Provides information on all things social work, including direct practice (both clinical and community organizing), research, policy, education... and everything in between.
[Episode 40] Today’s podcast is the first of three interviews with Kia J. Bentley on psychopharmacotherapy. Kia J. Bentley is Professor of social work at Virginia Commonwealth University in Richmond Virginia and has published extensively in the area of psychopharmacotherapy (see references below). Psychopharmacotherapy refers to the treatment of psychiatric disorders with the use of medication. But, as Kia pointed out in our interview, psychopharmacotherapy is not just about giving people medication and calling it a day. It is an approach to treatment that acknowledges the strengths and limitations of medications.
[Episode 35] In today's podcast, I talk with Dr. Christina Newhill, a nationally recognized expert on client violence and the author of Client Violence in Social Work Practice: Prevention, Intervention, and Research, published in 2003 by The Guilford Press. In today’s podcast, Dr. Newhill defines client violence, talks about why social workers should be concerned with client violence and identifies which social workers are at greater risk for violence. She discusses some ways to assess a client’s potential for violence, how to intervene with a violent or potentially violent client, and identifies some strategies for increasing worker safety. We end our interview with information about existing research and resources for social work educators.
[Episode 33] Today’s podcast is the last in a three part series on phone supervision. In Part I and Part II I spoke with Simon Feuerman and Melissa Groman about their experiences of providing phone supervision and consultation. In today’s interview I speak with Jody Bechtold about her experience receiving phone supervision as part of her process of becoming a Nationally Certified Gambling Counselor. We talked about the process she went through to find phone supervision, some of the pros and cons and likes and dislikes. Jody contrasted phone supervision with face-to-face supervision and talked about phone supervision etiquette.
There were some interesting similarities and differences between Jody's comments on Phone Supervision and those of Simon and Melissa. Compared to the phone consultation provided by Simon and Melissa, Jody’s phone supervision was very structured and targeted. Still, her description of the experience of phone supervision, and the apparent benefits of phone supervision to provide a focused and convenient forum for developing advanced clinical skills, was nearly identical to the description provided by Simon and Melissa, despite the fact that Simon and Melissa are the providers and work almost exclusively with clinicians who are not working towards advanced clinical license. The most significant difference was that Jody advocated for a very structured format with required pre-session reading, whereas Simon and Melissa described a more process oriented group, one that is probably more appropriate for the types of clinicians with whom they work.
Singer, J. B. (Host). (2008, February 18). Phone supervision (Part III): Interview with Jody Bechtold [Episode 33]. Social Work Podcast. Podcast retrieved Month Day, Year, from http://socialworkpodcast.com/2008/02/phone-supervision-part-iii-interview.html
[Episode 32] Today’s podcast is the second in a three part series on phone supervision. In today’s podcast I continue my discussion with Simon Feuerman and Melissa Groman about phone supervision. Simon and Melissa are licensed clinical social workers, clinical supervisors and consultants and founders of the The New Center for Advanced Psychotherapy Studies and The Good Practice Institute for Professional Psychotherapists. These businesses were established in 2006 and 2007 respectively, as learning programs for licensed clinicians from all training and theoretical backgrounds to learn together without geographic limitations. Simon and Melissa are two of a growing number of clinicians who use accessible and affordable telecommunications and internet technologies to eliminate traditional barriers to supervision, including geographical distance, time constraints, and lack of local clinical experts.
In this episode we talk about the technical details of setting up and participating in phone supervision, NASW guidelines for supervision and the benefits for supervision and consultation, and the future of phone supervision, including the emergence of webcam technologies. We end with an “off line” discussion about my experience conducting this interview over the phone. Download MP3 [17:58]
In the first part, I spoke with Simon and Melissa about the similarities and differences between face-to-face and phone supervision, advantages and disadvantages, the difference between clinical supervision and consultation, existing research on phone supervision and some thoughts about approaches to phone supervision. In the third episode I interview Jody Bechtold, whom regular listeners will recognize from the ever-popular series on pathological gambling. Jody and I spoke about her experience receiving phone supervision as she worked towards becoming a Nationally Certified Gambling Counselor.
