Process and Content

There are two types of people, generally speaking of course, Thinkers and Feelers.

We are all thinking and feeling human beings but we tend to lead with our head or our heart when processing information and making decisions.

After age 30, it is said that we become more integrated.  My integration took hold after 40 - late bloomer, I guess.  That is, the best decisions factor in both what we think about things and how we feel about it too - Is it safe? Is it fair? Will it work? How will people feel about it?

In therapy, there is BOTH process and content.  BOTH matter.  Both are important.  Let's attend to BOTH.

In the book, The Gift of Therapy:  An Open Letter to a New Generation of Therapists and Their Patients,  Irvin D. Yalom, MD writes:

...one must attend to both "content" and "process," the two major aspects of therapy discourse.  "Content" is just what it says - the precise words spoken, the substantive issues addressed.  "Process" refers to an entirely different and enormously important dimension:  the interpersonal relationship between the patient and therapist. When we ask about the "process" of an interaction, we mean:  What do the words (and the non-verbal behavior as well) tell us about the nature of the relationship between the parties engaged in the interaction?

So is therapy about the relationship or the techniques?  Both.  No "either/or" dilemma here.  No UCLA vs. USC rivalry here (we all know which is the better school, don't we?).  Without relationship, nothing we say or do matters much.  Without the best techniques/interventions/proven strategies, then aren't we just hanging out, being kind and chatting nicely?  No harm in that but you don't need an advanced degree or a license or to charge money for that!  In fact, if goals are not reached, growth and healing is not achieved, symptoms are not reduced, pain is not alleviated - then why would clients return and pay?  I guess they might if they are lonely.  That sucks.  Then we are high priced enabling friends.  I am sure we aim to do better than that.

We can apply empirically supported strategies, research based interventions and cultural/traditional healing practices (you know the kind with a 50,000 year track record) in the context of a warm, caring and genuine relationship.  Sounds good?

Study about Beliefs: Parents & Young People on Effective Interventions

"One surprising finding was that young people (particularly young adults) were more likely to see close family as a source of help than were parents, suggesting that parents may be underestimating their own potential role."

"Ideally, the public endorsement of recommended interventions should be close to 100%. The biggest gap is for psychiatric medications, where <50% rated recommended interventions as likely to be helpful."

"Psychological therapies, such as cognitive behaviour therapy, are recommended for all the disorders covered in the survey. Cognitive behaviour therapy was rated as likely to be helpful by less than half of adolescents, young adults and parents, and this held irrespective of the vignette presented. However, this low rating was largely because of ignorance of this treatment (which may be related to its limited availability). Unlike medication, respondents did not often see it as harmful. By contrast, the non-specific psychological intervention of counselling was overwhelmingly rated as likely to be helpful by all groups for all vignettes."

"Previous surveys of adults have shown relatively positive views of complementary and self-help therapies. In the present survey we asked about a range of interventions not covered in the earlier surveys. The complementary and self-help therapies included were those known to have some evidence for effectiveness in treating depression or anxiety disorders in adults, although the amount of evidence on these therapies with adolescents is much poorer, making comparison with young people’s preferences more difficult. Many of these therapies were frequently rated as likely to be helpful (physical activity, relaxation training, meditation, massages, morning light exposure, self-help books). St John’s wort did not rate so highly, but this appeared to be largely due to ignorance of what it was rather than a concern about possible harms."

"These findings have implications for areas on which campaigns to improve mental health literacy need to focus in the future. The first is in attitudes towards medication. Although there is evidence that attitudes of adults in Australia have become more favourable in recent years, there is still a considerable gap with clinical practice guidelines. The second is with the preference for generic psychological interventions (counselling) compared to specific interventions known to be effective (e.g. cognitive behaviour therapy). A similar gap exists with the professions providing psychological therapies (psychologists and psychiatrists vs counsellors). There is evidence that knowledge and attitudes of young people and adults can be changed by community campaigns so these are feasible goals. Recent changes in funding provided under Australia’s national health insurance scheme, Medicare, have made psychological services more readily available, but young people need to know about the availability and usefulness of these services."

