Provides information on all things social work, including direct practice (both clinical and community organizing), research, policy, education... and everything in between.
[Episode 98] Today’s episode of the Social Work Podcast is about Cognitive Enhancement Therapy (Eack, 2012) - a relatively new approach to addressing some of the most persistent and intractable problems faced by people with schizophrenia. In order to learn more CET, I spoke with Shaun Eack, Ph.D. Dr. Eack has been involved in most of the clinical research on CET. He is the David E. Epperson Associate Professor of Social Work and Psychiatry at the University of Pittsburgh, and the director of the ASCEND Program, which stands for "Advanced Support and Cognitive Enhancement for Neurodevelopmental Disorders.
Download MP3 [36:08]
I spoke with Shaun at the 2015 Society for Social Work and Research conference. In our interview, Shaun talks about the development of CET, the computer exercises and group therapy - the two components of the treatment, some amazing research findings, and how social workers can get trained in CET.
There’s an old saying, “What’s the fastest way to cure mental illness in an entire group of people? Get rid of the diagnosis.” The proposed changes to DSM-5 get rid of some diagnoses and add others. But that's not all. If you're like me, you have lots of questions about changes to DSM-5.
When I posted the question “what would you like to know about the DSM-5” to the Social Work Podcast Facebook page 11 people responded in less than an hour and 20 people responded by the end of the day. So, what did they want to know? Jessica, Shelly, Sandy, Spring, Paul, and Suzannah wanted to know about autism, depression, and personality disorders. Shylah and Jen wanted to know about addictions. Lisa wanted to know what was up with ADHD. Ciarrai and Lyndon posed some great questions about the merits of DSM diagnosis in social work practice.
In today's Social Work Podcast, I speak with Micki Washburn, MA, LPC-S, NCC and Danielle Parrish, Ph.D. about proposed changes in DSM-5. We talked about the cross-cutting dimensional assessment, changes in the organization of the DSM-5, and changes in diagnoses such as ADHD, Asperger’s, Autism, Depression, Substance Use, and personality disorders. We talked about some of the intended consequences such as greater accuracy for diagnosis, and some of the possible unintended consequences such as loss of funding for diagnostic-specific services. We end with some thoughts about social work’s role in the new DSM.
[Episode 60]Today’s Social Work Podcast is on social skills training with children and adolescents. My guest, Craig Winston LeCroy defines social skills as “a complex set of skills that facilitate the successful interactions between peers, parents, teachers, and other adults” (LeCroy, 2009, 653). Social skills include everything from dress and behavior codes, to rules about what, when, and how to say or not to say something. Social skills training is a form of behavior therapy, and as such focuses on behaviors, rather than thoughts or feelings, as the targets for change. Traditional behavior modification is often thought of in terms of task completion, for example, using star charts to get kids to clean their rooms or do homework. But in social skills training, behavior modification principles are used to teach people skills that help them to be successful in social situations.
[Episode 46] In today's podcast I speak with Dr. Elaine Congress about her creation, the Culturagram. Elaine and I talk about how and why she developed the culturagram, the ten assessment areas of the culturagram, and how social workers can use the culturagram to improve their services. We end the podcast with a discussion about research and resources about the culturagram.
Dr. Congress has provided a copy of the Culturagram that you can look at while listening to the podcast, or when thinking about your clients. Please see below to view the Culturagram.
[Episode 45] In today's podcast, I speak with Shaun Eack about schizophrenia and social work. We talk about some basic information that social workers need to know about the diagnosis of schizophrenia; Shaun identifies and describes the positive, negative and cognitive symptoms that are often present in people with schizophrenia. Around 13 minutes into the conversation we switch the focus from diagnosis to the role of the social worker in working with people with schizophrenia. We end our conversation with a discussion of treatment approaches, including a new approach that addresses cognitive content.
[Episode 29] Today's podcast is the second in a two-part series on Clinical Hypnosis. According to the American Society for Clinical Hypnosis, hypnosis is a state of inner absorption, concentration and focused attention. Today I spoke with Dr. Elizabeth Winter about how and when to use clinical hypnosis. In the first episode, Dr. Winter and I spoke about the history of clinical hypnosis, key assumptions, goals, the client's role and types of problems that might be addressed with clinical hypnosis.
Jonathan Singer: So as a clinician, how do you decide when to use hypnosis?
Elizabeth Winter: Probably the first caution is to use only to do something that you’re already trained to do. And that may sound a little bit obvious but for example, it would be appropriate for me as a social worker to use it with somebody who comes to see me for work on addictions. It would not be appropriate as a social worker for me to help someone to induce analgesia or anesthesia with an intention of my performing surgery on them. I’m not trained to do that, I shouldn’t do it. And conversely somebody who is perhaps and anesthesiologist shouldn’t be doing psychotherapy using hypnosis. So it may seem obvious, but it’s really important that you don’t work outside your field or do anything that you’re not already trained to do. Having said that, not everyone is going to want hypnosis and it’s not going to be something that I would do with everyone. If somebody specifically comes and asks for hypnotic intervention, typically I would do that as part of a broader therapeutic relationship. And it may or may not be appropriate. For example, people will sometime specifically ask if they can use hypnosis to recover memories, typically memories they think they may have buried somewhere about past abuse. Now, I won’t do that kind of work and I won’t do it for a number of reasons, the primary one being memory is not history. And the fact that you recall something in a trance state doesn’t make it true, and in fact there is a fair amount of research that suggests that people who appear to remember things in trance have a higher degree of confidence in those memories but less accuracy. So that would be a time not to use it. If someone is motivated to use it for something like habit control, or anxiety, then certainly it’s worth exploring, and you would start out by teaching the skill before you would use it for the specific purpose. And I’ll give you a quick example of that. I once heard a story of a woman who had grown up in Europe and was towards probably her middle years looking to stop smoking, and she had smoked for many many years, and she wanted to use hypnosis to stop smoking. And what she found was she really got stuck going into trance, and kind of couldn’t go into trance, and when she was asked what her first memory of smoking was, when did you start smoking, it was when she had been smuggled out of Germany in the late 1930’s early 1940’s during the second World War. She had been smuggled out, she was a Jewish woman, and when she crossed the border into Switzerland, someone gave her a cigarette, and she took the first puff of that cigarette, they said this is what freedom tastes like. And so until she knew that she had you know her belief in freedom paired with her smoking habit, then no amount of teaching her to go into trance was going to make any difference, and sometimes you find those things out as you work. So it really depends, it depends on do you have the training and the skill set to do a particular piece of work, and if you wouldn’t without hypnosis, you shouldn’t do it with.
