Showing papers in "Clinical Social Work Journal in 2013"

Disclosure of Child Sexual Abuse Among Adult Male Survivors

Abstract: Men who were sexually abused during childhood are a stigmatized, under-studied, and marginalized population that is at risk for long-term mental health problems. However, many mental health practitioners feel under-prepared and ill-equipped to effectively treat male survivors of child sexual abuse. Furthermore, little is known about factors that may impact the mental health of male survivors such as disclosure of the sexual abuse. The purpose of this study was to (a) describe the disclosure process of male survivors using a lifespan approach, (b) identify disclosure differences based on age and type of abuser, and (c) explore relationships between disclosure attributes and current mental health. Using a large, purposive sample of male survivors (N = 487), the study found that, on average, men delayed telling (M = 21.38 years) and discussing the abuse (M = 28.23 years) for many years. Older age and being abused by a family member (i.e., incest) were both related to delays in disclosure. Most participants who told someone during childhood did not receive emotionally supportive or protective responses and the helpfulness of responses across the lifespan was mixed. Several variables (e.g., timing of disclosure, discussing with a spouse, response to disclosure) were related to current mental health problems. These findings are helpful for clinical social workers who practice with clients from this population. Specific suggestions for improving clinical practice (e.g., assessment, treatment, professional training) are discussed.

The Pet Connection: An Attachment Perspective

Abstract: Using the ethological-evolutionary framework of attachment, and including how the theory has been updated and expanded by findings from attachment-based research, neuroscience and animal studies, this paper proposes that a relationship with a family pet, especially a dog or cat, reflects certain dynamics of attachment which may account for the sense of comfort and connection they provide to individuals at all stages of the life cycle. There is now convincing scientific evidence that companion animals have positive effects on psychological and physical well-being, helping shape how people regulate their emotions, deal with stress or trauma, and relate to others. Discussion considers the implications of these benefits for social work, in particular for policy, prevention, and psychotherapy. An illustration of treatment for pet loss, as well as a framework for promoting attachment in pets adopted from rescue shelters, is also presented. It is recommended that both social work professionals and social work students be educated about the human-animal bond and the significance of pets to so many of our clients.

Gender dysphoria: Two steps forward, one step back.

Abstract: The long-awaited DSM-5 has finally been published, generating controversy in many areas, including the revised diagnostic category of Gender Dysphoria. This commentary contextualizes the history and reform of the pathologization of diverse gender identities and expressions, within a larger perspective of examining psychological viewpoints on sexual minority persons, and the problems with continuing to label gender identities and expressions as pathological or disordered.

Gay Affirmative Cognitive Behavioral Therapy for Sexual Minority Youth: A Clinical Adaptation

Abstract: Sexual minority youth (SMY) are at high risk for negative mental health outcomes such as depression, anxiety, substance abuse, and suicidality. However, there has been a disconnect between clinical social work practice and research with SMY, resulting in a lack of rigorous research that demonstrates the use of effective interventions. While cognitive behavioral therapy (CBT) has long been established as a best practice option for the general adolescent population suffering from mental health problems, knowledge about the use of CBT with SMY lags far behind. Thus, the purpose of this article is to present a clearly defined adaptation of CBT for SMY that integrates gay affirmative practices for youth (e.g., coming out, stigma and discrimination, the role of social support and community). Specifically, the authors: (a) discuss the impact of minority stress on SMY; (b) highlight the specific components of CBT that represent a good fit for SMY and also address the criticisms of using such an approach; (c) consider the importance of using gay affirmative practices with SMY; and (d) offer recommendations for incorporating gay affirmative practices into traditional CBT models to better meet the needs of SMY.

