TH E N EWSLETTE R OF TH E N EW YORK STATE SOCI ETY FOR CLI N ICAL SOCIAL WORK, I NC.
SPRING 2010 | VOL. 41, NO. 1
IN THIS ISSUE
3 Leadership Committee Report
5 Private Practice Matters
8 Borderline or Bipolar, Part II
CONTINUED ON PAGE 7
CONTINUED ON NEXT PAGE
president’s message
The Society’s Identity
and Functioning
Who we are and
how we function
as a Society are
two issues that are
being addressed
this year. Thank you
to everyone who
responded to the
invitation to a dis
course about our
identity in the last
newsletter – your thoughts have contributed
more clarity about our identity as clinical
social workers – after all, who we are influ
ences all that we do. At the heart of what the
Society has to offer both current and future
members is a community of like-minded
individuals – psychotherapists who see
the world through relationships, a common
prism with its own culture and language.
As I began my second term as president,
I have made membership retention and
development a priority – and quickly real
ized that branding and marketing the Society
must flow from a clear identity. The State
Membership Committee, at its recent full
day retreat, has been charged with identity
Jonathan Morgenstern,
MSW, LCSW
Protecting the Public’s
Mental Health Services:
Who is watching the store?
By Marsha Wineburgh, DSW, LCSW, Legislative Committee Chair
T
he NYSSCSW Legislative Committee
continues to monitor the State
Education Department’s (SED)
progress in addressing the problems which
have arisen as the result of implementing
the 2002–2004 psychotherapy licensing laws.
SED is currently considering the experience
requirements for individual licensure as well
as the registration of authorized settings
for providing clinical services as provided in
A.8897-A/S.5921.
Experience Requirements for the LCSW
One of the current requirements for the
LCSW is completion of three years of
full-time supervised clinical experience
in the provision of psychotherapy services.
Where does this requirement come from?
In 1977, 33 years ago, the Legislature en
acted Chapter 893 of the Laws of 1977 adding
sections 162 and 253(8) to the Insurance
Law creating what is known as the “P.” This
law established the basic postgraduate
standard for the supervised clinical experi
ence that a “certified social worker” (cur
rently an “LCSW”) was required to meet in
order to attain the minimum level of compe
tence to provide diagnosis, psychotherapy
and assessment-based treatment planning,
independent of supervision. The current
LCSW statute also requires three years of
supervised clinical experience in diagno
sis, psychotherapy and assessment-based
treatment planning. In an effort to simplify
the regulation of social work psychotherapy,
an amendment was passed to integrate the
LCSW statute and the “P” insurance law. By
implication, the LCSW license now includes
an insurance reimbursement component.
For three decades, New York’s “P” stan
dard has required three years of supervised
clinical experience providing mental health
services for autonomous practice. It works.
Why change it? SED, influenced by NASW and
many social agencies, is considering reducing
You’re Invited to the 41st Annual Conference
LIVES DISRUPTED: Contemporary Approaches
to the Treatment of Trauma
May 8, 2010. See Page 7 for details.
2 The Clinician
The Clinician is published two times each year by
The New York State Society for Clinical Social Work, Inc.
www.clinicalsw.org
SOCIETY PHONE: 1-800-288-4279
EDITOR: Ivy Miller. 301 East 45th Street, Apt. 8D
New York, NY 10017 | tel. 917-606-0424
ivy.miller@yahoo.com
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NEW YORK
STATE
SOCIETY
FOR
CLINICAL
SOCIAL
WORK,
INC.
President’s Message
clarification and developing new outreach approaches to
agencies and schools. This committee is also in need of a
chairperson – please contact me if interested.
How we function as a Society is also being addressed.
The Society’s administrative and clerical needs have changed
over the years. Many needs have been out-sourced at consid
erable expense or have been handled by Society volunteers
who should be available for mission-related work. Mitzi
Mirkin has been a consultant to the Society, performing as
the Society Executive Secretary for 32 years, and is retiring
as of February 28th. She will be celebrated at our Annual
Membership Meeting planned for October 3rd. She has
agreed to remain a consultant on call for three months after
February in case we need her to answer questions, serve as a
resource, and lend us her expertise.
Society leaders have found that there is a growing need
for additional administrative, fiscal and clerical supports. The
Society has researched and determined that it would be best
to hire an association management company (AMC), based
on cost effectiveness, a need for the provision of a greater
range of services, and to relieve the administrative burden on
Society leaders. AMC services are supplied for a set fee that
is considerably less than the Society is currently paying for
fewer services; and many currently out-sourced services that
the Society is paying for are included in the basic supports
provided for the set fee. The AMC supplies a level of technol
ogy that the Society could not otherwise afford. It provides
clerical and administrative support as well as professional
expertise when needed, such as a bookkeeper, at no extra
cost. This allows the board and other leaders to focus on
policy, strategic thinking and decision-making, rather than on
administrative and clerical tasks. Their paid staff will support
our efforts and not duplicate them.
Several association management companies’ proposals
were considered and Total Management Solutions was se
lected based on offered services and competence reflected
in accreditation, experience and references. They were also
perceived as a good fit for our Society. As of March 1st, our
800 number will ring in their offices, where they will answer
the phone with “New York State Society for Clinical Social
Work.” You will have the opportunity to meet Sheila Guston,
Total Management Solutions President, at the Society’s
Annual Meeting in October. She is already working to set up
the site.
I know the Society is in good hands and that we will con
tinue to meet members’ needs. The Society’s infrastructure
has been strengthened with renewed purpose and supports
that will enable us to continue fulfilling our mission.
