Autism Blurs Distinctions Between Brain Regions

Erodes Molecular Identities in Cortex – NIH-funded Study
Autism blurs the molecular differences that normally distinguish different brain regions, a new study suggests. Among more than 500 genes that are normally expressed at significantly different levels in the front versus the lower middle part of the brain's outer mantle, or cortex, only 8 showed such differences in brains of people with autism, say researchers funded in part by the National Institutes of Health continuing education for social workers

"Such blurring of normally differentiated brain tissue suggests strikingly less specialization across these brain areas in people with autism," explained Daniel Geschwind, M.D., Ph.D., of the University of California, Los Angeles, a grantee of the NIH's National Institute of Mental Health. "It likely reflects a defect in the pattern of early brain development."

He and his colleagues published their study online May 26, 2011 in the journal Nature. The research was based on post mortem comparisons of brains of people with the disorder and healthy controls.

In fetal development, different mixes of genes turn on in different parts of the brain to create distinct tissues that perform specialized functions. The new study suggests that the pattern regulating this gene expression goes awry in the cortex in autism, impairing key brain functions.

"This study provides the first evidence of a common signature for the seemingly disparate molecular abnormalities seen in autism," said NIMH director Thomas R. Insel, M.D. "It also points to a pathway-based framework for understanding causes of other brain disorders stemming from similar molecular roots, such as schizophrenia and ADHD."

In an earlier study, the researchers showed that genes that turn on and off together at the same time hold clues to the brain's molecular instructions. These modules of co-expressed genes can reveal genetic co-conspirators in human illness, through what Geschwind and colleagues call "guilt by association." A gene is suspect if its expression waxes and wanes in sync with others in an illness-linked module.

Using this strategy, the researchers first looked for gene expression abnormalities in brain areas implicated in autism — genes expressed at levels different than in brains of healthy people. They found 444 such differently expressed genes in the cortexes of postmortem brains of people with autism.

Most of the same genes turned out to be abnormally expressed in the frontal cortex as in the temporal cortex (lower middle) of autistic brains. Of these, genes involved in synapses, the connections between neurons, tended to be under-expressed when compared with healthy brains. Genes involved in immune and inflammatory responses tended to be over-expressed. Significantly, the same pattern held in a separate sample of autistic and control brains examined as part of the study.

Autistic and healthy control brains were similarly organized –– modules of co-expressed genes correlated with specific cell types and biological functions.

Yet normal differences in gene expression levels between the frontal and temporal cortex were missing in the modules of autistic brains. This suggests that the normal molecular distinctions — the tissue differences — between these regions are nearly erased in autism, likely affecting how the brain works. Strikingly, among 174 genes expressed at different levels between the two regions in two healthy control brains, none were expressed at different levels in brains of people with autism.

An analysis of gene networks revealed two key modules of co-expressed genes highly correlated with autism.

One module was made up of genes in a brain pathway involved in neuron and synapse development, which were under-expressed in autism. Many of these genes were also implicated in autism in previous, genome-wide studies. So, several different lines of evidence now converge, pointing to genes in this M12 module (see picture below) as genetic causes of autism.

A second module of co-expressed genes, involved in development of other types of brain cells, was over-expressed in autism. These were determined not to be genetic causes of the illness, but likely gene expression changes related to secondary inflammatory, immune, or possible environmental factors involved in autism.

This newfound ability to see genes in the context of their positions in these modules, or pathways, provides hints about how they might work to produce illness, according to Geschwind and colleagues. For example, from its prominent position in the M12 module, the researchers traced a potential role in creating defective synapses to a gene previously implicated in autism.

Follow-up studies should explore whether the observed abnormalities in the patterning of gene expression might also extend to other parts of the brain in autism, say the researchers.

Children’s Mental Health Facts: Bipolar Disorder

Children’s Mental Health Facts: Bipolar DisorderHelping 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.

For More Information

Federal Government Resources

National Mental Health Information Center
Substance Abuse and Mental Health Services Administration
mentalhealth.samhsa.gov
Tel: 1.800.789.2647 (toll-free; English/Spanish)
TDD: 1.866.889.2647

National Institute of Mental Health
National Institutes of Health
www.nimh.nih.gov
Tel: 1.866.615.6464 (toll-free; English/Spanish)
TTY: 301.443.8431

Additional Resources

Following are some other resources that may be helpful. This list is not exhaustive, and inclusion does not imply endorsement by the Substance Abuse and Mental Health Services Administration or the U.S. Department of Health and Human Services.

Child and Adolescent Bipolar Foundation
www.bpkids.org
Tel: 847.256.8525

Federation of Families for Children’s Mental Health
www.ffcmh.org
Tel: 703.684.7710

NAMI (National Alliance on Mental Illness)
www.nami.org
Tel: 1.800.950.6264 (toll-free)

National Mental Health Association
www.nmha.org
Tel: 1.800.969.6642 (toll-free)

For information about children’s mental health contact the National Mental Health Information Center toll-free: 1.800.789.2647 (English/Spanish) 1.866.889.2647 (TDD)

Depression and Mood Disorders Continuing Education CEU

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


--------------------------------------------------------------------------------

References

Angst, J., Angst, F., and Stassen, H. H. (1999). Suicide risk in patients with major depressive disorder. Journal of Clinical Psychiatry, 60(supp. 2), 57-62.

Arato, M., Demeter, E., Rihmer, Z., & Somogyi, E. (1988). Retrospective psychiatric assessment of 200 suicides in Budapest. Acta Psychiatrica Scandinavica, 77, 454-456.

Asgard, U. (1990). A psychiatric study of suicide among urban women in Sweden. Acta Psychiatrica Scandinavica, 82, 115-124.

Barraclough, B., Bunch, J., Nelson, B., & Sainsbury, P. (1974). A hundred cases of suicide: Clinical aspects. British Journal of Psychiatry, 125,355-373.

Brent, D.A., Perper, J.A., Goldstein, C.E., Kolko, D.J., Allan, M.J., Allman, C.J., & Zelenak, J.P. (1988). Risk factors for adolescent suicide: A comparison of adolescent suicide victims with suicidal inpatients. Archives of General Psychiatry, 45,581-588.

Brent, D. A., Perper, J. A., Moritz, G., Allman, C., Friend, A., Roth, C., Schweers, J., Balach, L., & Baugher, M. (1993). Psychiatric risk factors for adolescent suicide: A case-control study. Journal of the American Academy of Child and Adolescent Psychiatry, 32,521-529.

Clark, D. C. (1991). Final Report to the AARP Adrus Foundation: Suicide Among the Elderly.

Conwell, Y. & Brent, D. (1995). Suicide and aging I: Patterns of psychiatric diagnosis. International Psychogeriatrics, 7, 149-164.

Dorpat, T. L., & Ripley, H. S. (1960). A study of suicide in the Seattle area. Comprehensive Psychiatry, 1, 349-359

Foster, T., Gillespie, K., McClelland, R., & Patterson, C. (1999). Risk factors for suicide independent of DSM-III-R Axis I disorder. British Journal of Psychiatry, 175, 175-179.

Henriksson, M. M., Aro, H. M., Marttunen, M. J., Heikkinen, M. E., Isometa, E. T., Kuoppasalmi, K. I., & Lonqvist, J. K. (1993). Mental disorders and comorbidity in suicide. American Journal of Psychiatry, 150, 935-940.

