Transcript Clinical Social Work in the 21st Century

CLINICAL SOCIAL WORK IN THE 21ST
CENTURY
PSYCHIATRIST'S PERSPECTIVE ON AN URGENT
AGENDA
Dr. Katherine Shear
Marion E. Kenworthy Chair
Columbia University School of Social Work
24 January 2007
The Marion E. Kenworthy Lecture
CLINICAL SOCIAL WORK IN THE 21ST CENTURY
FROM A PSYCHIATRIST'S PERSPECTIVE
Interdisciplinary Research-Practice Partnership
is an Urgent Social Work Agenda
CLINICAL SOCIAL WORKERS DOMINATE
THE U. S. PSYCHOTHERAPY WORKFORCE
200,000
180,000
192,814
160,000
140,000
120,000
100,000
80,000
73,014
60,000
40,000
33,486
20,000
17,318
0
Clinical Social
Workers
Psychologists
Slide provided by Myrna Weissman Ph.D.
Psychiatrists
Psychiatric
Nurses
SAMHSA 1998
OPPORTUNITIES FOR HIGH IMPACT
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Social workers have greater access to
individuals suffering from mental disorders than
any other professional group.
This provides an exciting opportunity for high
impact work
Clinical social work is in a position to shape the
mental health care system through creative
utilization of research-informed assessment and
intervention tools and through development of
innovative models of practice-based evidence
THINGS WE HAVE LEARNED
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Mental disorders are prevalent and debilitating
Environmental factors contribute to illness and health;
the most socially vulnerable are at greatest risk for
developing mental disorders
Both somatic and psychosocial interventions can play a
role in symptom relief and building resilience
However, most people do not get the help that should be
available; there is an urgent need to improve care of
mental disorders
We need partnerships between mental health
practitioners and researchers, across disciplines, to
achieve this common goal
THE RELATIONSHIP BETWEEN PRACTICE
AND RESEARCH
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Clinical research can only be conducted as a
partnership between research and practice.
This kind of partnership needs to be expanded
to include teams of dedicated clinical
administrators and practitioners working with
clinical and services researchers
The goal is a bi-directional system with research
informing practice and practice informing
research
THE RESEARCH-PRACTICE INTERFACE
Provides
•A foundation of basic science knowledge
•Collection of validated clinical tools
Supported by continuous infusion of research
knowledge and tools
RESEARCH
PRACTICE
Provides
•Clinical observations and outcome evaluation
•Generation of hypotheses
Supported by ongoing communication between practitioners and
researchers
WHAT ARE CLINICAL TOOLS?
A set of strategies and techniques targeting
 Alliance building to support treatment adherence
 Assessment, including
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Mental disorders and their consequences
Mental health
Social-environmental stresses and resources
Intervention/Treatment in order to
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Reduce symptoms and impairments
Enhance strengths
Reduce environmental stress
Enhance environmental resources
WHAT IS IN THE RESEARCH-INFORMED
CLINICAL TOOL BOX?
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Assessment instruments and methods to assist with a
range of clinical activities, e.g.
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Diagnosis of clinical problems
Evaluation of outcomes
Decisions related to type of intervention
Definitions of resilience, strengths and mental health
Well-specified intervention strategies and procedures
proven efficacious for target disorders and crossdisorder counseling goals
Methods for employing theoretically or empirically guided
strategies and techniques for use with individual clients
ASSESSMENT METHODS AND INSTRUMENTS
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Measurement based care: a strategy for integrating
assessment and treatment, entailing
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Implementation of regular, meaningful assessment of target
symptoms or other intervention targets
Use of valid reliable instrument
Inclusion of assessment results in intervention decision making
Most clinicians do not practice measurement-based care
Many are unaware of the range of assessment
instruments, their ease of administration and their
potential usefulness for clinical practice
EXAMPLES OF USER-FRIENDLY ASSESSMENT
TOOLS
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PHQ-9 as a diagnostic instrument and symptom
rating scale for depression
Work and Social Adjustment Scale
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5-item questionnaire
Has been shown to be reliable and valid
THE PHQ-9
Over the last 2 weeks, how often have you been bothered
by any of the following problems?
1.
2.
3.
4.
5.
Little interest or pleasure in
doing things
Feeling down, depressed, or
hopeless
Trouble falling asleep,
staying asleep, or sleeping
too much
Feeling tired or having little
energy
Poor appetite or overeating
6.
7.
8.
9.