Singer, J. B. (Host). (2008, February 10). Phone supervision (Part II): Interview with Simon Feuerman and Melissa Groman [Episode 32]. Social Work Podcast. Podcast retrieved Month Day, Year, from http://socialworkpodcast.com/2008/02/phone-supervision-part-ii-interview.html
[Episode 31] Today’s podcast is the first of a three part series on phone supervision. In parts one and two I speak with Simon Feuerman and Melissa Groman, licensed clinical social workers, clinical supervisors and consultants and founders of the The New Center for Advanced Psychotherapy Studies and The Good Practice Institute for Professional Psychotherapists. The New Center for Advanced Psychotherapy Studies was established in 2006 as a learning program for licensed clinicians from all training and theoretical backgrounds to learn together without geographic limitations. Simon and Melissa are two of a growing number of clinicians who use accessible and affordable telecommunications and internet technologies to eliminate traditional barriers to supervision, including geographical distance, time constraints, and lack of local clinical experts. Download MP3 [26:48]
In today’s podcast, Simon and Melissa talk about the similarities and differences between face-to-face and phone supervision, advantages and disadvantages, the difference between clinical supervision and consultation, existing research on phone supervision and some thoughts about approaches to phone supervision. In the second episode we talk about the mechanics of participating in phone supervision, how to set up phone supervision as the supervisor and the supervisee, risk management, and some of the benefits of on-going supervision or consultation for clinicians who have already obtained their advanced clinical license and are considered independent practitioners. In the third episode I interview Jody Bechtold, whom regular listeners will recognize from the ever-popular series on pathological gambling. Jody and I spoke about her experience receiving phone supervision as she worked towards becoming a Nationally Certified Gambling Counselor.
My interview with Simon and Melissa was a first for the social work podcast: it was the first time I interviewed two people at once and the first time I interviewed someone outside of the studio.
Today's interview about phone supervision was recorded using, what else, the telephone... or at least the 21st century version of the telephone - Skype. Skype is software that enables people to communicate for free computer to computer. I wanted to acknowledge the technical support of David Holzemer and the staff at the Faculty Instructional Development Lab at the University of Pittsburgh for figuring out how to set up Skype so that I could do this interview.
Interview Questions
1. I suspect that almost all of our listeners have had experience with face-to-face supervision. I was wondering if you could tell us what are some of the similarities and differences between face-to-face and phone supervision.
2. What are some reasons a social worker would use telephone supervision?
3. I’m wondering if you can discuss some of the advantages and disadvantages to using the telephone as a means of providing and participating in supervision. What are some of the common concerns about telephone supervision?
4. During my research for this interview, I came across a number of different approaches to supervision. For example, Baltimore and Crutchfield (2003) mention three models of supervision, each based on a different theoretical perspective – client centered, behavioral and family-systems. In the client-centered model, for example, the supervisor assumes that the supervisee has all the resources he or she needs to actively address the issues. In contrast, the behavioral model assumes that insight is less important than meeting goals and objectives, and using punishment and rewards to change the supervisee’s behavior. I’m wondering what approach you take to supervision and if you think that one approach is better suited for phone supervision than another.
5. Is there any research that supports the use of telephone supervision? Is less than, equal to, or more effective than traditional face-to-face supervision?
6. We’ve talked about some basic concepts related to phone supervision. I’m wondering if you could talk us through the process of becoming involved with phone supervision. Maybe we could start with the absolute basics - How does someone find phone supervision? Let’s say I find a phone supervision group, what are the next steps, the process of contracting, the logistics of the schedule, dropped calls, etc.
7. Part of risk management is receiving clinical supervision. However there are liabilities associate with supervision. Specifically, if your supervisee is sued, you can be held liable for inadequate supervision. As someone who does phone consultation, how do you address issues of liability and documentation of supervision sessions?
8. With the advent of sites like YouTube and Google Videos, it seems like people are rapidly becoming comfortable in front of the camera – at times embarrassingly so. As a result, people are using web cams like never before. How do you think that this increase comfort with video technology will change the way that distance supervision is conducted in the future? In other words, do you think that in 10 years we’ll be doing a podcast on the use of video supervision?