Lesage, A., Boyer, R., Grunberg, F., Vanier, C., Morissette, R., Menard-Bueeau, C., & Loyer, M. (1994). Suicide and mental disorders: A case-control study of young men. American Journal of Psychiatry, 151, 1063-1068.

Marttunen, M. J., Hillevi, M., Aro, H.M., & Lonnqvist, J. K. (1992). Adolescent suicide: Endpoint of long-term difficulties. Journal of the American Academy of Child and Adolescent Psychiatry, 34(4), 649-654.

Rich, C. L., Young, D., & Fowler, R. C. (1986). San Diego suicide study: Young vs old subjects. Archives of General Psychiatry, 43, 577-582.

Runeson, B. (1989). Mental disorder in youth suicide: DSM-III-R Axes I and II. Acta Psychiatrica Scandinavica, 79, 490-497.

Shaffer, D., Gould, M. S., Fisher, P., Trautmann, P., Moeau, D., Kleinman, M., & Flory, M. (1996). Psychiatric diagnosis in child and adolescent suicide. Archives of General Psychiatry, 53, 339-348.

An Overview of the Illness Management and Recovery Program

An Overview of the Illness Management and Recovery Program
for more on this topic,
mft ceus

The Illness Management and Recovery Program consists of a series of weekly sessions where mental health practitioners help people who have experienced psychiatric symptoms to develop personalized strategies for managing their mental illness and moving forward in their lives. The program can be provided in an individual or group format, and generally lasts between three and six months. In the sessions, practitioners work collaboratively with people, offering a variety of information, strategies, and skills that people can use to further their own recovery. There is a strong emphasis on helping people set and pursue personal goals and helping them put strategies into action in their everyday lives.

Materials for Providing the Illness Management and Recovery Program

In the Practitioners’ Workbook (this document) there are two sets of materials for Illness Management and Recovery: the Practitioners’ Guide (Chapters 1-10) and Educational Handouts. The educational handouts contain practical information and strategies that people can use in the recovery process. The handouts are not meant to stand alone. Practitioners are expected to help people select and put into practice the knowledge and strategies that are most helpful to themselves as individuals. The following topics are covered in nine educational handouts:

Recovery Strategies
Practical Facts about Schizophrenia/Bipolar Disorder/ Depression
The Stress-Vulnerability Model and Strategies for Treatment
Building Social Support
Using Medication Effectively
Reducing Relapses
Coping with Stress
Coping with Problems and Symptoms
Getting Your Needs Met in the Mental Health System
Chapter 1 of the Practitioners’ Guide contains overall strategies for conducting the program, and Chapters 2-10 contain practitioner guidelines for using each of the educational handouts to conduct sessions. The guidelines contain specific suggestions for using motivational, educational, and cognitive behavioral techniques to help people use strategies from the handouts in their daily lives. They also provide tips for developing homework assignments and for dealing with problems that might arise during sessions.

Getting started

First, practitioners are advised to familiarize themselves with the format, content and tone of the program. This can be accomplished by first reading the following:

Chapter 1 of the Practitioners’ Guide
Educational Handout #1 (“Recovery Strategies”)
Practitioner Guidelines for Educational Handout #1 (“Recovery Strategies”)
It is optimal for practitioners to read the remaining educational handouts and accompanying practitioners’ guidelines before beginning to work with people. Practitioners are advised to review specific handouts and guidelines prior to addressing these particular topic areas with people.

Preparing For Sessions

The first session is usually spent on orientation, using the “Orientation Sheet” (see Appendix 1) as a guide. The second (and sometimes third) session is spent on getting to know the person better, using the ”Knowledge and Skills Inventory” (see Appendix 2) as a guide. This inventory is focused on the person’s positive attributes rather than their problems or “deficits.” It is important to gather information in a friendly, low- key manner, using a conversational tone. The remaining sessions are focused on helping people to learn and practice the information and strategies in the educational handouts and to set and pursue their personal goals. Each session should be documented, using the “Progress Note for Illness Management and Recovery” (Appendix 3). The format of the progress note helps practitioners to keep track of the person’s personal goals, the kinds of interventions provided (motivational, educational, cognitive-behavioral), the specific evidence-based skill(s) that are taught (coping skills, relapse prevention skills and behavioral tailoring skills) and the homework that is agreed upon.

Before beginning each educational handout, the practitioner is encouraged to review the contents of the handout and the practitioner guidelines of the same title in the Practitioners’ Guide. Most educational handouts will require two to four sessions to put the important principles into practice. Preparation for sessions is most effective when practitioners review the educational handout and the corresponding practitioners’ guidelines side-by-side, noting the goals of the handout, the specific topic headings, the probe questions, the checklists, etc. As noted above, sessions should be recorded on the form “Progress Note for Illness Management and Recovery” (Appendix 3). Although for many people it is most helpful to go through the handouts in the order they are listed, it is important to tailor the program to respond to individual needs. For example, when a person is very distressed by the symptoms he or she is experiencing, it would be preferable to address this problem early in the program using Educational Handout #8, “Coping with Problems and Symptoms. ” Practitioners need to be responsive to people’s concerns and use their clinical judgment regarding the order and pacing of handouts.

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Importance of Recovery

There is widespread acceptance of the importance of recovery as a guiding vision for helping people who experience psychiatric symptoms to achieve personal success in their lives. The term recovery means different things to different individuals. Each person is free to define it in his or her terms. For some individuals, recovery means no longer having any symptoms or signs of a mental illness. For others, recovery means taking on challenges, enjoying the pleasures life has to offer, pursuing personal dreams and goals, and learning how to cope with or grow past one’s mental illness despite symptoms or setbacks.

Regardless of the personal understanding each individual develops about recovery, the overriding message is one of hope and optimism. The recovery vision is at the heart of the Illness Management and Recovery Toolkit. Through learning information about mental illness and its treatment, developing skills for reducing relapses, dealing with stress, and coping with symptoms, people can become empowered to manage their own illness, to find their own goals for recovery, and to assume responsibility for directing their own treatment. People who experience psychiatric symptoms are not passive recipients of treatment, and the goal is not to make them “comply” with treatment recommendations. Rather, the focus of Illness Management and Recovery is providing people with the information and skills they need in order to make informed decisions about their own treatment.

Broadly speaking, the goals of Illness Management and Recovery are to:
Instill hope that change is possible
Develop a collaborative relationship with a treatment team
Help people establish personally meaningful goals to strive towards
Teach information about mental illness and treatment options
Develop skills for reducing relapses, dealing with stress, and coping with symptoms
Provide information about where to obtain needed resources
Help people develop or enhance their natural supports for managing their illness and pursuing goals
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Importance of Helping People Set and Pursue Personal Goals

Being able to set and pursue personal goals is an essential part of recovery. At the same time that information and skills are being taught in the Illness Management and Recovery Program, people are also helped to define what recovery means to them and to identify what goals and dreams are important to them. The first educational handout, “Recovery Strategies,” contains specific information about setting goals. However, throughout the entire program, practitioners help people set meaningful personal goals and follow up regularly on those goals. As people gain more mastery over their psychiatric symptoms, they gain more control over their lives and become better able to realize their vision of recovery. In each session of the program, practitioners should follow up on the participants’ progress towards their goals. “Goals Set in the Illness Management and Recovery Program” (Appendix 5) helps practitioners to keep track of a person’s goals. Another form, “Step-By-Step Problem-Solving and Goal Achievement” (Appendix 6) is useful for helping a person plan the steps for achieving a goal (or solving a problem).

