Suicide Risk Assessment

 Suicide risk assessment shows up throughout the ASWB exam, particularly in the Assessment and Diagnosis section, but also in crisis intervention and ethical decision-making questions. Here's what you need to know:

Suicide risk assessment is an ongoing clinical process, not a one-time event. Social workers assess for suicide risk at intake, when circumstances change, and whenever warning signs emerge. The goal is to determine the level of risk and implement appropriate interventions to keep the client safe.

Risk Factors

Risk factors fall into two categories:

Static risk factors (unchangeable) - Previous suicide attempts, family history of suicide, history of trauma or abuse, chronic mental illness, chronic pain or terminal illness

Dynamic risk factors (changeable) - Current suicidal ideation, recent loss or crisis, access to lethal means, substance use, social isolation, hopelessness, recent psychiatric hospitalization or discharge

The more risk factors present, particularly when combined, the higher the risk. Recent research shows that hopelessness is often a stronger predictor than depression alone.

Protective Factors

Don't forget to assess strengths: strong social support, reasons for living, religious or cultural beliefs, engagement in treatment, future-oriented thinking, problem-solving skills, responsibility to children or others.

Direct Assessment Questions

Ask directly. Research shows that asking about suicide does not plant the idea or increase risk. Key questions include:

• Have you been having thoughts of hurting yourself or ending your life?
• Do you have a plan for how you would do it?
• Do you have access to [means mentioned in plan]?
• Have you taken any steps toward acting on these thoughts?
• When do you think you might act on these thoughts?
• What has kept you from acting on these thoughts so far?

The more specific and detailed the plan, and the more accessible the means, the higher the immediate risk.

Assessment Tools

Several structured tools can guide assessment:

SAD PERSONS Scale - Sex (male), Age (elderly or adolescent), Depression, Previous attempts, Ethanol/drug use, Rational thinking loss, Social supports lacking, Organized plan, No spouse, Sickness. Each factor scores one point; higher scores indicate higher risk. Note: This tool has limitations and shouldn't be used in isolation.

Columbia-Suicide Severity Rating Scale (C-SSRS) - Widely used, assesses ideation, intensity, behavior, and lethality. Distinguishes between passive ideation ("I wish I were dead") and active ideation with intent and plan.

Risk Levels

Generally categorized as:

Low risk - Ideation without plan or intent, strong protective factors, willing to contract for safety

Moderate risk - Ideation with some planning, ambivalence about living, some protective factors remain

High risk - Specific plan with access to means, intent to act, recent attempts, few protective factors, not willing or able to contract for safety

Imminent risk - Clear intent and plan to act in immediate future, means available, agitation, no protective factors

Safety Planning

For clients at risk but not requiring hospitalization, develop a safety plan that includes: warning signs, internal coping strategies, social contacts for distraction, people to ask for help, professionals to contact, and means restriction (removing or limiting access to lethal means).

Documentation

Document the assessment thoroughly: what questions were asked, client's responses, risk factors identified, protective factors present, your clinical judgment about risk level, and the intervention plan. This protects both the client and the clinician.

Important Notes

No assessment can predict suicide with certainty. Focus on identifying modifiable risk factors and mobilizing protective factors. When in doubt about level of risk, consult with colleagues or supervisors. Remember that risk fluctuates—someone assessed as low risk can become high risk if circumstances change.

For the exam, know the difference between passive ideation, active ideation, intent, and plan. Understand that hospitalization isn't always the answer, but it may be necessary for imminent risk. Be familiar with duty to warn/protect and how it applies in your jurisdiction.

Biopsychosocial Assessment

Biopsychosocial assessment is fundamental to social work practice and shows up throughout the Assessment and Diagnosis section of the ASWB exam. You'll want to know this model inside and out.

The biopsychosocial assessment framework recognizes that human behavior and well-being result from the interaction of biological, psychological, and social factors. Developed by George Engel in the 1970s as an alternative to the purely medical model, it's now a cornerstone of social work assessment.

The Three Domains:

Biological - Physical health, genetic factors, medications, substance use, sleep patterns, nutrition, chronic illness, brain chemistry, developmental factors, and any medical conditions affecting functioning.

Psychological - Mental health history, cognition, emotional regulation, coping mechanisms, self-esteem, trauma history, defense mechanisms, thought patterns, and internal psychological processes.

Social - Family systems, relationships, cultural background, socioeconomic status, employment, housing, education, community resources, social support networks, and environmental stressors.

The key insight here is that these three domains don't operate independently—they influence each other constantly. Depression (psychological) can manifest as fatigue and sleep problems (biological) and lead to job loss and social isolation (social). Understanding these interconnections is what makes assessment comprehensive rather than reductionist.