Singer, J. B. (Host). (2008, January 28). Phone supervision (Part I): Interview with Simon Feuerman and Melissa Groman [Episode 31]. Social Work Podcast. Podcast retrieved Month Day, Year, from http://socialworkpodcast.com/2008/01/phone-supervision-part-i-interview-with.html
[Episode 30] In today’s podcast, I talk about some basic concepts in supervision. I define administrative, clinical and supportive supervision, talk about differential uses of supervision, including improvement of clinical services and issues of liability. I also address the ethical standards for social workers providing supervision. Like many of the Social Work Podcasts, much has been written about the topic of supervision – more than can be covered in this short podcast. If you are interested in learning more about supervision or becoming a supervisor, schools of social work like the University of Texas at Austin and Smith College School of Social Work have continuing education programs dedicated to training clinical supervisors. There are dozens of independent continuing education programs as well as books and articles on the topic. As always links to further readings and resources can be found at the Social Work Podcast website at socialworkpodcast.com. Today’s podcast on supervision addresses a topic that is relevant to social workers at all stages of their career. It also sets the stage for an upcoming three part series on phone supervision in which I’ll be talking, over the phone, with two clinical social workers who provide phone supervision and consultation. The final episode in the series is an interview with a social worker who received phone supervision towards an advanced license because the resources were not available locally.
UPDATE October 20, 2008: University of Buffalo School of Social Work published a very engaging and informative interview with Dr. Lawrence Shulman about parallel process and honest relationships in supervision. Dr. Shulman's interview was full of practical tips for supervisors and clinicians in the field. You can hear this excellent podcast at the University of Buffalo School of Social Work Living Proof website.
[Episode 27] In today's podcast, I speak with Carol Anderson, who along with Gerry Hogarty, developed a family-based approach to working with people with schizophrenia called Family Psychoeducation. Family Psychoeducation is only one of a handful of treatments that has been empirically validated to improve the lives of people with serious mental illness. According to the American Psychiatric Association, when people with schizophrenia are involved in family psychoeducation while taking medication, there is a significant reduction in relapse and unemployment. In today's podcast, Carol describes the 5 stages of psychoeducation, distinguishes between psychoeducation and other forms of family therapy, provides some anecdotes about family psychoeducation treatment, and provides some information for people interested in learning how to do family psychoeducation.
[Episode 21] In today's podcast, I speak with Dr. Lambert Maguire about social networks. Dr. Maguire discussed the development of his interest in the topic, as well as some historical context for understanding social networks. We discussed the theoretical assumptions and differential applications in research and clinical work. Dr. Maguire relates the traditional understanding of social networks to contemporary uses of "web 2.0" social networking sites such as MySpace.com. We end out interview with a description of how social networks can be conceptualized throughout the life span.
Dr. Maguire's primary interests are in direct practice and the use of social support systems and networks in treatment, prevention, and rehabilitation. He has been the P.I. on NIMH grants for both research and training, and has experience as a researcher and practitioner in mental health and substance abuse. He is currently on the editorial board or serves as a reviewer for four journals. He teaches courses in direct practice, human behavior, groups, and advanced systems. Dr. Maguire is a member of the Society for Social Work and Research, the National Association of Social Workers, the Academy of Certified Social Workers, and the Council on Social Work Education, and has presented papers at over 30 national conferences. He has also served as a consultant to the National Institute of Mental Health and the Council on Social Work Education. He has chaired the direct practice concentration in the past and currently chairs the faculty search committee. His recent research interests are related to social systems and their relation to substance abuse.
Dr. Maguire has a joint doctorate in social work and psychology from the University of Michigan and received his master's degree in social work from the University of Chicago's School of Social Service Administration. He has 25 years of practice experience with children, groups, families, and couples.
Example of a Social Network Diagram (click to enlarge)
References
Books by Dr. Maguire that address Social Networks:
Maguire, L. (1983). Understanding Social Networks. Beverly Hills, CA: Sage Publications.
Maguire, L. (1991). Social Support Systems In Practice: A Generalist Approach. Washington, D.C.: National Association of Social Workers (NASW) Press.
Maguire, L. (2002). Clinical Social Work: Beyond Generalist Practice with Individuals, Groups, and Families. Pacific Grove, CA: Wadsworth Publishing Company.