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Logistics

The content and teaching methods used in the Illness Management and Recovery Program are derived from multiple studies of professionally based illness management training programs for people who have experienced psychiatric symptoms. Information is taught using a combination of motivational, educational, and cognitive-behavioral teaching principles. Critical information is summarized in educational handouts that are written for people who experience psychiatric symptoms but are also suitable for distribution to anyone with a professional or caring relationship with a person who experiences psychiatric symptoms (such as a case manager or a family member).

The information and skills taught in Illness management and Recovery are organized into nine topic areas: recovery strategies, practical facts about mental illness, the stress-vulnerability model, building social support, using medication effectively, reducing relapses, coping with stress, coping with problems and symptoms, and getting your needs met in the mental health system. There are educational handouts and practitioners’ guidelines for each topic area.

Each topic is taught using a combination of motivational, educational, and cognitive behavioral methods. Also, in order to help people apply the information and skills that they learn in the sessions to their day-to-day lives, the practitioner and the person collaborate to develop homework assignments at the end of each session. These homework assignments are tailored to the individual, to help him or her practice strategies in “the real world.” Because developing and enhancing natural supports is a goal of Illness Management and Recovery, people are encouraged to identify significant others with whom they can share the handout materials and who may support them in applying newly acquired skills or completing homework.

The amount of time required to teach Illness Management and Recovery depends on a variety of factors, including people’s prior knowledge and level of skills, the problem areas that they would like to work on, and the presence of either cognitive difficulties or severe symptoms that may slow the learning process. In general, between three and six months of weekly sessions of 45 to 60 minutes may be required to teach Illness Management and Recovery. Following the completion of the nine topic areas, people may also benefit from either booster sessions or participation in support groups aimed at using and expanding skills.

GIRL POWER! Is Good Mental Health

GIRL POWER!
Is Good Mental Health
GIRL POWER! is paving the way for girls to build confidence, competence, and pride in themselves, in other words, enhancing girls' mental wellness. Girl Power! is also providing messages and materials to girls about the risks and consequences associated with substance abuse and with potential mental health concerns. For instance, did you know:


Girls are seven times more likely than boys to be depressed and twice as likely to attempt suicide.*


Girls are three times more likely than boys to have a negative body image (often reflected in eating disorders such as anorexia and bulimia).*


One in five girls in the U.S. between the ages of 12 and 17 drink alcohol and smoke cigarettes.*


Girls who develop positive interpersonal and social skills decrease their risk of substance abuse.*


Girls who have an interest and ability in areas such as academics, the arts, sports, and community activities are more likely to develop confidence and may be less likely to use drugs.*


On the other hand, this also is a time when girls may make decisions to try risky behaviors, including drinking, smoking, and using drugs.*
The Girl Power! Campaign, under the leadership of the Center for Substance Abuse Prevention (CSAP), Substance Abuse and Mental Health Services Administration (SAMHSA) is collaborating with the Center for Mental Health Services (CMHS) to provide this valuable mental health information.

* Girl Power! Hometown Media Kit, Center for Substance Abuse Prevention, 1997.

Substance Abuse and Mental Health
Results from a study of nearly 6,000 people aged 15 to 24 show that among young people with a history of both a mental disorder and an addictive disorder, the mental disorder is usually reported to have occurred first. The onset of mental health problems may occur about 5 to 10 years before the substance abuse disorders.**

This provides a "window of opportunity" for targeted substance abuse prevention interventions and needed mental health services.

** "National Comorbidity Survey," Ronald C. Kessler, Ph.D., et al., American Journal of Orthopsychiatry, June 1996.

What Is Mental Health?
Mental health is how we think, feel, and act in order to face life's situations. It is how we look at ourselves, our lives, and the people we know and care about. It also helps determine how we handle stress, relate to others, evaluate our options, and make choices. Everyone has mental health.

A young girl's mental health affects her daily life and future. Schoolwork, relationships, and physical health can be affected by mental health. Like physical health, mental health is important at every stage of life. Caring for and protecting a child's mental health is a major part of helping that child grow to become the best she can be.

Girls' independence is usually encouraged in childhood, and their strengths nurtured. Most girls become emotionally, mentally, and physically healthy young adults. But sometimes, during the transition from childhood to adolescence, extra care is necessary, so that a girl's self-esteem and coping skills are not diminished. For more information on teen mental health, call 1-800-789-2647 and ask for the brochure: "You and Mental Health: What's the Deal?" (Order # CA-0002)

Nurturing Your Child's Mental Health
Parents and other caregivers are responsible for children’s physical safety and emotional well-being. Parenting styles vary; there is no one right way to raise a child. Clear and consistent expectations for each child, by all caregivers, are important. Many good books are available in libraries or at bookstores on child development, constructive problem-solving, discipline styles, and other parenting skills. The following suggestions are not meant to be complete.

Do your best to provide a safe home and community for your child, as well as nutritious meals, regular health check-ups, immunizations, and exercise.


Be aware of stages in child development so you don’t expect too much or too little from your child.


Encourage your child to express her feelings; respect those feelings. Let your child know that everyone experiences pain, fear, anger, and anxiety.


Try to learn the source of these feelings. Help your child express anger positively, without resorting to violence.


Promote mutual respect and trust. Keep your voice level down—even when you don’t agree. Keep communication channels open.


Listen to your child. Use words and examples your child can understand. Encourage questions.


Provide comfort and assurance. Be honest. Focus on the positives. Express your willingness to talk about any subject.


Look at your own problem-solving and coping skills. Do you turn to alcohol or drugs? Are you setting a good example? Seek help if you are overwhelmed by your child’s feelings or behaviors or if you are unable to control your own frustration or anger.


Encourage your child’s talents and accept limitations.


Set goals based on the child’s abilities and interests—not someone else’s expectations. Celebrate accomplishments. Don’t compare your child’s abilities to those of other children; appreciate the uniqueness of your child. Spend time regularly with your child.


Foster your child’s independence and self-worth.


Help your child deal with life’s ups and downs. Show confidence in your child’s ability to handle problems and tackle new experiences.


Discipline constructively, fairly, and consistently. (Discipline is a form of teaching, not physical punishment.) All children and families are different; learn what is effective for your child. Show approval for positive behaviors. Help your child learn from her mistakes.


Love unconditionally. Teach the value of apologies, cooperation, patience, forgiveness, and consideration for others. Do not expect to be perfect; parenting is a difficult job. Many good books are available in libraries or at bookstores on child development, constructive problem-solving, discipline styles, and other parenting skills.
Mental Health Problems
Many children experience mental health problems that are real and painful and can be severe.

Mental health problems affect at least one in every five young people, at any given time. At least 1 in 10 children may have a serious emotional disturbance that severely disrupts his or her ability to function.