State Board Members 2010
STATE EXECUTIVE COMMITTEE
President
Jonathan Morgenstern MjonathanM@aol.com
Past President
Hillel Bodek bodekmsw@verizon.net
First Vice President
Marsha Wineburgh mwineburgh@aol.com
Second Vice President
Shannon Boyle shannonboyle@hotmail.com
Treasurer
Helen Hinckley Krackow hhkrackow@aol.com
Board Secretary
Elizabeth Ojakian e08@nyu.edu
CHAPTER PRESIDENTS
Brooklyn
Carol Kamine-Brown c.kbrown@cohme.org
Manhattan (Met)
Ariane Sylva drsylva@drsylva.com
Mid Hudson
Rosemary Cohen rosemarycohen@gmail.com
Nassau
Sheila Peck sheila2688@aol.com
Queens
Fred Sacklow freds99@aol.com
Rockland
Dore Shepherd doreshep@yahoo.com
Staten Island
(vacant)
Suffolk
Sandra Jo Lane sjsunshine@aol.com
Westchester
Martin Lowery mlowery@maryknoll.org
MEMBERS-AT-LARGE
Manhattan (Met)
Fred Mazor fredm25@aol.com
Mid Hudson
Roberta Faulk srfaulke@juno.com
Nassau
Lorraine Fitzgerald cfgoodgnef@mac.com
Rockland
Beth Pagano bethpagano678@msn.com
Westchester
Sheldon Blitstein sabhidhammab@optonline.net
COMMITTEE CHAIRS
Annual Education Conference
Susan Klett suzannneklett@aol.com
Arts and Creativity
Sandra Indig psych4art@hotmail.com
By-Laws
Beth Pagano bethpagano678@msn.com
Chapter Development
Helen Hinckley Krackow hhkrackow@aol.com
Disaster Preparedness
Fred Mazor fredm25@aol.com
Ethics
Hillel Bodek bodekmsw@verizon.net
Forensic Social Work
Hillel Bodek bodekmsw@verizon.net
Independent Practice
Sheila Peck sheila2688@aol.com
Leadership
Beth Pagano bethpagano678@msn.com
Legislative Affairs
Marsha Wineburgh mwineburgh@aol.com
Membership
Gloria Robbins grobbins@hvc.rr.com
Mentorship
Helen Hinckley Krackow hhkrackow@aol.com
Newsletter
Helen Hinckley Krackow hhkrackow@aol.com
Nominations and Elections
Beth Pagano bethpagano678@msn.com
Palliative Care
Hillel Bodek bodekmsw@verizon.net
Strategic Planning
Judy Crosley crosleyj@yahoo.com
Vendorship and Managed Care Helen Hoffman helenhoffman@verizon.net
Website and Listserv
Robert Berger rsb111@columbia.edu
CONTINUED FROM PAGE 1
Spring 2010 3
C
ongratulations to our newly elected members of
the State Board and State Executive Committee.
Helen Hinckley Krackow will serve a second term
as Treasurer and Marsha Wineburgh will serve a second
term as First Vice President. Roberta Faulk from Mid-
Hudson, Lorraine Fitzgerald from Nassau and Sheldon
Blitstein from Westchester will serve as Members-at-
Large. Welcome newcomers, and many thanks to the
entire board for their dedication to our society and
the profession of clinical social work. As an organiza
tion comprised of volunteers, dedication and service is
imperative if we are to thrive and meet the challenges in
the field of mental health.
Our president Jonathan Morgenstern has led us
through a time of transition and much has been accom
plished. Communication at the State Board level and
between the state and chapter boards has become more
transparent and thus more effective; the administrative
infrastructure of the State Board has been strengthened
and essential duties have been decentralized; Society
policies and procedures have been compiled into formal
manuals to support current and future leaders; adminis
trative supports to the Society have been assessed and
an association management company has been retained
to better meet current and future administrative support
needs of the Society.
The Chapter Presidents Committee is grappling with
the most effective ways to connect the statewide mem
bership while supporting the individual identity of each
chapter. Helen Hinckley Krackow, as Chapter Development
Chair, has focused her efforts on the Brooklyn and
Metropolitan chapters. Robert Berger and the Website/
Listserv Committee have developed a strong listserv
program which strengthens and promotes networking. The
Clinician, edited by Ivy Miller, with Helen Hinckley Krackow
as the chair of the Newsletter Committee, will be available
on our website and continued in hardcopy, highlighting the
accomplishments of the organization while keeping the
membership current on important practice issues.
Judy Crosley, chair of the Strategic Planning Committee,
has led the group in the creation and completion of policy
and procedure manuals. Hillel Bodek, as Ethics Committee
Chair, responds to inquiries from members and non-mem
bers regarding ethics in practice issues, protecting clinical
standards and consumers of mental health services. The
Independent Practice Committee, chaired by Sheila Peck,
has developed a comprehensive program relevant to new
and seasoned clinicians.
The Mentorship Committee, with Helen Hinckley Krackow
at the helm, is active in most chapters. The mentorship groups,
open to non-members for a fee, serve as a public relations tool
as we help new clinicians working in both private and public
institutions establish and advance their clinical practice. Fred
Mazor, Disaster Preparedness Committee Chair, keeps us con
nected with the Red Cross and updates on crisis procedures.
Gloria Robbins has prepared the Membership Committee to
create a societal atmosphere that will ensure membership
retention and development.
Our Vendorship and Managed Care Committee, headed
by Helen Hoffman, works tirelessly to keep its finger on the
pulse of activity in the behavioral health financing companies.
The Legislative Committee, with Marsha Wineburgh as chair,
recently ran another campaign to ensure that standards of
practice will not be lowered. Through the listserv, the member
ship received information that connected them to our lawmak
ers, ensuring that the Clinical Social Work License would not
be diminished.