For the exam, remember that a complete biopsychosocial assessment goes beyond just checking boxes in three categories. It explores how factors interact and compound to create the client's current situation. This holistic view is what distinguishes social work assessment from purely medical or purely psychological approaches.

Some social workers add "spiritual" to create a biopsychosocial-spiritual model, recognizing that meaning-making and existential concerns are often central to client well-being.

Risk Assessment Methods

Risk assessment methods shows up in the Assessment and Diagnosis section of the ASWB exam outline. Here's more than you need to know for the exam on the topic:

Risk assessment enables social workers to identify potential risks and take necessary measures to prevent or minimize harm to clients. Methods of risk assessment include:

Structured Professional Judgment (SPJ) - Uses standardized tools and guidelines to assess risk. SPJ involves making informed professional judgments based on a structured analysis of the relevant factors in a given situation.

Dynamic Risk Assessment (DRA) - Focuses on identifying changes in the risks associated with a particular situation over time. DRA involves ongoing monitoring and assessment of risk factors to identify any changes that may require intervention.

Strengths-based risk assessment - Focuses on identifying and building on an individual's strengths and protective factors to reduce risk. This method emphasizes the individual's capacity to overcome challenges and promotes resilience.

Narrative Risk Assessment - Involves gathering and analyzing qualitative data, such as personal narratives, to identify risks and protective factors. Narrative risk assessment can be particularly useful in understanding the complex interplay of factors that contribute to risk in individual cases.

Honorable mention: 

Actuarial Risk Assessment - Involves the use of statistical models to predict the likelihood of specific outcomes based on relevant risk factors. Actuarial risk assessment is often used in criminal justice settings to assess the risk of reoffending.

Social workers may use one or a combination of these methods depending on the specific context and needs of the individuals or groups they are working with. It is important to note that risk assessment should be an ongoing process, with regular reassessment of risks and interventions to ensure the safety and well-being of vulnerable individuals and groups.

ASWB Exam Changes

 Take a look at the latest ASWB Exam Handbook for some new additions coming to the social work licensing exam. If you've taken the exam recently, you know they've already added highlighting and strikethrough to the exams. Handy tools for some, distracting--and potentially time-wasting--bells and whistles for others.

But a bigger, more meaningful change is happening. For the first time in who knows how long, the exam will include something other than just questions with a STEM (the question part) and FOUR ANSWER OPTIONS. It will now include--drumroll please--questions with a STEM and THREE ANSWER OPTIONS! So now, you'll have a 33% chance of getting a question right even if you have no idea what it's about and can't eliminate one of the options. This is up from 25% (one out of four) for coin-flippy efforts to answer tough questions correctly. 

How the content of these questions will differ from the traditional four answer options (A, B, C, & D) is unclear. More will be revealed soon.

In the meantime, take is as good news and go pass that exam!

LCSW Exam Scoring

One of the questions that comes up again and again regarding the LCSW exam is also a very basic one: what score do you need to pass? The answer is...no one can say for sure. There are multiple exams being given at the same level, at the same time around the country. The ASWB spells it all out here.  

Generally, pass points range from 90 to 107 correct answers of the 150 scored questions.

Okay, 90/150 to 107/150. That's [opens calculator] between 60 and 71%. Meaning that on some versions of the exam, you can miss nearly half the questions and still arrive at a pass sheet after your four-hour sit. If you're checking the math, remember, it's 90 out of 150, not 170. Twenty questions are being tested for future exam use and aren't counted for scoring. 

Another tidbit from the ASWB to keep in mind: 

ASWB has multiple forms of each exam for exam security and to ensure that candidates who retake the exam do not get the same set of questions.

So asking around about what's on the latest version of the exam isn't just unethical, it's going to be unproductive. No one can say exactly what you're going to encounter on the version of the test that you're given. But, they can say--if they read you the ASWB's published content outlines to you--what topics you should reasonably expect to appear on the test. (Note: you don't have to ask someone to read it to you, exam outlines are available, free of charge, at ASWB.org.) That's the same information that a reputable test prep company uses to weight practice tests by topic area.

Not only can you miss a bunch of questions on the LCSW exam and still pass. Twenty questions that you face won't count at all. So, as you encounter perplexing and confounding questions, remain calm. It's no big deal. Keep focused, keep at it, and pass that exam. Good luck!

Into the DSM - Antisocial Personality Disorder

When is bad behavior just bad behavior, and when does it cross the line into being clinically significant? Let's take a look at the DSM criteria for antisocial personality disorder. They are:

A. Pervasive pattern of disregard for and violation of the rights of others, occurring since age 15, including three or more of these:

1. Failure to conform to social norms.
2. Deceitfulness.
3. Impulsivity, failure to plan ahead.
4. Irritability and aggressiveness.
5. Reckless disregard for the safety of others.
6. Consistent irresponsibility (work, money).
7. Lack of remorse.

