7 simple (yet powerful) ways to stand out in the crowd and get more clients!

9 10 2017

 

 

 

Guest author: Deb Legge, PhD, CRC, LMHC

 success-opportunity sign

 

 

 

 

 

 

 

If you are holding off on your marketing efforts because you feel you haven’t found that “MAGICAL” thing that will get you noticed, here’s a secret you should know…

“Magic” comes in many forms!

As a mental health clinician in private practice, it is imperative to continually find ways to get your name and face in the minds of those with access to and influence over your ideal clients. It’s also necessary to find ways to prove your value to your referrers.  These activities occur over time.

There are, however, day-to-day things you can do that can make a huge impact on the reputation you develop in the community. You’d be surprised by the (simple) things that really make a difference to your referrers (including those clients who are a great source of word-of-mouth referrals).  I try to really listen to what my clients and referral sources say to me, especially when it comes to feedback about why they send me referrals over and over again.  I hope that you do, too.

Here’s what I’ve learned by listening to my “tribe”.  Do these things and you’ll be ‘head and shoulders’ above others in your market (because many people simply aren’t doing them).

  1. If you can’t take the referral for any reason (insurance issues, expertise issues, etc.), provide alternatives to your referrer (or to the client they sent to you). Your resourcefulness will be noted, and your efforts will be appreciated.
  2. Thank your referral sources. When you get a referral from a medical professional, have the client sign a release and then send a thank you note and a copy of your initial assessment to the collaborating physician for their chart.
  3. Maintain communication with the involved physician(s). Find out when your shared client will next be seeing the psychiatrist/medical doc, and send over a copy of your last couple of notes to assist in collaboration of care.
  4. Return phone calls in a timely manner. I can no longer keep track of how many new clients tell me that they called several clinicians when they first called me, and I was the only one to return their call. I don’t care how busy you are — check your voice mail every day, and have the courtesy to let people know whether or not you can see them.
  5. Keep up with your paperwork. When you get a request for clinical information (from social security disability, an attorney, etc.), take the time to honor the request as soon as possible. Don’t put your client in the uncomfortable position of hearing from someone else that you dropped the ball on them.
  6. Forget about the “competition”. Quit worrying about how many new clients your colleagues are getting. Be happy for them; develop and express an honest appreciation for others’ success and let go any jealousy you may have.  Successful therapists are always looking for good referrals for their overflow.
  7. Use your downtime (empty slots in your schedule) to check in with your referrers. Find out what you can do to help out your local psychiatric hospital’s discharge planner; ask your school district’s guidance department what services or groups they are in need of in the community; offer to do depression screenings at a local health fair. These things will keep you from grumbling about the holes in your schedule, and push you forward in your efforts to serve more clients.

Bottom line, a little bit of effort goes a long way to increase  your credibility in the community.  People will only do business with you to the extent they trust you —

GIVE THEM REASONS TO TRUST THAT YOU ARE THEIR BEST CHOICE!

Author Bio:

Deb Legge, PhD, CRC, LMHCDeb Legge, PhD, CRC, LMHC, works in private practice in Buffalo, NY. She also specializes in helping entrepreneurial therapists get ‘unstuck’ and grow their practices, including a focus on how to create growth with private pay clients. She recently provided a training on this topic at our 2017 Buffalo Niagara Summer Institute. Her coaching practice has helped thousands of clinicians fill their appointment books using her proven success strategies. Dr. Legge is a Board Certified Expert in Traumatic Stress from AAETS.  Her private practice, located at The Counselor’s Corner, focuses on individuals with chronic anxiety and mood disorders, PTSD and other trauma-related issues, borderline personality disorder, life transition, and grief and loss. In addition to her private clinical practice, she is the founder of Influential Insider’s Circle — the world’s first social learning platform for mental health professionals in private practice.

