Sunday, December 21, 2008

Bipolar I, II, and Cyclothymic Disorder

A friend and I were having this discussion about the differences between Bipolar I and II, and I had to revert to my trusty pocket version of the DSM to remind myself.

Bipolar I is the most extreme of the disorders. In order to receive a diagnosis of Bipolar I the individual must have at least one manic episode. MANIC is the key term here- HYPOMANIC is not the same.

Hypomania can have symptoms of rapid speaking, racing ideas, not sleeping, and surges of energy. Individuals who are hypomanic are usually able to keep up with their social and occupational obligations.

Mania is intense and often frightening. Individuals may lose touch with reality, believing they are a deity, on a mission from a deity (delusions of grandeur), or experience a psychotic break. They may fly into rages. They may engage in dangerous and destructive behaviors such as abusing stimulants (cocaine, speed) or reckless driving. They may spend money with abandon and may ruin their financial lives in a matter of days.

A mixed episode is when mania and the depressive state are happening at the same time. Just thinking about this occurring is a nightmare for me. Visualize a person in a very foul, depressed, hopeless mood and combine it with racing thoughts and raging energy. Mixed episodes have symptoms such as panic, paranoid delusions, suicidal ideation, and rage.

Ok, so back to Bipolar I and II.

Bipolar I must have had at least one manic episode. A depressive episode is not needed for the diagnosis, but will usually be present at least once.

Bipolar II must have had at least one hypomanic episode and one depressive episode.

Cyclothymia could be seen as Bipolar II Lite. There must be hypomanic episodes and depressive episodes, but the depressive episodes do not need to be as severe as they are for Bipolar II.

Wednesday, December 17, 2008

Anorexia and Bulimia

After taking the exam, realized there was quite a bit more about the DSM on the exam than I had anticipated. Therefore, I bring you another 'difference between' entry. The difference between Anorexia and Bulimia is a really sticky one. Sometimes you hear people say, 'I was anorexic and bulimic'. Well no, they were anorexic: purging type. Some people with anorexia will occasionally binge and purge, and some will eat small meals and purge. Both anorexia and bulimia have symptoms of abusing laxatives or diet pills, purging, and excessive exercising.

People with anorexia will always see themselves as fat no matter how thin they get. In order to get the diagnosis of anorexic, the person must refuse to maintain a healthy weight. Women will often stop menstruating.

People with bulimia tend to stay an average weight. They binge frequently and feel like once they start eating they are not able to stop.

In an oversimplified nutshell, remember that people with anorexia are irrationally convinced they are fat and are obsessed with being thin. People with bulimia are obsessed with food and purge/abuse pills/excercise to compensate for their binging. Anorexics are always underweight and bulimics are usually at an average weight.

Wednesday, December 10, 2008

I passed!

My exam was this morning, and I am pleased to report that I passed! It was 170 questions long and took me a little over 2 hours. A passing score in Indiana is a 75 and I scored an 86.

It was definately very nerve racking... I had dreams about it all night last night. Every time I fell back asleep I'd have another dream about it. I was terribly nervous when I started the exam, but you can't stay nervous through 170 questions (well, maybe you can, but I can't). After about question 20 I got into a good groove. There were many questions that were obvious, some that would have been difficult had I not studied, and a handful where I was like, "WTF?" After I finished all the questions and went over the flagged ones I started to really get nervous again. I sucked it up, hit the 'quit' button and... AN EXIT SURVEY! What? Who would possibly take their time filling out an exit survey knowing it was the only thing between them and knowing if they passed? After the survey a page pops up that says "Examination results: PASS"


So, now that I have sat through that monster, I will depart some wisdom.

First, there are approximately 10,000 questions that end with, "what would you do first?" For example:
You work in a dialysis clinic. A client comes to you complaining that the bus does not pick him up and he has been missing his treatments. What would you do first?
A. Move the client to an assisted living facility.
B. Call his family and ask them to start driving him.
C. Help him hire a private driver.
D. Assist him in calling the bus service to complain.

So, these are potentially all viable options, depending on what the specifics of the scenario are. But the question is not asking you, 'what do you think would be the best option?', it's asking you what your very first step would be. And in this case, the very first step would be to help the client advocate for himself (ie, D). Why would you skip right to B when the bus people may have just accidentally dropped him off their list or didn't realize the life sustaining necessity of him being on time?

There are also multiple questions about boundaries and dual relationships. There's supposed to be a small percentage of 'ethics' questions, and at least on my test, ethics = boundaries and dual relationships. In case you just got on the social work boat, we're not allowed to be business partners with clients, provide therapy to our co-workers, etc.

