Sally Wilkins presentation

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Information about Sally Wilkins presentation

Published on August 11, 2007

Author: GenX


Slide1:  Personality, Power and Risk:  Personality, Power and Risk An approach to managing distress and risk for people with complex needs. Dr Sally Wilkins Head, Community Psychiatry Program The Alfred Slide3:  A personal reflection only. Very little evidence. A way of thinking and working with complex clients where dysphoria - of whatever type - is contributing to the risk of self-harm. What’s available?:  What’s available? Lots on Demographics Assessment Diagnostic associations Documentation ‘Management using ‘external’ or system responses Medicolegal aspects Slide5:  Less on Prevention Reducing risk behaviours ‘Internal’ or personal responses. Learning from attempts. Paradigm of the weather But constant issue for some clients Need to achieve ‘climate change’ Slide6:  Risk-related dysphoria and distress may not be completely unstable and unpredictable states from which we have to be braced and protected They may also be understandable human states which should be amenable to intervention and possibly prevention. Response to self harm risk:  Response to self harm risk Internal and external responses- both have their place In parallel with tools that give us the power to protect our clients from self-harm, we also need tools we can offer to clients to help them reduce their propensity to self-harm in the first place - (primary prevention.) Three concepts:  Three concepts Personality Power Risk An alternate paradigm for understanding risk clients may find useful. Three concepts:  Three concepts Personality Power Risk An alternate paradigm for understanding risk clients may find useful. Risk :  Risk Assertion #1 All human behaviour is multiply determined. Risk:  Risk Assertion #2 Acts of self harm can be considered in the same way as other human actions for the purpose of understanding the behavioural forces (persuasive and dissuasive) at work. Slide12:  Slide13:  Slide14:  An act of self-harm occurs when the weight of these forces crosses a threshold point for that client and the indecision or ambivalence resolves itself by that action. Risk:  Risk A suicidal action then may be a behavioural choice made by a person at a moment in time acted on by a multitude of persuasive and dissuasive forces which will ultimately direct that choice. Risk:  Risk Assertion #3 Every person nurses some ambivalence about self harm. Slide17:  Fluid Vulnerability Theory (FVT) – Suicidal states - triggers, severity and duration – are fluid in nature but identifiable and quantifiable Everyone has baseline levels of risk – involving cognitive, physiological, affective and motivational components and episodes Triggers can be internal or external End result may be acute dysphoria, physiological arousal and 'death-related behaviours' Rudd 2006 Risk:  Risk Assertion #4 If a client is sitting in front of you alive and talking about self harm then you can and should assume that ambivalence is still at play and can be exploited. Until you’re dead you’re alive While you’re alive there is ambivalence, Ambivalence can be targeted and exploited, and therefore Change is always possible. Slide19:  Risk:  Risk Assertion #5 If the client themselves resolves their ambivalence in favour of choosing to live, this will have significant motivational influence on future behaviour. It is likely to be more influential than externally enforced choices. Three concepts:  Three concepts Personality Power Risk An alternate paradigm for understanding risk clients may find useful. Three concepts:  Three concepts Personality Power Risk An alternate paradigm for understanding risk clients may find useful. Slide23:  Power:  Power There are two types of power which should be delineated. Authoritarian power Therapeutic power Often confused in discourse. Slide25:  Authoritarian Power. Defined by its imbalance and maldistribution Only in evidence when not capitulated Promotes subordination, dependency and helplessness. Occasionally justifiable. Easily abused. Slide26:  Therapeutic Power. Defined by its transferability Only in evidence when shared. Promotes decision-making, independence and self-reliance. Frequently appropriate Almost unabusable. Slide27:  I suggest that this therapeutic power is the kind we are talking about when we talk about ‘empowering’ our clients. The transfer of therapeutic power is a win/win transaction not a win/lose one, This acquisition or re-instatement of genuine personal power is a target end point in managing clients with self-harming dysphoria as it is the diametric opposite to hopelessness Slide28:  A person with a sense of hopelessness reports that they cannot act on their environment, specifically