Jonathan Singer: So you use clinical hypnosis when someone asks for it, when it seems clinically appropriate, but also with the caveat that hypnosis is used within a treatment context that is within your scope of expertise and in your scope of practice.
Elizabeth Winter: Exactly.
Jonathan Singer: Let’s say they that all this criteria had been met with a client and you decided to use it. How do you actually use clinical hypnosis?
Elizabeth Winter: The first thing I do is to help someone learn how they best go into trance. There are a number of different inductions, so probably the one people are going to be most familiar with is fixing their eyes on a particular object, and it need not be a watch, and it need not be swinging in front of ones face, I will say that quite categorically now. But there is something called an eye fixation technique and this is one of what is known as the formal inductions. And when I talk about using hypnosis and what is ethical and what is appropriate, really talking about this sort of formal induction of hypnosis. Now the eye fixation may be helpful for someone who is more visually oriented and there are other forms of formal induction, one for example is an arm levitation induction. So that would be perhaps, and this is someone who is more comfortable with more physical and more body oriented rather than visual. There’s another, which focuses more on the ability to visualize things so that may be more appropriate for someone who thinks in that way. So there are different formal inductions. To use those help somebody to learn how to go into trance. Once somebody is in trance then a clinician would add what we would think of as a utilization, which would be what is it we are trying to accomplish, it may be suggestion in a fairly direct way, so you know one might say to somebody “You will be surprised at how much more comfortable you will be when …”. “As you monitor your breathing and slow down your next breath out, you will find that you’ve become calmer, more relaxed, and so on”. A simple example of just relaxation based, but that’s the utilization part of the trance. They then within that, or following that, perhaps be a suggestion for how that comfort or whatever it is will follow that person once the trance has ended. So just because the trance ends they don’t have to stop feeling comfortable you know, that comfort can go with you, that’s the post-hypnotic suggestion part of that. And then there is a termination of that, of the trance experience, which may sound something like “You return your attention to the room in your usual way in the next few breaths and so on”. So there is usually a structure to the formal induction of trance, but the induction, you know the induction of the early trance state is really just the beginning of that. And that will be completely really individualized for the person. There are some standard forms of script, actually some really really nice publications that have standardized scripts, and you know people often make their own but there are some really nice pieces of work for different applications. Now, formal induction is not the only way to use an understanding of hypnosis in the clinical setting. Now here’s the deal, since we go into trance spontaneously, I can intentionally work with someone to induce trance sitting in my office, but I can’t stop them spontaneously going into trance in my office. What I can do is recognize it and work with it because some spontaneous trances are useful and some are really quite harmful. So if there is a trance state which is what we would think of as a negative trance, so a highly focused attention perhaps in a relational situation, that is really really negative then my recognizing when someone has gone into hat sort of highly focused state that is not working well for them, is something that can be very useful clinically.
Jonathan Singer: So would this be something that you might recognize in a couples therapy session?
Elizabeth Winter: Oh sure, an induction into a trance state doesn’t have to be intentional obviously, so couples have a well worn path into an argument, into an old disagreement, into the you always do this, you never do that, so that can certainly operate as an induction if you like, with a focused attention or perhaps even more often focused disattenion, let’s say the induction "You never…"and then the other party disappears, they are not listening after that, they defocus, they have gone elsewhere. Could you view that as a couple’s trance? Certainly. I think it’s also helpful to consider negative trances that children go into and what operates as an induction for a child in a negative way might be the “You’re stupid, you never listen, you never get this right, you’re always so clumsy…” and at that point children often defocus and go elsewhere and they’re in their trance where they can’t get anything right, so of course the don’t. I think that can be a very helpful frame for parents to understand, for teachers to understand. Now on the positive trance side for children, I think it’s helpful again for parents, teachers, families to understand when a child is not being inattentive or disobedient, but simply highly focused in their internal world. So just useful ways to use that conceptualization of trance in a way that is helpful but does not involve necessarily a formal induction of a trance state, but really the recognition of naturally occurring states.
Jonathan Singer: So it does, it sounds like there’s a distinction between these naturally occurring and these formally induced trance states, and you’ve talked about positive and negative trance states. Are there limitations or strengths to clinical hypnosis in terms of the formal work that a clinician would do, not the naturally occurring trance states, but are there strengths and limitations or contraindications in terms of the clinical usage of hypnosis?
Elizabeth Winter: I think there are times when you absolutely wouldn’t use it, and we’ve certainly mentioned you know where you’re really not trained to. You may understand trance work but you may not be appropriate for you to use it in a particular area. Contraindications for me as a social worker seeing people for psychotherapy. I typically, probably would not use hypnosis for someone who has psychotic symptoms because they’re experiencing altered states in any case and adding in another form of altered state really is probably not going to be helpful, it just isn’t.
