When Veterans and Their Families Come for Help: What Service Providers Need to Know

10 04 2015

Guest author: Erica Zulawski, MS, MSW candidate

Military welcome home Jack

Through my personal and professional experience with veterans, I have come to understand the unique needs and challenges some male and female veterans experience when readjusting to civilian life. Many veterans say that the military has forever changed them, especially if deployed to areas of combat or conflict.

Soldier with flag FREE morguefile0001980652808

When PTSD is not diagnosed and treated…

My father was a Vietnam veteran. I would like to share some parts of our family’s story.

  • My father would wake up in the middle of the night screaming from awful nightmares and night terrors. I had never heard a man or anyone scream like that before. I was afraid. My siblings and I did not know what was happening to him, and there was no one to explain anything.
  • My dad drank a lot while I was growing up, and he would isolate himself from friends and family. He was there physically, but rarely emotionally available.
  • I resented him for missing a great part of my childhood because of his alcoholism. I also resented the military in many ways because it had taken away my father’s ability to be a good dad and live a meaningful and satisfying life.
  • He was always angry and irritable with overwhelming emotion, always on edge. Family members were also always on edge hoping not to upset him. My father’s illness controlled and dictated the temperament of each of us.

Vet Blog Post Man a with drink photo from FreeDigitalPhotos.net

  • Though severely “rocked” by his traumatic Vietnam experiences, my father would still proudly hang the American flag each morning. I would say that he struggled with a “love/hate relationship”, a love for his country and the military, but hatred for what he lost of himself in the war.
  • He was a very broken person, consumed with emotional and physical pain, suffering every day and drank heavily to self-treat his symptoms. He desperately needed help, but had no idea that he needed it and was deteriorating with each passing day. My mother had no idea how to get him help, so he suffered in silence until he wasn’t able to do it anymore. There was the lack of support and services available for my father and for us as a family to cope with his PTSD, depression and alcoholism. We felt helpless, scared and overwhelmed.

The only time I ever heard him talk about Vietnam was when his “war buddies” would come over to our house to talk and drink. I still don’t know what he endured in the military. When I began working with veterans, I gradually started to understand that what my father was struggling with wasn’t uncommon among that era of veterans: Post-Traumatic Stress Disorder (PTSD) and depression from his military service.

Why is it important to understand and identify the unique challenges and needs of veterans and their families?

Soldier hands behind back FREE morguefile0001566431353

I believe there is a great need for social workers  and other human service professionals within the community (both veteran and non-veteran affiliated agencies and organizations) to become educated on serving veterans and their families so that they can best meet their needs. Policies and program are needed to help veterans and families develop coping skills and find supports. Some of the reasons are listed below.

  • Many veterans fail to get the help they need because of social stigma and barriers to health care and other services. Some non-veteran affiliated organizations and agencies may provide services and treatment to veterans because they may not qualify for some or any VA benefits or health care because of their type of discharge; were never activated from a Reserve or National Guard unit; and/or have some apprehension about using the VA system. There are others who are unaware of the benefits and services available to them. Please refer to the link in the Resource section to learn more about the U.S. Department of Veterans Affairs: Health benefits and eligibility.
  • Being culturally competent and sensitive may decrease the challenges in providing effective services to veterans and their family members. Some veterans will present with chronic and acute mental, social, and physical conditions, as well as being at risk for: unemployment, poverty, homelessness, substance abuse, depression, and PTSD that may be attributed to military related trauma and experiences.
  • To alleviate the backlog of specialty appointments, particularly mental and behavioral health appointments, the VA and Congress implemented the Veterans Choice Card program in August 2014. Veterans who meet the criteria for the program will be allowed to seek health care services outside of the VA system. Please refer to the link in the Resource section to learn more about Veterans Access, Choice, and Accountability Act of 2014.
  • Veterans who live in rural areas may not have easy access to VA health care and services and are more likely be treated in non-VA affiliated agencies and organizations. Providers in these demographic areas need to be familiar with their unique needs and challenges. Please refer to the link in the Resource section for more information about Rural Assistance Center: Veterans and Returning Soldiers.
  • Both VA and non-VA affiliated providers need to understand the complexity of deployment and how multiple deployments can impact the mental, emotional and psychological well-being of a person and their ability to reintegrate and adapt back into civilian life, their community and their family. Please refer to the link in the Resource section to learn more about How Deployment Stress Affects Families.
  • Providers need to be aware of signs and symptoms to recognize if the person they are working with has been in the military. In addition, providers need to be aware of referring agencies and organizations and the services available to veterans and their families if the provider is unable to offer needed services. It’s important that the provider not be afraid to ask appropriate and sensitive questions about the person’s military experiences to gain a better understanding in an effort to treat the “whole” person.
  • VA and non-VA agencies and organizations can network to use the best assessment tools, interventions and treatments for veterans and their families.  Please refer to the link in the Resource section to learn more about the Joining Forces initiative.
  • Agencies and organizations can create an environment where veterans and their families feel safe to reach out and find the support and guidance they need. Make it as simple and convenient as possible, and remove barriers to rigid, structured and complex systems that may feel overwhelming and burdensome. Many who try to access services and treatment will either give up or not bother if it’s too confusing and/or has the potential to trigger or retraumatize.
  • Consider the veteran’s life before the military. Think about adverse childhood experiences (ACEs) that may contribute to the issues and problems that the veteran is struggling with- consider pre-military trauma. Think about how the veteran’s complex trauma, pre-military, peri-military and post-military experiences have impacted and affected their overall life within their roles and responsibilities to the family structure, the community, their jobs and school. Please refer to the Adverse Childhood Experiences Study link in the Resource section.
  • It is beneficial to ensure that services and treatment for veterans and their families are implemented in a way that provides the five principles of trauma-informed care: safety, empowerment, trustworthiness, collaboration and choice. Please refer to the link in the Resource section for more information about Trauma-Informed Care (TIC).
  • Children of service members and veterans also have unique needs and challenges, and can be at risk for emotional and mental health issues like secondary PTSD from being affected by their parents’ military related trauma. Please refer to the link in the Resource section for more information about Overall Effects on Children.

