Taking on "Constructive Criticism"

The idea of "constructive criticism" intrigues me.

Online dictionary definition: criticism or advice that is useful and intended to help or improve something, often with an offer of possible solutions

When I was in college, I had two friends with different attitudes about constructive criticism. Casey believed you did not leave your friends to their folly. Jorge believed it was not your place to offer such words of advice, even to friends, or something to that effect.

I find that people continue to fall into these two camps - each with their own rationale and sense of love and respect for people and friends.

My friend, Mik, just sent me a link to the following blog about "editing:" http://donmilleris.com/2010/10/21/do-you-have-a-team-of-good-life-editors

In this post, Don Miller writes about how he doesn't review other people's manuscripts anymore because of bad past experiences:

"I’d assume writers want to be told what should be cut out of their book, but this isn’t the case. Only the good writers want to know what should be cut from their manuscripts. The amateurs just want to be told they are good."

Dr. Walter Brakelmanns, an accomplished psychiatrist and octagenarian, said that many supervisees started off their relationship with him by asking for constructive feedback because "that is one of the best ways that I learn." After he offered this feedback, they didn't return. So he quit doing it. Makes sense.

Gerry, a UCLA field liaison, frequently introduced me to his students as a "challenging" field instructor, based on feedback he received from my master's-level social work interns. He also said I was "too much" for first year master's-level students. One of my interns told me she heard from other interns that I had "high expectations." I guess when you are starting out what you want is a lot of reassurance, not constructive feedback, even though none of us know what the heck we are doing when we are starting out.

As a field instructor, I offered constructive feedback during individual supervision meetings. I was mindful to maintain a ratio of 3 to 1 or 5 to 1. That is, 5 positive interactions for every 1 negative interaction. This appears to be the "magic ratio" for relationships - both at home and in the workplace. "How Full Is Your Bucket?" (a book by Tom Rath & Donald O. Clifton) describes a study that found workgroups with positive-to-negative ratios greater than 3 to 1 to be significantly more productive than teams that do not reach this ratio.

But is there such a thing as too much of a good thing? Yes! Frederickson and Losada's mathematical modeling of positive-to-negative ratios suggests the existence of an upper limit: Things can worsen if the ratio goes higher than 13 to 1. So it is possible to be too nice. No constructive feedback and productivity worsens.

This makes sense to me because after my daughter's 2nd grade parent-teacher conference, in which the teacher balanced feedback at a magical 5 to 1 ratio, (and my daughter was still upset!) I could say to my girl, "It's okay, nobody gets to be perfect, my love."

And if you think about it, too nice is a problem because it isn't real. It's not honest. And in intimate or important relationships, it means holding back. What I get now, that I didn't understand before, is that two people have to agree about just how intimate, honest or real you can be in the relationship. I have gone out on a ledge sometimes. Thinking I was sticking my neck out to offer a gift that no one in their right mind but a true friend would offer, only to be told, over and over and in many ways, to keep it to myself. Now I know better.

My friend, Mik, a brilliant Swedish composer, is described as "unkind" by close friends because when he does give honest feedback, it is brutally honest. Not brutal as in mean-spirited, he is very diplomatic and humble, but brutal as in "it pains me to see myself as I am, less than perfect, through your eyes."

Getting honest feedback about our work can be a gift. Don Miller describes it as a gift in our personal life as well:

"If you are like me, it’s easy to surround yourself with people who don’t tell you about your blind spots, your weaknesses. I told my friend Dave about a piece of criticism that was thrown at me last month, and he helped me dismiss it as a person consumed with bitterness. But he didn’t stop there, he asked me why I was sensitive about it, and pointed out that part of that persons criticism was actually true. And you know what? Dave was right. He wisely helped me separate the criticism from the motive of the messenger. A friend who can do this for you is a friend indeed.

Not having people around who can show us our blind spots is a sure path toward self destruction. I’m not talking about surrounding yourself with critics. People who offer empty criticism, especially if they don’t know you, are of little help. But if you have friends who are honest with you about your character defects, and yet are obviously for you, you’ve been given a gift."

I think of it as mama-love, that is, something only your mama would say to you out of love. Or your spouse, if they dare. My own loving husband has been persistently working on my tone for the last 19 years. His feedback has helped me to be aware of it in my relationship with him, my daughter and at work. What can I say, I am a slow learner in some areas. Having PTSD doesn't make it easier.

When I try to coach my daughter during our end-of-the-day talks in the car on the way home, she cuts me off and says that I am lecturing her. Point well-taken. Sometimes, I need to just listen. But sometimes, I gotta tell her what only a mama will say. Because some will think it. Some will tell others what they think of you. But few will say it to you - no matter how diplomatically - because it is not polite and they are being nice.

