By John D. Weaver, LCSW, BCD, ACSW, CBHE

People are always changed by disasters and other traumatic
life events, but they need not be damaged by them.

Introduction

Tropical storms, tornadoes, fires, floods, earthquakes, transportation accidents, mass murders, hazardous material spills, building collapses, nuclear plant malfunctions, terrorist bombings, and many other disasters occur throughout our country each year. In the wake of these events lies a wide path of catastrophic physical and emotional destruction. Many seriously traumatized people can be found there, struggling to recover from their losses and rebuild their lives.

Once a disaster occurs, folks look at a lot of things in a different way than they did before. Prior to the event, people have an order to their lives and they feel like they are in command. In the days and weeks following the disaster, they often feel they no longer have control over anything - the event has caused unexpected losses and has taken away their normal routines. They will find themselves awash in a sea of paperwork and bureaucracy (relief agencies and services, insurance claims, etc.) that many refer to as the second disaster. They soon begin to realize it will be some time before they will regain their former sense of stability and control. Faced with so many changes, people begin to react with fear, anger, anxiety, and depression - all normal stress reactions under the circumstances. Victims will expect themselves to “get over it” and to feel better quickly. When they don’t, they suddenly begin to fear they’re weak or they’re going crazy.

Typical Reactions to Disasters

These are the common feelings and reactions that most victims will express and/or display: basic survival concerns; grief over loss of loved ones and/or prized possessions; separation anxiety and fears for safety of significant others; regressive behavior (e.g., thumb sucking in children); relocation and isolation anxieties; need to express thoughts/feelings about experiencing the disaster; need to feel one is part of the community and rebuilding efforts; altruism and the desire to help others cope and rebuild.

Disasters often cause behavioral changes and regression in children. Many react with fear and show clear signs of anxiety about recurrence of the disaster event(s). Sleep disturbances are very common among children (and adults) and can best be handled by quickly returning to (or establishing) a familiar bedtime routine. Inability to do this often proves to be a major problem following major earthquakes, as frequent aftershocks and displaced residences make it difficult for anyone to return to regular sleep routines. Many families end up sleeping together in the same bed long after the main quake.

Similarly, school avoidance may occur and it can lead to development of school phobias, if children are not quickly returned to their normal routine of school attendance. In some disasters, the schools may be flooded (or damaged in another way), making them inoperable. This, and the need to be bused to other, unfamiliar buildings, will further add to the stresses on the children, who may prefer staying home due to fears of leaving their parents’ sides for the length of a school day.

Adults often report mild symptoms of depression and anxiety. They can feel haunted by visual memories of the event. Pre-existing physical problems such as heart trouble, diabetes, and ulcers, may worsen in response to the increased level of stress. They may show anger, mood swings, suspicion, irritability, and/or apathy. Changes in appetite and sleep patterns are quite common. Adults, too, may have a period of poor performance at work or school and they may undergo some social withdrawal.

Middle-aged adults, in particular, may experience additional stress, if they lose the security of their planned (and possibly paid-off) retirement home (or their financial nest egg), and if they are forced to pay for extensive rebuilding costs. Older adults will greatly miss their daily routines and will suffer strong feelings of loss from missing friends and loved ones. They may also suffer feelings of significant loss from the absence of their home or apartment or its sentimental objects (especially items like paintings, antiques, family Bibles, photo albums, and films or videotapes), which tied them to their past.

Timing of onset of these changes varies with each person, as does duration. Some symptoms occur immediately, while others may not show until weeks later. Just about all of these things are considered normal reactions, as long as they do not last for more than several weeks (to a few months). Unfortunately, victims and relief workers who are unfamiliar with these normal feelings/emotions/reactions will often begin to fear they are losing it or going crazy from the disaster related stress.
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By Chris Herman, MSW, LICSW

What Is a Case Manager? What Services Do Case Managers Provide?

Case managers help provide an array of services to help individuals and families cope with complicated situations in the most effective way possible, thereby achieving a better quality of life. They help people to identify their goals, needs, and resources. From that assessment, the case manager and the client—whether an individual or a family—together formulate a plan to meet those goals. The case manager helps clients to find resources and facilitates connection with services. Sometimes she or he advocates on behalf of a client to obtain needed services. The case manager also maintains communication with the client to evaluate whether the plan is effective in meeting the client’s goals.