"Another possible approach to improving evidence based care for young people would be to use terms to describe services that would make them more appealing to this age group and their parents. For example, services might be more acceptable if psychological therapies were labeled as ‘counselling’ and mental health professionals as ‘counsellors’. To some extent, this approach runs counter to the aim of improving mental health literacy and requires cautious exploration."

"The present results highlight the need for further evidence on complementary and self-help interventions. We face a situation in which some therapies that have a strong evidence base are perceived less favourably than others that have weaker supporting evidence. As well as trying to improve the mental health literacy of the public about what is known to work, we need to do further evaluation of interventions that already have wide acceptance and use. Interestingly, a recent study found that people who had experienced depression also rate many of these types of interventions as having helped them."

"Because of their more limited life experience, adolescents require assistance from others in their social network to seek appropriate professional help. In this regard, both family and close friends are viewed favourably as sources of help. However, parents tended to underrate their importance compared to their children. Parents need to be a target for first aid knowledge and skills to assist young people who develop mental disorders. Although it is perhaps too much to expect young people to provide a high level of peer support, there is certainly room for some basic skills. For example, adolescents often do not respond to a friend in a way that could facilitate appropriate help, such as engaging a parent, teacher or school counsellor to help. Even with a suicidal peer, many young people would not tell an adult."

"In conclusion, this is the first national survey of young people’s treatment beliefs in any country. As in previous surveys of adults, it found some gaps between public perceptions and current clinical practice. These gaps can be the target of community mental health literacy campaigns and training of key supporters in first aid skills. However, consideration can also be given to describing some interventions using terminology that may make them more acceptable to young people. Furthermore, the evidence base needs to be extended to more fully evaluate those complementary and self-help interventions that are already widely accepted by young people."

TITLE: Young people's beliefs about preventive strategies for mental disorders: findings from two Australian national surveys of youth
AUTHOR: Yap, Marie Bee Hui; Reavley, Nicola; Jorm, Anthony Francis
AFFILIATION: Orygen Youth Health Research Centre, Centre for Youth Mental Health,
University of Melbourne, Parkville VIC, Australia
SOURCE: Journal of Affective Disorders, 2007 Published online 3 October 2011

Harping on "Talking About It"

I get monthly updates about the latest in trauma research and this abstract has good info that can translate to practice, if you work with young people with PTSD.

"Prolonged exposure" is a therapeutic intervention that uses the repetition of story to habituate to a traumatic memory - in order to digest and archive the memory so it no longer chases you into the night and then day.

Long established as an effective treatment, it tends to be difficult for both clinician and client - at least initially.  What has been long avoided is greatly feared and what is greatly feared is long avoided.  After a few experiences with prolonged exposure and the resultant "sudden gains" observed in young clients - well, you can see how compelling it would be for a clinician.

Here's the abstract of the article for your learning pleasure...

Sudden gains in prolonged exposure for children and adolescents with posttraumatic stress disorder
Aderka, Idan M.; Appelbaum-Namdar, Edna; Shafran, Naama; Gilboa-Schechtman, Eva
Journal of Consulting and Clinical Psychology, Vol 79(4), Aug, 2011. pp. 441-446.

Abstract

Objective: Our objective was to examine sudden gains during developmentally adjusted prolonged exposure for posttraumaticstressdisorder (PTSD) among children and adolescents. We hypothesized that sudden gains would be detected and would be predictive of treatment outcome and follow-up.

Method: Sixty-three youngsters (ages 8–17) completed a developmentally adjusted protocol for the treatment of pediatric PTSD (Foa, Chrestman, & Gilboa-Schechtman, 2008). Participants' posttraumatic and depressive symptoms were assessed before each treatment session, as well as at approximately 3 and 12 months after treatment termination. We measured posttraumatic symptoms with the Child PTSD Symptom Scale (Foa, Johnson, Feeny, & Treadwell, 2001) and measured depressive symptoms with the Beck Depression Inventory (Beck, Ward, Mendelson, Mock, & Erbaugh, 1961) and the Children's Depression Inventory (Kovacs, 1981, 1982).

Results: Sudden gains were found among 49.2% of participants and constituted 48.6% of the total reduction in posttraumatic symptoms.  Compared to individuals who did not experience sudden gains, individuals who experienced sudden gains reported lower levels of posttraumatic symptoms, F(1, 61) = 14.4, p < .001, and depressive symptoms, F(1, 61) = 7.9, p < .01, at treatment termination. Differences in posttraumatic symptoms were maintained during both follow-up periods.

