In 60 Seconds, This Reveals The Most Harmful Influence On Kids. It’s Closer Than You Think.

I’ll be showing this video to more than a few client families this week. Effective behavioral health treatment must include family therapy.

First(s)

I have always understood my clinical work through the paradigm of firsts. I vividly remember my first clinical session. My first family session. My first group therapy session. My first suicide assessment. My first report to Child Protective Services. My first crisis intervention. My first client funeral. My first clinical breakthrough. My first success story. Lots of firsts. As one would expect, the frequency of new clinical situations decreases as the years pass; however, this reduced frequency is mirrored by an increase in the severity of firsts. As the saying goes, the calm comes before the storm.

For the past few months, I have been struggling with an intense new clinical situation.  I had originally written a lengthy article on my struggles, after all, I’ve done enough reading on the matter to write a dissertation. Unfortunately, I’ve decided to put the article aside for now. Discussing it in a public forum could ironically expose me to a whole new world of firsts.

While I wait for the dust to settle, some advise:  Never allow disrespect from a client to go unaddressed.  

I’m sorry you’re upset, have a nice day.

The responses from last week’s post have been overwhelming.  I spent a chunk of my weekend answering many of your private messages and have enjoyed the passionate dialogue.   

Some people have been offended by my deleting of their comments (especially on Facebook), so I guess I owe an explanation.  One aspect that I did not address in the original article is my belief that a major barrier to productive dialogue on gun restrictions (and pretty much any other topic for that matter) is the internet itself.   Basically, I believe that people are more vicious and less empathetic when discussing things on the internet. 

I have a personal tendency to say things in digital format that I would never dream of saying in a face to face conversation (just look at my tweets around the time of the last presidential election). I have also been shocked by vicious comments of close friends that seem completely out of character.  

The public nature of social media seems to amplify the competitive spirit of a debate.  It becomes more about grandstanding and “winning” than having an honest conversation.  In many forums, a group dynamic emerges in which likeminded people will gang up on someone they disagree with and overwhelm them with an impossible amount of responses.  

For the above reasons, I decided to delete most of the comments on the article and extend an invitation to each individual to participate in a conversation by private message or email.  For those who felt it unfair of me to “silence” their opinions, I suggested that they create a response post in the style of John Gruber on their own blog, Tumblr or Facebook page.  

With a few exceptions, I felt that the private conversations about my public post were a success.  There was very little name calling and almost everyone was respectful and articulate.  I suspect that I’ll be corresponding with several of you for weeks to come.  For those who sent me messages that were angry and unproductive, I simply replied with “I’m sorry you’re upset, have a nice day.”    

Although I will not be using this forum to discuss any details from private messages, I feel obliged to address one issue that came up several times, namely, the use of guns in social work.  Multiple clinicians from around the country have argued that they must keep a weapon in their vehicle for self protection.  

I guess I don’t understand how having a gun makes things any better if there is a problem.  In fact, I would argue that possessing a gun while working in the community would actually make a clinician less safe.  It goes without saying that most employers (including mine) have explicit policies against possessing a gun while on the job.  I also believe that bringing a gun to a clinical session violates the letter and spirit of the Code of Ethics for most clinical licenses.       

It is not my intention to downplay the concerns many social workers have about their safety in the field.  It can be a dangerous gig.  This is a serious issue and it deserves a serious debate.  For those who feel the need to carry a weapon, I would suggest finding a different venue in which to practice (definitely NOT home based).  I also wonder about how effective a clinician can be when they have such strong fearful feelings about their clients and the communities in which they live.  Hopefully we can find other ways to increase the safety of community based clinicians before one of us has to write a progress note about shooting someone during a session.  

Anatomy of a Gun Debate

Debating the merits of increased gun regulation has been something of a hobby of mine over the past few years. I call it a hobby because I usually argue with the same group of people on Facebook, Tumblr, and Twitter and we tend to say the same things over and over. From what I can tell, I have yet to change anyone’s mind regarding this issue. To be fair, they haven’t succeeded in changing mine either.

The conversation usually starts with a post or tweet about an incident of gun violence that has garnered significant national press. From there the debate tends to go down a practically predetermined set of paths. You’ve got your Constitutional arguments, libertarian arguments, plenty of anecdotes, conspiracy theories, and straw men. Regardless of how the discussion starts and progresses, it almost always ends with each side throwing statistics and “research” at each other. The essential assumption at this point is that the other side is simply uninformed and will clearly see the error of their ways upon a closer examination of the data.

Of course, there is “data” on both sides of the gun debate. The politically charged nature of our debate has led to the creation of an entire industry of “researchers” dedicated to collecting data that supports a priori beliefs (I’m looking at you CATO institute). Sample sizes are often skewed or inadequate and interpretive summaries tend to be hilariously generous in presenting the data in ways that are favorable to the agenda of whomever is bankrolling the study. This happens on both sides of the debate.