Each year the Education Committee, chaired by Susan
Klett, presents a relevant, stimulating program drawing on the
varied expertise of our members and other leading mental
health professionals. The Arts and Creativity in Clinical
Practice Committee, headed by Sandra Indig, always has an
eclectic, evocative calendar of events.
The level of dedication in our volunteer organization results
in the delivery of superior quality programs and services to
clinical social workers and the clinical social work profession
in New York State. Thank you to all committee chairs and mem
bers as well as all state and chapter board members.
Looking ahead, we are faced with the continued task of
maintaining standards in education and practice in the field
of clinical social work. The By-laws Committee will be review
ing the current by-laws, as amendment is necessary to reflect
changes brought about by our licensing law. Practice commit
tees – Family, Psychoanalytic and Group – will be reestab
lished and an Agency Practice Committee will be formed.
Leadership must continue to reflect the high standards
maintained by the Society since its inception. Our next election
involves nominating a president elect who serves for one year
with the current president before assuming the position of
president. The offices of secretary, second vice president and
two members-at-large are up for election this year as well.
Service is imperative for our organization to maintain
its history of excellence. We will be reaching out to current
leaders and members as we begin the nominations process.
Future leaders are encouraged to explore your potential in this
wonderful organization.
Leadership Committee
By Beth Pagano, LCSW-R, Chair
4 The Clinician
T
he State Membership Committee is currently chaired
by Gloria Robbins and includes Richard Joelson (Met
Chapter), Larry Lieberman (Staten Island Chapter), Haya
Caspi (Westchester Chapter) and Shirley Ross. The commit
tee’s work has led up to a full day retreat that took place in
January, facilitated by Marian Sroge, consultant to the Society,
and also attended by Jonathan Morgenstern, Helen Hinckley-
Krackow, Shannon Boyle, Beth Pagano, Rita Smith, Henni
Fisher and newly elected board member-at-large, Sheldon
Blitstein (Westchester). The purpose of the retreat was to con
solidate previous work and plan next steps regarding member
ship retention and development.
Growing the Society requires additional clarity about its
current identity, goals, and activities and, hence, the value of
membership, that is, what the Society has to offer. One first
step is the determination whether we are a society of private
practitioners or of clinical social work psychotherapists in
all practice settings (e.g., agencies, hospitals). What do you
think? Please e-mail Jonathan at mjonathanm@aol.com with
your input.
The Membership Committee functions were determined to
include:
• Welcoming and orienting new members to the Society and
their designated chapter, and helping them find their place
within the organization
• Setting up periodic orientation receptions to provide a set
ting for new members to meet existing members as well as
members of the board
• Consulting on methods to keep the membership apprised of
the work being done by committees and encouraging active
participation
• Developing and implementing specific outreach initiatives to
members who have not renewed their Society membership
• Communicating the needs and interests of members to both
chapter and state boards
• Planning, coordinating, and implementing various activities
to provide opportunities for networking among chapter
members.
The following strategies were proposed and are being
considered:
• Developing outreach strategies to schools of social work,
agencies and private practitioners
• Member-Get-A-Member campaigns
• Recognition and acknowledgment of recruiting and new
members in The Clinician and on the website
• Personally contacting and welcoming recently joined
members by telephone and at specially planned gatherings
• Having state and chapter board members and Membership
Committee members call new members
• Inviting new members to chapter board meetings to famil
iarize them with the Society’s functional infrastructure
• Outreach to colleagues about the Society and what it offers,
and inviting them to educational presentations.
Benefits of membership were considered to include:
• Keeping apprised of licensing law implementation and
related regulations
• Access to seasoned practitioners for peer consultation
• Mentorship groups; practice-oriented educational and train
ing presentations
• Access to a community of like-minded professionals
• Active listservs, which provide access to a wealth of useful
resources
• Contributing toward and supporting the Society’s efforts to
maintain professional integrity and standards of practice
while working to address workforce challenges.
Relatedly, the committee brought up the issue of Society-
facilitated supervision services to agencies; this issue had
been brought up before and merits reconsideration.
Outreach to schools of social work would emphasize
access to seasoned practitioners and mentorship, including
valuable professional support. Outreach to private practi
tioners would emphasize an alternative to feeling profes
sionally isolated, networking opportunities, ready access to
practice-related resources and information (e.g., managed
care-related information), referrals, and opportunities to
develop special interest areas.
Additional tools under consideration:
• Further developing the award of CEU credits at all Society-
sponsored professional/educational activities
• Advertising and inviting potential members to Society-
sponsored events as guests
• Public recognition of members who get members, e.g., a
statement of appreciation in The Clinician or some other
form of acknowledgment.
This is an exciting time for membership work and the commit
tee is seeking your help. Please consider offering your support
in any way. Additionally, Gloria has announced her intention
to step down as committee chair and a replacement is being
sought. If interested, please contact Jonathan Morgenstern at
mjonathanm@aol.com.
Membership Committee
By Gloria Robbins, LCSW, BCD, Chair and Jonathan Morgenstern, MSW, LCSW, Society President
Spring 2010 5
By Richard B. Joelson, DSW
T
his is the first of what will be a regular column in
future editions of The Clinician. Issues of interest and
concern to those in private practice or contemplating
a practice will be discussed with emphasis on money matters
and marketing. Readers are invited to submit their questions
to Richard at RBJoelson@aol.com. All questions will be
responded to regardless of whether or not they appear in The
Clinician.
Here are some tips and guidelines for handling money matters
in the current economic climate:
1
If, upon a client’s request based on changed
economic circumstances, you agree to reduce the
fee, do so for a time limited basis, e.g., three
months or 10 sessions, so that you build in a defined time for
when the issue will be revisited and reconsidered by both of
you. Many therapists reduce fees for good reason and then
find it difficult to restore the original fee (let alone ever raise
it) when the client’s financial circumstance changes.
