Working with Transgender Clients

After recently having a transgender client start in my outpatient group and his dropping out after only a few sessions, I realized cultural sensitivity regarding GLBTQ (especially the T) is an area where I need a little additional development.  To that end, I started doing some reading and have prepared a blog post focusing on social work with transgender clients.  If you disagree with any of what follows or have anything to add, please, comment below.  I am far from being an expert; I’m just a social worker trying to keep an open mind and provide the best possible care for all people who I have the
opportunity to serve.

Transgender is a term that encompasses several different identities.  Generally, transgender people have a substantial identification with a gender other than the sex they were assigned at birth or who otherwise
challenge the gender binary and press our cultural boundaries around gender norms.  The term sex refers to the sex that a person was born with; I think of it as the parts you came with.  Gender describes a person’s internal sense of being male, female or something else and gender identity refers to what gender you identify with.  Gender identity is generally a deeply felt sense of being male, female, or something else.  Gender identity is different from sexual orientation.  Sexual orientation describes what gender a person partners with.

Because the term transgender includes a number of identities, it is best to listen to how clients describe themselves and use their language and terminology.  In general, the term transvestite is considered outdated and offensive.  Some ways to inquire what terminology a person prefers are as follows:
•       I would like to show you respect.  How would you like to be addressed?
•       How would you like me to refer to you?
•       What name/pronoun is appropriate?
Asking may feel awkward, as it seemed for me, but this is the best way to find out from a client how they want you to address them.  It was suggested to me by a transgender person that it might be simplest to include a question on your intake forms, "Are you transgender?"  Often, I ask cisgender (a word for people who are not transgender) clients what name they prefer to be called, since many people use nicknames.
Making this a habit is a small way to respect people’s identities and how they think about themselves.  It is important to consistently use the name and pronouns that a client prefers.  However, it is also important to keep a person’s transgender status confidential.  To this end, it may be important to ask what pronouns and name the person prefers you use in his or her chart or when speaking to people outside
of your agency.

Sometimes, cisgender clients may feel uncomfortable with the presence of transgender clients.  This can sometimes be mitigated by listening to their concerns and providing information to further their understanding.  Sometimes, it may be appropriate to facilitate a conversation between clients so that the transgender issue is
demystified.  If people see that transgender clients are seeking treatment for the same reasons as any other client, they are likely to be more accepting and open minded about trans clients.

If gender specific groups are provided, transgender clients should go to the group for clients of the gender that the trans client identifies as.  Similarly, trans clients in residential programs should ideally room with the gender that they identify as.  However, the best course is to handle these situations on a case-by-case basis
with the input of the trans client.  Transgender people are often victims of hate crimes, so it is important to house people in a way that will ensure their safety.

Sometimes, a client’s sexual orientation and gender identity may be pertinent in treatment; other times, they may not.  As a therapist, you should not assume that a person’s gender identity is or is not an issue.  Rather, you should find this out as part of a thorough assessment that includes information about the client’s sexual orientation and gender identity.  Either way, therapists should be aware that transgender clients may be exposed to discrimination and stigma particularly when legal documentation reflect their sex but their gender presentation is different.  Think about how it would feel to be questioned when attempting to board a plane because your photo ID says you are a female but you look like a male, or how you would handle going to a job interview knowing that you usually look like a female but your social security card has a “male” name on it.

I’d be interested in hearing other social workers stories and experiences in working with trans clients.  I feel like I got it wrong with my most recent client, but after doing this reading and writing about it, I’m looking forward to having an opportunity to get it “right.”


Sources for this post:

http://www.abct.org/docs/Members/FactSheets/LGBT_for_therapists.doc
Giving the “T” it’s Due Attention: Social Work Practice with
Transgender Clients by David Nylund; www.nylundandtilsen.com
Culturally Competent Approaches for Serving Transgender Populations by
Willy Wilkinson; www.lgbt-tristar.com

Thinking About Getting Active Again

I had not thought about this blog in a long time, until I got an email the other day alerting me to a comment.  I was surprised when I checked back in here to see that I've been getting a number of page views everyday.  While I can't make any promises, I'm considering trying to post a weekly update.  Although I have passed my clinical exam in the time since starting this blog, I am continually reading and researching new topics.  If you have an idea for a new topic for me to write about, please comment here.  Thanks for reading!

