Professional Counselor Continuing Education

Aspira Continuing Education offers online CE courses for Professional Counselors in most states. View our state board approved list to see if Aspira’s CE courses are approved in your state. All of Aspira’s CE courses are NBCC approved and are available for online CEUs for Licensed Professional Counselors (LPC), Licensed Professional Clinical Counselors (LPCC) and Mental Health Counselors (MHC). Check with your State Board’s Website for more information. View our Board Approvals and Accreditations page for provider numbers. California Legislature passed Senate Bill 788 establishing a new license category for Licensed Professional Clinical Counselors (LPCC) to be regulated by the California Board of Behavioral Sciences (BBS). View the CA BBS Licensed Professional Clinical Counselors Information page. View Aspira’s CE courses to see the variety options you have to satisfy your CE requirements. Aspira Continuing Education is a board approved and accredited online CEU provider. Aspira is committed to excellence in the fields of Social Work, Marriage and Family Therapy and Professional Counseling providing board approved CEUs online. We offer MFT continuing education, Social Worker continuing education and Professional Counselor continuing education. Our online CE courses are the best you'll find. We offer a broad range of CE course subjects that are board approved for many professions and states. The process is as simple as selecting an online CE course, completing and passing the online exam, and receiving/printing your certificate. Your certificate is available to view/print once payment has been processed. With Aspira, you can: Satisfy your CE requirements conveniently anywhere you have online access. View all CE course materials in PDF format for FREE. View and take any exam at any time for FREE. Take as much time as needed to complete the exam. Take the exam as many times necessary to receive a 70% passing score. Pay after you have passed your exam. Purchase a subscription for unlimited units that could reduce your cost per unit to under $4. (This will vary depending on the number of units used during the 12 month subscription period.) Print your certificate at any time after passing your exam and purchasing your units. Earn CE hours for passing exams based on books you may have already read. (These CEU courses require purchasing a book separately, if not already owned.) Listen to selected audio CE courses directly from your computer or MP3 player. Keep track of CEUs earned from other sources on your own personalized myCourses page.

Drug Boosts Growth Factor to Jumpstart Rapid Antidepressant Response

Little-known Enzyme Pivotal, Mouse Study Reveals
A study in mice has pinpointed a pivotal new player in triggering the rapid antidepressant response produced by ketamine. By deactivating a little-known enzyme, the drug takes the brakes off rapid synthesis of a key growth factor thought to lift depression, say NIMH-funded researchers LPCC Continuing Education

"Other agents that work through this pathway and block the enzyme may also similarly induce anti-depressant-like effects and hold promise for development of new treatments," said Lisa Monteggia, Ph.D., of the University of Texas Southwestern Medical Center, Dallas.

Monteggia, Ege Kavalali, Ph.D., and colleagues reported their findings online June 15, 2011 in the journal Nature.

Unlike currently available antidepressants that take weeks to work, ketamine can lift mood within hours. Yet adverse side effects preclude it from becoming a practical treatment. So, researchers have been studying its mechanism of action, in hopes of developing safer alternatives that work the same way.

Earlier studies had shown that the growth factor, called brain-derived neurotrophic factor (BDNF), produces antidepressant-like effects. To find out if BDNF is involved in ketamine's action, the researchers gave the drug to mice genetically engineered to lack BDNF. Unlike in control mice, ketamine failed to produce a fast-acting antidepressant-like response in such BDNF knockout mice exposed to experimental situations that trigger depression-like behaviors. This and other tests confirmed that ketamine's rapid antidepressant effects depend on rapid synthesis of BDNF in the brain's memory center, or hippocampus.

The researchers determined that this happens so quickly — within 30 minutes — because it only requires the translation of BDNF mRNA into protein, rather than transcription, which involves new gene expression and takes much longer.

Ketamine achieves this boost in BDNF levels by first blocking a protein on neurons (brain cells) called the NMDA receptor. The Texas team discovered that this blockade, in turn, deactivates an enzyme called eukaryotic elongation factor 2 (eEF2) kinase, that restrains BDNF synthesis. So, ketamine (and presumably other agents that similarly turn off the enzyme) effectively takes the brakes off of this antidepressant mechanism.

"Selectively inhibiting the eEF2 kinase was sufficient to trigger a rapidly acting antidepressant response in control mice but not in mice lacking BDNF," explained Monteggia.

The researchers discovered that the boost in BDNF occurs while neurons are in their default mode — not doing anything in particular. But the cells continue communicating via a low level of background chatter, spontaneously releasing chemical messengers that bind to receptors. So, when ketamine blocks NMDA receptors, it prevents their naturally-occurring messenger chemical, glutamate, from binding to them.

"Interference with such spontaneous neurotransmission to trigger production of a protein represents a novel mode of drug action," Monteggia noted. "It may also hold clues to what goes awry in the brain in disorders like depression."

Although BDNF levels fall off sharply following the transient increase triggered by ketamine, she says evidence may also support a role for BDNF in the drug's longer-term antidepressant effects. The exact role of another enzyme implicated in ketamine's antidepressant action remains to be determined, in light of the new findings. Yale researchers reported last Fall that the drug triggered increased connections between neurons via effects on the enzyme, called mTOR.

"This discovery of a novel pathway involved in mediating fast-acting antidepressant action holds hope for development of new rapid-acting medications," said Monteggia.

When in their default state, neurons that mediate ketamine's action engage in the brain's equivalent of background chatter. They spontaneously spray out (orange) the chemical messenger glutamate (green circles), which binds to NMDA receptors (black ovals) on adjoining neurons. This activates the enzyme eEF2 kinase, which suppresses synthesis of BDNF, a growth factor that has antidepressant effects. Treatment with ketamine blocks the binding of the neurotransmitter to the receptors (blue dots on black ovals), which inactivates the enzyme, taking the brakes off translation of BDNF into protein. This jumpstarts a fast-acting antidepressant effect.

Source: Lisa Monteggia, Ph.D., University of Texas Southwestern Medical Center

Reference
NMDA receptor blockade at rest triggers rapid behavioural antidepressant responses. Autry AE, Adachi M, Nosyreva E, Na ES, Los MF, Cheng PF, Kavalali ET, Monteggia LM. Nature. 2011 Jun 15. doi: 10.1038/nature10130. [Epub ahead of print] PMID:21677641

Focusing on School Attendance Reduces HIV Risk Among Orphaned Teens

Source: iStock
A comprehensive school support program effectively reduced risk factors associated with infection with HIV among teens who had lost one or both parents, according to early results from a pilot study funded by NIMH. The paper was published online ahead of print on February 17, 2011, in the Journal of Adolescent Health LPCC Continuing Education

Background
Current statistics estimate there are more than 11 million children living in sub-Saharan Africa who have lost one or both parents to HIV/AIDS. These children are at increased risk of dropping out of school, which in turn increases their risk for unprotected sexual behavior. Some research suggests that interventions that aim to change a person's living conditions, such as methods designed to help them stay in school, may be effective in reducing or preventing HIV infection among these at-risk children.

To further explore this idea, Hyunsan Cho, Ph.D., of the Pacific Institute for Research and Evaluation in Chapel Hill, N.C., and colleagues recruited 105 students, ages 12-14, from a rural area in Kenya with high HIV prevalence who had lost one or both parents to any cause. All participants received supportive household supplies (e.g., mosquito nets, blankets, food supplements) every two weeks. Participants randomly assigned to the test group also received school uniforms and money to pay school fees. A local woman, designated as a "community visitor," was assigned for every 10 teens in the test group to visit their homes at least monthly. She also visited the teens' schools weekly to monitor their school attendance and address problems that may lead to absenteeism.

Results
After one year, teens in the test group were less likely to have:

Dropped out of school (4 percent vs 12 percent of the control group)
Begun having sex (19 percent vs 33 percent control)
Reported attitudes supporting initiation of sexual relationships at a young age
Teens in the test group were also more likely to perceive that adults in the family liked or cared about them, and were generally less likely to endorse attitudes accepting of husbands beating their wives.

Significance
According to the researchers, these findings support previous research suggesting that comprehensive, community-based school support can help reduce multiple HIV risk factors among orphaned teens. The researchers also found evidence that school support enhances social bonding and positive attitudes toward gender equity.