I try to hold up a mirror in my closest relationships with family, friends and clients. Most often, this means mirroring strengths. People have so many strengths. The sad part is that strengths rarely get noticed or acknowledged by self or others. And yet, when you look for them, strengths and talents are easy to spot. If you are right on, then the noticed strengths resonate within the person. It is like giving a person back to themselves. I try to never leave a genuine compliment on the tip of my tongue. These gifts are easier to receive for some.

Sometimes holding up a mirror means announcing "potential danger ahead!" or "You are worth more than that" or "I see your talent and worth and this behavior/choice doesn't seem to fit" or simply, "this could be better, you have it in you." That is what I want in return too.

Sometimes people say to me, "treat me as you would want to be treated." The question is, which tribe are you in - Tribe Casey or Tribe Jorge? Because it makes a difference. Now, I don't assume that we all want the same things in a relationship and I can respect that. I wish Facebook had a question people could answer about which tribe they are in. Until then, I keep these gifts to myself - unless you are my husband, my daughter, a bosom buddy or client that wants to hear it.

Lecture on Social Psychology by Dr. Hector Myers

Kurt Levine:

Behavior is a function of Person and Environment, B = f (P ←→ E)

All behavior occurs within context

Interaction is more than a sum of its parts

Both person and environment have active roles to play

We know a lot about P, but don't know a lot about E

Behavior therapy = contingency management, we manipulate contingencies to change behavior.

E has to be as important as P

Behavior is not accidental, it is partially influenced by the environment (to the extreme, this is environmental determinism)

Socialization = context influencing behavior

Animal behaviors increase or decrease based on changes in the environment. For instance, decrease in food leads to decrease in procreation. Increases in animal population leads to changes in the environment. Animal behavior ←→ Environment

P-E interaction is NOT environmental determinism

(to me, this means that the environment - family, schools, institutions, media, etc. - has a hand in shaping us - our decisions and behaviors - but does not have a final say in who we are or who we choose to become. We still retain personal power and self-determination.)

Relationship between P and context becomes more complex

Proximal influence = norms, values, beliefs, influences of group

Changes in color and layout of prison cells to control violence - The color pink was found to sap their energy - Manipulation of color or sounds to increase or decrease arousal

Human behavior can be shaped by environment

We can never train the amount of clinicians needed to meet mental health services demand

Treating disorder vs. addressing what is causing the disorder

You can change the context under which conditions are created for those in it and those that will enter it in the future

Mary McKay on Family Engagement Strategies

I attended a conference with Mary McKay, LCSW, PhD about Family Engagement Strategies. Here are some notes ...

Identify one obstacle that you have encountered as you tried to involve children and their families in services.

Parent-level obstacles:

• We want families to question our intentions and validity/benefits of services
• As mandated reporters, we are the arm of the government/child welfare
• Parents are protective of their family from potential dangers (child welfare & immigration) vs. trusting of us

System-level obstacles:

• Stigma around mental health services (accessing mental health services means you are "crazy")
• Work schedule

Identify when is the right time to get mental health counseling, because this service is seen as a last resort by families. Parents are told – “You’re bad parents,” “It’s your fault,” and “This kid would be okay born to a different family” – judgments! They have seen a heap of professionals before they have seen us. Parents experience trauma from helping systems, including horrible experiences requesting food stamps, for instance (parents don’t see a difference between food stamp clerks and mental health professionals).

Track efforts of parents before they get to you (parents seek help from friends, family, past counseling). It takes courage to finally make the call. Parents have tried everything else and feel like a failure when they call us.

Are your services so good that your families want to come back? “Wow, that was really helpful – I better come back.” We are usually on to the next thing ½ an hour before the end of session!

**How do we make services fun and engaging? Remember to nurture and feed parents and kids when they drag themselves in.

Change is threatening – we don’t like change. Families and organizational staff find change challenging = unpredictable, requires effort & hard work, causes confusion, loss, fear.

Parent: “I’ll consider this carefully and get back to you” – parents risk loss, make the effort – this is a lot – it means a lot of different things – “Can I trust you to remake my family?” – only courageous families embark on this journey of change and give us a chance if we go slow enough – “I want to partner with you and bust through my fear.”

Mental health providers should be prepared to:
• Engage
• Explain our role
• Have family therapy skills
• Have cultural application skills

We should be prepared to explain what we do:
• So how is talking supposed to help?
• What exactly is this?
• How will I know if this worked?
• How will I know this is over?

