Studying for the Exam

The hardest part about giving advice for the exam is that everyone studies differently and has different needs. However, I will tell you what was helpful to me.

The exam breaks down in this way:

Human growth and development - 22% of the questions
Diagnosis and Assessment - 16%
Clinical Theories and Practice - 16%
Professional Values and Ethics - 10%
Communication - 8%
Therapeutic Relationship - 7%
Diversity - 6%
Service Delivery - 5%
Clinical Practice and Management - 5%
Clinical Supervision, Consultation and Development - 4%
Research - 1%

I spent most of my time working through the first seven things on this list. This blog was my study guide as I wrote and rewrote the theories and methods in my own words.

The first seven categories make up 85% of the exam, and I figured if I knew them well enough to answer most of the questions related to their content accurately then I would have a good chance of passing the exam.

I did not neglect the other portions of the exam, I made sure I knew enough to make an educated guess with relationship to their content and to be relatively sure I would get about half of them right. I can't remember my score exactly, but I believe it was between 78-85, enough to pass in my jurisdiction.

I hope this helps, good luck to all who are taking the exam.

Theories and Methods - Gestalt Therapy

Gestalt therapy is based on the premise of each individual taking responsibility for the way they relate to others as well as living as an integrated self. Gestalt therapy is closely related to the concept of perception. The person is thought to consist of the self and the self-image. The self is the creative side that seeks to live life in an integrated fashion. The self-image is a dark side that imposes standards that inhibit growth. Maladaptive behavior is considered to be a lack of integration due to an abandoned self. Four disturbances mark Gestalt thoughts on maladaptive behavior: introjection is an overly compliant state where the client incorporates whole concepts without fully understanding them; projection is the disowning of certain parts of the self and attributing them to others; retroflection is the internalization of actions, thoughts, emotions, etc. that are meant for another; finally, confluence, is the abandonment of boundaries between the self and the environment.

The goal of Gestalt therapy is the integration of a unified self. Gestalt therapists use several techniques to achieve this goal. There is a focus on the here-an-now, questioning is discouraged, clients are encouraged to use “I” language to accept responsibility for their actions, clients further encouraged to claim responsibility using overt language, the use of role-playing and the empty-chair technique are designed to help clients externalize internal conflicts, finally, dreamwork is used to examine parts of the self that may not be fully accepted. Gestalt therapy is best used with clients who have the intelligence and education to withstand some of the confrontive techniques it uses.

For further review: Gestalt Therapy Integrated: Contours of Theory & Practice

Theories and Methods - Jung

Jung proposed that libidinal energy was more a general force than a sexual force. Furthermore, while paying attention to the ideas of the conscious and unconscious, Jung also proposed a personal and collective unconscious. The personal unconscious contains our experiences that were once conscious but are now unconscious. The collective unconscious is a vault of memories that is handed down from one generation to the next.

Archetypes are part of the collective unconscious and play a role in personality development. The most important archetypes include: the self, the persona, the shadow, the anima and the animus. Jung also posited four basic psychological functions of which one is generally in use by the conscious at all times. These four basic functions are: thinking, feeling, sensing and intuiting. For Jung, maladaptive behavior consists of a message from the unconscious that something has gone awry or that a task needs to be completed. Jungian therapists rely on interpretations in order to help people bridge the gap between the conscious and the unconscious in order to resolve conflict. Dreamwork and counter-transference also play significant roles in Jungian Analysis.

Theories and Methods - Adler

Adler, initially a disciple of Freud, parted ways with him to form an approach to individual psychology that was teleological and formulated that a person was largely motivated by future goals. Adler’s theory posits four major concepts. Inferiority feelings develop during childhood as a result of real or perceived weaknesses. Striving for superiority is a person’s tendency to move toward perfect completion. The way a person chooses to compensate for their inferiority and strive for superiority results in their style of life. Furthermore, Adler posits two different styles of life, healthy and mistaken. A healthy style of life is reflected through an optimistic outlook and contribution to the welfare of others. On the other hand, a mistaken style of life is marked by self-centeredness and striving for personal power.

Adler believes that maladaptive behavior is the result of taking on a mistaken style of life. In order to combat this Adler believed that therapists should establish a collaborative relationship with the client, understand their style of life, and help the client reorient their beliefs and goals. Adler proposes six techniques to further enhance this process, which include: the lifestyle investigation, study of dreams, interpretation of resistance and transference, role-playing of desired behaviors, paradoxical intentions, and encouragement and advice.

