California Society for Clinical Social Work

Professional Development | Advocacy | Connection

THE CLINICAL UPDATE | SUMMER 2019

Upcoming events

Letter from our President, Monica Blauner, LCSW

Founded in 1969, I am very proud to celebrate CSCSW’s 50th birthday year!  We had a “birthday party” in Los Angeles that was well attended, including four past presidents: Renee Lonner, Lynette Sim, Carole Bender, Jan Lipschutz and several early and founding members including Rama Weizman, Tanya Moradians and Masayo Isono. 

I’m pleased to report that our Society has had a flourishing year, providing excellent educational offerings and networking opportunities throughout the state. We conducted a series of surveys to learn more about our constituency and their professional needs.  The results are summarized in a separate article in this newsletter (see Member Survey).  We are already responding to the feedback we received. Some of our initiatives include focusing on increasing networking opportunities and providing information to support those entering private practice. We will be providing more webinars so that all our members across the state can have access to our educational offerings, including those required by the BBS.  Rob Weiss has generously offered to provide a series of webinars on Sexual and Relationship Health, beginning in September. A new law that went into effect January 1 requires that all BBS licensees have documented 6 hours of Suicide Prevention training which we are planning to offer to our members.

We continue to pursue cooperative agreements with other organizations to offer a broader range of educational opportunities to our members at reduced prices.  CSCSW members will be able to attend Los Angeles CAMFT events at the CAMFT member rate. We are co-hosting events with the America Association for Psychoanalysis in Clinical Social Work (AAPCSW) in both Northern and Southern California, and Concern: EAP in Palo Alto. We will also hold our third annual licensing event in collaboration with USC.  A second diversity event is currently being planned with San Fernando Valley CAMFT to be held in October.

Please see the summary of the active board committees in this newsletter and consider serving on a committee!  It is a great way to network with your peers and make new friends, while contributing to the Society and the profession.  Optimally, all the districts will be represented on each committee.  Any member of the Society can join, as only the committee chairs are required to be board members.

Membership Drive

Our membership year begins July 1, so now is the time to renew your membership! 

In order to continue to offer our current and expanded member benefits, we need to grow the organization and our financial resources.  You can help by telling your friends and colleagues about our organization and events, and inviting them to attend with you. Please let us know if you have contacts in schools or agencies that employ clinical social workers who might benefit from information about our organization.

Board News

Board elections will be held in June.  The board decided to maintain 12 members, adding a student member.  We have had applications from across the state, and the Nominating Committee will vet nominees for the election.  Criteria will include skills and interests that meet our board’s needs, as well as geographic distribution so all the districts are represented.                

Board meetings are open to all CSCSW members.  The next meeting is tentatively scheduled for September 21, 2019 in Los Angeles.

I’d like to acknowledge particular individuals’ efforts to serve the Society:

  • Natasha Singer has been acting as liaison to the BBS, helping individual members get needed information from the BBS.
  • Sharon Reiner has been attending BBS meetings, and reporting to the membership about recent changes in the law and the general functioning of the BBS.
  • Malena Ally, Cat Knell, Lindsey Peters and Roland Hsu have all been working on increasing our social media presence on Facebook, Instagram and LinkedIn.
  • Laura Alongi has updated our List of Supervisors and made it accessible to the public.
  • Mick Rogers and members of the Ethics Committee have been providing consultations to our members.
  • Jean Rosenfeld does a wonderful job editing and producing our newsletter, the Clinical Update. 
  • Jennifer Kulka, chair of the Member Benefits Committee, has revamped the mentorship program, making it easier and more efficient to match mentors with mentees.
  • Trish Yeh chair of the Education Committee and Robbie Limary-Kenobi are taking the lead on planning new workshops and online educational events.
  • Tanya Moradians, chair of the Advocacy Committee has done an excellent job of keeping our membership informed about legal and social justice issues, and served as liaison with the Clinical Social Work Association (CSWA).
  • Gabie Berliner, chair of the Fund Raising Committee, made a tireless effort to collect donated items to raise funds for the Jannette Alexander Foundation, which provides $1,000 scholarships to second year MSW students.
  • Amanda Lee, board secretary, is leading efforts to address diversity.  

Departing board members, Past President Leah Reider, Tanya Moradians and Gabie Berliner have been dedicated to the Society and its mission.  Each of them have served multiple terms on the board over the years, and made innumerable contributions to the Society.  We are grateful for your service!

Member Survey Results

By Monica Blauner, LCSW

In our effort to grow and revitalize the Society, we conducted several surveys to stay in touch with the needs of our members and potential members.  We constructed three different surveys, one for our current members (62 respondents), another for former members (37 respondents), and a third for those who have never been members (50 respondents). Thank you to all who participated in the surveys!  Below is a summary of the results.

CSCSW Members

Our members are overwhelming heterosexual women, LCSW’s (80%), in private practice (70%), with over 10 years of experience in the field (80%).

Top Reasons for Joining CSCSW for both members and former members were:

  • Networking
  • Updates on the profession
  • Advocacy
  • Free CEU’s

With the Clinical Update newsletter, discounted workshops and Liaison to the BBS being next.

When asked to rank the most important benefits, these included:

  • Advocacy
  • Updates on the field/profession
  • Networking

Also important were: Free CEU’s, discounted workshops, the Listserv, and Ethics Consultations.

Private practice was the most commonly stated career goal, and respondents requested practice related information and services in all of the surveys.

Webinars

Almost half of our members and former members were interested in webinars, and another quarter were “maybe” interested, while over 70% of non-members were interested

Former Members

Most of our former members were LCSW’s (56%), with ASW’s next (28%) and then students (11%).  While most (57%) were in the field over 10 years, a greater percentage of former members were in the field 1 – 5 years (20%) and some (17%) were not working.  The greatest number (34%) were in private practice. Next were agency workers (19%) and hospital workers (16%).  The most common reasons for not continuing with CSCSW membership included; insufficient benefit to justify the cost, dues too expensive, and living in an area without an active district.

Non-Members

Non-members were also overwhelmingly (96%) female, heterosexual (84%) and white (65%).  They have been in the field over 10 years (41%), 1 – 5 years (29%), less than 1 year (10%). The largest group work in agencies (38%), followed by private practice (19%), schools (13%), and hospitals (11%).  The non-members were the most diverse group of respondents, with Latina/o/x being the next largest group (30%), followed by bisexual (11%), American Indian (8%), and Asian and Pacific Islander (7%).

Non-members also indicated that Updates on the Profession, Advocacy and Free CEU’s were their most important priorities, with Networking and Discounted Workshops following.  Also important to them were the Listserv, Ethics and Legal Consultation, and the Liaison to the BBS.  Several comments requested more web-based educational opportunities, such as livestreaming and webinars. The reasons they have not joined CSCSW include: dues being too expensive (26%), living in an area without an active district (21%), belonging to another professional organization (18%), and meetings held at inconvenient times (9%).

Respondents were very generous in their suggestions for topics to be addressed at district meetings and workshops, and these have been forwarded to the local District Coordinators.

The board appreciates your feedback and encourage the membership to continue to communicate with us. Get involved and help us grow the Society to better meet your professional needs!

Member Spotlight: Nadia Aquino, LCSW

Written by Trish Yeh, ASW

This interview has been edited for length.

Trish: Hi Nadia, thank you very much for your contributions to the Society as our past Los Angeles District Coordinator. Thank you for being willing to share your experience in the social work field with fellow Society members through the Member Spotlight. How did you come to pursue a career in the social work field?

Nadia: When I was an undergraduate student, I volunteered extensively with organizations serving animals and the homeless population. As I approached graduation, I interviewed with a homeless shelter in Los Angeles because I had greatly enjoyed working with the homeless population. Over the course of the interview, I came to realize that I would like to pursue further education in the field. I had considered law school, but after a friend told me about social work school, I decided to give it a try. I’m so glad that I did!

T: How was your experience in pursuing your master’s degree in social work (MSW)?

N: I attended the School of Social Work at the University of Southern California, and my education helped me grow professionally and personally. I learned more about mental health and trauma, especially how common it was not only in our community but the world. One of my professors strongly inspired me to serve survivors of domestic violence, and what I learned from her class and her led me to do the work that I do today.

T: Congratulations on your recent accomplishment of having become a Licensed Clinical Social Worker, Nadia. How was your experience in working toward becoming licensed?

N: Honestly, I think my process of becoming licensed went smoothly. I received one hour of clinical supervision every week. When I gained the required number of hours, I gave myself some more time to prepare for the exam by continuing to work and receive supervision.