B. At least 18 years older.

C. Conduct disorder onset before age 15.

D. Does not occur exclusively during schizophrenia or bipolar disorder.

So, for the LCSW exam, imagine a question about a high school bully who lies, fights, cuts class, and shrugs off his impact on others. Antisocial? Not yet--not, at least, until he turns 18.

How about a high school bully-turned-Fortune 500-CEO who does the grown-up version of that and delights in humiliating underlings? Now you might be onto something. Take a look at the other choices. Maybe conduct disorder (but the adult CEO has outgrown that). Maybe other cluster B personality disorders BPD (not it), NPD (conceivable). Antisocial personality disorder is probably the best of those answers for the non-vignette sketched out above.

For more about the disorder, try the Mayo Clinic antisocial pages here: https://www.mayoclinic.org/diseases-conditions/antisocial-personality-disorder/symptoms-causes/syc-20353928

Test Preparation and Test Taking

There's more to effective exam prep than cramming lots of information into your head. This is especially true for the LCSW exam, which tests not only your understanding of social work essentials, but your ability to use them flexibly in various contexts.

A vignette may offer an easily identifiable set of symptoms, but don't be surprised if the question takes a sudden turn. Instead of asking, "What is the BEST diagnosis?"--the question you were prepared to answer with easy--you might be thrown a curve: "How would a social worker using cognitive behavioral therapy MOST likely respond?"

You've got to be smart and flexible and focused in your exam-taking. So it's wise to be smart, flexible, and focused in your exam prep. Combine approaches to learning. Take lots of practice tests. And stay calm.

That's some of the advice offered at studygs.net. Take a look at the test preparation and test taking suggestions there. Not all apply to the social work exam. A lot of them are common sense. Most of them should be helpful.

Into the DSM - Histrionic Personality Disorder

Let's visit Cluster B personality disorders. You know ones. The dramatic, emotional, erratic group: antisocial, borderline, narcissistic, and, today's spotlight item, histrionic personality disorder.

Personality disorders--as opposed to just personality--involve patterns of beliefs and behaviors that severely impair those diagnosed with them. A full 10-15%  of people meet criteria for a personality disorder. That's a whole lot of people suffering, and often making others suffer, with long-standing, difficult-to-treat conditions.

Those with histrionic personality disorder seek attention more-or-less constantly, exhibiting extremes of feeling and behavior. Focus is often on excessive flirting, attention to looks, and severe reactions when attention isn't given.

Five of the following must be present to make a diagnosis:

• When not receiving attention, feels less valued.
• Inappropriate flirting and seduction.
• Mood lability (quickly changing feelings).
• Attracts attention via physical appearance.
• Vague, detail-lacking style of speech.
• Extreme displays of feeling (aka "drama").
• Easily swayed by others and by fads.
• Rapid attachments with overestimated depth. 

There's a fair amount of overlap with BPD, but it's not the same thing. For the LCSW exam look for flirting, looks-focus, and attention-seeking as signs that a fictional, vignette client is possibly meeting criteria for histrionic PD. 

For more detail, plus a mnemonic (PRAISE.ME) to help remember criteria, take a look at Wikipedia: https://en.wikipedia.org/wiki/Histrionic_personality_disorder

Theories and Methods - Play Therapy

Play therapy is what it sounds like. Instead of talk being the currency of treatment, clients and therapist engage in play, exploring thoughts, feelings, and conflicts through playing.

The hive mind at Wikipedia adds:

Play therapy is a method of meeting and responding to the mental health needs of children and is extensively acknowledged by experts as an effective and suitable intervention in dealing with children’s brain development. It is generally employed with children aged 3 through 11 and provides a way for them to express their experiences and feelings through a natural, self-guided, self-healing process. As children’s experiences and knowledge are often communicated through play, it becomes an important vehicle for them to know and accept themselves and others.

Find more about how play therapy works and about its origins via this article at Good Therapy.

Will play therapy be on the LCSW exam? You never know. If you've glanced at the above articles, you'll be more than prepared to face a test question if it does. Good luck!

LCSW Exam Study Guides

It's nice to have some help as you're preparing to pass the licensing exam. Maybe lots of help. It's a big exam with potential content spanning just about everything you've learned in school and in social work practice. But there's no need to get overwhelmed. And there's no reason to do it all by yourself. Many, many social workers have travelled this road before you. They've passed the exam. And they've left their wisdom all over the net, on flash card sites, on blogs like this one, and have gone to work creating practice tests--based upon their experience--for various exam companies. Google will get you to lots of those.

Study guides are also easily tracked down via Internet search. Here are two that come up early have the advantage of being completely free: This (semi-outdated) pdf from University of Missouri-St. Louis. And this free (with sign up) study guide from Social Work Test Prep. Those should keep you busy for a while. If you find others that are great, post for others in comments. Passing the social work licensing exam is a team sport.