Jonathan Singer: That makes sense.
Elizabeth Winter: So I probably wouldn’t, I wouldn’t do it. I think I’ve already mentioned that I wouldn’t do, I don’t do memory retrieval work, and again that is something to be really cautious of. Might somebody remember something during the course of psychotherapy, absolutely, memory is not a continuous thing. Might somebody remember something while they’re in trance, certainly, but I wouldn’t go fishing for it. I wouldn’t use trance if somebody said I only want to do this and nothing else, that’s like telling a surgeon all they can use is a scalpel, nothing else, no retractors, no forceps, you know you wouldn’t limit yourself in that way. One aspect of using clinical hypnosis that I think is important for people to bear in mind is that where there is a legal case going on the admissibility of your clients evidence can really be put in jeopardy by that person having done hypnosis. Not because hypnosis makes them a less credible, well literally makes them a less credibly witness, but the law certainly views it that way. You know when, if you’re a forensic, if you’re doing forensic work as a therapist or a psychiatrist, you probably would not want to be using hypnosis. And it’s appropriate if someone wants you to work with hypnosis or if you’re considering it, to bear in mind that if they have a case pending or they might have a case against an abuser for example, that their testimony could be set aside in court. If you’re thinking of using clinical hypnosis with someone to really discuss with them in a psychotherapeutic setting whether this is something they’re comfortable with, not everyone is going to be comfortable with it. And there are some real cultural differences on the use of hypnosis with some people being very comfortable and some people being extremely uncomfortable and not feeling ok with that at all.
Jonathan Singer: And you are talking about informed consent, essentially, yes.
Elizabeth Winter: Absolutely, yes, and obviously that applies to anything but particularly to this. Particularly because of the misconceptions around it. You know just because I think it’s a great idea, if my client doesn’t then we’re not doing it, it’s really simple. The obvious limitation I think for clinicians is that you don’t do hypnosis as entertainment and you don’t do it if you’re not trained, same as anything else. You really, really want to receive the appropriate training. Interestingly, training for hypnosis puts people often in a multidisciplinary kind of setting because if you go and get formal training in clinical hypnosis, you’re probably going to be… As a social worker, you’re going to be with other social workers, but you’re also going to be with physicians, with dentists, you know nosis and so on because typically those trainings are multidisciplinary. Which is actually a very very interesting you know in addition to getting the training, it’s a very interesting setting to get some learning.
Jonathan Singer: If somebody is listening to the podcast and they say ok this sounds like it would be really a useful skill for me to have as an adjunct to what I normally do in my treatment, are there other references, are there books, are there authors, are there specific places where people could go to get training that you would recommend or that you would say off the top of your head?
Elizabeth Winter: I think I would probably start with the American Society for Clinical Hypnosis, which has an excellent website and I know and also look at the Milton Erickson Foundation website. But the American Society for Clinical Hypnosis, which is fondly known as ASCH (pronounced Ash) runs a number of trainings across the country, and these are very experiential trainings. To be an ASCH approved training it has to not just have lecture content but it has to have practical, you know practical learning. So learning how to induce trance, being a recipient of that, and really is quite extensive training. There are many places that you can an online or a weekend course, or a and get a, I think you can even get a Doctorate in hypnosis, that really is not the kind of training I would recommend, I have to say. I would say start with the American Society for Clinical Hypnosis; it is one of the very few national and longstanding professional organizations for therapeutic and clinical hypnosis.
Jonathan Singer: Well Dr. Winter this has been fascinating for me and I hope for our listeners. Thank you so much for being here and talking with us today about clinical hypnosis.
[Episode 28] Today's podcast is the first in a two-part series on Clinical Hypnosis. According to the American Society for Clinical Hypnosis, hypnosis is a state of inner absorption, concentration and focused attention. In today's podcast, I talked with Dr. Elizabeth Winter about the history of clinical hypnosis, key assumptions, goals, the client's role and types of problems that might be addressed with clinical hypnosis. In Part II, Dr. Winter and I talk about how and when to use clinical hypnosis.
Jonathan Singer: Dr. Winter thank you for joining us today, I am really looking forward to talking about clinical hypnosis. I was wondering if first you could give us a brief overview of the history of clinical hypnosis, including perhaps some of the key figures in its’ development?
Elizabeth Winter: Certainly. Clinical hypnosis started early in the 19th century when the term was coined by a physician called James Braid, who had observed exhibitions of what was then known as mesmerism or animal magnetism, and Braid thought that rather than a magnetic force of any kind, he thought that this was suggestibility and a form of sleep, which so he then called it hypnosis after the Greek word hypnos for sleep. Hypnosis was used for anesthesia and analgesia by a surgeon by the name of Esdale in India where he had used this on Indian patients in need of surgery and it was very successful in reducing what were then very very high mortality rates. With the advent of ether hypnosis became something that was a skill that had to be learned rather than a chemical that could be applied, and became less popular. It was used later in the 19th century by some of the big names in psychotherapy at that time such as Jacque, and Jeanea, Joseph Boyer and Freud of course. Freud had an early interest in hypnosis which gave way really as he developed psychoanalysis, and so hypnosis kind of waned in popularity again. Probably the main name from the 20th century was Milton Erickson and we still have the Erickson Foundation and what is often called the Ericksonian methods of hypnosis in hypnotherapy.
Jonathan Singer: What are some of the key assumptions of clinical hypnosis?