Theories and Methods - Neo-Freudians

The neo-Freudians are more apt to emphasize the role of interpersonal and social environmental factors in the development of personality. While the theorists disagree on the appropriate time to apply this emphasis they would admit that social factors are the primary determinants of personality.

Karen Horney viewed maladaptive behavior as the result of anxiety directly resulting from a child’s interpersonal relationships. Sullivan proposed that cognitive factors played a role in development. He proposed that maladaptive behavior stems from parataxic distortions which involve the client’s inability to perceive a person in the present, instead they are conceived of as a significant person from the past.

Sullivan also thought of the therapist as a participant/observer and expert in interpersonal relationships. His thoughts were that the more people were aware of their interpersonal relationships, the more healthy they became.

Theories and Methods - Object Relations

Object relations theory shares a similar interest in the early development of personality with Freudian theory. However, object relations is more concerned with the self and object relationship (hence the name) than with unconscious drives.

Margaret Mahler’s theory of development is well-known in object relations. Through this theory she posits four stages of development. First there is normal autism which is an undifferentiated state where the infant is oblivious to the external environment. Second is the symbiotic phase the infant recognizes but does not differentiate between the self and the mother. The third phase is differentiation where the child (7 months) separates the self from the other and begins to recognize the differences inherent in each. Finally, the child (2 years old by now) reaches the stage of integration or rapprochement during which the self and the external object are perceived as independent and can have a relationship with one another.

In order to be healthy the child must move through these four stages and develop a coherent idea of self as apart from the other. If the development of early object relations is stunted then the individual will be unable to render the self and the other appropriately and become fixated on an earlier stage of development. The goals of object relations therapy are to provide support, acceptance and opportunity for the client to view themselves and relate to others in a meaningful way.

For further review: Object Relations...in Social Work Practice

Theories and Methods - Ego Analysts

The ego analysts also place an emphasis on the development of the ego for personality characteristics; however, they also see development as taking place across the lifespan rather than just in childhood. Ego analysts view maladaptive behavior as the loss of control by or the assimilation of the ego, which allows the id and superego to run rampant. Ego analysts are more apt to focus on the present and on reparenting the individual, though their techniques of analysis do not differ much from Freudian analysis. Finally, ego analysts focus on the development of functional methods of living in a social reality rather than unconscious drives.

Theories and Methods - Defense Mechanisms

This list is not comprehensive but instead offers an overview of the most common defense mechanisms.

Repression – is the most basic of all defense mechanisms, repression occurs when the drives of the id are forced into the unconscious and denied by the individual

Regression – occurs when a person retreats to a safer earlier stage of development

Projection – happens when a person attributes their own unacceptable needs and drives onto another person.

Reaction Formation – occurs when a person avoids a particular instinct by expressing its opposite.

Displacement – is the transfer of an instinctual drive from one target to a less threatening target.

Sublimation – is the acting out of a socially acceptable behavior as a direct reaction to the drive to do something unacceptable

Denial – is the admission of socially unacceptable impulses joined with the inability to attribute them to oneself

Introjection – is the ascribing of another’s thoughts and behaviors to the self in order to better control one’s own thoughts and behaviors.

Rationalization – is the interpretation of behaviors in a manner that makes them appear more rational or logical

Fixation – is the arresting of libidinal energy in an unresolved conflict

Undoing – is the repetition of a behavior in order to undo the effects of a past action.

Theories and Methods - Brief Psychotherapies

Brief psychotherapy has its roots in psychoanalytic therapy but shares some characteristics with crisis interventions. However, brief psychotherapies are more apt to use catharsis, transference and interpretation as part of the therapeutic milieu.

Rather than seeing the client’s anxiety as situational, these therapies see them as pathological. The therapist takes on a participant observer role rather than being an active participant and focuses on the past rather than the current crisis.

For further review: Brief Dynamic Therapy

Theories and Methods - Crisis Intervention

A crisis manifests as an emotional and/or biophysical upset, or as a cognitive disturbance. Crisis treatment is time-limited and uses a here-and-now orientation and the interventions are concrete. Currently, there are thought to be three types of crisis: Situational, Motivational, and Cultural or societal crisis.

Crises tend to move through five stages: the hazardous event, a vulnerable state, precipitating factor, active crisis, and reintegration. Reintegration and a return to a previous level of functioning are the goals of the therapist using crisis intervention techniques.