Cultural competency: if I remember correctly, I had questions about Native American families, questions about working with Asian immigrants, and questions about working with Hispanics. Many of these questions just seemed to be about whether or not you were open minded enough to explore something further or if you would just freak out and call child services. (Note: the answer is not to freak out and call child services.)

Questions that you have absolutely no idea what the answer is: this happened to me several times. I would look at this question, read it four times, then think, 'what the hell... is this even social work? fhdfgkihd;'. Then I realized that while I didn't have a freaking clue what the answer was, I did recognize most of the answers. So the question would go something like this:
What modular battery is needed to launch a robotic jet pack?
A. Systems theory
B. Zoloft
C. Gestalt therapy
D. fission

Ok, so I never studied anything related to robotics. However, I did study systems theory and I don't recall it says anything about robots. Zoloft is a medicine and as far as I know does not double as an electronic energy source. Gestalt therapy... I'm pretty vague on that, but I think it involves talking to empty chairs. Fission... what the hell is fission? So I basically just match the WTF question to the WTF answer.

More revelations to come.

Friday, December 5, 2008

Metaframeworks and Family Therapy

I'm almost positive that nothing this complicated could possibly be on the test, but I wanted to make a note for anyone interested in family social work that there is a book I have used that will BLOW YOUR MIND. Seriously. I had an entire class on this book and I still can't get my head around it completely. It's called "Metaframeworks: Transcending the Models of Family Therapy" by Breulin, Schawartz, and Kune-Karrer. The book opens with a chapter on reality. Is there an unquestionable reality? Is reality subjective? Is reality something that doesn't exist at all? And if any of these are true, what does it mean for therapy?

It then progresses to break family dynamics and behavior down into hard science. Charts, graphs, sequences... it's like reading a biology book. They make arguments that there are four overarching patterns in our lives that all occur at different times and last different lengths of time. They range from face to face short occurrences (Class 1) to intergenerational patterns that transcend decades (class 4). All four patterns are related.

My favorite chapter is on gender. The authors point out five "gender evolution positions". In the first, traditional, "women may experience some oppressed and angry parts." (p. 250). (I should mention here that 'parts' of people are HUGE in this book. Angry parts, sad parts, abandoned parts, child parts... it's awesome.) The polarized part of the evolution has very angry women parts and very defensive and guilty man parts. The gender evolution isn't what is so awesome about this chapter. The awesome part is the discussion on how gender affects therapy. If the stage of gender evolution is seemingly causing problems, or if gender is part of a maladaptive sequence (pattern), how does a therapist begin to challenge the way gender is expressed in a family? How does culture affect gender patterns, and should culture be challenged if it is part of a distressful pattern? Strategies to move families through the next stage of the evolution are included.

Now, this short blurb is not displaying the true awesomeness that it is. I can't describe it well because I have a hard time understanding it myself. But you you're into family therapy and really stretching your brain, seriously, get this book. It's not an expensive textbook. I think I bought it for $12.

Generalist Intervention Model

When one thinks about intervention models, the firs thing that usually comes to mind is crisis intervention. What I'm going to be addressing here is a general overview of what any standard intervention should look like.

Step 1: Get an overview of the client/s situation. What is the client/s point of view of the problem? What do they believe is causing the problem? What possible solutions have been tried? How did they work? Think of this as information gathering.

Step 2: Assessment. Develop a possible hypothesis. What is making the situation worse? What systems are involved here? How are external and internal forces acting on the situation? This is not set in stone and may change as more information is presented. Assessment is key to intervention, so this should be done very carefully and thoroughly, and updated necessary. Good assessments are culturally competent.

Step 3: Come to a consensus with client on what needs to happen. What goals should be accomplished to work towards resolving the issue?

Step 4: Agree with the client on the client's role and your role in the intervention.

Step 5: Proceed with the intervention! (Example interventions, agreed on in step #3, could be drug and alcohol counseling, finding and applying for subsidized daycare, attending vocational training, etc.)

Step 6: Evaluate! Always evaluate! Evaluation is both for the client and yourself. After the intervention is over you want to know if it had lasting results.

Adapted from:
Ambrosino, R., Heffernan, J., Shuttlesworth, G., & Amrosino, R. (2001). Social work and social welfare: An introduction (4th ed.) Belmont: Brooks/Cole.

Thursday, December 4, 2008

Group Work - The Personalities

Groups are known for those very distinctive personalities. I believe it's safe to say that we all recognize these particular gems. Strategies for dealing with these individuals follows.

The member who always speak first, AKA The Excessive Talker (ET)
To encourage someone else to speak first, use your eye contact. Start with eye contact with the excessive talker, and sweep around and end the question with the ET completely out of your field of vision. This isn't guaranteed to work, but when the ET is not in your field of sight at all, it will appear you're not posing the question to them. Begin looking at them to avoid appearing rude.