What's Next
Given that these findings resulted from an experimental pilot study, the researchers emphasized that future studies should include more participants and focus on methods for generalizing this approach to broader populations.

Reference
Cho H, Hallfors DD, Mbai II, Itindi J, Milimo BW, Halpern CT, Iritani BJ. Keeping Adolescent Orphans in School to Prevent Human Immunodeficiency Virus Infection : Evidence From a Randomized Controlled Trial in Kenya. J Adolesc Health. 2011 Feb 17. [online ahead of print]

Same Genes Suspected in Both Depression and Bipolar Illness

Increased Risk May Stem From Variation in Gene On/Off Switch
Source: UCSC Genome BrowserResearchers, for the first time, have pinpointed a genetic hotspot that confers risk for both bipolar disorder and depression. People with either of these mood disorders were significantly more likely to have risk versions of genes at this site than healthy controls. One of the genes, which codes for part of a cell's machinery that tells genes when to turn on and off, was also found to be over-expressed in the executive hub of bipolar patients' brains, making it a prime suspect. The results add to mounting evidence that major mental disorders overlap at the molecular level. LPCC Continuing Education
"People who carry the risk versions may differ in some dimension of brain development that may increase risk for mood disorders later in life," explained Francis McMahon, M.D., of the NIMH Mood and Anxiety Disorders Program, who led the study.

McMahon and an international team of investigators, supported, in part by NIMH, report on the findings of their genome-wide meta-analysis online January 17, 2010 in the journal Nature Genetics.

Background
Major mood disorders affect 20 percent of the population and are among the leading causes of disability worldwide. It's long been known that bipolar disorder and unipolar depression often run together in the same families, hinting at some shared lineage. Yet, until now, no common genes or chromosomal locations had been identified.

McMahon and colleagues analyzed data from five different genome-wide association studies (GWAS) totaling more than 13,600 people, and confirmed their results in 3 additional independent samples totaling 4,677 people.

Findings of This Study
Genetic variations on Chromosome 3 were significantly associated with both mood disorders. The suspect gene, called PBRM1, codes for a protein critical for chromatin remodeling, a key process in regulating gene expression. A neighboring gene is involved in the proliferation of brain stem cells.

The researchers pinpointed a "protective" version of the PBRM1 gene that is carried by 41 percent of healthy controls, but only 38 percent of people with bipolar and unipolar depression. The risk version was found in 62 percent of mood disorder cases and 59 percent of controls. The researchers also showed that PBRM1 is expressed more in the prefrontal cortex of people with bipolar disorder than in controls.

Significance
Since mood disorders likely involve altered gene expression during brain development and in response to stress, PBRM1's profile makes it a good potential candidate gene. This first genetic evidence of unipolar/bipolar overlap is also the first significant genome-wide association with any psychiatric illness in the Chromosome 3p region.

However, the findings underscore limitations of the GWAS approach, which looks for connections to gene versions that are common in the population. Having one copy of this risk variant increases vulnerability for developing a mood disorder by a modest 15 percent. Why do some people with this variant — and presumably other, yet to be discovered, shared risk genes — develop bipolar disorder while others develop unipolar depression or remain healthy? Environmental influences and epigenetic factors may be involved, suggest the researchers, who note that "genetic association findings so far seem to account for little of the inherited risk for mood disorders."

"Our results support the growing view that there aren't common genes with large effects that confer increased risk for mood disorders," said McMahon. "If there were, in this largest sample to date, we would have found them. The disorders likely involve many genes with small effects — and different genes in different families — complicating the search. Rarer genes with large effects may also exist."

What's Next?
Ultimately, findings such as these may lead to identification of common biological pathways that may play a role in both unipolar and bipolar illness and suggest strategies for better treatment, said McMahon. The results add to other evidence of overlap that is spurring a new NIMH initiative to make sense of research findings that don't fit neatly into current diagnostic categories. See: Genes and Circuitry, Not Just Clinical Observation, to Guide Classification for Research.

Bipolar disorder and unipolar depression often run in the same families, as this pedigree diagram illustrates. The new study is the first to trace both illnesses to a shared chromosomal hotspot.

Source: NIMH Genetics Initiative Bipolar Disorder Consortium

Reference
Meta-analysis of genome-wide association data identifies a risk locus for major mood disorders on 3p21.1.the Bipolar Disorder Genome Study (BiGS) Consortium, McMahon FJ, Akula N, Schulze TG, Muglia P, Tozzi F, Detera-Wadleigh SD, Steele CJ, Breuer R, Strohmaier J, Wendland JR, Mattheisen M, Mühleisen TW, Maier W, Nöthen MM, Cichon S, Farmer A, Vincent JB, Holsboer F, Preisig M, Rietschel M. Nat Genet. 2010 Jan 17. [Epub ahead of print]PMID: 20081856

Samples included in the meta-analysis:
dbGaP National Institute of Mental Health bipolar disorder
Genetic Association Information Network MDD
Wellcome Trust Case Control Consortium
German sample
Systematic Treatment Enhancement Program for Bipolar Disorder

Behavioral Training Improves Connectivity and Function in the Brain

Children with poor reading skills who underwent an intensive, six-month training program to improve their reading ability showed increased connectivity in a particular brain region, in addition to making significant gains in reading, according to a study funded in part by the National Institute of Mental Health (NIMH). The study was published in the Dec. 10, 2009, issue of Neuron. LPCC Continuing Education
"We have known that behavioral training can enhance brain function." said NIMH Director Thomas R. Insel, M.D. "The exciting breakthrough here is detecting changes in brain connectivity with behavioral treatment. This finding with reading deficits suggests an exciting new approach to be tested in the treatment of mental disorders, which increasingly appear to be due to problems in specific brain circuits."

For the study, Timothy Keller, Ph.D., and Marcel Just, Ph.D., both of Carnegie Mellon University, randomly assigned 35 poor readers ages 8-12, to an intensive, remedial reading program, and 12 to a control group that received normal classroom instruction. For comparison, the researchers also included 25 children of similar age who were rated as average or above-average readers by their teachers. The average readers also received only normal classroom instruction.

Four remedial reading programs were offered, but few differences in reading improvements were seen among them. As such, results for participants in these programs were evaluated as a group. All of the programs were given over a six month schooling period, for five days a week in 50-minute sessions (100 hours total), with three students per teacher. The focus of these programs was improving readers' ability to decode unfamiliar words.

Using a technology called diffusion tensor imaging (DTI), the researchers were able to measure structural properties of the children's white matter, the insulation-clad fibers that provide efficient communication in the central nervous system. Specifically, DTI shows the movement of water molecules through white matter, reflecting the quality of white matter connections. The better the connection, the more the water molecules move in the same direction, providing a higher "bandwidth" for information transfer between brain regions.

At the outset of the study, poor readers showed lower quality white matter than average readers in a brain region called the anterior left centrum semiovale. Six months later, at the completion of the intensive training, the poor readers showed significant increases in the quality of this region. Children who did not receive the training did not show this increase, suggesting that the changes seen in the remedial training group were not due to natural maturation of the brain.

In an effort to further pinpoint the mechanism underlying this change, the researchers deduced that a process called myelination may be key. Myelin is akin to electrical insulation, allowing for more rapid and efficient communication between nerve cells in the brain. However, the directional association between brain changes and reading improvements remains unclear—whether intensive training brings about increased myelination that results in improved word decoding skills, or whether improved word decoding skills leads to changes in reading habits that result in greater myelination.

"Our findings support not only the positive effects of remediation and rehabilitation for reading disabilities, but may also lead to improved treatments for a range of developmental conditions related to brain connectivity, such as autism," noted Just.


Source: Timothy Keller, Ph.D.; Marcel Just, Ph.D.

Left brain image shows the area of lower quality white matter (blue area) among poor readers relative to good readers at the beginning of the study.

Center brain image shows the area where the white matter quality increased (red/yellow area) among poor readers who received the remedial reading instruction.

Right brain image shows that following the instruction, there were no differences between the poor and average readers with respect to the quality of their white matter.