Tragically an estimated two-thirds of all young people with mental health problems are not getting the help they need. Mental health problems can lead to school failure, alcohol or other drug abuse, family discord, violence, or even suicide.

Mental Health Links - Suicide

Mental Health Links - Suicide
Organizations
Iowa State Prevention Programs
http://www.idph.state.ia.us/bhpl/healthy_iowans_2010.asp
This web site provides an overview of Iowa’s prevention programs for violence and abusive behavior.


Ohio's Suicide Prevention Program
http://www.mh.state.oh.us/kids/suicideprev/suicide.prevention.plan.pdf
Ohio's Suicide Prevention Plan is the next step in saving lives and reducing suicidal behaviors by developing a comprehensive strategy in response to a very complex set of issues.


National Police Suicide Foundation
http://www.psf.org/index.htm
The numbers of deaths due to suicide are 2 to 3 times the number of line of duty deaths among law enforcement agencies and emergency workers. The mission of the National P.O.L.I.C.E. Suicide Foundation is to provide suicide awareness and prevention training programs and support services that will meet the psychological and spiritual needs of emergency workers and their families.


National Resource Center for Suicide Prevention and Aftercare
http://www.thelink.org/html/nrc.htm
The NRC's goal is to provide suicide-related community education in the areas of prevention, intervention, and aftercare, as well as healing support services for families, youth, and those affected by the psychological trauma of suicide.


National Center for Suicide Prevention Training
http://www.ncspt.org/courses/orientation/
The National Center for Suicide Prevention Training (NCSPT) currently has two internet-based workshops. The first one, “Locating, Understanding, and Presenting Youth Suicide Data” and is available on an ongoing basis. The second workshop, "Planning and Evaluation for Youth Suicide Prevention" is being prepared for pilot testing. This web site provides more information on the trainings.


National Strategy for Suicide Prevention Indicators
http://www.nsspi.org/
The goal of the National Strategy for Suicide Prevention Indicators project is to identify and develop indicators for each of the strategy's objectives. Indicators are measured in order to quantify the achievement of an objective.


Klingenstein Third Generation Foundation
http://ktgf.org/index.html
One of the two areas of interest for this foundation are Childhood and Adolescent Depression, including suicide and suicide prevention. Grants have primarily fallen under the categories of Intervention and Referral, Prevention, Public Education/Training, and Infrastructure. The Foundation also sponsors a Fellowship Program for post-doctoral research in depression.


American Association of Poison Control Centers
http://www.aapcc.org
The American Association of Poison Control Centers is a Nationwide organization of poison centers and interested individuals. It provides a forum for poison centers and interested individuals to promote the reduction of morbidity and mortality form poisoning and sets voluntary standards for poison centers. It also produces publications and holds a yearly conference.


American Association of Suicidology
http://www.suicidology.org/index.cfm
The American Association of Suicidology is dedicated to the understanding and prevention of suicide. The organization promotes research, public awareness programs, and education and training for professionals and volunteers.


American College of Emergency Physicians
http://www.acep.org
The American College of Emergency Physicians promotes the highest standards of patient care through its advocacy and leadership. This web site contains information on the organization, fact sheets, information on continuing education, and many other resources.


American Correctional Health Services Association
http://www.corrections.com/achsa/
The ACHSA mission is to be the voice of the correctional healthcare profession, and serve as an effective forum for communication addressing current issues and needs confronting correctional healthcare.


American Foundation for Suicide Prevention
http://www.afsp.org
The American Foundation for Suicide Prevention is the only international non-profit organization dedicated to funding the research and education needed to prevent suicide.


First World Report on Violence and Health (Full Report)
http://www.who.int/violence_injury_prevention/violence/world_report/wrvheng/en/
This report, produced by the World Health Organization, is written mainly for researchers and practitioners. Its goals are to raise global awareness about the problems of violence and to make the case that violence is preventable and that public health systems have a crucial role to play in addressing its causes and consequences.


Befrienders International
http://www.befrienders.org/
Befrienders International is a network of centers run by trained volunteers that offer a free listening service that is non-judgmental and completely confidential. People are befriended by telephone, letter and email, and in face-to-face meetings.


American School Health Association
http://www.ashaweb.org
The American School Health Association unites the many professionals working in schools who are committed to safeguarding the health of school-aged children. The Association, a multidisciplinary organization of administrators, counselors, dentists, health educators, physical educators, school nurses and school physicians, advocates high-quality school health instruction, health services and a healthful school environment.


Association of Maternal and Child Health Programs
http://www.amchp.org
The Association of Maternal and Child Health Programs is an organization representing State public health leaders and other individuals and organizations working to improve the health and well being of all women, children, youth, and families. The group accomplishes its mission through partnerships with government agencies and the participation of its members, families, advocates, health care purchasers, providers, academic and research professionals, and others at the National, State and local levels.


Association of State and Territorial Health Officials
http://www.astho.org
The Association of State and Territorial Health Officials is a National non-profit organization representing the State and territorial public health agencies of the United States, the U.S. Territories, and the District of Columbia. Its members, the chief health officials of these jurisdictions, are dedicated to formulating and influencing sound public health policy, and to assuring excellence in State-based public health practice. This site provides information on events, policy statements, and publications.


Georgia's Suicide Prevention Plan
http://www.georgiasuicidepreventionplan.org
People can stop suicide. This fact is the foundation of the Georgia Suicide Prevention Plan. This web site provides the plan’s text and staff contact information.


Selected Reviews of Suicide Research - 2001
http://www.nimh.nih.gov/suicideresearch/suibib2001.cfm
This list of review articles was compiled by the NIMH Suicide Research Consortium, whose members have found the articles useful when providing technical assistance to grant applicants.


SOS High School Suicide Prevention Program
http://www.mentalhealthscreening.org/sos_highschool
The SOS Suicide Prevention Program provides school health professionals with all the educational materials necessary to replicate this easy-to-use program in a variety of school settings. Schools have the flexibility to make use of the materials in as large or small a program as their needs and resources dictate. The program can also be blended into an existing health curriculum. You can find out more about it at their web site.


Students Against Destructive Decisions
http://www.saddonline.com
Students Against Destructive Decision strive to provide students with the best prevention and intervention tools possible to deal with the issues of underage drinking, other drug use, impaired driving and other destructive decisions. Their site has a number of resources including fact sheets, a resource center, a list of events, and newsletters.


State and Territorial Injury Prevention Directors' Association
http://www.stipda.org
The mission of the State and Territorial Injury Prevention Director’s Association is to promote, sustain, and enhance the ability of State and Territorial public health departments to reduce death and disability associated with injuries. It accomplishes its mission by disseminating information on state-of-the-art injury prevention and control policies and strategies.


Suicide Among the Aged (Canada)
http://www.suicideinfo.ca/csp/go.aspx?tabid=118
This web site illustrates, through statistics, that suicide rates for the elderly exceed suicide rates among adolescents.


Suicide Prevention Action Network of USA (SPAN)
http://www.spanusa.org
The Suicide Prevention Action Network USA is a non-profit national organization that links the energy of those bereaved or touched by suicide with the expertise of leaders in science, health, business, government and public service to achieve the goal of significantly reducing the national rate of suicide by the year 2010.