The Code of Ethics - Responsibilities to the Broader Society

Knowing the NASW Code of Ethics means knowing the entire NASW Code of Ethics. To be prepared for the clinical social work exam, it's wise to dig past the micro practice principles in the code and continue all the way through to item #6, "Social Workers' Ethical Responsibilities to the Broader Society." That includes four subsections: social welfare, public participation, public emergencies, and social and political action. Here are those sections with details:

Social Welfare
Social workers should promote the general welfare of society, from local to global levels, and the development of people, their communities, and their environments. Social workers should advocate for living conditions conducive to the fulfillment of basic human needs and should promote social, economic, political, and cultural values and institutions that are compatible with the realization of social justice.

Public Participation
Social workers should facilitate informed participation by the public in shaping social policies and institutions.

Public Emergencies
Social workers should provide appropriate professional services in public emergencies to the greatest extent possible.

Social and Political Action
This one's got several paragraphs--we covered it in an earlier post.  As it says there, it shouldn't take you by surprise to see this material appear on the exam. Public participation and political action have been on the rise, and social workers have either been a part of it or have wrestled with whether or not to be a part of it. That, of course, includes exam writers. What are they most likely to create questions about? Whatever's on their mind.

Read the entire NASW Code of Ethics here. Then read it again. This is important stuff--for the exam and beyond. Enjoy!

ASWB Exam Outline Changes

If you didn't know, you wouldn't notice, but the Association of Social Work Boards (the ASWB)--the people who write and administer the social work licensing exam--have made some changes. The minor tweaks to the old exam content outlines kicked in with the new year (2018).

The more with-it exam prep companies have adjusted their offerings to fit the new guidelines (SWTP, for example). But if you're prepping using older material, don't sweat it. The outline changes are minimal. Some areas of the exam are being stressed a little bit more, others a little bit less. And some of the areas in the outline have been merged or renamed. No matter. You still have to study all the content areas (which is what you're doing when you take a practice test, review your old social work notes, or run through the posts in this blog). If one area comprises 17% instead of 19% of the exam, does that mean you study it 2% less? If you're able to gauge such things...then, maybe. But, really, no.

If you want to know the details of the changes, the ASWB has spelled them out with nice graphs on their site: https://www.aswb.org/exam-candidates/about-the-exams/exam-development/2018-exam-blueprints/how-are-the-exams-changing/

For everyone else, just know that something changed a little and it doesn't really matter.

As you were. Prepping and, soon, passing the LCSW exam. Good luck!

NASW Code of Ethics Changes

To pass the licensing exam, you have to have a good grasp on the NASW Code of Ethics. And to pass it after January 1st, 2018, you have to know the new version of the code.

Here it is.

What's changed? Not an enormous amount, but enough to warrant some determined review. The main areas that have been updated relate to tech. There are new guidelines for Internet searches, social media, and the like. You can just read the code and see if you notice the changes. Or, maybe better, turn to an expert or two for their run-down: Here's Alan Barsky enumerating the changes. And here's Fredrik Reamer in Social Work Today doing the same.

There's also a new ASWB content outline (find it at aswb.org). Professional values and ethics, once 18% of the exam, has gotten a meager boost to 19%. That's nearly one in five questions you'll face that will be rooted in the code. It's very much worth your while to get it known. Happy reading, happy testing. Good luck!

Theories and Methods - Family Systems Theory

Family systems theory may or may not show up on the licensed clinical social work exam. And you may never practice family therapy. But the language of family systems theory can still come in handy, in clinical practice and in life. Take a moment to review.

Family systems theory springs from the work of Murray Bowen (you'll sometimes see it labelled "Bowenian Family Therapy"). It posits that clients cannot be understood on their own, but as a part of a larger system--their family--which is seen as an emotional unit unto itself.

Family roles, rules, boundaries, and patterns are all foci of family systems therapist, who turn to Bowen's eight interlocking concepts as they practice. They are: triangles, differentiation of self, nuclear family emotional systems, family projection process, multigenerational transmission process, emotional cutoff, sibling position, and societal emotional process.

Some of these have entered the vernacular--or, at least, the therapy vernacular. If you see any of them show up on the social work licensing exam, you can know with some confidence that you're facing a question about family systems theory and answer accordingly. Good luck.

For more reading about family systems theory, including quick definitions of the eight interlocking concepts, take a look at https://www.genopro.com/genogram/family-systems-theory/

Into the DSM - Schizoaffective Disorder

Schizoaffective disorder readily lends itself to close-call differential diagnosis questions and is a natural favorite for exam writers. A question may boil down to this: Is it schizophrenia or schizoaffective disorder? Well, here are the criteria for schizoaffective disorder:

A. A major mood episode (MDD or manic) concurrent with Criterion A of schizophrenia*
B. Delusions or hallucinations for two or more weeks in the absence of a major mood episode.
C. Symptoms meet criteria for a major mood episode for the majority of the illness.
D. Not attributable to substance or another medical condition.