I took the exam twice and didn’t pass the first time. I was frustrated and sought therapy to reduce my self-doubt. I also appreciated the support I received from my partner and supervisor. For the second exam, I started studying five weeks before the exam. I work better with having some adrenaline. (Laugh) It was the perfect length of time for me to study for the exam.

T: What have you done in your social work career after you completed your MSW studies?

N: In my last year of graduate school, I interned with the Jewish Family Services’ (JFS’) Family Violence Project, now called JFS Hope. I was an intern in their transitional shelter for families who had lived in an emergency shelter and needed more time to re-establish their lives. The agency provided me with opportunities to work with Spanish-speaking mothers who had experienced domestic violence. The experience led me to develop a passion in working with survivors of domestic violence, particularly among Latinas. As a Latina, I would love to contribute to a movement that helps reduce domestic violence in the Latino population. Now as a staff member at JFS, I provide counseling services in English and Spanish and lead a support group for Spanish-speaking survivors. I strive to be aware of cultural considerations not just when I work with Latino clients but with all clients by thinking about how culture affects their experiences of domestic violence. 

Currently, I work at JFS’ emergency shelter. My role involves a lot of safety planning, crisis intervention, and reporting of child abuse and neglect. I also work in the outpatient center where I provide short-term counseling and lead the support group. Since two years ago, I have been serving as a field supervisor and work with a first-year MSW intern every year.

T: What do you like the most about your work?

N: I greatly enjoy what I do. I enjoy witnessing the growth that my clients go through. Many of them have come in feeling guilty and ashamed. In many cases, through therapy, they become more empowered or at the very least, more informed. I have great colleagues and supervisor who has offered me space to grow as a therapist and professional woman. I am very thankful for my supervisor. I have also enjoyed giving back and helping someone who is entering the social work field as a field instructor.

T: What have been some of your biggest successes in your career?

N: I think it is important for people to feel safe and not judged. When a client tells me that they feel safe with me or appreciate me for not judging them for what they have shared, I feel great knowing that I am doing my job well. Especially in providing trauma-informed care to survivors, it is important to be mindful of who you are and how you present to clients. I work hard to develop strong self-awareness to be more empathetic, supportive, and caring towards my clients. It is something that I am continuing to work on, and I think I’ve gotten a lot better at it over the years through self-reflections and support from my supervisor and colleagues. 

T: As a Field Instructor who has been working with MSW students, what advice would you give a social work student in entering their field placement and the social work field?

N: I advise everyone to work towards becoming licensed, regardless of whether you would like to go into macro-level work or focus on clinical work. I think it shows your dedication to the social work career by putting in the hours and effort to become licensed. Also it is important to develop your self-awareness. In order to help someone else, I think you need to know who you are, where you come from, and what your personal struggles have been.

T: Thank you for your advice. Is there any strategy that you’d recommend or have utilized to build self-awareness?

N: I have worked with a wonderful therapist to address my personal challenges. Therapy has helped me become more focused at work and serve my clients better. I also love listening to podcasts. I listen to some of them for fun. For example, I really like Nicole Byers’ podcast “Why Won’t You Date Me.” it is so funny. I also listen to podcasts that are focused on self-development. I highly recommend the “Therapist Uncensored” podcast to all social workers. It is presented in language that everyone can understand. It is focused on attachment theories and discusses problems that clients might bring into sessions in an empathetic way.

T: I am looking forward to checking the podcasts out! In addition to what you’ve shared, how do you take care of yourself to continue to pursue your passion in the social work field?

N: I have three little dogs, Loepsie, Chloe, and Rocky, and also help take care of my dad’s dog, Chase, from time to time. I love dogs and like to take them out on walks. I also enjoy spending time with my partner.

T: How did you become involved with the California Society for Clinical Social Work? What have been some of your favorite memories with the Society?

N: I became involved with the Society after one of my colleagues invited me to attend a meeting. I had mentioned to her that I’d like to work on my identity as a social work professional, but I was not sure where to go or whom to talk to. I liked the event and thought the organization provided great opportunities for social workers to pursue further education.

Subsequently, I became involved with the Los Angeles Steering Committee. The District Coordinator had needed to step down from her position due to personal reasons, and I told Monica (Blauner) that I’d be willing to step in as a Coordinator with another member, Lauren Small. In my role as a District Coordinator, Monica has been so helpful in countless ways. She is just so energetic and has so many great ideas for the Society. Having her as the President and nearby has been very helpful for me.  In terms of my favorite memories, I have greatly enjoyed attending Steering Committee meetings. I appreciate that we support each other as colleagues in the field.

T: Is there anything else that you’d like to share with other members?

N: I’d recommend to everyone to come to meetings, participate in networking activities, and consider volunteering as speakers. Monica has said that the more you put into the Society, the more you’ll get out of it, and that’s definitely true. I know that we all have a lot on our plate as professionals. However, my involvements with the Society have helped me in so many ways, such as growing as a social worker, meeting other social workers, and hearing about great things that others are doing in the field!

T: Thank you so much for sharing your time and experience with me and other Society members. I had such a great time talking with you, Nadia, and it has been such a privilege to get to know you more and work with you through the Los Angeles Steering Committee. We appreciate your contributions to to the Society.

Trish Yeh, ASW graduated from the MSW program at the University of California, Berkeley in 2016 with a concentration in Community Mental Health. She is working as the Director of Resident and Family Services at Silverado the Huntington, a memory care community in Alhambra, CA. Along with other social workers, Trish has recently revived the NASW-CA’s Asian and Pacific Islander Social Work Council- Southern California in Los Angeles, CA. She is serving as a Board Member and Chair of the Education Committee for the California Society for Clinical Social Work. She also organizes Social Justice Book Club meetings in Los Angeles, CA. She can be reached at trish.yeh@gmail.com.

Jannette Alexander Scholarship Recipients

Belen Aguirre

As a first generation Latina, I was born to a migrant family that originates from the states of Jalisco and Durango, Mexico. I was born and raised in Salinas, CA to parents who worked and continue to work in agriculture related jobs. I too was able to accompany my parents at the age of 16 to work in lettuce fields on early weekend mornings. Growing up in Salinas was not the mellowest ride. It was difficult to understand why my parents valued my education so much and it was so I had a better future. Salinas is primarily identified for high crime and violence rates especially with gang culture. I can personally say that I connect with some of the struggles that my community faces every day. Because of such violence that interrupts and entangles the lifestyles of many residents, I can deeply identify with them as I too have lost loved ones to this issue. Despite some of its struggles, I believe Salinas has the potential to change. I see the potential in this community, yet I also see the struggles. I see the need for more mental health support in our community and change at all levels of systems. When I went to college, I found myself exploring possible career pathways either in human communications, or journalism. At that time, one of my main goals was to contribute back to my community in some form or way. I thought I would be able to do so through writing and informing the public of current news. By random, I decided to take an “Ethics for Health and Human Services” course by Dr. Raines. I had no idea what the word ethics meant, but today I can say that this ethics course was my first encounter with the exact definition of the social work profession. I began to recognize that there are many social issues today that are left ignored and unspoken of. While my goal remained the same, to contribute back to my community, my focus had now shifted into another form of contribution. I began to accumulate interest in the intense stories of people with high crisis situations and needs. At that point, I had found my profession. By choosing a profession in social work, there was no doubt that I would be able to contribute in many ways to my community. I find value in contributing back to my community because I am part of this community and my community is part of me. By becoming an advocate for families, groups and individuals I am also becoming an advocate for myself. Today, I have a desire to reach to those that are marginalized, and those that are exposed to being absorbed by the cracks.

Cklara Moradian

Cklara Moradian is a diaspora Kurd, former refugee, survivor, social justice advocate, spoken word poet, and social worker in training. Cklara's work and clinical practice attempts to bear witness to the resilience and strengths of people she serves. She hopes to facilitate narratives of survivorship in the face of hardship and pain. Cklara is a 2nd year CSUN MSW Candidate in the 2019 cohort, completing a Department of Mental Health internship, and a graduate fellowship at Children's Hospital Los Angeles. She also works with the elderly and immigrant populations in the San Fernando Valley. Her practice is rooted in anti-oppressive theory and praxis. She hopes to continue to serve multiply marginalized communities, center disenfranchised voices in policy and research, and elevate the strength and resiliency of people who have and continue to deal with trauma.