This sounds good, but I’m not sure about the term case manager. Do case managers really manage people? I don’t want to lose control, and I’m not a case.

Excellent question. A good case manager will work with you to determine what is important to you and what you think would be the most effective way to reach those goals. Case managers don’t manage people—they help people to manage complicated situations. Simply put, they help to keep you, or your loved ones, at the center of services being provided on your behalf.

Care management and care coordination are two other terms sometimes used to describe this work. Different organizations and individuals define these terms in different ways; for example, professionals providing services to older adults often call themselves geriatric care managers. (Click here� to read an article about geriatric care managers.)� The terms case management and case manager are used in this article for the sake of simplicity, but the information also applies to care management and care coordination.

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By Andrew J. McCormick, MSW, PhD

ntroduction

For many people, having a family member in the intensive care unit (ICU) can be very difficult. The experience raises concerns about dying and can cause a lot of stress. Throughout the ICU stay, many decisions regarding the patient’s care may have to be made.� Often the decisions must be made while dealing with both the shock of seeing� a loved one attached to high tech medical equipment and experiencing a range of emotions including loss and fear. This article offers� suggestions� for preparing� to meet with medical staff members to help� individuals and family members� make the best decisions� they can.

How to Approach Making Decisions in the ICU

One should always understand� questions� that may need to be answered. There� are� sometimes critical� decisions to be made� in today’s intensive care unit.� Here are a few questions that� family members might expect� from the ICU staff:

• Did your family member ever talk to you about how much medical care they would want in a situation like this?
• How much should we use� artificial life support such as� a ventilator (respirator) or feeding tube?
• Should we change the treatment to palliative care to make your family member comfortable and let them die naturally?� (Palliative care or comfort care is treatment that reduces pain and other symptoms rather than providing a cure.)

Get Good Information

Information is vital� to� good� decision-making. Many people are reluctant to ask doctors questions, but those who do get more information. Get support from other family members or your social worker to get your questions answered. Here are some suggested questions:

• What are the immediate goals of the treatment you are proposing?
• What is the long-term outcome of the treatment?
• What has been your experience in this situation with other patients?
• What kind of care is palliative care?
• What is your recommendation?

Also,� other family members should be involved. Some family members have a legal authority to make decisions and other family and some friends should be involved because it would be important to the patient.� For example,

• If the patient has a guardian or has signed a durable power of attorney, that person must be part of the decision.� (A durable power of attorney is a legal document that enables an individual to designate another person to act on his/her behalf, even in the event the individual becomes disabled or incapacitated.)
• If the spouse, children and brothers and sisters are available, they are other essential decision makers.
• If the patient has important friends including life partners to whom they are not married, they should also be consulted.

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By Brenda Rodstrom, LCSW

Introduction

Summer is winding down, and anticipation of a new school year is all around us. Kids are wondering about new teachers, new classes, and the myriad of school activities. Some of these activities will involve parents. For parents who are divorced, this can be a time loaded with difficult emotions.

As a stepfamily coach and counselor, I hear many single mom’s dread the times when they will have to be in the same space as their ex. Worse than that, they eventually have to share that space with the ex’s new wife. Here is one case scenario.

The School Play

Stephanie’s daughter Sarah is in a school play. Stephanie has been coaching Sarah on her lines. mother and daughter are very excited. However, as the night of the play approaches, Stephanie feels a knot growing in her stomach. Her ex-husband, Charles, will be there – with his new wife. She cannot bear to be in the presence of the woman who ruined her marriage. She does not plan on speaking to her. She will stay as far away from both of them as possible.

What Should Stephanie Do?

Stephanie’s feelings are understandable. It is painful to see her ex-husband with “the other woman.” But, it would be damaging to Sarah to see so much friction between her parents.

Getting Through the Night

Stephanie’s situation is similar to many that I have helped women get through. Here are a few ideas that have helped others.