DSM-5: An Overview of Changes and Controversies

Abstract: The DSM-5 offers many changes in the criteria and categories used in clinical diagnosis. The provocative and sometimes controversial nature of the changes has enlivened debate in the mental health field about how we should best understand our clients. I selectively survey what is new in DSM-5, why changes were made, and what about them is so controversial. First, I summarize the main metastructural and organizational changes, including elimination of the multiaxial system and changed chapter groupings. Second, I survey the most important new categories of disorder and the most important changes to the diagnostic criteria for existing categories of disorder. I focus on particularly controversial changes, such as those to substance use and addictive disorders, autism spectrum disorders, and posttraumatic stress disorder. Pros and cons are provided for changes in criteria as well as for the addition of new disorder categories, such as hoarding disorder and binge eating disorder. Finally, I offer a more in-depth review and analysis of the changes to the depressive disorders chapter, which was subject to some of the most intense controversies and had some of the most extensive changes.

Facilitating Transition Among Transgender Clients: Components of Effective Clinical Practice

Abstract: Although transgender clients seek services in a number of settings in which social workers practice, there is a dearth of scholarly literature available to guide effective clinical practice with this population. When transgender issues are included in the practice literature, the trend has been to consolidate the needs of transgender clients with those of the larger lesbian, gay, and bisexual community or to simply focus on increasing the comfort level of clinicians working with this population. This is concerning because transgender individuals represent a vulnerable subgroup of clients with unique and specific treatment needs related to the transition experience. Social workers play a critical role; they may serve transgender clients and their families in many ways: as advocate, educator, diagnostician, and individual, couples or family therapist. The purpose of this article is to identify several key components of trans-specific clinical practice and the role of social workers in supporting and facilitating client transition. Specifically, the authors will discuss: (a) relevant definitions and terminology, (b) emerging issues related to depathologizing the needs and experiences of transgender individuals, (c) the critical elements of trans-specific clinical assessment, and (d) clinical advocacy associated with the medical legal and social aspects of the transition process. Specific recommendations for trans-affirmative social work practice will be offered.

Clinical Practice with Older LGBT Clients: Overcoming Lifelong Stigma Through Strength and Resilience

Abstract: This article provides an overview of the unique challenges and strengths of the older lesbian, gay, bisexual, and transgender (LGBT) population and the theories and evidence-based interventions that can be used to work with them in a clinical setting. Two case studies will be used to highlight potential issues in clinical social work and provide guidance for intervention with LGBT older adults. The article concludes with a summary and implications for clinical social work practice.

The Use of Adventure Therapy Techniques by Clinical Social Workers: Implications for Practice and Training

Abstract: Adventure therapy, an experiential intervention that combines outdoor, adventure based activities and group process, is used in direct practice by clinical social workers; however, it is unclear to what extent clinical social workers are actually utilizing these techniques. This research project surveyed a random sample of clinical social workers and examined in greater depth how they are utilizing adventure therapy programming with different clients in various treatment settings, as well as what type of education and training they received for engaging in these practices. A random sample of 646 clinical social workers in NASW responded to the survey, and more than 1/3 of this sample (35.1 %) reported the use of adventure based activities for therapeutic purposes in their social work practice. However, few of the social workers reported formal education or training in the use of adventure therapy, highlighting the need for more attention in both educational and clinical settings to proper instruction around this growing intervention.

“Walking the Tightrope:” Clinical Social Workers’ Use of Diagnostic and Environmental Perspectives

Abstract: The purpose of this study was to understand how clinical social workers think about and utilize two distinct worldviews: the psychiatric perspective of DSM diagnosis (Diagnostic and Statistical Manual of Mental Disorders) and the contextual person-in environment perspective. The former is a requirement for service and reimbursement in nearly every clinical setting, while the latter has always been the hallmark of a distinctively “social work” approach. Although there have been quantitative surveys of social workers’ use of the DSM, this is the first qualitative study to examine how social workers actually navigate these two worldviews. Thirty clinical social workers took part in individual interviews, and their responses were analyzed thematically using HyperRESEARCH, a qualitative data management program. Findings reveal an array of ethical and practical issues, including the central “tightrope” of balancing the need to “ramp up” problem formulation in order to access service with the desire to “damp down” in order to minimize stigma and avoid pathologizing problems in living. Implications are addressed for social work practice, policy, and education.