Conclusions: Sudden gains are common in pediatric prolonged exposure for PTSD and are predictive of long-term outcome.  Treatment planning can benefit from consideration of the intra-individual course of improvement, and treatment development may be enriched by understanding the mechanisms responsible for sudden gains.

The Gap

While there is widespread agreement that research should inform policy and practice, there is no clear roadmap for how to bring research to bear on solving important problems.

Tseng, V. (2010). Learning About the Use of Research to Inform Evidence-Based Policy and Practice: Early Lessons and Future Directions. William T. Grant Foundation 2009 Annual Report. William T. Grant Foundation, New York, NY.

Integrating Practice & Research

"The prize that my eye is always on, however, is the integration of practice and research, not for its own sake or to enhance the status of social work, but in the interest of those we serve and should be serving.  To me, that is the essence of professionalism."

"...the integration of practice and research in social work is essential to social work's effectiveness and survival as a profession."

"...seeking ways to successfully engage practitioners in research studies, research consumption, research ways of thinking, and ultimately, research utilization."

"...practice and research are inextricably linked."

"...the Council on Social Work Education require that schools of social work prepare their students to 'engage in research-informed practice and practice-informed research.' "

--Irwin Epstein in Clinical Data-Mining

Adapting CBITS for American Indian Youth

Title:  Adaptation and implementation of cognitive behavioral intervention for trauma in schools with American Indian youth

Author: Goodkind, Jessica R; LaNoue, Marianna D; Milford, Jaime L

Source: Journal of Clinical Child and Adolescent Psychology, vol. 39, no. 6, pp. 858-872, November 2010

Abstract:
American Indian adolescents experience higher rates of suicide and psychological distress than the overall U.S. adolescent population, and research suggests that these disparities are related to higher rates of violence and trauma exposure. Despite elevated risk, there is limited empirical information to guide culturally appropriate treatment of trauma and related symptoms.

We report a pilot study of an adaptation to the Cognitive Behavioral Intervention for Trauma in Schools in a sample of 24 American Indian adolescents. Participants experienced significant decreases in anxiety and PTSD symptoms, and avoidant coping strategies, as well as a marginally significant decrease in depression symptoms. Improvements in anxiety and depression were maintained 6 months postintervention; improvements in PTSD and avoidant coping strategies were not.

School-Based Intervention for PTSD

Title:  School-based intervention programs for PTSD symptoms: a review and meta-analysis

Author:  Rolfsnes, Erika S; Idsoe, Thormod

Source: Journal of Traumatic Stress, vol. 24, no. 2, pp. 155-165, April 2011

Abstract:
This is a review and meta-analysis of school-based intervention programs targeted at reducing symptoms of PTSD. 19 studies conducted in 9 different countries satisfied the inclusionary criteria. The studies dealt with various kinds of type I and type II trauma exposure. 16 studies used cognitive–behavioral therapy methods; the others used play/art, eye movement desensitization and reprocessing, and mind-body techniques. The overall effect size for the 19 studies was d = 0.68 (SD = 0.41), indicating a medium-large effect in relation to reducing symptoms of PTSD. The authors' findings suggest that intervention provided within the school setting can be effective in helping children and adolescents following traumatic events.

Preventing Children's PTSD School-Wide

Title:  Preventing children's posttraumatic stress after disaster with teacher-based intervention: a controlled study

Author: Wolmer, Leo; Hamiel, Daniel; Laor, Nathaniel

Source:  Journal of the American Academy of Child and Adolescent Psychiatry, vol. 50, no. 4, pp. 340-348, April 2011

Abstract:

OBJECTIVE: The psychological outcomes that the exposure to mass trauma has on children have been amply documented in the past decades. The objective of this study is to describe the effects of a universal, teacher-based preventive intervention implemented with Israeli students before the rocket attacks that occurred during Operation Cast Lead, compared with a nonintervention but exposed control
group.