For the above reasons, I have begun to limit the kinds of research I use when debating gun policy to large scale, epidemiological studies. The sample size of an these studies are as close to 100% of a population as you can get (especially when dealing with data related to mortality). Since many countries keep pretty good data on their citizens, one can draw from this historical information and examine correlations between gun deaths and gun ownership/restriction laws in different communities. After all, when someone is killed by a gun, the cause of death is usually pretty clear.

As with any research, there are some limitations to the use of epidemiological data when discussing gun policy (I can practically hear angry typing accusing me of Cum Hoc fallacy). A preemptive response: I am aware that correlation does not necessarily equal causation. Having said that, it’s not like I’m trying to make a connection between gun ownership and obesity. It is hardly a stretch to connect the gun policies of a community and that same community’s rate of gun violence. As with any research, there are also outliers (i.e. Mexico, Brazil, and other countries with elevated levels of organized crime). It goes without saying that these countries are exceptions that should not be the basis for our domestic policies.

Meta rambling aside, allow me to present data from a peer-reviewed article published in the International Journal of Epidemiology (Krug EG. Intl J Epidemiology. 27:214-22). Total firearm deaths in the US were found to occur at a rate of 14.24 per 100,000 persons, the highest rate of all countries studied, and a rate that was eight-fold higher than the combined rate of firearm deaths in all economically similar countries. This study and others like it draw a bleak picture: the US has more killings due to firearms than any other industrialized country in the world. Furthermore, the data seems to provide a very clear formula for policy makers: more guns equal more gun deaths and fewer guns equal fewer gun deaths. The argument that the United States has a gun problem is irrefutable.

Obviously, the fact that we have a gun problem is not enough to sway most gun advocates on their positions. In fact, many prominent gun advocates will argue that we need more guns precisely because we have a gun problem. Their next move is almost always to throw lots of little straw men at anyone who dares suggest even modest regulations. Careful readers will note that I have yet to make a single suggestion about what changes I would like to see to our gun laws. Contrary to the accusations in the pile of hay that is filling my inbox, I do not believe that civilian gun ownership should be outlawed. However, I am also aware that many gun advocates believe that they need to resist even minor regulations because of “slippery slope” logic. Basically, they believe that any gun regulations will inevitably lead to the eventual prying of said guns out of cold dead hands.

For those who can resist making assumptions about my “agenda,” here it is:

I stand with 77% of NRA members in favor of a waiting period for handgun purchases. I am with the 82% of Americans who support limiting the sales of military-style assault weapons. I support background checks on private gun sales, including gun shows. Finally, I would like to see, as would 79% of Americans, the registration of all handguns. Basically, I am in favor of regulating firearms at a similar level to automobiles. It you find that offensive, I’m sorry. Just know that you are in the minority.

To summarize, we have a gun problem and most of us want to do something about it. End of discussion? Nope. From here the debate usually moves back into the Constitutional argument or some form of anecdote about the right to defend one’s family from a gang of rapists.

Regarding the Constitutional “silver bullet” I say: The Constitution isn’t a set of answers, but a framework for argument. It is successful because people don’t agree about what it means. If you want to use it as a trump card, then we haven’t really been having a conversation about policy, have we?

The self defense argument is much more nuanced and emotional. People have a strong instinct to secure and protect their homes and families. I get it. As I’ve said, I don’t believe that gun possession within one’s home should be prohibited (although I am against the recent expansions of concealed-carry in many states). Having said that, I do believe that having a gun in one’s home is a bad idea for most families. There is solid evidence connecting the presence of guns in homes to an increase risk of dying by gun fire (Wiebe D. Annals of Emergency Medicine. 2003; 41:771-82). Gun ownership does not appear to be protective of violent firearms-related killings. Sadly, a large percentage of home gun deaths are suicides. The destructive power of a gun in the hands of a fragile and impulsive person is truly terrifying.

On a socialworky note, I have spent the last ten years of my professional life working with the very people the “good guys” are afraid of. I spend my afternoons and evenings working with families in the most dangerous neighborhoods in Tulsa. I am fully aware that something could happen. I also could die in a car crash or have a stroke or trip and fall on my head or get struck by lightning. I could live every moment of my life in fear of any number of dangers, but that’s no way to live. I am not trying to make excuses for criminal acts, but I also don’t believe that there is any virtue in demonizing a fellow human being. Some people make bad decisions that have devastating effects on their victims. It’s easier to process these things when we put a “bad guy” label on the perpetrator. However, I believe that our tendency to label those who break the rules of society is poison to all involved. For more on this I would highly recommend listening to a recent story of forgiveness and redemption discovered by the excellent team at Radiolab.