Culturally Competent Practice with Bisexual Individuals

Abstract: Working with lesbian, gay, and bisexual individuals requires clinical social workers to demonstrate cultural competency with these populations. Although there are many common issues across these identities, bisexual individuals experience unique challenges that differ from lesbian and gay individuals. Bisexuality is sometimes misunderstood by heterosexual as well as lesbian and gay individuals, leading to experiences of marginalization from multiple sources. Moreover, clinical social workers may incorrectly assume that the treatment needs of bisexual individuals are the same as lesbian and gay individuals. This paper utilizes qualitative interviews with 45 bisexual-identified people to illuminate five prominent issues in clinical practice with bisexual people. They are: (a) biphobia, (b) practitioner attitudes about bisexuality, (c) identity development, (d) social relationships, and (e) sexual health. Findings illuminate clinical practice strategies that will facilitate culturally competent social work practice with this population.

Out of the Darkness: Three Waves of Family Research and the Emergence of Family Therapy for Lesbian and Gay People

Abstract: Like family relationships themselves, the history and treatment of lesbian and gay people and their families is complicated. For this paper, three waves of research on the families of gay and lesbian individuals are described. During the first wave, gay and lesbian sexual orientation was seen as a disease and family dynamics were blamed for its genesis. Subsequently in the second wave it was believed that, fearing rejection many gay and lesbian people either distanced or were rejected from their own families and established friendship networks that have been described as families of choice. More recently, in the third wave, the family has been identified as a resource for lesbian and gay youth whereby open relationships with parents can help protect them from mental illness, substance abuse, and HIV risk. Furthermore, an increasing number of same-sex couples are choosing to become parents, overcoming biological and social obstacles. In this article these shifting views of the role of family in the lives of lesbian and gay people will be described along with case material that illustrates the historic influences, current developments and future directions of family treatment for this population. To be maximally effective with gay and lesbian people and their families, clinical social workers and other mental health professionals must understand how family therapy has been influenced by a progression of ideas that continue to evolve. In this paper, research examining the role of the family in the lives of lesbian and gay people will be described in three waves; as a source of blame, to an impediment to gay and lesbian happiness and ultimately a resource that can enhance lesbian and gay well-being. The influences of research on family therapy with this population will be described and case examples will demonstrate how to harness the strengths of family relationships identified in the most recent wave.

Acknowledging the Impact of Social Forces on Sexual Minority Clients: Introduction to the Special Issue on Clinical Practice with LGBTQ Populations

Abstract: Over the last two to three decades, advances in clinical practice with lesbian, gay, bisexual, transgender, and queer (LGBTQ) individuals have been extensive. Many clinical social workers now incorporate LGBTQ-affirmative approaches into their practice, and a number of social workers have contributed to the literature on clinical practice with sexual minority clients. Despite these advances, we still require specialized knowledge to understand a number of LGBTQ-related mental health issues. The Clinical Social Work Journal’s first special issue on clinical practice with LGBTQ populations emphasizes psychotherapy techniques that acknowledge and also address social forces (e.g., transphobia, homophobia, and heterosexism) that affect the psychosocial functioning of LGBTQ clients. The special issue focuses on LGBTQ populations, such as transgender and bisexual individuals, sexual minority youth, and older adults, and psychotherapy modalities informed by a number of clinical and theoretical approaches. These in-depth articles offer guidance to clinical social workers who need to expand their knowledge of LGBTQ-related mental health issues and also provide those with existing knowledge an opportunity to refine their clinical skills and sharpen their thinking.

Treatment Engagement Using Motivational Interviewing for Low-Income, Ethnically Diverse Mothers with Postpartum Depression

Abstract: Postpartum depression (PPD) places women, and their children, at risk for many untoward outcomes including lack of responsivity, low self-efficacy, and insecure infant attachment. Especially at risk for untreated PPD are low-income, ethnically diverse mothers. Seeking and accepting treatment for depression may be impeded by the many psychological and social barriers that mothers may bring with them. Obstacles might include a lack of resources (e.g., lack of transportation or child care), stigma, distrust, and a lack of knowledge about stress and depression. To reduce these and other barriers to treatment, this paper points to the value of utilizing motivational interviewing techniques to engage and retain low-income, ethnically diverse women for treatment of PPD. Following a review of PPD and related barriers to treatment, a case study is presented with example dialogue. The suggestions for practice represent starting points for effective engagement of women in any number of treatments provided by social and health services settings. With federal mandates to screen for depression in many settings and to provide treatment, using motivational interviewing may be an effective prelude to treatment adherence.