Resources

Online self-study course: Trauma-Informed Care: Working with Veterans, Service Providers and the Military Culture with Patrick Welch, PhD, Sgt. USMC (Ret)

U.S. Department of Veterans Affairs: Health benefits and eligibility

Veterans Access, Choice, and Accountability Act of 2014

Rural Assistance Center: Veterans and Returning Soldiers

How Deployment Stress Affects Families

Joining Forces initiative

The Adverse Childhood Experiences Study

Overall Effects on Children

Treatment Approaches

NASW Standards for Social Work Practice with Service Members, Veterans, & Their Families

Free online course: The National Child Traumatic Stress Network: Trauma-Focused Cognitive Behavioral Therapy (TF-CBT)

Cognitive Processing Therapy (CPT) Fact Sheet for Clinicians

Free online course: Cognitive Processing Therapy

Trauma-Informed Care (TIC)

U.S. Department of Veterans Affairs: PTSD: National Center for PTSD

Other Helpful Resources

‘Why Is Dad So Mad?’ Veteran writes book to explain his PTSD to his daughter.  Also available at www.amazon.com

Military Times: Rand: Civilian mental health providers don’t ‘get’ the military

The Impact of Deployment on U.S. Military Families

Understanding the Impact of Deployment on Children and Families

Using Trauma-Informed Care with Veterans – Dr. Patrick Welch

Use Veteran recovery stories to build connections

Photo Credits

Welcome Home Jack- Our Hero

Hands behind his back

Soldier with flag

Man with a drink





Got Barriers? Improving Access to Mental Health Care for Children & Adolescents

23 01 2015

Guest author:

Melanie Washington, LMSW, MPH, PhD candidate

  Child concerns on a corkboard

If it were not for social work interventions I had as a child, my life trajectory may have been completely different.  I am eternally grateful for those individuals who, with moderate intervention, helped to shape the individual that I am today and be a part of what facilitated the passion that I have for mental health care for children and adolescents.  With my life experiences, both personally and professionally, I fervently believe that every child deserves the opportunity to have mental health treatment, therefore it is my hope through my future work we will be able to figure out solutions to help increase access to mental health care for all children.

I had my first interaction with a social worker in second grade.  I was fortunate to have parents who recognized the struggle that I was having and were unconcerned about the stigma of seeking mental health treatment.  In general, I was an irritable, angry, and strong willed child, with a low sense of self-worth (it wasn’t until I was an adult that I was diagnosed with depression and learned that this is often how depression presents in young children).  However, at school, I was shy and quiet, allowing myself to be walked on by my peers and then I would come home and take it out on my family, verbally and physically.  It was through family and individual work that I was able to start making improvements and gaining more confidence in myself.

Then in sixth grade, I became well acquainted with the school social worker who assisted me in dealing with tremendous challenges and stress at home (although this time I was not the cause of it).  Her assistance and support shaped not only my personal trajectory, but also my career.

After obtaining my bachelors in social work, I worked as an intake coordinator in an outpatient mental health clinic for children and adolescents; I saw the heartache and immense challenges caregiver’s face in attempting to access treatment for their children.  Therefore, I made the decision to go back to school to become a researcher to find solutions to this issue.  I have also begun working on an exciting new grant funding a white paper exploring the issues of access to child and adolescent mental health care in Western New York.

Why is this issue important?

  • Children globally (1 out of 4) have at least one diagnosable mental health disorder.
  • There are not enough child mental health providers to meet the current needs within the population.
  • The World Health Organization has estimated a 50% increase in childhood mental health needs by 2020.

Closed Road with signs

Potential (and too often) Real Barriers:

  • Financial barriers:
    • Insurance coverage- plan may not include mental health services, minimal number of visits allowed, therapists may not be “in network”, may have high deductible plan
    • No insurance
    • Co-pays and families without money to pay the co-pay
    • Sliding fee scales- if they are offered, still may not be low enough for families to afford the payment
  • Geographic barriers: There may not be any clinics in the communities in which individuals live. If a child is below the age of 5, the family may have to travel further distances to find a therapist willing to see children under this age
  • Transportation barriers: Does the family own a car? Can they afford gas? If not, do they have access to Medicaid funded transportation or have money to take the bus? Is your clinic on a bus line? How many bus transfers would might families have to take to get to the office? Is there enough time for the family to take the bus to the appointment after they get out of work? Is the family ashamed or embarrassed to tell you that they don’t have the adequate transportation to access services?
  • Organizational barriers:
    • Hours of operation: Do the clinic hours of operation provide enough flexibility for days, evenings and weekend appointments or does the schedule of therapy create a barrier to access?
    • Does the clinic engage in practices of double booking that can cause people to wait past their appointment time when both appointments show up as scheduled and someone has to wait? These delays may not be tolerable for the children and adolescent or their family due to behavioral and schedule needs (such as the last bus leaves before their appointment ends).
    • Is there enough diversity in the sex and race/ethnicity of therapists so that families have a choice of someone they feel comfortable with?
    • Are there therapists who have appropriate specializations to work with diverse clientele in a clinic as well as evidence-based treatment skills to provide effective treatment?
    • Is the organization trauma-informed and trauma-sensitive so that people seen feel safe and welcome, and are not re-traumatized through service provision?
  • Availability of services:
    • Is a family able to easily obtain an appointment when they first call? If not, what does the process entail for a family to get one? How long do they have to wait for the first appointment? How are they treated by the person who handles the initial contact with the agency? Does the family feel cared for, engaged and that their social or cultural differences will be recognized and understood?
    • If an appointment is given, is it within a reasonable period of time?
    • Are there therapists available to take on new clients?
    • Are there delays or interruption in service being provided- for example if an agency has a high turnover rate, how long to families have to wait to see a new therapist when their current one leaves, and what impact might that disruption in services have on the child?
  • Lack of awareness and willingness to access care:
    • Caregivers may not recognize the signs that a child or adolescent needs mental health treatment. Or they feel there is a stigma related to this. How to we help educate them?
    • Caregiver may be unsure about how to access care, who to ask, and how to navigate the mental health system. Their primary physician also may not be knowledgeable about how to assist them. How do we help them find access to care?
    • Fear: Caregivers may be fearful that if their child does need mental health care that they will be blamed for their child’s behavior or that their child will be taken away from them. Social workers are often equated with Child Protection Services and the myth that CPS only takes away children from families. How do we educate families that therapists can help?