You can gain access to Dr. Legge’s soon-to-be-released, FREE training:

How to Fill Your Book with Private Pay Clients… And End Your Insurance Struggles for Good, at www.PrivatePayPractice.com

Dr. Legge’s websites:

http://influentialtherapist.com

www.PrivatePayPractice.com 

www.counselorscorner.net

 

 





Men & Trauma: 5 Dynamic, Solution-Focused Questions to Use in Therapy

7 09 2017

Guest Author:

Daniel Lawson, LMHC, CASAC

man in therapy

 

 

 

 

 

 

“I am not what happened to me, I am what I choose to become.” –  Karl Jung

Jung penned these words in 1965, and I find myself returning to them often in my work. The intention of this blog post is to provide clinicians with tangible and pragmatic tools to enhance treatment effectiveness with men who have with trauma histories.  As a solution-orientated therapist, the tools I use are questions.

My hope is that in using these questions effectively with the men you serve, they become more of who they are, and less of who they aren’t.

QUESTION 1: “What has been the greatest accomplishment of your life?”

Whenever I do an initial intake, I spend at least five to ten minutes at the beginning of the appointment with this question.  Asking your client about what they have achieved, builds awareness of their patterns of success.  This also helps the client feel at ease and competent.

Naturally, this question also helps men build confidence.  Confidence in many ways is a requirement for successful goal formulation.  Confidence also decreases men’s fears about treatment and making change.

Sometimes, the client may respond saying that they have not achieved anything great in their life.  As the therapist, it’s important to add, “not yet.”  If a client gives that response, it becomes a very appropriate time to talk about goals and ask, “Well, what would you like to say someday is one of your great achievements?”

QUESTION 2:  “What helped you survive?”

Often times our work as a therapist is to reframe the experience of our client.  This question alters the client’s perception from a place of being a “victim” to being a “survivor.”  This creates different expectations and also allows the client to see that in fact they have done something valuable.  It may also allow them to see other strengths that they possess as well as ways to build upon them.

It is important to note that male trauma survivors may habitually destroy their own self-worth, abusing themselves and ruminating on past failures. This question subtly harnesses the power of positive blame, demanding the client to take responsibility for their success and good decisions.

QUESTION 3: “How do you think other people have gotten through something similar to you?”

One crucial element in maintaining the therapeutic relationship and achieving positive treatment outcomes is respecting the client’s theory of change.  This question begins a conversation about what the client believes about their diagnosis/prognosis and their preferred method for recovery.  This also empowers male clients, offering them a way to collaborate and contribute to their own treatment process.

Sometimes the answers clients give reveal the client has very little hope in therapy in general.  In those cases, it becomes more important to explore ways to increase hope before more recommendations are made.

Clinicians can also use this as an opportunity to task clients to do some “research” and identify people who have recovered from similar situations.  Stories of others’ success increase hope and motivation for change.

 QUESTION 4: “Since this all happened, when have you felt at your best?”

Traumatic experiences can alter our observational skills.  Often times, periods when symptoms are less intense (or absent) remain outside of our client’s awareness.  If a client has no clearly defined goal, or they seem to “complain” habitually in session, it is very useful to provide the client with observational tasks.

This question increases the client’s awareness of what is working in their life and has a meditative quality, allowing them to be more present for greater periods of time.  It also enhances confidence and hope that may set the groundwork for the client to begin communicating about future goals for therapy.  Remember that attention is a limited resource, so whatever your client focuses on gets bigger.

 QUESTION 5:  “Who do you feel closest to in your life?”

David W. Smith coined the term “Friendless American Male” during the 1980’s recognizing the consequences associated with disconnected men.  Many healthy men prefer to connect and socialize with each other through experience rather than dialogue.  In building a positive post-traumatic identity, men can benefit from the company and friendship with other men.

This question helps to identity places of support and connection already in place in the client’s life.  Each client is different and therefore patterns and preferences for connection may be vastly different.  However, this is a respectful way to enhance the client’s support network and enhance their awareness of their process of connection. Once recognized, it may be replicated.