Andy Le

Andy Le is a candidate for the Master of Social Work from the California State University, Fullerton. He earned his Bachelor of Arts in Criminology, Law and Society with a minor in Asian American Studies from the University of California, Irvine. Andy received a nomination for the UC Irvine’s Chancellor’s Living Our Values Award in 2014 for his contributions to the university’s student life and leadership. He has extensive experience working in various capacities such as non-profits, juvenile probation, higher education, and health care in Orange and Sacramento counties. Andy is currently serving children, families, and older adults at an outpatient clinic for Kaiser Permanente. He provides services such as individual and group psychotherapy, biopsychosocial assessments, and crisis management. As a fellow for the Council of Social Work Education Minority Fellowship Program, Andy is committed in addressing disparities in mental health and substance use among diverse racial and ethnic groups on national and local levels.

Andy is a dedicated professional with outstanding organizational and innovation skills that is vital in supporting his patients’ holistic needs and course of recovery.

Sexual Infidelity vs. Sex/Porn Addiction

Robert Weiss LCSW, CSAT-S

Infidelity vs Addiction: What’s the Difference?

This article looks at the difference between infidelity and addictive/compulsive sexual behavior and suggests where effective therapy and support can be found for each of these issues.

Infidelity (cheating) is the breaking of trust that occurs when you keep intimate, meaningful sexual and/or romantic secrets from your primary romantic partner.

Please notice that this definition does not talk specifically about affairs, porn, strip clubs, hookup apps, or any other specific sexual or romantic act. Instead, it focuses on what matters most to a betrayed partner—the loss of relationship trust. For cheated-on spouses, it’s usually not any specific sexual or romantic act that causes the most pain. Instead, it’s the lying, the secret keeping, the lies of omission, the manipulation, and the fact that they can no longer trust a single thing their partner says or does (or anything their partner has said and done in the past).

This is not the same thing as sex/porn addiction. The ICD-11 criteria for defining Compulsive Sexual Behavior Disorder (the World Health Organization’s term for sex/porn addiction) boil down to the following:

  • Preoccupation to the point of obsession with sexual fantasy and/or activity
  • Loss of control over the use of sexual fantasy and/or activity, typically evidenced by failed attempts to quit or cut back
  • Negative consequences linked to the obsessive, out of control sexual fantasies and behaviors—relationship trouble, issues at work or in school, declining physical health, depression, anxiety, diminished self-esteem, isolation, financial woes, loss of interest in previously enjoyable activities, legal trouble, etc.

Generally speaking, sex and porn addicts, like alcoholics and drug addicts, use their behavior to “numb out” and to escape from stress and other forms of emotional (and sometimes physical) discomfort, including the pain of underlying emotional and/or psychological issues like depression, anxiety, unresolved early-life trauma, etc. So, sex addicts don’t use compulsive sexual fantasies and behaviors to feel good and have a good time, they use them to feel less and to temporarily escape the pain of life.

Can You Be a Cheater and a Sex/Porn Addict?

The short answer is yes. But not all cheaters are sex/porn addicts, and not all sex/porn addicts are cheaters. If a person is keeping important sexual and romantic secrets from his or her significant other, that person is cheating. That person might also be preoccupied to the point of obsession with his or her sextracurricular behaviors, unable to quit, and running into all sorts of life issues as a result. If so, there is a good chance that person is also sex/porn addicted. But plenty of men and women cheat, even regularly, without meeting any of the criteria for sex/porn addiction. And plenty of sex/porn addicts are not in relationships and therefore can’t cheat.

Unfortunately, those who’ve been caught cheating will sometimes plead “sex/porn addiction” as an excuse for their behavior, hoping to avoid or at least to minimize the judgment and reprisals they experience related to their infidelity. Sometimes these men and women really are sexually addicted, but just as often they are not. Either way, a diagnosis of sex/porn addiction does not let the addict off the hook for what he or she has done.

Most of the confusion around sex/porn addiction and sexual infidelity (a pathological versus a non-pathological behavior) stems from the fact some moralistic or deeply religious clinicians try to use the sex/porn addiction label to define any type of sexual behavior that doesn’t mesh with their personal, social, religious, familial, or marital beliefs and values. These under informed (or overly moralistic) therapists seek to pathologize all sorts of relatively normal (whatever that means) sexual desires and behaviors, including things like porn, affairs, same-sex attractions, kinks, fetishes, etc.

Does the Distinction Matter?

When a person (or a couple) begins therapy, it is always important for the clinician to fully and correctly assess the situation so proper treatment can be implemented. Just as a medical doctor would not want to use medications for high blood pressure to treat cancer, we would not want to use the tried and true methodologies of sex/porn addiction treatment to address infidelity without addiction. So yes, the distinction between sexual infidelity and sex/porn addiction is important.

Sexual infidelity without sex/porn addiction is best addressed in treatment with an experienced couple’s therapist. Issues related to sex/porn addiction are best handled by a Certified Sex Addiction Therapist. When there is overlap (both infidelity and sex/porn addiction), the treatment approaches utilized will also tend to overlap, possibly requiring the services of both a couples therapist and a Certified Sex Addiction Therapist. 

Robert Weiss PhD, MSW, CEO of Seeking Integrity LLC, is a digital-age sex, intimacy, and relationship specialist. Dr. Weiss has spent more than 25 years developing treatment programs, educating clinicians, writing, and providing direct care to those challenged by digital-age infidelity, sexual addiction/compulsivity, and other addictive disorders. He has authored books on sex and intimacy disorders including Prodependence, Out of the Doghouse, Sex Addiction 101, and Cruise Control, among others. He also podcasts (Sex, Love, & Addiction 101) and hosts a free, weekly interactive sex and intimacy webinar via SexandRelationshipHealing.com. His current projects are:

Dr. Weiss can be reached at: RobertWeissMSW.com and SexandRelationshipHealing.com, or follow him on Twitter (@RobWeissMSW), LinkedIn (Robert Weiss LCSW), and Facebook (Rob Weiss MSW).

Treating Obsessive-Compulsive Disorder in Your Private Practice

By Robin Taylor Kirk, LMFT

When clinicians come to me for consultation, they often describe a desire to help people with Obsessive-Compulsive Disorder (OCD), but have experienced frustration and confusion about how best to go about it.  Maybe they’ve been doing talk therapy and aren’t seeing improvement or maybe they’ve taken a stab at Exposure and Response Prevention (ERP) and have run into difficulties doing in-session exposures. They are not alone.  Even clinicians who are veterans of residential or Intensive Outpatient Programs can have difficulty translating exposure work from a controlled and time-friendly environment to a private practice setting. Often clinicians don’t want to specialize in OCD, but want to be able to treat it effectively when the issue presents itself.  Since approximately one in 40 adults in the United States has OCD during their lifetimes, it’s likely that a sufferer will present themselves in your office at some point.

The idea behind ERP is simple enough:  a patient’s anxiety is triggered by coming in contact with an obsession and then the patient resists doing compulsions.  Easy enough, right?  But what if the obsession involves something that’s not readily available?  What if it isn’t feasible (e.g. a new mom with the obsession that she might drown her baby)?  With an open mind, some creativity and planning, it is possible to do effective ERP in a private practice setting.  

Clinicians doing exposure work generally work from one of two different approaches, either Habituation and CBT-based ERP or Mindfulness/ACT-Based Exposure.  A discussion of the differences between these two approaches is beyond the scope of this article, but what follows applies whether one does Habituation/CBT or Mindfulness/ACT exposures.

As a brief review, once the obsession (generally a “what if” thought) has been triggered, several types of compulsions may follow.  Let’s use the example of someone with contamination OCD.  The compulsions might be “approach” compulsions such as handwashing.  They might be “avoidance” compulsions such as standing back so that others will open the door/touch the door handle first (“If I take an extra few seconds to put my checkbook back in my purse, Robin will have opened the door already.”).  They could be thought compulsions taking the form of a mental review (“I heard someone coughing earlier; it might have come from Robin’s office.”), planning (or “If I can just use my pinkie finger, I won’t touch many germs.”) or reassurance (“I’m the first appointment of the day; any germs from yesterday are probably dead.”).  Asking about thought compulsions will serve you and your client well.  So often clients will engage in exposure only to report afterward that it went really well because they kept telling themselves it was an exposure that the clinician thought up and so it wasn’t the client’s responsibility, thus negating the benefit of the exposure. 