The member who tells the same stories or shares the same problems over and over, AKA The Broken Record
Disengage eye contact and hope for the ‘wind down’. When the member lacks eye contact they usually realize it's time to move on. If this happens so much it's disruptive or the eye contact isn't working, scan the group. If everyone has checked out it’s time to be frank. "Cara, have you noticed that our attention is waning? This is probably because we’ve heard this story before. What can we do to help you?"

The Quiet Member
It's best to draw out quiet members as soon as possible, sometimes even in the first session. The longer a member waits to participate the harder it will become. If they seem to be agreeing quietly or deep in thought, the following are appropriate ways to gently prompt participation:
"Donna, you seem to be agreeing with what Will said. Would you like to tell us a little about what you’re thinking?”
“Caleb, you look like you’re thinking about something. Would you share with us?”
You can also pose a general question while looking directly at the member. The member can chose to accept the eye contact as an invitation to speak, or ignore it. Although it is awkward to ignore a question that appears to be posed directly at you even if it is phrased as a question for everyone.
Dyads are also helpful because when two people pair up to speak, it's usually impossible for the member to not speak with their partner. This also helps the shy member meet other members and feel more comfortable.

Adapted (very loosely) from:
Jacobs, E., Masson, R., & Harvill, R. Group counseling strategies and skills. (5th ed.) Belmont: Thomson.

Tuesday, December 2, 2008

Group Work

The following are types of groups and a brief description of them.

Education Group
In an education group, the facilitator's main goal is to provide information. Some discussion is appropriate. Examples include youth learning study skills and dialysis patients learning about transplant.

Discussion Group
In a discussion group, the participants discuss topics and not their personal issues. The facilitator is just the person in charge and not necessarily an expert. An example would be a book club.

Task Group
A task group is a group that forms in order to accomplish a task. When the task is completed, the group is dissolved. Examples include students working on a group project, or a committee planning an event.

Growth or Experiential Groups
This type of group's task is to grow as individuals. Examples include spiritual encounter retreats, and physical challenge retreats.

Counseling Groups
Counseling groups are typically for individuals who are experiencing life challenges such as divorce, making friends, life changes, etc. The facilitator may guide the group on topics and tease out details of an individuals situation. The group members are encouraged to help each other.

Therapy Groups
Therapy groups are typically for individuals with problems that are more severe than those in counseling groups. There are many techniques for group therapy and they may look radically different from each other. Examples include groups for women who have been assaulted, individuals in residential addiction rehabilitation, and people with anxiety.

Support Groups
A support group is a group where the members have something in common and meet regularly to support each other. Support groups allow members to realize there are people with the same struggles they have. Members should talk to each other and the facilitator role should be minimal. Examples include groups for people living with a specific illness, parents who have lost children, or people who experienced a common event (such a school shooting).

Self Help Groups
Self help groups do not have social workers are their leaders; they are lead by one of the participants. They typically follow the AA model.

Adapted from:
Jacobs, E., Masson, R., & Harvill, R. Group counseling strategies and skills (5th ed.) Belmont: Thomson.

Saturday, November 29, 2008

Licensing in Indiana

I've always been confused about what all the initials mean after social worker's names. ACSW seems to be a popular one, but I never knew what that mean. So I spent some time learning about Indiana licensing and the NASW credentials. Here's what I understand:

An LSW (a licensed social worker) can be obtained on two levels in Indiana. There is the BSW, LSW, or the licensed bachelor of social work. The BSW, LSW social worker obtained their BSW from an accredited institution, then spent two years practicing before they were eligible to take the exam. The second level of LSW is the MSW, LSW, which is the master's level license. This social worker graduated with their MSW from an accredited institution and is eligible to take the LSW exam immediately after graduation.

The LCSW (a licensed clinical social worker) in Indiana is a MSW who has practiced for two years under supervision of an LCSW and during those years worked in a position that was at least 50% therapeutic practice.

Both levels of the LSW and the LCSW exam are offered through the ASWB, or the Association of Social Work Boards. The link to the exam is here: ASWB.

So what is with the ACSW? The ACSW stands for the Academy of Certified Social Workers. Well, NASW, or the National Association of Social Workers, offers credentials to NASW members in good standing. These are not licenses to practice in your state. The NASW has their own standards for obtaining the ACSW, which includes two years of postgraduate work supervised by another MSW and professional evaluations.