Currently, I have three clients for whom I reduced the fee
with a scheduled discussion of the matter within a mutually
agreed time frame. All were quite appreciative and under
standing of the idea that we have to be fair to both of us and
not just one of us.
2
If a client requests a fee reduction, this is some
thing that should be explored, rather than immedi
ately granted. There is probably much “grist for the
mill” here that should be considered prior to a decision (e.g.,
is the therapy fee the only item that is being reduced in their
budget or is it the only one that occurred or the easiest one
to try and get reduced?). Remember that fee matters are
treatment issues, not just money issues.
3
In the current, or any, economy it is important to
convey and clarify your fee policies (and if you
don’t have fee policies, I urge you to develop
them...now!) so that clients understand what is expected
of them and how the two of you will be handling financial
matters throughout the treatment. I do not believe it to be
reasonable or fair to create and/or invoke a policy on the
spot for such occasions as late cancellations, missed
appointments, etc., if client was not informed of your policy
earlier. If, in the beginning, I neglect to inform a client about
my fee policies and procedures and they miss a session, for
example, I do not charge for that event, but will in the future
once they have been informed. Some therapists use a written
policy statement which is handed to clients in the first or
second session in order to insure clarity.
4
Many premature or abrupt treatment terminations
can be traced to unacknowledged and, therefore,
therapist-and-client-avoided fee-related conversa
tions in the course of the treatment. Watch for signs of
fee-related issues that occur, however subtly. Examples
include chronic late payment, promises to send the forgotten
fee that are never received, repeated checkbook forgetting,
forgetting the balance due and whether or not they paid for
that month, etc. Work at getting comfortable discussing
money matters if you are not already. Too many of us have
been in the position of chasing after unpaid balances
(often quite large) after a problematic or even conventional
termination.
next issue: Tips on cultivating new referral sources.
Richard B. Joelson, DSW, has been a clinical social work
psychotherapist, educator, and administrator since 1970. He received
his master’s degree from Columbia University School of Social Work
and his Doctor of Social Welfare degree from Hunter College School
of Social Work. He has been the executive director of a mental health
clinic and the Director of Admissions and Student Affairs at New York
University School of Social Work. He was an assistant professor of
social work at New York University and taught in both the doctoral
program and the post-master’s program in social work administration
at Hunter College School of Social Work.
From 1991 to 2002, he taught a course at Hunter College School
of Social Work on developing and succeeding in private practice,
and currently conducts workshops for his chapter on the topic.
He is the new chair of the Membership Committee for the Met Chapter.
E-mail him at RBJoelson@aol.com or visit his website,
www.richardbjoelsondsw.com.
Private Practice Matters
6 The Clinician
Vendorship and Managed Care Committee
By Helen T. Hoffman, LCSW, Chair
T
he Vendorship and Managed Care Committee meets by
teleconference six to eight times a year, and occasionally
in person, focusing on insurance issues. Members commu
nicate frequently by e-mail and post bulletins on the listserv. The
purpose of the Committee is to gather and disseminate informa
tion about insurance issues, to assist individual members with
specific problems, and to explore ways of influencing external
forces. Some of their most recent issues or initiatives include:
• Anticipating the Oxford/UBH transition
• Warning members about Medicare audits and the need for
careful documentation
• Discussing ethical issues raised by Medicaid managed care
• Educating members about the Federal Parity Act
• Following the national healthcare debate
• Exploring how the Society may advocate for the financial health
of clinical social workers (Advocacy Study Group)
• Participation in a New York Business Group on Health pilot
project promoting integrative care (see box)
You are invited to contact members of the Vendorship and
Managed Care Committee to share your experiences or obtain
information on specific problems:
CHAPTER/NAME
E-MAIL
OFFICE PHONE
metropolitan
Helen Hoffman
helenhoffman@verizon.net
212-873-3052
Ruth Washton
rwashton@verizon.net
917-584-7783
Michael Koetting
mkoetting@aol.com
212-741-2606
Virginia Lehman*
LehmanV117@aol.com
212-674-2984
Mary Freeman**
bullpen@mindspring.com
212-348-0004
queens
Shirley Sillekens
ssillekens@aol.om
718-527-7742
northeast
Doris Tomer
tomerd@juno.com
518-271-1862
westchester
Linda Plastrik
LPtunedin@aol.com
914-631-6342
rockland
Lorraine Schorr
lorrainesara@aol.com
845-354-5040
nassau
Susan Kahn
shkahn@verizon.net
516-482-1269
staten island
Colleen Downs
eve114@aol.com
718-816-0712
Integrative Care: Partnering with
Primary Care Physicians
Two years ago, Frank Munoz, a speaker at our annual meeting,
told us that clinical social workers need to discover new roles
in order to prosper. Since then, we have been thinking about
how we might reinvent ourselves. One idea that has been taking
shape as a proposal for a pilot project is that of partnering with
primary care physicians. A grant proposal is being drafted by New
York Business Group on Health, a community coalition of which
the Society is a member. This group is comprised of behavioral
health and pharmaceutical executives, private consultants, and
representatives from the NYC Department of Health, NAMI, and
various professional organizations.
The mission of the pilot is to get primary care physicians in
the commercial sector to screen, treat and follow depressed pa
tients. More than half of patients being medicated for depression
are being treated by PCPs, but the quality of care is uneven and
follow-up uncertain. Access to enough psychiatrists who are on
managed care panels is a serious problem. PCPs may or may not
make referrals for psychotherapy.