METHOD: The study sample consisted of 1,488 students studying in fourth and fifth grades in a city in southern Israel who were exposed to continuous rocket attacks during Operation Cast Lead. The intervention group included about half (53.5%) of the children who studied in six schools where the teacher-led intervention was implemented 3 months before the traumatic exposure. The control group
(46.5% of the sample) included six schools matched by exposure in which the preventive intervention was not implemented. Children filled out the UCLA-PTSD Reaction Index and the Stress/Mood Scale 3 months after the end of the rocket attacks.

RESULTS: The intervention group displayed significantly lower symptoms of posttrauma and stress/mood than the control group (p < .001). Control children had 57% more detected cases of PTSD than participant children. This difference was significantly more pronounced among boys (10.2% versus 4.4%) and less among girls (12.5% versus 10.1%).

CONCLUSIONS: The teacher-based, resilience-focused intervention is a universal, cost-effective approach to enhance the preparedness of communities of children to mass trauma and to prevent the development of PTSD after exposure.

Building the Capacity to Bounce Back

Title: Promoting stress resistance in war-exposed children [editorial]

Author:  Asarnow, Joan Rosenbaum

Affiliation: Department of Psychiatry, University of California, Los Angeles CA, USA

Source:  Journal of the American Academy of Child and Adolescent Psychiatry, vol. 50, no. 4, pp. 320-322, April 2011

Abstract:   
The question of how to best enhance stress resistance and resilience in war- and trauma-exposed communities urgently needs data to inform public health and clinical programs.

Although some individuals and communities appear resilient and recover rapidly after exposure to war/traumatic experiences, others develop multiple secondary adversities and persistent mental health and functioning problems.

A report by Wolmer and colleagues focuses on children's reactions after a 3-week armed conflict in Israel and the Gaza Strip during which the civilian population was exposed to rocket and mortar attacks, extensive time in shelters, and continuing threats to safety and survival. The report describes the effects of a school-based stress-inoculation training (SIT) program designed to enhance stress resistance and resilience in fourth- and fifth-grade Israeli school children and implemented before the 3-week armed conflict. The preventive SIT intervention was integrated within the school curriculum and delivered by teachers.

Three months after the conflct, children from the six schools implementing the intervention compared with children from six other schools reported significantly lower levels of PTSD symptoms and lower scores on a scale assessing mood, anxiety, and stress problems.

Latinos, Families and Mental Health Intervention

“Secondary data analysis using Add Health data set indicates that high amounts of parental control function positively for Latino families (contrary to some findings for non-Latinos)…Parental warmth significantly reduced alcohol use and also positively affected the parent-youth relationship which decreased alcohol use…Unique family mechanisms for Latino families that should be considered when developing intervention options” (Mogro-Wilson, 2008).

Parent Participation is the Gold Standard

“Community-based child and adolescent mental health services routinely involve parents along parents along with their children; indeed, parent participation is a hallmark of gold standard child mental health interventions. There are compelling reasons for tackling the issue of parent involvement in concert with focused attention to children’s mental health needs. Families provide the primary social context in which children function, influence access to services and shape attitudes toward service use that are critical to outcomes” (Kemp, 2009).

Families and Retention in Treatment

“The second reason for working with families is that families are powerful groups of people who exert significant influence on their members. In treatment, families can either be a tremendous support or an impediment which can undermine and sabotage treatment. From a practical standpoint it is wise to involve families in treatment to engender their support. A recent study found a significant difference between two similar treatment facilities in the dropout rate when family therapy was used. In one treatment facility families were involved in family therapy. Within the first week the adolescent was in treatment and continued on a regular basis. This facility had a significantly lower drop out rate than the similar facility which did not involve families in treatment until the third or later month and did not have family therapy as a required treatment component. There was also a significant relationship between the number of family therapy sessions attended and the drop-out rate in that the more family therapy sessions attended the less likely it was that the youth would drop out of treatment” (Weidman, 1985).

