Disaster Crisis Counseling Program

Crisis Counseling Programs for the Rural Community
Disaster Crisis Counseling Program
The Nature of Disasters
Definition of a Federal Disaster Declaration

The Federal Emergency Management Agency (FEMA) provides supplemental funding to States for short-term crisis counseling projects to assist survivors/victims of Presidentially declared major disasters. FEMA supplements, but does not supplant, mental health services traditionally provided by State and local mental health agencies. The Crisis Counseling Assistance and Training Program (commonly referred to as the Crisis Counseling Program) was first authorized by the U.S. Congress under the Disaster Relief Act of 1974 (Public Law 93-288) and later modified by the Robert T. Stafford Disaster Relief and Emergency Assistance Act of 1988 (Public Law 100-707). FEMA is responsible for administering the disaster assistance programs of the Stafford Act, including Federal assistance for crisis counseling services.

A major disaster, as defined by the Stafford Act, is any natural catastrophe, or regardless of cause, any fire, flood, or explosion, which in the determination of the President causes damage of sufficient severity and magnitude to warrant major disaster assistance to supplement efforts and available resources of States, local government, and disaster relief organizations in alleviating the damage, loss, hardship, or suffering caused by the disaster.

Disaster Types

Different types of disasters covered by the Stafford Act that may impact rural areas include: hurricane, tornado, storm, high water, wind driven water, tidal wave, tsunami, earthquake, volcanic eruption, landslide, mudslide, snowstorm, drought, fire, flood, or explosion. Disasters also differ by a number of characteristics including the following:

Origin of disaster (natural versus human-caused)


Length of warning time

Intensity of the event

Extent of property damage

Number of persons impacted

Number of injuries and deaths

Dynamics of the recovery period
Each type of disaster has its own unique pattern of destruction and characteristics that affect the emotional response of disaster victims (NIMH, 1983):

Flood disasters can result in long incident periods and the evacuation of whole communities.

Earthquakes strike without warning and after shocks intensify fright and despair.

Tornadoes randomly choose their victims, skipping one house and striking the next.

Hurricanes can be unpredictable and suddenly change course causing the evacuation of large areas.
Disasters may be classified as either natural or human-caused. The following chart describes the different characteristics of natural and human-caused disasters. Blame is a characteristic that differs significantly for natural and human-caused disasters. Disaster survivors of human-caused disasters may blame and feel anger toward individuals, groups, or organizations they believe caused or contributed to the disaster. In contrast, survivors of natural disasters may blame and feel anger toward themselves, believe it is "God's Will" or a punishment. Survivors of natural disasters may project their anger onto caretakers, disaster workers, or others (CMHS, 1996).


Natural vs. Human-Caused Disasters

Natural Human-Caused
Causes Forces of nature Human error, malfunctioning
Examples Earthquakes, hurricanes, floods Airplane crashes, major chemical leaks, nuclear reactor accidents
Blame No one Person, government, business
Scope Various locations Locations may be inaccessible to rescuers, unfamiliar to survivors, little advance warning
Post-disaster
Distress High Higher, often felt by family members not involved in actual disaster

Source: CMHS. Psychosocial Issues for Children and Families in Disasters. A Guide for the Primary Care Physician. Washington, D.C.: U.S. Department of Health and Human Services; Publication No. (SMA) 96-3077, 1996.


Definition of Crisis Counseling Services
The Crisis Counseling Program, as it has been supported in the past twenty-five years by the Federal government, provides for short-term interventions with individuals and groups experiencing psychological sequelae from Presidentially-declared disasters. This type of intervention involves classic counseling goals of helping people to understand their current situation and reactions, assisting in the review of their options, providing emotional support, and encouraging linkage with other resources and agencies who may assist the individual. The assistance is focused upon helping the person deal with the current situation in which they may find themselves.

It draws upon the assumption, until there are contradictory indications, that the individual can resume a productive and fulfilling life following the disaster experience if given support, assistance, and information at a time and in a manner appropriate to his or her experience, education, developmental stage, and ethnicity (CMHS, 1994.

The Emergency Services and Disaster Relief Branch (ESDRB) of the Center for Mental Health Services (CMHS) will provide technical assistance to states in developing a grant request.
The ESDRB can be reached by phone at (301) 443-4735.
The Crisis Counseling Program is unique in comparison to the mix of Federal programs made available through a Presidential disaster declaration. It is the one program for which virtually anyone qualifies and where the person affected by disaster does not have to recall numbers, estimate damages, or otherwise justify need. The program provides primary assistance in dealing with the emotional sequelae to disaster.

Robert T. Stafford Act

The Stafford Act authorizes the President to provide training and services to alleviate mental health problems caused or aggravated by declared disasters. The Crisis Counseling Program is designed to provide supplemental funding to States for short-term crisis counseling services and is implemented when creating such services are beyond the resources of the State or local providers, given a Presidential disaster declaration.

FEMA may fund two separate portions of the Crisis Counseling Program: Immediate Services (IS) and Regular Services (RS). The IS grant enables the State and its local agency to respond to the immediate mental health needs with crisis counseling services. IS can be funded for up to sixty days after the Presidential declaration. If an RS application has been submitted, the program period for the immediate services may be extended thirty days and additional funding may be awarded. FEMA may approve a longer extension, if the review process of the regular program application exceeds thirty days. Costs incurred from the date of the incident to the date of declaration may be reimbursable under the immediate services program. The RS provides up to nine months of crisis counseling services, community outreach, and consultation and education services to people affected by the disaster. Funding for RS is separate from IS. The State may apply for either or both portions of the Crisis Counseling Program.

Application for IS funding must be completed within fourteen days of the disaster declaration. The application must contain a disaster description, needs assessment, program plan, budget, and budget narrative. The needs assessment is based on the needs of the affected communities and the ability of the current mental health system to respond to those needs. A State must demonstrate that State and local resources are insufficient to provide adequate services.

Differences Between Disaster Mental Health and Traditional Mental Health Programs

Disaster Crisis Counseling Programs are a departure from traditional mental health practice in many ways. The program is designed to address incident specific stress reactions, rather than ongoing or developmental mental health needs (CMHS, 1994). Programs must be structured and implemented according to Federally established guidelines and for a specific period. Emphasis is on serving individuals, families, and groups of people - all of whom share a devastating event that most likely changed the face of their entire community.

CRISIS COUNSELING PROGRAM
Immediate Services
Application due in fourteen days
Sixty-day program
Extension if RS is applied for
Regular Services
Apply within sixty days of declaration
Nine month program
Applications must include
Disaster description
Needs Assessment
Program Plan
Budget
Budget narrative
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crisis counseling ceus

Outreach and crisis counseling activities are the core of the Crisis Counseling Program and create a unique set of challenges. Disaster crisis counseling requires breaking out of traditional ways of identifying people in need of services, providing access to those services, maintaining documentation, and determining effectiveness. Mental health professionals will work hand-in-hand with paraprofessionals, volunteers, community leaders, and survivors/victims of the disaster in ways that may be foreign to their clinical training. This publication will focus on the implementation of appropriate crisis counseling services for rural communities across the United States.

After The Disaster: A Children’s Mental Health Checklist

After The Disaster: A Children’s Mental Health Checklist

Disasters can be particularly traumatic to children. Sometimes, it can be difficult to determine the extent of the psychological trauma, and whether or not professional mental health services are indicated. This checklist is one way to assess a child’s mental health status.

Add up the pluses and minuses to obtain a final score. If the child scores more than 35, it is suggested you seek a mental health consultation.

Has the child had more than one major stress within a year BEFORE this disaster, such as a death in the family, a molestation, a major physical illness or divorce? If yes: +5


Does the child have a network of supportive, caring persons who continue to relate to him daily? If yes: -10


Has the child had to move out of his house because of the disaster? If yes: +5


Was there reliable housing within one week of the earthquake with resumption of the usual household members living together? If yes: -10


Is the child showing severe disobedience or delinquency? If yes: +5
Is the child showing any of the following as NEW behaviors for more than three weeks after the disaster?

Nightly states of terror? +5


Waking from dreams confused or in a sweat? +5


Difficulty concentrating? +5


Extreme irritability? +5


Loss of previous achievements in toilet or speech? +5


Onset of stuttering or lisping? +5


Persistent severe anxiety or phobias? +5


Obstinacy? +5


New or exaggerated fears? +5


Rituals or compulsions? +5


Severe clinging to adults? +5


Inability to fall asleep or stay asleep? +5


Startling at any reminder of the disaster? +5


Loss of ambition for the future? +5


Loss of pleasure in usual activities? +5


Loss of curiosity? +5


Persistent sadness or crying? +5


Persistent headaches or stomach aches? +5


Hypochondria? +5


Has anyone in the child’s immediate family been killed or severely injured in the disaster (including severe injury to the child)? +15
Note: Preoccupation with death, unusual accident proneness or suicidal threats are reasons for immediate consultations. It is also recommended that any child who has been seriously injured or who has lost a parent, sibling or caregiver by death, have a psychological evaluation and/or brief therapy.

Note: This checklist was developed under the auspices of Project COPE, a federal funded (FEMA) crisis counseling program activated in Santa Cruz, California, in response to the October 17, 1989 Loma Prieta Earthquake. The project provided individual, family and group counseling, agency debriefing services and a school intervention program. Over the course of 16 months, the project provided services to more than 25,000 individuals. Peter J. Spofford, M.S. served as Project COPE Director.