1. Invite a friend or relative to accompany you to school events when your ex will be there. The friend serves as a buffer and support.
2. It is important that Stephanie does talk to her “ex” – and his wife. They don’t have to sit together, but civility is required. Children who fare best after a divorce are those whose parents make a real effort to form a co-parenting relationship.
3. After that very difficult task, Stephanie deserves a treat! A massage the next day, a good movie, or a night out with friends.

For the rest of this article, click here.

Introduction

Have you ever said to a friend “I’m looking for my perfect job” or “I want to find the perfect man (or woman)?”

If so, you are not alone. Far from it.

Unfortunately, we don’t do ourselves any favors by seeking perfection. Expecting
perfection — in ourselves, in others, in our careers — is not only unrealistic, it is self defeating.

We simply set ourselves up for failure by demanding perfection. That’s because there’s nowhere to go but down, even when all objective measures say you are successful. For example, when a child expects to get a score of 100% on every test in school, she will be disappointed when she gets a 93 – an otherwise fantastic score.

The same is true with adults.

We may be in a good relationship or we may have a rewarding job. But when our reality doesn’t match our idealized notions of what a job or a mate is supposed to be, not only are we disappointed, we often become depressed, angry and resentful. We feel as if we have failed in some deep and meaningful way.

Perfectionistic Thinking

Perfectionistic thinking comes in different forms: We may think we have to lose five pounds to get that great body, or we think we must have a Norman Rockwell sort of holiday get-together.

This sort of thinking often comes from our families. Many of us were taught either implicitly or explicitly that we were loveable to our parents only if we performed at a high level in school, on the athletic field or on stage. We grew up thinking that if we’re not perfect we won’t be loved. Love was conditional; it wasn’t about who we were but what we did.

It’s important to change that belief to something more rational and self-affirming. Here are a few examples: “I’m going to do the best I can on this project” or “I’d like to meet someone who shares similar interests as me.” Remove the word “perfect” from your vocabulary. You will find you’ll be just as successful as before – and a whole lot happier.

### To read more articles by Mr. Sternberg, visit his web site: www.dctalktherapy.com. You can contact him at (240) 393-1148 or at david7747@starpower.net.

By Lisa E. Cox, PhD, LCSW, MSW
Introduction

Diabetes mellitus is a group of disorders characterized by high levels of glucose (sugar) in the blood. All of them result from problems with insulin, a hormone that removes glucose from the blood and causes it to be stored in body cells. Type I and Type II diabetes are the most common forms, but up to 3 percent of women who did not previously have (or know they had) diabetes may develop it during pregnancy (a condition called gestational diabetes).

Type I

In Type I diabetes (also called juvenile diabetes) the pancreas—a long, soft, irregularly shaped gland located behind the stomach—produces very little or no insulin. All people with Type I diabetes require regular injections of insulin for life. Although girls and boys run an equal risk of developing Type I until about age 12, around the time of puberty the incidence in females begins to decrease in comparison to that in males. Up to age 30, approximately 25 percent more men than women develop Type I, but later on the risk is about the same for men and women.

Type II

Most people who develop diabetes as adults have Type II, a form in which the body requires greater than normal amounts of insulin to maintain normal blood glucose levels, probably because cells throughout the body do not respond appropriately to insulin. Type II (which used to be called adult-onset diabetes) typically begins after the age of 40, although now we have seen Type II diabetes in obese children. Whether men or women get Type II diabetes more often is still unsettled (Carlson, Karen J., Einstat, Stephanie A. & Ziporyn, T., 1996).

Gestational Diabetes

Gestational diabetes is a unique form of the disorder which occurs in pregnancy, probably as a result of hormones made by the placenta which alter the way insulin works. Although glucose levels usually return to normal after the baby is born, women who have gestational diabetes and required insulin during pregnancy do run a higher than average risk of developing Type II diabetes later in life. Gestational diabetes most often occurs in pregnant women who are over the age of 30, who are obese, who have previously given birth to a very large (over 9 pounds) or stillborn baby, or who have a family history of diabetes. (more…)

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By Mary Raymer, MSW, ACSW

Introduction

The social work profession helps individuals, families, groups and/or communities enhance or restore their capacity for optimal psychological, emotional, spiritual, social and physical health. Social workers are a core service on hospice and palliative care teams. Their professional values and skills are a perfect match with hospice and palliative care programs, which are designed to treat the whole person in an interdisciplinary manner to enhance quality of life during challenging times. Social workers are strong advocates for self-determination and culturally appropriate care. They are trained in evaluating the strengths of individuals and families and understand that good medical care requires that the wishes and needs of the individuals being served are respected. When cure is no longer possible, a host of psychological, physical, and spiritual stressors arise that social workers are specifically trained to assist the individual and family to cope and manage.