The NASW also offers certifications. There are currently seven certifications, which include the C-SWHC (Certified Social Worker in Health Care), the C-CATODSW (Certified Clinical Alcohol, Tobacco and Other Drugs Social Worker), AND THE C-CYFSW (Certified Children, Youth, and Family Social Worker). A link to the NASW credential website is here: NASW Credentialing.

Thursday, November 27, 2008

Alfred Adler and Personality

Adler had a handful of theories about why we are the way we are. Major ones are inferiority, parenting styles, and birth order.

Adler believed that we all begin with feelings of inferiority as children, and strive to overcomes these feelings our entire lives. Some people are particularly driven to overcome these feelings and strive to be very successful and powerful. This theory would argue that our most powerful leaders (presidents, religious leaders) are driven by a need to be superior in order to negate their inferior feelings. If you think about it, one could analyze W. Bush by saying that he was driven by a need to become president to shake off the feeling that he was the least successful and dumbest of the Bush dynasty. And now he's the least popular president in the history of popularity polls. That can't be good for the inferiority complex.

Parenting styles refer to how parents protect their children from the world. If a parent shelters their child from even the knowledge of bad or dangerous things in the world, when the child grows up and discovers them, the child will regress and seek the same shelter they had with their parents. This could manifest in living with their parents and refusing to 'grow up' or finding a significant other to act as a surrogate parent. When parents do not shelter their children from any of the bad or dangerous things in the world the children grow up to distrust everyone and have difficulty forming healthy relationships. Adler recommends parents do not shelter their children from the bad in the world, but do protect them from danger.

Lastly, Adler has a lot to say about birth order. He believes that the oldest child originally believes they are the center of their parents' world, and when the second child is born, this theory is shattered. The oldest child resents the younger child, feels inferior, and competes for love and attention. The older child is also under pressure from the parents to be responsible for the younger child. This theory states that the oldest child will be the one with the most emotional problems. The youngest child is the child that is most doted on by the parents', so that child is most likely to grow up feeling inferior to others, believing they are not capable of taking care of themselves. According to Adler, the middle child is the one who will be the most emotionally stable. Coincidentally, Adler was a middle child.

Adapted from:
Robbins, S.P., Chatterjee, P., & Canda, E.R. (2006). Contemporary human behavior theory: A critical perspective for social work (2nd ed.). Boston: Pearson.

Wednesday, November 26, 2008

Freud and Personality

Well, it had to happen. We have to talk about Freud. We'll start with the Id, Ego, and Superego.

The id represents our basic human instincts. They are drives that want to be satisfied right now . The id is present at birth. Some of the basic drives it represents are food, attention, and sex.

The ego develops as the baby becomes a child. The ego strives to fulfill the needs of the id while staying within socially acceptable behavior. The child realizes that s/he cannot have everything all the time. "I really want that cookie, but if I just take it mom will be mad. I'll try asking politely."

The superego develops when the individual internalizes societal norms and buys into them. The superego can also be seen as our conscious.

The id and the superego are in constant battle... "I really want to take my coworker's Mt. Dew out of the fridge and eat it... but that would be stealing..." In a well balanced individual, the ego is able to negotiate between the id and the superego.

Sublimation is the term used for when one socially unacceptable drive is channeled into a socially acceptable one. The book that I'm working from uses sex as an example, saying that sexual urges are seen as socially inappropriate, so we turn to marriage, in which sex is socially appropriate. I prefer their other example, channeling aggressive or violent behaviors into competitive sports.

adapted from:
Macionis, J. (2008). Sociology (12th ed.) New Jersey: Pearson.

Tuesday, November 25, 2008

Basics of Family Therapy

Despite which technique or theory you use, typically the beginnings of family therapy will look the same. Usually, family therapy includes everyone who lives in the household, and sometimes extended family members. The therapist begins by establishing report with all the members. Greet the contact person first, and greet everyone, including children, individually. After everyone has settled, summarize the initial contact conversation and ask for input. Listen and reflect every point of view. When someone does not offer input in the initial conversation, ask for it directly. Establish a bond with every family member to reduce anxiety. You want to convey the message that you are not going to scapegoat anyone or jump to conclusions. Develop a hypothesis about the family; are there triangles? How do they benefit from the presenting problem? What is the cycle of the presenting problem? Is there a scapegoat? What are the boundaries like?

To minimize yelling, establish a rule that only one person may speak at a time. If emotions are becoming too volatile too early, change directions. Exploring strengths is always a good idea. Imagine a couple who entered therapy as a last resort to avoiding divorce. The wife is counting off a list of complaints about the husband, saying he's emotionally distant, ignores her, etc etc. The husband is becoming tense and annoyed hearing a reiteration of his failings. When the wife slows down, the therapist could say, 'I can see how that would be frustrating. I'm just curious; what do you think his strengths are in this family?' The wife switches directions and begins to talk about how good of a father he is, how he responds to his children's needs. First, the husband has probably heard his list of failures many times, but probably not heard his wife praise his parenting skills recently. The tension between the two deescalates. The strengths question and answer here could also be taken down the solution focused path and search for exceptions. But I'll come back to the solution focused technique in a later entry.