Questions to Help Children Talk About a Disaster

Emergency Mental Health and Traumatic Stress
Tips for Teachers
Questions to Help Children Talk About a Disaster
Disasters hit children hard. It is difficult for them to understand and accept that there are events in their lives that cannot be predicted or controlled. Perhaps worst of all, we as adults cannot "fix" a disaster, solve it, or keep it from happening again.

As a classroom teacher, you can play an important role in the healing process of children who are affected by a disaster. One technique you can use to help children cope and heal is to assist them in expressing their experiences and feelings by talking. This technique works best when you use "open-ended" questions that require more than a "yes" or "no" answer. There are many leading questions you can use to encourage children to talk, such as:

Where were you and what were you doing when the disaster happened?
What was your first thought when it happened?
What did other people around you do during/after the disaster?
Was anyone you know hurt or killed?
Did/do you dream about the disaster?
What reminds you of the disaster?
What do you do differently since the disaster?
How do you feel now?
How have you gotten through rough times before?
What, if anything, would you do differently if this happened again?
As the children begin to open up, encourage various views. Acknowledge their experiences and reassure them that what they are feeling is "normal." Play a guiding role, rather than trying to control the discussions.

Allow children with low language skills, shyness, or discomfort to be silent. It might be helpful to encourage peer support for these children. If a child has limited English-language skills, consider asking for a translator to help the child express him/herself. Create an atmosphere in which a child can feel comfortable sharing experiences and feelings in any language. The goal of the process is to help children feel better. If any of your students show serious signs of distress, consult a school counselor or mental health professional.

Disaster counseling

DISASTER COUNSELING SKILLS

Disaster counseling involves both listening and guiding. Survivors typically benefit from both talking about their disaster experiences and being assisted with problem-solving and referral to resources. The following section provides "nuts-and-bolts" suggestions for workers.

ESTABLISHING RAPPORT

Survivors respond when workers offer caring eye contact, a calm presence, and are able to listen with their hearts. Rapport refers to the feelings of interest and understanding that develop when genuine concern is shown. Conveying respect and being nonjudgmental are necessary ingredients for building rapport.

ACTIVE LISTENING

Workers listen most effectively when they take in information through their ears, eyes, and "extrasensory radar" to better understand the survivor's situation and needs. Some tips for listening are:

Allow silence - Silence gives the survivor time to reflect and become aware of feelings. Silence can prompt the survivor to elaborate. Simply "being with" the survivor and their experience is supportive.

Attend nonverbally - Eye contact, head nodding, caring facial expressions, and occasional "uh-huhs" let the survivor know that the worker is in tune with them.

Paraphrase - When the worker repeats portions of what the survivor has said, understanding, interest, and empathy are conveyed. Paraphrasing also checks for accuracy, clarifies misunderstandings, and lets the survivor know that he or she is being heard. Good lead-ins are: "So you are saying that . . . " or "I have heard you say that . . . "

Reflect feelings - The worker may notice that the survivor's tone of voice or nonverbal gestures suggests anger, sadness, or fear. Possible responses are, "You sound angry, scared etc., does that fit for you?" This helps the survivor identify and articulate his or her emotions.

Allow expression of emotions - Expressing intense emotions through tears or angry venting is an important part of healing; it often helps the survivor work through feelings so that he or she can better engage in constructive problem-solving. Workers should stay relaxed, breathe, and let the survivor know that it is OK to feel.

SOME DO'S AND DON'T'S

Do say:


These are normal reactions to a disaster.

It is understandable that you feel this way.

You are not going crazy.

It wasn't your fault, you did the best you could.

Things may never be the same, but they will get better, and you will feel better.


Don't say:

It could have been worse.

You can always get another pet/car/house.

It's best if you just stay busy.

I know just how you feel.

You need to get on with your life.

The human desire to try to fix the survivor's painful situation or make the survivor feel better often underlies the preceding "Don't say" list. However, as a result of receiving comments such as these, the survivor may feel discounted, not understood, or more alone. It is best when workers allow survivors their own experiences, feelings, and perspectives.

Helping Children and Youth With Bipolar Disorder

Helping Children and Youth With Bipolar Disorder: Systems of Care
This fact sheet provides basic information on bipolar disorder in children and describes an approach to getting services and supports, called “systems of care,” that helps children, youth, and families thrive at home, in school, in the community, and throughout life.

What Is Bipolar Disorder?
Bipolar disorder is a brain disorder that causes persistent, overwhelming, and uncontrollable changes in moods, activities, thoughts, and behaviors. A child has a much greater chance of having bipolar disorder if there is a family history of the disorder or depression. This means that parents cannot choose whether or not their children will have bipolar disorder.

Although bipolar disorder affects at least 750,000 children in the United States 1 , it is often difficult to recognize and diagnose in children. If left untreated, the disorder puts a child at risk for school failure, drug abuse, and suicide. That is why it is important that you seek the advice of a qualified professional when trying to find out if your child has bipolar disorder.

Symptoms of bipolar disorder can be mistaken for other medical/mental health conditions, and children with bipolar disorder can have other mental health needs at the same time. Other disorders that can occur at the same time as bipolar disorder include, but are not limited to, attention-deficit/hyperactivity disorder, conduct disorder, oppositional defiant disorder, anxiety disorders, autistic spectrum disorders, and drug abuse disorders. The roles that a family’s culture and language play in how causes and symptoms are perceived and then described to a mental health care provider are important, too. Misperceptions and misunderstandings can lead to delayed diagnoses, misdiagnoses, or no diagnoses—which are serious problems when a child needs help. That is why it is important that supports be in place to bridge differences in language and culture. Once bipolar disorder is properly diagnosed, treatment can begin to help children and adolescents with bipolar disorder live productive and fulfilling lives.

What Are the Signs of Bipolar Disorder?
Unlike some health problems where different people experience the same symptoms, children experience bipolar disorder differently. Often, children with the illness experience mood swings that alternate, or cycle, between periods of “highs” and “lows,” called “mania” and “depression,” with varying moods in between. These cycles can happen much more rapidly than in adults, sometimes occurring many times within a day. Mental health experts differ in their interpretation of what symptoms children experience. The following are commonly reported signs of bipolar disorder:

Excessively elevated moods alternating with periods of depressed or irritable moods;
Periods of high, goal-directed activity, and/or physical agitation;
Racing thoughts and speaking very fast;
Unusual/erratic sleep patterns and/or a decreased need for sleep;
Difficulty settling as babies;
Severe temper tantrums, sometimes called “rages”;
Excessive involvement in pleasurable activities, daredevil behavior, and/or grandiose, “super-confident” thinking and behaviors;
Impulsivity and/or distractibility;
Inappropriate sexual activity, even at very young ages;
Hallucinations and/or delusions;
Suicidal thoughts and/or talks of killing self; and
Inflexible, oppositional/defiant, and extremely irritable behavior.
What Happens After a Bipolar Disorder Diagnosis?
If a qualified mental health provider has diagnosed your child with bipolar disorder, the provider may suggest several different treatment options, including strategies for managing behaviors, medications, and/or talk therapy. Your child’s mental health care provider may also suggest enrolling in a system of care, if one is available.

What Is a System of Care?
A system of care is a coordinated network of community-based services and supports that are organized to meet the challenges of children and youth with serious mental health needs and their families. Families, children, and youth work in partnership with public and private organizations so services and supports are effective, build on the strengths of individuals, and address each person’s cultural and linguistic needs. Specifically, a system of care can help by:

Tailoring services to the unique needs of your child and family;
Making services and supports available in your language and connecting you with professionals who respect your values and beliefs;
Encouraging you and your child to play as much of a role in the design of a treatment plan as you want; and
Providing services from within your community, whenever possible.
How Can I Find a System of Care for My Child With Bipolar Disorder?
Contact the system of care community in the box on the back of this fact sheet. If none is listed or that system of care community is not in your area, visit mentalhealth.samhsa.gov/cmhs and click “Child, Adolescent & Family” and then “Systems of Care” to locate a system of care close to you. If you prefer to speak to someone in person to locate a system of care, or if there is not a system of care in your area, contact the National Mental Health Information Center by calling toll-free 1.800.789.2647 or visiting mentalhealth.samhsa.gov.

Are Systems of Care Effective?
National data collected for more than a decade support what families in systems of care have been saying: Systems of care work. Data from systems of care related to children and youth with bipolar disorder reflect the following:

Children and youth demonstrate improvement in emotional and behavioral functioning.
Caregivers report that children and youth have a reduction in conflicts with others in the family.
Caregivers experience an increased ability to do their jobs.
Caregivers report fewer missed days and a reduction in tardiness from work.
Children and youth with bipolar disorder improve in school-related tasks, such as paying attention in class, taking notes, and completing assignments on time.
Children and youth with bipolar disorder have fewer contacts with the juvenile justice system after enrolling in a system of care.
The Core Values of Systems of Care
Although systems of care may be different for each community, all share three core values. These values play an important role in ensuring that services and supports are effective and responsive to the needs of each child, youth, and family. These core values are:

Systems of care are family-driven and youth-guided.
Systems of care are culturally and linguistically competent.
Systems of care are community-based.
Austin’s Story
At age 12, Austin appears to be a typical sixth grader—he likes to play basketball and video games, and is enrolled in an after-school horseback riding program. He is an honor roll student, and his mother describes him as compassionate, loyal, and a champion for the “underdog.” Austin and his family also manage the challenges of bipolar disorder each day.