Assumption that families with more concrete obstacles are less likely to come to appointment. This is why research matters - found that not all barriers are created equal. For urban families, race/culture and poverty matter. Stigma and attitudes about mental health treatment are stronger than concrete barriers.

Which barriers matter most:
• Concrete obstacles never predict utilization
• How do I feel about coming?
• What kind of lens do I see help-seeking with based on previous negative experiences?
• I have skills/tools to get to where I need to – going to see you (MH provider) is not the most important
• Parental concerns that this will be a waste of time
• Parents may have less time problem solving concrete obstacles
• Mental Health providers can ask parents - How do you feel about starting with me? How do you feel about coming to me?

**Trainings raise awareness to issues that need to be attended to – things we tend to forget with day-to-day stress!

Focused telephone procedures were associated with increased initial show rates (more parents showing up to their intake appointments). Structural family therapy telephone engagement intervention was associated with 50% decrease in initial no show rates and a 24% decrease in premature termination (more parents and families showing up and staying for mental health treatment).

Mary asked the audience: “Is anybody ever happy when clients don’t show up?”
Our answer illustrates what we bring to the party. We feel overwhelmed by our jobs. We build in appointment schedule expecting "no shows" – what we expect is what we get.

**Parent advisory group critique after observing a conversation between social worker and parent (GREAT IDEA!)

Clarify the need (from parent vs. collaterals) – SWs almost never asked families whether they agreed with referral. “Do you agree with that?” Whose needs are most important? Parents say, “the only way we will engage with you, talk to you, is if you’re meeting our needs.”

Parents have gone through a lot – this is one their bleaker moments – “neighbors know that SW is in my home.”

To Parents in the Audience: Sometimes you love your kids every minute and sometimes it’s just your job (ruining my life).

Throw parents a lifeline – “This is a lot, I can see you journeying on – good for you!” See their strengths, commitment, burden, distress. Contact by parent can be seen as courageous and hardy. Parent Advisory Group came up with "50 ways you can tell parents you see their strength" (“good job for calling” sounds empty).

Ask parents, “How do you feel about getting counseling with us?” “How do you feel about getting help for your kid?” Probe for their unexpressed concerns and unasked questions! (Reevah Simon calls this “exploring their ambivalence” because “we all feel ambivalent about everything”) “There are a set of questions that families wonder about but don’t ask. Many families are wondering about…medication, information sharing…Is that on your mind? Do any of those ring true for you?”

Unanswered questions sort families out of services. “You’ve got help from somewhere else before – tell me about that?” Typically negative experience – distinguish self as not allowing that to happen again. When parent describes negative experience – “That must have been horrible for you” & “Tell me how that…” instead of defending previous provider, “The provider must have meant…”

Telephone engagement interview elements:
• “What do you think your family/child needs?”
• “Do you agree with referral?”
• Probes: “If you have questions or concerns, we want to answer them now”
• Parent courage acknowledged

**When we see their pain & strengths, allay their concerns – parents are more likely to show up.

Comparing two approaches (using a Randomized Control Trial):

1. Telephone engagement with parents using a "structural family therapy approach" resulted in 21 intakes (kept appointments) & 6 no shows (29%)
2. "Business-as-usual" resulted in 13 intakes & 14 no shows (50%)

Treatment Retention vs. Dropout
Jose Szapocznik, Miami – his intensive treatment keeps parents motivated and in treatment for 6 months. In Mckay’s clinic, only 12% were still in treatment 3 months later.

Initial engagement is important but not enough! Must focus on retention too by using engagement interventions at every contact (not just before initial intake).

Train admin staff/intake workers in engagement issues. Implement routine reminder calls before appointment. At what places in our organization do we have to use parent engagement strategies more fully?

Remember to systematically apply 1-4 elements...

Element 1
First session: Parents are so uncomfortable/nervous, they don’t hear the 1st 10 minutes of the intake interview. If you have been a mental health provider for 6 months or longer, then we can’t be nervous meeting people. Don’t forget how nervous the human being in front of us is – chat! – “how can I help you?” is a hard question – parent needed to review problem list first – they need time to assess us – if they feel rushed in, then they will not disclose. “If I don’t trust you, if I don’t know what you’re about…then I won’t disclose.” Re-explain who, what, when, where and why. Talk/chat for the first ten minutes so that the client can catch their breath.

Element 2
What do we mean by collaboration/partnership vs. meeting mandate?
“This better be good – this better help”
Feeling desperate – “I’ve tried everything I can think of, go to it”
**Growing body of research shows that without strong family partnership, disruptive kids don’t do better and have a negative trajectory.
Mental health professional can say, “This really won’t work if we don’t work together.”