Families Matter in Children's Mental Health Treatment

“Regardless of the specific goals of treatment, a fundamental assumption of MST is that the youth’s family or caregiver is the key to favorable long-term outcomes, even if that caregiver presents serious clinical challenges. Treatment goals are therefore largely defined by family members or caregivers, and the vast majority of MST clinical resources are devoted to developing the capacity of the caregiver to achieve those goals (versus treating the child or adolescent individually). Within this context, engagement of the family in the clinical process is viewed as primary – an essential (but not sufficient) step toward achieving targeted outcomes. Regarding outcomes, MST has a strong track record in improving family functioning and decreasing long-term rates of antisocial behavior and out-of-home placement, as demonstrated through numerous randomized clinical trials. Hence, the utility of MST engagement strategies is supported by the effectiveness of interventions used within the MST model; interventions that draw from pragmatic family therapy approaches (Haley, 1976; Minuchin, 1974); evidence-based intervention models such as behavior therapy; and cognitive behavior therapy” (Cunningham, 1999).

Families and Children's Mental Health Treatment

“…treatment cannot progress unless key family members are engaged and actively participating in the treatment process – helping to define problems, setting goals, and implementing interventions to meet those goals.

The clinician may have developed a ‘brilliant’ set of intervention strategies, but such strategies will have little value in the absence of a strong therapeutic alliance.

Practitioners must remember that parents and other family members are essential to achieving positive outcomes, and such outcomes are almost always accomplished through hard work by family members.

Family members who are not engaged in treatment are unlikely to put for the effort needed for favorable outcomes. Hence, concomitant with a thorough assessment process, MST (Multi-Systemic Therapy) practitioners work toward achieving strong engagement from the time of their first contact with the family.

When clinical progress is slow or seems to have stalled, a common reason is that key family members (the child’s caregivers, those adults who control family resources or have decision-making authority) are not truly “on board” with the treatment plan.

Although the therapist may have believed that the family was engaged, a closer look might reveal otherwise. Often, we (therapists, supervisors, consultants) assume that family members are committed to a particular treatment goal that seems logical to us, but may not be viewed in the same way from the perspectives of family members. In any case, engagement is a precursor to successful outcome, and fortunately, the behavioral signs of engagement are available for observation” (Cunningham, 1999).

Family Therapy for Children's Mental Health Problems

"For a wide range of child-focused problems, systemic interventions (for example, family therapy) are effective. The evidence supports the effectiveness of systemic interventions either alone or as part of multimodal programs for:
sleep,
eating disorders,
feeding and attachment problems in infancy,
child abuse and neglect,
somatic problems,
conduct problems,
emotional problems (anxiety, depression, grief, bipolar and suicidality)
(Carr, 2009).

Understanding Helps Therapists

“…the resistance of many families of substance abusing adolescents to becoming involved in treatment also contributes to therapist reticence about working with these youths and their families. However, the author’s experience has indicated that the resistance of therapists to treating this population in part stems from the therapists’ lack of practical knowledge of how to engage substance abusing adolescents and their families in treatment. Once therapists have a viable framework for understanding substance abuse and specific interventions upon which to draw, they are more willing to work with substance abusing adolescents, and treatment is more successful” (Weidman, 1985).

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?

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.

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?

Universal Screening (Rocks!)

Say there is a mass traumatic event - many people affected. Or say you work at a school - with thousands of students.

What is the most efficient way to identify those that need intervention?

• Individual clinical interviews? (Probably not)
• A brief questionnaire excellent at predicting a PTSD diagnosis that "performs equivalent to agreement achieved between two full clinical interviews"!

Edna Foa et al. has developed a questionnaire for efficient identification of PTSD among children and adolescents. This can be done for other common, and sometimes hidden, disorders. Teachersfrequently refer students (boys) with disruptive behavior disorders. But how can clinicians identify the underlying disorders (ADHD, PTSD, attachment disruption)? And for students not presenting with disruptive behavior disorders, how can clinicians identify the internalizing disorders (depression, anxiety, PTSD)? And what about the girls?

Universal screening is not only promising for efficient identification of disorders, but a fair and equitable referral system for distributing services. Otherwise, only the most disruptive students get the attention and mental health services. Universal screening provides practical hope for preventing children from "falling through the cracks."

Source:

Brief screening instrument for post-traumatic stress disorder
CHRIS R. BREWIN, SUZANNA ROSE, BERNICE ANDREWS, JOHN GREEN, PHILIP TATA, CHRIS McEVEDY, STUART TURNER and EDNA B. FOA
BRITISH JOURNAL OF PSYCHIATRY (2002) , 181, 158 - 162