Suicide Assessment

In a suicide assessment, you want to determine lethality & severity and predict risk of immediate harm to self.  Lacking a crystal ball or other psychic abilities, you will need to rely on your clinical skills, rapport with the client, information gathered from the client’s loved ones (with a release of information, naturally), and skillful use of a suicide assessment.  You will need to gather information related to suicide risk factors.

So what are suicide risk factors, anyway?  Risk factors are a combination of individual, relational, community, and societal factors that increase the risk of suicide. Risk factors are characteristics associated with suicide and may not be direct causes.  The single greatest predictor of a future attempt is a past attempt.  I will say again, the single greatest predictor of a future attempt is a past attempt.  So, no matter what your setting, you should be asking, “Have you ever tried to kill yourself?”  You need to be direct, and use words like kill, dead and suicide, not euphemisms, such as, “Have you ever tried to hurt yourself?”  You don’t want your questions to be misunderstood on this subject.  Anyway, suicide risk factors include the following:

• Family history of suicide
• Family history of child maltreatment
• Previous suicide attempt(s)
• History of mental disorders, particularly clinical depression
• History of alcohol and substance abuse
• Feelings of hopelessness
• Impulsive or aggressive tendencies
• Cultural and religious beliefs (e.g., belief that suicide is noble resolution of a personal dilemma)
• Local epidemics of suicide
• Isolation, a feeling of being cut off from other people
• Barriers to accessing mental health treatment
• Loss (relational, social, work, or financial)
• Physical illness
• Easy access to lethal methods
• Unwillingness to seek help because of the stigma attached to mental health and substance abuse disorders or to suicidal thoughts

These risk factors are lifted directly from the CDC at http://www.cdc.gov/violenceprevention/suicide/riskprotectivefactors.html.  The NASW adds to this being a white male over 65 or under age 30, having a medical condition, a recent discharge from a psychiatric hospital, and being single, separated or divorced.  If you're like me, most of your clients have most of these risk factors.  Yay for working with the vulnerable, oppressed and impoverished!

Happily, there are also some factors that seem to buffer people from suicidal ideation and attempts.  However, protective factors have not been researched as extensively as risk factors have.  Please do not assume that a person who has these protective factors is not a suicide risk.

• Effective clinical care for mental, physical, and substance abuse disorders
• Easy access to a variety of clinical interventions and support for help seeking
• Family and community support (connectedness)
• Support from ongoing medical and mental health care relationships
• Skills in problem solving, conflict resolution, and nonviolent ways of handling disputes
• Cultural and religious beliefs that discourage suicide and support instincts for self-preservation
• Having dependent children

When assessing suicidality, you want to gather information related to client’s suicidal ideation & planning.  You will ask questions about:

• Ideation – thoughts of harming/killing oneself.  These are questions like:
• Are you thinking about killing yourself?
• How often do you have thoughts of suicide?
• Have you ever written a suicide note?
• Plan – how/when the person will kill him/herself.
• When are you going to kill yourself?
• How will you kill yourself?
• Intent – level of motivation/ability to follow through w/ a suicide plan.  These are questions like:
• Do you have [whatever the means to the plan is] at home?
• On a scale of 1 to 5, how much do you want to die?
• What will happen to your [family, friends, dog, goldfish] when you die?
• Have you made any preparations for what will happen after your death?

The more clear, specific and lethal the plan, the more you want to step in and take directive action.  So, I would worry more about a plan like, "My wife and kids are away next weekend, and I'm going to shoot myself on Saturday night after they go," than I would worry about a plan like, "Well, I have a couple Valiums, and I might take them if I don't find a job soon."  Plan A is specific, lethal, with a specific time frame.  Plan B is not likely to be lethal and with no specific time frame or preparations, you may be able to talk about alternative ways of coping, use some other wonderful social work interventions, and send the client home with a plan to follow up.

A light and happy subject for a lovely Friday night!  Please feel free to add your own thoughts or experience.  I don’t think you can ever spend too much time learning about suicide assessment and prevention, particularly when you consider that suicide is the 4^th leading cause of death for adults 18 – 65 years old.

Save money!

So I went to my local NASW's exam prep class yesterday, and I am very disappointed to say that I did not find it all that beneficial.  Perhaps my hopes were too high.  We spent the morning reviewing Freud, Erikson, and Piaget.  Then, we reviewed some diagnoses in the afternoon.  So as you can see, most of what we covered, I've already talked about on this here blog.  And if I do say so myself, I'm quite a bit more interesting than the ol' NASW.  And a whole lot freer.  I guess I did learn that I am a lot more prepared for the exam than I thought, and if you want to be prepared too, just keep on reading.