Subtypes:
Bipolar type (that is, psychotic symptoms alongside--but not exclusively during--a manic episode).
Depressive type (same as a above, but with symptoms of MDD).

Remember that psychotic symptoms can be present within bipolar or depressive illness. They can also be present--with the absence of any major mood episodes--in schizophrenia and other psychotic disorders.

That's a lot to have understood before facing down a question about mood/psychotic symptoms. But now you're that much closer to correctly answering a social work exam question on the topic.

For a lot more about schizoaffective disorder, try this long Wikipedia page: https://en.wikipedia.org/wiki/Schizoaffective_disorder

*Here's Criterion A of schizophrenia, referenced above: Two or more of the following present most of the time for a month or more:

• Delusions
• Hallucinations
• Disorganized speech
• Grossly disorganized or catatonic behavior
• Negative symptoms (e.g., blank affect, avolition)

Theories and Methods - Reality Therapy

Reality therapy (RT) was developed in the 1960s by William Glasser. Glasser's view is that people suffer from the human condition rather than mental disorders. RT helps people focus on pursuing their needs, leaving aside discussion of symptoms, the past, and the unconscious--an enormous departure from other, traditional modes of psychotherapy. The focus is here-and-now problem solving and the "three Rs": realism, responsibility, right-and-wrong. In RT treatment, clients aim to identify what they need and develop a workable plan to achieve those ends. The therapist employs a patient, supportive non-judgmental stance.

This is just a quick summary (though probably sufficient for answering a social work exam question). Find much more about reality therapy at Wikipedia and the William Glasser Institute.

The Code of Ethics - Social and Political Action

The majority of ethics questions on the LCSW exam are likely to be drawn from the first sections of the NASW Code of Ethics. Informed consent, self-determination, privacy and confidentiality, etc. The bread and butter of ethics question writing. But as you're preparing, take care to read to the end of the code. Section six--last-but-not-least--is Social Workers' Ethical Responsibilities to the Broader Society. The code reaches beyond clients and colleagues into the macro realm. Ethical social workers' focus is expected to extend to social welfare, public participation, help in public emergencies, and into social and political action. Here's the social and political action part in full:
 

(a) Social workers should engage in social and political action that seeks to ensure that all people have equal access to the resources, employment, services, and opportunities they require to meet their basic human needs and to develop fully. Social workers should be aware of the impact of the political arena on practice and should advocate for changes in policy and legislation to improve social conditions in order to meet basic human needs and promote social justice.

(b) Social workers should act to expand choice and opportunity for all people, with special regard for vulnerable, disadvantaged, oppressed, and exploited people and groups.

(c) Social workers should promote conditions that encourage respect for cultural and social diversity within the United States and globally. Social workers should promote policies and practices that demonstrate respect for difference, support the expansion of cultural knowledge and resources, advocate for programs and institutions that demonstrate cultural competence, and promote policies that safeguard the rights of and confirm equity and social justice for all people.

(d) Social workers should act to prevent and eliminate domination of, exploitation of, and discrimination against any person, group, or class on the basis of race, ethnicity, national origin, color, sex, sexual orientation, gender identity or expression, age, marital status, political belief, religion, immigration status, or mental or physical disability.

Given that macro issues are filling headlines daily, don't be surprised to see macro questions drawn from section six of the code. If you've got this read and understood, you'll be ready. Good luck!

For more reading on the topic, there's no better place to turn than to the Code of Ethics itself. Enjoy it again.

The Code of Ethics - Informed Consent

Here's an essential piece of the NASW Code of Ethics, a favorite of exam writers--section 1.03, Informed Consent. In six quick paragraphs, lots of fodder for LCSW exam questions:

(a) Social workers should provide services to clients only in the context of a professional relationship based, when appropriate, on valid informed consent. Social workers should use clear and understandable language to inform clients of the purpose of the services, risks related to the services, limits to services because of the requirements of a third-party payer, relevant costs, reasonable alternatives, clients’ right to refuse or withdraw consent, and the time frame covered by the consent. Social workers should provide clients with an opportunity to ask questions.

(b) In instances when clients are not literate or have difficulty understanding the primary language used in the practice setting, social workers should take steps to ensure clients’ comprehension. This may include providing clients with a detailed verbal explanation or arranging for a qualified interpreter or translator whenever possible.

(c) In instances when clients lack the capacity to provide informed consent, social workers should protect clients’ interests by seeking permission from an appropriate third party, informing clients consistent with the clients’ level of understanding. In such instances social workers should seek to ensure that the third party acts in a manner consistent with clients’ wishes and interests. Social workers should take reasonable steps to enhance such clients’ ability to give informed consent.