Reference
Keller TA, Just MA. Altering cortical connectivity: Remediation-induced changes in the white matter of poor readers.

Resilience

What Is Resilience?

Resilience is the ability to:
Bounce back
Take on difficult challenges and still find meaning in life
Respond positively to difficult situations
Rise above adversity
Cope when things look bleak
Tap into hope
Transform unfavorable situations into wisdom, insight, and compassion
Endure

Resilience refers to the ability of an individual, family, organization, or community to cope with adversity and adapt to challenges or change. It is an ongoing process that requires time and effort and engages people in taking a number of steps to enhance their response to adverse circumstances. Resilience implies that after an event, a person or community may not only be able to cope and recover, but also change to reflect different priorities arising from the experience and prepare for the next stressful situation.

Resilience is the most important defense people have against stress.
It is important to build and foster resilience to be ready for future challenges.
Resilience will enable the development of a reservoir of internal resources to draw upon during stressful situations.
Research (Aguirre, 2007; American Psychological Association, 2006; Bonanno, 2004) has shown that resilience is ordinary, not extraordinary, and that people regularly demonstrate being resilient.

Resilience is not a trait that people either have or do not have.
Resilience involves behaviors, thoughts, and actions that can be learned and developed in anyone.
Resilience is tremendously influenced by a person's environment.
Resilience changes over time. It fluctuates depending on how much a person nurtures internal resources or coping strategies. Some people are more resilient in work life, while others exhibit more resilience in their personal relationships. People can build resilience and promote the foundations of resilience in any aspect of life they choose.

What Is Individual or Personal Resilience?
Individual resilience is a person's ability to positively cope after failures, setbacks, and losses. Developing resilience is a personal journey. Individuals do not react the same way to traumatic or stressful life events. An approach to building resilience that works for one person might not work for another. People use varying strategies to build their resilience. Because resilience can be learned, it can be strengthened. Personal resilience is related to many factors including individual health and well-being, individual aspects, life history and experience, and social support.

Individual Health and Well-Being Individual Aspects Life History and Experience Social Support These are factors with which a person is born.

Personality
Ethnicity
Cultural background
Economic background

These are past events and relationships that influence how people approach current stressors:
Family history
Previous physical health
Previous mental health
Trauma history
Past social experiences
Past cultural experiences

These are support systems provided by family, friends, and members of the community, work, or school environments:
Feeling connected to others
A sense of security
Feeling connected to resources
(Adapted from Simon, Murphy, & Smith, 2008)


Along with the factors listed above, there are several attributes that have been correlated with building and promoting resilience.

The American Psychological Association reports the following attributes regarding resilience:
The capacity to make and carry out realistic plans
Communication and problem-solving skills
A positive or optimistic view of life
Confidence in personal strengths and abilities
The capacity to manage strong feelings, emotions, and impulses

What Is Family Resilience?
Family resilience is the coping process in the family as a functional unit. Crisis events and persistent stressors affect the whole family, posing risks not only for individual dysfunction, but also for relational conflict and family breakdown. Family processes mediate the impact of stress for all of its members and relationships, and the protective processes in place foster resilience by buffering stress and facilitating adaptation to current and future events. Following are the three key factors in family resilience (Wilson & Ferch, 2005):

Family belief systems foster resilience by making meaning in adversity, creating a sense of coherence, and providing a positive outlook.
Family organization promotes resilience by facilitating flexibility, capacity to adapt, connectedness and cohesion, emotional and structural bonding, and accessibility to resources.
Family communication enhances resilience by engaging clear communication, open and emotional expressions, trust and collaborative problem solving, and conflict management.

What Is Organizational Resilience?
Organizational resilience is the ability and capacity of a workplace to withstand potential significant economic times, systemic risk, or systemic disruptions by adapting, recovering, or resisting being affected and resuming core operations or continuing to provide an acceptable level of functioning and structure.

A resilient workforce and organization is important during major decisions or business changes.
Companies and organizations, like individuals, need to be able to rebound from potentially disastrous changes.
The challenge for the incorporation of resilience into a workplace is to identify what enhances the ability of an organization to rebound effectively.
Measuring workplace resilience involves identifying and evaluating the following:
Past and present mitigative mechanisms and practices that increase safety
Past and present mitigative mechanisms and practices that decrease error
Necessary redundancy in systems
Planning and programming that demonstrate collective mindfulness
Anticipation of potential trouble and solutions to potential problems

What Is Community Resilience?
Community resilience is the individual and collective capacity to respond to adversity and change. It is a community that takes intentional action to enhance the personal and collective capacity of its citizens and institutions to respond to and influence the course of social and economic change. For a community to be resilient, its members must put into practice early and effective actions so that they can respond to change. When responding to stressful events, a resilient community will be able to strengthen community bonds, resources, and the capacity to cope. Systems involved with building and maintaining community resilience must work together.
mental health and social work ceus

How Does Culture Influence Resilience?
Cultural resilience refers to a culture’s capacity to maintain and develop cultural identity and critical cultural knowledge and practices. Along with an entire culture fostering resilience, the interaction of culture and resilience for an individual also is important. An individual’s culture will have an impact on how the person communicates feelings and copes with adversity. Cultural parameters are often embedded deep in an individual. A person’s cultural background may influence one deeply in how one responds to different stressors. Assimilation could be a factor in cultural resilience, as it could be a positive way for a person to manage his/her environment. However, assimilation could create conflict between generations, so it could be seen as positive or negative depending on the individual and culture. Because of this, coping strategies are going to be different. With growing cultural diversity, the public has greater access to a number of different approaches to building resilience. It is something that can be built using approaches that make sense within each culture and tailored to each individual.

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What Factors Promote Resilience?
Resilience involves the modification of a person's response to a potentially risky situation. People who are resilient are able to maintain high self-esteem and self-efficacy in spite of the challenges they face. By fostering resilience, people are building psychological defenses against stress. The more resources and defenses available during a time of struggle, the better able to cope and bounce back from adverse circumstances people will be. A person’s ability to regain a sense of normalcy or define a new normalcy after adverse circumstances will be partially based on the resources available to him/her. Resilience building can begin at any time. Following is information regarding applicable ways to implement resilience practices, as well as situations that could inhibit resilience, situations that enhance resilience, and people who help facilitate the growth of resilience.

Resilience


Demonstrating Resilience Vulnerability Factors Inhibiting Resilience Protective Factors Enhancing Resilience Facilitators of Resilience
Individual Resilience
The ability for an individual to cope with adversity and change
Optimism
Flexibility
Self-confidence
Competence
Insightfulness
Perseverance
Perspective
Self-control
Sociability
Poor social skills
Poor problem solving
Lack of empathy
Family violence
Abuse or neglect
Divorce or partner breakup
Death or loss
Lack of social support
Social competence
Problem-solving skills
Good coping skills
Empathy
Secure or stable family
Supportive relationships
Intellectual abilities
Self-efficacy
Communication skills

Individuals
Parents
Grandparents
Caregivers
Children
Adolescents
Friends
Partners
Spouses
Teachers
Faith Community

Organizational Resilience
The ability for a business or industry, including its employees, to cope with adversity and change
Proactive employees
Clear mission, goals, and values
Encourages opportunities to influence change
Clear communication
Nonjudgmental
Emphasizes learning
Rewards high performance
Unclear Expectations
Conflicted expectations
Threat to job security
Lack of personal control
Hostile atmosphere
Defensive atmosphere
Unethical environment
Lack of communication

Open communication
Supportive colleagues
Clear responsibilities
Ethical environment
Sense of control
Job security
Supportive management
Connectedness among departments
Recognition

Employers
Managers
Directors
Employees
Employee assistance programs
Other businesses

Community Resilience
The ability for an individual and the collective community to respond to adversity and change.
Connectedness
Commitment to community
Shared values
Structure, roles, and responsibilities exist throughout community
Supportive
Good communication
Resource sharing
Volunteerism
Responsive organizations
Strong schools

Lack of support services
Social discrimination
Cultural discrimination
Norms tolerating violence
Deviant peer group
Low socioeconomic status
Crime rate
Community disorganization
Civil rivalry
Access to Support services
Community networking
Strong cultural identity
Strong social support systems
Norms against violence
Identification as a community
Cohesive community leadership
Community leaders
Faith-based organizations
Volunteers
Nonprofit organizations
Churches/houses of worship
Support services staff
Teachers
Youth groups
Boy/Girl Scouts
Planned social networking events

(Adapted from Kelly, 2007)
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How Is Personal Resilience Built?
Developing resilience is a personal journey. People do not react the same way to traumatic events. Some ways to build resilience include the following actions:

Making connections with others
Looking for opportunities for self-discovery
Nurturing a positive view of self
Accepting that change is a part of living
Taking decisive actions
Learning from the past
The ability to be flexible is a great skill to obtain and facilitates resilience growth. Getting help when it is needed is crucial to building resilience. It is important to try to obtain information on resilience from books or other publications, self-help or support groups, and online resources like the ones found in this resource collection.