Sometimes, clients may respond saying that they are close to no one in their life.  In those cases, it may be useful to ask them if there was anyone they were close to in their past. If so, how did they go about that process?

CONCLUSION

Remember that all people are patterns that persist.  Change the pattern you focus on, change the life you lead.  Have the courage to ask better questions with your clients.  Our lives are the answers the questions we ask.  Better questions can mean a better life for your clients.

SELECT RESOURCES

Post Traumatic Success: Positive Psychology and Solution-Focused Strategies to Help Clients Survive and Thrive by Fredrike Bannink 2014 (book)

101 Solution-Focused Questions for Help with Trauma by Fredrike Bannink  2015 (book)

American Psychological Association “10 Factors of Resilience”

Based on TIP 56: Addressing the Specific Behavioral Health Needs of Men KAP Keys for Clinicians (SAMHSA)   

 TIP 56: A Treatment  Improvement Protocol Addressing the Specific Behavioral Health Needs of Men 

 Grit: The Power of Passion and Purpose by Angela Duckworth (book)

Essential Research Findings in Counseling and Psychotherapy, the Facts are Friendly by Mick Cooper (book)

Video-“Facts are Friendly Pt 1” – Mick Cooper

Video-“Facts are Friendly Pt 2” – Mick Cooper

Video-“Facts are Friendly Pt 3”  – Mick Cooper

1001 Solution-Focused Questions by Fredrike Bannink (book)

Quick Steps to Resolving Trauma by Bill O’Hanlon (book)

BRIEF, an SF training institute in London

ICCE, a worldwide community dedicated to promoting excellence in behavioral healthcare services

Pennsylvania University  Positive Psychology Center (Seligman)

Penn University with positive psychology questionnaires (VIA Character Strengths Survey)

 Author Bio: Daniel Lawson, LMHC, CASAC, works in private practice in Buffalo, NY. He specializes in working with men to overcome issues with relationships, depression, anxiety, substance abuse, death of a child, childhood trauma, or feelings of anger. Dan is a passionate, eclectic practitioner and bases his practice heavily on a solution-focused approach to therapy.  As a result, many of his clients see the results they are looking for in less than six sessions. Dan also uses DBT, positive psychology, mindfulness, CBT, existential, motivational interviewing, and narrative therapy. When working with men, he focuses on restoring hope and connecting them to their ability to do what it takes to heal. In every session, clients leave with a plan to begin improving their life. In addition, Dan also specializes in supporting Catholic men and woman. He effectively combines his faith with his psychological training to provide therapy deeply rooted in Catholic Theology and Philosophy. Dan is a balanced professional and works effectively with his clients regardless of their spiritual/religious beliefs.  Prior to starting a private practice, Dan worked at Horizon Health Services for ten years. In addition to his clinical experience, Dan has experience in training provision and clinical supervision services.  Visit his websites for information at:

http://catholictherapysolutions.com

www.counselorscorner.net/clinicians.html

 

 

 





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





Behind the Human Curtain: The Courage to Look

2 11 2014

Wow…I was blown away when I read In the Ogre’s Lair: Seeing Light in Shadow by J. Scott Janssen, LCSW, in The New Social Worker Magazine. Scott tells a powerful story of helping a challenging client who was hiding behind his ‘curtain’, behind a very big and intimidating wall. What a blessing it was for this man’s life and for his transition into death that Scott persisted in providing support, even though it was a very stressful relationship. So much of what happens to our clients remains hidden. Sometimes when we consistently present ourselves as compassionate, sensitive and trustworthy people, the curtain will slowly move away-  just enough to allow room for hope and help to slip in.

Through his skillful storytelling In the Ogre’s Lair: Seeing Light in Shadow, Scott shares his experience with us and I included an excerpt below.

Read the full online article here.

I should have seen it coming when I slipped on the bullet casings strewn across the front steps. Or when I rang the doorbell and heard an angry-sounding voice bellow, “Who are you and what do you want?” I identified myself as the hospice social worker and waited…

“I don’t need a social worker,” he growled.