  Kids enjoying family timeThere are many barriers faced by families as they attempt to obtain mental health services for their children.  Yet I passionately believe we also have also have the ability to create some solutions for children and adolescents, their families, mental health care organizations, and the research and policy community.

Possible Solutions for Families:

  • Take action! If you are concerned about your child, talk to their primary care doctor or school social workers.
  • Keep a positive attitude: Help is available and the sooner mental health issues receive effective interventions, the healthier the outcome will be for the child and family.
  • Don’t worry: Getting mental health help for your child does not mean you are a bad parent!
  • Communicate (there is a questions at the end of this post to ask of different providers) with your child’s providers and advocate for them if you do not like the way services are provided. (There is a link at the end of this post on the family resource page with 25 ways to advocate for your child.)

 Possible Solutions for Organizations:

  • Improve engagement and retention of clients by following Trauma-informed Care (TIC) principles and educate all staff at the clinic, from the receptionist to the director on TIC. (Refer to the resource section at the end of this post.)
  • Review and adjust, if needed, clinic hours of operation to ensure they meet the needs of family schedules.
  • Attempt to hire a diverse group of individuals and provide training in cultural competency.
  • Advance the education of your workforce to enhance their skills in treatment provision including evidence-based treatments
  • Include access to services in agency strategic planning.
  • Review and adjust, if needed, your intake process. For example: is there a way to streamline it and make it more family friendly, decrease the waiting times for services, etc.?
  • Review and adjust, if needed, scheduling so that clinicians can see their clients at the time that their appointments are scheduled.
  • Pursue grants or a charitable fund to assist families who are unable to cover the cost of services, bus passes to get to the clinic, and other needs that create barriers to access.
  • Consider, if possible, performing home or school visits for families who have transportation issues.

Possible Large System Solutions:

  • Enhanced integration of physical and mental healthcare
    • Mental health screenings in pediatric clinics, starting from birth
    • Having mental health professionals on staff so that a child or adolescent screens positive they are able to see someone immediately, in addition to providing regular treatment
  • Enhanced integration of mental health clinics into schools or increase of therapists within schools who are able to provide regular psychotherapy, as opposed to crisis management
  • Evaluate tele-mental health: To assist with families to who have transportation issues or may not have easy geographic access to a mental health clinic. Yes, billable regulations need to be investigated and policy advocacy may be part of this with funding bodies.

 Resources:

New York Child and Adolescent Psychiatry for Primary Care

25 ways to advocate for your child

Questions for caregivers to ask providers

SAMHSA’s Concept of Trauma and Guidance for a Trauma-Informed Approach

US Dept. of Health & Human Services. Access to Adolescent Health. Access to Mental Health Care

American Psychological Association. Strengthening the Child and Adolescent Mental Health Workforce

American Psychological Association. Increasing Access and Coordination of Quality Mental Health Services for Children and Adolescents

Photo Credits

Closed Road with Signs

Child Concerns on a Cork Board

Piggy Ride Time, Kids Enjoying





Improving the System for Our Loved Ones: A Mother’s View of Addiction and Services

16 07 2014

Depressed teen free Morgue file

Guest author: name withheld for confidentiality

The day before Christmas, I received a phone call from my oldest son asking me to pick him up on a downtown corner in a risky neighborhood. He gets in the car wearing sunglasses even though the day is dark and cloudy.  My inner alarm sounds and my heart starts to tear… he is high again.  Back home I watch him slowly begin to detox. How many times does this need to happen?  My rule is that he can stay at home as long as he is willing to get help. Of course he agrees as he has nowhere to go. We plan to go to a local hospital inpatient unit but you have to be in a certain physical state to get admitted, and this depends on who is doing the intake and bed availability. Sometimes he can be admitted, sometimes not- yet he is the same person each time, out of control and in need of addiction treatment. We have to wait until Christmas morning to go there.  Not exactly my plan for a family Christmas but I am prepared to do whatever it takes to save his life. 

We arrive at the inpatient unit only to have him turned away. They say he is not sick enough. Really? He is an out of control addict using heroin, asking for help and I am terrified he will die. So now what?  He can’t come back home and refuses to go to a different hospital inpatient unit to see if he can be admitted there. So he decides to stay with a ‘friend’ as he cannot stay with me if he is not in treatment- it is too risky for my family because of past incidents. I drop him off, not knowing what he will do next and the heartache I feel is overwhelming.  What kind of mother turns her son out Christmas day? I feel like I am living in a perpetual grief state as I wait for the worst to happen.  Will this be the last time I see him?

It wasn’t always like this. His childhood was blessed- large and loving family, many friends, fun activities, and strong church involvement.  He graduated near the top of his high school class and attended a private university. But drugs don’t care if you have a college degree.