Austin was diagnosed in first grade with attention-deficit/hyperactivity disorder and separation anxiety disorder, but Austin’s mother, Kim, recalls a series of incidents that led her to question whether her son’s mental health needs were being met. At age 9, Austin set two fires within a week. The first time it happened, Kim thought it was an isolated incident that would not be repeated— Austin said he was lighting candles.

The second time Austin set a fire, however, the situation was very different. While bringing groceries into the house, Austin set a small fire in the car. When Kim discovered signs of the fire the next morning, she says, “I immediately got on the phone and started calling his physician. Thoughts were flashing through my mind about what could have happened.”

After Kim received a referral from Austin’s physician for diagnostic testing and other mental health services, she learned that her son had been experiencing hallucinations, which were causing him to set the fires. She also learned that his extreme mood swings, as well as his unusual sleep patterns, were signs of bipolar disorder. As a result, Austin was hospitalized for 20 days and diagnosed with bipolar disorder. During this time, Austin was accepted into a system of care through a referral from his school guidance counselor.

Kim says the system of care played an important role in helping Austin make the transition from the hospital to his home—even providing transportation, as Kim’s car was being repaired at the time. System of care staff helped Kim learn more about her son’s disorder. They also helped her locate services and supports tailored to Austin’s needs, including counseling, health care, specialized schooling, after-school programs, transportation, and child care.

The system of care also empowered Kim to be a more effective advocate for Austin’s needs. Before joining the system of care, she says, “I tried to fit the service to the need, rather than fit the need to the service. That was a mistake.”

Kim also assumed that professionals were best able to determine how to meet her child’s needs. After working in partnership with the system of care, Kim now knows that services and supports should be responsive to Austin’s needs and that her and her son’s input into the services and supports is crucial.

Despite the successes her family has had, Kim emphasizes that the journey to wellness is not over. In addition to coping with the symptoms of bipolar disorder, she and Austin also must overcome the stigma associated with mental illnesses. Together, Kim and Austin counter this stigma by educating others that he, and others with mental illnesses, should be known for who they are rather than the disorders they happen to have. Despite the ongoing challenges of stigma and bipolar disorder, Kim believes that the system of care has made a huge difference in terms of helping her family move forward.

What Steps Are Necessary To Enroll in a System of Care?
Although each community’s system of care is different, most children and youth in a system of care go through the following steps to be enrolled:

Step One: Diagnosis and Referral—To be considered for system of care enrollment, your child must have a diagnosed behavioral, emotional, or mental health disorder that severely affects his or her life. Additionally, most children and youth are referred to a system of care by mental health providers, educators, juvenile justice professionals, child welfare professionals, physicians, and others who might already be serving your child.

Step Two: Assessment and Intake—Once your child has been diagnosed and has been referred to the system of care, the system of care may ask you to answer some questions that will help you determine whether or not your child and family are eligible to receive services and supports. If your child and family are eligible, you may have to answer more questions so the system of care can begin to understand your needs. Throughout these steps, the system of care will work with you to fill out all of the necessary paperwork.

Step Three: Care Planning and Partnership Building—After your child and family are enrolled, the system of care will work with you to determine what services and supports best fit your child’s and family’s needs. Once the care planning is complete, the system of care will develop partnerships among you and all of those who are helping your child and family to ensure that services and supports are as effective as possible.

NBCC CEUs

Aspira Continuing Education http://www.aspirace.com is NBCC certified.
Mission
The National Board for Certified Counselors (NBCC) is the nation's premier professional certification board devoted to credentialing counselors who meet standards for the general and specialty practices of professional counseling.


History of NBCC

Thomas Clawson, Ed.D.
President and CEOThe National Board for Certified Counselors, Inc. and Affiliates (NBCC), an independent not-for-profit credentialing body for counselors, was incorporated in 1982 to establish and monitor a national certification system, to identify those counselors who have voluntarily sought and obtained certification, and to maintain a register of those counselors.

NBCC's certification program recognizes counselors who have met predetermined standards in their training, experience, and performance on the National Counselor Examination for Licensure and Certification (NCE), the most portable credentialing examination in counseling. NBCC has approximately 42,000 certified counselors. These counselors live and work in the US and over 50 countries. Our examinations are used by more than 48 states, the District of Columbia, and Guam to credential counselors on a state level.

NBCC was initially created after the work of a committee of the American Counseling Association (ACA). The committee created NBCC to be an independent credentialing body. NBCC and ACA have strong historical ties and work together to further the profession of counseling. However, the two organizations are completely separate entities with different goals.

•ACA concentrates on membership association activities such as conferences, professional development, publications, and government relations.
•NBCC focuses on promoting quality counseling through certification. In addition, NBCC promotes professional counseling to private and government organizations.
NBCC's flagship credential is the National Certified Counselor (NCC). NBCC also offers specialty certification in several areas:

•School counseling - The National Certified School Counselor (NCSC)
•Clinical mental health counseling - The Certified Clinical Mental Health Counselor (CCMHC)
•Addictions counseling - The Master Addictions Counselor (MAC)
The NCC is a prerequisite or co-requisite for the specialty credentials.

NBCC's Accreditation
The National Board for Certified Counselors is accredited by the National Commission for Certifying Agencies (NCCA), the accrediting body for the National Organization for Competency Assurance (NOCA). NOCA is the leader in setting quality standards for credentialing organizations.

For confirmation of this accreditation, as well as descriptions of the services and missions of NOCA and NCCA, please feel free to visit NOCA's website at www.noca.org.

Statistics on NCCs
Statistical information based on active certificants as of 12/30/2008
NCC
CCMHC
NCCC
NCGC
NCSC
MAC

43960
1088
540
148
2287
642


NCC - National Certified Counselor
CCMHC - Certified Clinical Mental Health Counselor
MAC - Master Addictions Counselor
NCCC - National Certified Career Counselor
NCGC - National Certified Gerontological Counselor
NCSC - National Certified School Counselor

Benefits of Becoming an NCC
National certification can be a continuing source of career enhancement and pride for you as a counseling professional.

What the NCC Credential Does for You

•Generates client referrals for you through CounselorFind, NBCC's referral service linking potential clients to nearby NCCs.
•Travels with you when you relocate in or outside the US.
•Keeps you in touch with current professional credentialing issues and events through The National Certified Counselor, NBCC's newsletter.
•Advances your professional accountability and visibility.
•Ensures a national standard developed by counselors, not legislators.
•Supports the rights of NCCs to use testing instruments in practice through NBCC’s participation in the National Fair Access Coalition on Testing (FACT).
•Offers, through Lockton Affinity, liability insurance to NCCs at bargain rates.
•Allows online access to verification of national certification through the NBCC Registry.

Trauma and PTSD Continuing Ed

Supporting the Survivor

A guide to understanding the impact of violent trauma on your loved ones and how you can help them

for more information on this topic, visit website below
Trauma and PTSD ceus, mft ceu, lcsw ceu, lpc ceuIn the United States, your odds of falling victim to violence at some point in your lifetime are high. Even if you don’t encounter violence directly, chances are that you know someone who has or will experience trauma. While a victim copes with the direct impact of trauma, those close to the victim also struggle in the aftermath. What do I say? What do I do? Why does my loved one seem so distant?

This brochure is intended to help you begin to understand what happens to many victims of violent crime and what you might do to help them along the healing process.

How Does Trauma Affect Survivors?
Victims of violence often face a wide range of struggles. They often question what has happened or what they may have done to cause or prevent it. Many wonder how they will heal and why they cannot connect with their loved ones as they once did. It is also common for survivors to feel anger or frustration as they ponder whether they will ever feel “normal” again. While every survivor’s experience is unique, violent trauma is almost always a life-changing experience that can affect everything from one’s ability to sleep to his or her ability to concentrate at work.

Understanding the nature and impact of trauma can be key to helping your loved one. Many survivors find themselves in unfamiliar and distressing psychological territory. It is common for them to endure intense feelings of isolation, insecurity, and fear, and their most treasured relationships often suffer as a result. Trauma can also lead to Post Traumatic Stress Disorder (PTSD), which may include both substance abuse and mental health problems.

Violent Trauma, Substance Abuse, and Mental Health Concerns
Many victims turn to alcohol or other substances in an attempt to get some relief from their emotional turmoil and suffering. All trauma survivors manage their experiences in different ways. However, substance abuse is not only ineffective in healing from trauma, but it also can present a host of additional problems that make the healing process even more difficult.

Violence is also a widely recognized catalyst for mental health concerns such as PTSD, a condition that can be caused by experiencing or observing virtually any kind of deep emotional or physical trauma. Millions of people in the United States suffer from PTSD, resulting from many different types of trauma—from enduring years of domestic violence to a single violent attack that lasts but a few seconds. PTSD is characterized by both emotional and physical suffering; many afflicted by it find themselves unintentionally revisiting their trauma through flashbacks or nightmares. PTSD can make a survivor feel isolated, disconnected, and “different” from other people, and it can even begin to affect the most routine activities of everyday life. Psychologists and counselors with experience in treating trauma survivors can be very helpful in working through PTSD, and there are prescription drugs available to help ease PTSD symptoms. PTSD is a potentially serious condition that should not be taken lightly.

According to a recent study conducted by the U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, the most effective way to combat trauma, substance abuse, and mental health problems is through an integrated, holistic approach, taking into account how each individual problem affects the others. To begin, it can be helpful for a survivor to share experiences and concerns with a service provider who can assist in developing a plan to address these struggles comprehensively.

Many wonder how they will heal and why they cannot connect with their loved ones as they once did.