Social Workers assist individuals and families in the following areas:

• Symptom Management. � Physical symptom management, such as relaxation exercises to help with nausea or pain, is just one example of the services that social workers provide.
• Psychological and Spiritual Stress.� Psychological/spiritual stressors such as anxiety, guilt, or depression can be addressed and managed through counseling (including emotional support), education, or short-term psychological techniques.
• Ethical Dilemmas. � � Ethical dilemmas (such as withdrawing or withholding treatment) may also arise, and social workers are adept at problem solving, advocacy and facilitating the proper resources to find solutions that are helpful for each family.
• Financial Stress. � Financial concerns are often an issue at the end of life, and this is another area where social workers are extremely knowledgeable and successful at helping people navigate resources such as health insurance coverage, medical costs, and bills, or accessing disability income.
• Advance Care Planning.� Assistance with advance care planning to ensure that all treatments meet the wishes of the people receiving care is also within the purview of social work intervention. Advance care planning entails making decisions about treatment in end of care and funeral planning, and communicating this with loved ones and in legal documentation.
• Grief and Bereavement.� Coping with loss and the ensuing grief process is another area in which social workers are well versed. Dealing with the intense emotions associated with grief can be overwhelming without the proper support and information. Social workers have information and skills that help facilitate grief and help people avoid obstacles that can lead to more complicated reactions like depression.

How Do� Social Workers Evaluate with Individuals and Families?

Social workers on hospice and palliative care teams make an initial psychosocial evaluation that is essential to making medical care effective and appropriate for each unique family. In this evaluation, questions include spiritual and cultural beliefs so that social workers can help educate other team members as well as themselves about what each family wants, and even more importantly, what they might not want.

Past history is also crucial, because social work takes into account past strengths of the family, and identifies coping skills and strengths people have already utilized. These skills and strengths are drawn upon and enhanced to help people during their current challenge. If there are special difficulties, such as multiple losses or financial stresses, social workers help make plans to provide extra interventions, support, and/or resources.

Social Workers Are Part of a Hospice Team

As a part of the interdisciplinary team, social workers will represent the individual/family’s wishes at every team meeting and advocate within other systems to enhance their responsiveness and insure that each family receives care that is hand tailored to fit their needs. After death, social workers provide bereavement information, education, and support to help survivors cope with the death and the subsequent adjustment (”new normal”) to a life without their loved one.

A recent study (Reese and Raymer, “Relationships Between Social Work Involvement and Hospice Outcomes: Results of the National Hospice Social Work Survey”, Social Work, 2004) showed, among other things, that there was higher client satisfaction and fewer nights of inpatient care when there was more frequent social work intervention on hospice teams. With about 2.4 million people dying each year in America, it is helpful to know that more and more social workers in the field are receiving even more specialized training to help people live the last days of life as fully as possible and to help survivors find a meaningful “new normal.”

### The opinions expressed in this article are those of the writer, and do not necessarily reflect those of the National Association of Social Workers or its members.

By Teri Browne, MSW, LSW

Introduction

Chronic kidney disease may be caused by diabetes, high blood pressure and other health problems. Early detection and treatment can often keep chronic kidney disease from getting worse. When kidney disease progresses, it may eventually lead to kidney failure, which requires dialysis or a kidney transplant.

What Is Chronic Kidney Disease (CKD)?