Prep Class Tomorrow!

I'm going to a prep class tomorrow with the NASW NJ chapter.  Here's hoping I'll learn some cool stuff, get some helpful pointers, and walk away feeling a little more confident (and be able to share that here).  I'll try to post tomorrow and let you know how it went.  Is it dorky that I'm a little excited about this?

Roberts’s Seven-Stage Model for Crisis Intervention

This goes out to all my CISes (those are crisis intervention specialists, if you didn't know).  Most folks think of Roberts as THE crisis guy, and his seven stage model is included in pretty much every crisis intervention manual ever.

• Assess safety & lethality – Begin with a fast yet thorough biopsychosocial assessment.  You want to find out what the supports & stressors are, any medical issues, medications, any current substance use, and coping strategies & resources.  If there is concern about suicidality, you want to find out what the thoughts are, if there is intent & the strength of the intent, whether there is a plan & if the plan is potentially lethal, any history of past attempts, and other specific risk factors (substance abuse, social isolation, losses such as divorce or employment).
• Rapport building – In a crisis, you must do this quickly & it will ideally happen as part of your assessment.  Here, we harken to Rogers’s warmth, genuineness and empathy.  These three skills will go a long way in developing rapport with your client in crisis.
• Problem identification – Find out from the client why things have come to a head.  There is usually a so-called last straw, but you also want to find out what other problems the client is concerned about.  It can also be useful to prioritize the problems in terms of which problems the client wants to work on first.
• Address feelings – Validate, validate, validate!  You want to let the client vent about his or her feelings about the crisis.  This is achieved using active listening skills, like paraphrasing, reflective listening and probing questions.  With caution, you can also challenge maladaptive beliefs.
• Generating alternatives – This is where you come up with a plan.  The clinician and the client (ideally) begin to come up with options that will help improve the current situation.  You can brainstorm about possibilities or ask about what has been helpful in the past as ways to get the client’s input.
• Develop action plan – This is where you shift from a crisis to a resolution.  The client & worker will begin to take the steps negotiated in the previous stage.  This is also where the client will begin to make meaning of the crisis event.
• Follow up – The follow up can take on many forms.  A postcrisis evaluation may look at the client’s current functioning and assess the client’s progress and satisfaction with treatment.  It can also involve phone or in person visits at specific intervals.

Bandura & Social Learning Theory

Bandura’s social learning theory is sometimes seen as a bridge between cognitive and behavioral theories because he believed that people learn by observing others, which involves cognition (memory, attitude, beliefs) and behavior (actions taken, rewards).  He posited that children learn by observing the actions of others, such as parents, siblings & other peers.  This observation leads to the acquisition of new skills & information.  Intrinsic reinforcements such as a sense of pride, accomplishment & satisfaction also lead to learning.

Bandura developed this theory in part by conducting what was called the Bobo doll experiment.  Here, a video is work a thousand words: http://video.google.com/videoplay?docid=-4586465813762682933.  Basically, Bandura found that kids who watched a video of an adult aggressing upon an inflatable doll would in turn aggress upon a similar doll.  Bandura’s research primarily concentrated on the impact of TV violence on children’s behaviors.

Bandura thought that four processes were necessary for the child or other observer to learn a behavior via social modeling.

• Attention: Obviously you have to be paying attention to what the other people are doing to learn anything from it.  If I’m ignoring the people on the dance floor, I’m not going to learn to dance just by standing close by.
• Retention: You have to remember the stimuli to imitate later.
• Reproduction: This is when you reproduce the image of what you observed.  You have to have the physical capability to do so.
• Motivation: There has to be some reason that you want to recreate what you observed.  Some reasons might be positive reinforcement (a reward, a promise of a reward) or a negative reinforcement (punishment of some kind).

The main critique of Bandura’s theory is that it does not reliably predict behavior.  In his experiments, the relationship between observing & recreating violence was strong.  In later longitudinal studies, the relationship was much weaker.

Crisis Intervention

Just to keep things interesting, I'm going to start mixing in some posts based on a study guide I created for my clinical practice course final exam.  See, kiddies, it pays to hang on to old study materials!  Today, we'll start with some overview information on crisis intervention.