 Drug use. addictionImage courtesy of Victor Habbick-FreeDigitalPhotos.net ID-10073274I was told people can have the potential to be an addict long before they touch a drug.  This is true of my son.  He is very creative with an eccentric personality that is so fun yet always intensely, sometimes obsessively, focused on the current interest. When he latched onto a new interest that was not so healthy, the consequences became deadly.  After having suffered several major psychological traumas in his late teens, his addictive personality took over to stop his thoughts and feelings.  First it was alcohol, then marijuana, then pain killers finally escalating to heroin. The lies, the deceptions, the thefts from family and friends could no longer be ignored but I was determined not to lose my child. The service system is far from perfect and whether or not your child is receptive to help makes a difference.

older woman head in hands free morgue fileI have had people telling me to cut him off, let him hit rock bottom, and move on in with my life. And a few who said never give up on your child. How can I move on in my life when my son is a big part of it and needs help?  I also walked a fine line trying to avoid being the enabler. I struggled with every decision and often doubted if my choices were right.  Rock bottom can mean death. Will this push him to suicide or will he survive the next overdose? Will he start cutting his arms again? I have cried my eyes out over this, made myself physically and emotionally sick with worry and stress, mourned his death over and over, and planned his funeral.

Twice he was kicked out of inpatient residential programs for not following the rules leaving him with no place to go. How did that help him? He also quit seeing several outpatient therapists because he was smart enough to recognize their insufficient skills or they lacked the rapport needed to keep him in treatment. I have had him arrested, requested a three-day hold in psychiatric unit, cut him off financially, visited him in jail, begged for the best treatment placements through the drug court, taken him to therapy, attended NA meetings with him- often to no avail. I watched him make gains in his recovery only to relapse and have to start over. I remember when I first admitted to friends that he was an addict, I was told that expect him to relapse.  I was stunned by this statement- not my kid, he can do this. I was so wrong as the addiction was more powerful than my amazing, talented son.

 If I could offer any advice to families walking in my path and the service system, it would be:

 

  • For families, please persevere.  Ask many questions, seek help, get therapy, cry if you need to, get mad, and be prepared to fight the battle of your life. Give them hope when they are unable to do it for themselves.
  • Always believe in the person battling an addiction and never give up on them. Be compassionate and persistent even in the face of lies and relapses.
  • The addiction service system needs to find improved ways to meet the needs of people who are up sick and desperate for treatment.
  • Please stop turning them away from treatment saying they don’t meet criteria, or there is no room and giving them no place to go when they are sick and desperate.  
  • Find better places for residential treatment homes so they are not close to ‘crack’ houses that create great temptation.
  • When they keep their cell phones in residential treatment their dealers are still calling them- another temptation that could be avoided.
  • When they are in drug court, break the rules for participation and get throw out of treatment,  why are they immediately discharged from treatment on their own  and not turned immediately back over the custody of the courts?  They do eventually get re-arrested but the time in between can be deadly.  This is a big gap in the program that needs to be fixed.
  • Trauma and addiction go together as I saw this with my son. Psychological trauma is often part of why the person is addicted and both parts of who they are need to be treated as the drugs never go away as long as the emotional pain is still there. So intertwined, yet many of the counselors I interacted with did not have the skills or knowledge to provide effective treatment. I am told this is called a dual-disorder. Agencies need to support staff in gaining advanced treatment skills.
  • Remember that the family is suffering, too. My son’s addiction traumatized all of us. Family members need support. Whether you are a friend, family member or service provider, please understand and empathize with the feelings of shame, sadness, anger, guilt, embarrassment and helplessness we feel. The effect of addiction is devastating and the impact on families and friends is horrific, widespread and so long lasting as trust is often irreparably broken.

Epilogue: As of this moment, my son is in recovery and making progress with the support of a very skilled trauma and addiction therapist. I hope and pray each day that healing and recovery continue. Yet part of me still is still scared, still holding my breath each time the phone rings…

Resources:

New York State Combat Heroin & Prescription Drug Abuse http://combatheroin.ny.gov/

National Institute on Drug Abuse www.drugabuse.gov

Narcotics Anonymous www.na.org

Alcoholics Anonymous www.aa.org

Nar-Anon Family Groups www.nar-anon.org

National Council on Alcoholism and Drug Dependence www.ncadd.org

SAMHSA evidence-based treatments for addiction http://www.nrepp.samhsa.gov/SearchResultsNew.aspx?s=b&q=addiction

SAMHSA Co-Occurring Disorders http://media.samhsa.gov/co-occurring/

National Center on Trauma and Trauma-Informed Care http://beta.samhsa.gov/nctic/trauma-interventions

Photo credits:

Woman and teen photos from www.morguefile.com

Drug photo credit- Drug and addiction use courtesy of Victor Habbick at www.freedigitalphotos.net





Hoarding: the complex slide into clutter blindness

13 04 2014

room that is hoarded

Hoarding is a personal and/or professional issue for many of us. Some have a gift for viewing it compassionately. For others, especially when confronted by family members who are hoarding, it can create revulsion, horror, anger and great sadness for their lack of quality of life. Children may grow up experiencing shame and trauma from living with a caretaker who cannot stop hoarding. I have been on the verge of vomiting after trying to tackle the hoarding of a family member, and I could not go in to the house without someone with me for support.

Locally, we sometimes hear about animal hoarding in the press where someone whose love for animals and other mental health issues causes them to adopt more animals than they can manage. In areas populated by apartment and condominium complexes, there is the added risk to neighbors’ safety due to the potential for fire, mold growth and rodent/insect infestations. Some people are able to keep the hoarding inside their homes and family members, neighbors and co-workers are unaware of the situation. Others have lost control and the hoarding spreads out onto the lawn and other property. One woman even bought the house next door so she could expand her storage as she had filled her own home to capacity with hoarding. The thought of giving away a small item that most of us would consider as trash can cause significant anxiety for some individuals. My heart aches for them. It is important to remember that hoarding is not about laziness, yet this is often the judgment made.

What is hoarding?