Chronic kidney disease includes conditions that damage your kidneys and decrease their ability to keep you healthy. If kidney disease gets worse, wastes can build to high levels in your blood and make you feel sick. You may develop complications like high blood pressure, anemia (low blood count), weak bones, poor nutritional health and nerve damage. Also, kidney disease increases your risk of having heart and blood vessel disease. These problems may happen slowly over a long period of time. Chronic kidney disease may be caused by diabetes, high blood pressure and other disorders. Early detection and treatment can often keep chronic kidney disease from getting worse. When kidney disease progresses, it may eventually lead to kidney failure, which requires dialysis or a kidney transplant to keep the condition from becoming fatal.

The Facts About Chronic Kidney Disease (CKD)

• 20 million Americans - 1 in 9 US adults - have CKD and another 20 million more are at increased risk.
• Early detection can help prevent the progression of kidney disease to kidney failure.
• Glomerular filtration rate (GFR) is the best estimate of kidney function.
• Hypertension (high blood pressure) causes CKD and CKD causes hypertension.
• Persistent proteinuria means CKD.
• High risk groups include those with diabetes, hypertension and family history of kidney disease.
• African Americans, Hispanics, Pacific Islanders, Native Americans, older adults and people with a family history of kidney disease are at increased risk for CKD.
• Three simple tests can detect CKD: blood pressure, urine albumin and serum creatinine.
• Your doctor will help you decide when you need to start treatment. This decision is based on your medical condition, how much kidney function you have left, and your nutritional health.

Treatment Options

The treatment options for chronic kidney disease (CKD) are dialysis, kidney transplantation, and no treatment. Two different kinds of dialysis can be done—hemodialysis and peritoneal dialysis. Each type of treatment has pros and cons. You will need to speak to your doctor and your family about which treatment is best for you. The decision will be based on a number of factors including your medical condition, your lifestyle and your preferences. Most patients try different types of CKD treatment options.

Hemodialysis

Hemodialysis is a treatment that cleanses your blood of the wastes and excess fluid that have built up. During hemodialysis, your blood travels through soft tubes to a dialysis machine where it goes through a special filter called a dialyzer, or an artificial kidney. As your blood is cleansed, it is returned to your bloodstream. Only a small amount of blood is out of your body at any time. In order to be connected to the dialysis machine, you need to have a catheter, fistula or graft, which is an access to your bloodstream. Hemodialysis treatments can be done at a dialysis center or at home. Treatments are done at least three times a week (some patients dialyze everyday and report feeling better from more frequent dialysis), and each one lasts about three to five hours. Dialysis clinics have a team of dialysis professionals to help patients get the most from their treatments and deal with any issues that may arise. This team includes nephrologists (kidney doctors), dialysis nurses and technicians, dieticians and social workers. With home hemodialysis, you and an assistant are trained to do all the steps of the procedure and you can dialyze to fit your own schedule. On home hemodialysis, you only have to visit the clinic once a month for routine care like blood tests to make sure dialysis treatments are going well at home.

Peritoneal Dialysis

In peritoneal dialysis, your blood does not travel to a machine, but is cleaned inside your body. The lining of your abdomen (the peritoneum) acts as a natural filter. You pass a cleansing solution, called dialysate, into your abdomen (your belly) through a soft tube called a catheter. The catheter is placed during minor surgery. Wastes and excess fluid pass from your blood into the cleansing solution. After several hours, you drain the used solution from your abdomen and refill with fresh cleansing solution to begin the process again. Removing the used solution and adding fresh solution takes about a half hour and is called an “exchange.” Peritoneal dialysis can be done at home, at work, at school or even during travel. Many people who choose peritoneal dialysis feel it allows them greater flexibility.

Kidney Transplant

A kidney transplant is an operation that places a healthy kidney from another person into your body. The kidney may come from someone who has died or from a living donor who may be a relative, a partner, a friend, or someone who wished to donate a kidney to anyone in need of a transplant. The failed kidneys may be left in place in your body. Your new kidney will be placed in your lower abdomen and connected to your bladder and blood vessels. The transplant operation takes about three hours and you usually will be in the hospital for about five to seven days. After the transplant, you will need to take special medications to prevent your body from rejecting the new kidney. You will have to take these medications as long as you have the transplant. Many patients want to have a transplant because it gives them more freedom, allows for a less restricted diet and eliminates the need for dialysis.

What if I Do Not Want to Start Treatment for My CKD?