Finally, there are several things that can be said about the types of interventions and treatment that are indicative of crisis therapy. In this form of therapy interventions are immediate, concentrate on limited goals, and focus on problem solving. Furthermore, the treatment is active and directive, encourages self-reliance, supports the client, is designed to give hope, and enhances self-esteem.

For further review: Essentials of Crisis Counseling and Intervention (Essentials of Mental Health Practice)

I passed

I took the exam today and passed. I have a great sense of relief and will post the rest of my notes on the theories and other pieces I used as a study guide. I am going on vacation first though...

Theories and Methods - Systems Theory

This theory is often used in the family therapy realm, but generally seeks to describe the interactions between the client and the environment and vice versa. There are two types of systems, open and closed. An open system is deemed functional and is continually interactive with its environment. An open system may become a closed system. This usually occurs when the system attempts to protect itself from the environment, leading to a blockage of energy and isolation which is maladaptive. Systems are prone to change and this is a good thing.

Systems theoreticians believe that systems interact in a way that maintains homeostasis. That is, they behave in a way that is balanced and somewhat flexible towards influence. The homeostatic state of particular systems can have both negative and positive connotations. Systems do what ensures their survival, and often this might include maladaptive behaviors in order to maintain homeostasis. A variety of techniques are used in systems theory to bring about changes. Systems therapists believe in peoples’ capacity and motivation for change.

For further review: There are a variety of books on different variations of family systems theory. Most of the ones I have found are expensive and thus I cannot really recommend a decent reader.

Group Therapy

Group information

This information on group therapy will center on several factors to consider when thinking about the role that group therapy will have in your practice. For a better resource on group therapy, especially group psychotherapy, pick up the latest edition of Theory and Method of Group Psychotherapy by Irving Yalom (I think the 5th edition is the latest). Having been a co-therapist in both a psychotherapy and psycho-educational group I have seen the promises and the difficulties groups can have on the lives of clients.

Three practical considerations concerning groups are: the group, the therapy, and the therapist. Groups tend to work best when the members share similar ages, intelligences and developmental levels. Age is a primary concern with groups for adolescents and children, with developmental level playing a larger role in the adolescent area. Furthermore, gender should play a role in group selection with these age cohorts as well. Finally, there is some discrepancy in thought concerning the role of the problem in selection for a group. Evidence and thought both support homogeneity and heterogeneity.

Groups can also function as closed or open entities. Closed groups are often more task-oriented and function in a short-term fashion. In this form of group, the members are constant from beginning to end. In an open group, members come and go and the group does not really have a specified ending. These groups tend to be more psychotherapeutically oriented. Group size seems to be most effective when it ranges from 7 to 10 members.

Irving Yalom is the leader in theory and method of group psychotherapy. He posits three stages to a group. In the first stage group members are searching for a way to connect with one another and the group as a whole. This stage is dominated by a lack of depth to the communication as the group members feel one another out. In the second stage, group members begin to entrench themselves in particular roles and a social ethos begins to emerge. This stage is marked by an increase in resistance as the members realize they are going to have to “share” the therapist. The final stage is marked by the development of group cohesiveness. Here the group becomes genuine in word and action and a sense of group empathy emerges. Following the establishment of cohesiveness the group matures and much of its “real” work begins. Yalom also believes that the group becomes a small social reality for each individual where they play out their healthy and unhealthy behaviors. Therefore, the group becomes the place where maladaptive behaviors can be tested and reframed in relative safety.

The therapist plays a key role in the group, especially in the beginning stages. The therapist is responsible for creation and maintenance of the group and for building a safe atmosphere for cohesion to emerge. The therapist also keeps the group from wandering too far from its purpose through a gentle nudging back to the present atmosphere of the group. Co-therapists also offer a unique opportunity for group members to see others modeling appropriate behaviors, especially during conflict.

For further review: Theory and Practice of Group Psychotherapy, Fifth Edition

Specific Populations

There are several factors that therapists should be aware of when counseling members of different cultural groups. These factors include: language, acknowledgement of a specific ethic identity, an understanding of how the client views the world, clarity in treatment and goals, recognition of the role that discrimination plays in the lives of culturally diverse populations, be wary of overgeneralizations, encourage clients when discussing differences, and finally don’t assume that all behaviors are dysfunctional because some might derive from culturally significant phenomena.

African-Americans

Without over-generalizing, several ideas should be considered when beginning therapy with an African-American. Therapists should pay heed to a people orientation, the extended family (including church), and a particular form of cultural paranoia. In African-Americans, a healthy form of cultural paranoia exhibits as a reaction of mistrust due to inherent racist structures in the predominant American culture. On the other hand, this must be distinguished from functional paranoia which is the general mistrust of all people and structures. This form of paranoia is seen as maladaptive to the individual.