This proposal, following an “integrative care” or “collabora
tive care” model, calls for the collaboration of a PCP, a psychia
tric consultant provided by the insurance company, and an inde
pendent clinical social worker. Two possible types of locations
are the community health group, in which the LCSW would have
an office on the premises (co-location), and the solo practice,
in which the LCSW would be available several days a week either
in the PCP’s office or nearby, and available by telephone. The
LCSW would perform assessments, follow up patients who have
difficulty with medication, perform brief interventions, make re
ferrals to psychiatrists, refer for longer term psychotherapy, and
consult throughout with the PCP. Each step in the intervention
would be documented for program evaluation purposes.
How to properly compensate the LCSW for these tasks is
one of the main areas that remain to be resolved. Behavioral
healthcare managers are being asked to propose alternatives
to the existing fee-for-service model. Otherwise independent
LCSWs can have reason to fear that they will be overworked and
underpaid if they are recruited to participate.
LCSWs who perform as “depression care managers” in the
public sector and are salaried tell us that this work takes a high
degree of skill and experience and an acceptance of a more ac
tive, short-term role with the client, but that the work can be ex
tremely meaningful. The work requires a change of mindset from
traditional ideas of treatment. To help in that transition, this pilot
program could include training of LCSWs for the specific role of
“Depression Care Manager” or “Integrative Care Specialist.” In
so doing, it could create a new clinical social work identity for
LCSWs who wish to play a role in a new, less fragmented, and
more collaborative healthcare system.
*Medicare Liason; ** National Health Insurance Observer
Spring 2010 7
Saturday, May 8, 2010
8:00am – 4:00pm
The Nightingale-Bamford School Auditorium
20 East 92nd Street, New York, NY 10128
keynote presentations
Treating Family Relational Trauma
Catherine Lewis, LCSW, MS
Extending Kohut’s Concept of Selfobject
Crayton E. Rowe, Jr., MSW, BCD-P
eight afternoon workshops
CEU credits are available
For information, please call (212) 755-4765
Members, Non-Members, MSW Students are welcome!
Conference Chair: Susan A. Klett, LCSW-R
New York State Society for Clinical Social Work 41st Annual Conference
CONTINUED FROM PAGE 1
CONTINUED ON PAGE 11
and/or diluting the clinical experience requirements as a solution to
a multifaceted problem which has made it difficult for many LMSWs to
obtain the requisite three years of supervised clinical experience for
the LCSW. The Clinical Society recognizes this problem with obtaining
the experience needed for minimum competence in psychotherapy.
But we oppose a solution which reduces the proven minimum
experience requirements. Such an action is detrimental to public
protection and to minimum standards of competence in clinical work.
It also insults our membership, many of whom have spent years in
advanced psychotherapy education programs and gathered extensive
supervised clinical experience beyond their initial MSW/Ph.D. and “P”
experience to provide the highest quality psychotherapy services.
Why We Need to Preserve the Current Supervised Clinical
Experience Standard
1. Combining didactic education with supervised clinical experience
is traditionally how health care professionals learn their trade.
2. The “P” Law established the psychotherapy insurance privilege
for social work, a privilege the four new mental health disciplines
(licensed marriage/family therapists, licensed mental health counsel
ors, licensed psychoanalysts and licensed creative arts therapists) do
not have.
3. Since the 1978 “P” law was passed, the knowledge base for treat
ing mental and emotional disorders has exponentially expanded to
include information from neuroscience, brain development, new
findings on the etiology and evidenced-based treatment of mental
illnesses, and research studies of the efficacy of treatment modalities
and their appropriate use. This increase in the knowledge base of
mental health care would seem to require an increase in supervised
clinical experience, not a decrease.
4. “Counseling” is not the same as “treating” mental illness.
5. When compared to the four new disciplines of mental health
practitioners, the LCSW has the broadest scope of practice, and is
akin to psychology’s scope of practice. The LCSW scope of practice
includes all the functions of the LMSW scope of practice and adds
the functions of diagnosis, treatment planning, psychotherapy and the
administration and interpretation of tests and measures of psychoso
cial functioning.
Only licensed psychologists and LCSWs are permitted to diagnose
mental illnesses and to provide services autonomously, i.e. free of
physician consultation, referral or supervision.
Opposition to the Current LCSW Statute
NASW-NYC and many social agencies are currently pressuring SED to
change the experience requirements for the LCSW law. Their argu
ment appears in the most recent issue of the Currents New York City
Chapter of NASW (Vol. 54/No.3, January 2010). In an authorless opin
ion article entitled “Issue Paper on Social Work Licensing in New York
State,” it argues that the LCSW license for diagnosis, treatment and
treatment planning is too narrow and action is needed to “broaden
the experience requirement for obtaining the LCSW.” It mentions the
Legislative Committee
LIVES DISRUPTED:
Contemporary Approaches
to the Treatment of Trauma
LIVES DISRUPTED:
Contemporary Approaches
to the Treatment of Trauma
8 The Clinician
Recognizing Bipolar Spectrum Illness in Depressed
and Personality Disordered Patients
Have you worked with patients who have tried several differ
ent antidepressants, improved for a time on one or more of
them, and then slipped back into depression? Have some of
your patients become mired in lethargic, irritable, unrelent
ing depressions despite combinations of antidepressants and
other drugs such as Abilify? The most common reason is that
these patients do not just have depression or a personality
disorder. They have undiagnosed bipolar illness (Sharma et
al., 2005). Antidepressants can cause a number of problems
in bipolar patients that may make effective psychotherapy
difficult if not impossible.
Primary care physicians and psychotherapists misdiag
nose 3 out of 4 bipolar patients, typically as having unipolar
depression. Patients spend roughly 9 years working with
these professionals before a correct diagnosis is made.
Alarmingly, psychiatrists do not fare much better, making the
wrong diagnosis in about half of bipolar patients and allowing
6 ½ years to pass before getting the diagnosis right (see
charts below).
