Friday, February 17, 2012

Empowerment & Voice

I teach an Empowerment & Recovery in Mental Health course.  I lectured for an entire class period about the nuanced meaning of empowerment.  Then I challenged students to examine their own level of empowerment in all of their life roles.

Too often we buy into the idea of empowerment, but less so it's application.

Too often we complain about constraints and expectations put upon us, but spend less time speaking up, using our voice to offer alternative solutions, to demand better conditions, or to ask for basic wants and needs.

This is not just abstraction for me.  It is how I've chosen to live my life wholeheartedly.  So I gave students an example of my voice.

Below is a correspondence between an employer and colleagues about the role of assessment and diagnosis in social work practice.  Let me be clear - I really needed a salary to support myself and my daughter, so challenging the status quo was risky.  It seems that everything I do is risky.  I would not live it any other way but My Way (by Frank Sinatra).

I started the e-mail chain by sending various resources as attachments.  One of these was the Department of Mental Health biopsychosocial child/adolescent intake assessment form. I informed the team that I would be training interns to use this form with all their clients/families for supervision purposes.  Then I got this response from one of the team members:
Hi Alejandra,
Thank you so much for sending the screener. I think that is something that we can implement agency wide and will help us document 
I do want to have a discussion, however, about using the DMH psychosocial assessment instead of our in-house tool. 
First of all, I feel that all programs under the same funding should have the same paperwork for ease of quality control. 
Second, I think that the DMH assessment, although very thorough, is not necessarily the right tool for short-term, time-limited, family based services particularly by inexperience 1st time interns. Having done the DMH assessment I found it that although it is very thorough, it is very time consuming. It used to take me about 2 hours to complete the interview plus about 2 hours to write up. Our tool covers similar ground in a brief manner. Because we want to keep their caseloads at 50% clinical time plus some macro outreach activities, we have to truly assess whether that is a good use of their time.  
Third, I'm not sure I would feel comfortable formally diagnosing clients, particularly by interns, as required by this psychosocial. Because of our solution-focused strength based orientation we have decided not to formally diagnose any client in the agency. [Your site] would be the exception. 
Executive Director, what are your thoughts about this? Maybe we can setup some time for all of us to talk. Please note I removed the interns from this discussion thread so we can sort out this issue.
At this point, I had some choices, I suppose.  The following was my response:
Thanks, --------, for voicing your concerns. I support a group discussion around the issue and I believe we can come to an agreement about this.

1. I support your efforts to standardize the forms used by programs for quality control purposes. 
2. I am training interns to use the DMH form because I believe it is a reflection of good SW practice and these learned skills will be transferable to any setting in the future. I agree that a good assessment can take 2-3 hours. I believe that being comprehensive at the beginning saves a lot of time and misdirected/ineffective interventions later. I am training them to collect data for the assessment and then with my assistance during individual supervision, we can together come up with a short list of possible diagnoses.

For instance, if we are dealing with a student that I believe has moderate to severe ADHD and moderate to severe depression then I will move toward recommending that interns link them to services like a psych eval for treatment purposes because in my experience these students are at great risk for suicide. In this case, I think referral, family psychoeducation and advocacy make more sense as interventions conducted by grad interns than say, generic individual counseling.

I will train and supervise interns every step of the way - engagement, assessment, diagnosis, treatment planning, evidence based interventions, evaluation and termination. 
Another example is if we determine a student is depressed and one of his primary symptoms is irritability (most common symptom of depression among children and adolescents) then I would rather use a gold standard intervention like CBT and exercise than say, anger management counseling. 
Another example is if we determine the primary presenting problem is behavior problems and disruptive behavior (90% of children's mental health referrals) then the gold standard treatment is parenting and systemic or family therapy. The effect size of individual therapy is only .24 compared to .46 for parenting/family therapy. Also, some studies have shown that individual or group counseling may even make matters worse. 
I also support brief treatment and find that engaging families expedites child behavior change. Parents have a lot of power over child behavior. Also, happy parents-happy children, angry parents-angry children, depressed parents-depressed children. 
3. Finally, I believe that diagnoses give us an idea about how to intervene and choose evidence based interventions, whenever possible/available. I work in the paradigm of the recovery model where everything is done in the service of meeting the client treatment goals. I don't see diagnosis as a life sentence. I also do not see diagnosis as a stigmatizing label. I see diagnosis as a guide for choosing the most effective and efficient interventions.

I am also strength-based and practice (and teach interns) Solution-Focused Brief Therapy. I conduct (and train interns to conduct) a thorough assessment - both risks and protective factors. Last week, I gave them a personal resiliency checklist to use with their students to identify their own protective factors. I have both an informal and formal resilience scale that I use as part of my comprehensive biopsychosocial assessment. It is another potential for agency wide client data collection and reporting. 
I feel like I can work with students and their families to accomplish behavior change in 10 sessions or less, that includes 2-3 sessions for assessment. 
4. I want to share the framework I am using and training the interns to use: 
    The Levels of Intervention - Individual/Family, Organization/School, and Community. My goal is that their assessment, treatment plan and interventions reflect all relevant levels. 
    The Social Work Process - Engagement, Assessment, Diagnosis, Treatment Planning, Interventions, Progress Monitoring/Evaluation and Termination. This is our scientific process but not linear, rather I teach it as a circular process with Engagement (the relationship between clinician and client) as an important aspect throughout. 
    Mind-Body-Spirit-Soul - When we get to interventions, I will encourage them to use evidence based practices but also to privilege what our families say works and is important to them. I believe focusing on talk therapy alone may help kids to get a little better, engaging the body (exercise, sports, yoga, dance, etc) will make them feel even better, and engaging spirit and soul (if this is something that families value) will truly transform. 
Thanks for the communication, collaboration and opportunity to do this very important work. I am so impressed by your staff and team and the families with whom I get to work. I am having a great time and look forward to a further discussion in the near future. 
Fortunately, my voice (big mouth) did not get me fired.  Rather, the Executive Director offered me more hours.  And I would like to think that it is our voice, singular and collective, that leads to progress.  I don't know of any other way.

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