What Can I Do to Help My Loved One?
Since each individual’s experience is unique, there is no one-size-fits-all remedy for victimized loved ones. For those who care about a person who has experienced a violent trauma, finding ways to be helpful and maintaining a healthy relationship can be challenging. Following are some tips to help your loved one who has been victimized.

Listen . Talking about the experience, when the survivor is ready, will help acknowledge and validate what has happened to him or her and can reduce stress and feelings of isolation. Let your loved one take the lead, and try not to jump in with too many comments or questions right away.

Research . If the victim wants more information, would like to report a crime, or has other questions, you can help find answers and resources.

Reassure . As strange as it may sound, survivors often question whether an incident was their fault or what they could have done to prevent the crime against them. They may need to hear that it was not their fault and be assured that they are not alone.

Empower . Following trauma, victims can feel as though much of their lives is beyond their control. Aiding them in maintaining routines can be helpful, as can offering survivors options or possible solutions.

Be patient . Every journey through the healing process is unique. Try to understand that it will take time, and do what you can to be supportive. The healing process has no pre-determined timeline.

Ask . Your loved one may need help with any number of things or have questions on many different topics. Even a favor as mundane as running a few errands or taking the dog for a walk can be a big help, so consider lending a hand.

ADHD Resources and CEUs

Attention-deficit/hyperactivity disorder, sometimes called ADHD, is a chronic condition and the most commonly diagnosed behavioral disorder among children and adolescents. It affects between 3 and 5 percent of school-aged children in a 6-month period (U.S. Department of Health and Human Services, 1999).

Children and adolescents with attention-deficit/hyperactivity disorder have difficulty controlling their behavior in school and social settings. They also tend to be accident-prone. Although some of these young people may not earn high grades in school, most have normal or above-normal intelligence.

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What are the signs of attention-deficit/hyperactivity disorder?

There are three different types of attention-deficit/hyperactivity disorder, and each has different symptoms. The types are inattentive, hyperactive-impulsive, and combined attention-deficit/hyperactivity disorder.

Children with the inattentive type may:


Have short attention spans.
Be distracted easily.
Not pay attention to details.
Make many mistakes.
Fail to finish things.
Have trouble remembering things.
Not seem to listen.
Not be able to stay organized.
Children with the hyperactive-impulsive type may:


Fidget and squirm.
Be unable to stay seated or play quietly.
Run or climb too much or when they should not.
Talk too much or when they should not.
Blurt out answers before questions are completed.
Have trouble taking turns.
Interrupt others.

The most common type is combined attention-deficit/hyperactivity disorder, which, as the name implies, is a combination of the inattentive and the hyperactive-impulsive types.

A diagnosis of one of the attention-deficit/hyperactivity disorders is usually made when children have several of the above symptoms that begin before age 7 and last at least 6 months. Generally, symptoms have to be observed in at least two different settings, such as home and school, before a diagnosis is made.

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How common is attention-deficit/hyperactivity disorder?

Attention-deficit/hyperactivity disorder is found in as many as one in every 20 children (U.S. Department of Health and Human Services, 1999). Boys are four 4 times more likely than girls to have the disorder (U.S. Department of Health and Human Services, 1999).

Children and adolescents with attention-deficit/hyperactivity disorder are at risk for many other mental disorders. About half of those with attention-deficit/hyperactivity disorder also have oppositional or conduct disorder, and about a fourth have an anxiety disorder. As many as one-third have depression, and about one-fifth have a learning disability. Sometimes children or adolescents will have two or more of these disorders in addition to attention-deficit/hyperactivity disorder. Children with attention-deficit/hyperactivity disorder are also at risk for developing personality and substance abuse disorders when they are adolescents or adults.

Attention-deficit/hyperactivity disorder is a major reason that children are referred for mental health services. Boys are more likely to be referred for treatment than girls, in part, because many boys with attention-deficit/hyperactivity disorder also have conduct disorder. Although mental health and special education services for children and adolescents with attention-deficit/hyperactivity disorder cost millions of dollars each year, in the long run, underachievement and lost productivity can be more costly for them and their families.

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What causes attention-deficit/hyperactivity disorder?

Many causes of attention-deficit/hyperactivity disorder have been studied, but no one cause seems to apply to all young people with the disorder. Viruses, harmful chemicals in the environment, genetics, problems during pregnancy or delivery, or anything that impairs brain development can play a role in causing the disorder.

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What help is available for families?

Many treatments, some with scientific basis and some without, have been recommended for children and adolescents with attention-deficit/hyperactivity disorder. Traditional approaches to treatment involve medications and/or behavior therapy.

Many types of medications have been used to treat attention deficit/hyperactivity disorder. The most widely used drugs are stimulants. Stimulants increase activity in parts of the brain that appear to be underactive in children and adolescents with attention-deficit/hyperactivity disorder. Experts believe that this is why stimulants improve attention and reduce impulsive, hyperactive, or aggressive behavior. For some children and adolescents, certain antidepressants may also help alleviate symptoms of the disorder. Tranquilizers also have been effective for some individuals. Care must be taken when prescribing and monitoring all medications, and it is important to note that these are not the only medications that may be prescribed for this disorder.

Like most medications, those used to treat attention-deficit/hyperactivity disorder have side effects. These medications may cause some children to lose weight, have reduced appetites, and temporarily grow more slowly. Others may have trouble falling asleep. However, many doctors believe the benefits of these medications outweigh the possible side effects. Often, health care providers can alleviate side effects by adjusting the dosage.

Another treatment approach, called behavior therapy, involves using techniques and strategies to modify the behavior of children with the disorder. Behavior therapy may include:


Instruction for parents and teachers on how to manage and modify children's or adolescents' behavior, such as rewarding good behaviors.
Daily report cards to link efforts between home and school, where parents reward children or adolescents for good school performance and behavior.
Summer and Saturday programs.
Special classrooms that use intensive behavior modification.
Specially trained classroom aides.
While a combination of stimulants and behavior therapy is believed to be helpful, it is not clear how long the benefits from this approach last. The Federal government's National Institute of Mental Health is supporting research on the long-term benefits of various treatments, as well as research to determine if medication and behavior treatment are more effective when combined. Ongoing research efforts also are aimed at identifying new medicines and treatments.

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Can attention-deficit/hyperactivity disorder be prevented?

Given that there are many suspected causes of attention-deficit/hyperactivity disorder, prevention may be difficult. However, as a precaution, it is always wise for expectant mothers to receive prenatal care and stay away from alcohol, tobacco, and other harmful chemicals during pregnancy. It also makes good sense for mothers to obtain good health care for their children. These recommendations may be particularly important when attention-deficit/hyperactivity disorder is suspected in other family members.

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What else can parents do?

When it comes to attention-deficit/hyperactivity disorder, parents and other caregivers should be careful not to jump to conclusions. A high energy level alone in a child or adolescent does not mean that he or she has attention-deficit/hyperactivity disorder. The diagnosis depends on whether the child or adolescent can focus well enough to complete tasks that suit his or her age and intelligence. This ability is most likely to be noticed by a teacher. Since some children with attention-deficit/hyperactive disorder have many different types of needs and often require special accommodations to help them function, input from teachers should be taken seriously.

If parents or caregivers suspect attention-deficit/hyperactivity disorder, they should:


Make an appointment with a psychiatrist, psychologist, child neurologist, or behavioral pediatrician for an evaluation. (Ask the child's doctor for a referral.)
Be patient if the young person is diagnosed with attention-deficit/hyperactivity disorder, and recognize that progress takes time.
Instill a sense of competence in the child or adolescent. Promote his or her strengths, talents, and feelings of self-worth.
Remember that, in many instances, failure, frustration, discouragement, low self-esteem, and depression cause more problems than the disorder itself.
Get accurate information from libraries, hotlines, or other sources.
Ask questions about treatments and services.
Talk with other families in their communities.
Find family network organizations.
People who are not satisfied with the mental health care they are receiving should discuss their concerns with the provider, ask for information, and/or seek help from other sources. It may take time for families and providers to find the right "mix" of services and supports that work best for a child. While treatment may not fully eliminate unwanted symptoms, most children with attention deficit/hyperactivity disorder do respond to medication and behavioral therapy.

Children with attention-deficit/hyperactivity disorder may qualify for free services within public schools. Most children with attention-deficit/hyperactivity disorder or other disabilities are eligible to receive special education services under the Individuals with Disabilities Education Act (IDEA). This act guarantees appropriate services and a public education to children ages 3 to 21 with disabilities.

This is one of many fact sheets in a series on children's mental health disorders. All the fact sheets listed below are written in an easy-to-read style. Families, caretakers, and media professionals may find them helpful when researching particular mental health disorders. To obtain free copies, call 1-800-789-2647 or visit http://mentalhealth.samhsa.gov/child.

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Other Fact Sheets in this Series are:

Order Number Title
CA-0000 Caring for Every Child's Mental Health Campaign Products Catalog
CA-0004 Child and Adolescent Mental Health
CA-0005 Child and Adolescent Mental Health: Glossary of Terms
CA-0006 Children and Adolescents With Mental, Emotional, and Behavioral Disorders
CA-0007 Children and Adolescents With Anxiety Disorders
CA-0009 Children and Adolescents With Autism
CA-0010 Children and Adolescents With Conduct Disorder
CA-0011 Children and Adolescents With Severe Depression
CA-0014 Facts About Systems of Care for Children's Mental Health

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Important Messages About Children's and Adolescents' Mental Health:

Every child's mental health is important.
Many children have mental health problems.
These problems are real and painful and can be severe.
Mental health problems can be recognized and treated.
Caring families and communities working together can help.