Adapted from:
Nichols, M. (2009). The essentials of family therapy (4th ed.) Boston: Pearson.

Sunday, November 23, 2008

Depression and Dysthymic Disorder

The criteria for the two disorders follow, directly from the DSM-IV TR. (emphasis added) An explanation follows at the end.

The criteria for Dysthymic Disorder is:
A. Depressed mood for most of the day, for more days than not, as indicated either by subjective account or observation by others, for at least 2 years. Note: In children and adolescents, mood can be irritable and duration must be at least 1 year.
B. Presence, while depressed, of two (or more) of the following:
1. poor appetite or overeating
2. insomnia or hypersomnia
3. low energy or fatigue
4. low self-esteem
5. poor concentration or difficulty making decisions
6. feelings of hopelessness
C. During the 2-year period (1 year for children or adolescents) of the disturbance, the person has never been without the symptoms in Criteria A and B for more than 2 months at a time.
D. No Major Depressive Episode (see p. 356) has been present during the first 2 years of the disturbance (1 year for children and adolescents); i.e., the disturbance is not better accounted for by chronic Major Depressive Disorder, or Major Depressive Disorder, In Partial Remission.

Note: There may have been a previous Major Depressive Episode provided there was a full remission (no significant signs or symptoms for 2 months) before development of the Dysthymic Disorder. In addition, after the initial 2 years (1 year in children or adolescents) of Dysthymic Disorder, there may be superimposed episodes of Major Depressive Disorder, in which case both diagnoses may be given when the criteria are met for a Major Depressive Episode.

E. There has never been a Manic Episode (see p. 362), a Mixed Episode (see p. 365), or a Hypomanic Episode (see p. 368), and criteria have never been met for Cyclothymic Disorder.
F. The disturbance does not occur exclusively during the course of a chronic Psychotic Disorder, such as Schizophrenia or Delusional Disorder.
G. The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., hypothyroidism).
H. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Specify if:

* Early Onset: if onset is before age 21 years
* Late Onset: if onset is age 21 years or older

The criteria for a major depression episode is:
A. Five (or more) of the following symptoms have been present during the same 2-week period and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure.

Note: Do not include symptoms that are clearly due to a general medical condition, or mood-incongruent delusions or hallucinations.

1. depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad or empty) or observation made by others (e.g., appears tearful).Note: In children and adolescents, can be irritable mood.
2. markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation made by others)
3. significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day.Note: In children, consider failure to make expected weight gains.
4. insomnia or hypersomnia nearly every day
5. psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down)
6. fatigue or loss of energy nearly every day
7. feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick)
8. diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others)
9. recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide
B. The symptoms do not meet criteria for a Mixed Episode (see p. 365).
# The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
C. The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., hypothyroidism).
D. The symptoms are not better accounted for by Bereavement, i.e., after the loss of a loved one, the symptoms persist for longer than 2 months or are characterized by marked functional impairment, morbid preoccupation with worthlessness, suicidal ideation, psychotic symptoms, or psychomotor retardation.

So there is a very marked difference between Dysthymic Disorder and a Major Depression Episode. A huge difference is that in order to get the dysthymic diagnosis, one has to display the symptoms almost everyday for two years! For a major depression episode, the individual must show five symptoms nearly every day for two weeks. Personally, I think the time frame difference is a bit too much... two weeks for one and two years for another? I suppose if I wrote the book I'd lessen the time period for Dysthymic Disorder to maybe a year. But once again, the writers of the book did not ask me.

There are some other key points to remember here. When any mood change happens, be it depression, agitation, mania, etc., it is important to screen for substance use; both prescription and recreational. I had a therapist (who was a social worker) tell me that chronic marijuana use can mirror Dysthymic Disorder. I haven't seen the research on this, but it sounds plausible. And having experienced taking Topamax, I can say first hand that prescriptions can not only make you feel depressed but actually slow your psychomotor functioning. There are also medical conditions that would cause mood changes, such as hyper or hypothyrodism, brain tumors, even UTIs in the elderly. Lastly, when a patient presents with depressive symptoms it is imperative to screen for possible manic or hypomanic episodes.