Some guidelines when working with African-American clients include: adopting a problem-solving approach (such as solution-focused therapy), understanding the systemic influences on particular behaviors, fostering empowerment, attending to nonverbal behaviors, and don’t avoid the issue of racism.

American Indians

Some characteristics that American Indians might share include: a naturalistic outlook that views harmony between humans and nature as a good thing, an emphasis on extended family, present oriented, cooperative, and will listen more often than speak. Therapy can take on a collaborative approach that emphasizes problem-solving while validating the client’s experiences and culture. Trust and flexibility are a must. As well, therapists should understand that particular behaviors may have cultural roots rather than pathological roots. Finally, the use of the community as part of the healing process can be helpful as well.

Asians

When working with the Asian population the therapist can expect the client to understate the problems they are experiencing. Furthermore, modest can be expected as well as difficultly talking about family matters and sexual issues. One source of stress for the immigrant population is assimilation especially at the end of the first year. In addition, conflict between generations and degree of acculturation often occur. The therapist should use a directive approach to alleviate specific symptoms and expect more nonverbal and indirect communication from the client. The therapist should focus on establishing creditability, providing immediate benefit and being aware of issues of shame.

Hispanics

Hispanic clients vary depending on issue of acculturation. They are more likely to emphasize family over individual welfare, focus on interdependence, have difficulty discussing problems, are more concrete, and have “magical” beliefs about God or other powers. Family therapy can be helpful because of its extended reach and multi-focus inventions. Exploring the information that the client shares is important for both rapport and interventions.

Theories and Methods - Existential therapy

Existential therapy is primarily concerned with a growth oriented approach focusing on one’s existence. The therapist uses a person’s struggles with death, isolation, freedom and meaninglessness in order to help the client adapt to life. Anxiety is the result of conflicts that arise between these four realms.

Existentialists view humans as having the capacity for self-awareness, having freedom and responsibility, striving for identity and meaningful relationships, searching for meaning, aware of death and anxious. People are constantly striving for meaning, being and feeling alive and they have the capacity and freedom to make these choices regardless of their circumstances. An existential view of maladaptive behavior takes into account the guilt felt by an individual who chooses not to choose or who have rigid and restrictive ways of thinking and acting.

Existential therapy encourages people to take responsibility for their lives while helping them achieve greater intimacy, interpersonal success, and learn about themselves. The therapist is ultimately hoping to move a client towards a more authentic way of being.

One particular form of existential therapy is logotherapy, which was created by Victor Frankl and focuses on the use of confrontation as a means of creating meaning.

For further review: Existential Psychotherapy, Love's Executioner & Other Tales of Psychotherapy, Man's Search for Meaning

Theories and Methods - Person-centered (Rogerian) therapy

Person-centered therapy assumes that every person is motivated towards self-actualization and positive healthy growth. For Rogers, growth occurs when the self remains unified, whole and organized. Maladaptive behavior surfaces when there is incongruence between the self and one’s experiences. Incongruence is a sense that challenges one’s feelings of worth. It is the feeling that one gets when one believes they are accepted unconditionally, but finds out that people place conditions upon their acceptance. Incongruence produces anxiety which operates defenses and halts self-actualization. The goal of Rogerian therapy is to re-institute congruence between the self and experience.

To this end, there are three important Rogerian techniques. Unconditional positive regard is the genuine care that a therapist offers to a client. Accurate empathic understanding involves the therapist seeing the world through the client’s eyes and sharing that view with the client. Genuineness includes the therapist’s ability to disclose honestly his or her feelings at the appropriate time. Rogerian therapy is non-directive and lacks techniques such as interpretation or assessment. Furthermore, the client is assumed to be the expert on him or herself and the therapist is the witness to the client’s capacity for insight and decision-making.

For further review: The Carl Rogers Reader, On Becoming a Person: A Therapist's View of Psychotherapy

Theories and Methods - Narrative Therapy

In narrative therapy the therapist assumes the role of explorer by gathering and examining the myths and patterns that shape the lives of an individual or family system. The therapist focuses on understanding the client’s experiences and how those experiences create expectations through stories. Our stories influence our views of the present and future and contain the things that we choose to remember and notice in our lives. Life Stories are filter narratives that serve as gatekeepers for our experiences. These stories function to weed out experiences that do not fit the plot of our lives, or alter the experiences until they fit the plot.