In the Spring 2009 issue of the newsletter, I discussed how
familiarity with the seven cardinal symptoms of mania and
hypomania* and asking patients and their families about epi
sodes of increased activity and productivity (the hallmarks of
a hypomanic episode), can help clinicians identify depressed
or character disordered patients who are bipolar.
Clinicians can further improve their chances of identifying
bipolar illness by learning to recognize “features of bipolar
ity” in depressed and character disordered patients who do
not have a history of mania or hypomania (Ghaemi, 2008).
Features of bipolarity include symptoms, course of illness
patterns, family histories, and responses to antidepressant
medication that occur in patients with clearly identified
bipolar disorder but that are not typically found in those with
classic unipolar depression.
Following are the features of bipolarity clinicians should
look for in depressed and character-disordered patients
(especially those patients with DSM Cluster B disorders such
as borderline and narcissistic personality). Patients with
varying combinations of these features should be suspected
of having a “bipolar spectrum illness” (Akiskal, 1996; Ghaemi,
2008) even if they have not had a clear-cut history of mania
or hypomania.
Symptoms and Signs Suggesting Bipolar
Spectrum Illness
There are three symptom clusters that should alert the social
worker to the possibility a patient may have bipolar spec
trum illness: depressive mixed states, atypical symptoms of
depression, and psychotic depression.
Patients are said to be in depressive mixed states when
they have many symptoms of depression but also some
hypomanic ones, as well. Hypomanic symptoms may include
distractibility, racing or crowded thoughts (flight of ideas),
and loud, rapid, and sometimes difficult to interrupt speech.
These individuals may be animated, engaging, and amusing
Borderline or Bipolar
Part II
?
Correct Diagnosis of Bipolar Disorder by Profession
Delay in Diagnosis by Profession
[note: Part I of this article appeared in the Spring 2009 issue.]
By Brian Quinn, LCSW, Ph.D.
Spring 2010 9
despite meeting criteria for depression, but often their mood
is irritable or dysphoric. Because these patients are talk
ative, therapists may have little opportunity to speak without
feeling as if they are interrupting. Patients in depressive
mixed states may have an increased sex drive (patients with
unipolar depression complain of decreased sex drive).
Unipolar patients often have “typical symptoms” of
depression: Middle of the night or early morning awakening
and loss of appetite. The clinician’s index of suspicion for
a bipolar spectrum illness should rise if, by contrast, the
patient has so-called “atypical symptoms:” oversleeping,
overeating or leaden paralysis (a feeling of overwhelming
heaviness and fatigue in the arms and legs). Atypical features
are more common in bipolar patients than unipolar ones
(Angst et al., 2006).
An adolescent or young adult with psychotic depression
(depression accompanied by delusions or hallucinations)
is likely to later develop mania. Psychotic depression is
sometimes not as easy to spot as the clinician might expect:
Psychotically depressed patients tend not to reveal their
delusions and hallucinations. Psychotic depression should
therefore be suspected in an adolescent or young adult who
is very guarded, excessively guilt-ridden, confused or has
extreme psychomotor retardation (Goes et al., 2007).
Course and Temperament Characteristics of Patients
with Bipolar Spectrum Illness
Individuals with unipolar disorder typically have their first
episode of depression in their late twenties. Bipolar de
pression begins, by contrast, in the mid to late teens. The
younger the age of onset of depression, the more likely the
patient will eventually develop a manic or hypomanic episode
(Goodwin & Jamison, 2007).
Bipolar depressions typically have a more rapid onset than
unipolar depressions (days to weeks as opposed to months),
may last less than 3 months (unipolar depressions typically
last 6 to 12 months) , and are highly recurrent.
Individuals who, before their depressive episode, consis
tently got along on 6 hours of sleep a night or less, and were
cheerful, talkative, over-confident risk-takers may have what
is referred to as a hyperthymic temperament (Akiskal, 1996).
These individuals often end up in business, sales, politics, or
entertainment. Depressed patients with premorbid hyper
thymic and cyclothymic (chronically moody, irritable, and
unstable) temperaments should be suspected of having a
bipolar spectrum illness.
Post-partum onsets of depression (especially psychotic
forms) and seasonal cycling of depression should raise clini
cians’ suspicion of bipolar illness, as well.
Family Histories of Patients with Bipolar Spectrum Illness
According to DSM-IV a depressed patient without a history of
mania or hypomania whose father or mother has bipolar illness
is considered to have a unipolar disorder. Yet, antidepressants
don’t work as well in depressed patients with an immediate
family history of bipolar disorder and can prompt the earlier
expression of hypomanic or manic episodes in these individu
als (Calabrese, J. et al., 2006; O’Donovan et al., 2008).
But, the absence of a clear family history of bipolar
disorder does not rule out the possibility of a bipolar
spectrum illness. The most common disorder found in the
family histories of patients with bipolar disorder is, in fact,
depression, not bipolar disorder. Multiple relatives over
several generations with depression or other evidence of
mood dysregulation such as explosive temper are a marker
for bipolar illness. Other family history features of bipolarity
include a family history of completed suicide and alcoholism
(Guillaume et al., 2009; Winokur et al., 1996).
Clinicians should consider the possibility of bipolar dis
order in depressed patients who have ambitious, successful,
or creative relatives. Some of the genetics at the root of bi
polar disorder may also confer on some family members the
drive and energy needed for high achievement (Simeonova
et al., 2005).
Responses to Antidepressants That Suggest Bipolar
Spectrum Illness
In perhaps 20 percent of patients with bipolar depression,
SSRI antidepressants precipitate a manic episode within
8 weeks of the start of treatment (Goodwin and Jamison,
2007). The use of mood stabilizing medication with an antide
pressant lowers but does not eliminate the risk of mania.