(d) In instances when clients are receiving services involuntarily, social workers should provide information about the nature and extent of services and about the extent of clients’ right to refuse service.

(e) Social workers who provide services via electronic media (such as computer, telephone, radio, and television) should inform recipients of the limitations and risks associated with such services.

(f) Social workers should obtain clients’ informed consent before audiotaping or videotaping clients or permitting observation of services to clients by a third party.

Don't stop with reviewing this one section. Check out the entire Code of Ethics. It's a click away. 

Into the DSM - Narcissistic Personality Disorder

NPD has been thrown around in the news a lot lately. Does that make it any more likely to show up on the social work licensing exam? Hard to say. Exam writers read the news too! Criteria for NPD are:

A pervasive pattern of grandiosity (in fantasy or behavior), need for admiration, and lack of empathy, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:

1. Has a grandiose sense of self-importance (e.g., exaggerates achievements and talents, expects to be recognized as superior without commensurate achievements).
2. Is preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love.
3. Believes that he or she is "special" and unique and can only be understood by, or should associate with, other special or high-status people (or institutions).
4. Requires excessive admiration.
5. Has a sense of entitlement (i.e., unreasonable expectations of especially favorable treatment or automatic compliance with his or her expectations).
6. Is interpersonally exploitative (i.e., takes advantage of others to achieve his or her own ends).
7. Lacks empathy: is unwilling to recognize or identify with the feelings and needs of others.
8. Is often envious of others or believes that others are envious of him or her.
9. Shows arrogant, haughty behaviors or attitudes.

And that's it. Simple--and difficult--as that. Narcissistic personality disorder is grouped with antisocial personality disorder, borderline personality disorder, and histrionic personality disorder in Cluster B.

Seasoned social workers can usually assess the presence of a personality disorder pretty quickly, without knowing which PD they're facing. The quick summary you'll hear all the time in the field: "Cluster B." On the exam you have to be more certain--know these criteria and how to distinguish from the other personality disorders and you'll be able to correctly answer without too much difficulty.

For further reading, try the Mayo Clinic's NPD page: http://www.mayoclinic.org/diseases-conditions/narcissistic-personality-disorder/basics/definition/con-20025568 and Wikipedia's pages, linked here: https://en.wikipedia.org/wiki/Cluster_B_personality_disorders

Good luck on the exam!

Time Management and Test Preparation

This blog contains lots of information that might help you on social work licensing exam, but it's only the beginning. There's much, much more info to digest. The posts here can only really serve as reminders about what you've already memorized or as prompts for further review.

That raises the question: further review when?...memorized how?

Here's a site that aims to help you get those important questions answered. What is the best way to go about learning all the information that may show up on the LCSW exam? And how can you best organize your time to make room for all that learning? The too long; didn't read version is this: You already know how to learn and how to make time for learning. You've been doing it your whole life, running a decades-long experiment about what works best for  you.

That doesn't mean you can't use additional guidance. So check out the test preparation and time management skills detailed at studygs.net. The site quotes William Shakespeare for inspiration: "Study is like the heaven's glorious sun. You may feel differently about it. But with the study tips detailed on the site, you at least don't have to be completely in the dark regarding best study practices. Enjoy and good luck!

The Code of Ethics - Core Values

Exam item writers live in the same world that you do and read the same headlines. Don't be too surprised to see items in future versions of the LCSW exam that pull from the conflicts that occupy your news and social media feeds today. One simple way to stay grounded in social work ethics as you approach these questions is to remember the six core values spelled out in the NASW Code of Ethics:

• service
• social justice
• dignity and worth of the person
• importance of human relationships
• integrity
• competence

They're right at the top of the Code of Ethics. Give the descriptions a careful read! http://www.socialworkers.org/pubs/Code/code.asp They're not easy principles to live and work (and answer vignette questions) by...but definitely worth the effort. Good luck!

The Code of Ethics - Self-Determination

There's just no way to successfully make your way through the social work licensing exam without having a good working knowledge of the NASW Code of Ethics. This has been stressed on this blog before, but it bears repeating. Social work is too vast a subject to be covered in every respect by the exam. But this area--social work ethics and how to put them to use--is guaranteed to show up on the exam. With that in mind, let's take a look at an especially exam-friendly section of the code:

1.02 Self-Determination
Social workers respect and promote the right of clients to self-determination and assist clients in their efforts to identify and clarify their goals. Social workers may limit clients’ right to self-determination when, in the social workers’ professional judgment, clients’ actions or potential actions pose a serious, foreseeable, and imminent risk to themselves or others.