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What Can Be Done to Promote Family Resilience?
Developing family resilience, like individual resilience, is different for every family. The important idea to keep in mind is that an underlying stronghold of family resilience is cohesion, a sense of belonging, and communication. It is important for a family to feel that when their world is unstable they have each other. This sense of bonding and trust is what fuels a family's ability to be resilient. Families that learn how to cope with challenges and meet individual needs are more resilient to stress and crisis. Healthy families solve problems with cooperation, creative brainstorming, openness to others, and emphasis on the role of social support and connectedness (versus isolation) in family resiliency. Resilience is exercised when family members demonstrate behaviors such as confidence, hard work, cooperation, and forgiveness. These are factors that help families withstand stressors throughout the family life cycle.

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How Is Community Resilience Fostered?
Fostering community resilience will greatly depend on the community itself and involves the community working as a whole toward preparedness. It is the capacity for the collective to take preemptive action toward preparedness. Community resilience involves the following factors:

Connection and caring
Collective resources
Critical analysis of the community
Skill building for community members
Prevention, preparedness, and response to stressful events
Resilience is exercised when community members demonstrate behaviors such as confidence, hard work, cooperation, and resourcefulness, and support of those who have needs during particular events. These are factors that help communities withstand challenging circumstances. There are other tips about how to foster community resilience in this resource collection.

Developing resilience is a personal journey. All people do not react the same to traumatic and stressful life events. An approach to building resilience that works for one person might not work for another. People use varying strategies. Resilience involves maintaining flexibility and balance in life during stressful circumstances and traumatic events. Being resilient does not mean that a person does not experience difficulty or distress. Emotional pain and sadness are common in people who have suffered major adversity or trauma in their lives. Stress can be dealt with proactively by building resilience to prepare for stressful circumstances, while learning how to recognize symptoms of stress. Fostering resilience or the ability to bounce back from a stressful situation is a proactive mechanism to managing stress.

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References
Aguirre, B. (2007). Dialectics of vulnerability and resilience. Georgetown Journal of Poverty Law and Policy, 14(39), 1–18.

American Psychological Association. (2006). The road to resilience. Retrieved March 20, 2009, from " target="_blank">http://www.apahelpcenter.org/featuredtopics/feature.php?id=6.

Bonanno, G. (2004). Loss, trauma, and human resilience: Have we underestimated the human capacity to thrive after extremely aversive events? American Psychologist, 59, 20–28.

Kelly, S. (2007). Personal and community resilience: Building it and sustaining it. Retrieved March 23, 2009, from the University of California Los Angeles Bureau for Behavioral Health and Health Facilities at " target="_blank">http://www.wvdhhr.org/healthprep/common/resiliency.ppt#256.

Simon, J., Murphy, J., & Smith, S. (2008). Building resilience: Appreciate the little things in life. British Journal of Social Work, 38, 218–235.

Wilson, S., & Ferch, S. (2005). Enhancing resilience in the workplace through the practice of caring relationships. Organization Development Journal, 23(4), 45–60.

Getting Through Tough Economic Times

This guide provides practical advice on how to deal with the effects financial difficulties can have on your physical and mental health -- it covers:

•Possible health risks
•Warning signs
•Managing stress
•Getting help
•Suicide warning signs
•Other steps you can take
Possible Health Risks
Economic turmoil (e.g., increased unemployment, foreclosures, loss of investments and other financial distress) can result in a whole host of negative health effects - both physical and mental. It can be particularly devastating to your emotional and mental well-being. Although each of us is affected differently by economic troubles, these problems can add tremendous stress, which in turn can substantially increase the risk for developing such problems as:

•Depression
•Anxiety
•Compulsive Behaviors (over-eating, excessive gambling, spending, etc.)
•Substance Abuse
Warning Signs
It is important to be aware of signs that financial problems may be adversely affecting your emotional or mental well being --or that of someone you care about. These signs include:

•Persistent Sadness/Crying
•Excessive Anxiety
•Lack of Sleep/Constant Fatigue
•Excessive Irritability/Anger
•Increased drinking
•Illicit drug use, including misuse of medications
•Difficulty paying attention or staying focused
•Apathy - not caring about things that are usually important to you
•Not being able to function as well at work, school or home
Managing Stress
If you or someone you care about is experiencing these symptoms, you are not alone. These are common reactions to stress, and there are coping techniques that you can use to help manage it. They include:

•Trying to keep things in perspective - recognize the good aspects of life and retain hope for the future.
•Strengthening connections with family and friends who can provide important emotional support.
•Engaging in activities such as physical exercise, sports or hobbies that can relieve stress and anxiety.
•Developing new employment skills that can provide a practical and highly effective means of coping and directly address financial difficulties.
Getting Help
Even with these coping techniques, however, sometimes these problems can seem overwhelming and you may need additional help to get through "rough patches." Fortunately, there are many people and services that can provide help. These include your:

•Healthcare provider
•Spiritual leader
•School counselor
•Community health clinic
If you need help finding treatment services you can access our Mental Health Services Locator for information and mental health resources near you. Similarly, if you need help with a substance abuse problem you can use our Substance Abuse Treatment Facility Locator.

Specific help for financial hardship is also available, on issues such as:

•Making Home Affordable
•Foreclosure
•Reemployment
•Financial assistance
There are many other places where you can turn for guidance and support in dealing with the financial problems affecting you or someone you care about. These resources exist at the federal, state and community level and can be found through many sources such as:

•Federal and state government
•Civic associations
•Spiritual groups
•Other sources such as the government services section of a phone book
Suicide Warning Signs
Unemployment and other kinds of financial distress do not "cause" suicide directly, but they can be factors that interact dynamically within individuals and affect their risk for suicide. These financial factors can cause strong feelings such as humiliation and despair, which can precipitate suicidal thoughts or actions among those who may already be vulnerable to having these feelings because of life-experiences or underlying mental or emotional conditions (e.g., depression, bi-polar disorder) that place them at greater risk of suicide.

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These are some of the signs you may want to be aware of in trying to determine whether you or someone you care about could be at risk for suicide:

•Threatening to hurt or kill oneself or talking about wanting to hurt or kill oneself
•Looking for ways to kill oneself
•Thinking or fantasying about suicide
•Acting recklessly
•Seeing no reason for living or having no sense of purpose in life
If you or someone you care about are having suicidal thoughts or showing these symptoms SEEK IMMEDIATE HELP. Contact your healthcare provider, mental health crisis center, hospital emergency room or the National Suicide Prevention Lifeline at 1-800-273-TALK (8255) for help.

Other Steps You Can Take
•Acknowledge that economic downturns can be frightening to everyone, but that there are ways of getting through them - from engaging in healthy activities, positive thinking, supportive relationships, to seeking help when needed from health professionals.


•Encourage community-based organizations and groups to provide increased levels of mental health treatment and support to those who are severely affected by the economy.


•Work together to help all members of the community build their resiliency and successfully return to healthy and productive lives.
For further information on mental health or substance abuse issues please visit The Substance Abuse and Mental Health Services Administration (SAMHSA).


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Special Note to Journalists
For ideas on how to best cover sensitive issues like suicide prevention in a thoughtful and constructive manner you can check out suggestions developed by the Annenberg Public Policy Center in conjunction with leading suicide prevention experts and journalists.