Narrative therapy is influenced by social constructionism which states that: realities are socially constructed, constituted through language, organized into narratives, and that there are no meta-truths. Furthermore, therapists in this mould are encouraged to collaborate with clients, search for counter-narratives (those narratives that function in opposition to dysfunctional narratives), use questions for clarification and insight into new stories, and help people author new stories apart from those that derive from culturally dominant sources. The postmodern approach that underlies much of narrative therapy forces the therapist to eschew labels and diagnosis in order to re-humanize the client.

The goal of narrative therapy is the awakening of the client to the experiences before them and the co-authoring of new stories that speak of the way a person wishes to relate to the world. Therapists seek to remove (externalize) the problem from the person so that a separate entity is created and attacked apart from the person. Moreover, through careful use of questions the narrative therapist can get to know the client apart from the problem, further externalize the problem and examine its effects on the person, and help the person re-author dominant stories and deconstruct cultural stories that may hold a person back.

For further review: Maps of Narrative Practice, Narrative Therapy, Narrative Means to Therapeutic Ends

Getting Started

I was asked a question about where to begin when wanting to become licensed as a soical worker. My first thought is begin with your state website. In Colorado (where I currently live) the webiste is found here:

http://www.dora.state.co.us/mental-health/sw/licensing.htm

For other states I would recommend a Google search containing the keywords: social, work, boards, (your state).

Assuming you have completed the required supervisory and clinical hours, the application and payment will need to be filled out and sent in. Then the state board will approve the application and send further instructions for taking the national exam.

Registration for the national exam is through www.aswb.org. Once you are approved you sign up with them, pay another fee, and pick your date and location.

One other place to get information about licensure is through your supervisor or another licensed social worker. It would seem, to me at least, that those who are lisenced and provide supervision should also have information regarding the requirements and steps needed to fulfill the process.

Finally, different states have different concepts of "preparedness." Therefore, check the state website for what you might need before applying. Furthermore, due to a lack of initiative or the inability to agree, there is little reciprocity between states. Therefore, your license in Virginia is no good in Colorado until you fill out the Colorado application, pay the fee, and hope they approve of the work you have already done.

Into the DSM-IV - Generalized Anxiety Disorder

Generalized Anxiety Disorder is diagnosed when a person suffers from excessive anxiety and worry that takes place for more than half the days in a 6 month time period. Furthermore, the anxiety causes impairment in social, occupational or other areas of functioning. Criteria for this diagnosis includes at least three of the following:

• Restlessness or feeling keyed up or on edge


• Easily fatigued


• Difficulty concentrating


• Irritability


• Muscle tension


• Sleep disturbance

Risk Factors

• Having a comorbid DSM-IV disorder. Generalized anxiety disorder is often diagnosed in those who have another anxiety disorder, a mood disorder or substance-related disorder


• Having a family member who suffers with Generalized Anxiety Disorder


• Being female (it is twice as common in women)


• Having a history of frequent losses or severe childhood fears


• Having a poor psychological disposition (irrational thinking, negative thinking, overgeneralizing)


• Being neurotic or excessively conscientious


• Experiencing a number of overly stressful life events

Protective Factors

• Healthy childhood development


• Appropriate parental attachments


• Strong social supports


• Knowledge and use of stress management techniques


• Optimism and self-confidence


• Psychotherapy: behavioral approaches involving coping skills, relaxation and medication

Multi-dimensional assessment

As social workers we are charged with assessing multiple sources of information as we examine the lives of our clients. Elizabeth Hutchison, in Dimensions of Human Behavior: The Changing Life Course (1999, Pine Forge Press) lists eight different perspectives that can inform a multidimensional assessment. These eight perspectives are divided between their sociological and psychological roots. What I will quote below is a brief chart from each perspective. Hutchison does a nice job of practically relating each perspective to a case study in her book.

Sociological Perspectives

Systems Perspective (chart, p. 42)

• Systems are made up of interrelated members that constitute an ordered whole
• Each part of the system impacts all other parts, and the system as a whole
• All systems are subsystems of other larger systems
• Systems maintain boundaries that give them their identities
• Systems tend to move towards homeostasis, or equilibrium

A key term in the systems perspective is Role, which is described as the behaviors that a person assumes as a part of a particular social position.