For many people with kidney failure, dialysis greatly improves quality of life. For some patients, however, dialysis may not improve quality of life significantly, often because of the severity of their health problems. You have the right to decide not to start treatment if you feel that the burdens of dialysis or a transplant would outweigh the benefits. Before considering this option, you should discuss it carefully with your doctor and your loved ones. However, the final choice about starting or not starting treatment is up to you. A nephrology social worker at a dialysis or transplant center can help you with this difficult choice. It is important to know that even if you decide to start dialysis, you always have the option to discontinue. For people who decide to quit dialysis, support services are available.

How Social Workers Help

When you or a member of your family is diagnosed with kidney disease, you may have many questions such as:

• What treatment choice is best for me?
• How will my life change because of my illness?
• How will my illness affect my family?
• How will I pay for my treatments?
• Will I be able to return to work and my daily activities?
• Is it normal to feel sad and depressed?

Kidney disease can change your life. Your health care team works together to help you return to many of your normal activities. You may also want to become involved in new activities. Every dialysis and transplant center has a nephrology social worker who is there to help you and your family adjust to your illness. You are an important part of the health care team. Your social worker can help you understand your feelings and adjust to your new lifestyle with dialysis or a
transplant. Your social worker can help you with:

• deciding which CKD treatment is best for you
• concerns about your job
• your feelings
• concerns about death and dying
• your marriage and family life
• problems with sex and intimacy
• body image issues
• information about health care decisions
• changes in your role in your family
• providing a support group
• speaking on your behalf to the health care team
• dealing with the many changes in your life
• feeling sad and depressed
• coping with kidney disease and its treatments
• guiding you to community resources that may help you and your family, such as: income to meet day-to-day expenses, finding employment or volunteer work, programs that pay for the cost of treatment or medications, home health care services, medical equipment, ideas/resources for exercise.

Working with your nephrology social worker can help you live life to the fullest. Every dialysis and transplant center in the United States has a master’s level social worker who can help you with your CKD.

For more information and resources on this topic, click here.

Teri Browne, MSW, LSW, is a social worker. Ms. Browne has been a member of the executive committee of the National Kidney Foundation’s Council of Nephrology Social Work since 2000 and is their current national chairperson. With more than a decade of experience as a nephrology social worker, she co-edited The Handbook of Health Social Work (2006) and serves on numerous kidney disease committees. A social work doctoral candidate at the University of Chicago, she teaches a health social work course, and has published and presented extensively about nephrology social work.

By Frederic G. Reamer, PhD, and Deborah Siegel, PhD, LICSW, ACSW, DCSW

Introduction

The adolescent years can be very challenging for some teenagers and their families. While adolescence can be an emotionally intense, stormy phase for virtually all teenagers, sometimes a teen’s struggles require special intervention. Many teens struggle with issues related to mental health, family relationships, friends, school performance, substance abuse, sexuality, and other high-risk behaviors.

Warning Signs

Struggling teens usually show signs of distress. Common warning signs include:

• Low self-esteem
• School failure and truancy
• Defiance towards authority (such as parents, teachers, police)
• Running away from home
• Choosing the “wrong” friends
• Impulsive behavior (such as speeding, taking other unsafe risks)
• Getting in trouble with the law
• Depression
• Abusing alcohol or drugs
• Social isolation
• Eating disorders (overeating, not eating, self-induced vomiting)
• Self injury (such as cutting)

There is help for these youngsters and their families through many avenues.

How to Find Help

There are many ways to locate and access programs and services for struggling teens. Initially parents can seek help by contacting school personnel (guidance counselors, social workers, administrators), family service agencies, community mental health centers, other community-based social service programs designed specifically for at-risk youngsters and their families, public child welfare agencies, family and juvenile courts, and specialty courts (such as truancy and drug courts).

Social workers can help parents and struggling teens identify and explore difficult and challenging family issues. Individual, family, and group counseling provided by clinical social workers may help parents and teens improve their communication skills and relationships, resolve conflicts, and address important mental health issues.