Elizabeth Winter: There are a number of things to consider here, one is that trance, or the hypnotic state is usually conceptualized as highly focused attention so that a person in trance is very highly focused on a certain thing, and conversely defocused on other things. So it’s a very tightly focused attention on the inward rather than in the outward, not exclusively but certainly, probably most commonly. What it is not is perhaps also extremely important. It isn’t sleep as we said earlier, it isn’t a form of mind control, which is perhaps how it’s popularly portrayed in terms of stage hypnosis, so it really does need to be distinguished from hypnosis, as a form of entertainment. A person who is going to be working with hypnosis clinically really needs to be I think well trained in the use of that. So perhaps one of the assumptions if you like is that the person doing this has had appropriate training. Other assumptions are that a trance state enables a person to perhaps address both their mind and their body at the same time. People may have come across this stage before, is that every psychological event is a physical event and every physical event is a psychological event. So it’s never one thing or the other, we perhaps have a slightly dualistic concept of the mind and the body. But working in trance really tends to draw on the idea of a holistic single thing. Again, one of the ways I think of that is you can look into a building through one window and see a particular view, you can look into a building from another window and see another view, but it’s the same building, it’s the same contents. Other assumptions would be that obviously, the obvious things like informed consent and so on and so forth, so the same kinds of assumptions that you would have for any forms of treatment.
Jonathan Singer: So it sounds like one of the main assumptions of clinical hypnosis is that it’s an internal focusing, possibly to the exclusion of the external world, and that there is an understanding of the mind and the body as a Gestalt.
Elizabeth Winter: I think that’s right, and I think that I’d also add that there’s an assumption that trance is a naturally occurring phenomenon. In other words, when you use it clinically you’re intentionally using something that we all know how to do anyway, and to give you an example of that, if you have ever watched a young child glued to a television set or to a computer screen, to the exclusion of all else, they’re not perhaps focused internally, but they are very very tightly focused on that thing, and you can talk to them sometimes for quite some time and they have absolutely no idea that you are there, not because their ears don’t work but because they have defocused on that particular form of input. So that if you like is a naturally occurring trance state. Likewise, if you’ve ever driven home and completely spaced the drive, and you know that you knew where you were going, but you have no recollection of how you got there, chances are that was a naturally occurring, and what is often called the driving trance. It is a naturally occurring thing, the difference is when you are using it clinically is that you have an agenda. So you have a therapeutic intention and an agenda for that trance, and if you can enter trance spontaneously, then you can enter it intentionally, and that’s also I think an assumption of practice. For research purposes, people often use hypnotizeability scales, which will show that some people are more hypnotizeable than others, and that can be tremendously useful for research work. From a clinical practice perspective, most people who work with this particular skill, will make the assumption that if someone can go into trance naturalistically or naturally if you like, then they can do it intentionally.
Jonathan Singer: Is clinical hypnosis a stand-alone treatment or is it something that can be used in conjunction with other forms of treatment, such as behavior therapy or solution focused treatment?
Elizabeth Winter: Hypnotherapy is not a treatment per say, it really is a skill or a tool; it’s a sort of scalpel if you like, it’s analogist to that, so does it stand-alone? Well, not really, it depends on what you want to do with it. So you can use trance work or hypnosis as part of cognitive behavioral therapy, as part of psychodynamic therapy, as part of couples therapy, individual, group, self-management, you can really use it a variety of different ways. So no it’s not a stand alone, in my estimation best used as part of an ongoing planned psychotherapeutic intervention. People will often say well can you just teach me how to go into trance so I can quit smoking, well yes you can absolutely teach it as a skill, and it certainly might preference to teach it as a skill that someone takes away with them rather than as something that the clinician does to them, but it’s not going to be something that will stand alone without looking at what, you know someone wants it for habit cessation, why do the smoke, what’s the context of that, obviously it’s not you know a magic solution but sued within an appropriate course of treatment, then yes it’s a very useful tool.
Jonathan Singer: What is the role of the client when the clinician is using hypnosis?
Elizabeth Winter: That’s really an interesting question and I think it depends as much on the clinician in question as much as it does on anything else. Clinical hypnosis is used really by a broad variety of folks, so that may be social workers, it may be psychologists, it may also be dentists, physicians, chiropractors, nurses, so how the clients role is conceptualized is really as much a function of whether and to whom they’re presenting for service as it is of hypnosis itself. So I’m speaking personally as a social worker, I will usually be working with someone on the basis of using hypnosis as a personal skill, for example, typically in the first session with someone who wants to learn hypnosis, we will do some trance work in that first session with the goal that this person can then induce trance for themselves, whether or not I happen to be there. So really for me it is something that someone takes away, not something that they have to come to me to get.
Jonathan Singer: So it sounds like the clients role differs based on the setting, so if I was a patient in a dentist’s office, it would be different than if I was in a psychotherapy office.
Elizabeth Winter: I think that’s right and I think that, as we talk more about how it’s used, I think perhaps that will become clearer too. I am thinking of people that I’ve worked with over the years, some of whom practice it and practice a great deal because it’s a skill, practice is important, and so they have sort of taken it as their own and do what they need to do with it, and I’m thinking that there are other people who use it more rarely but will come in and say I’m having trouble with this, can we do some trance work around this particular thing. One example that comes to mind is somebody who is getting some quite distressing physical discomfort and couldn’t work out whether this was stress related or not, well of course as a social worker the first thing you do is send someone to get a complete medical workup, but in terms of preparation for that workup one of the things that we did was to have this person go into trance, and they were very good at that, they had done it many times, and to do what you might call a full-body scan, what was paining them, how was it paining them, what was the quality of that, so that when they went for their medical workup, they could really give some high quality information to the physician, and also be a little calmer in themselves about knowing what was going on for themselves.
Jonathan Singer: What are some other types of problems that can be addressed using clinical hypnosis?