NIDA InfoFacts: Understanding Drug Abuse and Addiction

Many people do not understand why individuals become addicted to drugs or how drugs change the brain to foster compulsive drug abuse. They mistakenly view drug abuse and addiction as strictly a social problem and may characterize those who take drugs as morally weak. One very common belief is that drug abusers should be able to just stop taking drugs if they are only willing to change their behavior. What people often underestimate is the complexity of drug addiction—that it is a disease that impacts the brain and because of that, stopping drug abuse is not simply a matter of willpower. Through scientific advances we now know much more about how exactly drugs work in the brain, and we also know that drug addiction can be successfully treated to help people stop abusing drugs and resume their productive lives.

Drug abuse and addiction are a major burden to society. Estimates of the total overall costs of substance abuse in the United States—including health- and crime-related costs as well as losses in productivity—exceed half a trillion dollars annually. This includes approximately $181 billion for illicit drugs,1 $168 billion for tobacco,2 and $185 billion for alcohol.3 Staggering as these numbers are, however, they do not fully describe the breadth of deleterious public health—and safety—implications, which include family disintegration, loss of employment, failure in school, domestic violence, child abuse, and other crimes.


What is drug addiction?

Addiction is a chronic, often relapsing brain disease that causes compulsive drug seeking and use despite harmful consequences to the individual who is addicted and to those around them. Drug addiction is a brain disease because the abuse of drugs leads to changes in the structure and function of the brain. Although it is true that for most people the initial decision to take drugs is voluntary, over time the changes in the brain caused by repeated drug abuse can affect a person’s self control and ability to make sound decisions, and at the same time send intense impulses to take drugs.

It is because of these changes in the brain that it is so challenging for a person who is addicted to stop abusing drugs. Fortunately, there are treatments that help people to counteract addiction’s powerful disruptive effects and regain control. Research shows that combining addiction treatment medications, if available, with behavioral therapy is the best way to ensure success for most patients. Treatment approaches that are tailored to each patient’s drug abuse patterns and any co-occurring medical, psychiatric, and social problems can lead to sustained recovery and a life without drug abuse.

Similar to other chronic, relapsing diseases, such as diabetes, asthma, or heart disease, drug addiction can be managed successfully. And, as with other chronic diseases, it is not uncommon for a person to relapse and begin abusing drugs again. Relapse, however, does not signal failure—rather, it indicates that treatment should be reinstated, adjusted, or that alternate treatment is needed to help the individual regain control and recover.

What happens to your brain when you take drugs?

Drugs are chemicals that tap into the brain’s communication system and disrupt the way nerve cells normally send, receive, and process information. There are at least two ways that drugs are able to do this: (1) by imitating the brain’s natural chemical messengers, and/or (2) by overstimulating the “reward circuit” of the brain.

Some drugs, such as marijuana and heroin, have a similar structure to chemical messengers, called neurotransmitters, which are naturally produced by the brain. Because of this similarity, these drugs are able to “fool” the brain’s receptors and activate nerve cells to send abnormal messages.

Other drugs, such as cocaine or methamphetamine, can cause the nerve cells to release abnormally large amounts of natural neurotransmitters, or prevent the normal recycling of these brain chemicals, which is needed to shut off the signal between neurons. This disruption produces a greatly amplified message that ultimately disrupts normal communication patterns.

Nearly all drugs, directly or indirectly, target the brain’s reward system by flooding the circuit with dopamine. Dopamine is a neurotransmitter present in regions of the brain that control movement, emotion, motivation, and feelings of pleasure. The overstimulation of this system, which normally responds to natural behaviors that are linked to survival (eating, spending time with loved ones, etc.), produces euphoric effects in response to the drugs. This reaction sets in motion a pattern that “teaches” people to repeat the behavior of abusing drugs.

As a person continues to abuse drugs, the brain adapts to the overwhelming surges in dopamine by producing less dopamine or by reducing the number of dopamine receptors in the reward circuit. As a result, dopamine’s impact on the reward circuit is lessened, reducing the abuser’s ability to enjoy the drugs and the things that previously brought pleasure. This decrease compels those addicted to drugs to keep abusing drugs in order to attempt to bring their dopamine function back to normal. And, they may now require larger amounts of the drug than they first did to achieve the dopamine high—an effect known as tolerance.

Long-term abuse causes changes in other brain chemical systems and circuits as well. Glutamate is a neurotransmitter that influences the reward circuit and the ability to learn. When the optimal concentration of glutamate is altered by drug abuse, the brain attempts to compensate, which can impair cognitive function. Drugs of abuse facilitate nonconscious (conditioned) learning, which leads the user to experience uncontrollable cravings when they see a place or person they associate with the drug experience, even when the drug itself is not available. Brain imaging studies of drug-addicted individuals show changes in areas of the brain that are critical to judgment, decisionmaking, learning and memory, and behavior control. Together, these changes can drive an abuser to seek out and take drugs compulsively despite adverse consequences—in other words, to become addicted to drugs.

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Why do some people become addicted, while others do not?

No single factor can predict whether or not a person will become addicted to drugs. Risk for addiction is influenced by a person’s biology, social environment, and age or stage of development. The more risk factors an individual has, the greater the chance that taking drugs can lead to addiction. For example:

Biology. The genes that people are born with––in combination with environmental influences––account for about half of their addiction vulnerability. Additionally, gender, ethnicity, and the presence of other mental disorders may influence risk for drug abuse and addiction.


Environment. A person’s environment includes many different influences––from family and friends to socioeconomic status and quality of life in general. Factors such as peer pressure, physical and sexual abuse, stress, and parental involvement can greatly influence the course of drug abuse and addiction in a person’s life.


Development. Genetic and environmental factors interact with critical developmental stages in a person’s life to affect addiction vulnerability, and adolescents experience a double challenge. Although taking drugs at any age can lead to addiction, the earlier that drug use begins, the more likely it is to progress to more serious abuse. And because adolescents’ brains are still developing in the areas that govern decisionmaking, judgment, and self-control, they are especially prone to risk-taking behaviors, including trying drugs of abuse.


Prevention is the Key

Drug addiction is a preventable disease. Results from NIDA-funded research have shown that prevention programs that involve families, schools, communities, and the media are effective in reducing drug abuse. Although many events and cultural factors affect drug abuse trends, when youths perceive drug abuse as harmful, they reduce their drug taking. It is necessary, therefore, to help youth and the general public to understand the risks of drug abuse, and for teachers, parents, and healthcare professionals to keep sending the message that drug addiction can be prevented if a person never abuses drugs.

National Strategy for Suicide Prevention

National Strategy for Suicide Prevention: Goals and Objectives for Action CEU Course