Hoarding is a complex disorder that includes: collecting too many items (valuable as well as trash); difficulty letting items go (selling, giving away, throwing away, recycling); and disorganization (growing piles mixed with valuable items and trash with difficulty de-cluttering). There is also commonly a lack of recognition of the seriousness of the problem. Hoarding may be referred to as “compulsive hoarding”.  Clutter blindness refers to the inability to “see” and recognize the accumulation of hoarding and its impact. Animal hoarding focuses more specifically on the acquisition of animals and often includes the inability to adequately care for the animals resulting in unsafe situations for the animals and humans caring for them. DSM-5 hoarding disorders summary.

Why do people develop hoarding behavior?

This is a hard question to answer. Hoarding may co-occur with other diagnoses including Obsessive Compulsive Disorder, depression, General Anxiety Disorder, eating disorders, as well as Posttraumatic Stress Disorder. Hoarding can be a reaction to psychological trauma. When there is hoarding involved, it adds an additional level of complexity to the assessment, diagnosis and treatment plan. Sometimes hoarding is seen in several family members such as the adult child raised by a hoarder grows up and displays similar hoarding behavior.

Other aspects of hoarding development are defined by Paul Salkovskis, PhDobsessive compulsive hoarders; deprivation hoarders (have been through a period of massive deprivation) and those that Salkovskis defines as the hardest to treat – sentimental hoarders (damaged by unpredictability and possibly even neglect during childhood, possessions have become more reliable than people).

How to assess and diagnose hoarding behavior

There are tools at the International OCD Foundation website and the tools below are an excerpt from their website:

 Saving Inventory-Revised (SIR)

The Saving Inventory-Revised is a 23-item questionnaire designed to measure three features of hoarding: excessive acquisition, difficulty discarding, and clutter.

Hoarding Rating Scale (HRS)

The Hoarding Rating Scale is a 5-item semi-structured interview that can also be used as a questionnaire. The five questions include questions about clutter, difficulty discarding, excessive acquisition, distress caused by hoarding and impairment resulting from it. Initial studies suggest that a score of 14 or higher indicates a probable hoarding problem.

Clutter Image Rating (CIR)

In our work on hoarding, we’ve found that people have very different ideas about what it means to have a cluttered home. For some, a small pile of things in the corner of an otherwise well-ordered room constitutes serious clutter. For others, only when the narrow pathways make it hard to get through a room does the clutter register. To make sure we get an accurate sense of a clutter problem, we created a series of pictures of rooms in various stages of clutter – from completely clutter-free to very severely cluttered. People can just pick out the picture in each sequence comes closest to the clutter in their own living room, kitchen, and bedroom. This requires some degree of judgment because no two homes look exactly alike, and clutter can be higher in some parts of the room than others. Still, this rating works pretty well as a measure of clutter. In general, clutter that reaches the level of picture # 4 or higher impinges enough on people’s lives that we would encourage them to get help for their hoarding problem. These pictures are published in our treatment manual (Compulsive Hoarding and Acquiring: Therapist Guide, Oxford University Press) and in our self-help book (Buried in Treasures: Help for Compulsive Acquiring, Saving, and Hoarding, Oxford University Press).

How to treat hoarding

Hoarding is often very challenging to treat. In many areas, there are not any experts in hoarding behavior. Treatment approaches may include elements of Motivational Interviewing; Cognitive Behavioral Therapy (CBT); individual and group therapy; medication for depression, anxiety or OCD;  and trauma specific treatment for those who have a trauma history. When the person feels ready and choose to de-clutter their home, a plan for volunteers and services to assist them.

Author: Lesa Fichte, LMSW, Director of Continuing Education
Photo Credit: Compulsive Hoarding Wikipedia

Select Resources

Understanding a Hoarding Disorder

Compulsive Hoarding

Hoarding as a reaction to trauma. Psychology Today

International OCD Foundation, Annual Hoarding Meeting

Anxiety and Depression Association of America Hoarding Basics

Help for Hoarders (UK)

Hoarding Inventories and Scales, International OCD Foundation

Treatment for Hoarding Disorder: Therapist Guide (Treatments That Work) by Gail Steketee, Randy O. Frost

Buried in Treasures: Help for Compulsive Acquiring, Saving, and Hoarding (Treatments That Work) by David Tolin, Randy O. Frost and Gail Steketee

Stuff: Compulsive Hoarding and the Meaning of Things Hardcover by Randy O. Frost  (Author), Gail Steketee

Animal hoarding FAQs, ASPCA

Animal hoarding and laws, Animal Legal and Historical Center, Michigan State University College of Law

Animal Hoarding from Wikipedia

Diogenes Syndrome, Hoarding – or Merely an Avid Collector? (thanks to Dorlee at Social Work Career Development blog)

From Dante to DSM-5: A Short History of Hoarding

Hoarding disorder as defined in the DSM-5

 





EMDR- rapid healing of “small t” and “big T” trauma

4 12 2013

The beginning of the end…

I recently received a new, unexpected diagnosis when I went to a skilled EMDR  therapist for help with chronic pain: Post-traumatic Stress Disorder (PTSD- DSM-IV definition and PTSD DSM-5 definition). Eye Movement Desensitization and Reprocessing (EMDR) is an evidence-based treatment for trauma developed by Francine Shapiro, PhD.  I have a less severe form of PTSD than many others who have been through horrific experiences. I have what Shapiro calls “small t” trauma. LOTS OF IT! “Big T” trauma is comprised of the things people typically think about as major causes of PTSD (see the chart below).

For me, one more thing happened this year and my resilience and coping efforts were just worn out. My already daily pain escalated. Many of us have “small t” trauma and our own unique levels of resiliency.  I grew up as a Campbell’s Condensed Soup kid (tomato was my favorite). Going into treatment I felt like a can of “Trauma Soup”- lots of trauma ingredients packed tightly into the can of mind/body/spirit!  Yet I never really considered these “small t’s” as causing my pain and other struggles. I felt as if I had these evil gremlins clinging to my mind and body, persistently resisting cognitive-behavioral efforts to make them let go of me.

