CLINICAL SOCIAL WORK IN THE 21ST CENTURY

PSYCHIATRIST'S PERSPECTIVE ON AN URGENT

AGENDA Dr. Katherine Shear

Marion E. Kenworthy ChairColumbia 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

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Psychologists Psychiatrists PsychiatricNurses

SAMHSA 1998

CLINICAL SOCIAL WORKERS DOMINATE THE U. S. PSYCHOTHERAPY WORKFORCE

Slide provided by Myrna Weissman Ph.D.

OPPORTUNITIES FOR HIGH IMPACT

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

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

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

PRACTICEPRACTICERESEARCHRESEARCH

Provides•A foundation of basic science knowledge

•Collection of validated clinical toolsSupported by continuous infusion of research knowledge

and tools

Provides•Clinical observations and outcome evaluation

•Generation of hypothesesSupported by ongoing communication between practitioners and

researchers

THE RESEARCH-PRACTICE INTERFACE

WHAT ARE CLINICAL TOOLS?

A set of strategies and techniques targeting Alliance building to support treatment adherence Assessment, including

Mental disorders and their consequences Mental health Social-environmental stresses and resources

Intervention/Treatment in order to Reduce symptoms and impairments Enhance strengths Reduce environmental stress Enhance environmental resources

WHAT IS IN THE RESEARCH-INFORMED CLINICAL TOOL BOX?

Assessment instruments and methods to assist with a range of clinical activities, e.g. 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 cross-disorder counseling goals

Methods for employing theoretically or empirically guided strategies and techniques for use with individual clients

ASSESSMENT METHODS AND INSTRUMENTS

Measurement based care: a strategy for integrating assessment and treatment, entailing 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

PHQ-9 as a diagnostic instrument and symptom rating scale for depression

Work and Social Adjustment Scale 5-item questionnaire Has been shown to be reliable and valid

THE PHQ-9

1. Little interest or pleasure in doing things

2. Feeling down, depressed, or hopeless

3. Trouble falling asleep, staying asleep, or sleeping too much

4. Feeling tired or having little energy

5. Poor appetite or overeating

6. Feeling bad about yourself, that you are a failure, or that you have let people down

7. Trouble concentrating on things such as reading or watching television

8. Moving or speaking very slowly or being fidgety or restless

9. Thinking you would be better off dead or that you want to hurt yourself

Over the last 2 weeks, how often have you been bothered by any of the following problems?

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)

Because of _________, 1. my ability to work (occupational, studying, etc.) is impaired.2. my home management (cleaning, tidying, shopping, cooking, looking

after home or children, paying bills) is impaired.3. my private leisure activities (done alone, such as reading, gardening,

collecting, sewing, walking alone) are impaired.4. my social leisure activities (with other people, such as parties, bars,

clubs, outings, visits, dating, home entertainment) are impaired.5. 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 standardizedassessment 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 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-informedmoderators

1 McBride et.al. JCCP 2006

STRENGTHS BASED ASSESSMENT

A focus on client strengths has been a mainstay of social work practice 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.)

1. Positive attitudes toward oneself (self-acceptance)

2. Positive attitude toward others (social acceptance)

3. Insight into own potential, open to new experiences ( personal growth)

4. Belief that people have potential and can grow (social actualization)

5. Goals/beliefs that affirm sense of purpose and meaning ( purpose in life)

6. Feel that one’s life is useful and valued by others (social contribution)

7. Capability to manage complex environment, (environmental mastery)

8. Interested in society or social life (social coherence)

9. Guided by internal standards; resists social pressures (autonomy)

10. Warm, satisfying relationships; empathy and intimacy (positive relations with others)

11. Sense of belonging; comfort and support from community (social integration)

Keyes CLM J Clin Consult Psychol 539-548 2005

Positive functioning: high level on six or more of the following

GOAL FOR THE 21ST CENTURY: FOCUS ON PROMOTING HEALTH

However measured, mental health is a concept that needs attention

Mental health is not the same as the absence of mental disorder 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

There are now a large group of proven efficacious interventions for 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

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?

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

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 trauma1. Traumatic stress: Actual or threatened death or serious injury

2. Traumatic loss: Permanent loss of an attachment figure

Both types of trauma entail problems comprehending the event, resulting in intrusions and avoidance

1. Traumatic stress provokes hypervigilance to danger

2. 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 ATTACHMENT-TRAUMA BASED GRIEF FORMULATION: USUAL GRIEF

BEREAVEMENT(attachment loss)

BEREAVEMENT(attachment loss)

ACUTE GRIEFACUTE GRIEF

Traumatic loss reaction

Caregiver self-blame

INTEGRATEDINTEGRATEDGRIEFGRIEF

INTEGRATEDINTEGRATEDGRIEFGRIEF

Permanent background stateBittersweet memories that areaccessible and changing

Resolution of trauma (Comprehension, meaning-making, sense of controllability)Reconfiguration of the working modelPositive emotions Forgiveness, compassion

Transient, dominant statePainful and preoccupying

Exploratory systemInhibited

SCHEMATIC DEPICTION OF OUR FORMULATION PROLONGED (TRAUMATIC) GRIEF

BEREAVEMENT(attachment loss)

INTEGRATEDINTEGRATEDGRIEFGRIEF

INTEGRATEDINTEGRATEDGRIEFGRIEF

ACUTE GRIEFACUTE GRIEF

Traumatic loss reaction

Caregiver self-blame

Exploratory systeminhibited

Maladaptive beliefs and behaviors•Unresolved trauma•Continued yearning and searching•Dominant negative emotions

Maladaptive beliefs and behaviors•Unresolved trauma•Continued yearning and searching•Dominant negative emotions

PROLONGED (TRAUMATIC) GRIEF

DECIDE ON INTERVENTION TARGETS

Target Problem1. Negative interpretations of grief

2. Unresolved trauma

3. Maladaptive beliefs related to caregiver self-blame or survivor guilt

4. Compulsive proximity seeking

5. Avoidance of reminders of the death

Treatment Goal

1. Acceptance of grief

2. Comprehension of 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

CHOOSE A SET OF INTERVENTION COMPONENTS

Target Goal1. Acceptance of grief

2. Comprehension fo the death3. 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

Treatment Component1. IPT: define the problem and

give permission for a “sick role”2. CBT: Imaginal revisiting of the

death; situational revisiting3. MET: Personal goals, self care;

IPT: strengths-focused encouragement of interaction with others

4. CBT: imaginary conversation with the deceased; memories and pictures

5. CBT: Revisiting situations related to loss;

Stroebe and Schut Death Studies 23: 197–224, 1999 p.213

TREATMENT PROCESS GUIDED BY BEREAVEMENT COPING THEORY

Dual process theory of coping Bereavement entails both loss-related and

restoration-related stressors Effective coping is achieved by a process of

oscillating between addressing loss and restoration This model guided the process of the treatment

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

SUMMARY: CLINICAL PRACTICE IN THE 21ST CENTURY

Research informed practice, in combination with practice-informed research, holds great promise for enhancing the lives of people with mental disorders

Goal: Utilize assessment research findings to Implement measurement-based care Inform treatment decisions using moderator variables Systematize the assessment of mental health and strength-

based 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, 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