Singer, J. B. (Host). (2007, July 30). #21 - Social Networking: Interview with Dr. Lambert Maguire [Audio Podcast]. Social Work Podcast. Podcast retrieved from http://socialworkpodcast.com/2007/07/social-networking-interview-with-dr.html
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 second in our four-part series on pathological gambling. I talk with Jody Bechtold, LCSW, NCGC-II, PC about treatment basics for clinicians who work with pathological gamblers. We'll start with a quick overview of crisis intervention and then move into some of the assumptions and techniques of the treatments with the most empirical support in the treatment of pathological gamblers - behavior and cognitive therapy. We end with a brief overview of some challenges that can arise during the treatment of pathological gambling.
This interview targets practicing clinicians or students in clinical courses. If you are not familiar with the approaches discussed in this podcast, you can find more general overviews of crisis intervention, behavior therapy and cognitive-behavioral therapy on the Social Work Podcast website. Disclaimer - this podcast is intended to be a general overview of treatment approaches, rather than a clinical training. If you are currently working with, or intend to work with people with gambling addiction, proper education and training is essential. In the fourth part of this series, Jody and I talk about some of the requirements for obtaining the NCGC-1 - the national certified gambling counselor certification.
Download MP3 [27:00] This series on pathological gambling includes the following podcasts:
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 28). Treatment of pathological gambling [Episode 18]. Social Work Podcast. Podcast retrieved Month Day, Year, from http://socialworkpodcast.com/2007/05/treatment-of-pathological-gambling.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
In today’s podcast, I talk with Dr. Edward Sites about women in social work. Dr. Sites gives us a historical perspective of the role of women who were born at or before 1900 in the development of social work as a profession in the United States.
Dr. Edward Sites, Ph.D., ACSW, LCSW, BCD, has devoted his entire career of nearly 50 years to child welfare practice, education and research, the last 41 years of which have been as a faculty member at the University of Pittsburgh School of Social Work where Dr. Sites was a full professor from 1978 until his retirement in 2006. He is the longest serving School of Social Workfaculty member in the School’s 70 year history.At his retirement, he was the principal investigator of 9 projects and programs with total annual budgets of over $30 million and a state-wide staff of nearly 100 faculty and professional staff.These projects included research, degree and training programs in collaboration with 16 universities, and provided over 35,000 days of training annually to 4,000 public child welfare employees and 9,000 foster parents in all of Pennsylvania’s 67 counties as well as baccalaureate and master’s degree programs for hundreds of child welfare workers annually. Dr. Sites has received a number of prestigious awards including NASW Social Worker of the Year in Pennsylvania (1996); the Bertha Paulssen Medal (2001); the Chancellor’s Distinguished Public Service Award from the University of Pittsburgh (2003), and the Distinguished Alumni Award from the School of Social Work at the University of Pittsburgh (2004).
Some of Dr. Site's recent publications include:
Cahalane, Helen and Sites, Edward W.(in press). Is it hot or cold? The climate of child welfare employee retention.Child Welfare.
Newhill, Christina E. and Sites, Edward W. (2005).Identifying Human Remains Following an Air Disaster: The Role of Social Work.In Turner, Francis J. (Editor) Social Work Diagnosis in Contemporary Practice.New York: OxfordUniversity Press.
Sites, Edward W.(2001).Paulssen Power.Seminary Ridge Review, 3(2), 31-37.
Newhill, Christina E. and Sites, Edward W. (2000).Identifying Human Remains Following an Air Disaster:The Role of Social Work. Social Work in Health Care, 31(4), 85-105.
ReferencesNational Conference of Charities and Correction. (1910). Proceedings of the National Conference of Charities and Correction. (Alexander Johnson, Editor). Fort Wayne: The Archer Printing Company.
National Conference of Charities and Correction. (1911). Proceedings of the National Conference of Charities and Correction. (Alexander Johnson, Editor). Fort Wayne: The Fort Wayne Printing Company.
National Conference of Charities and Correction. (1912). Proceedings of the National Conference of Charities and Correction. (Alexander Johnson, Editor). Fort Wayne: Fort Wayne Printing Company.
National Conference of Charities and Correction. (1913). Proceedings of the National Conference of Charities and Correction. (Alexander Johnson, Editor). Fort Wayne: Fort Wayne Printing Company.
National Conference of Charities and Correction. (1914). Proceedings of the National Conference of Charities and Correction. (William T. Cross, Editor). Fort Wayne: Fort Wayne Printing Company.
National Conference of Charities and Correction. (1935). Proceedings of the National Conference of Social Work: Index 1874-1933. Chicago: University of Chicago Press.