A more common outcome of antidepressant treatment
in bipolar patients is referred to as cycle acceleration: An
initial positive response to an antidepressant is followed by
repeated relapses into depression despite dosage increases
(Goodwin & Jamison, 2007). Sometimes patients have had
this experience with two, three, or more antidepressants.
Women are likely more vulnerable to this adverse outcome.
Antidepressants can thus hasten the onset of another
depressive episode in bipolar patients and actually increase
Antidepressant Outcomes in
BP and UP Depression
CONTINUED ON PAGE 12
10 The Clinician
Chapter Reports
ROCKLAND • QUEENS • WESTCHESTER
Rockland Chapter
Dore Sheppard, President
• On February 21st, the chapter
hosted two returning speakers, Ruth
Bowles, CPP, BS, and Starlee Qualter,
LCSW, CEAP, who discussed treating
alcoholism.
• On March 28th at 12:00 pm, the chap
ter will hold a Pot Luck Lunch for the
Rockland CSW community to network
and express gratitude for what our
social workers do for the community.
• On April 24th from 12:00 pm to 1:45 pm,
Helen Adrienne, LCSW, BCD, will speak
on “The Challenge of Infertility for the
Patient: Options for the Therapist.”
Anyone who is not on the mailing list for
the sites, dates and times can call me at
845-358-6433.
Thank you!
Queens Chapter
Fred Sacklow, President
The Queens Chapter has had four board
and educational meetings to date.
• On October 18th, Karen Arthur, LCSW,
spoke to us about energy psychology in
clinical practice.
• Sheila Peck, LCSW, shared her knowl
edge and experience on developing a
private practice on November 22nd.
• On December 13th, Andrea Auther,
Ph.D., and Gary Brucato, Ph.D., from
the North Shore/LIJ System, spoke
about their work on early detection
and intervention for the prevention of
psychosis. More info can be found
at www.rapprogram.org.
• Our own Hanna Turken, LCSW, spoke
on January 24th on marriage, love, sex
and the Internet. She shared some very
interesting cases on the subject.
• On February 28th, Ed Petrosky, Psy.D.,
who always gives a comprehensive
and well-researched presentation,
spoke on the subject of adult ADD.
You can find more information at
www.toolsforstudents.info.
We have many more presentations to
come. Watch for our listings on the
website.
The Queens Chapter has also been
busy communicating via our listserv. I did a
YouTube video which can be seen at http://
www.youtube.com/watch?v=Mr-N7tRs6Mg.
You will find many interesting things there
related to social work. Feel free to contact
me at freds99@aol.com.
Westchester Chapter
Martin J. Lowery, President
We began the year with the sad news of
the death of Chapter Vice-President Cori
Maass. A letter of condolence was sent to
her family and a gift to the American Liver
Foundation was given in her name. Her fa
ther sent a hand-written note of thanks on
behalf of his family. We all mourn together
and remember Cori with fondness.
With gratitude for their willingness to
serve, we welcome a new Vice-President,
Karen Kaufman, and a new Treasurer, Ruth
Rosenblum.
February’s General Membership
Meeting consisted of the Chapter’s Annual
Film Screening and Discussion. We viewed
the 1993 movie, What’s Eating, Gilbert
Grape, with a discussion facilitated by
Jackie Mann that focused on the clinical
reality of obsessional behavior and human
strength in the face of familial, social and
political struggles.
The monthly meetings on the Chapter
on the first Saturday of each month from
September to June continue to strengthen
our supportive bonds and advance our
skills, from the special interest group
meetings that start the day to the educa
tional presentations that end it.
We also have periodic Leadership
Luncheons, during which those respon
sible for various aspects of the Chapter’s
work can bring one another up to date and
ask for needed help. Following the March
meeting, we hope to speak, among other
things, to the issues raised at the January
Membership Committee Retreat.
Spring 2010 11
Arts and Creativity in Clinical Practice Committee
W
e opened our Sunday series of presentations/
workshops on October 4th with Gloria Robbins,
LCSW, BCD, presenting “Ego in Motion: Examining
Patterns of Ego Structure in Child’s Play.” Through video
and discussion, we examined four patterns of ego structure.
Drawing from material presented and clinical practice expe
rience offered by participants, we discussed the presenting
problems, interventions, observable growth and indications
of change in the vignettes of children presented in treatment
sessions. Gloria is a member-at-large of the State Board as
well as membership chairperson and past president of the
Mid- Hudson Chapter.
On November 8th, Gary Prottas, LMSW, LP, presented
“Containment of Trauma and Shame with Survivors of Sexual
Abuse.” This workshop focused on issues, myths, patient
symptoms, tools for the therapist, and case presentations.
Personal experience from members enriched the discussion.
Active group participation was encouraged and there was a
lively exchange of ideas.
Gary also specializes in issues concerning free associa
tion and creativity. He utilizes meditation practices gleaned
from a Tibetan Buddhist perspective, and has taught and led
meditation groups
On January 31st, Hilary Ryglewicz, LCSW presented
“Color Me Green: Using Graphic Metaphors in Couple and
Group Work” for the Arts and Creativity in Clinical Practice
Committee of Met Chapter.
She presented a group of “graphic metaphors” (drawings)
used in Dialectical Behavior Therapy (DBT)-related work with
couples and groups in mental health center programs and in
private practice. The graphics are used as a framework for
exploring problems in affect management and communication.
They function as “shorthand” for emotional and relationship
issues in a variety of situations and with diverse populations.
The meeting included discussion of the spectrum of
therapeutic approaches and the use of cognitive techniques
within a psychodynamic framework for specific situations and
patient populations. Group members discussed their own
use of arts and cognitive approaches in therapy.