LCSW CEUS

LCSW CEUS
Online Continuing Education for LMFT, MFTI, LCSW, ASW

Satisfy your CE requirements conveniently anywhere you have online access.
Take your test and even print your completion certificate at any time.
Take as much time as needed to complete the exam.
Take the exam as many times necessary to receive a 70% passing score.
Pay only after you have passed your exam.
Earn hours for passing exams based on books you may have already read.
Listen to selected audio courses directly from your computer or MP3 player.
Take some time to browse our courses, and become a part of the Aspira family.

Course Listing:

Domestic Violence/Spousal and Partner Abuse
Substance Abuse and Dependence
Law and Ethics (Califonia only)
HIV and Aids
Aging and Long Term Care
Child Abuse
Crisis Counseling
Cross Cultural Counseling
Managed Care
PTSD
Anxiety Disorders
Depressive Disorder
Medical Necessity
Cognitive Behavioral Therapy
Pychopharmacology
BipolarDisorder
Conflict Resolution
Anger Management
Assessment and Diagnosis
Elder Abuse
Family Therapy
Group Therapy
Human Sexuality

MFT CEUS and MFT Resources

MFT CEUS and MFT Resources

Online Continuing Education for LMFT, MFTI, LCSW, ASW

Satisfy your CE requirements conveniently anywhere you have online access.
Take your test and even print your completion certificate at any time.
Take as much time as needed to complete the exam.
Take the exam as many times necessary to receive a 70% passing score.
Pay only after you have passed your exam.
Earn hours for passing exams based on books you may have already read.
Listen to selected audio courses directly from your computer or MP3 player.
Take some time to browse our courses, and become a part of the Aspira family.

Course Listing:

Domestic Violence/Spousal and Partner Abuse
Substance Abuse and Dependence
Law and Ethics (Califonia only)
HIV and Aids
Aging and Long Term Care
Child Abuse
Crisis Counseling
Cross Cultural Counseling
Managed Care
PTSD
Anxiety Disorders
Depressive Disorder
Medical Necessity
Cognitive Behavioral Therapy
Pychopharmacology
BipolarDisorder
Conflict Resolution
Anger Management
Assessment and Diagnosis
Elder Abuse
Family Therapy
Group Therapy
Human Sexuality

Substance Abuse and Chemical Dependency Continuing Education CEU

B. Models of Preventive Services

Two well-known models of preventive services are used when referring to behavioral programming for public health or mental health promotion and substance use prevention. They are reviewed briefly here.

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The Public Health Model
Public health traditionally defines preventive services as “primary,” “secondary,” or “tertiary.” Primary preventive services, such as immunizations and programs related to tobacco, diet, and exercise, are intended to intervene before the onset of illness to prevent biologic onset of illness. Secondary preventive services include screening to detect disease before it becomes symptomatic, coupled with follow-up to arrest or eliminate the disease. The Pap test and mammography are medical examples of secondary prevention. Tertiary prevention refers to prevention of complications in persons known to be ill. Prevention of stroke through effective treatment of hypertension is an example of tertiary prevention. Much of disease management is tertiary prevention. In the public health model, the three levels of prevention are separate and distinct.

The Continuum of Health Care Model According to the Institute of Medicine (IOM)
When dealing with substance use and other behavioral disorders in clinical settings, the levels of prevention are less distinct than with physical illnesses. The tasks of identifying risk factors and detecting earlystage disease are usually accomplished by patient or family interview. Initial management of both risk and early stage disease is often conducted via patient and family counseling by the primary care provider. Thus, the continuum of the health care model is more practical than the public health model when dealing with preventive behavioral health services.

The continuum of health care model is drawn from a 1994 report of the Institute of Medicine (IOM) (Mrazek & Haggerty, eds., 1994), as originally proposed by Gordon (1983). It differs from the public health model in that it covers the full range of preventive, treatment, and maintenance services. There are three types of preventive services in the IOM model—universal, selective, and indicated. These do not correspond to the primary, secondary, and tertiary services in the public health model. Screening and follow-up preventive behavioral services correspond to secondary prevention within the public health model. Other preventive behavioral services, including most community-based services, correspond to primary or tertiary prevention.

Figure 1. Continuum of Health Care



Source: Reprinted with permission from Reducing Risks for Mental Disorders. Copyright 1994 by the National Academy of Sciences, Courtesy of the National Academy Press, Washington, DC.

In the IOM model, a “universal” preventive measure is an intervention that is applicable to or useful for everyone in the general population, such as all enrollees in a managed care organization. A “selective” preventive measure is desirable only when an individual is a member of a subgroup with above-average risk. An “indicated” preventive measure applies to persons who are found to manifest a risk factor that puts them at high risk (Mrazek & Haggerty, eds., 1994). All these categories describe individuals who have not been diagnosed with a disease.

Universal interventions, on a per-client basis, are relatively inexpensive services offered to the entire population of a lifestage group. They are conducted as a primary prevention or screening to identify sub-populations and individuals who need more intensive screening, preventive, or therapeutic services. A clinical example would be the provision of prenatal care as a universal service for all pregnant women. A behavioral health example would be the use of a simple screening protocol to identify depression in all adult patients at all primary care visits.

Selective interventions are more intensive services offered to subpopulations identified as having more risk factors than the general population, based on their age, gender, genetic history, condition, or situation. For example, more intensive breast cancer screening is provided for women with a family history of breast cancer. A behavioral health example would be offering smoking cessation programming to all smokers.

Indicated interventions are based on higher probability of developing a disease. They provide an intensive level of service to persons at extremely high risk or who already show asymptomatic, clinical, or demonstrable abnormality, but do not meet diagnostic criteria levels yet. Case management and intensive in-home assessment, health education, and counseling are examples of indicated interventions (Mrazek & Haggerty, eds., 1994).

Sometimes a universal service is a screening procedure provided to all, or a primary prevention procedure such as vaccinations for children. The selective service involves diagnostic procedures to confirm or deny a diagnosis, and the indicated service involves much more intensive, individualized services for those at highest risk.

The efficacy and cost-efficiency of preventive services depend on the entire array of universal, selective, and indicated service components. They also depend on the ability of the health care system to target and limit the more costly indicated interventions to those who could most benefit from them.

Appendix C to this report provides a more detailed presentation of the following policy, management, planning, and evaluation issues:

Translation of preventive behavioral research into health care practice
Assessment of the need for preventive services
Assessment of the efficacy of preventive services
Infrastructure and service components for preventive services
“General” vs. “Targeted” Services
Within this monograph, services are also classified into one of two categories, “general” and “targeted,” depending on the evidence base and the nature of the service. Those designated as “general” are supported by the evidence base as being appropriate for universal implementation by all health care systems. Services that are classified here as “targeted” appear to be appropriate for selected populations (e.g., selective or indicated populations if applying the IOM model), or they have a developing research base that is promising. “Targeted” services might also be social or educational interventions that could be provided by nonmedical staff to secure educational and social benefits.

C. Clinical vs. Community Preventive Services

Most preventive behavioral services are delivered in school and community settings, not health care settings (Schinke, Brounstein, & Gardner, 2002; DHHS, 1999). In a 1998 review of indicated preventive behavioral services for children and adolescents, Durlak and Wells (1997) used meta-analysis to review 177 programs—73 percent were in a school setting, compared with 23 percent that were mainly in medical settings. In a similar review published 1 year later by the same authors (Durlak & Wells, 1998), none of the programs was in a medical setting.

This report has been prepared to summarize and analyze the most promising preventive interventions (based on rigorous research studies) for consideration by health care organizations. Only interventions deliverable by health care systems are reviewed in this report. Most community preventive services are oriented toward school-age children, adolescents, and young adults—age groups with relatively low exposure to health care delivery settings. Such services generally are provided by and through schools and community organizations.

Health care settings, however, are effective in reaching pregnant women, infants, adults with major chronic medical illnesses, and those in need of surgical procedures. For example, these settings provide a place to address the behavioral needs of these patients through behavioral screening and preventive services, with follow-up in prescribed regimens of care. In this way, clinical preventive services for depression and substance abuse can reduce emergency room use and hospitalization (Olfson, Sing, & Schlesinger, 1999). Psychoeducational services also can speed recovery of postsurgical patients (Egbert, Battit, Welch, & Bartlett, 1964; Mumford, Schlesinger, & Glass, 1982).

It may not be incumbent upon health care delivery systems to provide highly specialized social and educational support services (Devine, O’Connor, Cook, Wenk, & Curtin, 1988), but health care delivery systems do have a role to play. Through their mental health and social work staff, they maintain working relationships with communitybased, social service, educational, and even correctional agencies to ensure they meet the needs of members of the health care delivery system.

D. Health Care Delivery System Provision of Preventive Behavioral Services

The need for behavioral services is substantial. Many who could benefit from treatment for these disorders do not receive care (Woodward et al., 1997; Harwood, Sullivan, & Malhorta, 2001).

Some of the lack of development of behavioral health services within health care delivery systems may be owing to the perception that mental health and substance use disorder services may be “softer” and therefore less effective than conventional medical therapy. However, the efficacy and cost-efficiency of these services is well established and has been recommended by multiple national organizations since at least the early 1990s (U.S. Preventive Services Task Force [USPSTF], 1996, 2002a, 2003).