There are two roads, both of which lead to anxiety.  There are in vivo (doing in real life) exposures and imaginal (using one’s imagination to trigger anxiety) exposures.  Imaginal exposures are enhanced by using Virtual Reality (VR) technology which is much more affordable than in the past.  I recommend getting a headset that is compatible with your phone.  It’s also important to get disposable hygiene eye mask face cover and headphone covers which are inexpensive and easy to find on Amazon.  There are simulation products available, but I’ve found it easy to find relevant videos on YouTube that can be streamed through the headset.  Also, whether you use your phone or something like a GoPro, shooting your own videos is easy and very customizable to a particular client’s needs.  For instance, I take videos in gas station bathrooms, while taking out the garbage and touching the can, while in crowds, and while driving on local freeways or stuck at busy intersections.  Customized roadway videos have the advantage of being in locations with which people are familiar and that they’re likely to encounter in their daily driving.  You might want to have a phone memory card that’s devoted to exposure videos and always set your phone to airplane mode before doing a VR exposure.  The last thing you want is for a personal text message or the slideshow of your last vacation to pop up on the VR screen!  You can also upload your video to a YouTube channel or to your website and clients can stream from there for home practice.  Clients might be willing to purchase a headset, but if not, they can simply view the video at home for exposure practice.  It is almost always easier for clients to do exposures in the office because the therapist acts as a form of reassurance or comfort and so watching a video at home is often as triggering as watching on a VR headset in the office.

So, what do you do with yourself while your client is doing ERP in your office?  One of the drawbacks of working outside a treatment center is a lack of extra rooms or a central work room in which the therapist can hang out.  Let’s imagine your client is doing an imaginal exposure and is listening to a voice recording to trigger anxiety.  Each exposure varies, but I will often have them do the exposure first with me in the room.  I ask them to close their eyes and I do as well, both so they know I’m not staring at them and so I’m sitting quietly.  The client then repeats the exposure while alone in my office.  It probably goes without saying that all documents should be locked away.  If the client is doing habituation exposure, have them come get you once their anxiety has decreased by half (or whatever measure you use).  If you do a more mindfulness-based exposure, return to the office after the agreed-upon length of time. A waiting room, break room or chair set up in the hall can all serve as places to be during the client’s exposure.

After an exposure has been practiced during a session, it’s time for exposure practice at home.  A frequent problem is encouraging clients to do exposure practice in-between sessions.  Pen and paper records are helpful, but there are also quite a few helpful apps available. For the client’s evaluation of the severity of their OCD, the OCD Test by Mood Tools is an app that allows patients to evaluate their symptoms using the Obsessive Compulsive Inventory-Revised.  With respect to planning and carrying out exposures, NOCD is a free and highly customizable app that allows users to develop hierarchies, set a timer for exposure sessions, and record “loop tapes” used for exposures.

The typical time constraints in private practice can be challenging.  Fitting a review of exposures practiced at home, planning in-session exposure, doing the exposure, reviewing how it went and planning the next in-home exposures all within a 45-50 minute session can be a daunting task.  If you take insurance, CPT code 90837 allows for a 60-minute session and some insurance providers allow for an additional 15 minutes administering assessments.  These extra few minutes can make a big difference.  In my private practice, patients doing exposures will often come in for 90 minutes at a fee that is less than that for two full sessions.   

Another difficulty in private practice is having a supply of items which will trigger clients’ obsessions.  Often, reading an article about the fear (e.g. a child who developed a mysterious fever and dies suddenly) will suffice.  Spending a little time searching for articles, printing them, and having them on hand can save time when trying to work within the constraints of a 50-minute session.  Also, online shopping makes it quick and easy to have a toy snake on hand when needed. Canned chocolate frosting makes great fake poop.   And, don’t forget to frequent Halloween stores for fake bugs and bloody things.  Doing ERP work is obviously quite different from talk therapy, not only because of the props.  It is often a bit more active and directive on the therapist’s part.  The transition can be a bit jarring if you have only ten minutes between sessions.  I prefer to schedule 15 or 20 minutes in between sessions to give myself time to do any needed cleanup or putting away of triggering “props.” 

Another caution is to do one’s own work if needed.  I’ve had a strong snake phobia for as long as I can remember.  The can’t-walk-down-the-toy-store-aisle-that-has-plastic-snakes kind of phobia.  It didn’t get in my way very much until I decided I wanted to start going camping.  Time for DIY ERP.  The timing was perfect because I was soon working with someone with a snake phobia and watching Snakes on a Plane with him.  The good news is I was able to watch it without screaming and running from the room.  Odds are, whatever phobia you have will show up in your office and it will serve you well to do your own exposure before that happens.  

With a little creativity, flexibility and preparation, it is possible to do the rewarding work of using ERP within the confines of private practice.  

Robin Taylor Kirk, LMFT specializes in the treatment of Anxiety Disorders, including OCD using a mindfulness-based approach.  She directed an Intensive Outpatient Program and developed an ACT-Based Exposure protocol for use in the IOP.  She is currently in private practice in Sacramento, CA.  Ms. Kirk is also available for telemedicine sessions with people living in California and for consultation with clinicians treating OCD.  She can be reached at: 916-614-9200  robin@sagepsychotherapy.org  www.sagepsychotherapy.org

A Brush Up on Clinical Documentation: A Clinician’s Considerations

By Elizabeth Irias, LMFT     

We therapists and social workers are told time and time again that our notes are legal documents, yet we often receive very little training about what actually needs to be in them.  Further, there are a number of myths that float around the therapist community that can get providers into serious legal trouble (for example: "Notes need to be short and vague to protect client confidentiality,” or, “Clinicians in private practice don’t really need to keep notes”).  Many therapist do not realize that inadequate documentation can have grave consequences, including threats such as loss of licensure and even time behind bars, not to mention the potential negative impact on our clients.  With all of the responsibilities facing busy clinicians, clinical documentation often becomes an afterthought, though it behooves us to stay on top of our records, as a service to ourselves, our practices, and our clients. Let’s take a few minutes to review some California laws and standards, and their impact on our clinical documentation.

According to California Business & Professions Code §4982.05, licensed clinicians can have their licenses suspended or revoked due to unprofessional conduct, including, “...failure to keep records consistent with sound clinical judgment, the standards of the profession, and the nature of the services being rendered.”  Our records, therefore, need to adequately record the care we provide to our clients.  When we boil it down, our charts ought to tell the story of the Five W’s: The who, what, where, why, and when of a client’s treatment, and this standard applies to all California clinicians, regardless of their workplace (private practice, agency, etc.) or payment type (insurance, Medicare, private pay, etc.).   David Jensen, a former staff attorney for the California Association of Marriage & Family Therapists, calls clinical documentation a ‘persuasive tool’ and stresses that it really ought to persuade a reader why we did what we did.  This persuasive tool can be used for multiple purposes, including in matters like insurance authorizations, custody cases, short-term and long-term disability cases, or investigations conducted by licensing boards, not to mention in legal investigations should there be a significant client incident.  When it comes to an investigation of any kind, it may (and often will) depend on whether our documentation can prove that our treatment was appropriate.  Did we do what other prudent, well-trained, and ethical clinicians would have done in our shoes?  If a client were to have a significant incident, like a suicide attempt, would our records back up our choices and illustrate our appropriate clinical decision-making and competence?  Quality documentation reduces our liability risks, and helps us sleep a little better at night, knowing that we have both done what is required of us by law, and also made steps to protect our licenses.

Though unpleasant to consider, our profession includes legal risks, and our charts are effectively legal documents.  We clinicians never want to find ourselves in a legal “he said, she said” scenario, and sound clinical records protect us… how awful to consider a clinician needing to question the competence of a past client in order to protect him/her/themself because the record itself did not sufficiently capture the relevant details.  Relating to audits across the board, the old adage remains true: “If it’s not in the chart, then it didn’t happen.”  We may tell ourselves that our memories are good and we will be able to recall important details, but let’s be honest: Who among us has been immune to the occasional oversight like putting our fresh milk in the pantry and our laundry detergent in the fridge?  Our attention to detail simply is not that good, nor are our memories; and timely, sound charting is like an insurance policy for our hard-earned licenses.  California Business & Professions Code §4993 states that clinicians should retain records for seven years, or for minors, seven years after age of majority (18 years of age). It is important to keep in mind that a CA Board of Behavioral Sciences complaint can be filed for up to ten years after the service occurred, which implies a tip for providers:  If we really want to be careful, we should keep our records for a decade after treatment concludes, at a minimum, and longer if the client is a minor.  If there is a board complaint, the BBS may go into the chart looking for one thing and find other inadequacies.  Additionally, if you are found medically negligent, you could lose more than your license, including thousands upon thousands of dollars in legal bills, and you could even potentially do jail time if the situation were very extreme… the importance of sound clinical documentation can rarely be overstated.