Feeling bad about yourself, that
you are a failure, or that you have
let people down
Trouble concentrating on things
such as reading or watching
television
Moving or speaking very slowly or
being fidgety or restless
Thinking you would be better off
dead or that you want to hurt
yourself
2. If you checked off any problems, how difficult have these problems made it
for you to do your work, take care of things at home, or get along with other
people?
WORK AND SOCIAL ADJUSTMENT SCALE
(WSAS)
1.
2.
3.
4.
5.
Because of _________,
my ability to work (occupational, studying, etc.) is impaired.
my home management (cleaning, tidying, shopping, cooking, looking
after home or children, paying bills) is impaired.
my private leisure activities (done alone, such as reading, gardening,
collecting, sewing, walking alone) are impaired.
my social leisure activities (with other people, such as parties, bars,
clubs, outings, visits, dating, home entertainment) are impaired.
my ability to form and maintain close relationships with others,
including those I live with, is impaired.
Each item is rated on a 0-8 Scale, from “not at all” to “severe interference”
Goal: Implementation of simple, user-friendly standardized
assessment tools to measure outcome
TREATMENT MODERATORS
Moderators are client characteristics that predict
outcome with one intervention compared to
another
Example: Attachment style as assessed with the
Relationship Styles Questionnaire
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High attachment avoidance predicts WORSE
outcome with a supportive, relationship-oriented
treatment and BETTER outcome with structured CBT
approach 1
Goal: Individualized treatment by employing research-informed
moderators
1
McBride et.al. JCCP 2006
STRENGTHS BASED ASSESSMENT
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A focus on client strengths has been a mainstay
of social work practice
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Social workers have long recognized that mental
health is not simply the absence of mental disorders
A growing body of research supports the importance
of positive emotions, optimism and wellbeing to both
mental and physical health
However, systematic assessment of strengths is
rarely done
Many clinicians are unaware that mental health
assessment instruments do exist
EXAMPLE: DIAGNOSIS OF MENTAL HEALTH
Criteria for a categorical diagnosis of flourishing
 Hedonia: high level on at least one of the following
1. Regularly cheerful, in good spirits, happy, calm and
peaceful, satisfied, and full of life (positive affect past 30
days)
2. Feels happy or satisfied with life overall or domains of
life (avowed happiness or avowed life satisfaction)
Keyes CLM J Clin Consult Psychol 539-548 2005
MENTAL HEALTH (CONT.)
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Positive functioning: high level on six or more
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
of the following
Positive attitudes toward oneself (self-acceptance)
Positive attitude toward others (social acceptance)
Insight into own potential, open to new experiences ( personal growth)
Belief that people have potential and can grow (social actualization)
Goals/beliefs that affirm sense of purpose and meaning ( purpose in life)
Feel that one’s life is useful and valued by others (social contribution)
Capability to manage complex environment, (environmental mastery)
Interested in society or social life (social coherence)
Guided by internal standards; resists social pressures (autonomy)
Warm, satisfying relationships; empathy and intimacy (positive relations
with others)
Sense of belonging; comfort and support from community (social
integration)
Keyes CLM J Clin Consult Psychol 539-548 2005
GOAL FOR THE 21ST CENTURY: FOCUS ON
PROMOTING HEALTH
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However measured, mental health is a concept that
needs attention
Mental health is not the same as the absence of mental
disorder
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A person without a mental disorder can have a low level of
mental health
A person with a mental disorder can have a high level of mental
health
Clinicians need to evaluate both mental disorders and
mental health and work simultaneously to reduce
symptoms and enhance health
INTERVENTION TOOLS
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There are now a large group of proven efficacious
interventions for
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A range of mental disorders, e.g. Depression; Anxiety; Eating
disorders; Psychotic disorders; Substance abuse, etc.)
Cross-diagnosis counseling, e.g. Illness Management and
Recovery; Psychoeducation; Assertive community Treatment;
Supported employment
Most clinicians do not utilize these tools
Clinicians are often uncertain how to implement a new
treatment and whether it is appropriate for their clients
There is a need to find ways to employ efficacious
intervention strategies as tools, used flexibly to address
targeted problems
USING INTERVENTION TOOLS
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Devising individualized treatments consisting of
efficacious intervention modules, following principles of
measurement-based care, may be a way to optimize
intervention outcomes
Our work provides an example of using the intervention
“tool box” in conjunction with measurement- based care,
to address a new problem
WHAT WERE THESE PEOPLE
EXPERIENCING?
Depression?
Posttraumatic stress disorder?
 A normal bereavement response?