The 1994 IOM report was titled Reducing Risks for Mental Disorders—Frontiers for Preventive Intervention Research (Mrazek & Haggerty, eds., 1994). A 1998 follow-up report, Preventing Mental Health and Substance Abuse Problems in Managed Care Settings (Mrazek, 1998), was completed in collaboration with the National Mental Health Association (NMHA). This report recommended widespread implementation of primary preventive programming to address five problem areas within health care systems:

Prevention of initial onset of unipolar major depression across the life span
Prevention of low birthweight and prevention of child maltreatment in children from birth to 2 years of age whose mothers are identified as being at high risk
Prevention of alcohol or drug abuse in children who have an alcohol- or drugabusing parent
Prevention of mental health problems in physically ill patients (comorbidity prevention)
Prevention of conduct disorders in young children
The 1999 Surgeon General Report was titled Mental Health: A Report of the Surgeon General (DHHS, 1999). Although the major focus of this report was care and management of mental disorders, all major preventive services were included.

SAMHSA published two recent prevention-related health care reports. The 2000 literature review titled Preventive Interventions Under Managed Care (Dorfman, 2000) used broader definitions of “prevention” and “mental health services” and recommended six interventions for managed care plans:

Prenatal and infancy home visits
Targeted cessation education and counseling for smokers—especially those who are pregnant
Targeted short-term mental health therapy
Self-care education for adults
Presurgical educational intervention with adults
Brief counseling and advice to reduce alcohol use
This new literature review retains four of the above services and omits numbers three and four on short-term mental health therapy and self-care. The companion document published in 2002 was titled Estimating the Cost of Preventive Services in Mental Health and Substance Abuse Under Managed Care (Broskowski & Smith, 2002). This report provided cost data for each of the services recommended in the 2000 literature review. It also featured, for each set of recommended services, a range of costs and options based on case mix and private versus public insurance coverage. It estimated the cost to managed care organizations (MCOs) to implement recommendations for four possible scenarios ranging from most expensive to least expensive, given drivers such as enrollment mix, staffing, staff salaries, and fixed and variable expenses. This report did not consider savings in other health care expenses. Even with the most expensive of cost profiles, the report did conclude that all six services could be fully implemented at a marginal cost of less than a 1 percent increase in cost, per member per month.

During this period, SAMHSA and the National Committee on Quality Assurance (NCQA)–sponsored Health Employer Data Information Set (HEDIS) program have attempted to bring preventive behavioral services to the attention of the managed care community. In response to market pressures to demonstrate high scores on HEDIS measures, the managed care community has taken giant strides to improve the care of patients with depression and has taken steps to enhance member adherence to prescribed regimens of care for diabetes.

In 1998, SAMHSA’s Center for Substance Abuse Prevention created the National Registry of Effective Programs (NREP) as a resource to help professionals in the field become better consumers of prevention programs (Schinke et al., 2002). NREP reviews and screens evidence-based programs (conceptually sound and/or theoretically driven by risk and protective factors) that, through an expert consensus review of research, demonstrate scientifically defensible evidence. NREP initially focused on substance use prevention but has expanded to include mental health; co-occurring mental health and substance use disorders; adolescent substance use treatment; mental health promotion; and adult mental health treatment. Many programs focus on school and family, but increasingly, programs from community coalitions and environmental programs are being identified as well implemented, well evaluated, and effective.

NREP evaluates programs for substance abuse prevention and treatment, co-occuring disorders, and mental health treatment, promotion, and prevention. After receiving published and unpublished program materials from candidates, NREP reviewers, drawn from 80 experts in relevant fields, rate each program according to 18 criteria for methodological rigor, and they also score programs for adoptability and usefulness to communities (Schinke et al., 2002). Based on the overall scoring, NREP categorizes programs as Model Programs, Effective Programs, Promising Programs, or Programs with Insufficient Current Support. Those wishing to learn more about Model Programs can visit www.modelprograms.samhsa.gov. At this site, there is also a link providing detailed information about NREP and the process for submitting a program for NREP review.

Despite these efforts, behavioral services— both preventive and therapeutic—still are not adequately identified, provided, or arranged by primary care practitioners. They also are not adequately promoted by health care systems. Brief screening instruments for alcohol and drug problems, for example, have been available for a number of years but are not widely used by practicing physicians (Duszynski, Nieto, & Vanente, 1995; National Center on Addiction and Substance Abuse at Columbia University, 2000). In a 2002 review, Garnick et al. (2002) conducted a telephone survey covering 434 MCOs in 60 market areas nationwide and secured useful responses from 92 percent of them. Only 14.9 percent of MCOs required any alcohol, drug, or mental health screening by primary care practitioners. Slightly more than half distributed practice guidelines that addressed mental illness, and approximately one third distributed substance use disorder practice guidelines.

DHHS’s 2003 campaign, Steps to a Healthier U.S., focuses on chronic disease prevention and health promotion with the goals of decreasing both the prevalence of certain chronic diseases and the risk factors that allow conditions to develop. This initiative aims to bring together local coalitions to establish model programs and policies that foster health behavior changes, encourage healthier lifestyle choices, and reduce disparities in health care.

In early 2003, SAMHSA published a review of the delivery of behavioral services by managed care organizations, based on 1999 data. This report, The Provision of Mental Health Services in Managed Care Organizations (Horgan et al., 2003), showed substantial variability from plan to plan, as well as substantial variability among health maintenance organizations (HMOs), pointof- service (POS) plans, and preferred provider organizations (PPOs). All MCOs provided behavioral services, but these services usually had limits and copayments that were more restrictive than for comparable medical services. Fewer than 10 percent required screening for behavioral disorders in primary care settings (Horgan et al., 2003).

Another SAMHSA report, also published early in 2003, offers some insight into discrepancies in coverage, comparing medical to behavioral services and discrepancies in policy and coverage, comparing therapeutic to preventive services. This report, titled Medical Necessity in Private Health Plans: Implications for Behavioral Health Care (Rosenbaum, Kamoie, Mauery, & Walitt, 2003), noted that services are covered by health insurance plans only if they are considered a “medical necessity.” The term medical necessity was defined differently for different services within each health plan, with due consideration given for each of the following five domains:

Contractual scope—whether the contract provides any coverage for certain procedures and treatments, such as preventive and maintenance treatments that are not necessary to restore a patient to “normal functioning.” This dimension preempts any other coverage decision.
Standards of practice—whether the treatment (as judged by the health plan) accords with professional standards of practice.
Patient safety and setting—whether the treatment will be delivered in the safest and least intrusive manner.
Medical service—whether the treatment is considered medical as opposed to social or nonmedical.
Cost—whether the treatment is considered cost-effective by the insurer (Rosenbaum et al., 2003).
The medical necessity report noted that Federal or State regulation is limited in covering how health insurance plans define medical necessity (Rosenbaum et al., 2003). This SAMHSA update is intended to build upon the reports noted above to further enhance implementation of preventive behavioral services in health care settings.

Women's Mental Health

Since the publication of Mental Health: A Report of the Surgeon General in 1999, an increasing body of evidence from the research base, public policy analysis, consumer advocacy, and health care practice has underscored the critical importance of mental health to the overall health of women—and to our Nation as a whole. Many advances have been made in our understanding of mental illnesses, effective treatments, and promising approaches for promoting mental health, resilience, and fulfilling lives for those living with mental illnesses. A key component of this progress has been the increased understanding of the critical role of gender in the risks, course, and treatment of mental illnesses. New research findings also have pointed to the effectiveness of a growing array of treatment options for mental illnesses and of a new model of treatment that is recovery-oriented, strengths-based, and includes the active participation of individuals in their treatment. The recent advances in the science and practice of women’s mental health provide an unprecedented opportunity to address the burden of mental illnesses on women’s lives and increase the capacity for recovery. However, for this knowledge to be effective, it must be translated into tangible actions that can promote change and support progress to improve the mental and overall health of our Nation’s women and girls. Thus, this report proposes the following actions:

Promote the widespread understanding that women’s mental health is an essential part of their overall health.
Improve the interface of primary care and mental health services for women.
Accelerate research to increase the knowledge base of the role of gender in mental health and to reduce the burden of mental illnesses in both women and men.
Increase gender and cultural diversity in academic research and medicine.
Support efforts to track the mental health, distress, and well-being of women and girls in national, State, and large community-based surveillance systems.
Decrease the amount of time it requires to translate research findings on women’s mental health into practice.
Recognize the unique prevalence of trauma, violence, and abuse in the lives and mental health of girls, women, and female veterans. Address their effects and support promising new approaches that enhance recovery.
Address the cultural and social disparities that place women at greater risk for certain mental illnesses by including considerations of these disparities in diagnosis and intervention and by investigating ways to increase cultural competence in treatment approaches.
Promote a recovery-oriented, strengths-based approach to treatment for women promulgated by the recommendations of the President’s New Freedom Commission.
Build resilience and protective factors to promote the mental health of girls and women and aid recovery.
Meet the mental health needs of girls and young women as part of overall health care.
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Incorporate gender issues and considerations in emergency preparedness and disaster planning, including mental health issues.
The Action Steps for Improving Women’s Mental Health represent a collaborative effort of women’s health experts across multiple agencies and offices of the U.S. Department of Health and Human Services (HHS) including the HHS Office on Women’s Health, Office of the Surgeon General, Substance Abuse and Mental Health Services Administration, Office of Minority Health, National Institute of Mental Health, National Institute on Drug Abuse, Indian Health Service, and Office of the Assistant Secretary for Policy and Evaluation. Its purpose is to spur positive changes. The hope is that policy planners, healthcare providers, researchers, and others will take up its suggested actions and help translate them into reality. In this way, we can promote improved mental health and a healthier future for the women and girls of America.