Try putting your gun away and show some kindness to a fellow human being. You’ll be surprised by how safe you feel.

Goals and Habits

The essential job of clinical social work is to help clients to identify and achieve their goals. Although it sounds simple, this process can be extremely complex.

If a client is underage, they usually don’t get much say in the direction of thier treatment since their parent/guardian is the primary source of consent. It should come as no surprise that the goals of parents/guardians are not always in sync with the goals of clients (especially teenagers).

There is also the implicit influence of referral sources on “client” goals. If a school is referring a child to therapy, there is an expectation that work will be done on behaviors that directly affect teachers and peers. Doctors tend to expect goals that compliment pharmacological interventions and reduce the need for frequent medical visits. Courts expect clients to be working on issues of delinquency and compliance with probation contracts.

All these expectations emerge before a clinician has heard a single word from their client. To be fair, environmental and social data can be very useful in providing clues as to the likely focus of therapy; however, it may also prove to be a barrier to fully listening and understanding the client’s perspective.

Furthermore, I have begun to feel that the terms “goal” and “objective” may be unhelpful for many people. Goals tend to be very big and challenging. They can be intimidating and even discouraging for some. Because of this, I have begun to subtly use the word “habit” in place of goal. I’m not suggesting that we do away with goals, but that we place a greater emphasis on habits as a key strategy for pursuing goals.

Most clients tend to focus on eliminating maladaptive habits. However, I have found that just as much time and energy needs to be spent on developing new, healthy habits as processing undesired habits.

Lately, I have been using the below flowchart to facilitate the discussing of habits with clients:

Of course, even when using the concepts and language of “habits,” many clients will still struggle to make progress due to a lack of motivation. People won’t pursue new habits any more than “treatment goals” if they don’t want to.

I guess its time for a Motivational Interviewing refresher.

Teaching Emotional Literacy

A common goal in clinical social work is to increase a client’s ability to read themselves and the reactions of others.  Research has shown that learning to read emotions is as important to human development as learning how to read words and numbers (Cohen, 1999a; Elias et al., 1997). 

I have been using several tools over the years to increase emotional literacy in my clients; however, most of these techniques are geared towards younger clients.  I’m always on the lookout for good tools to develop emotional literacy in teenagers and adults and, oh boy, did I find a good one this week: 

This chart is the product of a recent study in the Proceedings of the National Academies of Sciences that explored the connections between the cognitive and physical effects of different emotions.  The researchers used self-reported body maps showing areas where subjects felt sensations increased (warm colors) or decreased (cool colors) for a given emotion. Using five experiments, 701 participants “were shown two silhouettes of bodies alongside emotional words, stories, movies, or facial expressions. They were asked to color the bodily regions whose activity they felt increasing or decreasing while viewing each stimulus.”  

The clinical applications of this chart are exciting and I anticipate that it will become a frequently used tool in my practice.  

All good children’s stories…

All good children stories are the same: young creature breaks rules, has incredible adventure, then returns home with the knowledge that aforementioned rules were there for a reason.

Of course, the actual message to the careful reader is: break rules as often as you can, because who the hell doesn’t want to have an adventure?

- Saga, chapter 16

Essential Productivity Apps

My iPhone is my office. I spend my days in schools, homes, community centers and a lot of time in my car. I don’t have a desk, but that doesn’t keep me from getting loads of emails, phone calls, paper work, and deadlines. It just means that I need to tackle all these things while on the go. Below is my list of essential productivity apps for community based clinicians:

  1. Mailbox. With Mailbox, I keep my inbox under control. Mailbox uses a gesture system to allow quick decisions by sorting emails into one of three categories: later, lists, and archive. The “later” function is basically a snooze button for your email. If a message is low priority, just tell the app to remind you about it on the weekend. If it is important, delay it for a few hours. See it in action here.

  2. The Reminders app is included in iOS 7. Although I generally prefer the UI of other todo apps (Clear & ToDo by Apigo), Reminders has several significant features that beat out third party options. Most of these advantages center around Siri integration. For example, I can say “Siri, remind me to turn in the ROI’s when I get to the office” and the app will create a todo item that will notify me of the task when my phone detects that I have arrived at the office. I can create similar todo items for any of the locations in which I work. It’s effortless and keeps me organized as I see clients all over town.

  3. Vesper. If a note or reminder doesn’t include an actionable and attainable goal, I do not place it in my Reminders app. For these kinds of notes, I use Vesper. Vesper is a fantastic app for brainstorming and storing other useful information. The app has a tagging system that lets you quickly label each note/photo/link in way that makes searching and finding items a breeze. An example: if I have an idea for a group activity, I will type it into Vesper and tag it as “group.” If I hear about a book or article that I may want to read, I tag it as “research.” With Vesper I basically create a searchable bucket of ideas and thoughts.