cannot change it for the better and cannot foresee that ability arising in the future. They are describing powerlessness in another way. Three concepts:  Three concepts Personality Power Risk An alternate paradigm for understanding risk clients may find useful. Slide30:  Slide31:  These diagnoses have come to be loaded with a number of secondary associations. One of these is the notion of ‘untreatability’ and related to that is the fear of having our personal clinical resources drained or found wanting in face of very high demand. So clinicians without a clear strategy confront - A ‘demand that can’t be met’ An ‘outcome that can’t succeed’ and A ‘high risk of self-harm’ So we need some clear strategies - because this is interesting and important work which we know can be successful Slide32:  Tony is a 24-yr old man who comes to you requesting help with stress and depression. He has moved down to Melbourne from Darwin with his girlfriend of 2 years and their 6-month-old son and is now looking for work. He has had more than 8 brief admissions to psychiatric facilities over 6 years following acts of self harm and suicide attempts He spent 18 months in gaol when he was 20 for burglary, which he committed in order to support a heavy heroin habit, which he has now kicked. He continues to use THC, alcohol and nicotine in moderate amounts. He has a h/o angry verbal outbursts and reports he has verbally abused his g/f on at least one occasion. He says he finds it very hard to trust her or anyone else. Slide33:  He describes his natural father as a ‘bastard’ who would frequently hit his mother and the children when drunk until he left the family when Tony was 9. He reports frequent episodes of sexual abuse from his father prior to his departure. He lived in foster care for 2 years in his early teens after repeated disputes with his step-father. He left school at 15 after failing yr 9 for the second time. He has no tertiary training and has not held a job for more than 3 months. He started working for a removalist on arriving in Melbourne but was sacked after a fight with the boss and repeated lateness. You notice he has a slightly wary, dysphoric and guarded presentation and a tattoo on his forearm that says ' FUCK THE WORLD'. There are also multiple laceration scars on both arms and wrists. Slide34:  Assertion #6 Complexity is not a problem for the ‘good enough’ therapist, it is a gift. Slide35:  If you are being presented with a multitude of problem areas with a plethora of interconnecting facets you are being offered a huge range of potential intervention points. EMBRACE COMPLEXITY!! (Also, the human psyche is a phenomenon of cosmic proportions and exploring it is a privilege and a trip.) Slide36:  Was born 8 weeks prematurely and was delayed in several milestones including bed-wetting until he was ten. At school he was delayed in his reading acquisition and this was worsened by 5 different changes of school between the ages of 5 and 9. He stuttered when he was anxious as a small boy and was the victim of bullying at primary school. He has a lifelong love of music however and is a gifted guitar player. He has never been involved in any incident involving physical aggression towards another person. He has a close and loving relationship to his maternal grandmother who lives in Melbourne. Whilst in gaol he attended literacy classes and is now fully literate. Slide37:  He is devoted to his son and minds him whilst his partner works as a casual at Safeway two days a week. He has recently reduced his cigarette smoking from 40 to 25 per day. He has a love of birds and a collection of 6 budgies which are at his grandmothers house - he tends them daily. He would like to work with birds if he could. When he was in Darwin he spent 3 months working casually with an Aboriginal theatre group as a roadie and developed a love of aboriginal culture. He has kept in touch with the group and considers one of them his best friend. He is going to stay with Tony when he comes to Melbourne in 2 weeks. Slide38:  Needs to be explored and extracted though careful questioning. May be ‘invisible’ to the client – especially at times of lowered mood. We may inadvertently collude with them by failing to shine our light in the right places at times. Taking a careful clinical history and a strength based assessment of the client’s personality gives you the broadest possible number of intervention points. These intervention choices may cover the full biopsychosocial range. The other bits of the history that count:  The other bits of the history that count Problem-free areas Awareness of problems Positive reactions to change or crisis. Enduring relationships Positive relationships Talents and passions Interests, aspirations and goals Areas of self reliance and independence