In terms of the impact of clinical documentation on our clients, what stories do our records tell, and how could this affect our clients?  There have been many cases where individuals have lost significant and critical behavioral health benefits like insurance authorizations or short-term disability payments as a result of a clinician’s failure to appropriate document the client’s symptoms and prognosis.  Even in cases that do not involve financial benefits or authorizations, our charts support collaborative and ethical care, potentially allowing future clinicians to be able to pick up where we picked off.  Though macabre, we clinicians need to consider what would happen if we need to abruptly leave our practices, become disabled, or pass away… our documentation needs to tell the next person who sees it what happened, and it must be clear, specific, and legible. Our charts are held to the same standard as medical charts, and need to reflect the same caliber.  I have occasionally been asked this question: “In order to protect client privacy, shouldn’t we leave certain things out of the record?”  The answer there is something worth consideration: The standard of care dictates that we accurately record what happened in session… essentially, what influenced our clinical decision-making.  If we jump into the world of the medical model, imagine a doctor choosing not to document a symptom, procedure, or consideration due to concerns about the patient’s privacy: The chart is simply there to record what happened, to tell the story of an encounter.  When clinicians leave out critical details (ie- details that have influenced the provider’s clinical decision-making, like symptoms that support a diagnosis, etc.) to protect a client’s privacy, the clinician has made a subtle choice that the client’s privacy is higher ranking than the clinician’s license... it is ultimately the clinician who the record may protect (or fail to protect).

One of the complicated considerations for counseling and therapy is the concept of ‘medical necessity’... what does this nebulous term really mean, and how do we illustrate it? Simply put, medical necessity requires that there is a legitimate clinical need for behavioral health treatment, and our charts must record the factors that indicate medical necessity.  Per California Welfare And Institutions Code §14059.5, “[A] service is ‘medically necessary’ or a ‘medical necessity’ when it is reasonable and necessary to protect life, to prevent significant illness or significant disability, or to alleviate severe pain.” As such, our records need to illustrate why we believe treatment is necessary to prevent significant illness, disability or alleviate severe pain… they need to pass the smell test, so to speak.  Even in cases where clinicians are providing long-term therapy to clients who are generally stable, there still must be medical necessity… why do you think this person needs this service?  Do you believe that attending weekly therapy helps them maintain their treatment gains, or stave off another depressive episode?  If yes, document it. 

It’s also important to note that this concept of medical necessity is as relevant for self-paying clients as it is for insurance clients.  Again, jumping back into the medical model: Imagine a surgeon not documenting a service he/she/they had performed because of how the patient was paying for it.  To do so would be incredibly risky for the doctor, and automatically treads into delicate ethical territory.  Regardless of the pay source, the record need to tell the story of what happened.  Moreover, imagine that a large-scale audit of your charts is being performed, and the charts for insurance clients are much detailed than the charts for your private-pay clients.  It could appear, then, that the insurance-paying clients were actually receiving better care, since the records are better and more thoroughly explain what treatment the client received.  Once again, this discrepancy could be interpreted in a way that is damaging to the clinician: The provider offered better care to those who used their insurance to pay for treatment, even though this may not be the case.

To sum it up, when it comes to our clinical documentation, there are many factors to consider: We need to remember that medical necessity is the backbone of the care we provide, and that the quality of the charts we maintain is critical to the security of our practices.  Truthfully, none of us entered this field because we love to document (at least, I haven’t met this person yet!). We went into the field because of a love of people and a commitment to healing.  In order for us to continue to do what we do, and provide the artful dance of therapy and social work, our records give us a jumping-off point that either give us more security or more risk, and the choice really comes down to us, via our pens or our keyboards.

Elizabeth Irias, LMFT, is the founder and president of Clearly Clinical, a national, affordable, podcast-based behavioral health Continuing Education program approved by CCAPP, CAMFT, the APA, CPA, NBCC, and NAADAC.  She has specializations in Utilization Review, Clinical Documentation, and Quality Assurance, and works closely with clinical teams across the country to reduce documentation-related liability risks and improve their quality of care, documentation practices, and Utilization Review outcomes.  An adjunct graduate professor at Pepperdine University, Beth provides dynamic, targeted presentations for national conferences, seminars, universities, and mental health providers.  She also operates a private practice in Westlake Village, CA, where she provides therapy to adolescent/young adult clients, members of the LGBT population, and those with addictive disorders. To learn more about her work and to take one of her free CE courses, please visit Clearly-Clinical.com.

No Medication Required:  Cognitive Behavioral Therapy for Insomnia, an Evidence-Based Treatment

By Kim Roser-Kedward, LCSW

“...Sleep that knits up the ravell’d sleave of care,

The death of each day’s life, sore labour’s bath,

Balm of hurt minds, great nature’s second course,

Chief nourisher in life’s feast.” ~ Macbeth (2.2.46-51)

Sleep. We all need it. While many people reference not sleeping the night before as having “insomnia,” an estimated 10-30% of adults in the general population suffer from persistent  problems with sleep that meet criteria for the clinical diagnosis of Insomnia (Bhaskar et al 2016).  It is believed that an estimated 20-40% of adults seeking healthcare in a primary care office, suffer from Insomnia. These numbers are higher for Veterans and persons suffering from other mental health diagnoses.

Adults with Insomnia typically seek care from their Primary Care doctors, many who are unfamiliar with treatment options other than prescribing a medication to aid sleep. The problems with medication are that there is a risk of dependency, the medication becoming less effective over time, and the person may develop the belief that they are unable to sleep without medication.  However, there is another way to treat insomnia: Cognitive Behavioral Therapy for Insomnia (CBT-I), surprisingly not commonly known, despite 30 years of research supporting its efficacy.

What is Insomnia?

The DSM-V Insomnia diagnostic criteria requires the complaints of difficulty falling asleep or staying asleep that are clinically significant and result in daytime complaints of feeling tired, distress about poor sleep, having low energy, increased irritability, problems with attention, concentration, memory, and relationships or school/work performance. Additionally, the problems with sleep must occur at least 3 nights per week, for at least 3 months, and occurs despite adequate opportunity to sleep. There are other distinguishing criteria outlined, but these are the essential features.

It is important to highlight that Insomnia is different from Insufficient Sleep Syndrome which is inadequate sleep that is voluntarily restricted. This pattern of sleep behavior may be unintentional (e.g., staying up too late multiple nights binge-watching Netflix, working, consuming social media, etc.), and is very different from the inability to sleep.

How does Insomnia Persist?

Spielman’s model of Insomnia (1987) identifies three factors that contribute to the development of chronic insomnia:  Predisposing Factors, Precipitation Factors, and Perpetuating Factors. A fourth factor, Conditioned Response, is also considered and addressed in CBT-I.

Some people have greater vulnerability to sleep difficulties (predisposing factors).  Circumstances such as stressful life events may precipitate sleep difficulties. This is more likely to occur in people with a predisposition for Insomnia.

In most cases, sleep difficulties are temporary when the original stress subsides. However, some people become overly focused on their sleep difficulty.  This excessive attention to sleep tends to perpetuate sleep difficulties, because it increases anxiety about sleep.

Other maladaptive/perpetuating strategies occur, intending to improve sleep, but contribute to the persistence of insomnia (e.g., napping, irregular sleep/wake times, spending too much time in bed while awake/trying to sleep). These perpetuating factors are the targets of CBT-I.

What is CBT-I?

Considered the “golden standard” for Insomnia treatment by researchers, CBT-I is the recommended first-choice treatment for people meeting criteria for the Insomnia diagnosis. The American College of Physicians recommends that “all adult patients receive Cognitive Behavioral Therapy for Insomnia (CBT-I) as the initial treatment for insomnia.” (Qaseem et al. 2016)

How does CBT-I Improve Sleep?

In brief, CBT-I addresses an individual’s sleep-related behaviors and thoughts. The behavioral component of treatment is aimed at improving the quality and quantity of sleep through Sleep Restriction (to decrease wakefulness after sleep onset) and Stimulus Control (to strengthen the bed and bedroom as a cue for sleep).

What does CBT-I Involve?