Friday, November 21, 2008

Bowen Family Systems Therapy

Key conceptions of Family Systems Therapy are Differentiation of Self, Emotional Triangles, Fusion, and Emotional Cutoff

Differentiation of Self is a term that refers to an individual's ability to think clearly and logically, even in the face of anxiety. Undifferentiated people react automatically with emotions. Undifferentiated people "... find it difficult to maintain their own autonomy, especially around anxious issues. Asked what they think, they said what they feel; asked what they believe, they echo what they've heard... Differentiated people are able to take stands on issues because they're able to think things through, decide what they believe, and then act on those beliefs." (p. 87)

How people become differentiated will be addressed soon.

Emotional triangles are when two people are locked in conflict and bring in a third party who then because fixed in the conflict. This forms a dysfunctional, three party relationship. The third party relieves some of the anxiety involved with the conflict, but also prevents the conflict from being resolved. An example of this could be a married couple who are having conflict and instead of dealing with the conflict, involve themselves with their child who acts as a distraction and someone to involve ("your father is so unemotional", "your mother spends too much money"). Emotional triangles can also form between a young married couple and a set of inlaws.

Emotional fusion is when two people become so over-involved in each others lives they lose their autonomy. Bowen, the man who originated this theory, first saw the concept of emotional fusion when working with young men with schizophrenia. He saw this concept between the men and their mothers, but after practicing in different fields, noticed this concept was in all types of families.

Emotional cutoff "The greater the emotional fusion between parents and children, the greater the likelihood of cutoff. Some people seek distance by moving away; others do so emotionally by avoiding personal conversations or insulating themselves with the presence of third parties." (p. 89) The book equates parents with kryptonite for some seemingly well adjusted adults.

Back to how a person ends up differentiated or undifferentiated. When a family is involved in fusion, the child most involved with the fusion becomes more undifferentiated and also experiences a high level of emotional anxiety. The child who is least involved in the fusion experiences the highest level of differentiation. THE REASON FOR THIS is because the child most involved in the fusion is forced to either "conform or rebel" (p. 89), emotionally while the child not involved in the fusion is able to learn to think for themselves.


The goals of Family Systems Therapy are to help those involved realize the difference between thinking and feeling, lower anxiety, and to increase the realization of how the individual affects the family.

The therapy begins with the assessment of the families function and the relationships between the family members. Genograms are appropriate here.

Process questions are also the staple of Family Systems Therapy. Process questions are questions designed to move people towards differentiation. They help the person think logically and less emotionally about their problems and their involvement in them. An example exchange could be,
Therapist: "When your husband doesn't return your calls, what goes on inside you?"
Wife: "I get scared. And then I feel disrespected."
Therapist: "And how does that manifest?"
Wife: "I withdraw from him."
Therapist: "What are you trying to tell him when you do that?"
Wife: "That I'm hurt."
Therapist: "Does it work?"

The therapist is NEVER to take sides between couples. The therapist's job is not interfere with the content of the arguments, but to help the couple work on the process of their arguments. The therapist should work to keep those involved in therapy calm and rational, because when discussions become emotional, those involved are not able to think about their processes objectively.

Individual therapy with this theory involves helping the individual gain autonomy and to remove themselves from triangles.

Adapted from:
Nichols, M. (2009). The essentials of family therapy (4th ed.) Boston: Pearson.

Thursday, November 20, 2008

Substance Abuse and Substance Dependence

The DSM-IV TR criteria for substance ABUSE:

A. A maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by one (or more) of the following, occurring within a 12-month period:

1. Recurrent substance use resulting in a failure to fulfill major role obligations at work, school, or home (e.g., repeated absences or poor work performance related to substance use; substance-related absences, suspensions or expulsions from school; neglect of children or household)

2. Recurrent substance use in situations in which it is physically hazardous (e.g., driving an automobile or operating a machine when impaired by substance use)

3. Recurrent substance-related legal problems (e.g., arrests for substance-related disorderly conduct)

4. Continued substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance (e.g., arguments with spouse about consequences of intoxication, physical fights)

B. The symptoms have never met the criteria for Substance Dependence for this class of substance.

The DSM-IV TR criteria for substance DEPENDENCE:

A maladaptive pattern of substance use, leading to clinically significant impairment or distress, as manifested by three (or more) of the following, occurring at any time in the same 12-month period:

1. tolerance, as defined by either of the following:
a. a need for markedly increased amounts of the substance to achieve Intoxication or desired effect
b. markedly diminished effect with continued use of the same amount of the substance

2. Withdrawal, as manifested by either of the following:
a. the characteristic withdrawal syndrome for the substance (refer to Criteria A and B of the criteria sets for Withdrawal from the specific substances)
b. the same (or a closely related) substance is taken to relieve or avoid withdrawal symptoms

3. the substance is often taken in larger amounts or over a longer period than was intended