Hilary is a supervisor and faculty member at the Training
Institute for Mental Health in New York City. She has also
trained nationwide on treatment for “dual (mental/emotional
and substance use) disorders.”
Other Events
• February 26, The Morgan Library exhibit: “A Woman’s Wit:
Jane Austen’s Life and Legacy”
• March 28, Roberta Ann Shechter, DSW, LCSW, “Source
Material of the Writer: Reflections on Jane Austen”
• May 16, Bryan Hazelton, LCSW, CASAC, BCD, “Embracing
Empathy Through the Use of Imagination in Treatment.”
by Sandra Indig LCSW, ATR-BC, Chair
possibility that “a shortage of clinical social workers is developing.”
The article also advocates expanding Medicare – which covers mental
health services – to additionally include geriatric social services.
The issue paper would be more informative if it included specific
recommendations for new minimum standards for psychotherapy
experience in the LCSW license and considered their implications
for consumer protection, first and foremost. We look forward to more
information in these areas.
The Law Regulates Practice to Protect the Public
In summary, the purpose of the 2004 LCSW law is to regulate the
practice of psychotherapy in order to protect the public when they
seek mental health services. It is not and never was, intended to
define clinical social work, a broad spectrum of practice areas
in the social work profession.
The LCSW is a license which deems the holder capable of
diagnosing, developing treatment plans and providing psychothera
peutic treatment for mental illness. This is an advanced practice
specialty which requires knowledge and experience beyond the
LMSW. The LCSW license allows its holder to provide mental health
services in any setting, whether it is an agency, private practice, or
an HMO. It is the individual practitioner whose expertise is licensed
and this expertise does not depend on the setting where one pro
vides psychotherapy.
Efforts to treat the LCSW license as a problematic, narrow defini
tion of clinical social work practice areas misses the critical point
of the legislation, protection of the public by assuring that providers
of mental health services are properly qualified. Perhaps the LCSW
should be re-titled “Licensed Clinical Social Work Psychotherapist”
– because the standards for training for this area of practice are
essential to quality diagnostic, treatment planning and psychotherapy
services for people who suffer from mental illness. And that was the
purpose of the legislation, after all.
Legislative Committee
CONTINUED FROM PAGE 7
12 The Clinician
the number of depressive episodes the patient experiences in the long
run. The frequency of adverse outcomes of antidepressant treatment in
bipolar and unipolar depression is shown in the following chart.
While no one feature of bipolarity is diagnostic, the presence of
several of them together (particularly a family history of bipolar illness
or antidepressant-induced mania) increases the probability that the pa
tient has a bipolar spectrum illness. Effective psychotherapy with these
patients generally becomes possible only after accurate diagnosis leads
to withdrawal of destabilizing antidepressant medications.
*The seven cardinal symptoms of mania and hypomania can be recalled
using the mnemonic DIGFAST (William Falk, MD Massachusetts
General Hospital; Ghaemi, 2008): Distractibility; Insomnia; Grandiosity;
Flight of ideas; Activity: goal-directed hyperactivity; Speech: Pressured,
loud, rapid; Thoughtless behavior: foolish business ventures, over-
spending, sudden travel, sexual indiscretions
References available upon request to bquinnphd@verizon.net
Brian Quinn, LCSW,
Ph.D. author of Wiley
Concise Guides to Mental
Health: Bipolar Disorder
and The Depression
Sourcebook, 2nd ed.,
is private practice in
Huntington. He specializes
in working with people
with mood disorders
and substance abuse. He earned his master’s degree in social
work at the University of Chicago and his Ph.D. in clinical social
work at New York University. He has a post-graduate certificate
in psychoanalytic psychotherapy from Beth Israel Medical Center
in New York City. He has given seminars on the diagnosis and
treatment of bipolar disorder at several graduate schools of social
work, the New York and Delaware State Society for Clinical Social
Work, and to thousands of clinicians nationwide in seminars
sponsored by professional education seminar companies.
O
n January 1, 2010, the New York State
Society for Clinical Social Work unex
pectedly lost Sharon Lasky to cancer.
Sharon served on the State Board for over four
years as voting representative of the Brooklyn
Chapter. She also served as treasurer of the
Brooklyn Chapter and was tireless in her work
to build the chapter.
Sharon’s dedication to life and community
service was reflected not only in her contribu
tions to the Society, but in her leadership of
the Hadassah Bay Ridge Chapter as well. A deeply moving memorial event
was held in Brooklyn by Hadassah on February 21. Society members, work
colleagues and Hadassah friends spent a touching afternoon remembering
all her contributions to all of our lives and celebrating her life.
Sharon worked at Kings County Hospital for over 40 years as a Level
5 Supervisor of the Maternal Child and Pediatrics Service. She handled
many high profile trauma cases and proved relentless in getting patients’
needs met and following up with families. The memorial service held at
the hospital was so crowded that it spilled into the corridor. There are
plans to name a portion of the hospital in her honor.
Sharon was also in charge of social work training and the education
of social work interns. She worked as a field supervisor for four schools
of social work. She was always an enthusiastic, life-affirming person
who worked hard and played hard. Her passing is a tremendous loss to
everyone who knew her.
IN MEMORIAM
Borderline or Bipolar, Part II
CONTINUED FROM PAGE 9
Spring 2010 13
14 The Clinician
Spring 2010 15
NEW YORK
STATE
SOCIETY
FOR
CLINICAL
SOCIAL
WORK,
INC.
New York Society for
Clinical Social Work, Inc.
350 Fifth Avenue, Suite 3308
New York, NY 10118
Address Correction Requested
STD. PRESORT
U.S. POSTAGE PAID
PERMIT NO. 382
ROCKVILLE CENTRE, NY