• What is a crisis?
• Event is perceived as a threat, danger or loss
• Coping strategies are overwhelmed and insufficient
• Person is in a state of disequilibrium
• There is a window of opportunity to intervene
• Opportunity for growth
• What are the types of crises?
• Situational – specific incidents (dumped by boyfriend, fail a test, busted for possession)
• Developmental – developmental tasks produce a crisis. If prior developmental tasks have not been completed successfully, future tasks can produce crises
• Environmental – different from situational crises because they affect groups of people (human disasters, political disasters, economic, natural disasters)
• Existential – escalating inner conflicts related to issues of purpose in life, responsibility, independence, freedom and commitment (teen angst, midlife crisis, spiritual crisis)
• Compound or Transcrisis – crisis reaction due to multiple partially unresolved prior crises
• Dilation-Constriction Continuum Model
• The dilation-constriction continuum assesses a person's affect, behavior & cognitions related to the crisis.
• It can be used to assess where the person is on the continuum of dilation & constriction & try to bring the person back to center if they’re at extremes

	Dilation	Constriction
Affect	Overemotional Worker response: focus on specific feelings, work w/ cognitive material	Holding in feelings Worker response: facilitate emotional expression
Behavior	Excessive behavior, acting out Worker response: reality oriented & problem solving	Paralyzed, immobile, withdrawn Worker response: stimulate movement, help ct do for themselves
Cognition	Disorganized, chaotic, confused Worker response: clarification, specifics, problem identification	Preoccupied w/ solutions, ruminative, obsessive Worker response: id alternatives & workable solutions

Edited to add:  Upon listening to the social work podcast on crisis intervention, I realized that this post is essentially a summary of that podcast.  You can listen to that podcast here: http://socialworkpodcast.blogspot.com/2007/01/crisis-intervention-and-suicide.html Since Jonathan, the host of the social work podcast, is so kind as to include on his blog a properly formatted APA reference, here that is as well. Singer, J. B. (Host). (2007, January 29). Crisis intervention and suicide assessment: Part 1 - history and assessment [Episode 3]. Social Work Podcast. Podcast retrieved October 1, 2011, from http://socialworkpodcast.com/2007/01/crisis-intervention-and-suicide.html

Major Depressive Disorder (MDD)

MDD is characterized by one or more major depressive episodes & no history of manic, hypomanic or mixed episodes.  MDD can begin at any age but most often onsets in the mid-20s.  The course can be quite variable.  Some people may have isolated episodes of depression with remissions of many years; others may have clusters of episodes with brief remissions.  You can use specifiers to indicate the course of the disorder, such as the specifier “With Full Interepisode Recovery” or “Without Full Interepisode Recovery.”

The criteria:

• Presence of a single major depressive episode (see previous post)
• Episode is not better accounted for by schizoaffective disorder & is not superimposed on schizophrenia, schizophreniform disorder, delusional disorder, or psychotic disorder not otherwise specified.
• There has never been a manic, mixed or hypomanic episode unless that episode is substance or treatment induced or due to a general medical condition.

• If the full criteria are met at the current time for a major depressive episode, specify its current clinical status and/or features:
• Mild (with 5 – 6 symptoms of a major depressive episode), moderate (between mild & severe), severe with psychotic features (with most symptoms of a depressive episode and psychosis) or severe without psychotic features (with most of the symptoms & no psychosis)
• Chronic – full criteria have been met for a major depressive episode for at least the previous 2 years
• With catatonic features – with 2 of the following
• Motor immobility as evidenced by muscular rigidity or stupor
• Excessive motor activity that serves no evident purpose & is not influenced by external stimuli
• Extreme negativism (resistance to instructions with no evident motive or maintenance of a rigid posture against attempts to be moved) or mutism
• Peculiarities of voluntary movement such as posturing (assuming bizarre or inappropriate postures), stereotyped movements, prominent mannerisms or prominent grimacing
• Echolalia (repeating what you say) or echopraxia (imitating your physical movements)
• With melancholic features – defined by
• Either loss of pleasure in nearly all activities or lack of reactivity to usually pleasurable stimuli at the most severe point of the episode.
• Three or more of the following symptoms:
• Distinct quality of depressed mood
• Depression regularly worse in the morning
• Early morning awakening (at least 2 hours before usual time of awakening)
• Marked psychomotor retardation or agitation
• Significant anorexia or weight loss
• Excessive or inappropriate guilt
• With atypical features
• Mood reactivity – mood improves in response to positive events
• Two or more of the following:
• Significant weight gain/increased appetite
• Hypersomnia
• Leaden paralysis – a heavy, leaden feeling in extremities
• Long standing pattern of sensitivity to interpersonal rejection that results in significant social/occupational impairment
• Criteria are not met for melancholic or catatonic features during the same episode
• With postpartum onset – episode onsets within 4 weeks postpartum

Mood Disorders & Mood Episodes

Mood disorders are characterized by having mood episodes.  I will here define the types of mood episodes: major depressive episode, manic episode, mixed episode and hypomanic episode.  The presence of these mood episodes will define mood disorders, which will be covered in subsequent posts.