Conflict Perspective (chart, p. 45)

• Groups and individuals try to advance their own interests over the interests of others
• Power is unequally divided, and some social groups dominate others
• Social order is based on manipulation and control of nondominant groups by dominant groups
• Lack of open conflict is a sign of exploitation
• Social change is driven by conflict, with periods of change interrupting long periods of stability

Rational Choice Perspective (chart, p. 47)

• People are rational and goal-directed
• Social exchange is based on self-interest, with actors trying to maximize rewards and minimize costs
• Reciprocity of exchange is essential to social life
• Power comes from unequal resources in an exchange

Social Constructionist Perspective (chart, p. 51)

• Actors are free, active and creative
• Social reality is created when actors, in social interaction, develop a common understanding of their world
• Social interaction is grounded in language customs, as well as cultural and historical contexts
• People can modify meanings in the process of interaction
• Society consists of social processes, not social structures

Social constructionist positions seem to occupy a majority of the thought in philosophical and therapeutic realms that embrace postmodernity. It has a close relationship with contextualism and is helpful in narrative forms of therapy.

Psychological Perspectives

Psychodynamic Perspective (chart, p. 53)

• Emotions have a central place in human behavior
• Unconscious, as well as conscious, mental activity serves as the motivating force in human behavior
• Early childhood experiences are central in the patterning of an individual’s emotions, and therefore, central to problems of living throughout life
• Individuals may become overwhelmed by internal and/or external demands
• Individuals frequently use ego defenses to avoid becoming overwhelmed by internal and/or external demands

Developmental Perspective (chart, p. 55)

• Human development occurs in clearly defined stages
• Each stage of life is qualitatively different from all other stages
• Stages of development are sequential, with each stage building on earlier stages
• Stages of development are universal
• All environments provide the support necessary for development

Personally, this perspective is the hardest for me to embrace. It seems to directly contrast the social constructionist point of view, as well as postmodernity and contextualism. However, this perspective also has a great deal of research to back it up. What needs to be said is that the research is myopic in its scope and only really incorporates the perspective of white middle class men.

Behavioral Perspective (chart, p. 57)

• Human behavior is learned when individuals interact with the environment
• Similar learning processes taking place in different environments produce differences in human behavior
• Human behavior is learned by association of environmental stimuli
• Human behavior is learned by reinforcement
• Human behavior is learned by imitation
• Human behavior is influenced by personal expectations and meanings.

Several key terms function in this perspective. First, Classical Conditioning Theory (Pavlov), uses the relationship of conditioned and unconditioned stimulus to describe the reasons for a particular behavior. Second, Operant Conditioning Theory (Skinner, Watson), uses reinforcement as the primary motivator for behavior. Finally, Cognitive Social Learning Theory (Bandura), uses imitation and cognitive processing as the primary motivators in developing a behavior.

Humanistic Perspective (chart, p. 59)

• Humans are “spiritual, rational, purposeful, and autonomous” (Monte, 1995, p. 665)
• Human behavior can be understood only from the vantage point of the phenomenal self—from the internal frame of reference of the individual
• People make psychologically destructive demands on each other, and attempts to meet those demands produce anxiety
• Human behavior is driven by a desire for growth and competence, and by a need for love and acceptance

The humanistic perspective has its roots in philosophy and grew through existentialism (Kierkegaard, Nietzche, Camus, Buber, Tillich). Rogerian therapeutic paradigms are probably the quintessential example of the humanistic perspective. Maslow’s work also fits into this perspective.

For the purpose of assessment, these eight perspectives provide an introduction to the possible forms of information that one can gather about an individual’s situation and self. I have to believe that no one can use one perspective exclusively. Therefore, it is necessary to understand the basics of each so that we can utilize their features and theories when particular forms of information appear. Furthermore, while we do not operate out of one perspective totally, we often favor one perspective over others. In order to best serve our clients it is necessary to realize our perspectives and their biases.

Into the DSM-IV - Anorexia Nervosa

Anorexia Nervosa is an eating disorder characterized by the following symptomatic clues:

• An inability to maintain a healthy or minimum body weight
• A distorted body image
• An intense fear of gaining weight or becoming overweight
• An excessive emphasis on weight
• The denial of the seriousness of their condition
• In females an additional characteristic is the cessation of the menstrual cycle.

Anorexa Nervosa can be further classified as a Restricting type, which involves volutary starvation, Binge/Purging (including the use of laxatives or vomit induction). The onset of Anorexa Nervosa typically occurs in adolescence and affects about 1% of the female population.