It bothers me greatly that people often focus on the “big T” trauma and overlook the damaging power of “small t” trauma. Many of our clients have both types, and tragically for some, years of horrific “big T” trauma. “Small t” traumas  can also derail  quality of life and functioning. Universal trauma screening could identify many trauma survivors, change treatment plans,  and CHANGE THEIR LIVES!  Psychological trauma is a hidden epidemic. 90% of clients in public behavioral health settings have experienced trauma. – SAMHSA-HRSA Center for Integrated Health Solutions.

Below is a great chart from the TraumaAndDissociation Facebook page via www.dissociative-identity-disorder.net/wiki/Trauma  that shows some differences between “small t” and “big T” trauma. “Small t” trauma is sometimes called complex trauma and those with multiple incidents of “big T” trauma can also have complex trauma. (Link to the graphic image of this chart.) 

“Big T” Trauma

  • Major events normally seen as traumatic
  • Emotions, beliefs  & physical sensations occur in both the mind & body

Examples

-Serious accidents

-Natural disasters

-Robbery, rape and urban violence

-Major surgeries, life threatening illness

-Chronic or repetitive experiences, e.g., child abuse & neglect

-War, combat, concentration camps

*May cause PTSD in some people but not all

“Small t” Trauma

  • Overwhelming but not often seen as traumatic
  • Emotions, beliefs  & physical sensations occur in both the mind & body
  • Unprocessed traumas have a long-lasting, negative effect
  • Can cause concentration, self-esteem & emotional regulation difficulties
  • Stunts and colors later perceptions
  • Often no intrusive imagery
  • Most common in neglected/abused children
  • Become part of a negative spiral when a “Big T” trauma occurs
  • Sometimes referred to as “complex trauma”

 

What does EMDR treatment feel like?

  • I have been told that it is not possible to accurately describe what EMDR feels like to someone who has not experienced it. I agree that this is probably true- even when I give a trusted person very detailed descriptions of a session. But I wanted to try in the hope that more clinicians will consider becoming EMDR trained and  more people will seek out treatment.
  • Memory reprocessing is unique to each person. No judgments are to be made. There is structured EMDR protocol as well as strong clinical skill used. (Here are some EMDR Frequently Asked Questions.)
  • Every EMDR treatment session feels like a miracle to me. It rapidly reprocesses the gremlins of traumatic memories in my brain so that they no longer control me. And after resolving memories in an EMDR session, it is fascinating how much easier cognitive-behavioral methods now work!
  • After the basic intake information, I was asked to go back to my earliest memories and quickly give a short statement to create a log the therapist wrote of bullet points for  all of my memories. No judgments were made about what felt traumatic to me. Traumatic is a person’s perception of the experience. This list created the working plan for how we would proceed from beginning to end. Some memories are treated as individual memories, and some that have a similar theme are addressed through a cluster that enables the first, worst,  and most recent to be reprocessed and then the larger cluster is pulled together for reprocessing.
  • Before starting EMDR, I was taught to make a mental container so that I could place disruptive or unfinished memory reprocessing into the container. Using the EMDR technique, the container was “installed” so that it would stick (my word) in my brain and be there to use when needed. I practiced in session and then practiced using my container in various ways during the week so that I had mastery before I needed to use it for powerful feelings and memories.
  • To the best of my recollection, working on a single memory feels like this: I am asked to briefly describe it, notice and rate the distress level as well as the place in my body where I feel the trauma. I hold that focus and then starting using the eye moment as directed by my therapist. I can feel the memory changing in many ways during EMDR. After a brief period of doing the eye moment, we stop and I take a relaxing breath.  I share how the memory and feelings changed. No matter how crazy I feel about the way the memory is reprocessing (sometimes like watching a movie that I am writing as I sit there), there is no judgment- just attentive, compassionate focus from my therapist. We keep repeating the process- focusing on changing feelings, reassessing my distress level as we work to let my distress drop down to zero, and installing positive feelings/affirmations. Yes, there are tears but it still feels so effortless for me, so fast. I feel very relaxed and free the entire time, even when a tough memory makes me weary or takes 1 ½ sessions to complete the reprocessing. Sometimes we can do two memories in a one hour session.
  • When I arrive for the next session, my therapist always checks in to ensure that the memory work done in the last session has remained at zero distress. In one instance, more feelings bubbled up over the week and we had to work a while longer to finish resolving the memory. That is normal.
  • I am committed that I am not going to stop treatment until I get through every bit of trauma. As they say, “the way out is the way through”. I attend weekly sessions. Some people have a need or an option to go through an EMDR intensive that is usually done in a couple of days and includes multiple sessions during that time. Here are some examples of how people healed in a recent blog written by Ricky Greenwald, PsyD about the intensive EMDR treatment model.

View a client video about EMDR including the effect of PTSD on the brain (this video shows the use of EMDR equipment instead of therapist fingers for the eye movement).

Summary

Trauma is NOT about what is wrong with someone, it is about what HAPPENED to them. Needing treatment to heal and asking for it is about COURAGE, not about society’s perception that it is a weakness.

We need to remember that there two faces of trauma, “Big T” and “small t”- both deserve equal respect and a nonjudgmental approach. Evidence-based practices and a good therapeutic relationship can take you behind the human curtain and help a person heal. When trauma is not treated, people do not heal and sometimes they die. EMDR is evidence-based, fast, and life changing. We need more skilled EMDR therapists across our country, throughout the world.

I know there are people who think I should not talk about this in the way that I am in this blog…I do so because I am a social worker…I am an advocate…I am one of the many faces of PTSD…one of the many trauma warriors battling to become stronger, wiser, healthier, and happier than we ever thought possible.