For exam item writers, this may be a particularly alluring paragraph. Social workers are usually by nature caretakers, givers, helpers. But when is helping unhelpful or just plain unethical? Don't be surprised to find questions about close-call situations that put your caregiving instincts at odds with the principle of self-determination. A client chooses to live on the street...chooses addiction over recovery...chooses anything that may not ultimately be in their self-interest. Remember this part of the code and you'll know how to answer.

For further reading try this article from Social Work Today:

Into the DSM - Schizophrenia

Schizophrenia will doubtless come up for social workers employed in clinic settings. That means it's one of the diagnoses that you may find appear on the social work licensing exam. Here are the criteria:

A. At least two of the following for a significant portion of the time during a one-month period:

1. Delusions
2. Hallucinations
3. Disorganized speech
4. Grossly disorganized or catatonic behavior
5. Negative symptoms (e.g., flat affect)

B. Level of functioning is markedly below level at onset of symptoms.

C. Disturbance persists at least six months.

D. Schizoaffective, depressive, and bipolar disorder ruled out.

E. Symptoms not attributable to the effects of a substance.

F. If there is a history of autism spectrum disorder or a communication disorder of childhood onset, a schizophrenia diagnosis is made only if prominent delusions or hallucinations are present for at least one month.

Specifiers include:

• First episode, currently in acute episode
• First episode, currently in partial remission
• First episode, currently in full remission
• Multiple episodes (acute, partial, or full remission)
• Continuous
• With catatonia

DSM-5 also includes a severity rating for schizophrenia--each symptom can receive its own rating ranging from 0 (not present) to 4 (present and severe).

For further reading, including risk factors and treatment, take a look at http://www.nimh.nih.gov/health/topics/schizophrenia/index.shtml

Into the DSM - Autism Spectrum Disorder

New in DSM-5, autism spectrum disorder covers a wide array of symptoms. It's wise to review them ahead of sitting for the social work licensing exam. Here we go...

A. Persistent deficits in social communication and social interaction across multiple contexts, for example:

• Deficits in social-emotional reciprocity (back-and-forth conversation, sharing of interests)
• Deficits in nonverbal communication (eye contact, body language)
• Deficits in developing, maintaining, and understanding relationships (adjusting behavior to context, making friends)

B. Restricted, repetitive patterns of behavior, interests, or activities, including at least two of the following:

• Stereotyped or repetitive motor movements (lining up toys, echolalia, idiosyncratic phrases)
• Insistence on sameness, inflexible adherence to routines, or ritualized patterns of verbal or nonverbal behavior 
• Highly restricted, fixated interests that are abnormal in intensity or focus
• Hyper- or hyporeactivity to sensory input (indifference to pain/temperature, adverse response to specific sounds...)

C. Symptoms present in early development.

D. Symptoms cause clinically significant impairment.

E. Disturbances not better explained by an intellectual development disorder or global developmental delay.

Specifiers include:

• With or without intellectual impairment
• With or without language impairment
• Associated with a medical or genetic condition or environmental factor
• Associated with another neurodevelopmental, mental, or behavioral disorder
• With catatonia

Since ASD encompasses old (DSM-IV-TR) diagnoses of autistic disorder, Asperger's disorder, and pervasive developmental disorder, severity levels play an important part in the diagnosis. More about those in a future post!

For further reading try NIMH and/or the CDC.

Into the DSM - Panic Disorder

Panic disorder can be summed up in four words: Recurrent unexpected panic attacks. But there's more to it than that. First, what's a panic attack (and what's not a panic attack)? The DSM answers: A panic attack is an abrupt surge of intense fear or intense discomfort that reaches a peak within minutes. During that time, four of the following symptoms occur:

1. Palpitations, pounding heart, or accelerated heart rate.
2. Sweating.
3. Trembling or shaking.
4. Sensations of shortness of breath or smothering.
5. Feelings of choking.
6. Chest pain or discomfort.
7. Nausea or abdominal distress.
8. Feeling dizzy, unsteady, light-headed, or faint.
9. Chills or heat sensations.
10. Paresthesias (numbness or tingling sensations)
11. Derealization (feelings of unreality) or depersonalization (being detached from oneself).
12. Fear of losing control or "going crazy."
13. Fear of dying.

With that you know most of what you need to know about the diagnosis, but not all. There's a crucial addition--criterion B: At least one of the attacks has been followed by one month (or more) of one or both of the following:

1. Persistent concern or worry about additional panic attacks or their consequences.
2. A significant maladaptive change in behavior related to the attacks (e.g., avoidance)

Of course, there are the usual "not better explained by" caveats. And that's it.

Risk factors for panic disorder include:

• Family history of panic.
• Major life stress or life changes.
• Trauma.
• Excessive caffeine intake and/or smoking.
• History of childhood physical or sexual abuse.

With the above information digested, consider yourself readied for a panic disorder question on the ASWB exam. For further study try: Panic attacks and panic disorder at MayoClinic.org.