Personal view of survival skills Slide40:  Problem-free areas No physical aggression Is housed, fed and clothed adequately Can attend organised appointments when made. Physically well- no long term sequelae of AOD problems. Slide41:  Awareness of problems Believes he needs assistance. Recognises he has a problem with anger and with relationships Able to see where he has made ‘mistakes’. Slide42:  Positive reactions to change or crisis Has re-settled in Melbourne without incident. Managed the unplanned pregnancy without problem and is committed to the baby Managed to reduce his cigarette smoking despite being ‘stressed out’ about money. Improved his literacy in gaol. Slide43:  Enduring relationships Positive relationships His girlfriend His son His grandmother His friend. His birds Slide44:  Talents and passions Interests, aspirations and goals Music, guitar Budgies Aboriginal culture Wants to be a ‘better father than he had’ Wants to work Wants to stay out of hospital. Slide45:  Areas of self reliance and independence Can usually find work quite easily Manages his own money quite well Can look after his son without help Is quite intelligent and reflective. Slide46:  Personal view of skills and assets Believes he is a ‘survivor’ Proud of his fathering skills Likes his sense of humour Knows he is good to animals and knows a lot about birds Loves his grandma. Proud of ‘getting out of gaol’ and ‘getting straight’ Slide47:  There is good evidence to suggest that there are four core themes that are often associated with depressed or dysphoric states that are specifically associated with suicidality. The belief of unloveability The belief of helplessness Poor distress tolerance Perceived ‘burdensomeness’. Slide48:  If the presence of these belief systems are factors that influence baseline levels of risk for our clients then these may be the areas where they need to gain both mastery and power. So Can we influence –and in particular challenge - these belief systems working in the long term with our high risk clients by exploiting their existing strengths and capacities so that when trigger events occur, they will be making decisions about self harm from a safer zone. Slide49:  We can sway the decisional balance about self-harm in a positive direction using this information You can start to re-set the baseline influence of persuasive and dissuasive forces which contribute to his personal safety environment You can target the four emotional belief systems that may specifically be associated with risk using his own personal experience which can’t be denied. For example his lived experiences of success and contribution where they have occurred can be explored and examined to see if he can replicate those experiences in new areas. This may challenge his feelings of helplessness or burdensomeness. Slide50:  I have suggested that self-harm behaviour, in the setting of dysphoria, may be subject to persuasive and dissuasive forces, or, forces that increase risk and forces that increase protection, and that these competing internal factors contribute to the ambivalence around these actions. Slide51:  I have suggested that when the balance of these forces crosses an individually determined threshold point, self-harm activity may occur and that a reasonable role for clinicians is to assist clients to conceptually move away from this threshold zone. Slide52:  I have suggested that the complexity of psychopathology such clients exhibit is often matched by a complexity of strengths and capacities often overlooked by clinicians and sometimes by the client themselves. Slide53:  I have suggested that by exploiting and enhancing these strengths we can access a multitude of intervention points through which we can leverage change. This may have the effect of altering the baseline level of risk for the client and imbuing them with a sense of readiness and resilience. Slide54:  If this works for the client, then we might be able to take this internal sense of power and impact on the decisional balance around self-harm at times of higher risk. Slide55:  It may be possible to use modified motivational interviewing techniques, focussing particularly on enhancing self-efficacy, to help resolve ambivalence around self-harm in the direction of personal safety at these times. Slide56:  The enhancement of self-efficacy, self-agency and personal choice involved in these tasks push the ‘self-harm’ decisional balance in a positive direction. It may also result in a genuine transfer of mastery and capacity to the client. Genuine therapeutic power has been exercised because genuine personal power has been enhanced. Summary:  Summary A good clinical history and risk assessment is essential in complex clients. To add to this a full exploration and joint exploitation of