1. Increase awareness of suicide prevention methods
2. Increase familiarity with broad based support systems
3. Become familiar with strategies to reduce stigma
4. Learn how to promote efforts to reduce efforts to lethal means of self harm.
5. Identify at risk behavior
6. Implement appropriate treatment and resources
7. Develop and Promote Effective Clinical and Professional Practices
Table of Contents:
1. GOAL 1: Promote Awareness that Suicide is a Public Health Problem that is Preventable
2. GOAL 2: Develop Broad-Based Support for Suicide Prevention
3. GOAL 3: Develop and Implement Strategies to Reduce the Stigma Associated with Being a Consumer of Mental Health, Substance Abuse, and Suicide Prevention Services
4. GOAL 4: Develop and Implement Community-Based Suicide Prevention Programs
5. GOAL 5: Promote Efforts to Reduce Access to Lethal Means and Methods to Self-Harm
6. GOAL 6: Implement Training for Recognition of At-Risk Behavior and Delivery of Effective Treatment
7. GOAL 7: Develop and Promote Effective Clinical and Professional Practices
8. GOAL 8: Improve Access to and Community Linkages with Mental Health and Substance Abuse Services
9. GOAL 9: Improve Reporting and Portrayals of Suicidal Behavior, Mental Illness, and Substance Abuse in the Entertainment and News Media
10. GOAL 10: Promote and Support Research on Suicide and Suicide Prevention
11. GOAL 11: Improve and Expand Surveillance Systems
12. Looking Ahead
13. References
GOAL 1: Promote Awareness that Suicide is a Public Health Problem that is Preventable
Why is this Goal Important to the National Strategy?
In a democratic society, the stronger and broader the support for a public health initiative, the greater its chance for success. The social and political will can be mobilized when it is believed that suicide is preventable. If the general public understands that suicide and suicidal behaviors can be prevented, and people are made aware of the roles individuals and groups can play in prevention, many lives can be saved.
In order to mobilize social and political will, it is important to first dispel the myths that surround suicide. Many of these myths relate to the causes of suicide, the reasons for suicide, the types of individuals who contemplate suicide, and the consequences associated with suicidal ideation and attempts. Better awareness that suicide is a serious public health problem results in knowledge change, which then influences beliefs and behaviors (Satcher, 1999). Increased awareness coupled with the dispelling of myths about suicide and suicide prevention will result in a decrease in the stigma associated with suicide and life-threatening behaviors. An informed public awareness coupled with a social strategy and focused public will lead to a change in the public policy about the importance of investing in suicide prevention efforts at the local, State, regional, and national level (Mrazek & Haggerty, 1994).
Background Information and Current Status
The factors that contribute to the development, maintenance, and exacerbation of suicidal behaviors are now better understood from a public health perspective (Silverman & Maris, 1995). A public health approach allows suicide to be seen as a preventable problem, because it offers a way of understanding pathways to self-injury that lend themselves to the development of testable preventive interventions (Gordon, 1983; Potter, Powell & Kachur, 1995). Although some have criticized the public health model of suicide as being too disease-oriented, it does, in fact, take into account psychological, emotional, cognitive, and social factors that have been shown to contribute to suicidal behaviors (Potter, Rosenberg, & Hammond, 1998).
Did You Know?
In the 10 years 1989-1998, 307,973 people died as a result of suicide.
Suicide is a major public health problem. It is one of the top ten leading causes of death in the United States, ranking 8th or 9th for the last few decades. For the approximately 31,000 suicide deaths per year, there are an estimated 200,000 additional individuals who will be affected by the loss of a loved one or acquaintance by suicide. The economic and emotional toll on the Nation is profound (Palmer, Revicki, Halpern, & Hatziandreu, 1995).
How Will the Objective Facilitate Achievement of the Goal?
The objectives established for this goal are focused on increasing the degree of cooperation and collaboration between and among public and private entities that have made a commitment to public awareness of suicide and suicide prevention. To accomplish this goal, support for innovative techniques and approaches is needed to get the message out, as well as support for the organizations and institutions involved.
Objective 1.1:
By 2005, increase the number of States in which public information campaigns designed to increase public knowledge of suicide prevention reach at least 50 percent of the State's population.
Suicide has been designated as a serious public health problem by the U.S. Surgeon General, and the 105th U.S. Congress has recognized that this problem deserves increased attention [U.S. Senate Resolution 84 (5/6/97) and U.S. House Resolution 212 (10/9/98)]. They recognize suicide as a national problem and declare suicide prevention as a national priority, encouraging the development of an effective national strategy for the prevention of suicide. Public and private organizations have developed information campaigns to educate the public that suicide is preventable, as it can be a consequence of other treatable disorders such as depression, schizophrenia, bipolar illness, alcohol and drug abuse, and certain medical conditions. Campaigns alert professional, community, and lay groups about the common signs and symptoms associated with suicidal behavior. Some organizations with existing campaigns include the American Association of Suicidology (AAS), the American Foundation for Suicide Prevention (AFSP), the Suicide Awareness\Voices of Education (SA\VE), the Suicide Prevention Advocacy Network (SPAN USA), and Yellow Ribbon Suicide Prevention Program.
Ideas for Action Work with local media to develop and disseminate public service announcements describing a safe and effective message about suicide and its prevention.
Public information campaigns can take many forms. No single slogan or message works for everyone. For example, the primary purpose of the annual National Depression Screening Day is to identify, in a variety of settings, individuals with symptoms of depression and refer them for treatment (Jacobs, 1999b). However, such a screening program performed at primary care centers, mental health and substance abuse treatment centers, colleges, universities, and places of employment can play an important role in raising awareness and educating large groups of individuals about this mental disorder and its association with suicidal behaviors. Because no one
is immune to suicide the challenge is to develop a variety of messages targeting the young and the old, various racial and ethnic populations, individuals of various faiths, those of different sexual orientations, and people from diverse socioeconomic groups and geographical regions.
Objective 1.2:
By 2005, establish regular national congresses on suicide prevention designed to foster collaboration with stakeholders on prevention strategies across disciplines and with the public.
Broad-based participation and involvement is needed to ensure progress in reducing the toll of suicide. Open discussion and assessment of suicide prevention programs can only lead to their refinement and better chances for success.
The techniques and tools to create and implement prevention initiatives can be taught and demonstrated. Learning how to develop and disseminate public health messages and to mount public health campaigns is critical to implementing suicide prevention efforts.
A number of organizations have convened annual, national meetings devoted to suicide prevention. Currently, such meetings are sponsored by AAS, AFSP, and biennially by the International Association for Suicide Prevention (IASP). The establishment of regular national congresses on suicide prevention, collaboratively sponsored by more than one organization, will maintain interest and focus on this issue. Ideally, these national congresses should be sponsored by public/private partnerships (see Objective 2.2), and focus on needs and plans for coordinating effective suicide prevention efforts.
Ideas for Action Identify foundations and other stakeholders to contribute to the support of national congresses on suicide prevention.
Objective 1.3:
By 2005, convene national forums to focus on issues likely to strongly influence the effectiveness of suicide prevention messages.
National forums increase awareness of the problem of suicide and serve to mobilize social will. Such meetings keep the subject in the forefront of attention and raise concerns to the national level. Such activities increase connectedness between and among key stakeholders, and serve to bring support, consensus and collaboration to suicide prevention efforts.
Focusing on factors that influence the effectiveness of suicide prevention initiatives is critical to an overall strategy. National forums are opportunities to focus on specific issues that affect all efforts to mount suicide prevention initiatives. By highlighting specific areas, consensus can be reached on how best to incorporate elements into a suicide prevention plan and how best to evaluate effectiveness.
Ideas for Action Incorporate suicide awareness and prevention messages into employee assistance program activities in businesses with greater than 500
employees.
Objective 1.4:
By 2005, increase the number of both public and private institutions active in suicide prevention that are involved in collaborative, complementary dissemination of information on the World Wide Web.
The World Wide Web offers an unparalleled opportunity to bring public health information to a much broader audience because it can be accessed at home, at work, at schools, at community centers, at libraries, or at any other location where there is access to the Internet. Not only does the World Wide Web offer exciting possibilities for the delivery of public health messages (including promoting awareness and referral sources for those in need), but it offers an opportunity to develop preventive interventions as well.
For example, the World Wide Web offers the potential for interactive dialogue and exchange of accurate information. Clear, concise, and culturally sensitive public health messages are key to assisting individuals to evaluate their at-risk status accurately and to know where and how to get help. It therefore is important that both public and private institutions committed to suicide prevention activities collaborate and cooperate to deliver information that is consistent, comparable, complementary, and not competitive. In addition to several Federal websites (see Appendix D); some of the key national organizations currently disseminating suicide prevention information on the World Wide Web include AAS, AFSP, IASP, SPAN USA, and the American Academy of Pediatrics.
Did You Know? Suicide is the eighth leading cause of death for all Americans.
GOAL 2: Develop Broad-Based Support for Suicide Prevention

Anniversary Reactions to a Traumatic Event

Anniversary Reactions to a Traumatic Event:
The Recovery Process Continues
As the anniversary of a disaster or traumatic event approaches, many survivors report a return of restlessness and fear. Psychological literature calls it the anniversary reaction and defines it as an individual's response to unresolved grief resulting from significant losses. The anniversary reaction can involve several days or even weeks of anxiety, anger, nightmares, flashbacks, depression, or fear.

On a more positive note, the anniversary of a disaster or traumatic event also can provide an opportunity for emotional healing. Individuals can make significant progress in working through the natural grieving process by recognizing, acknowledging, and paying attention to the feelings and issues that surface during their anniversary reaction. These feelings and issues can help individuals develop perspective on the event and figure out where it fits in their hearts, minds, and lives.