Professionals called “educational advocates” and “educational consultants” may be able to help parents and teens obtain needed services. Educational advocates, who are often attorneys, help people obtain specialized educational services. Educational advocates charge parents a fee and work with local, state, and federal education officials to ensure that students receive the services and “special accommodations” to which they are entitled by law. Advocates may file claims in court to force school districts to provide or pay for special-needs services and programs outside the school district.

Educational consultants help parents locate programs and services designed to meet their child’s needs. Educational consultants charge parents a fee, assess each teen’s unique strengths and needs, and help the family find the most appropriate schools or programs for their teen. Many educational consultants monitor students’ progress in the new program or school and, when necessary, advocate for the teen with that program or school when challenging issues arise.

Cost of Programs and Services

Programs and services for struggling teens can be very expensive. Some families are able to pay for these programs and services “out of pocket.” Some families have health insurance that pays for all or part of the program, or the public school system may pay the cost.

Many families cannot afford needed programs and services, do not have adequate insurance, and are unable to obtain funding from their public school department. In some instances families that cannot afford needed services agree to give legal custody of their teen to the local public child welfare agency, which then funds the services or programs (in several states the public child welfare agency will fund services without requiring that parents hand over legal custody). In still other circumstances, desperate parents may turn to the juvenile or family court and formally request that the teen be declared “wayward,” thus enabling the court to require the child to accept intervention. In these cases the state typically pays for needed services and programs. Some parents may be reluctant to use this route to services because the court, not they, determine where the child goes for help.

There is a wide range of services and programs run by private and public agencies for struggling teens and their families. Some programs may be available locally; however, some programs may be in other communities or states, which means that the teen must live away from home in order to receive needed services.

Crisis Intervention

A broad range of professionals and agencies offer crisis intervention and follow-up counseling services to teens and families. These services may be available through family service agencies, community mental health centers, hospital outpatient clinics, public child welfare departments, and psychotherapists in private practice (such as clinical social workers, clinical and counseling psychologists, mental health counselors, pastoral counselors, psychiatric nurses, and psychiatrists).

Many communities offer comprehensive counseling and family-intervention programs specifically for teens and families in crisis. These programs – known by names such as “comprehensive emergency services” or “comprehensive intensive services” – provide home-based assessment, emergency counseling, information, and referrals for longer term help.

Special Schools and Programs

A variety of alternative schools, therapeutic schools, and treatment programs serve teens who struggle with significant behavioral, emotional, mental health, and substance abuse issues. Some programs, such as alternative high schools, focus primarily on education while being sensitive to students’ mental health and behavioral challenges. Other programs, such as residential treatment programs, therapeutic boarding schools, and wilderness therapy programs, focus primarily on mental health, emotional and behavioral issues, while including an educational component. “Emotional growth” boarding schools address mental health, emotional, behavioral, and educational issues simultaneously. Other boarding schools focus on specific learning disabilities while also paying attention to the whole student. In short, different programs give different degrees of emphasis to personal and academic issues.

Parents of struggling teens – particularly teens who are oppositional and defiant – may be tempted to place their child in a school or program that promises to impose needed discipline and structure. Often these schools and programs – such as some military boarding schools and those that advertise their mission as “character education” – do not provide the mental health services many struggling teens need. These schools and programs can cause more harm than good for struggling teens who have personal and mental health issues that contribute to their challenges.

Prominent program options include:

• Alternative high schools provide education, including special education services to teens who have floundered academically or socially in traditional high schools. These schools may be freestanding or sponsored by a community mental health center, family service agency, school district, or a “collaborative” composed of several social service and educational programs.

• Youth diversion programs typically attempt to help struggling teens who have had contact with the police avoid more formal involvement in the juvenile justice system (juvenile courts and correctional facilities). Typical youth diversion programs offer first offenders individual and family counseling, links to other needed services (such as psychiatric medication), and education.

• Independent living programs are designed to help adolescents develop the skills they need to live independently. These programs primarily serve teens who do not have stable families and are in the state’s custody. Some independent living programs also serve teens whose families are able to pay for these services privately. Typical services include practice in daily living skills, money management, career and educational planning, mental health services, housing assistance, recreational, and social activities and case management.