What is the difference between an Online Interactive CE Course and a Homestudy Course?

What is the difference between an Online Interactive CE Course and a Homestudy Course?
If you submit a completed course/exam to the CE provider via regular mail, then you have taken a homestudy course. If the course/exam is completed and submitted online, then the hours are approved as regular continuing education. Many state boards, such as the California Board of Behavioral Services, allow all required continuing education to be earned from online interactive continuing education courses. Check with your respective board to determine the amount of hours/units are permitted online.

Social Phobia

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Social phobia, also called social anxiety disorder, is diagnosed when people become overwhelmingly anxious and excessively self-conscious in everyday social situations. People with social phobia have an intense, persistent, and chronic fear of being watched and judged by others and of doing things that will embarrass them. They can worry for days or weeks before a dreaded situation. This fear may become so severe that it interferes with work, school, and other ordinary activities, and can make it hard to make and keep friends.

While many people with social phobia realize that their fears about being with people are excessive or unreasonable, they are unable to overcome them. Even if they manage to confront their fears and be around others, they are usually very anxious beforehand, are intensely uncomfortable throughout the encounter, and worry about how they were judged for hours afterward.

Social phobia can be limited to one situation (such as talking to people, eating or drinking, or writing on a blackboard in front of others) or may be so broad (such as in generalized social phobia) that the person experiences anxiety around almost anyone other than the family.

Physical symptoms that often accompany social phobia include blushing, profuse sweating, trembling, nausea, and difficulty talking. When these symptoms occur, people with social phobia feel as though all eyes are focused on them.

Social phobia affects about 15 million American adults.1 Women and men are equally likely to develop the disorder,10 which usually begins in childhood or early adolescence.2 There is some evidence that genetic factors are involved.11 Social phobia is often accompanied by other anxiety disorders or depression,2,4and substance abuse may develop if people try to self-medicate their anxiety.4,5

Social phobia can be successfully treated with certain kinds of psychotherapy or medications.

BUSINESS AND PROFESSIONS CODE OF CALIFORNIA

BUSINESS AND PROFESSIONS CODE OF CALIFORNIA
CHAPTER 13. MARRIAGE AND FAMILY THERAPISTS
ARTICLE 1. REGULATION
§4980. NECESSITY OF LICENSE
(a) Many California families and many individual Californians are experiencing difficulty and distress, and are in need of wise, competent, caring, compassionate, and effective counseling in order to enable them to improve and maintain healthy family relationships. Healthy individuals and healthy families and healthy relationships are inherently beneficial and crucial to a healthy society, and are our most precious and valuable natural resource. Marriage and family therapists provide a crucial support for the well-being of the people and the State of California. (b) No person may engage in the practice of marriage and family therapy as defined by Section 4980.02, unless he or she holds a valid license as a marriage and family therapist, or unless he or she is specifically exempted from that requirement, nor may any person advertise himself or herself as performing the services of a marriage, family, child, domestic, or marital consultant, or in any way use these or any similar titles, including the letters “M.F.T.” or “M.F.C.C.,” or other name, word initial, or symbol in connection with or following his or her name to imply that he or she performs these services without a license as provided by this chapter. Persons licensed under Article 4 (commencing with Section 4996) of Chapter 14 of Division 2, or under Chapter 6.6 (commencing with Section 2900) may engage in such practice or advertise that they practice marriage and family therapy but may not advertise that they hold the marriage and family therapist’s license.
§4980.01. CONSTRUCTION WITH OTHER LAWS; NONAPPLICATION TO CERTAIN PROFESSIONALS AND EMPLOYEES
(a) Nothing in this chapter shall be construed to constrict, limit, or withdraw the Medical Practice Act, the Social Work Licensing Law, the Nursing Practice Act, or the Psychology Licensing Act. (b) This chapter shall not apply to any priest, rabbi, or minister of the gospel of any religious denomination when performing counseling services as part of his or her pastoral or professional duties, or to any person who is admitted to practice law in the state, or who is licensed to practice medicine, when providing counseling services as part of his or her professional practice. (c) (1) This chapter shall not apply to an employee working in any of the following settings if his or her work is performed solely under the supervision of the employer: (A) A governmental entity. (B) A school, college, or university. (C) An institution that is both nonprofit and charitable. (2) This chapter shall not apply to a volunteer working in any of the settings described in paragraph (1) if his or her work is performed solely under the supervision of the entity, school, or institution.
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(d) A marriage and family therapist licensed under this chapter is a licentiate for purposes of paragraph (2) of subdivision (a) of Section 805, and thus is a health care practitioner subject to the provisions of Section 2290.5 pursuant to subdivision (b) of that section. (e) Notwithstanding subdivisions (b) and (c), all persons registered as interns or licensed under this chapter shall not be exempt from this chapter or the jurisdiction of the board
§4980.02. PRACTICE OF MARRIAGE, FAMILY AND CHILD COUNSELING; APPLICATION OF PRINCIPLES AND METHODS
For the purposes of this chapter, the practice of marriage and family therapy shall mean that service performed with individuals, couples, or groups wherein interpersonal relationships are examined for the purpose of achieving more adequate, satisfying, and productive marriage and family adjustments. This practice includes relationship and pre-marriage counseling. The application of marriage and family therapy principles and methods includes, but is not limited to, the use of applied psychotherapeutic techniques, to enable individuals to mature and grow within marriage and the family, the provision of explanations and interpretations of the psychosexual and psychosocial aspects of relationships, and the use, application, and integration of the coursework and training required by Sections 4980.36, 4980.37, and 4980.41.
§4980.03. DEFINITIONS
(a) "Board," as used in this chapter, means the Board of Behavioral Sciences. (b) "Intern," as used in this chapter, means an unlicensed person who has earned his or her master's or doctor's degree qualifying him or her for licensure and is registered with the board. (c) "Trainee," as used in this chapter, means an unlicensed person who is currently enrolled in a master's or doctor's degree program, as specified in Section 4980.36 and 4980.37, that is designed to qualify him or her for licensure under this chapter, and who has completed no less than 12 semester units or 18 quarter units of coursework in any qualifying degree program. (d) "Applicant," as used in this chapter, means an unlicensed person who has completed a master's or doctoral degree program, as specified in Section 4980.36 and 4980.37, and whose application for registration as an intern is pending, or an unlicensed person who has completed the requirements for licensure as specified in this chapter, is no longer registered with the board as an intern, and is currently in the examination process. (e) "Advertise," as used in this chapter, includes, but is not limited to, any public communication, as define din subdivision (a) of Section 651, the issuance of any card, sign, or device to any person, or the causing, permitting, or allowing of any sign or marking on, or in, any building or structure, or in any newspaper or magazine or in any directory, or any printed matter whatsoever, with or without any limiting qualification. Signs within church buildings or notices in church bulletins mailed to a congregation shall not be construed as advertising within the meaning of this chapter. (f) "Experience," as used in this chapter, means experience in interpersonal relationships, psychotherapy, marriage and family therapy, and professional enrichment activities that satisfies the requirement for licensure as a marriage and family therapist pursuant to Section 4980.40. (g) "Supervisor," as used in this chapter, means an individual who meets all of the following requirements:
(1) Has been licensed by a state regulatory agency for at least two years as a marriage and family therapist,
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licensed clinical social worker, licensed psychologist, or licensed physician certified in psychiatry by the American Board of Psychiatry and Neurology. (2) Has not provided therapeutic services to the trainee or intern. (3) Has a current and valid license that is not under suspension or probation. (4) Complies with supervision requirements established by this chapter and by board regulations. (h) "Client centered advocacy," as used in this chapter, includes, but is not limited to, researching, identifying, and accessing resources, or other activities, related to obtaining or providing services and supports for clients or groups of clients receiving psychotherapy or counseling services.
§4980.04. MARRIAGE AND FAMILY THERAPIST ACT
This chapter shall be known and may be cited as the Marriage and Family Therapist Act.
§4980.07. ADMINISTRATION OF CHAPTER
The board shall administer the provisions of this chapter.
§4980.08. LICENSE TITLE NAME CHANGE
(a) The title “licensed marriage, family and child counselor” or “marriage, family and child counselor” is hereby renamed “licensed marriage and family therapist” or “marriage and family therapist,” respectively. Any reference in any statute or regulation to a “licensed marriage, family and child counselor” or “marriage, family and child counselor” shall be deemed a reference to a “licensed marriage and family therapist” or “marriage and family therapist”. (b) Nothing in this section shall be construed to expand or constrict the scope of practice of a person licensed pursuant to this chapter. (c) This section shall become operative July 1, 1999.
§4980.10. ENGAGING IN PRACTICE
A person engages in the practice of marriage and family therapy who performs or offers to perform or holds himself or herself out as able to perform this service for remuneration in any form, including donations.
§4980.30. APPLICATION FOR LICENSE; PAYMENT OF FEE
Except as otherwise provided herein, a person desiring to practice and to advertise the performance of marriage and family therapy services shall apply to the board for a license, pay the license fee required by this chapter, and obtain a license from the board.
§4980.31. DISPLAY OF LICENSE
A licensee shall display his or her license in a conspicuous place in the licensee’s primary place of practice.