Suicide Prevention Advocacy Network - California
http://www.span-california.org
Suicide Prevention Advocacy Network-California (SPAN-California) was founded in 1999 as a force for suicide prevention, an arena for collaboration among agencies, and a voice in the California state capital.


The Project Hope Foundation
http://www.project-hope.co.nz
The Project Hope Foundation is dedicated to reducing depression and suicide (especially youth suicide). It has books, videos and instructions on self-education and how to run Life Skills Open Forums.


Training Institute for Suicide Assessment and Clinical Interviewing
http://www.suicideassessment.com/
This group provides mental health professionals with information on the development of suicide prevention skills, crisis intervention skills, and clinical interviewing skills.


University of Washington, MCH Program
http://depts.washington.edu/mchprog/cmh_home.html
On December 8-9, 2002, the Northwest Children's Public Health Network: Building an Action Agenda for Mental Health was held in Seattle, Washington. Representatives from six States met to identify issues specific to the region and their communities and to outline State plans for promoting mental health in children and young people. Four plenary speakers presented information on mental health at various stages of childhood and adolescence and took part in a panel discussion. The details of the meeting are found on this web site.


World Health Organization Fact Sheet on Violence
http://www.who.int/violence_injury_prevention/violence/world_report/wrvh1/en/
This fact sheet, prepared by the World Health Organization, contains worldwide statistics for suicide and self inflicted injuries.


World Health Organization Report on Violence and Health - Summary
http://www.who.int/violence_injury_prevention/violence/world_report/en/Full%20WRVH%20summary.pdf
This document is a comprehensive summary to the World Health Organizations first World Report on Violence and Health.


Online Resources
National Vital Statistics Reports
http://www.cdc.gov/nchs/data/nvsr/nvsr49/nvsr49_08.pdf
This report presents the final 1999 data on U.S. deaths and death rates according to demographic and medical characteristics. Trends and patterns in general mortality, life expectancy, and infant mortality are also described.


New Freedom Commission on Mental Health Subcommittee on Suicide Prevention
http://www.mentalhealthcommission.gov/subcommittee/Suicide_Prevention_Outline.doc
Summary Report


Hawaii State Department of Health: Suicide
http://www.state.hi.us/health/shpda/shinjury.pdf
This is a report by the State of Hawaii on injury prevention, both accidental and self-inflicted. IT touches on suicide, domestic violence, and drug and alcohol abuse.


In Harm's Way: Suicide in America
http://www.nimh.nih.gov/publicat/harmaway.cfm
This fact sheet from the National Institute of Mental Health provides statistics about suicide incidents in the United States.


Media Coverage of Suicide
http://www.afsp.org/education/mediacoverage2.8.htm
This site, provided by the American Foundation for Suicide Prevention, illustrates various harmful ways in which the media can depict suicide.


Minnesota Department of Health Report to the Minnesota Legislature: Suicide Prevention Plan
http://www.health.state.mn.us/divs/opa/suicide.pdf
This report to the Minnesota Legislature details the development of the State’s suicide prevention plan.


EL SUICIDIO EN LOS ADOLESCENTES
http://www.aacap.org/publications/apntsfam/suicide.htm
Cada año miles de adolescentes se suicidan en los Estados Unidos. El suicidio es la tercera causa de muerte más frecuente para los jóvenes de entre 15 y 24 años de edad, y la sexta causa de muerte para los de entre 5 y 14 años.


National Organization for People of Color Against Suicide - Statistics
http://www.nopcas.com/stats/
This web site provides statistics on the amount of people who have committed and attempted suicide. It also lists conferences for suicide survivors.


National Registry of Effective Prevention Programs
http://www.modelprograms.samhsa.gov
Information on effective programs that enhance outcomes for substance abuse, violence and high-risk behaviors in community, family, school, clinical, faith-based, and workplace settings.


Depression and Bipolar Support Alliance (DBSA) - Suicide
http://www.dbsalliance.org/info/suicide.html
If you or someone you know suffers from depression or manic depression (also known as bipolar disorder), you understand all too well its symptoms may include feelings of sadness and hopelessness. These feelings can also include thoughts of self-harm or suicide.


Louisiana's Youth Suicide Prevention Program
http://www.dhh.state.la.us/NEWS/YouthSuicide02.htm
The Louisiana Youth Suicide Prevention Task Force is a Statewide response to the U. S. Surgeon General's call to action to prevent suicide. The mission of the Task Force is to develop a Statewide plan on youth suicide prevention in Louisiana. This press release provides more information on the Task Force as well as suicide statistics for Louisiana.


Guidelines for School Based Suicide Prevention Programs
http://www.suicidology.org/associations/1045/files/School%20guidelines.pdf
These guidelines, compiled by the Prevention Division of the American Association of Suicidology, can be used by schools to help prevent suicide. They are in PDF format.


Florida Suicide Prevention Coalition
http://www.floridasuicideprevention.org/
In August, 2002, the Florida Suicide Prevention Task Force announced the Statewide Suicide Prevention Strategy to reduce the incidence of suicide in Florida by one-third by 2005.


Canadian Association for Suicide Prevention
http://www.thesupportnetwork.com/CASP/main.html
This site provides resources and information about suicide prevention. It also contains new bulletins and a list of links to related sites.


A Call to Collaboration: The Federal Commitment to Suicide Prevention
http://www.sprc.org/library/collabcall.pdf
A Call to Collaboration: The Federal Commitment to Suicide Prevention highlights the Department of Health and Human Services' activities and their link to the National Strategy for Suicide Prevention, the plan which will guide the nation's suicide prevention efforts for the next decade.


Air Force Suicide Prevention Program
http://www.osophs.dhhs.gov/ophs/BestPractice/usaf.htm
The Suicide Prevention Program of the Air Force is described and highlighted as one of the nation's most effective health prevention programs.


Children's Safety Network - Injury Data
http://www.injuryprevention.org/info/data.htm
This web page provides charts and tables illustrating children’s injury data for each U.S. State and Territory.


Homicide and Suicide Risks Associated with Firearms in the Home
http://www.annemergmed.com/article/PIIS0196064403002567/fulltext?kwhquery=Homicide+and+Suicide+and+Risks+and+Associated+and+with+and+Firearms+and+Home&search_area=platform%2Bmedline&search_articletype=all&search_cluster=phoenix&search_currenturi=http%3A%2F%2Fjournals.elsevierhealth.com%2Fsearch%2Fquick&search_datecombo=0%3AALL&search_dateradio=combo&search_discipline=all&search_doi=&search_federated=yes&search_issue=&search_keyword=&search_language=all&search_medline=yes&search_mode=platform&search_monthendcombo=jan&search_monthstartcombo=jan&search_operator1=and&search_operator2=and&search_preview=no&search_reqcount=20&search_reqfirst=1&search_resulturi=%2FBRAND%2Fsearch%2Fresults&search_s200=yes&search_searchuri=%2FBRAND%2Fsearch%2Fadvanced&search_sort=relevance&search_startpage=&search_submode=&search_text1=Homicide+and+Suicide+Risks+Associated
This is a document about injury prevention titled, Homicide and Suicide Risks Associated With Firearms in the Home: A national case-control study.