• Wilderness therapy programs offer highly structured intensive short-term (three to six weeks) therapy in remote locations that remove adolescents from the distractions available in their home communities (such as television, music, computers, cars, drugs and alcohol, movies, delinquent peer groups). The challenges of living full-time outdoors and developing wilderness survival skills help teens develop self-confidence and pro-social behaviors. Often, families are advised to send their struggling teen first to a wilderness therapy program and then to a therapeutic or emotional growth boarding school, rather than return the teen to their home community environment.

• Boarding schools for teens with significant learning disabilities offer structured academic programs that focus on education and learning while addressing relevant emotional and behavioral issues.

• Emotional growth boarding schools offer structured academic programs and focus on emotional development and personal growth but do not provide the intensive treatment services offered by therapeutic boarding schools.

• Therapeutic boarding schools focus intensively on students’ mental health, substance abuse, and behavioral needs while also providing an academic educational program.

• Residential treatment centers offer highly structured treatment addressing substance abuse, family, and other mental health issues. In contrast with therapeutic boarding schools, residential treatment centers are more like a psychiatric hospital than a school, although they may have an academic/educational component in their program.

Substance Abuse and Truancy Courts

Many communities run substance abuse courts (sometimes known as drug courts) and truancy courts. These specialty courts use a supportive and nurturing approach rather than a punitive one to help struggling teens. Using case management, counseling, tutoring, mentoring, and parent education, the courts’ goal is to prevent future problems and more formal involvement with the juvenile justice system.

How Social Workers Help

Social workers can provide struggling teens and their families with:

• Assessment of the teenager’s and family’s needs and strengths
• Information about and referral to needed programs and services
• Information about financial and legal issues and resources
• Names of reputable educational advocates and educational consultants
• Crisis intervention counseling services
• On-going psychotherapy for the teen, the parents, and the family as a whole
• Case management (helping staff from multiple agencies coordinate and communicate on behalf of the teen, and advocating for the family with these providers)
• Information about important “warning signs” of teens who are on a downward spiral and the steps needed to get help

Resources

Information about services and programs for struggling teens and families is available from social workers, schools, public child welfare agencies, juvenile and family courts, family service agencies, community mental health centers, educational advocates, educational consultants, and lawyers. Useful Web sites include:

• Adventure and Wilderness Therapy Treatment Programs (http://www.wilderness-therapy.org/)
• Alcoholics Anonymous (http://www.alcoholics-anonymous.org/)
• The Association of Boarding Schools (http://www.schools.com/)
• Cocaine anonymous (http://www.ca.org/)
• The Drug Court Clearinghouse (http://spa.american.edu/justice/drugcourts.php)
• The Independent Educational Consultants Association (http://www.educationalconsulting.org/)
• Narcotics Anonymous (http://www.na.org/)
• National Association of Therapeutic Schools and Programs (NATSAP): (http://www.natsap.org/)
• The National Independent Living Association (http://www.nilausa.org/)
• The National Youth Court Center (http://www.youthcourt.net/)
• The Substance Abuse Treatment Facility Locator, Center for Substance Abuse Treatment, Substance Abuse and Mental Health Services Administration (http://findtreatment.samhsa.gov/)
• Woodbury Reports – a guide to programs for struggling teens (http://www.strugglingteens.com/)

Dr. Reamer and Dr. Siegel are the authors of Finding Help for Struggling Teens, A Guide for Parents and the Professsionals Who Work for Them available through the NASW Press. Dr. Reamer is also the author of The Pocket Guide to Essential Human Services which contains diverse resources compiled into a user-friendly guidebook appropriate for use by professionals, volunteers, and consumers.

### The opinions expressed in this article are those of the writer, and do not necessarily reflect those of the National Association of Social Workers or its members.Frederic G. Reamer, Ph.D., is professor at the School of Social Work, Rhode Island College, Providence, RI. His research, teaching, and social work practice focus on criminal justice, professional ethics, risk management, and mental health. Deborah H. Siegel, Ph.D., LICSW, DCSW, ACSW is professor at the School of Social Work, Rhode Island College, Providence, RI. Her research, teaching, and social work practice focus on clinical work with children and families, focusing especially on ADHD and adoption.