  4. Occasionally, I will have an idea or see something that doesn’t immediately fit into Reminders or Vesper. For this kind of note, I use an app called Drafts. Drafts always launches to a blank text field. Simply type some text and decide where is needs to go. Drafts can send data as an email, a text message, to facebook/twitter/tumblr, to other apps like Byword or Pages, create a todo item in Reminders, create a new calendar event, copy to the clipboard, or even save a plain text document in Dropbox. Basically, worry about entering the note first and deciding where it goes second.

  5. Keeping track of mileage ranks among my least favorite activities as a clinician. Thankfully, MileBug makes this task bearable. The app lets you create a database of common destinations. I have entered all of my coffee shops, offices, community centers, and schools into the app allowing me to quickly set my origin and destination. The app learns from patterns of behavior and will provide an educated guess of where it thinks I’m going next. Its creepy good. All I need to do is remember to enter my odometer reading throughout the day. Best of all, the app allows for the creation of a custom spreadsheet of monthly mileage that does all the hard work for me. Just tell it which dates and variables are needed and out comes a finished mileage report.

  6. Second to tracking mileage, my least favorite task is keeping track of expenses, productivity, and other numerical data. For these tasks I have Soulver. It’s a spreadsheet app for humans. The app uses plain english and basic mathematical principles to create amazingly powerful notes. Create a list of numbers and the app will automatically add them up. Type in any sentence with numbers and the app will interpret their mathematical relationship. Check out this video for a short demo of Soulver in action.

  7. JotNot Pro is my app of choice for scanning documents. After taking a picture of a document, the app will determine the edges of the paper and crop it to size. From there you can save it in the app or export it to any other app as a PDF.

  8. Speaking of PDFs, PDFpen is my app of choice for managing and annotating PDFs. I primarily use it to sign documents, but it has also proven to be a powerful tool for a variety of tasks such as redacting sections of documents and filling in forms.

  9. In my opinion, 1Password is an essential app for any smartphone user. All of my passwords are ridiculously complex and never duplicated thanks to 1Password. As its name suggests, I only need to remember one password to unlock the app that stores all my other passwords.

  10. Byword is my text editor of choice. It’s super simple and syncs flawlessly with its siblings on iPad and OS X. It’s perfect for long form writing, especially if you’re into using markdown syntax. Byword is also the primary text editor that I use to post on this blog.

  11. Occasionally I will need to work with a Word document or develop a more traditional page layout for something. For these tasks I use Pages. It is a powerful word processor and plays well with other apps. It’s also free.

  12. To finish this list, I would like to talk about two apps that are not related to productivity in the least. I have found that taking small breaks throughout my day to think about something completely unrelated to therapy is very important to my own mental health. Reeder is a beautifully designed RSS aggregator that I have set up to collect a variety of feeds from tech, comedy, and news sites. Its perfect for those brief moments between client sessions. When commuting throughout the day, I have found that podcasts are a good way to relax. There are lots of “podcatchers” to choose from, but I have been pretty happy with Apple’s free Podcasts app. The cool thing about podcasts is that you can find a show about pretty much any topic you may be interested in. For what its worth, my weekly playlist includes:

The Talk Show with John Gruber

The Prompt with Steven Hackett, Federico Viticci, and Myke Hurley

The Accidental Tech Podcast with John Siracusa, Marco Arment, & Casey Liss

The Besties from polygon.com

Back to Work with Dan Benjamin and Merlin Mann.

Good luck out there everyone.

It’s not about the ACA anymore

"Keep in mind, the debate we’re having now is over a six-week continuing resolution and a short-term debt ceiling increase. What will they demand next? Why should Republicans care about winning outside of their southern and mountain west bastions if they can get their way through these guerrilla warfare tactics?"


This is spot on. It took the House, the Senate, the presidency, and the validation of the Supreme Court for the ACA to become law. It should certainly take more than 30 pissed off house republicans and a couple of senators to repeal it.

McDonalds’ suggested budget for employees shows just how impossible it is to get by on minimum wage | Death and Taxes

And what do you get for working 74 hours a week? Well, you don’t get heat, clearly. There’s a big ol’ zero next to the heat in that chart. In my building– we have separate checks for gas and electric– that would mean that not only do you not get to heat and cool your home, but also that you do not get to heat your water, or cook on your stove, if you have a gas stove (I do).

Also noticeably absent in this budget? Food. And gas. There’s a line for a car payment, but not for gas. Which is suspect, because if you’re working two jobs it’s possible you will pay more for your gas than you’d be paying for your car. Also… health insurance for $20 a month? […]

There are people who comfort themselves by telling themselves that poor people are only poor because poor people are lazy. Pretty sure someone who works 74 hours a week isn’t lazy.

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blog by Jon Kratz, MSW, LCSW

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