Assisted Suicide and End-of-Life Decisions
http://www.apa.org/pi/aseol/introduction.html
A Report from an American Psychological Association Working Group


Assisted Suicide: A Disability Perspective
http://www.ncd.gov/newsroom/publications/1997/suicide.htm
Written for the National Council on Disability, this paper analyzes the issues related to assisted suicide and discusses current court cases.


At a Glance: Suicide Among the Elderly
http://mentalhealth.samhsa.gov/suicideprevention/elderly.asp
The National Strategy for Suicide Prevention provides this fact sheet on suicide among the elderly.


If You Are Thinking About Suicide...READ THIS FIRST
http://www.metanoia.org/suicide/
The information on this site is intended to help and support persons who may be feeling suicidal.


Legislative Advisories From the American Association on Child and Adolescent Psychiatry
http://www.aacap.org/legislation/Lalerts.htm
These legislative alerts, provided by the American Academy of Child and Adolescent Psychiatry, concern Congressional action on issues related to the health of children and adolescents.


A Public Health Approach to Preventing Suicide
http://www.sprc.org/library/phaprev.pdf
This brochure illustrates how better data collection, including the National Violent Death Reporting System, can inform prevention strategies and make a real difference.


Oklahoma State Youth Suicide Prevention Plan
http://www.health.state.ok.us/program/ahd/spsp.pdf
The Oklahoma Youth Suicide Prevention State Plan works to address the problem of suicide by introducing multi-level strategies that communities can customize based on available resources and experiences.


Preventing Suicide: Individual Acts Create a Public Health Crisis
http://www.cfah.org/factsoflife/vol7no8.cfm
This site provides a resource of background information, interviews, and statistics for health reporters.


Reporting on Suicide: Recommendations for the Media
http://www.afsp.org/education/recommendations/
This is the full report of media recommendations presented on the American Foundation for Suicide Prevention Web site. This resource contains links to the specific media recommendations as well as an introduction to the topic area, a list of danger signs, examples of reporting, and frequently asked questions.


Reporting on Suicide: Recommendations for the Media
http://www.nimh.nih.gov/suicideresearch/mediasurvivors.cfm
This National Institute of Mental Health Web site presents media recommendations that were produced in the spirit of the public-private partnership recommended by the Surgeon General’s National Strategy for Suicide Prevention.


Suicide Prevention
http://mentalhealth.samhsa.gov/suicideprevention
The National Strategy for Suicide Prevention is a collaborative effort between the Substance Abuse and Mental Health Services Administration, the Centers for Disease Control and Prevention, the National Institutes of Health, the Health Resources and Services Administration, and the Indian Health Services. The site has a wealth of resources including a newsroom, links State Suicide Prevention Programs, features publications, and much more.


Suicide Warning Signs
http://mentalhealth.samhsa.gov/publications/allpubs/walletcard/engwalletcard.htm



Tennessee Suicide Prevention Strategies
http://www.state.tn.us/mental/mhs/suicdeprev.pdf
The Tennessee strategy for suicide prevention builds on the fifteen points raised in “The Surgeon General’s Call to Action to Prevent Suicide, 1999.” This publication lists each of the fifteen points and Tennessee’s responses.


The Centre for Suicide Prevention, Manchester, England
http://www.national-confidential-inquiry.ac.uk/
The Centre for Suicide Prevention at the University of Manchester brings together projects on policy and service planning. This United Kingdom research centre in the field of suicidal behaviour carries out studies of suicide and homicide by those in contact with mental health services.


The National Association of Injury Control Research Centers
http://www.naicrc.org
An organization devoted to promoting scholarly activity in injury control, the Association addresses issues relevant to the prevention, acute care and rehabilitation of traumatic injury through multiple activities in research; research dissemination; program development and evaluation; consultation; and education and training.


The Surgeon General's Call To Action To Prevent Suicide, July 1999
http://www.surgeongeneral.gov/library/calltoaction/default.htm
The Surgeon General and the U.S. Department of Health and Human Services outline more than a dozen steps that can be taken by individuals, communities, organizations, and policymakers on this site. Site provides links to other related resources.


Virginia Youth Suicide Prevention Plan
http://www.vahealth.org/civp/preventsuicideva/
The Virginia Youth Suicide Prevention Plan addresses youth suicide in the Commonwealth by focusing on several key areas including: leadership, public awareness, media education, school-based strategies, surveillance, and evaluation. On this site there are statistics, free publications, and the number of a hotline for people contemplating suicide or people who know someone contemplating suicide.


Washington State Youth Suicide Prevention Program
http://www.yspp.org
The mission of the Youth Suicide Prevention Program is to reduce suicide attempts and deaths among Washington State youth. Working toward that goal, the group builds public awareness, offers training, and supports communities taking action.


Wisconsin Suicide Prevention Strategy
http://www.dhfs.state.wi.us/dph_emsip/InjuryPrevention/SuicidePrevention.htm
This report details Wisconsin’s Suicide Prevention Strategy. It provides a framework for getting every interested person in Wisconsin involved in preventing suicide and is designed to guide individuals, agencies, organizations in local communities and at regional and State levels in suicide prevention efforts.

Helping Children Cope With Fear & Anxiety

Helping Children Cope With Fear & Anxiety
Whether tragic events touch your family personally or are brought into your home via newspapers and television, you can help children cope with the anxiety that violence, death and disasters can cause.

The Caring for Every Child's Mental Health Campaign offers these pointers for parents and other caregivers:

Encourage children to ask questions. Listen to what they say. Provide comfort and assurance that address their specific fears. It's okay to admit you can't answer all of their questions.

Talk on their level. Communicate with your children in a way they can understand. Don't get too technical or complicated.

Be honest. Tell them exactly what has happened. For example, don't say that someone who has died has "gone to sleep;" children may become afraid of going to bed.

Find out what frightens them. Encourage your children to talk about fears they may have. They may worry that someone will harm them at school or that someone will try to hurt you.

Focus on the positive. Reinforce the fact that most people are kind and caring. Remind your child of the heroic actions taken by ordinary people to help victims of tragedy.

Pay attention. Your children's play and drawings may give you a glimpse into their questions or concerns. Ask them to tell you what is going on in the game or the picture. It's an opportunity to clarify any misconceptions, answer questions and give reassurance.

Develop a plan. Establish a family emergency plan for the future, such as a meeting place where everyone should gather if something unexpected happens in your family or neighborhood. It can help you and your child feel safer.
If you are concerned about your child's reaction to stress or trauma, call your physician or a community mental health center.

To learn more about children's mental health:
Call toll-free: 1.800.789.2647
(TDD): 301.443.9006
Web site: mentalhealth.samhsa.gov/child

Comprehensive Community Mental Health Services
for Children and Their Families Program
Child, Adolescent and Family Branch
Center for Mental Health Services
Substance Abuse and Mental Health Services Administration
U.S. Department of Health and Human Services

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.

CEU Training Video for MFTs, LCSWs, LPCs, Social Workers and Counselors

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Continuing Education CEU Training Video for MFTs, LCSWs, LPCs, Social Workers and Counselors

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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

for more on PTSD and CBT,click link below
PTSD CEUs CBT CEUs

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.

Anxiety Disorders

What are anxiety disorders?