4. there is a persistent desire or unsuccessful efforts to cut down or control substance use

5. a great deal of time is spent in activities necessary to obtain the substance (e.g., visiting multiple doctors or driving long distances), use the substance (e.g., chain-smoking), or recover from its effects

6. important social, occupational, or recreational activities are given up or reduced because of substance use

7. the substance use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance (e.g., current cocaine use despite recognition of cocaine-induced depression, or continued drinking despite recognition that an ulcer was made worse by alcohol consumption)

Specify if:

With Physiological Dependence: evidence of tolerance or withdrawal (i.e., either Item 1 or 2 is present)

Without Physiological Dependence: no evidence of tolerance or withdrawal (i.e., neither Item 1 nor 2 is present)

To summarize, substance abuse is when a person uses a substance dangerously, or the use of the substance damages the person's home/work/school life. Substance dependence is more severe. The person does not have to be physiologically addicted to the substance if there is an intense psychological need for the substance. The person spends lots of time on the substance; thinking about it, trying to find it, using it, recovering from it, wanting to stop or cut back but being unable to.


Theory X and Theory Y are theories that describe employee motivation. Theory X states that workers are only motivated by not getting in trouble. That is, workers are inherently lazy, do not want to work, and are not invested in their work or the company. Theory Y states that employees are motivated by doing good work. They enjoy working, and desire to be creative in their jobs. A manager in Theory X would act as an authoritarian boss, constantly prodding the workers to do their jobs. A manager in Theory Y would encourage ideas and value collaboration between management and employees.

Theory Z, which was developed after X and Y, is also known as the Japanese management approach. Theory Z can best be described as loyalty begetting loyalty. The company is loyal to the employee, providing long term employment, job security, promotion from within, and concern for the holistic needs of the employee and his/her family. In return, the employee has high job satisfaction and high production rates, and the employer sees low turnover. Examples of employers taking care of the employees holistic needs could include on-site daycare, (or crib in the cubicle- it happens!) exercise or meditation in the morning, and pets in the office place (I really wish I could bring my cat to work.)

Americans with disabilities act of 1990: this act prohibited discrimination in the workplace, in housing, and in public accommodations (the library, the mall, etc). The law states that employers must make ‘reasonable accommodations’ for employees with disabilities. Personally, I knew a man who had kidney failure and needed dialysis. The only time the clinic could run him was in the morning, so a reasonable accommodation in this case was to push his shifts back a few hours three times a week to accommodate dialysis. An example I have experienced that was very illegal was another dialysis patient being fired because the employer said he was driving up the cost of the business’s health insurance.

Kettner, P. M. (2002). Achieving excellence in the management of human service organizations. Boston: Allyn & Bacon.

Tuesday, November 18, 2008

Systems Theory

Back to freshman year of the BSW!

A 'system' is a group of parts that together make up a whole of something. Like our organs and tissue are parts that make up our bodies. In the same way, individual people, families, and organizations together make systems.

A key part of systems is the boundary. Boundaries are the outside of the system. For example, one could see my husband and I as a system. Together we are a married couple. You could also expand this system to include any children we may have (we just have cats, but you get the idea) and us and our children would make up another system. Or you could go out even further to encompass our parents and our sisters and brothers. Systems can also include our schools, our places of work, our communities, etc.

A 'closed' system is a system that has impassible boundaries. Open systems have boundaries that are flexible. Systems can be too closed or too open. For example, a couple with children who allows random strangers to sleep in their home has created a system that is so open it is dangerous. A less extreme example could be boundaries between children and parents that are so loose they act more as peers than parents and children. A family system that is too closed leads to isolation.

Organizational systems can also be open or closed. Personally, I've observed a support group that ignored new and inquiring members. This system (the support group) was supposed to be open, but the members maintained a closed group.

The book I am working from cites ecological levels of systems.

"Microsystem: situations in which the person has face to face contact with influential others.
Examples: family, school, workplace, church...
mesosystem: relationships between microsystems; the connections between situations.
Examples: home-school, home-workplace, home-church...
Exosystem: settings in which the person does not participate but in which significant decisions are made affecting the person or others who interact directly with the person.
Examples: ... school board, local government...
Macrosystem: 'blueprints' for defining and organizing the institutional life of the society
Examples: ideology, social policy, shared assumptions about human nature..." p. 66

In a nutshell, intervention using the systems theory would take into account outside forces on the person. Family needs, the neighborhood, factories leaving the state, and the state of the economy all impact a person's employment status. A student who is not fed at home is not going to excel in school despite any in-school interventions that may be made.