It is important to note that not all survivors of a disaster or traumatic event experience an anniversary reaction. Those who do, however, may be troubled because they did not expect and do not understand their reaction. For these individuals, knowing what to expect in advance may be helpful. Common anniversary reactions among survivors of a disaster or traumatic event include:

Memories, Dreams, Thoughts, and Feelings: Individuals may replay memories, thoughts, and feelings about the event, which they can't turn off. They may see repeated images and scenes associated with the trauma or relive the event over and over. They may have recurring dreams or nightmares. These reactions may be as vivid on the anniversary as they were at the actual time of the disaster or traumatic event.
Grief and Sadness: Individuals may experience grief and sadness related to the loss of income, employment, a home, or a loved one. Even people who have moved to new homes often feel a sense of loss on the anniversary. Those who were forced to relocate to another community may experience intense homesickness for their old neighborhoods.
Fear and Anxiety: Fear and anxiety may resurface around the time of the anniversary, leading to jumpiness, startled responses, and vigilance about safety. These feelings may be particularly strong for individuals who are still working through the grieving process.
Frustration, Anger, and Guilt: The anniversary may reawaken frustration and anger about the disaster or traumatic event. Survivors may be reminded of the possessions, homes, or loved ones they lost; the time taken away from their lives; the frustrations with bureaucratic aspects of the recovery process; and the slow process of rebuilding and healing. Individuals may also experience guilt about survival. These feelings may be particularly strong for individuals who are not fully recovered financially and emotionally.
Avoidance: Some survivors try to protect themselves from experiencing an anniversary reaction by avoiding reminders of the event and attempting to treat the anniversary as just an ordinary day. Even for these people, it can be helpful to learn about common reactions that they or their loved ones may encounter, so they are not surprised if reactions occur.
Remembrance: Many survivors welcome the cleansing tears, commemoration, and fellowship that the anniversary of the event offers. They see it as a time to honor the memory of what they have lost. They might light a candle, share favorite memories and stories, or attend a worship service.
Reflection: The reflection brought about by the anniversary of a disaster or traumatic event is often a turning point in the recovery process. It is an opportunity for people to look back over the past year, recognize how far they have come, and give themselves credit for the challenges they surmounted. It is a time for survivors to look inward and to recognize and appreciate the courage, stamina, endurance, and resourcefulness that they and their loved ones showed during the recovery process. It is a time for people to look around and pause to appreciate the family members, friends, and others who supported them through the healing process. It is also a time when most people can look forward with a renewed sense of hope and purpose.
Although these thoughts, feelings, and reactions can be very upsetting, it helps to understand that it is normal to have strong reactions to a disaster or traumatic event and its devastation many months later. Recovery from a disaster or traumatic event takes time, and it requires rebuilding on many levels - physically, emotionally, and spiritually. However, with patience, understanding, and support from family members and friends, you can emerge from a disaster or traumatic event stronger than before.

Stressful Life Events

Stressful Life Events
The most common psychological and social stressors in adult life include the breakup of intimate romantic relationships, death of a family member or friend, economic hardships, racism and discrimination, poor physical health, and accidental and intentional assaults on physical safety (Holmes & Rahe, 1967; Lazarus & Folkman, 1984; Kreiger et al., 1993). Although some stressors are so powerful that they would evoke significant emotional distress in most otherwise mentally healthy people, the majority of stressful life events do not invariably trigger mental disorders. Rather, they are more likely to spawn mental disorders in people who are vulnerable biologically, socially, and/or psychologically (Lazarus & Folkman, 1984; Brown & Harris, 1989; Kendler et al., 1995). Understanding variability among individuals to a stressful life event is a major challenge to research. Groups at greater statistical risk include women, young and unmarried people, African Americans, and individuals with lower socioeconomic status (Ulbrich et al., 1989; McLeod & Kessler, 1990; Turner et al., 1995; Miranda & Green, 1999).

Divorce is a common example. Approximately one-half of all marriages now end in divorce, and about 30 to 40 percent of those undergoing divorce report a significant increase in symptoms of depression and anxiety (Brown & Harris, 1989). Vulnerability to depression and anxiety is greater among those with a personal history of mental disorders earlier in life and is lessened by strong social support. For many, divorce conveys additional economic adversities and the stress of single parenting. Single mothers face twice the risk of depression as do married mothers (Brown & Moran, 1997).

The death of a child or spouse during early or midadult life is much less common than divorce but generally is of greater potency in provoking emotional distress (Kim & Jacobs, 1995). Rates of diagnosable mental disorders during periods of grief are attenuated by the convention not to diagnose depression during the first 2 months of bereavement (Clayton & Darvish, 1979). In fact, people are generally unlikely to seek professional treatment during bereavement unless the severity of the emotional and behavioral disturbance is incapacitating.

A majority of Americans never will confront the stress of surviving a severe, life-threatening accident or physical assault (e.g., mugging, robbery, rape); however, some segments of the population, particularly urban youths and young adults, have exposure rates as high as 25 to 30 percent (Helzer et al., 1987; Breslau et al., 1991). Life-threatening trauma frequently provokes emotional and behavioral reactions that jeopardize mental health. In the most fully developed form, this syndrome is called post-traumatic stress disorder (DSM-IV), which is described later in this chapter. Women are twice as likely as men to develop post-traumatic stress disorder following exposure to life-threatening trauma (Breslau et al., 1998.)

More familiar to many Americans is the chronic strain that poor physical health and relationship problems place on day-to-day well-being. Relationship problems include unsatisfactory intimate relationships; conflicted relationships with parents, siblings, and children; and “falling-out” with coworkers, friends, and neighbors. In mid-adult life, the stress of caretaking for elderly parents also becomes more common.

Relationship problems at least double the risk of developing a mental disorder, although they are less immediately threatening or potentially cataclysmic than divorce or the death of a spouse or child (Brown & Harris, 1989). Finally, cumulative adversity appears to be more potent than stressful events in isolation as a predictor of psychological distress and mental disorders (Turner & Lloyd, 1995).

Past Trauma and Child Sexual Abuse
Severe trauma in childhood may have enduring effects into adulthood (Browne & Finkelhor, 1986). Past trauma includes sexual and physical abuse, and parental death, divorce, psychopathology, and substance abuse (reviewed in Turner & Lloyd, 1995).

Child sexual abuse is one of the most common stressors, with effects that persist into adulthood. It disproportionately affects females. Although definitions are still evolving, child sexual abuse is often defined as forcible touching of breasts or genitals or forcible intercourse (including anal, oral, or vaginal sex) before the age of 16 or 18 (Goodman et al., 1997). Epidemiology studies of adults in varying segments of the community have found that 15 to 33 percent of females and 13 to 16 percent of males were sexually abused in childhood (Polusny & Follette, 1995). A recent, large epidemiological study of adults in the general community found a lower prevalence (12.8 percent for females and 4.3 percent for males); however, the definition of sexual abuse was more restricted than in past studies (MacMillan et al., 1997). Sexual abuse in childhood has a mean age of onset estimated at 7 to 9 years of age (Polusny & Follette, 1995). In over 25 percent of cases of child sexual abuse, the offense was committed by a parent or parent substitute (Sedlak & Broadhurst, 1996).

The long-term consequences of past childhood sexual abuse are profound, yet vary in expression. They range from depression and anxiety to problems with social functioning and adult interpersonal relationships (Polusny & Follette, 1995). Post-traumatic stress disorder is a common sequela, found in 33 to 86 percent of adult survivors of child sexual abuse (Polusny & Follette, 1995). In a recent review, Weiss et al. (1999) found that sexual abuse was a specific risk factor for adult-onset depression and twice as many women as men reported a history of abuse. Other long-term effects include self-destructive behavior, social isolation, poor sexual adjustment, substance abuse, and increased risk of revictimization (Browne & Finkelhor, 1986; Briere, 1992).

Very few treatments specifically for adult survivors of childhood abuse have been studied in randomized controlled trials (IOM, 1998). Group therapy and Interpersonal Transaction group therapy were found to be more effective for female survivors than an experimental control condition that offered a less appropriate intervention (Alexander et al., 1989, 1991). In the practice setting, most psychosocial and pharmacological treatments are tailored to the primary diagnosis, which, as noted above, varies widely and may not attend to the special needs of those also reporting abuse history.