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WE CONCLUDED THAT THIS WAS A
MALADAPTIVE
BEREAVEMENT RESPONSE
A 4-STEP APPROACH TO CONSTRUCTING A
TREATMENT
Step 1: Develop a formulation of the target
problem
Step 2: Decide on intervention goals
Step 3: Choose a set of efficacious treatment
components to achieve these goals
Step 4: Monitor outcome and make needed
adjustments
DEVELOP A FORMULATION OF THE
PROBLEM
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Confrontation with a severely threatening reality,
inconsistent with an internal working model is the
hallmark of trauma
We conceptualized bereavement as attachment loss
that met this criterion for trauma
We postulated that there are 2 generic types of trauma
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Both types of trauma entail problems comprehending
the event, resulting in intrusions and avoidance
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Traumatic stress: Actual or threatened death or serious injury
Traumatic loss: Permanent loss of an attachment figure
Traumatic stress provokes hypervigilance to danger
Traumatic loss provokes longing, searching for proximity
An unresolved trauma reaction impedes the natural
progress of adjustment to the severely threatening
event
SCHEMATIC DEPICTION OF OUR ATTACHMENTTRAUMA BASED GRIEF FORMULATION: USUAL GRIEF
BEREAVEMENT
(attachment loss)
ACUTE GRIEF
Traumatic loss
reaction
Caregiver selfblame
Exploratory system
Inhibited
Transient, dominant state
Painful and preoccupying
Resolution of trauma (Comprehension,
meaning-making, sense of controllability)
Reconfiguration of the working model
Positive emotions
Forgiveness, compassion
INTEGRATED
GRIEF
Permanent background state
Bittersweet memories that are
accessible and changing
SCHEMATIC DEPICTION OF OUR FORMULATION
PROLONGED (TRAUMATIC) GRIEF
BEREAVEMENT
(attachment loss)
ACUTE GRIEF
Traumatic loss
reaction
Caregiver selfblame
Maladaptive beliefs and behaviors
•Unresolved trauma
•Continued yearning and
searching
•Dominant negative emotions
Exploratory system
inhibited
PROLONGED
(TRAUMATIC) GRIEF
INTEGRATED
GRIEF
DECIDE ON INTERVENTION TARGETS
Target Problem
Negative interpretations of grief
2. Unresolved trauma
3. Maladaptive beliefs related to
caregiver self-blame or survivor
guilt
4. Compulsive proximity seeking
1.
2.
3.
5. Avoidance of reminders of the
death
5.
1.
4.
Treatment Goal
Acceptance of grief
Comprehension of the death
Forgiveness of self and
others; freedom to experience
positive emotions
Sense of a comfortable
relationship to the deceased
Reduce avoidance; Find other
ways to manage emotional
pain
CHOOSE A SET OF INTERVENTION
COMPONENTS
Target Goal
1. Acceptance of grief
2. Comprehension fo the death
3. Forgiveness of self and
others; freedom to experience
positive emotions
4. Sense of a comfortable
relationship to the deceased
5. Reduce avoidance; Find other
ways to manage emotional
pain
1.
2.
3.
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5.
Treatment Component
IPT: define the problem and
give permission for a “sick role”
CBT: Imaginal revisiting of the
death; situational revisiting
MET: Personal goals, self care;
IPT: strengths-focused
encouragement of interaction
with others
CBT: imaginary conversation
with the deceased; memories
and pictures
CBT: Revisiting situations
related to loss;
TREATMENT PROCESS GUIDED BY
BEREAVEMENT COPING THEORY
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Dual process theory of coping
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This model guided the process of the treatment
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Bereavement entails both loss-related and
restoration-related stressors
Effective coping is achieved by a process of
oscillating between addressing loss and restoration
All sessions focused on both loss and restoration
Goal was to help the person feel comfortable with
engaging the loss and also with setting it aside
We added a focus on restoration-based
strengths
Stroebe and Schut Death Studies 23: 197–224, 1999 p.213
SUMMARY: CLINICAL PRACTICE IN THE 21ST
CENTURY
Research informed practice, in combination with practiceinformed research, holds great promise for enhancing
the lives of people with mental disorders
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Goal: Utilize assessment research findings to
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Implement measurement-based care
Inform treatment decisions using moderator variables
Systematize the assessment of mental health and strengthbased care
Goal: Utilize intervention research findings to
individualize treatment using target symptoms or
impairments defined by formulating clinical problems and
defining treatment goals
CONCLUSIONS
This is an exciting time for clinical social workers
who are in a position to lead the field in
 Renewed emphasis and rigor in strength-based
assessment and intervention,
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Mental health is not the absence of mental disorder
Mental disorder is not the absence of mental health
Creative utilization of research informed
assessment and intervention tools, and
Establishment of innovative models for clinical
practice and practice-based research