I’d read his medical history—respiratory disease, diabetes, hypertension, skin ulcerations that just wouldn’t heal, a long history of uncontrolled pain. And a single line entered under “Social History”—patient can be hostile and combative.

Our visit that day consisted mainly of him telling me what a bunch of incompetents his medical team had been and why it was their fault he was in such bad shape. He alluded to talks he was having with his lawyer and how he would “settle with those cranks” before he died. He came across as angry, self-righteous, and abrasive. And, yes, hostile and combative…

The visit tension hit its high note when I asked if he was having any suicidal ideation. It was a reasonable question—an ex-cop with guns, over sixty-five, male, socially isolated, terminal illness, secretive, hyper-vigilant, apparent anger issues, wanting to be in control but facing increasing physical decline, protective of his privacy but needing help, possible impulsivity, possible depression, possible aggression, possible PTSD—but Jack didn’t see it that way. He hit the roof.

Over the next many months, I called him regularly and offered visits, bracing each time for rebuff and/or complaint…No conversation, however, remained civil for long. He always found his way back to things about which he was angry, always went back on the attack…

Funny thing was, despite his sarcasm, complaining, and opposition to almost everything our nurses suggested, Jack’s medical condition was stabilizing. Steady care from our staff and Jack’s reluctant willingness to listen to a few recommendations here and there allowed his wounds to begin healing. His blood sugar was controlled, and so was his blood pressure. He even began taking more pain medication and getting more sleep at night. Taken together, his underlying respiratory disease began appearing more chronic, less terminal…

When Jack was finally discharged from hospice service because of this stabilization, I was relieved. I walked away thinking I knew him, thinking I’d seen him, and glad to be done with him. As far as I was concerned, he was an egotistical bully. He was insensitive, foul-tempered, devoid of empathy as well as the most remedial signs of social or emotional intelligence. Although I admired the determination and discipline it took to live alone with all the challenges he faced, these were no excuses for being a mean-spirited, anger-addicted pain-in-the-neck…

Sometimes I felt relief that I’d never see him again. At other times, I had a sense of dread that sooner or later, he’d be back…

On the morning I saw his name once again listed under the previous day’s new admissions, I swallowed hard…

The visit was to be our last. I walked in, and Jack was awake. He smiled wide and held out both arms as if to hug me. My first thought was that he was confused. “Hi, Jack. Remember me?”

His smile broadened (something I’d never seen before), and he said, “My social worker.”

He clasped my hand and continued holding it throughout the visit as I sat beside the bed. “I feel so much better now that you’re here,” he said.

Masking my surprise, and wondering if he was being sarcastic or setting me up, I asked him about what had been going on recently.

“It’s been a hard time.” His eyes appeared to water slightly, “I think I might be dying.”

No secretiveness, no defensiveness, no complaints, no blame or attacks… His memory and concentration were taxed, and he had a hard time finding words, but slowly, methodically, Jack searched for language to describe and process what he was experiencing…

Read the full online article here.

Other Resources

Janssen, J. S., (2004) Dawn is Never Far Away: Stories of Loss, Resilience, and the Human Journey

Janssen, J. S., (2013) Locked in the Vault — Survivor Guilt in Combat Veterans, The New Social Worker Magazine

Janssen, J. S., (2012) Just Plain Stephie: Conversations at the End of Life, The New Social Worker Magazine

The New Social Worker- free e-magazine www.socialworker.com

Lacay, S. (2013) Breaking Boundaries With Empathy: How the Therapeutic Alliance Can Defy Client/Worker Difference, The New Social Worker Magazine

The Therapeutic Alliance: An Evidence-Based Guide to Practice (2010)

Author: Lesa Fichte, LMSW, Director of Continuing Education
Photo Credit: Creative Commons Attribution: privatenobby flickr.com




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

 








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