Element 3
Focus on immediate, practical concerns (food pantry transportation & pick-up, tutoring)

Element 4
Don’t assume parent will return to next appointment. “I know I’ve asked you a lot of questions.” Explain what we do with their intake information (privacy, sharing of info). Take some stress off – provide info. “After coming here and seeing the inside of our agency, are you interested in doing this again?” “Are you interested in meeting with me again?” It is respectful to check-in to see if parents are interested in coming back – parents need alternatives. Don’t assume overcoming the 1st barrier will mean overcome a 2nd barrier.

McKay debriefed families after intake assessments – families expressed regret after providing so much information (79% felt this way!)

Ask the smallest amount of information that is needed. Parents need to know why we’re asking. Learn the rationale for each question asked on the intake form. Sometimes being apologetic is perceived as not very competent and doesn’t engender confidence (“I hate asking you all these questions and I don’t really know why I have to but I have no choice” vs. “Here are some reasons why we’re collecting it”).

Every session had to be an opportunity to engage, assess and help. Breathe engagement life into EBPs written by academics.

**Provide services that are so relevant, important & helpful, that families want to come back.

CHS 292 - Communication and Media Development in Health Promotion/Education

Mixing the use of digital and social media (internet, web pages, YouTube, podcasts) with older media (print, journalism, advertising, television, training) is currently changing the way we communicate health messages.

No matter what media is used, the messages must be well-crafted and integrate theoretical ideas as well as knowledge about the issue and population targeted. What we do and why must be thought through.

In this class, we are being shown how to use Adobe Photoshop, Adobe InDesign, Adobe Dreamweaver and Audacity/Windows Movie Maker.

I am most interested in using video to:

• collect qualitative data such as interviews
• train practitioners in specific clinical methods or approaches (how to conduct a bio-psycho-social assessment, how to conduct a trauma narrative/prolonged exposure session, how to conduct a family therapy session using a solution-focused brief therapy approach, etc.)
• provide psycho-education to young people (and the people who care about them) about trauma and resilience (incorporating photos, poems, music, images)

It's a whole new world and opportunities open up before us with endless possibilities. Who said social work can't be fun and creative????

If Stress Kills, Then What Brings Us Life?

We are not at our best when we are overly-stressed and being chronically over-stressed kills.

If stress is epidemic (pandemic?), then what is the equal and opposite force? What brings us life?

I am starting a personal list - please feel free to join in...

• Unconditional Love and Loving Relationships. My husband and daughter mean the world to me. They inspire me and nurturing our relationship is the most important, satisfying, meaningful and difficult of any work I choose to do.
• Forgiving myself and others. Empathy - understanding the story behind the story - helps me to forgive. It is realizing there is a good reason why we do what we do - acceptance. Imagining or knowing the story helps put behavior and relationships in context (Oh, I get it - that makes sense now). And forgiveness is liberating - it feels lighter than anger that lingers into bitterness.
• Meditation and Prayer. A family retreat at a Buddhist monastery helped me to finally experience the calm that my clinical supervisor always advised in order to be an effective parent. Praying in the car (with my eyes open and out loud) on my commute to work really does make my day and work go better. Writing is also a form of meditation practice and brings me peace.
  
• Supplements. Salmon oil (really good grade, not Target or Trader Joe's brand, unfortunately) and B vitamins (B3, B6, B12, etc.)
• Exercise. Whatever makes me feel happy while doing it, works for me - dancing, tennis, walking around the Rose Bowl with friends (walking and talking has replaced doing lunch to catch up). Working out with weights is also really effective for me - good results without a lot of strenuous effort. And the fact that muscles burn fat while I'm reading feels like cheating (in a good way).
• Going to church. Growing up, I used to go to church two to four times a week (!). Now I go whenever I please. And when I do, I never regret having gone. After a small tour of every church in a 20 mile radius, I found one I can live with and feel proud of - All Saints in Pasadena. The hymns, the sermons by Ed Bacon, communion every Sunday, and so on, rejuvenate me.
• Saying No whenever possible. Also known as setting limits and boundaries. In this way I focus on the things that are most important and essential to me right now without overextending myself and feeling stretched thin.
• Saying Yes to help. There is no shame in accepting help from others. Sooner or later, everybody needs help. That's just how we are built. Helpers are no exception. Accepting help is being resourceful.
• I matter - You matter. At a recent massage in Ojai, a massage therapist shared that in her training she was taught to "practice not injuring yourself in order to help others." This entails setting energetic and physical boundaries with clients (and others).
  