Mental Status Exam

The questions in the mental status exam include all the basic of social work assessment. While the MSE's lack of full exploration into the biopsychosocialspiritual components of client experience makes it an imperfect tool for social work, it's still a good start. That's why you'll see the MSE used in many clinical settings and why you shouldn't be surprised to see a question about the MSE on the social work licensing exam (e.g., "A social workers asks a client to spell a word backwards. What is the social worker assessing for?")

The general elements covered in the MSE are as follows:

• General Appearance
•  Psychomotor Behavior
• Mood and affect
• Speech
• Cognition
• Thought Patterns
•  Level of Consciousness

There's too much detail in the exam to recount here, but click through to the further reading to get more comfortable with the details of the exam. 

Further reading: "How to Do a Mental Status Exam," and Mental Status Examination at Wikipedia.

Into the DSM - Bipolar I Disorder

To meet criteria for bipolar I disorder, a manic episode is required--it may be followed by a hypomanic or major depressive episode. (For bipolar II, a hypomanic episode + a current or past major depressive episode are required.) Here are the criteria for a manic episode:

A. Distinct period of abnormally and persistently elevated, expansive, or irritable mood with increased goal-directed activity or energy, lasting at least 1 week.

B. Three or more of the following during the mood disturbance:

1. Inflated self-esteem or grandiosity
2. Decreased need for sleep
3. Increased talkativeness
4. Racing thoughts or flight of ideas
5. Distractibility
6. Increased goal-directed activity or psychomotor agitation
7. Excessive risk-taking

C. Mood disturbance severe enough to cause impairment.

D. Episode is not attributable to effects of a substance or another medical condition.

Hypomanic episodes include many of the same symptoms, but are not severe enough to cause marked impairment in social or occupational functioning or to require hospitalization.

Specifiers for bipolar I disorder include:

• With anxious distress
• With mixed features
• With rapid cycling
• With melancholic features
• With atypical features
• With mood-congruent psychotic features
• With mood-incongruent psychotic features
• With catatonia
• With peripartum onset
• With seasonal pattern

Risk factors include:

• Having a first-degree relative (e.g., parent or sibling) with the disorder.
• Substance abuse
• High stress
• Major life changes (e.g., death of loved one)

For further study: Bipolar I Disorder at MayoClinic.org

Into the DSM-5 - Schizoaffective Disorder

If you've encountered schizoaffective disorder in your work  with clients, questions about the diagnosis on the licensing exam shouldn't give you much trouble. For everyone else, here's a quick primer. The essential formula to remember with schizoaffective disorder is psychotic symptoms + mood symptoms which are independent of the psychotic symptoms. Common rule-outs: schizophrenia, bipolar disorder, MDD with psychotic features.

There are two essential criteria:

• Major mood episode concurrent with symptoms of schizophrenia
• Delusions or hallucinations in the absence of mood symptoms at some point

 Specifiers include:

• Bipolar type
• Depressive type
• With catatonia

Risk factors: Having a blood relative with schizophrenia, schizoaffective disorder, or bipolar disorder; stress; drug use.

For further study: Schizoaffective disorder at MayoClinic.com

Theories and Methods - Attachment Theory

Attachment Theory, conceived by John Bowlby and furthered by Mary Ainsworth, explores the centrality of attachment bonds in human development and emotional life. Particular attention is paid to the degree of security infants and children feel in relationship to their caregivers and the consequences when a felt sense of security is lacking (as in cases of even mild emotional neglect). Mary Ainsworth's experimental "strange situation" examined the responses of children to different caregiver behaviors and identified a set of attachment patterns (e.g., anxious-resistant, avoidant...) which followed the children into their adult relationships. Radical when originated, attachment theory has since been thoroughly integrated into much clinical practice, especially that of social workers.

For futher review: Attachment theory at Wikipedia, at Simply Psychology, attachment theory books at Amazon.

Studying with Social Work Podcasts

Some people learn best via text, others via charts and images, still others like to listen their way to knowledge. Everyone can benefit from the free audio exam preparation available on the net. Podcasts are a great way to load up on information and general social work knowledge. Early episodes of the Social Work Podcast are especially useful as they cover the very theories and approaches that may show up on the ASWB exam. (Here's a helpful menu of useful Social Work Podcast episodes.) Other podcasts may make for inefficient but effective social work exam studying. An episode of inSocialWork, focused on one content area (and not designed for exam preparation) will give you the type of depth of knowledge that will make it impossible to miss a question on that topic. But will that topic actually show up on the exam? There's no saying. What you will get is a ever-increasing sense of what it means to be a social worker and how social workers think about difficult questions. That's something you can bring to just about every question on the exam! Links:

• The Social Work Podcast
• inSocilWork Podcast
• Podsocs