After a comprehensive assessment of symptoms, sleep behavior and the sleep environment, the CBT-I patient is educated about how sleep is regulated (Process S: the Sleep Drive and Process C: Circadian Rhythm), the Four-Model of how sleep problems develop into Insomnia (Predisposing Factors, Precipitating Factors, Perpetuating Factors, and Conditioning).  The patient is instructed on how to complete a Sleep Diary that captures lots of sleep-related data and assists with calculating the patient’s Sleep Efficiency. A Sleep Prescription is established, with consideration of the patient’s current ability to sleep and desired rise time. The Sleep Prescription helps with Circadian Rhythm entrainment, and improves Sleep Drive through Sleep Restriction. Over the course of six to eight sessions the patient achieves a target Sleep Efficiency, then the Sleep Prescription is increased by 15-30 minutes weekly.  Improvements in sleep can be seen very quickly. This typically motivates patients to stick to their Sleep Prescription (or Sleep Plan) and meaningful improvements in sleep are typically seen in four to eight weeks. Through this process of education and a customized Sleep Plan, the patient essentially learns how to become their own Sleep Coach. Because CBT-I strictly focuses on sleep, this therapy can be conducted adjunctive to other therapeutic approaches. So patients who are already in psychotherapy with one clinician, could be referred to a CBT-I specialist for short-term, sleep-focused treatment.

Gateway Treatment

It is not uncommon to discover that many people with Insomnia may also suffer from an underlying anxiety or adjustment disorder. Since accessing mental health care still holds social stigma for some individuals, I like to think that CBT-I can be a “gateway treatment”. Since it focuses primarily on sleep behavior and related sleep beliefs, it is an accessible (and acceptable) psychotherapy for those who may be reluctant to expose themselves to the typical vulnerabilities of the therapy chair. Building trust and rapport with clients who see improvements in their sleep may build confidence and willingness to work on their other symptoms and stressors.

Access to Treatment?

Licensed since 2004, I was not exposed to CBT-I until 2012!  Many clinicians simply do not know it exists and may not know where to find the training (more on that below). If clinicians are unfamiliar with this treatment approach, then there is a missed opportunity for assessment and treatment of Insomnia in their caseload. Another challenge for patients accessing treatment is that often Primary Care Physicians (as well as psychiatrists) do not know that CBT-I exists and where to refer them.

Training

If you work in a large hospital setting that has a Sleep Clinic that treats Insomnia, you may find internal training opportunities for CBT-I.  Another option includes The Center for Deployment Psychology (CDP), which offers affordable training in a number of evidence-based therapies (including CBT-I) known to improve mental-health outcomes for active duty and veteran populations. Although CDP’s focus is treatment for the military population, the treatment methods are the same for civilians. Visit CDP’s website for more information.  A Google search reveals that PESI may also offer CBT-I trainings.

References

  • American Psychiatric Association (2013), Diagnostic and Statistical Manual V.  Washington, DC: American Psychiatric Publishing
  • Perlis, Michael (2005), Cognitive Behavioral Treatment of Insomnia, A Session by Session Guide.  New York, NY: Springer
  • Qaseem et al. Management of Chronic Insomnia Disorder in Adults:  A Clinical Practice Guideline From the American College of Physicians.  Annals of Internal Medicine.  2016, July 19. 165: 125-133.
  • Swapna Bhaskar,1 D. Hemavathy,2 and Shankar Prasad3; Prevalence of chronic insomnia in adult patients and its correlation with medical comorbidities, J Family Med Prim Care. 2016 Oct-Dec; 5(4): 780–784.

Resources

Kim Roser-Kedward, LCSW specializes in treating Insomnia and Anxiety Disorders.  A former UC San Diego Healthcare and VA Healthcare San Diego mental health clinician, she has been in private practice in San Diego since 2007.  Kim is also Adjunct Faculty at San Diego Miramar College.  For more information about her practice, visit www.KimRoser.net.

On Being a Mother and a Therapist

By Leah M. Niehaus, LCSW

This article is really a love story about my profession of working with adolescents and my role of being a mother, both of which are so central and important to who I am…and the challenge of bridging the two roles at times.   We have a daughter in eighth grade and two sons, fifth and third grade.   As a therapist in a small community, it is tricky to open up about my work with local adolescents and their families while maintaining their confidentiality… and it also feels vulnerable as a mother to share my own struggles and maintain some privacy for my family.  I am hoping that I can provide a glimpse for you into my thinking about adolescents, ways in which I grapple as a parent, and ultimately some tips and goals as we parent our growing children.  I love to work with adolescents, but it is a whole new endeavor to parent them!

While part of me is excited about this new parenting territory that my husband and I are embarking on as our oldest enters high school next year, our middle enters middle school, and our youngest will be in fourth grade--the other part of me is a bit terrified.  Ask my husband.  Ask my friends.  Ask my kids—I’m sure they pick up on my current growing pains in this area.  I know too much.  I work with teens and hear the inner workings of their thinking and emotional life.  I know their experiences with alcohol, drugs, sex, and the new landscape of social media.  I know how they are affected by school stresses and pressures, friendship troubles, trauma, and family discord.  I see the high rates of anxiety, depression, and disconnection—despite the fact that most of them live in a safe area, many with intact families, good schools, and community support.   I hospitalize them when they are suicidal, put them in preventative drug treatment when it’s gone beyond experimentation, and I send them to Residential Treatment when they need more containment than their families and support team can provide.  These dilemmas cause me to toss and turn at night.  Then I try to remind myself of the stories of resilience, triumph, and courage that I also hear from these same adolescents.

Many parents don’t really want to know the details of adolescent angst.  I can empathize with that feeling in my role as a parent—I don’t want to know everything and my children will need to keep some feelings and experiences separate from me.  This is a normal and healthy boundary—we cannot be everything for our children, nor should we attempt to try.  The reality is that I might well know more about the inner life of my adolescent clients than of my own children as they get older.  And the flip side is also true—that in the likely situation that my children would someday need the support of a therapist—that person would know them at a different level than I will as their mother.  I value therapy…and so this idea does not scare me.  I hope that our children have an open mind about therapy and personal growth—and can appreciate their mother’s profession as they mature.  So while it’s not right for me to try to be their therapist and I won’t know all their specific inner struggles, I can’t escape the general “knowing” because of the nature of my work.  I often wish that I could quiet my brain and not overanalyze or worry so much.  Sometimes, I just want to be a mom without all the knowledge creeping in.  Like you, I am a parent—we have similar hopes and dreams for our kids…and similar concerns and fears.

Does my training as a therapist help me to be a better parent?   I might be more educated on child and adolescent development and have read more parenting and self-help books than the average parent.   I likely have a few more tools in my pocket during rational parenting moments—though in my experience as a mom, the most difficult parenting dilemmas are often fraught with emotion and I am likely to forget some of my useful tools.  I am also probably more agitated by my knowledge, having a tendency to overthink and worry more than I need to.  I often rely upon my husband to help contain my concerns and remind me that I don’t need to be fearful for our children’s teen years just because I work with teens.  Often the things that we are anxious about in life aren’t actually the challenges that we ultimately face.   I am definitely harder on myself and my partner when we make parenting mistakes…and harder on my children when they misstep because of my profession—therapists and their families are put on a pedestal of sorts and that makes it challenging to struggle in the public eye.  Would I trade it?  Not a chance.  I’ll take the low level of worry that I walk around with on a daily basis—because I love this meaningful work and because I am fueled to be “good enough” for my own kids.   

So for my own children, I need to be their mother—the one who tucks them in at night, the one who makes them soup when they’re sick, and the one who just loves them for being who they are.  I need to keep my two different hats, mother and therapist, separate but informing each other.  I need to heed my own advice to other parents:  take a deep breath, don’t be so hard on them, get my own support when it’s called for, work out the co-parenting struggles with my spouse, slow down, lighten up, call a friend, role model appropriately for them, prioritize family time, pray, and apologize and forgive.  I need to remind myself it’s all about keeping the connection paramount and keeping the door open to communication.  It’s about unconditional love—which is much harder to do than we all admit.  I know that I feel more confidant as a therapist than as a mother.  It is ever so much easier to be a good sounding board to an adolescent that is not related to me.  Being a parent is a humbling experience and I’m skeptical of anyone who thinks they have it all figured out.  I certainly don’t have it all figured out, but I keep seeking…trying…contemplating…grappling…and putting one foot in front of the other each day on this parenting journey.  As challenging as some of the moments can be, it is indeed precious and fleeting time that we have while our children are living under our roofs.