• Self-Reflection. Our own still, small voice will speak to us in whispers but scream if we don't listen. If you have ears to hear, then you had better listen.
  
• Hope. Always there is hope and sometimes all we have is hope. And when all we have is hope, hope is enough. We tend to get what we expect, so hope is a pretty good intention to set in motion. Martin Seligman talks about the research that shows how optimism makes us more likely to be healthy, happy and productive. Seeing the glass as half-empty or half-full is more than an issue of semantics, it has real-life consequences.
• Balance. Freud said that good mental health consists of work, love and play. My clinical supervisor taught me that being whole meant integrating our inner parent, adult and baby parts into equal parts.
• Laughter. Do I really need to explain this? Natural pain killers are released in our bodies when we laugh...but you know that because you can feel it on a visceral level. That's one of the many reasons I gravitate toward funny friends.
• Strengths. Focusing on who I am, what I want and what I do well grounds me. It steers me toward my purpose and motivates me, even in dark times, to be persistent.
  

Okay, okay, nothing on this list is revolutionary or anything that you have never seen or heard before. But the point is when we are stressed we tend to be forgetful and not just about where we left our car keys! Making a list or being reflective is an exercise in gentle reminders when we need them most.

La Vanguardia

Scouts need to be smart and brave. They venture out ahead of the group into uncharted territory. They move toward "the enemy" (in this case, "the unknown" will suffice) in small units of one to three individuals. They don't have the safety and security of numbers and therefore need to be courageous. They also have to be critical thinkers, able to weigh new information, because there is no one to tell them what to do. Their job is to explore and send back important information to the larger group.*

In the journey to ourselves we are our own scout. In our profession or field, we need more scouts. Humanity needs scouts.

My courage comes from my deep (longtime) faith. If God inspires me to go where not many have been, I trust in the direction. Standing still is scarier.

I read this passage in a Time or Life magazine article recently:

"When he presented his findings to colleagues, he was greeted with hoots and jeers. 'Heart disease was supposed to be all about genetics or adult lifestyle factors,' says Barker, now 72 and a professor of the University of Southampton in England and at Oregon Health and Science University. 'People scoffed at the idea that it could have anything to do with intrauterine experience.' Barker persisted, however, amassing evidence of the connection between birth weight and heart disease in many thousands of individuals. For years the idea was known as the Barker hypothesis. In time his idea began to win converts..."

Being a vanguard requires developing a thicker skin and having a laser focus in order to be persistent in the face of public scoffing. It requires time for wild imagining. Sometimes drawing inspiration from the transcendental force means seeing things, envisioning, imagining things not yet seen. In the book, Stumbling Upon Happiness, Daniel Gilbert notes that what distinguishes humans from other animals is the capacity to think about the future:

"To see is to experience the world as it was, but to imagine - ah, to imagine is to experience the world as it isn't and has never been, but as it might be. The greatest achievement of the human brain is its ability to imagine objects and episodes that do not exist in the realm of the real, and it is this ability that allows us to think about the future. As one philosopher noted, the human brain is an 'anticipation machine,' and 'making future' is the most important thing it does."

What other tools are needed for this journey?


*Thanks to my husband for describing the specific attributes of scouts for this post.

Spread the Word: Effective Treatments for PTSD

Psychotherapy for posttraumatic stress disorder
Williams, Monnica T., Cahill, Shawn P. & Foa, Edna B.

This chapter reviews psychotherapy for posttraumatic stress disorder.

There are at least four treatment approaches that have empirical support for posttraumatic stress disorder - all forms of cognitive behavioral therapy; these include exposure therapy, cognitive therapy, SIT, and eye movement desensitization and reprocessing.

Cognitive-behavioral therapy has been shown to significantly reduce symptoms of posttraumatic stress disorder from a wide variety of traumas, including combat, natural disasters, sexual assault, nonsexual physical assault, childhood abuse, and a combination of traumas.

Prolonged exposure, a specific cognitive-behavioral exposure therapy program, is currently the best-supported approach to treatment. Concerns about this approach linger, despite evidence of safety and tolerability comparable to that of other forms of cognitive-behavioral therapy. Prolonged exposure is a relatively short-term treatment that can be administered effectively by clinicians who have limited experience with cognitive-behavioral therapy. An important challenge at the present time is disseminating information about effective treatment programs.

Source: Stein, Dan J.; Hollander, Eric; Rothbaum, Barbara O. (2010). Textbook of anxiety disorders (2nd ed.). (pp. 603-626). Arlington, VA, US: American Psychiatric Publishing, Inc.. xxiv, 798 pp.