Risk Factors

• Having a history of dieting (diets do not cause, instead all eating disorders originate through dieting attempts
• Being female (95% of diagnoses are in females)
• Having a parent in the family system who is overly concerned with weight issues
• Being a prepubscent or adolescent female (due to the incongruence of actual and ideal female body types portrayed in cultural situations)
• Biological predispostion.
• Psychological characteristics: distorted thinking, low self-esteem, stress, anxiety, perfectionism, and fear of rejection
• A history of trauma, sexual or physcial abuse
• Socio-cultural factors such as media or peer influences.

Protective Factors

• Psychological characteristics: high self-esteem, internal locus of control, high self-efficacy, mature defense mechanisms and coping strategies
• Personality characteristics: easy temperment, ability to make and maintain friendships, optimism
• Secure attachment to a parent
• Good parental adjustment. Parents with healthy attitudes towards weight and food can pass these along to children
• Socio-cultural factors: low levels of stress, high levels of support, minimal exposure to media images.

Into the DSM-IV – OCD

Obsessive-Compulsive Disorder is an anxiety related disorder that is marked by recurrent obsessions and compulsions that persist for more than one hour daily. Moreover, these obsessions and compulsions cause significant amounts of distress or impairment in daily functioning.

Obsessions consist of the repetition of distressing thoughts, impulses, ideas or images.

Compulsions are repetitive behaviors or mental acts that are intended to quell the anxiety of the obsession.

Risk factors

• Having a history of eating disorders in first degree relatives
• Having another mental disorder (OCD is comorbid in over 50% of cases)
• Being biologically pre-disposed to the condition
• Having a reduced rate of serotonin (persons who suffer with OCD have difficulty entering REM sleep)

Theoretical risk factors

• Psychodynamics – the person is stuck in the anal stage of development seeking rigidity and over control
• Learning theory – the person plays out classical and operant conditioning and negative reinforcement
• Family Systems – OCD develops to serve as a function of the family.

Protective Factors

• The development of better diagnostic categories to capture a better understanding of the disorder in adolescence
• Better education of family members in order to better recognize and monitor OCD inclinations.

Into the DSM-IV – Major Depression

As of 1996, Major Depression was diagnosed in roughly 17% of the total population, with a majority of that population being women (21%). Major Depression is the single largest disease that affects the US population in terms of economic scale.

To be diagnosed with Major Depression the symptoms must not have been the result of substance use, a general medical disorder or bereavement in the previous two months.

Furthermore, the client must have exhibited four of the following symptoms for at least two solid weeks:

1) Depressed mood for most of the day (irritability in adolescents and males)
2) Loss of interest or pleasure in all activities
3) Gains or losses in weight or increased/decreased appetite
4) An interruption in sleep patterns (sleeping more or less)
5) Fatigue
6) Others view the person as speeding up or slowing down
7) Feelings of worthlessness or inappropriate guilt
8) Inability to concentrate
9) Experiencing repeated thoughts about death

Risk factors for Depression

Gender – More females are diagnosed with depression than males
Age – Major Depression occurs in 1 in 6 adults over the age of 59
Health – Poorer general health increases risks, as well as a medical illness
Substance Abuse – increases risks (cannot be comorbid with Major Depression)
Genetics – There is some research that posits a genetic component to Major Depression
Comorbidity – Major Depression is often comorbid with anxiety, dysthymia or other disorders
History – Recurrence of depression is likely over the life-span
Abuse – Women who experience abuse are more likely to exhibit Major Depressive features
Economics – Lower socio-economic classes have higher rates of depression
Support – Isolation, divorce, widowed, separated and single individuals have greater risks
Stress – Major life events contribute to risks of major depression

Protective Factors for Depression

Social – Extended education, employment, financial stability, close relationships, marriage (for men), and adequate social support can protect against depressive symptoms
Medication – Can help resolve chemical imbalances in some individuals (must be weighed against side-effects and often work better in conjunction with psychotherapy)
Exercise – This is especially important for older adults, but has some protective factors for others as well.

Treatment Possibilities

Three forms of therapy have been researched and have proven effective for the treatment of Major Depression. Cognitive, Behavioral and Interpersonal therapeutic paradigms have provided the best outcomes for clients who suffer from Major Depression. Furthermore, a fourth paradigm that combines Cognitive and Behavioral treatments is effective. Finally, there is some research that states that therapy in conjunction with medication provides for the most effective and longest lasting results in the treatment of Major Depression.

Freud - In the Beginning...