Elizabeth Winter: Well, if we look at that in a very general way, those are going to fall into the more medical kinds of things, and then what we would think of as the more psychosocial kinds of areas. Hypnosis certainly can be used both with adults and with children, and actually since children, their natural ability to go into trance is really really high until we train them not to, and so they are very very susceptible and very comfortable going into trance. And there’s a lot of medical work done with kids around pain control, and to prepare children for procedures, particularly painful procedures. Karen Ulness actually has written a very very nice book and done a great deal of work on working with children in medical settings using hypnosis. Obviously pain control or shifting perceptions of pain is certainly a way to use hypnosis and there is a fair amount of evidence actually looking at using hypnosis to reduce the need for using analgesic medication post-operatively to reduce subjective perception of pain and to decrease wound healing time also, so some quite nice evidence out there for that.
Jonathan Singer: I also know that hypnosis is used in birthing, there’s a whole area called hypno-birthing, and in hypno-birthing they reconceptualize pain as pressure and suggest that if you’re in a state of deep relaxation you won’t be fighting your body’s natural process. So the idea is that the fight is what causes the pain, and hypno-birthing points to cultures where the birth experience is not discussed in terms of pain, like it is in the United States. Interestingly this approach seems to be very different than other birthing classes, like Bradley or Lamaze, even though those classes include basic hypnotic techniques, like breathing for relaxation.
Elizabeth Winter: Interestingly Lamaze was trained in hypnosis, so you know there are probably some very strong links around what Lamaze did in childbirth and his training in hypnosis, as I understand it. But yes, certainly, that’s a very nice cognitive intervention to reconceptualize pain as something that is not pathological, but quite appropriate for the process, and there’s again a lot of folks working with childbirth preparation with hypnosis so to help somebody to understand what to expect and again going back to that assumption that you’re not just talking to the mind but you’re talking to the body. So one of your suggestions may be as you feel a certain kind of pressure, than that will be your cue to allow that muscle to relax and lengthen or the ligament to soften and lengthen and do what it needs to do in the childbirth process. So that would be a very nice example. In the sort of psychotherapeutic world hypnosis is used in a number of different ways. Anxiety, and of course that could well be related, well it could be related to anything at all, but I am thinking of your example of childbirth, so you would deal not only perhaps with the physical sensations of that but also fear of pain, fear of the process, whatever the process is. So anxiety certainly, depression, ADHD actually. There’s some of use of that in terms of filtering input, if you consider hypnosis again as a state of highly focused attention, and if you think of Attention Deficit Disorders as the inability to not focus, something that would help somebody filter input would be very very helpful. Addictions, as a skill in terms of perhaps understanding and identifying some of the triggers for addictions, and also in dealing with cravings when they arrive. Some very good applications there, and then some really general things, like general ego strengthening, general relaxation, stress reduction, and actually I tend to use hypnosis for folks who have post-traumatic symptoms, helping people to find a way to ground and to deal with some of the physiological anxiety symptoms that really hit people hard in Post-traumatic Stress Disorder.
Jonathan Singer: It sounds like a wide variety of issues that can be addressed with clinical hypnosis and it sounds like with the examples that you gave there are similarities but they are really targeted to whatever the most distressing symptom is, so with the ADHD with be attention, with the childbirth it might be what does this pain mean, you know what is this triggering, what is this telling you to do at this point as opposed to “Oh my God make it stop”.
Elizabeth Winter: Right, and what you’re dealing with is our ability to focus. So whatever one focuses on or chooses not to focus on, I mean that’s why it’s a wide variety, because focus itself can be applied to absolutely anything. I think it’s also important to add that contrary to the misconception that hypnosis reduces somebody’s control, or has control over the person that you’re working with, the goal if you like of the many uses of trance is to increase control. So that somebody has more control over emotional responses, over physiological processes, and can again given the childbirth example, feel more control of what is happening in that particular process. So control over levels of perceived pain, control over how long something appears to take. There’s a concept in hypnosis called time distortion, and if you think about being a kid on the last afternoon on the last day of school before summer vacation, how long does that afternoon stretch out? Subjectively for a kid, it’s forever, now if you want to make something last longer, that’s great, you then might cue somebody to remember that long long long time, if you’re dealing with something like discomfort or pain, then you might want to do the opposite, and talk about how quickly time can pass, so that our ability to experience time in this very subjective way is something that we can use in a trance state to have some control over procedures, and some of the procedures that you know things that involve like bone marrow procedures, and so on where there’s a high degree of discomfort, and use trance to sort of go away and you know change the length of time that that seems to take can be very very helpful to people. But the whole idea of this is to have more control over what’s happening. So for anxiety for example, the control that one might like to have is control over some of the physiological aspects of anxiety. Things like reducing your heart rate, calming your breathing down, and when you do that then your subjective experience of anxiety changes because you’ve dealt with some of the physiological things that you know are part of it and that then feed that whole process of becoming anxious and maintaining an anxious state. So it really is about putting control, you know giving control to the person who is learning to do this, and again importantly, taking that away out of the office so they can do it as and when they need to or want to.
In this podcast, the last of four on pathological gambling, I speak with Jody Bechtold, LCSW, NCGC-II, PC about the process for becoming a nationally certified gambling addictions counselor. Jody compares the national certification process with the process to be designated as "competent" to treat pathological gambling in the state of Pennsylvania. If you are interested in becoming nationally certified, you might want to listen to the podcast a couple of times, as there are a number of steps in the process.
June, 2012: Journal of Social Work Education publishes Jody's article on graduate education and gambling:
Engel, R.J., Bechtold, J., Kim, Y., & Mulvaney, E. (2012) Beating the odds: Preparing graduates to address gambling-related problems. Journal of Social Work Education, 48, 321-335. doi: 10.5175/JSWE.2012.201000128.