Adapted from:
Ambrosino, R., Herrfernan, J., Shuttlesworth, G., & Amrosino R. Social work and social welfare: An introduction. (4th ed.) Belmont: Brooks/Cole.

DSM Layout

Because this is not the clinical exam, I imagine there is not a lot of in depth questions on less common mental illnesses. However, I feel that as a social worker, it is important to at least be familiar with the DSM and the more common diagnoses and their treatments.

There are five axises in the DSM-IV TR. The following is a direct quote out of the DSM-IV TR from page 27:
Axis I: Clinical Disorders and Other Conditions That May Be a Focus of Clinical Attention.
Axis II: Personality Disorders, Mental Retardation
Axis III: General Medical Conditions
Axis IV: Psychosocial and Environmental Problems
Axis V: Global Assessment of Functioning

So, essentially, Axis I holds all the mental health diagnoses except personality disorders and mental retardation. Mental retardation does NOT include Pervasive Developmental Disorder (PDD) which is the umbrella for Autism and Aspergers. To further complicate things, other (what could be considered developmental disorders) disorders, such as Cerebral Palsy, are not considered mental health at all, but a 'General Medical Condition', so it would be coded under Axis III.

The reasoning is that personality disorders and mental retardation exist throughout the entire person. 'Pervasive', if you will. However, Pervasive Developmental Disorder is a 'clinical disorder'.

No, it doesn't make a whole lot of sense. But we didn't write the book, we just know how to use it. And this is how to use it.

The last Axis, the GAF, is a number scale of overall functioning. Many practitioners find it to be crap and don't use it at all because it is too subjective.

Suicide Prevention

Behavioral warnings of suicidal ideation:

• A tendency toward isolation and social withdrawal
• Increasing substance abuse
• Expression of negative attitudes toward self
• Expression of hopelessness or helplessness
• Loss of interest in usual activities
• Giving away valued possessions
• Expression of a lack of future orientation: "It won't matter soon anyway."
• For someone who has been very depressed, when that depression begins to lift, the individual may be at INCREASED risk of suicide, as the individual will have the psychological energy to follow-through on suicidal ideation.

People with untreated severe mental illness are at risk of suicide. Possibly symptoms of mental illness may include:

• Extreme personality changes
• Loss of interest in activities that used to be enjoyable
• Significant loss or gain in appetite
• Difficulty falling asleep or wanting to sleep all day
• Fatigue or loss of energy
• Feelings of worthlessness or guilt
• Withdrawal from family and friends
• Neglect of personal appearance or hygiene
• Sadness, irritability, or indifference
• Having trouble concentrating
• Extreme anxiety or panic
• Drug or alcohol use or abuse
• Aggressive, destructive, or defiant behavior
• Poor school performance
• Hallucinations or unusual beliefs

College students who commit suicide often do not have effective coping mechanisms. Because of this, students are at the highest risk of suicide 48 hours after a triggering event. Triggering events are stressful events that the student cannot effectively cope with. Examples of triggering events are, but are not limited to: death of a friend or family member, failing school, family crisis, a break-up with a significant other, and fights with friends.

If you suspect someone may commit suicide, ask them. If they have, ask if they have a plan. The more specific the plan, the more likely they are to follow through. If they have a plan, find out if they have the means to execute the plan. If the plan is specific and the means are readily available and they have set the time: you MUST take the person to a mental health professional or the emergency room. If you are on the phone with them, call 911.

If the individual has a plan but you assess the threat to not be immediate, you must help the person seek help. Individuals overwhelmed with suicidal ideation are not capable of seeking help for themselves. Drive them to a mental health facility or walk them to a walk-in counselor. Reassure them that while the pain they are feeling is overwhelming, it can get better.

Adapted from:
National Alliance on Mental Illness

The Trevor Project

Monday, November 17, 2008

Piaget's Developmental Theory

Birth to 2 years
The child experience the world through their five senses. She learns to differentiate herself from objects. The child learns that things continue to exist even when they are not present. The child is 'egocentric', meaning the child is not capable of viewing the world from any point of view but their own.

2 years to 7 years
Thinking is still egocentric. The child learns to use language to represent objects. The child understands rules, although not why the exist and do not see them as modifiable.

Concrete operational
7 years to 11 years
The child can think logically about objects and events. Can begin to understand different points of view. Understands why rules exist.

Formal operational
11 years and up
The child can think logically about the abstract. They can think about the hypothetical, the future, and ideological problems. They can form and test hypotheses.

Critics of Piaget believe that some children advance much faster to concrete and formal thought.

Adapted from:
Robbins, S.P., Chatterjee, P., & Canda, E.R. (2006). Contemporary human behavior theory: A critical perspective for social work (2nd ed.). Boston: Pearson.