National Association of Social Workers. (1995). Encyclopedia of Social Work, Vol. 3. (R. L. Edwards, Editor) Washington: NASW Press.
Singer, J. B. (Host). (2007, April 19). Interview with Dr. Edward Sites: Women in social work [Episode 16]. Social Work Podcast. Podcast retrieved Month Day, Year, from http://socialworkpodcast.com/2007/04/interview-with-dr-edward-sites-women-in.html
[Episode 8] Today we're going to talk about Carl Rogers and his revolutionary approach to psychotherapy - Person-Centered Therapy. Next to Freud, no other therapist has influenced the practice of therapy more than Carl Rogers. The humanistic assumptions at the core of Person-Centered therapy stand in stark contrast to the problem-centered, expert-oriented approach of what was then the dominant model of psychotherapy - Freudian Psychoanalysis. Rogers gave us an equation that would forever change the concept of therapy...
[Episode 7] In today's podcast, I talk about Existential therapy as an intellectual or philosophical approach to working with people. Although some authors have attempted to manualize Existential therapy (see Keshen, A. (2006). A new look at existential psychotherapy. American Journal of Psychotherapy, 60(3), 285-298), the existential approach is not known for specific techniques or procedures. Rather, its influence has been most notable in encouraging clinicians to focus on the ideas of freedom of choice, the responsibility that accompanies choice, and the notion that the inevitability of death is what gives life meaning.
Today, we're going to be talking about existential therapy. Existential therapy is an insight-oriented therapy much like Freudian psychoanalysis or Adlerian personal psychology. What distinguishes existential therapy from other insight-oriented therapies is that existential therapy is more of a philosophical or intellectual approach to understanding a person’s problems rather than a set of techniques. Existential therapy emphasizes our freedom to choose what we make of our circumstances and believes that we are free and therefore responsible for our choices and actions.
In essence, as Gerald Corey (2005) writes, we are the authors of our lives. Gerald Corey identifies six key concepts associated with existential therapy. The first is that we have the capacity for self awareness. Now, the greater our awareness, the greater our responsibilities for freedom and Corey writes that awareness is realizing that we are finite, that we understand that time is limited. We have the potential and the choice to act or not to act and that meaning is not automatic that we must seek it. And finally, that we are subject to loneliness, meaninglessness, emptiness, guilt and isolation.
The second key concept is that because we're basically free beings, we must accept the responsibility that accompanies our freedom. In other words, because we're free to choose we have to take responsibility for the choices that we make.
A third key concept is that we have a concern to preserve our uniqueness and identity. We come to know ourselves in relation to knowing and interacting with others. Our identity is the courage to be. We must trust ourselves to search within and find our own answers. Corey writes that one of our greatest fears is that we'll discover that there is no core and no self. Another key concept is that the significance of our existence and the meaning of our life are never fixed once and for all. Instead, we recreate ourselves through our projects. Our search for meaning must be pursued obliquely. This means that finding meaning in life is by necessity a by-product of a commitment that we make to creating, loving and working.
Another way of thinking about this is that we can't directly seek meaning. Rather, we have to engage in activities and it is through that engagement that we actually find the meaning in our lives. Viktor Frankl talked about the will to meaning as our primary focus in life. Frankl said that life in and of itself is not meaningful. The individual must create and discover that meaning.
Now, one of the themes here is that people are creating their own realities and this is a phenomenological approach similar to Adler but very dissimilar to Freud and this phenomenological approach assumes that we are actively involved in the creation of our own realities. As a therapist, if we understand that our client is creating their own reality, it's therefore important for us to assess and identify what that reality is and the meanings that our client is making of his or her reality.
Final key concepts include anxiety as part of the human condition. The existentialist believes that anxiety is a basic condition of life and they call this existential anxiety and they consider it to be normal. In fact, life can't be lived nor can death be faced without anxiety. Anxiety can be a stimulus for growth as we become aware of and accept our freedom. We can blunt our anxiety by creating the illusion that there is security in life and if we have the courage to face ourselves in life, we might be frightened, but we will be able to change.
A final concept is that death is a basic human condition and awareness of death gives significance to living. So, these are the six key concepts that Corey identifies in existential therapy.