In the beginning there was Freud. While mental processes had been tweaked throughout the years in philosophy, it was Freud who really began to systematize and bring together psychological thought into a coherent framework. Regardless of Freud’s current status in the psychological and therapeutic community, his work is nonetheless foundational and important (all quotes in this essay are from Gleitman, Psychology (3rd ed.), W.W. Norton and Company, 1991).

Freud’s psychoanalytic tradition began with an attempt to "understand the forces of human irrationality through reason and science" (p. 426). Freud’s method of therapy included free association which allowed room for "clients" to tell whatever came to mind. This was precipitated by the notion that everything in the mind was connected and that whatever was mentioned would lead to the problems that hindered an individual. Instead of willing participants, Freud found that people opted to resist instead of comply with his requests. Resistance became one of the things Freud and his clients would look for in the stories they told, believing that revealing whatever repressed memory was resisted would help in the healing process.

For Freud, repression became known as a defense mechanism used to push uncomfortable thoughts out of our consciousness. Furthermore, these thoughts most often dealt with sexual drives and instinctual urges. Unconscious conflict became a source of study for Freud. He used three terms to describe the never-ending internal sources of power and conflict.

The Id became synonymous with the instinctual and primal portions of our personalities. It was governed by the pleasure principle which sought to relieve one’s biological urges with utmost haste. The id is reflexive rather than thoughtful. This idea also gives rise to the second of Freud’s concepts, The Ego. The ego is governed by the reality principle which seeks to alleviate the urges of the id through socially acceptable means. The ego serves the id, but works in some ways as an opposite of the id’s urges. Finally, Freud constructed the Superego as the watchdog of the ego. The superego’s function is to praise or punish the actions of an individual based on the constructed social reality that they have internalized.

The interplay of these three dynamics often results in unconscious conflict, leading a person to incorporate defense strategies and mechanisms. As the conflict plays out our anxiety rises, resulting in the need for strong defenses (repression is the primary defense) against the unsettled nature of the conflict.

Several other defense mechanisms were posited by Freud through his work. These included: displacement or the transferring of repressed urges from one situation to another, reaction formation or the transfer of feelings from one emotional pole to the other (ie – turning hate into a smothering love), rationalization or the attempt to re-interpret a situation into something more acceptable, projection or the attribution of one’s feelings to another person, and isolation or the separation of emotions from memories. For Freud, these many of the conflicts of adults can be traced back to developmental memories that have been repressed.

Psychosexual Development
This is one of Freud’s best known and longest lasting contributions to the psychological realm. Every time someone says, “He’s so anal,” about a neat-freak they pay tribute to Freud.

Freud’s model of psychosexual development takes shape through five stages. If a child’s development is arrested in a particular stage, then that child will manifest certain behaviors in adulthood.

The first stage is the oral stage which is marked by a fixation with the mouth. This stage lasts from birth through about the first year and a half and arrested development here results in passivity or excessive eating or smoking.

The second stage is the anal stage which is concerned with the elimination of bladder and bowel functions; lasting from ages 18 months through about 3 years old, those whose development have stopped here often exhibit obsessions with neatness (anal-retentive) or are excessively reckless and disorganized (anal-expulsive).

The third stage is the phallic stage which focuses on the genitals and lasts from ages 3 to 6. It is in this stage the boys deal with the Oedipus Conflict or girls deal with the Electra Complex (that is, identification or love for the opposite parent (sexual love) and hatred of the same sex parent who dominates the attention).

The fourth stage, latency, lasts from 6 to puberty and everyone gets a break from fixations.

The final stage is the genital stage which begins in puberty and lasts through adulthood and our sexual interests are thought to mature. However, given Freud’s fixation with fixations it is a wonder that any of us ever really reach this stage where our libidinal energy can focus on the tasks at hand.

This has been a brief review of Freudian thought; feel free to add anything I might have missed…

For further review: The Freud Reader, Freud: A Very Short Introduction

Taking the LCSW Exam

I am taking the National Clinical Social Worker exam in late July. So far, most of the online resources that I have found have been either boring or full of editing mistakes. Therefore, I am going to try and write up as much of the material I can before the late July and post it here for myself and others who might want the resources without the hassles. Feel free to comment, request or add to the material I present.

I have the belief that all of those who are taking the test are in it together. Furthermore, those who come after us can benefit from the wisdom and studies of those who have completed the clincal requirements and preparing for the exam. Therefore, let us contribute wisely and succinctly from our reading and our experiences.

I will probably alternate between posting psychotherapuetic theories and DSM-IV disorders. I would appreciate additional information from anyone who has studied for the research, ethics and HIPPA portions of the test.