Author: Lesa Fichte, LMSW, Director of Continuing Education

Photo credit: free photos at www.morguefile.com and drkathleenyoung.wordpress.com through Creative Commons Attribution

Additional Resources

EMDR & EMDR Training

EMDR International Association www.emdria.org

Trauma Institute & Child Trauma Institute (Ricky Greenwald) http://www.childtrauma.com/

EMDR Institute, Inc. (Francine Shapiro) http://www.emdr.com/francine-shapiro-phd.html

Western New York EMDR Training http://www.socialwork.buffalo.edu/conted/emdr.asp

 Trauma-Informed Care

 National Center on Trauma-Informed Care http://www.samhsa.gov/nctic/

National Child Traumatic Stress Network http://nctsnet.org/

International Society for Traumatic Stress Studies http://www.istss.org//AM/Template.cfm?Section=Home

Online Trauma-Informed Clinical Foundation Certificate Program, University at Buffalo School of Social Work Office of Continuing Education http://www.socialwork.buffalo.edu/conted/trauma-ticfc.asp

University at Buffalo School of Social Work Institute on Trauma and Trauma-Informed Care http://www.socialwork.buffalo.edu/research/ittic/

The Anna Institute www.theannainstitute.org





Therapeutic Relationships: What more do you need?

17 09 2013

Help puzzle freeditigalphotos.netID-100124223

I spent a day with Scott D. Miller, PhD, watching him training people on the power of the therapeutic relationship and how to assess client satisfaction and outcomes with performance metrics for session and outcome rating tools. Since then,  I have been fascinated by the healing power of the therapeutic relationship and its relationship to treatment. There are  evidence-based practices related to establishing therapeutic relationships at the SAMHSA Evidence-Based Therapeutic Relationships page. Yet at the same time, there needs to be a solid treatment approach. I have seen people not heal even though they had a good relationship with their therapist. And I have heard therapists say that they don’t like evidence-based practice because it takes away from the relationship and choice of the client. Perhaps fear of the unknown talking.

Good therapeutic relationships + effective treatment approaches + assessment of sessions and outcomes by the client=  the road to success and healing. And these are all essential in a trauma-informed service environment so that clients receive services within the the five-guiding principles of Trauma-Informed Care (Fallot, 2006): safety, trustworthiness, choice, collaboration, and empowerment.

Recently, trauma therapist  and founder of the Trauma Institute and Child Trauma Institute, Ricky Greenwald, PsyD, wrote a great blogpost about the  Therapeutic Relationship vs. Treatment Model. Here is an excerpt from the post that has already received 147 shares to date from his blog site.

“When I call therapists in other locations to check them out for a referral, I briefly describe the case and ask what their approach would be. Quite a number of these therapists have said something like, “I mainly focus on the relationship, since that’s where the healing comes from.” In a recent survey I saw a number of similar comments. One question focused on choice of technique in a particular context, and a number of respondents wrote some version of, “The technique is irrelevant – it’s the relationship that heals.” Based on my nonscientific sample, I suspect that this position is not uncommon among therapists.

The way it is expressed indicates that this view of the relationship’s primacy is not about psychodynamic theory – in which the therapy relationship is systematically utilized for healing. Psychodynamic people tell you that they’re psychodynamic; they’re clear about what they’re doing, and about the role of technique. No, these therapists are saying that they’ve extracted the essence of the so-called “common factors” research, and concluded that as long as they develop a good relationship with their client, everything else falls into place.

The common factors research – focusing on factors such as empathy, warmth, and positive regard, that may be common across treatment approaches – is quite important, and the centrality of common factors to therapy’s effectiveness has become ever more widely recognized and embraced (e.g., Duncan, Miller, Wampold, & Hubble, 2010). However, this valuing of the relationship over treatment approach reflects a profound misunderstanding of the common factors research.

Duncan & colleagues’ (2010) recent synthesis of the common factors research emphasized the integration and inextricability of the various factors. That is, you can’t just add more empathy or therapeutic alliance to an otherwise non-viable treatment approach and suddenly have a viable treatment. Rather, the common factors are necessarily grounded in a coherent and credible treatment model – itself a common factor – that is embraced by therapist and client. Such a treatment model serves as the foundation for the explanation of the problem, the plans for rectifying the problem, and the hope for successful change. These constitute much of the basis for the therapeutic alliance, the most important predictor of treatment success (Norcross, 2010).

Although it is heartening to see that the common factors literature has reached the practice community, it is concerning to see that it has been commonly misinterpreted in such a way that many therapists may be disregarding the importance of using a coherent treatment approach.”

via Ricky Greenwald, PsyD, Once Upon A Time… TI/CTI Blog–  Therapeutic Relationship vs. Treatment Model, August 6, 2013.

Like this post? check out our other posts on Behind the Human Curtain.

Author for the introductory paragraphs: Lesa Fichte,  LMSW, Director of Continuing Education

Photo Credit: Help Puzzle by Stuart Miles, www.freedigitalphotos.net





Dueling Disorders- the battle inside…

30 08 2013

Dueling

No, the title is not a typo. I know that Dual Disorders   and Co-occurring Disorders  are the correct terms for the combination of substance abuse and mental health disorders. I think a better term to bring home the power of this comorbid brain and body chaos is “Dueling Disorders.”  That’s what killed my brother. The mental health issues and addictions battled within him, each fueling the fight until he finally surrendered. The treatment he was given did not help him stop the battle.

I do not believe he had any hope that the behavioral health and medical system could help him. Maybe it was the lack of hope for healing that really killed him and not the Dueling Disorders? Our family will never know for certain.

In our work, I ponder if we too easily  compartmentalize people’s needs and address only their parts we are most comfortable with?  If yes, does this impair our ability to see the whole person in front of us- their strengths, their joys, their dreams, their level of confidence, their history of trauma, their façade or “curtain” that they put forth to hide behind, as well as the parts of themselves with addictions and mental health challenges? Humans hide in plain sight so what does it take to create a good therapeutic relationship so you can have a chance to  see the whole person and engage them in treatment?