National Testing Corporation for the NCGC exams: http://www.ptcny.com/clients/NGCCB/
The following is an example of costs associated with becoming a certified gambling counselor:
Singer, J. B. (Host). (2007, June 11). How to become a nationally certified gambling addictions counselor [Episode 20]. Social Work Podcast. Podcast retrieved Month Day, Year, from http://socialworkpodcast.com/2007/06/how-to-become-nationally-certified.html
Today's podcast is the first in our four-part series looking at the DSM-IV-TR diagnosis of pathological gambling. In today's podcast, Jody Bechtold, LCSW, NCGC-II, PC looks at what it is, what it is not, and what are the similarities and differences between pathological gambling and substance use disorders.
June, 2012: Journal of Social Work Education publishes Jody's article on graduate education and gambling:
Engel, R.J., Bechtold, J., Kim, Y., & Mulvaney, E. (2012) Beating the odds: Preparing graduates to address gambling-related problems. Journal of Social Work Education, 48, 321-335. doi: 10.5175/JSWE.2012.201000128.
Singer, J. B. (Host). (2007, May 22). What is pathological gambling? [Episode 17]. Social Work Podcast. Podcast retrieved Month Day, Year, from http://socialworkpodcast.com/2007/05/what-is-pathological-gambling.html
[Episode 12] In this lecture, I focus on the concepts of stimulus and response, rewards and punishments, and how these concepts make operant conditioning such a powerful approach to behavior change. Also in this lecture I touch on classical conditioning, social learning theory and cognitive behavior therapy. The role of the therapist, client, expectations for treatment, implications for multicultural treatment, and the strengths and limitations of the approach are covered.
[Episode 4] This is part two of a two-part series on Crisis Intervention. In this lecture, I discuss individual crisis intervention within the context of Roberts's Seven-Stage Model of Crisis Intervention, and the most popular group crisis intervention model currently in use, Critical Incident Stress Debriefing. The podcast ends with a detailed review of suicide assessment.
Now that you’ve assessed the affective, behavioral and cognitive domains of your client, we're going to move to the intervention model for today’s lecture. And although there are a variety of intervention models, including James and Gilliland (they have a 6-stage intervention model) and Hillman (has a 14-stage model of intervention), I'm going to talk today about Roberts’ 7-stage model for crisis intervention. And I'm going to talk about it because it provides a useful framework for crisis intervention, but it's not prescriptive to the point where it can't be modified to be used in either a single session or over multiple sessions. And Congress in 2000 (the author Congress, not the governmental body, but Elaine Congress) noted that it is, its flexibility enables it to be used in a culturally competent manner.
On the first stage is the assessment of safety and lethality and when we talk about suicide and risk assessment later, you'll get a better idea of specifically how to do that. But suffice it to say that in Stage One, you want to make sure that you are safe, that the client is safe, that the surroundings are safe. So you want to identify whether the client is at risk for harm to self or others or whether someone or something is putting the client at risk.
In Stage Two, that’s the rapport building stage and Roberts notes that that often happens concurrently with Stage One. As you're establishing safety, you're building a rapport and rapport, as I mentioned in the beginning of lecture, is the foundation for any clinical intervention (crisis intervention included). The Third Stage is problem identification. This is where you really identify what the precipitating event was and what problem the crisis intervention will focus on.
In Stage Four, you address feelings and emotions and this is where your assessment of affective, behavioral and cognitive domains is useful. You can implement Myer’s Triage Assessment at this stage or you can use it throughout. In Stage Five, you generate and explore alternatives. Now, similar to the problem solving method, generating and exploring alternatives is an area where the crisis worker can be more active in the crisis intervention model without necessarily being directive.
Being directive in Stage Five would look like presenting the client with a list of possible actions that they could do or solutions to the problem. Active would be collaborating with the client to identify things that they could use. One technique in particular that’s very congruent with social work perspective is using a very solution-focused approach in Stage Five. For example, when you're generating and exploring alternatives, you can review exceptions or use the miracle question or use other techniques that enable the client to think about times when they have actually been successful in resolving issues and thereby drawing on those successful opportunities as a way of reminding them of things that they can do in the current situation.
In Stage Six, you develop an action plan and again the action plan is very specific. It's concrete. It's measurable and it usually has a very short time frame. When I was doing crisis intervention in Austin, Texas, our crisis plans often lasted no longer than 24 hours without meeting again. And so they would include things like: When I leave here I will drive my child home. We will do this, this and this and this and this. It was very prescriptive. It provided structure and it was organized and it enabled me to review with the parents and the children the plan to find out exactly where it worked and where it didn’t, both as a way of helping me gather information, but also as a way of letting the family know exactly what it was that they were and were not doing to resolve whatever crisis was at hand.
And the Final Stage is follow up, and this looks like the referral stage for most traditional treatments because crisis intervention is short term and does not address long term intrapsychic or interpersonal or social problems (social environmental problems). [00:05:00] The need for a referral is great and it is expected that in fact you will be referring your clients out once the crisis has been resolved. So for that reason, follow up is a significant part of crisis intervention.
In different cultures, follow up can look like different things. If you have a family from the dominant culture that does not demonstrate underlying psychopathology and once they’ve reestablished prior coping skills, they're fairly easily able to address their activities of daily living. Then referrals can be fairly traditionally professional and say: “Here’s a phone number. We’d like you to follow up with them.” They agree to it and then you check up and you say: “Did you call?” It's great.