Tips from my observations and work with adolescents

  • Begin to think of yourself as going from a “manager” to a “consultant” role with your adolescent.  You want to earn the respect from them so that they consider “consulting” with you.  Respecting them fosters their respect of you.
  • Rethink happiness as the ultimate goal for our children.  It is unrealistic to think or hope they will be happy all the time—life has many struggles.  Allow them opportunities to struggle and sit with uncomfortable feelings or consequences.  Model this yourself and verbalize to them how you navigate through tough times.  Remind them when they are struggling how they have persevered in the past.  Reimagine life goals to include close relationships, purpose, and meaning.
  • Rest, play, joy, and gratitude are family values to be upheld.
  • Think of your family as a team—work together and foster belonging.
  • Unplug and connect with them.  Think family dinner, taking a walk, talking in the car, getting to know their interests and their friends, and let your face light up when you see them.
  • Rethink Zero period and whether your kid can cope with less sleep.  Seriously consider what type of realistic academic load your child can handle and adjust accordingly.  If they need extra tutors and support, they are likely in the wrong level class.  They often end up in the therapist’s office if they cannot meet the academic expectations in their family.
  • Good coping strategies are necessary and can be taught.  However, there are times when one has to sit and be still with something uncomfortable (grief, loss, break-ups, divorce).  Often our coping strategies make us run away from pain, instead of going through it—which ultimately makes the suffering last much longer.
  • Monitor and observe your teen—let them know that you are paying attention.
  • Set boundaries for cell phone usage and social media parameters—be clear with expectations and take away privileges when necessary.  Focus on character, kindness, and respect for self and others when coaching them about posting.
  • Strong social skills and a sense of belonging is more critical to teens’ feelings of happiness and success, than school performance.
  • In general, teach your daughters not to be constant “pleasers” and teach your sons to be respectful.  Model this.  It becomes important as they date and become intimate.
  • Try not to come to the college admissions process with an attitude of scarcity.  There is a match for everyone.  If your child is close-minded, encourage them to be open.  If you are close-minded, work to stay open and encouraging.
  • Allow room in their schedule for them to have a part-time job or volunteer, mellow time to “hang” alone/and with friends, and to date if they are interested.  These are critical skills for them to learn while having some guidance.  They are supposed to be having fun and enjoying their time in high school.
  • Consider service to others/animals/environment.  Teens are developmentally self-absorbed, which is normal.  If your teen is anxious or depressed, they spend way too much time in their own heads and on themselves.  Get out there and expose them to situations that encourage growth and thinking of others.
  • Teens, like all of us, truly want to be seen and valued for who they are.  The rub and conflict often comes when they don’t feel like they will be accepted for who they are. 
  • When they are behaving in an un-loveable way, love them more.

Leah M. Niehaus is a psychotherapist in private practice in Hermosa Beach.  She specializes in working with adolescents, young adults, and their families—individually or in family therapy.  In her practice, there are current group therapy options for Middle School Girls, High School Girls, and Young Adult Women as well.  Leah can be reached at (310) 546-4111 or leahniehaus@me.com.  Check out her website at www.leahmniehaus.com. <

Book Review: Prodependence, Moving Beyond Codependency, by Robert Weiss, PhD, MSW

Published by Health Communications, Inc. Deerfield Beach, Florida. 2018. 154 pages. Amazon

Review written by Laura Wilson LMFT

In his book Prodependence, Moving Beyond Codependency, Robert Weiss, PhD, MSW offers a provocative and new approach to working with caregivers of addicts that is useful and strength based. Dr. Weiss succinctly challenges, and in this writer’s opinion rightly so, the Codependent movement.  His book begins with a brief summary of past trends in the mental health and addiction fields that I found helpful as a reminder that a health provider’s primary priority must be first and foremost to “do no harm.” He makes the case that although well-meaning, the Codependent movement often causes unintentional harm by “pathologizing” those who love and care for addicts. Dr. Weiss asks the question “How is this helpful?” and proposes instead that we should provide our clients with a model of treatment that moves away from shame and blame, to one of viewing caregivers as “loving, caring, connection-oriented individuals in crisis.” Dr. Weiss points out that “what typically does not work is telling loved ones of addicts that their desire is a manifestation of disease.”

His Prodependence model supports the codependency movement regarding the encouragement of self-care and setting better boundaries with the addict and others in their lives. However, he departs from the Codependency model in their definition of codependent family members as “driving the addiction,” rather than placing the responsibility upon the addict.  Dr. Weiss acknowledges the “trauma” of loving an addict and offers useful treatment that moves away from further trauma and toward healthy attachment and caring.

Chapter Seven, “Applied Prodependence,” offers guidelines for healthy attachment and how to coach and support caregivers in the process of staying connected. “The goal is to move both loved ones and addicts incrementally across the relational continuum, one step at a time, toward prodependence and healthier relating.”(p. 101-102)

Dr Weiss’s book is well outlined, comprehensive and appropriate for those entering the addiction field, as well as for those of us who have been in the mental health field for many years and wish to re-examine and learn about other addiction models of treatment. The book may be appropriate for some clients.

Laura Wilson LMFT has a private practice in Fair Oaks, CA.  She can be reached at 916-768-6756 or Safespacewithlaura.com


Book Review: Ending the Parent-Teen Control Battle by Neil D. Brown, LCSW

Review written by: Marlene Faye Glenn

New Harbinger Publications, Inc.  176 pages  - Amazon 

Ending the Parent-Teen Control Battle by Neil D. Brown, LCSW, is a book for parents of middle and high school teenagers and for therapists who treat them.  I found this book very effective in helping to move strained relationships toward rewarding, cooperative ones.  With insights on every page, it is a roadmap leading to solutions and results that are sorely needed by many families. 

The author states that the mistakes made in parenting lead parents to seek greater understanding and better ways to deal with their problems.  He defines the Control Battle as the parent-teen push and pull of negotiating rules, regulations and agreements, as each tries to get the other to do what he or she wants them to do.  Driven by negative expectations and patterns in the relationship, the Control Battle continues to repeat even when participants have the best intentions. The longer the Control Battles last, the more destructive the behaviors are. This can impede the teen’s development and lead to parental burnout.  Useful to the reader, Brown offers an Internet site with a survey to help parents determine whether a family is in a Control Battle. 

Reactivity, negative emotional tone, and being other-person focused are qualities that he states lead to continued conflict. He works to raise self-esteem and uses earned privileges to assist behavioral changes.  He helps families make big shifts by laying out ways to both address underlying issues and envision a healthier relationship. 

This book is informed by Brown’s long experience treating families and his approach that primarily stems from Salvador Minuchin’s structural family therapy. It helps families transform their enduring negative patterns into positive ones.  For parents at their wits’ end who are tired of the constant power struggles, it may help take the pressure off and guide them to healthier patterns of relationships and behaviors.

Marlene Faye Glenn, AMFT is in private practice in the San Fernando Valley and is a family-child advocate in Northridge, California.  She is a practicing Buddhist and believes in the oneness of person and planet, seeing treatment on a grander scheme than the individual level.   She is supervised by Sheree Jones Pistol, LMFT, and can be reached at marlenestherapy@gmail.com.

POETRY | From: The Way Back: Poems by Mike Owens

Published with permission from Random Lane Press at randomlanepress@gmail.com

A Litany for Folsom - By Mike Owens

I praise my life in prison.

I praise the strength of the coffee bean,
crumbled in the bottom of my cup,
awaiting the chance to give its gift.

I praise the nearness of Sacramento,
the consolation of knowing family is just up the highway.

I praise the ancestors standing on my altar shelf.

I praise each one of the thirty-seven steps of peaceful
sunrise between my cellblock and work area.

I praise my secret toast connection.

I praise quality office chairs with lumbar support.

I praise the job and responsibility, and the solitude of my workstation.

I praise Windows ‘O7 and the publishing wizard.

I praise my furrowed brow,
the weight of my concentration upon the monitor,
the psychic fence of inaccessibility.

I praise my words,
the inky black ravens who convey my soul far beyond
the reach of this fragile flesh.

I praise my guerilla writer’s life,
liberated moments between endless reports.

I praise the end of another busy shift.

I praise fifteen minutes of heart space – a phone call to my wife.

I praise junk TV.

I praise unhealthy snacks and high blood pressure meds.

I praise fatigue.

I praise a day well spent.

Mike Owens discovered poetry and creative writing while in prison serving Life Without Parole in the California Prison System. He's been incarcerated for over twenty years for two gang-related murders he was convicted of in the 1990s. Mike now serves as a mentor for at-risk youth, and will soon receive his A.A. degree from Folsom Lake College in Sociology. He's working on a facilitator’s manual as a companion book to his poetry collection, so that his ideas will reach others in the system who might benefit from writing, reading, and talking about it.