One of the criticisms of existential therapy is that its concepts can be vague and hard to understand, so in the attempt to make it a little bit more clear what existentialist stand for I'm going to compare and contrast the existential approach to therapy with Freud’s psychodynamic approach.
Existentialism believes that we are free to make our choices and we're not hindered by the past or by biological drives. In contrast, Freudian psychoanalysis believes that freedom is restricted by unconscious forces, irrational drives and past events. In existentialism, anxiety can be useful. In psychodynamic theory, anxiety or neurosis is not useful and is in fact pathological and something that needs to be addressed.
In existentialist therapy, techniques are antithetical to truly being there for the client. This is one of the reasons why existential therapy is more of an approach rather than a prescription for therapy. In Freudian psychoanalysis, techniques are essential to making the unconscious conscious and these techniques can include dream analysis, transference, counter-transference, interpretation, very specific things and it's specific because the therapist is considered the expert in interpretation and understanding the objective world of the client.
Now both existential and psychodynamic are insight orient. In existential therapy, treatment is based on the here and now and explorations of the past seek to identify the origins of the world view. Again, there we have this idea that our clients are constantly creating the way that they understand the world, so explorations of the past are simply a way of better understanding how our clients came to view the world that they do.
In psychodynamic therapy, change occurs by exploring the past. In existential treatment, dream analysis sheds light on possibilities. Dreams are commonly understood to mean I don’t know what's happening to me. In contrast in Freudian psychoanalysis, dream analysis identifies unconscious content that symbolizes conscious issues. This is a very different approach because again you have symbols that have objective meanings in psychodynamic frameworks
such as a cigar is sometimes not a cigar.
In contrast in existential therapy, dreams are seen more as close as to the meaning that people have made for themselves. So, one clarifying example is that if we imagine that we're working with a war vet and the vet meets criteria for posttraumatic stress disorder, is having difficulty focusing on family relations, difficulty holding a job, has exaggerated sterile response, is increasingly focused on issues related to current conflicts around the world as presented on the TV and radio.
Psychoanalysis might say that the war experiences have triggered repressed pre-sexual experiences for the vet and that the impulses are in conflict with the super ego. In contrast, in existential approach to therapy, you must say that without the focus on the Vietnam and posttraumatic symptomology, the vet’s world would be revealed as pointless and absurd. If there were specific issues around building a family or future orientation that the vet was having a hard time addressing, existential therapy would probably say this is because the vet is not considering the future as viable and instead understanding that the imminence of death is causing serious questions as to the point of life.
Now, the therapist-client relationship is considered to be collaborative. In fact, Corey describes it as a journey taken by the therapist and the client together. The relationship demands that the therapist be in contact with his or her own phenomenological world. That is, the therapist must be aware of the way that he or she is constructing their own world so that they understand that their client is constructing his or her own world and that those worlds are necessarily going to be somewhat different.
The core of the therapeutic relationship is respect and faith and the client’s potential to cope and sharing reactions with genuine concern and empathy. Now, some therapeutic goals in existential therapy include giving attention to the client’s immediate ongoing experience with the aim of helping them to develop a greater presence in their quest for meaning and purpose.
Another goal is to recognize factors that block freedom. A third goal is to challenge clients to recognize that they are doing something that they formally thought was happening to them. So, again, this addresses the concept of freedom and responsibility. If your client believes that child protective services is something that is happening to them, it's important for you to help them understand that in fact they are active participants in this world in this situation and that their choices and their decisions are components of the current situation that they're in.
No judgment on whether or not a confirmed case of abuse has merit, but I'm just saying that in existential theory that the important thing is to focus on helping your client understand their own action as being part of their world. And finally, the goal – the final goal is to accept freedom and responsibilities that go along with that action.
The phases of counseling can be broken down into the initial, the middle and final.
In the initial phase, you really want to see how your client understands their world. Again, this is the phenomenological viewpoint. In the middle phase, you can explore how your clients develop that view of the world and how that view of the world is affecting what's currently going on with them, how that emphasize or how that influences what it is that they see as their responsibilities, their actions, what they have choices over. And finally, the last phase of counseling is geared towards understanding how clients can take what they’ve learned in making their lives more purposeful, intentional and grounded in meaning.
