrounded by healing light. Visualize their higher self, not their nasty, mean Earth self (their soul, not their personality). If you have a number of people to forgive, you may wish to complete this in several sessions.

4. State the forgiveness affirmation

Bring each person into your mind’s eye one at a time, and say the forgiveness affirmation to each of them. Next, visualize them smiling sincerely and accepting your forgiveness. When you say, “and all again is well between us,” this means “the energy is now released.” It doesn’t mean you’re now buddies. Next, see that person walking off a stage or out a door, and bring the next person into your mind’s eye. You can say the affirmation aloud or silently. If you are forgiving a group, organization or country, picture the group in your mind’s eye and state the forgiveness affirmation. You may even visualize the group members saying the affirmation to one another. To make forgiveness real, you must be sincere. It is recommended that you should state the affirmation as it is written, as it has proven so successful with numerous Law of Attraction and Law of Forgiveness students. Remember if you change the words around to continue to justify your anger such as, “I forgive you for not being the person I wanted you to be,” or something similar, this means you are not willing to entirely “release” and “let go.” Therefore, you will not receive the full benefits of complete forgiveness.

Affirmation to Forgive Others
I forgive you completely and freely, I release you and let you go. So far as I’m concerned, the incident that happened between us is finished forever. I wish the best for you. I wish for you your highest good. I hold you in the light. I am free and you are free, and all again is well between us. Peace be with you.

Affirmation for Others to Forgive You
[Name] forgives me completely and freely. He releases me and lets me go. So far as [name] is concerned the incident that happened between us is finished forever. [Name] wishes the best for me. [Name] wishes for me my highest good. [Name] holds me in the light. [Name] is free and I am free, and all again is well between us. Peace be with us.

Affirmation to Forgive Yourself
I forgive myself completely and freely. I release myself and I let me go. So far as I am concerned the incident that happened is finished forever. I wish the best for me. I wish for myself the highest good. I hold myself in the light. I am free and all again is well with me. Peace be with me.

Take a deep breath! You did it!

The 2 Sides of Fear

It may seem that fear has gotten a bad rap on this blog - overcome your fears, don't feed your fears and all that jazz.

Fear is a gift too (and the title of a book by Gavin de Becker).

When is our fear trying to send an important message for our safety, protection and well-being? And when is it getting in the way of what we really want to do?

All I can offer is that we listen to our inner voice, pay attention to our body clues and reflect - we are the experts of our own messages and we get to choose.

Friday, November 4, 2011

Breastfeeding

86% of mothers do not meet recommendations to breastfeed infants until they reach at least 6 months.


CDC. 2003 National Immunization Survey in Social Marketing:  Influencing behaviors for good by Philip Kotler and Nancy R. Lee, 3rd Edition, CA: Sage Publications, 2008.

What to Do and Say...

 “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)


You really gotta trust the client and the process in order to not do certain things.  You really gotta believe in and respect the client in order to appreciate how they think and make decisions.  You gotta trust and believe.

Thursday, November 3, 2011

Managing our Aggressive Drive

We all have an aggressive drive (all of us!) - built in when we were born.

1.  So how do you want it served up from others?

a.  Passive aggressively (consider that hiding our feelings in order to be polite does not dissipate the aggression, only channels it underground where it is expressed in some other way)

b.  Assertively (consider that it might be most respectful to self & others to state clearly what we want and need, regardless of what the other person might say or do)

c.  Aggressively (do what we want without regard for others and their safety - it may seem to work for a time, but this can come back to bite us and cost us in both the short-term and long-term)

If you chose b., then use your voice. Consider doing to others as you would have them do to you.

Wednesday, November 2, 2011

Conflict Resolution

"Conflict avoidance guarantees a certain sense of equilibrium but at the same time prevents growth and differentiation. Growth and differentiation are the offspring of conflict resolution."
Stay quiet and keep the peace?  

Or choose to use your voice and grow up into who you really are?


Szapocznik, J. (1989).  Structural family versus psychodynamic child therapy for problematic Hispanic boys.  Journal of Consulting and Clinical Psychology, 57(5), 571-578. 

Structural Family Systems Theory

"One of the central tenets of family systems theory is that the child, the identified patient, is serving an active role in holding the family together by helping the family avoid other problems."
In one study, when the behavior of disruptive boys improved, the families began to deteriorate in their general functioning.  This only occurred when only psychodynamic child therapy was used  to improve child behavior but did not occur when structural family therapy was used.
"Structural family systems therapy assumes that treating the whole family is important because it improves the symptoms and protects the family, whereas treating only the child may result in deteriorated family functioning."
"Structural family therapy (SFT) is well suited because of the match between this approach and the value orientations and interpersonal style of Latino families." 
"Underlying processes are seen as being primarily responsible for the symptoms.  SFT aims at symptom reduction.  SFT postulates that family interactions represent the intervening variable that needs to be modified in order to eliminate the symptom."
"Psychotherapy does not have the answers to poverty and other social problems."
"Therapeutic strategy focused on realignment of the structural relationships within the family. The therapeutic solution is in the modification of such structure - changes in positions of family members.  Hierarchical relations and coalitions are frequently in need of a redefinition." 
Szapocznik, J. (1989).  Structural family versus psychodynamic child therapy for problematic Hispanic boys.  Journal of Consulting and Clinical Psychology, 57(5), 571-578. 

Family Systems by Bowen



Overall Principles of Family Systems Theory & Therapy
"The same patterns that exist in families are present also in social and work relationships and relationship patterns have the quality of systems."
"Systems therapy assumes that all important people in the family unit play a part in the way family members function in relation to each other and in the way the symptom finally erupts." 
"The family is a system in that a change in the functioning of one family member is automatically followed by a compensatory change in another family member."
Alcoholism as viewed through family systems theory and family psychotherapy by Murray Bowen in Annals of New York Academy of Sciences (1974).

Tuesday, November 1, 2011

The Family Can Have the Corrective Experience

"In psychodynamic therapy, the therapist provides the corrective experience.  In family therapy, the parent is taught to change his or her behavior so that the parent becomes the source of the corrective experience."

Szapocznik, J. (1989).  Structural family versus psychodynamic child therapy for problematic Hispanic boys.  Journal of Consulting and Clinical Psychology, 57(5), 571-578.