Depression and Mood Disorders

Depression and Mood Disorders
The Prevalence of Major Depression and Mood Disorders in Suicide

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Mental Health: A Report of the Surgeon General, states that "major depressive disorders account for about 20 to 35 percent of all deaths by suicide" (p. 244). This estimate is based on a review of psychological autopsies conducted by Angst, Angst, and Stassen (1999). This brief review is intended to address this prevalence estimate. It is important to note that this estimate refers only to the prevalence of major depressive disorder among those who commit suicide, not any other mood disorders (e.g., bipolar I & II, dysthymia, adjustment disorder with depressed mood). Prevalence estimates that include other mood disorders in addition to major depression are much higher.

Major depression in suicide
The lower bound of the 20-35% estimate of the prevalence of major depression in suicide is loosely based on one psychological autopsy study; a study where the reliability of the diagnoses are somewhat questionable. This study (Rich, Young & Fowler, 1986) of 204 subjects identified 15% of suicides as having major depressive disorder. However, an additional 30% were reported as having "atypical depression," defined in this study as having a depressive syndrome that followed the onset of substance use. If this ambiguously defined group were to be considered major depression, the estimate climbs to 45%. A number of other studies suggest that the prevalence of major depression in suicide is somewhat over 30%. The four other available psychological autopsy studies that include samples of suicides from the full age range and reliable diagnoses based on structured interviews (Arato, Demeter, Rihmer & Somogyi, 1988; Dorpat & Ripley, 1960; Foster, Gillespie, McClelland & Patterson, 1999; Henriksson et al., 1993) obtained prevalence estimates of major depression ranging from 30-34% of suicides. In addition, several psychological autopsy studies examining more specific subsamples (e.g., the elderly, adolescents, women) find even higher prevalence estimates. In three psychological autopsy studies of adolescents (Brent et al. 1988; Brent et al., 1999; Shaffer et al., 1996) 41%, 43%, and 32% of adolescent suicides were determined to have had major depression prior to death. Two studies of young adults (Lesage et al. 1994; Runeson, 1989) found a prevalence of 40% and 41%, respectively. A study of 104 women by Asgard (1990) found a 35% rate of major depression. One study of 54 older adults over age 65 found a prevalence of 54%. In summary, the available data suggest that the 20-35% estimate for the prevalence of major depressive disorder in completed suicide is probably somewhat conservative and that a 30-40% prevalence estimate is probably more accurate. This estimate includes both secondary and primary depression. Many of these individuals would also be comorbid with other disorders, especially substance abuse.

Mood disorders in suicide
Prevalence estimates for all mood disorders in suicide (including MDD, Bipolar I & II, dysthymia, and adjustment disorder with depressed mood) are much higher than for major depression alone. These rates are probably closer to 60%, although as noted below, this estimate varies because of inconsistency of the criteria used to define a "mood disorder" across investigations. Four studies examining the full age range of suicides estimate that 36%, 48%, and 66%, and 70% of suicides have some sort of "depressive disorder" or "depression" (Foster et al., 1999; Rich et al., 1986, Henriksson et al., 1993, Barraclough, Bunch, Nelson, & Sainsbury, 1974). Three studies of adolescents found prevalence estimates for "mood disorders" or "affective disorders" of 61%, 63%, and 67% respectively (Shaffer et al., 1996; Brent et al. 1988; Marttunen et al., 1992). Two studies of young adults (Lesage et al., 1994; Runeson, 1989) found estimates of 60% and 64%. A study of 104 women by Asgard (1990) found a 59% rate of "mood disorders." In a review of psychological autopsy studies that examined patterns of psychiatric diagnosis across age groups, Conwell and Brent (1995) concluded that depressive disorders increased with age. Overall estimates for the rates of mood disorders range from 36% to 70% with great interstudy variability. This variability is probably partly a combination of unreliable methods of diagnosis and different definitions of what constitutes a "mood disorder." Despite this variability, a number of studies have found a pattern for increasing mood disorders with aging.

Building Self-Esteem in Children

Building Self-Esteem in Children

Most parents have heard that "an ounce of prevention is worth a pound of cure" and it's especially true with self-esteem in children. All children need love and appreciation and thrive on positive attention. Yet, how often do parents forget to use words of encouragement such as, "that's right," "wonderful," or "good job"? No matter the age of children or adolescents, good parent-child communication is essential for raising children with self-esteem and confidence.

Self-esteem is an indicator of good mental health. It is how we feel about ourselves. Poor self-esteem is nothing to be blamed for, ashamed of, or embarrassed about. Some self-doubt, particularly during adolescence, is normal—even healthy-but poor self—esteem should not be ignored. In some instances, it can be a symptom of a mental health disorder or emotional disturbance.

Parents can play important roles in helping their children feel better about themselves and developing greater confidence. Doing this is important because children with good self-esteem:

Act independently
Assume responsibility
Take pride in their accomplishments
Tolerate frustration
Handle peer pressure appropriately
Attempt new tasks and challenges
Handle positive and negative emotions
Offer assistance to others
Words and actions have great impact on the confidence of children, and children, including adolescents, remember the positive statements parents and caregivers say to them. Phrases such as "I like the way you…" or "You are improving at…" or "I appreciate the way you…" should be used on a daily basis. Parents also can smile, nod, wink, pat on the back, or hug a child to show attention and appreciation.

What else can parents do?

Be generous with praise. Parents must develop the habit of looking for situations in which children are doing good jobs, displaying talents, or demonstrating positive character traits. Remember to praise children for jobs well done and for effort.
Teach positive self-statements. It is important for parents to redirect children's inaccurate or negative beliefs about themselves and to teach them how to think in positive ways.
Avoid criticism that takes the form of ridicule or shame. Blame and negative judgments are at the core of poor self-esteem and can lead to emotional disorders.
Teach children about decisionmaking and to recognize when they have made good decisions. Let them "own" their problems. If they solve them, they gain confidence in themselves. If you solve them, they'll remain dependent on you. Take the time to answer questions. Help children think of alternative options.
Show children that you can laugh at yourself. Show them that life doesn't need to be serious all the time and that some teasing is all in fun. Your sense of humor is important for their well-being.
The Caring for Every Child's Mental Health Campaign Campaign is part of The Comprehensive Community Mental Health Services Program for Children and Their Families of the Federal Center for Mental Health Services. Parents and caregivers who wish to learn more about mental well-being in children should call 1-800-789-2647 (toll-free) or visit mentalhealth.samhsa.gov/child/ to download a free publications catalog (Order No. CA-0000). The Federal Center for Mental Health Services is an agency of the Substance Abuse and Mental Health Services Administration, U.S. Department of Health and Human Services.

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Cognitive Behavioral Therapy CBT and PTSD

CMHS Consumer Affairs E-News
November 27, Vol. 07-187
Internet-Based PTSD Therapy May Help Overcome Barriers to Care

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NIMH-funded researchers recently completed a pilot study showing that an Internet-based, self-managed cognitive behavioral therapy (CBT) can help reduce symptoms of post-traumatic stress disorder (PTSD) and depression, with effects that last after treatment has ended. This study supports further development of PTSD therapies that focus on self-management and innovative methods of providing care to large numbers of people who do not have access to mental health care or who may be reluctant to seek care due to stigma. The researchers published their study in the November 2007 issue of the American Journal of Psychiatry.

Brett Litz, Ph.D., of the National Center for PTSD at the VA Boston Healthcare System and Boston University, and colleagues recruited service members from the Department of Defense who had developed PTSD following the September 11, 2001, attack on the Pentagon or from recent combat exposure. Forty-five participants first met with a therapist to determine their baseline PTSD and depression symptoms, and then were randomly assigned to one of two 8-week long, therapist-assisted, Internet-based treatments.

One treatment used strategies from CBT, which previous research has shown to be effective in relieving symptoms of PTSD. This CBT-based therapy aimed to first help participants identify situations that triggered their PTSD symptoms by working with a therapist and then improve their ability to manage those symptoms through on-line homework assignments. The other therapy, called supportive counseling, asked participants to monitor their own current, non-trauma-related problems, and then write about those experiences online. These participants also received periodic phone calls or emails from their therapist, who provided supportive but non-directed counseling. Participants in both groups were asked to log on daily to a Web site specific to their assigned treatment. After rating their PTSD and depression symptoms using a checklist, participants were allowed access to the Web site where they could find information about PTSD, stress, trauma, and other related health topics; communicate with their therapist; or complete treatment-specific activities.

After eight weeks of treatment, participants in both groups had fewer or less severe PTSD and depression symptoms, but those in CBT-based therapy showed greater improvements than those in supportive counseling therapy. Six months after their first meeting with a study therapist, participants who received CBT-based therapy showed continued improvements, while those in the supportive therapy group experienced an increase in PTSD and depression symptoms.

These findings suggest the CBT-based online therapy may be an efficient, effective, and low-cost method of providing PTSD treatment following a traumatic event to a large number of people. The researchers noted that fewer people completed the CBT-based therapy than the supportive counseling therapy. However, regardless of therapy group, the discontinuation rate among study participants was similar to the 30 percent discontinuation rate reported in studies of face-to-face treatment. Further study is needed to improve treatment use and completion and to test Internet-based PTSD therapies in a larger study population.

Reference

Litz BT, Engel CC, Bryant R, Papa A. A Randomized Controlled Proof-of-Concept Trial of an Internet-Based, Therapist-Assisted Self-Management Treatment for Posttraumatic Stress Disorder. Am J Psychiatry. 2007 Nov;164(11):1676-84.