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Anxiety Disorders CEUs Panic Disorders CEUs BBS Approved MFT LCSW

Anxiety disorders range from feelings of uneasiness to immobilizing bouts of terror. This fact sheet briefly describes the different types of anxiety disorders. This fact sheet is not exhaustive, nor does it include the full range of symptoms and treatments. Keep in mind that new research can yield rapid and dramatic changes in our understanding of and approaches to mental disorders. If you believe you or a loved one has an anxiety disorder, seek competent, professional advice or another form of support.


Generalized Anxiety Disorder: Most people experience anxiety at some point in their lives and some nervousness in anticipation of a real situation. However if a person cannot shake unwarranted worries, or if the feelings are jarring to the point of avoiding everyday activities, he or she most likely has an anxiety disorder.
Symptoms: Chronic, exaggerated worry, tension, and irritability that appear to have no cause or are more intense than the situation warrants. Physical signs, such as restlessness, trouble falling or staying asleep, headaches, trembling, twitching, muscle tension, or sweating, often accompany these psychological symptoms.
Formal diagnosis: When someone spends at least six months worried excessively about everyday problems. However, incapacitating or troublesome symptoms warranting treatment may exist for shorter periods of time.
Treatment: Anxiety is among the most common, most treatable mental disorders. Effective treatments include cognitive behavioral therapy, relaxation techniques, and biofeedback to control muscle tension. Medication, most commonly anti-anxiety drugs, such as benzodiazepine and its derivatives, also may be required in some cases. Some commonly prescribed anti-anxiety medications are diazepam, alprazolam, and lorazepam. The non-benzodiazepine anti-anxiety medication buspirone can be helpful for some individuals.


Panic Disorder: People with panic disorder experience white-knuckled, heart-pounding terror that strikes suddenly and without warning. Since they cannot predict when a panic attack will seize them, many people live in persistent worry that another one could overcome them at any moment.
Symptoms: Pounding heart, chest pains, lightheadedness or dizziness, nausea, shortness of breath, shaking or trembling, choking, fear of dying, sweating, feelings of unreality, numbness or tingling, hot flashes or chills, and a feeling of going out of control or going crazy.
Formal Diagnosis: Either four attacks within four weeks or one or more attacks followed by at least a month of persistent fear of having another attack. A minimum of four of the symptoms listed above developed during at least one of the attacks. Most panic attacks last only a few minutes, but they occasionally go on for ten minutes, and, in rare cases, have been known to last for as long as an hour. They can occur at any time, even during sleep.
Treatment: Cognitive behavioral therapy and medications such as high-potency anti-anxiety drugs like alprazolam. Several classes of antidepressants (such as paroxetine, one of the newer selective serotonin reuptake inhibitors) and the older tricyclics and monoamine oxidase inhibitors (MAO inhibitors) are considered "gold standards" for treating panic disorder. Sometimes a combination of therapy and medication is the most effective approach to helping people manage their symptoms. Proper treatment helps 70 to 90 percent of people with panic disorder, usually within six to eight weeks.


Phobias: Most of us steer clear of certain, hazardous things. Phobias however, are irrational fears that lead people to altogether avoid specific things or situations that trigger intense anxiety. Phobias occur in several forms, for example, agoraphobia is the fear of being in any situation that might trigger a panic attack and from which escape might be difficult. Social phobia is a fear of being extremely embarrassed in front of other people. The most common social phobia is fear of public speaking.
Symptoms: Many of the physical symptoms that accompany panic attacks - such as sweating, racing heart, and trembling - also occur with phobias.
Formal Diagnosis: The person experiences extreme anxiety with exposure to the object or situation; recognizes that his or her fear is excessive or unreasonable; and finds that normal routines, social activities, or relationships are significantly impaired as a result of these fears.
Treatment: Cognitive behavioral therapy has the best track record for helping people overcome most phobic disorders. The goals of this therapy are to desensitize a person to feared situations or to teach a person how to recognize, relax, and cope with anxious thoughts and feelings. Medications, such as anti-anxiety agents or antidepressants, can also help relieve symptoms. Sometimes therapy and medication are combined to treat phobias.


Post-traumatic Stress Disorder: Researchers now know that anyone, even children, can develop PTSD if they have experienced, witnessed, or participated in a traumatic occurrence-especially if the event was life threatening. PTSD can result from terrifying experiences such as rape, kidnapping, natural disasters, or war or serious accidents such as airplane crashes. The psychological damage such incidents cause can interfere with a person's ability to hold a job or to develop intimate relationships with others.
Symptoms: The symptoms of PTSD can range from constantly reliving the event to a general emotional numbing. Persistent anxiety, exaggerated startle reactions, difficulty concentrating, nightmares, and insomnia are common. People with PTSD typically avoid situations that remind them of the traumatic event, because they provoke intense distress or even panic attacks.
Formal Diagnosis: Although the symptoms of PTSD may be an appropriate initial response to a traumatic event, they are considered part of a disorder when they persist beyond three months.
Treatment: Psychotherapy can help people who have PTSD regain a sense of control over their lives. They also may need cognitive behavior therapy to change painful and intrusive patterns of behavior and thought and to learn relaxation techniques. Support from family and friends can help speed recovery and healing. Medications, such as antidepressants and anti-anxiety agents to reduce anxiety, can ease the symptoms of depression and sleep problems. Treatment for PTSD often includes both psychotherapy and medication.

For more information, as well as referrals to specialists and self-help groups in your State, contact:

Anxiety Disorders Association of America
8730 Georgia Avenue - Suite 600
Silver Spring, MD 20910
Telephone: 240-485-1001
Fax: 240-485-1035
www.adaa.org

Mental Help Net
CenterSite, LLC
570 Metro Place
Dublin, OH 43017
http://mentalhelp.net/poc/center_index.php?id=1

National Mental Health Association
2001 Beauregard Street, 12th Floor
Alexandria, VA 22311
Telephone: 800-969-6642
Fax: 703-684-5968
(TDD): 800-433-5959
www.nmha.org/infoctr/factsheets/index.cfm

The National Institute of Mental Health's toll-free information line is
1-866-615-6464; their web address is www.nimh.nih.gov/healthinformation/anxietymenu.cfm.

Managed Care and MFTs

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Managed Care CEUs

In 2009, legislation that would provide Medicare coverage for MFTs was passed in the House of Representatives (H.R. 3962) version of Health Care Reform (“HCR”). Further, a commitment was made to include the MFT provision in the Senate version of HCR. Although CAMFT was hopeful that Medicare inclusion for MFTs be placed in the final HCR bill (which was scheduled to go forward in 2010), based on the new make-up of Congress, it is unlikely that HCR will move forward. Whether or not HCR does move forward, does not mean our issue is dead. Congress is likely to enact some type of Medicare legislation in 2010, and our challenge will be to get into the vehicle that will go to the President.


The Department of Veterans Affairs (“DVA”) recently indicated that their plan was to complete the new MFT qualification standards by September 2010. Subject Matter Expert (SME) workgroups have been established and are meeting weekly to develop separate qualification standards. Once the draft qualification standards are developed, the DVA will formally submit a request to the Office of Personnel Management (OPM) to establish a new, separate occupational series for MFTs. CAMFT remains committed to helping usher these long overdue standards into reality to enable the VA facilities to recruit and hire MFTs in VA Medical Centers, Outpatient Clinics, and Veterans Outreach Centers.