Why was I inspired to write this post?

Obviously, my brother is always on my mind. But also because the title of an article in the August 2013 publication of Counselor: The Magazine for Addictions Professionals stopped my breath: Dual Diagnosis: Expectation, Not Exception.   The point being that we should expect that our clients come to us with a Dual Diagnosis and not just expect a single diagnosis.  And working at a school of social work with a trauma-informed curriculum and trauma continuing education programs, I am acutely aware of the need to see the whole person. I don’t know if any care provider ever saw the whole of my brother. I think they only saw his successful facade and the little bits he would reveal that he needed help with. 

According to SAMHSA, approximately 8.9 million adults have co-occurring disorders.  And approximately 90% of those seen in public behavioral health settings have a trauma history. I find these numbers horrifying, a sad statement about the world we live in.

Thoughts on how to begin to help people more effectively

  • Is your agency or practice current with evidence-based treatment for co-occurring disorders? Does it adhere to the principles from SAMHSA for an integrated screening and assessment process?
  • Does it offer a trauma-informed environment that follows the guiding principles of safety, trustworthiness, choice, collaboration, and empowerment? Are services person-centered? Is there universal trauma screening? How do staff effectively build  therapeutic relationships?
  • If your organization has clinicians who are highly skilled in working with those who have a co-occurring disorders, is there anything more that can be done to share their skills with less experienced clinicians?
  • If your clinicians lack sufficient skills and knowledge to best meet the needs of this population, what is one step you could take to begin to address this need?
  • Is lethality assessed and if there is risk, is it part of the treatment plan?
  • If you or your agency are in state of “overwhelm” from workloads, complex client needs, and rapidly changing regulatory expectations, what is one step you can take to best serve this population? If you woke up tomorrow, and clients were better served, what would be different?
  • if your services are not where you want them to be and you do not know what to do first, start by asking the “5 Whys” to get to the root issue.
  • Have you reviewed your strategic plan  for needed updating to better serve people’s needs?
  • Do you collect program evaluation data so you know what service  outcomes are?

Some days, we just need to stop and take a breath to celebrate how much we already do to effectively help people heal, and identify the steps to get us to enhanced skills in evidence-based and best practice so that even more people can have that chance. And remember that hope is one of the most powerful things we can give our clients in a therapeutic relationship. Resource information is listed below.

Hope and belief in the ability to heal is a lifeline.

Author: Lesa Fichte, LMSW, Director of Continuing Education

Selected References & Resources

 SAMHSA

TIP 42 Substance Abuse Treatment for Persons with Co-Occurring Disorders http://store.samhsa.gov/product/TIP-42-Substance-Abuse-Treatment-for-Persons-With-Co-Occurring-Disorders/SMA12-3992

Based on TIP 42 Substance Abuse Treatment for Persons with Co-Occurring Disorders http://www.samhsa.gov/co-occurring/topics/healthcare-integration/CODQGAdmin.PDF

Effectively serving individuals with co-occurring mental and substance use disorders requires integrated screening and assessment processes.http://www.samhsa.gov/co-occurring/topics/screening-and-assessment/index.aspx

Evidence-based Practice for Dual Disorders  http://www.samhsa.gov/co-occurring/topics/training/OP5-Practices-8-13-07.pdf

Jacobs, D. & Brewer, M. (2004).  American Psychiatric Association Practice Guideline: Provides recommendations for Assessing and Treating Patients with Suicidal Behaviors. Psychiatric Annals 34:5 (373-380). Also on line at www.stopasuicide.org/downloads/Sites/Docs/APASuicideGuidelinesReviewArticle.pdf

Trauma-Informed Care

National Center on Trauma-Informed Care  http://www.samhsa.gov/nctic/

Trauma-Informed Assessment and Screening PowerPoint http://view.officeapps.live.com/op/view.aspx?src=http%3A%2F%2Fwww.theannainstitute.org%2FDTSA.ppt

Trauma Assessment for Adults – Self-Report Version (one tool from the above PowerPoint) http://www.istss.org/AM/Template.cfm?Section=TraumaAssessmentandDiagnosisSIG&Template=/CM/ContentDisplay.cfm&ContentID=3227

Greater Buffalo Trauma-Informed System of Care Community Plan http://www.hfwcny.org/Tools/BroadCaster/Upload/Project327/Docs/HFCWNY_Trauma_Report_Interactive___Final.pdf

Online Trauma-Informed Clinical Foundation Certificate Program, University at Buffalo School of Social Work Office of Continuing Education http://www.socialwork.buffalo.edu/conted/trauma-ticfc.asp

University at Buffalo School of Social Work Institute on Trauma and Trauma-Informed Care http://www.socialwork.buffalo.edu/research/ittic/

Treatment Outcome Evaluation

Scott D. Miller, PhD. Free Session Rating Scale and Outcome Rating Scale. http://scottdmiller.com/performance-metrics/

Therapeutic Relationship

Evidence-based Therapeutic Relationships http://www.nrepp.samhsa.gov/Norcross.aspx

Therapeutic Relationship vs. Treatment Model blog post by Ricky Greenwald, PsyD http://www.childtrauma.com/blog/therapeutic-relationship-vs-treatment-model/

Videos

Video from TedX: 11 minutes of a powerful story from a young man who tells a “stop in your tracks” story about what depression feels like. A must listen for every human service professional. http://www.upworthy.com/this-kid-thinks-we-could-save-so-many-lives-if-only-it-was-okay-to-say-4-words?c=ufb1

Video: 5 minutes from Claudia Black Ph.D. – Double Jeopardy: Addiction & Depression http://www.youtube.com/watch?v=Xean4EFGjC0

Photo Credit: Free Photos from www.morguefile.com

 








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