In families that might not be from the dominant culture, for example let's say you have a Latino family that has recently immigrated to the United States: follow up might be more personal. For example, making personal introductions, (assuming that consents have been signed) and really being more active in the follow up to make sure that both the information has been transferred to the new clinician, but also that there's that sense of trust that the family can have in the new provider.
Those were the Seven Stages of Roberts’ crisis intervention model. And again, it's a very flexible and very useful framework to have in mind when doing crisis intervention. And Roberts discusses this model in numerous articles and publications and books most recently in the third edition of the Crisis Intervention Handbook and also in an article that he wrote for the journal Brief Treatment in Crisis Intervention.
A second approach to crisis intervention that’s commonly used with groups is Critical Incident Stress Debriefing (CISD) or Critical Incident Stress Management. Everly and Mitchell are the main authors and proponents of this model. Critical Incident Stress Debriefing is typically used with first responders, for example: firefighters, EMS workers, police officers and it follows a group format. The CISD occurs no later than one week after the critical incident and the debriefing is run by a first responder who’s trained in the model.
And so again, if we think back to Hillman’s critique of the current research on crisis intervention, the question is: Is a peer who has been trained actually better than a licensed professional doing crisis intervention? If you have a police officer that has been trained in Critical Incident Stress Debriefing and they run a group with other police officers who have been involved in a critical incident, then it is possible that they would be more effective in this particular type of crisis intervention.
The CISD centers on the workers and is sensory-based and it encourages the participants to report on what each of them saw during the critical incident, what they heard and what sort of physical and emotional feelings they had, as well as what they smelled and tasted. After a critical incident such as a multi-car pile-up with fatalities on a highway or a shooting or some other critical incident that first responders are involved in, this type of debriefing can have the effect of reducing anxiety, letting people know they're not “crazy.”
Also important in these debriefings is that information about the event is shared. Crisis situations are fast-paced and people are not always sure that what they're experiencing is actually true. And so if during a fire, a floor collapses and a firefighter falls three or four storeys and the other firefighters are called in for Critical Incident Stress Debriefing, some information can be shared about the nature of the fire, how it developed, what other people were doing at that time. And in this way, it can actually provide concrete information that can be useful for individuals in reducing anxiety and addressing this critical incident.
In the protocol for Critical Incident Stress Debriefing is that the trained mental health professional is a silent observer of the proceedings and his or her purpose is to identify first responders who might benefit from individualized crisis intervention and/or ongoing psychotherapy. So, again, Roberts’ model is typically used with individuals or families and if you're in a group situation, the most commonly used approach is the Critical Incident Stress Debriefing Model by Everly and Mitchell.
The final area we're going to cover today in our discussion of crisis intervention is suicide assessment and this is a special instance of crisis intervention, so don’t go anywhere. We'll be back after this [00:10:00] brief pause for the cause.
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Break
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Now, the purpose of suicide assessment is to determine the lethality and severity of suicidal behaviors. It's also to predict risk of imminent harm to self. Empirical evidence does not support that we know how to predict future suicidal behaviors. However, the courts and the public expect mental health professionals to be able to predict future behaviors.
The third purpose of suicide assessment is to gather information used for crisis planning and intervention and treatment and management of suicidal behaviors. Now, this is of course is only if suicidal behaviors are present and you won't know that if you do not do a crisis – rather if you do not do a suicide assessment. Because suicidal attempts are higher with people who have psychiatric disorders than in the general population, anytime you're working in a psychiatric setting, either outpatient or inpatient, and you're working with people with a diagnosis, it is important to do suicide assessments so that you can determine whether past suicidal behaviors have been present. If so, what those triggers were and/or if there is current suicidal ideation.
So, the basic suicide assessment covers three areas. It covers ideation (and those were thoughts), intent (which is how serious the thoughts are and how serious the person is about dying by suicide). And the third area is the plan (how, with what, when, access to the means, etc. etc.). During the suicide assessment, it's important to use the words kill and die and specific words like that, so that your client knows you're not afraid of the topic and they’ll be more likely to confide in you and also that you can gather more accurate information.
The father of suicidology, Edwin Shneidman, suggested that people choose suicide because it's a means to end intolerable psychic pain. And if you ask people if they want to hurt themselves, which is the more mild way of addressing suicide assessment that people who were not trained sometimes do, if you say – if you ask people if they want to hurt themselves, somebody who’s actively suicidal might honestly say no because in fact they do not want to inflict more pain on themselves. They do not want to hurt more. In fact, they want to end their pain. They want to end the hurt and that is why they're suicidal.
So, that’s just one example of – or one reason why it's important to be specific when talking with clients about suicidal ideation and why it's important to use the words such as: “Do you want to kill yourself? Have you thought of dying?”
Ideation: “Do you have thoughts of killing yourself? If so, how frequent do you think of killing yourself? Every hour, a couple of times a day, weekly or never? How long are your suicidal thoughts? What is the longest time period in which you’ve consistently thought of killing yourself and what is the shortest? And answers can range from you know: “It just flashed into my mind and then it was gone” to you know, “I was thinking about it constantly for eight hours. I just couldn’t get it out of my head.”
In intensity: “How strong or weak are these thoughts? Do they interfere with your activities of daily living?” For example: “Are you afraid to go into the kitchen because your suicidal thoughts are so intense that you're afraid you're going to do something like grab a knife from the kitchen and cut yourself?”
The intent areas, how serious and one way of using scaling questions for this area is to say: “On a scale of 1 to 3, how badly do you want to die?” When you're talking with someone who’s actively suicidal, it's not necessary to give a 1 to 10 scale, which can be difficult to interpret and also it can be a little overwhelming. But a 1 to 3 scale is not cognitively complex and also if somebody says that on a scale of 1 to 3, 1 being “I'm not serious at all” and 3 being “I'm totally serious,” if they give you 1, 2 or 3 then you pretty much know what they're talking about and you can ask more detailed questions at that point.