Growing Pains: An Eriksonian View of the Arc of Presenting Concerns in an LGBT Community Mental Health Center

Abstract: This article explores the evolving landscape of mental health practice at a New York City community health center serving lesbian, gay, bisexual, and transgender (LGBT) persons and those living with HIV/AIDS. Erikson’s theory of psychosocial development is used to understand the shift in presenting problems that has occurred over the past decade. In the authors’ analysis, the emphasis in treatment of LGBT persons has evolved from “coming out” concerns to issues related to developing intimate relationships, fostering generativity, and ego integrity in later adulthood. Case examples illustrate the changing focus of treatment over time. This article concludes by providing mental health practitioners with recommendations for working with the LGBT community now and over the following decade.

DSM-5 and the General Definition of Personality Disorder

Abstract: There is a fundamental change proposed for DSM-5 in the general definition of personality disorder, representing a new conceptualization that shapes how the DSM distinguishes personality pathology from other undesirable or negative personality features. The change is needed due to serious deficiencies in the current DSM-IV approach. Specifically, personality disorder is to be conceptualized as impairment in both self organization and interpersonal relating, caused by pathological (extreme) personality traits. This represents progress in that marked impairment in self organization and interpersonal relating are plausibly characteristic of personality disorder. However, the required level of impairment remains too low, and the kinds of impairment are not restricted to those which indicate disorder versus culturally undesirable features. Moreover, extreme traits are neither necessary nor sufficient for personality disorder because personality represents not the sum of traits but the holistic organization of traits and other meanings. The DSM-5’s diagnostic focus on traits thus potentially opens the way to massive false positive diagnoses. An earlier proposal to reframe personality disorders using global similarity matching of the patient’s condition to prototypical descriptions of specific personality disorders is argued to also lead toward less valid diagnoses.

Shame in the Clinical Process with LGBTQ Clients

Abstract: This commentary integrates the literature on the social and psychological dynamics of shame and discusses its relevance to the clinical process, especially with lesbian, gay, bisexual, and transgender and queer clients. It is argued that engagements with shame, especially where sexual desire, sexual orientation, or gender identity is a foremost consideration or conflict, may be the most important factor in producing and maintaining the therapeutic alliance. Shame, a social emotion, is considered in the light of work done in sociology, psychology, neuroscience, and psychoanalysis. Future directions for clinical research are suggested.

Changes in the Conceptualization of Personality Disorder: The DSM-5 Debacle

Abstract: Lanier, Bollinger, and Krueger (2011) provide an overview of proposed changes to the diagnosis and classification of personality disorders to appear in the forthcoming fifth edition of the American Psychiatric Association’s (APA) Diagnostic and Statistical Manual of Mental Disorders (DSM-5). They are correct that the proposed changes to the personality disorders section are fundamental, and in some respects may represent a true paradigm shift in how a mental disorder is conceptualized and diagnosed. As expressed by the Chair of the DSM-5 Personality and Personality Disorders Work Group (PPDWG), ‘‘the work group recommends a major reconceptualization of personality psychopathology’’ (Skodol 2010, ‘‘Reformulation of personality disorders in DSM-5,’’ para. 1). I do not myself disagree with some of the more radical proposals that are being made, but a difficulty I do have is the surprisingly liberal threshold that has been accepted for making any such revisions (Frances 2009; Widiger 2011). In addition, one point of strong agreement with Lanier et al. is that the construction of DSM-5 is in a state of ‘‘flux,’’ to the point that it is frankly difficult to predict or anticipate what may in fact happen to the diagnosis of personality disorders. Lanier et al. state that the proposals for DSM-5 consist of four major changes (see Table 1 of Lanier et al.): (1) a change to the definition of personality disorder to require the presence of a pathology of identity integration, integrity of self-concept, and self-directedness in order for a diagnosis to be made; (2) an assessment of level of self and interpersonal dysfunction; (3) the deletion of five diagnoses; and (4) the inclusion of a six domain (37 trait) dimensional trait model. However, since this paper was written, there have been quite a few significant changes to these (and other) proposals.