Federal Mental Health Parity Regulations



Federal regulations (which are necessary to implement the Federal Mental Health Parity law which passed in 2009) were released on January 29, 2010. The public comment period to express concerns or suggestions about the parity regulations will close April 29, 2010. CAMFT will be submitting comments requesting greater clarification of certain sections, including but not limited to scope of services, and exact conditions/diagnoses included within mental health and substance use coverage. If you wish to view or comment on the parity regulations, please see the following link: http://www.regulations.gov/search/Regs/home.html#documentDetail?R=090000648096e4d2



U.S. Nuclear Regulatory Commission



Currently, federal regulations only allow licensed psychiatrists, licensed psychologists, and licensed clinical social workers to work as “Substance Abuse Experts” within the Nuclear Regulatory Commission (“NRC”.) The stated knowledge, training, and education requirements to become an NRC Substance Abuse Expert are well within the MFT scope of practice, and therefore MFTs should be included as potential providers. CAMFT will submit a Petition for Rulemaking (or a 10 CFR 2.802 action) to request that the NRC amend their regulations to allow MFTs to be included as Substance Abuse Experts.



Government Employees Health Association



Effective January 1, 2010, the Government Employees Health Association (a company that provides health care insurance to federal employees/retirees) will include MFTs as covered health care providers. The Government Employees Health Association provides health care insurance to over 400,000 employees/retirees. For more information about becoming a panel provider for the Government Employees Health Association, please call 816-257-5500.

Child and Adolescent Mental Health

Child and Adolescent Mental Health
Children's and Adolescents' Mental Health

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Online CEUs for MFTs, LCSWs, Social
Workers
Like adults, children and adolescents can have mental health disorders that interfere with the way they think, feel, and act. Mental health influences the ways individuals look at themselves, their lives, and others in their lives. Like physical health, mental health is important at every stage of life.



Child, Adolescent and Family Branch
The Child, Adolescent, and Family Branch of the Federal Center for Mental Health Services promotes and ensures that the mental health needs of children and their families are met within the context of community-based systems of care. Systems of care are developed on the premise that the mental health needs of children, adolescents, and their families can be met within their home, school, and community environments.



Caring for Every Child's Mental Health
Systems of Care the Caring for Every Child's Mental Health communications campaign is a public information and education program to:

Increase public awareness about the importance of protecting and nurturing the mental health of young people.
Foster recognition that many children have mental health problems that are real, painful, and sometimes severe.
Encourage caregivers to seek early, appropriate treatment and services.

The National Child Traumatic Stress Network
The mission of the National Child Traumatic Stress Network (NCTSN) is to raise the standard of care and improve access to services for traumatized children, their families and communities throughout the United States. This site includes an article on school planning for disasters and the aftermath of September 11, 2001.



Youth Violence Prevention
The CMHS initiative on school violence focuses on the collective involvement of families, communities, and schools to build resiliency to disruptive behavior disorders.

Make Time to Listen,
Take Time to Talk 15+
The campaign is part of the CMHS School Violence Prevention Initiative and is designed to provide practical guidance to parents and caregivers about "how to" create time to listen and take time to talk with their children.

Listening Dads Are Champs 15+
Children whose fathers are highly involved with them in a positive way do better in school, demonstrate better psychological well-being and lower levels of delinquency, and ultimately attain higher levels of education and economic self-sufficiency.

Family Guide To Keeping Youth Mentally Healthy and Drug Free
A public education Web site, developed to support the efforts of parents and other caring adults to promote mental health and prevent the use of alcohol, tobacco, and illegal drugs among 7- to 18-year-olds.

Youth Violence: A Report of the Surgeon General
This Surgeon General's report seeks to focus on action steps that all Americans can take to help address the problem, and continue to build a legacy of health and safety for our young people and the Nation as a whole.

Publications on Children and Families
Free information from the Center for Mental Health Services about children and families.

LCSW CEUs

LCSW CEU's
LCSW CEUs
LCSW Continuing Education Online
California 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

Law and Ethics CEUs

Law and Ethics Ceus
MFT, LCSW, LMFT
BBS Approved

Mom's House, Dad's House

Mom's House, Dad's House


3 Hours
AR, CA, CO, FL, HI, KY, LA, MA, MI, MO, NV, NY, OH, OR, TX

According to the Stepfamily Association of America, 60 percent of all families are breaking up, and custody and visitation issues loom large in the lives of many parents. Isolina Ricci's Mom's House, Dad's House guides separated, divorced, and remarried parents through the hassles and confusions of setting up a strong, working relationship with the ex-spouse in order to make two loving homes for the kids.

Boundaries in Marriage

Boundaries in Marriage

Two lives becoming one: That’s the marriage ideal. But maybe you’ve discovered that it’s easier said than done. How do you solve problems? How do you establish healthy communication? How do you work out conflict and deal with the struggle of differing needs? In the process of knitting two souls together, it’s easy to tear the fabric. That’s why boundaries—the ways we define and maintain our sense of individuality, freedom, and personal integrity—are so important. And it’s why the principles described in Boundaries in Marriage are essential if you want your marriage to flourish.

Human Sexuality Online Course

Human Sexuality Online Course
Human Sexuality CEUS
Human Sexuality Continuing Education
Interns and License Renewal
Full text Click hereHuman Sexuality
(10 hours/units)
© 2009 by Aspira Continuing Education. All rights reserved. No part of this material may be transmitted or reproduced in any form, or by any means, mechanical or electronic without written permission of Aspira Continuing Education.

1. Define the different study/research areas of human sexuality.
2. Increase familiarity with concepts related to the psychology of sex
3. Identify and evaluate clinical perspectives related to sexual activity and lifestyles.
4. Explore the impact religious belief systems on sex.
5. Learn specific laws related to sex and sexual crimes.
6. Identify the causes and symptoms of STDs
7. Increase familiarity with sexual disorders
Table of Contents:
1. Definition
2. Psychology and Sex
3. Sexual Activity and Lifestyles
4. Religion and Sex
5. The Law and Sex
6. Sexually Transmitted Diseases
7. Masters and Johnson
8. Sexual Disorders
9. References

1. Definition
Human sexuality can be defined as the manner in which people experience and express themselves as sexual beings. There are many facets in the study of human sexuality including:
• Biological
• Emotional
• Physical
• Sociological
• Philosophical
(Ellen Ross, Rayna Rapp Sex and Society: A Research Note from Social History and Anthropology Comparative Studies in Society and History).
From a biological perspective, sexuality is defined as “the reproductive mechanism as well as the basic biological drive that exists in all species and can encompass sexual intercourse and sexual contact in all its forms”. There are also emotional or physical perspectives of sexuality, which refers to the “bond that exists between individuals, which may be expressed through profound feelings or emotions, and which may be manifested in physical or medical concerns about the physiological or even psychological aspects of sexual behavior”. Sociologically, it includes the cultural, political, and legal aspects of sexual behavior. Philosophically, it emphasizes the moral, ethical, theological, spiritual or religious aspects of sexual behavior (Ellen Ross, Rayna Rapp Sex and Society: A Research Note from Social History and Anthropology Comparative Studies in Society and History).