Some of the things to do during the assessment phase is to identify existential themes and these are themes related to responsibility, mortality, isolation and meaningless. These are the big four that Yalom discussed in his classic 1980s text “dreaming like waking is a mode of existence or being in the world and special attention is paid to themes and dreams in making sure not to place emphasis on the therapist’s interpretation.”
So whereas in Freudian psychoanalysis, really it's the therapist that’s responsible for ultimately interpreting what a dream means not because the client is unconscious of the meaning. In existential approaches, it's really the client that ultimately determines what a dream means. Some assessment techniques are the use of objective and projective tests such as the Rorschach and the thematic apperception test, the purpose of life test. This addresses individuals’ views of life goals, their world and their death and the experiencing scale which looks at feelings and self-awareness.
Because there are no specific techniques in existential therapy, application really looks like incorporating techniques and approaches that you as a therapist are comfortable using. Just remember that as you use your techniques, the primary emphasis is on understanding the client’s current experience. As you adapt interventions that you're really focusing on these issues of choice, freedom and responsibility and ultimately you're guided by the philosophical framework about what it means to be human.
Now, existential therapy has been applied to multiple areas. Clients who are seeking personal growth are great candidates for taking an existential approach, career or marital failure, retirement, grief work and any transition from one stage of life to another. Existential approaches are wonderful for working with teenagers and for whom the questions of what is my purpose, what is the meaning of my life, how am I to live the best life I can, all of these questions are classic teenage angst questions.
A final area of application is helping those who are struggling to find meaning in life and facing the anxiety of their eventual death. An obvious group for this is older adults. Existentialist philosophy and existential therapy have contributed a lot to social work practice and clinical work in general. One of the big ones is that existential theory contributed the concepts of self-determination and personal responsibility. It provided a perspective for understanding the value of anxiety and guilt and the role and meaning of death in treatment.
The existential approach really enables clients to examine the degree to which their behavior is influenced by social and cultural conditioning. In his 2005 text, Gerald Corey in fact argues that the existentialist approach is perhaps the most culturally competent approach because it provides social workers with a framework for understanding the universal issues of freedom, choice, life and death and because it's not technique-bound there are no cultural limitations on how this approach is practiced.
However, one of the limitations of an existentialist approach is that it lacks systematic statements of principles and practices of therapy. It uses vague and global terms and abstract concepts that can be very difficult to grasp such as the will to meaning. Finally, it's not been subjected to scientific research as a way of validating its procedures.
Now, in a recent article, Aaron Keshen acknowledged the limitations of existential therapy primarily in its lack of empirically testable techniques or approaches. In a 2006 article, he attempts to operationalize existential techniques. If you want more information on his approach, his article can be found in the American Journal of Psychotherapy, volume 60, issue 3 and the article is called “A New Look at Existential Psychotherapy” and in this article he attempts to operationalize the issues of your actual purpose or your substituted purpose in life and then he applies those to issues of mental illness, substance abuse, personality disorders, things like that.
So, in conclusion, existential therapy is really a philosophical or intellectual approach that provides the therapist with a framework to understanding their client’s problems rather than providing a set of techniques for actually addressing the problems the clients come in with. The main issues that existential approaches address are issues of freedom, the freedoms that we have to choose and the responsibilities that come with those choices. The other main issues that are significant are issues of the meaning of life and the reality and acceptance of death.
References
Burke, J. F. (1989). Contemporary approaches to psychotherapy & counseling: The self-regulation and maturity model. Belmont, CA: Wadsworth Press.
[Episode 6] In this lecture, I discuss key elements of Adler's Personal psychology and how this approach contrasts with Freud's theory. The contrast between Adler's and Freud's approaches can best be summed up in the quote "We are pulled by our goals, rather than pushed by our drives."
[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. Podcast retrieved Month Day, Year, from http://socialworkpodcast.com/2007/02/crisis-intervention-and-suicide.html
[Episode 40] Today’s podcast is the first of three interviews with Kia J. Bentley on psychopharmacotherapy. Kia J. Bentley is Professor of social work at Virginia Commonwealth University in Richmond Virginia and has published extensively in the area of psychopharmacotherapy (see references below). Psychopharmacotherapy refers to the treatment of psychiatric disorders with the use of medication. But, as Kia pointed out in our interview, psychopharmacotherapy is not just about giving people medication and calling it a day. It is an approach to treatment that acknowledges the strengths and limitations of medications.