Utilizing Spiritual Lifemaps with LDS Clients: Enhancing Cultural Competence in Social Work Practice

Abstract: Few people realize that the Latter-day Saints (LDS) or Mormon Church currently ranks as the fourth largest religious denomination in the United States. Although spirituality and religion play a central role in the beliefs, lifestyle, and culture, of many LDS clients, very few spiritual assessment tools have been validated with this population. Utilizing a mixed method design, this study modified an existing spiritual assessment tool—spiritual lifemaps—that may be particularly congruent with LDS client populations. A sample of recognized experts in LDS culture (N = 100) examined how consistent the spiritual lifemap assessment tool was with LDS culture, and how consistent the four sample question sets were with LDS culture. Overall, results indicate that the spiritual lifemap assessment tool is consistent with LDS clients’ beliefs, lifestyle, and culture. This study represents an important step at providing more culturally competent practice with LDS clients.

Treating Trauma Through Three Interconnected Lenses: Body, Personality, and Intersubjective Field

Abstract: The neuroscience of trauma in increasingly oriented to the importance of understanding right brain to right brain dynamics and helping the therapist to respond to implicit communication, which is discussed, as well as Porges’ polyvagal theory. The traumatized patient presents a variety of challenges to clinicians, including a dysregulated autonomic nervous system (ANS), compromised ability to self-soothe and diminished capacity for relatedness with others. Therefore, one effective approach to treating trauma (especially dissociation) includes conceptualizing and responding to our patients through three separate but interconnected lenses: (1) patient and therapist as human mammals—orientation to the ANS, (2) patient and therapist as personalities—orientation to the internal world and, (3) patient and therapist as inhabiting an intersubjective field together—orientation to shared, co-created body/psychological states. The capacity to be guided by countertransference is an especially valuable skill for therapists, as well as the ability to know when they are being experienced as helper or adversary by their patients. Different dynamics driving dissociation and different strategies for responding to the dissociating patient are discussed. Clinical examples are included.

Beyond the Pale of Psychoanalysis: Relational Theory and Generalist Social Work Practice

Abstract: Many have noted the consonance between contemporary relational theory and classic social work values and practice principles such as person in environment and starting where the client is. However, there have been few efforts to explore relational theory’s utility to the generalist social work framework. This paper takes the position that relational theory’s intersubjective stance lends new coherence to classic social work principles, and therefore elucidates the process aspects of evidence-based social work practice. In order to illustrate this point, the author applies relational theory to implementation issues around early childhood home visitation with Spanish-speaking immigrant clients—a social work service modality that, like so many others, does not fall into the category of individual psychotherapy in the context of private practice.

Interrupting Trauma and Advancing Development: Considering Parent Education in Contemporary Psychoanalytic Treatment

Abstract: This paper centers on the exploration and utilization of a contemporary, psychoanalytically-based parent education perspective aimed at interrupting intergenerational trauma. It highlights The Parenting Process, an integrative model of parent education that is at once educational and therapeutic. This model is explored in light of a third listening stance based on James Fosshage’s listening perspectives concept. This paper underscores and illustrates through clinical material the benefits of playing with implicit and explicit communication across various sensory modalities.