Major Depressive Episode

• 5 or more of the following symptoms during the same 2 week period; must have either depressed mood or loss of interest/pleasure.
• Depressed mood for most of the day, nearly every day, as indicated by either self report or observation made by others. (In children/adolescents, mood by be irritable, rather than classically depressed.)
• Diminished pleasure in all or nearly all activities for most of the day nearly every day.  Again, this may be indicated by self report or observation made by others.
• Weight loss or gain (more than 5% in a month), or increase or decrease in appetite nearly every day.  (In children/adolescents, look for the child not to gain weight as expected.
• Insomnia/hypersomnia nearly every day.
• Psychomotor agitation/retardation nearly every day (must be observable by others; not just feelings of restlessness or being slowed down).
• Fatigue/loss of energy nearly every day.
• Feelings of worthlessness/excessive or inappropriate guilt nearly every day.  Guilt may be delusional & must be more than just self-reproach about being sick.
• Diminished ability to think, concentrate or make decisions nearly every day, indicated by either self report or observations of others.
• Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan or a suicide attempt or suicide plan.
• Symptoms do not meet the criteria for a mixed episode.
• Symptoms cause clinically significant impairment in social, occupational, or other important areas of functioning.
• Symptoms are not due to the direct physiological effects of a substance or a general medical condition.
• Symptoms are not better accounted for by bereavement.  Diagnosis may be made if the symptoms persist for longer than two months, or are characterized by marked functional impairment.

Manic Episode

• Period of abnormally & persistently elevated, expansive or irritable mood, lasting at least one week (or less if hospitalization is required).
• During the period, three or more of the following symptoms have persisted (four if the mood is only irritable), and the symptoms have been present to a significant degree:
• Inflated self esteem/grandiosity
• Decreased need for sleep (feeling rested after only a few hours)
• More talkative than usual/pressure to keep talking
• Flight of ideas or report of racing thoughts
• Distractibility
• Increase in goal-directed activity in any life sphere or psychomotor agitation
• Excessive involvement in pleasurable activities that have a potential for danger or harm (shopping sprees, gambling, risky investments).
• The symptoms do not meet the criteria for a mixed episode.
• The mood disturbance causes marked impairment in social or occupational functioning.  If there is psychosis, this criterion is considered to have been met.
• The symptoms are not due to the direct physiological effects of a substance or a general medical condition.

Mixed Episode

Mixed episodes may evolve out of a manic or major depressive episode, or can arise on their own.  A mixed episode can turn into a major depressive episode, or may remit to an asymptomatic period.  It is unusual for a mixed episode to turn into a manic episode.  Mixed episodes, by definition, must last longer than one week.

• The criteria are met both for a manic & a major depressive episode (except for duration) for at least one week.
• The symptoms must cause impairment in social or occupational functioning, require hospitalization, or have psychotic features.
• The symptoms are not caused by the direct physiological effects of a substance or a general medical condition.

Hypomanic Episode

Hypomanic episodes are essentially manic episodes that do not cause impairment in functioning.  The criteria are below, and you will find that the criteria are identical to the criteria for a manic episode except for the difference noted above & shorter duration.

• Period of persistently elevated, expansive or irritable mood, lasting at least 4 days & is clearly different from the normal nondepressed mood.
• During the period, three or more of the following symptoms have persisted (four if the mood is only irritable), and the symptoms have been present to a significant degree:
• Inflated self esteem/grandiosity
• Decreased need for sleep (feels rested after only a few hours)
• More talkative than usual/pressure to keep talking
• Flight of ideas or report of racing thoughts
• Distractibility
• Increase in goal-directed activity in any life sphere or psychomotor agitation
• Excessive involvement in pleasurable activities that have a potential for danger or harm (shopping sprees).
• The episode is associated with an unequivocal change in functioning that is not typical of the person when they are not having symptoms.
• The disturbance is observable by others.
• The mood disturbance does not cause marked impairment in social or occupational functioning. 
• The symptoms are not due to the direct physiological effects of a substance or a general medical condition.