The third area is the plan: “Do you have a plan? Is your plan general or is it detailed? How will you do it? Do you have access to the means?” And that could be to the materials or the specific weapons. [00:15:00] “And when are you planning on killing yourself?” I've worked with a number of children who in response to that question would say: “Well, there's a party this weekend and so I'm not planning on killing myself until Monday.” Well, that was important and significant information for me to have because even though they might have had a detailed plan and they might have frequent thoughts, it provided information about how serious they were imminently ending their life.
After you talk about ideation, intent and plan, it's useful to talk about prior attempts, because prior attempts have been reported to be the single best indicator of a future death by suicide. So, you want to ask: “How recent was your prior attempt?” and because there's usually a limited time to discuss suicidal ideation with a client either because you're in a crisis situation or because that’s not the primary focus of your work with the client. Shawn Shea, who wrote a wonderful book on The Practical Art of Suicide Assessment, he suggests that the most valuable thing for a clinician is to find out what the most serious prior attempt was, as opposed to getting an exhaustive history of all the prior attempts.
And by getting details on the most important prior attempt, then you gather information on triggers, on what kept the person alive, how long it lasted, things like that. So, other questions to ask are: “Do you know somebody who has recently died by suicide? Do you have friends or family members who have died by suicide? Have you told anyone about your ideation, intent or plan?” Finally, you can ask the client who do they talk to when they're really down, when they're having thoughts of killing themselves, and this can give a lot of information about their social support or lack thereof.
It also provides information about resources for the clinician about who they can contact in the event of a suicidal emergency that would enable them to breach the limits of confidentiality and go outside of the client-therapist relationship.
At the end of the suicide assessment, you should be able to establish a severity rating. Rudd and his colleagues in 2001 recommended a five-level severity rating ranging from 1 (which is nonexistent) to 5 (which is extremely severe). The least and most severe ratings are relatively easy to establish and have clear plans of action.
Number one: nonexistent, there's no identifiable suicidal ideation. Number five is: there is extremely severe suicidal risk. And this looks like frequent, intense and enduring suicidal ideation, specific plans, clear subjective and objective intent, evidence of impaired self-control, severe dysphoria and symptomology and many risk factors and almost no protective factors.
The middle ratings are: mild, moderate and severe. Mild risk would look like: suicidal ideation of limited frequency, intensity and duration, no identifiable plans or intent, mild dysphoria and symptomology, good self-control, few risk factors and identifiable protective factors. Moderate suicidal risk looks like: frequent suicidal ideation with limited intensity and moderation. So, again, the distinction between mild and moderate is you have limited intensity and duration, but you have frequent ideation for the moderate, but for the mild it is limited ideation, frequency and intensity and duration. For the moderate, you also have good self-control, limited dysphoria and symptomology, some risk factors and identifiable protective factors.
Severe suicidal risk looks like: frequent, intense and enduring suicidal ideation, specific plans, no subjective intent, but some objective markers of intent for example: they talk about specific lethal methods, they know that the method is available and there are some limited behaviors in preparation for death by suicide. There's evidence of impaired self-control, severe dysphoria and symptomology and multiple risk factors present and few if any protective factors.
In summary, the big three areas to cover in a suicide assessment are suicidal ideation (that is thoughts of suicide), suicidal intent (that would be motivation to die by suicide) and plan (which looks at how and when somebody is going to try to kill themselves). Another area that’s also useful is prior attempts and prior attempts are useful because the best predictor for a future attempt is a past attempt.
Ultimately, the purpose of gathering information [00:20:00] about intent, ideation and plan is to be able to determine the client’s risk for imminent harm to self. Once you have a severity rating, such as the one developed by Rudd, Joiner and colleagues, you're able to quickly and easily identify what the next step is in terms of a treatment plan. This has the obvious benefit of providing safety for the client and has the less obvious, but no less important benefit of providing the clinician with solid clinical evidence to support their decision.
Well, that’s it. Congratulations. You’ve made it through Crisis Intervention. Today, we've talked about crisis intervention, crisis assessment and suicide assessment and all of these are invaluable skills for social workers. In fact, they're some of the few skills that you really want to memorize because well, during a crisis you don’t really have time to look things up.
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Transcription generously donated by Kelsi Macklin.
Simpson, S., and Stacy, M. (2004). Avoiding the malpractice snare: Documenting suicidal risk assessment. Journal of Psychiatric Practice, 10(3), 185-189.
Singer, J. B. (2006). Making stone soup: Evidence-based practice for a suicidal youth with comorbid ADHD and MDD. Brief Treatment and Crisis Intervention, 6(3), 234-247.
Weller, E. B., Young, K. M., Rohrbaugh, A. H., & Weller, R. A. (2001). Overview and assessment of the suicidal child. Depression and Anxiety 14,157-163.
Singer, J. B. (Host). (2007, January 29). Crisis intervention and suicide assessment: Part 2 - intervention and crisis assessment [Episode 4]. Social Work Podcast. https://socialworkpodcast.com/2007/02/crisis-intervention-and-suicide.html
[Episode 2] This is the second part of a two-part lecture on diagnosis and assessment. In the first episode I reviewed the history of the DSM and the multiaxial system. In this lecture, I discuss the Bio-psychosocial-spiritual (BPSS) assessment as the means for providing context for the client's presenting problems. I discuss the purpose of each of the four life domains and how the information is used in social work practice. Emphasis is placed on solution-focused approaches to assessment. I end with a brief description of traditional format for organizing observations about the client - the Mental Status Exam.