Psychoanalytic Theory and Psychotherapy: A Dynamic Systems View of Change

Abstract: This paper explores the application of nonlinear dynamic systems theory and concepts to the investigation of the psychotherapeutic situation. Although dynamic systems theory was originally applied in the study of chemistry, mathematics, and physics—not initially for its application to psychotherapy—its emphasis on contextualization provides a rich platform for the reconsideration of how change occurs in the therapeutic dyad. This paper first reviews some tenets of dynamic systems theory, in particular the general processes of system change including the introduction of novelty and perturbation. It then examines some psychoanalytic theories from a dynamic systems vantage point. This is followed by the presentation of two cases that illustrate the application of systems concepts to clinical work. This paper concludes that psychoanalytic psychotherapy from the perspective of dynamic systems theory views moments of change as unpredictable, soft assembled, and emergent in the dialogue and context created mutually by therapist and patient.

Advances in the Conceptualization of Personality Disorders: Issues Affecting Social Work Practice and Research

Abstract: This article provides a review of the research that has informed the proposed changes to the DSM-5 conceptualization of personality psychopathology with a focus on implications for social work practice and research. A paradigm shift to a dimensional model is likely to replace the current categorical model of personality disorders and will have profound implications for the profession. While establishing a diagnostic system that is grounded in empirical knowledge is the primary benefit, this tool will also be more consistent with social work’s orienting theories and values. Social workers should gain knowledge about the proposed changes and actively participate in the review process.

Sibling Discord: A Force for Growth and Conflict

Abstract: Drawing on research findings and clinical experience, this paper considers the contributions that sibling envy, jealousy, and rivalry can make to healthy development as well as the way in which sibling discord may compromise development and in some cases lead to pathology. An account of the treatment of a depressed and anxious woman, Marcia, whose pain and rage at being displaced by her 4-year-younger brother contributed to her pathology, is offered. Through attention to sibling transferences, countertransferences, and the enactments that occurred during the treatment, the paper demonstrates how an individual may misperceive and misrespond to her children as well as her therapist as if they were a sibling rival or the mother who they experienced as rejecting them in favor of a brother or sister. The paper attests to the importance of recognizing siblings as persons in their own right who hold an important place in each other’s minds, rather than as simply displacement objects for parents, as they were often regarded in the past.

Revenge: Interplay of Creative and Destructive Forces

Abstract: This paper presents a theory about degrees of revenge and proposes creative, libidinal, and contained ways in which to express this otherwise destructive desire. A review of the literature on revenge first underlines its inherent ubiquity, self-preservative, and adaptive propensities. The exploration of the topic draws from cultural, social/judicial, and clinical texts to elucidate the interplay of creative and destructive elements in revenge. I have used the Structural Model developed by Freud to illuminate and sharpen the argument about revenge because I feel that it is a particularly efficient lens through which to view the issue and because I regularly draw from Freudian and post-Freudian theories, amongst others, in my assessment and interventions with clients.

Policy, Practice and People: Current Issues Affecting Clinical Practice

Abstract: This commentary highlights current policy issues affecting lesbian, gay, bisexual, transgender, and queer (LGBTQ) people in the US with implications for mental and behavioral health care and social work services. These issues include conversion or reparative therapies, especially for young people, and conscience clauses that may exempt some students and practitioners from serving LGBTQ people and their families. While not a “policy” per se, emerging knowledge about health disparities that affect LGBTQ people will also be summarized because of its relevance to practice; many of these concern mental health and behavioral health. Finally, some resources for making health care organizations more responsive to the needs of LGBT people are identified.

Understanding the Meanings Behind Adolescent Non-Suicidal Self-Injury: Are We Missing the Boat?

Abstract: Despite the fact that adolescent non-suicidal self-injury (NSSI) has garnered a good deal of attention in the recent clinical and empirical literature, our conceptualization of this behavior continues to rely on an individualistic framework. Expanding the current theoretical model to include perspectives that focus on social context and constructed meaning is necessary, especially given the importance that the peer group and social context have for this age group. This paper proposes a theoretical framework that combines Symbolic Interactionism with Social Learning Theory in an effort to broaden our understanding of NSSI among adolescents. Implications and recommendations for social work practice are then discussed.

Variations from the Therapeutic Frame

Abstract: This article provides a commentary and discussion of alterations in the therapeutic frame in a paper by Paula Shatsky.