For his poem “Black Settlement Photo: Circa 1867,” Mike Owens won the 2010 PEN American Dawson Prize, and his writings have been featured in numerous collections and journals. He self-published Foreign Currency, a full-length poetry collection in 2012.

Important BBS Regulation Changes 

Two significant changes in law reported by the BBS, which became effective January 1, 2019 are summarized below:

Suicide risk assessment and intervention education requirement: Assembly Bill 1436 mandates that effective January 1, 2021, all licensees must either:

  • obtain certification from their graduate school registrar or training director that a minimum of 6 hours of instruction in suicide risk assessment and intervention education was provided as part of their graduate school coursework or field instruction;
  • obtain certification from their program training director or primary supervisor that they received this 6 hour training as part of their qualifying supervised experience
  • complete an approved 6-hour continuing education course in this subject.

Translation for licensees who have been licensed for more than a few years: it probably makes more sense to simply take the course (which counts as part of the 36-hour CE requirement for each renewal cycle) and retain the certificate in case of a future audit. Please note that proof of compliance does not need to be submitted to the Board unless specifically requested as part of a CE audit.

Supervision of associates: Assembly Bill 93 allows for "triadic" supervision and more specifically delineates the responsibilities of supervisors. Previously, the law only defined, and allowed for, individual (one-on-one) supervision and group supervision. Triadic supervision refers to one supervisor meeting with two supervisees. This change in the law is included in the following excerpt:

 One hour of direct supervisor contactmeans any of the following:

(1) Individual supervision means one hour of face-to-face contact between one supervisor and one supervisee.

(2) Triadic supervision means one hour of face-to-face contact between one supervisor and two supervisees.

(3) Group supervision means two hours of face-to-face contact between one supervisor and no more than eight supervisees. Segments of group supervision may be split into no less than one continuous hour. A supervisor shall ensure that the amount and degree of supervision is appropriate for each supervisee.

For more information check out the website of the Board of Behavioral Sciences at https://www.bbs.ca.gov/pdf/legupdate_18.pdf

CSCSW Members Can Receive Free Ethics Consultations from an LCSW Trained in Ethics Consulting

To receive an over-the-phone consultation from a trained ethics consultant email your request to info@clinicalsocialworksociety.org and include:

  • A brief description of your question/ethical dilemma  
  • Several time slots when you will be available to talk
  • Your contact number  

This information will help us link you with the right consultant at a time you are available. A consultant will return your call within 48 hours.  

If you are unsure if your concern is ethical, legal or clinical, please reach out anyway. We will refer if appropriate. In our shared experience most ethical consultations touch on all three aspects.

Ethic Consultants:
Carole Bender, LCSW, JD
Joan Fisch, LCSW
Michael J. 'Mick' Rogers, LCSW (Chair)
Jane Zeiger, LCSW
Rama Weizmann, LCSW (retired) serves as a support to the active consultants.

Meet the CSCSW District Coordinators

Joan Berman, LCSW –Co-coordinator Mid Peninsula District

Joan has had a private practice in Palo Alto for over 30 years working with children and adults with a specialty in high conflict divorce. In addition to her practice, she has worked as child therapy consultant at the International School of the Peninsula and Child Advocates, Silicon Valley. She is currently the co-coordinator of the Mid Peninsula District. She can be reached at Berman.joan@gmail.com


Ros Goldstein, LCSW – Coordinator San Diego District

I joined CSCSW in 1985, shortly after moving to San Diego from Northern California. Soon thereafter I became the editor of the San Diego District’s newsletter, Connections. Around 2002 I became co-chair of the local CSCSW Steering committee and a few years later joined the State Board of Directors for a four year period. In 2005/6 I became the coordinator.

After 20 years as an RN, I returned to University of Illinois to receive an MSW, then returned to Northern California to complete my hours for my LCSW. After becoming an LCSW in San Diego I began working at Jewish Family Service & retired in August 2015. Goldseigel@gmail.com

Tanya Moradians, Ph.D. LCSW – Co-coordinator San Fernando District

Dr. Tanya Moradians has a private practice in Encino where she treats adults and seniors (she accepts Medicare as a service to her older clients). She has been in private practice since 1972 and a group psychotherapist for over 35 years. In addition to her private practice, she worked concurrently as a full-time Psychiatric Social worker in the LA County Department of Mental Health at Olive View Hospital and later at UCLA Semel Institute (also known as NPI - Neuro-Psychiatric Institute) where she taught psychiatric residents. She is a UCLA Honorary Faculty Member for the Department of Psychiatry.

Currently, Dr. Moradians is a co-coordinator of the San Fernando District of the Society. As A Board member of CSCSW she is head of the Legislative Committee, sending Legislative Alerts and information about humanitarian issues to members. As one of the first members of the Society, in 1975 she took part in testifying in front of the State Legislature to obtain Parity for Social Workers. After this testimony and the Legislative favorable ruling, California Social Workers were able to bill insurance companies for their services, much as the psychologists and psychiatrist did. She can be reached Tmoradia@ucla.edu.

Becky Melton, LCSW – Coordinator Sacramento/Davis District

Becky Melton, LCSW is owner and therapist at her private practice Life Calibrations Counseling in Sacramento. She works with children, families, individuals, and couples with a specialty in complex trauma, adoption, and attachment. Becky also works as an Adjunct Professor at Sacramento State University in Social Work Department and a clinical supervisor for ASW and MFTI clinicians in community mental health. She has been in the field professionally for 15 years and is an Advanced Trainer of the Nurtured Heart Approach, Certified Adoption Competent Therapist, Theraplay practitioner, and has extensive training in play therapy. She can be reached at Becky@lifecalibrations.com

Consider joining a CSCSW Committee!

Serving on a committee is a great way to build your network and make friends in the profession throughout the state. It is also an excellent way to get leadership experience, build your resume, and have an impact on both the Society and the profession.

CSCSW relies on people like you all across California to serve in leadership positions and provide the Society’s benefits to its members. We need your help.

Below is a brief description of the statewide committees and the committee chair’s name and email, so you contact them directly to express interest or ask questions.

The Member Benefits Committee maintains, improves, and monitors the benefits of the society. Goals of the committee are to increase awareness of benefits and increase and monitor usage of benefits. This includes monitoring the Supervisor List, the Listserv, and the Therapist Finder. The BBS Liaison is also on this committee. Our two subcommittees are Ethics Consultation and the Mentorship program.

Chair: Jennifer Kulka - jvkulka@gmail.com

The Education Committee identifies topics of interest to members and organizes additional district- and state-wide workshops, as well as developing webinar offerings. When needed, the Committee provides support to district steering committees in planning educational offerings and networking events.

Chair: Trish Yeh - trish.yeh@gmail.com

The Communications Committee serves the role of communicating with members and non-members about Society benefits. This includes initiating and overseeing marketing, member recruitment, the society’s website and social media, and the newsletter, The Clinical Update. Tasks focus on creating and updating effective advertising (print-based and social media, including Facebook, LinkedIn, etc.), capturing advertising impact metrics, coordinating the Society’s communications including member surveys, promoting district-sponsored workshops and initiating webinars.

Chair: Roland Hsu - rohsu@stanford.edu

The Fundraising Committee plans and produces events, including: writing appeal letters, hosting small groups in homes, as well as large events such as silent auctions, musicales, theater parties, and professional meetings with notable speakers.

Chair: Gabie Berliner - gberliner@comcast.net

The Advocacy Committee enables LCSWs in California to speak with one voice in support of State and Federal laws that advocate for our profession and promote quality mental health service to the public. Where appropriate, CSCSW will join with the BBS, CSWA and other organizations in this endeavor.

Chair: Tanya Moradians - tmoradia@ucla.edu

About the Clinical Update

Editor: Jean Rosenfeld, LCSW

The next issue of the Clinical Update will be published in Fall 2019. We look forward to publishing relevant, educational, and compelling content from clinicians on topics important to our members. We welcome your contributions. Please email jeanrosenfeld@gmail.com if you are interested in publishing your writing -- please write "Newsletter" in the subject line. 

Ad placement?  Contact Donna Dietz, CSCSW Administrator - info@clinicalsocialworksociety.org


CSCSW | P.O. Box 60937, Palo Alto, CA 94306 | 650-460-9210 | info@clinicalsocialworksociety.org

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