Domestic Violence
Domestic violence is a serious and startlingly common public health problem with mental health consequences for victims, who are overwhelmingly female, and for children who witness the violence. Domestic violence (also known as intimate partner violence) features a pattern of physical and sexual abuse, psychological abuse with verbal intimidation, and/or social isolation or deprivation. Estimates are that 8 to 17 percent of women are victimized annually in the United States (Wilt & Olsen, 1996). Pinpointing the prevalence is hindered by variations in the way domestic violence is defined and by problems in detection and underreporting. Women are often fearful that their reporting of domestic violence will precipitate retaliation by the batterer, a fear that is not unwarranted (Sisley et al., 1999).

Victims of domestic violence are at increased risk for mental health problems and disorders as well as physical injury and death. Domestic violence is considered one of the foremost causes of serious injury to women ages 15 to 44, accounting for about 30 percent of all acute injuries to women seen in emergency departments (Wilt & Olsen, 1996). According to the U.S. Department of Justice, females were victims in about 75 percent of the almost 2,000 homicides between intimates in 1996 (cited in Sisley et al., 1999). The mental health consequences of domestic violence include depression, anxiety disorders (e.g., post-traumatic stress disorder), suicide, eating disorders, and substance abuse (IOM, 1998; Eisenstat & Bancroft, 1999). Children who witness domestic violence may suffer acute and long-term emotional disturbances, including nightmares, depression, learning difficulties, and aggressive behavior. Children also become at risk for subsequent use of violence against their dating partners and wives (el-Bayoumi et al., 1998; NRC, 1998; Sisley et al., 1999).

Mental health interventions for victims, children, and batterers are highly important. Individual counseling and peer support groups are the interventions most frequently used by battered women. However, there is a lack of carefully controlled, methodologically robust studies of interventions and their outcomes, according to a report by the Institute of Medicine and National Research Council (IOM, 1998). A research agenda for violence against women was developed (IOM, 1996) and has served as an impetus for an ongoing research program sponsored by the U.S. Departments of Justice and Health and Human Services. Clearly, there is an urgent need for development and rigorous evaluation of prevention programs to safeguard against intimate partner violence and its impact on children.

Interventions for Stressful Life Events
Stressful life events, even for those at the peak of mental health, erode quality of life and place people at risk for symptoms and signs of mental disorders. There is an ever-expanding list of formal and informal interventions to aid individuals coping with adversity. Sources of informal interventions include family and friends, education, community services, self-help groups, social support networks, religious and spiritual endeavors, complementary healers, and physical activities. As valuable as these activities may be for promoting mental health, they have received less research attention than have interventions for mental disorders. Nevertheless, there are selected interventions to help people cope with stressors, such as bereavement programs and programs for caregivers (see Chapter 5) as well as couples therapy and physical activity.

Couples therapy is the umbrella term applied to interventions that aid couples in distress. The best studied interventions are behavioral couples therapy, cognitive-behavioral couples therapy, and emotion-focused couples therapy. A recent review article evaluated the body of evidence on the effectiveness of couples therapy and programs to prevent marital discord (Christensen & Heavey, 1999). The review found that about 65 percent of couples in therapy did improve, whereas 35 percent of control couples also improved. Couples therapy ameliorates relationship distress and appears to alleviate depression. The gains from couples therapy generally last through 6 months, but there are few long-term assessments (Christensen & Heavey, 1999). Similarly, interventions to prevent marital discord yield short-term improvements in marital adjustment and stability, but there is insufficient study of long-term outcomes. The prevention programs receiving the most study are the Couple Communication Program, Relationship Enhancement, and the Prevention and Relationship Enhancement Program (Christensen & Heavey, 1999). Greater research is needed to overcome gaps in knowledge and to extend findings to a broader array of programs, to diverse populations of couples, and to a wider set of outcomes, including effects on children.

Physical activities are a means to enhance somatic health as well as to deal with stress. A recent Surgeon General’s Report on Physical Activity and Health evaluated the evidence for physical activities serving to enhance mental health (U.S. Department of Health and Human Services [DHHS], 1996). Aerobic physical activities, such as brisk walking and running, were found to improve mental health for people who report symptoms of anxiety and depression and for those who are diagnosed with some forms of depression. The mental health benefits of physical activity for individuals in relatively good physical and mental health were not as evident, but the studies did not have sufficient rigor from which to draw unequivocal conclusions (DHHS, 1996).

Prevention of Mental Disorders
A promising development in prevention of a specific mental disorder in adults occurred with the publication of results from the San Francisco Depression Research Project (Munoz et al., 1995). This study investigated 150 primary care patients who did not meet diagnostic criteria for depression and who were being seen in a public clinic for other problems. They were randomized to either psychoeducation—an 8-week cognitive behavioral course to help them control and manage moods—or to a control condition. One year later, those who received psychoeducation were found to have developed significantly fewer depression symptoms than members of the control group. This trial is noteworthy in two major respects: it was a randomized controlled trial and its participants were low-income individuals, with high representation of all major minority groups. Low-income individuals are considered a high-risk population because of studies documenting their higher prevalence of mental disorders. This study demonstrated in a methodologically rigorous fashion that depression may be preventable in some cases. It serves as a model for extending the concept of prevention to many mental disorders. Prevention research is vitally important and needs to be enhanced.

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CE Courses for MFT Interns
and LMFTs
In 2009, the Licensed Professional Clinical Counselor licensure law was passed and signed here in California . For already licensed MFTs, grandparenting is available from January 1, 2011 through June 30, 2011. For interns who expect to be licensed before June 30, 2011, they too will have the option to apply for LPCC grandparenting. However, pre-licensed members who wish to obtain their LPCC license, and who are already in the pipeline (but will not be licensed by June 30, 2011) will need to adhere to specific education and experience requirements, as well as take the required licensing examinations.



For those who are outside of the grandparenting timeframe, the required education and experience is reviewed below. However, the specific regulations still need to be drafted by the Board of Behavioral Sciences. For example, can you count any and all supervised hours of experience towards both LPCC and MFT licensure? Will the BBS require national and/or state-developed examinations? Will the BBS allow more than one course to satisfy a particular required core course content area? These types of questions still need to be addressed through regulation, and we will share that information as the regulations evolve. As to the general education and experience required, please see the summary below[i]:





Education Requirements
Experience Requirements



· Masters or doctoral degree that is counseling or psychotherapy in content obtained from an accredited or approved institution containing not less than 48 graduate semester or 72 graduate quarter units of instruction.

· Three semester units or four and one-half quarter units of graduate study in each of following nine (9) areas: counseling and psychotherapeutic theories and techniques; human growth and development; career development; group counseling; assessment, appraisal, and testing of individuals; multicultural counseling; principles of the diagnostic process; research and evaluation; and, law and ethics.[ii] NOTE: An applicant whose degree is deficient in no more than two of the required nine (9) areas of study listed above, may satisfy those deficiencies by successfully completing post-master’s or postdoctoral degree coursework at an accredited or approved institution.

· A minimum of 12 semester units or 18 quarter units of advanced coursework to develop knowledge of specific treatment issues, special populations, application of counseling constructs, assessment and treatment planning, clinical interventions, therapeutic relationships, psychopathology, or other clinical topics.

· Six semester units or nine quarter units of supervised practicum or field study experience.[iii]
· A minimum of 15 contact hours of instruction in alcoholism and other chemical substance abuse dependency.

· A minimum of 10 contact hours of training or coursework in human sexuality.

· A two semester unit or three quarter unit survey course in psychopharmacology (at an accredited or approved institution).

· A minimum of 15 contact hours of instruction in spousal or partner abuse assessment, detection, and intervention strategies.

· A minimum of seven contact hours of training or coursework in child abuse assessment and reporting.

· A minimum of 18 contact hours of instruction in California law and ethics (school coursework may count towards this requirement.)

· A minimum of 10 contact hours of instruction in aging and long-term care.

· A minimum of 15 contact hours of instruction in crisis or trauma counseling.