strengths may arm us with useful therapeutic power that is easily transferred to our clients. Slide58:  ‘Complexity’ - with all its biopsychosocial components - should imply a broad palette of therapeutic possibilities. The analogy of persuasive and dissuasive forces amenable to personal influence may be a helpful and workable metaphor for ambivalence for some clients. Slide59:  This enhanced mastery and self-awareness may decrease baseline risk levels over time. By using motivational enhancement techniques it may be possible to promote positive personal choices around self-harm at times of higher risk. Slide60:  Hopefully the outcome is an informed, reflective client able to see and utilise their strengths to reduce their dysphoria make safer personal choices reduce the need for external constraints and maintain a secure belief in their own recovery. Slide61:  Viola Perchance my brother is not drown’d What think you sailor? Captain I saw your brother, Most provident in peril, bind himself, Courage and hope both teaching him the practice, To a strong mast that liv’d upon the sea; Where, like Arion on the dolphin’s back, I saw him hold acquaintance with the waves So long as I could see. Slide62:  NON-TRADITIONAL MODELS OF TREATMENT DELIVERY FOR ANXIOUS CHILDREN AND ADOLESCENTS:  NON-TRADITIONAL MODELS OF TREATMENT DELIVERY FOR ANXIOUS CHILDREN AND ADOLESCENTS RONALD M RAPEE MACQUARIE UNIVERSITY, SYDNEY Slide64:  MAIN COLLABORATORS MAREE ABBOTT MICHAEL CUNNINGHAM JONATHAN GASTON JENNIFER HUDSON HEIDI LYNEHAM CAROLYN SCHNIERING VIVIANA WUTHRICH Support from NHMRC, ARHRF, ARC CHILDHOOD ANXIETY DISORDERS ARE::  CHILDHOOD ANXIETY DISORDERS ARE: PREVALENT – UP TO 5-10% IMPACTFUL – SCHOOLING, FAMILY LIFE, HEALTH, RELATIONSHIPS CHRONIC – PREDICT ADOLESCENT AND ADULT DISORDERS TREATMENT WORKS:  TREATMENT WORKS CARTWRIGHT-HATTON ET AL (2004) REVIEW OF 19 RCTS. TX = 57% REMISSION WAITLIST = 34% REMISSION. LIMITATIONS OF THERAPIST TREATMENT:  LIMITATIONS OF THERAPIST TREATMENT ONLY 17% OF PEOPLE WITH ANXIETY DISORDERS RECEIVE HELP FROM PSYCHOLOGIST/ PSYCHIATRIST (ANDREWS ET AL., 1999) IN AUSTRALIA MANY PEOPLE HAVE LITTLE ACCESS TO MENTAL HEALTH SERVICES USUAL THERAPY IS EXPENSIVE NOT ENOUGH THERAPISTS REASONS FOR NOT SEEKING HELP (ISSAKIDIS & ANDREWS, 2002):  REASONS FOR NOT SEEKING HELP (ISSAKIDIS andamp; ANDREWS, 2002) 301 PEOPLE MEETING CRITERIA FOR AN ANXIETY DISORDER BUT NOT GETTING HELP IN PREVIOUS 12 MONTHS DIDN’T REALISE HELP EXISTS – 14% DIDN’T KNOW WHERE – 16% EMBARRASSED – 20% PREFER TO MANAGE MYSELF – 58% IN SUMMARY:  IN SUMMARY TRADITIONAL PSYCHOTHERAPY FOR ANXIETY WORKS BUT IT DOES NOT HAVE THE REACH AND IT IS TOO EXPENSIVE FOR EVERYONE SO A COMPREHENSIVE PUBLIC HEALTH SYSTEM NEEDS ALTERNATIVES NOT TO REPLACE THERAPISTS, BUT TO COVER ALL BASES The TRADITIONAL MODEL:  The TRADITIONAL MODEL COOL KIDS PROGRAM SKILLS-BASED TRAINING 10 SESSIONS APPROX. 20 HOURS PARENTS andamp; CHILDREN INCLUDED RUN BY CLINICAL PSYCHOLOGISTS THERAPIST TEACHES SKILLS ALTERNATE #1PARENT-ONLY DELIVERY:  ALTERNATE #1 PARENT-ONLY DELIVERY CAN SIMILAR EFFECTS BE ACHIEVED WITHOUT CHILDREN AND FEWER SESSIONS? SHIFT IN FOCUS TO SELF-LED INFORMATION REDUCTION IN THERAPIST TIME AND FAMILY BURDEN PARENT GROUP SUPPLEMENTED BIBLIOTHERAPY FOR CHILD ANXIETY DISORDERS Lyneham, Abbott & Rapee, in preparation:  PARENT GROUP SUPPLEMENTED BIBLIOTHERAPY FOR CHILD ANXIETY DISORDERS Lyneham, Abbott andamp; Rapee, in preparation Identical content to traditional tx Information delivered via written manuals A Child Workbook that contains detailed explanations of skills, activities and practice tasks from Cool Kids A Parent Workbook that integrates 'Helping Your Anxious Child: A Step by Step Guide for Parents' with tasks from Cool Kids Program Designed to be completed over 3-4 months Suitable for children in primary school Augmented with 5 group sessions – parents only; approx 1 hr each. Problem solving approach to tx delivery Evaluation:  Evaluation N= 172; 54% male Principal diagnosis of anxiety Comorbid externalising disorder 19% Mean age of 9 years 5 months Block randomisation to three conditions Traditional Family Group CBT (Cool Kids): 10 sessions over 12 weeks, parents andamp; kids Parent Group supplemented Bibliotherapy: 5 sessions over 12 weeks, parents only. Waitlist Control: 6 to 22 weeks, mean = 11 weeks % Diagnosis Free for Principal Anxiety Disorder:  % Diagnosis Free for Principal Anxiety Disorder Child and Family Interference – Child report:  Child and Family Interference – Child report Benefits of Parent-only groups:  Benefits of Parent-only groups It works as well as traditional group treatment. Provides a cost effective and more flexible option. ALTERNATE #2SCHOOL DELIVERY:  ALTERNATE #2 SCHOOL DELIVERY UNIVERSAL DELIVERY HAS A MORE PREVENTION FOCUS INDICATED HAS MORE CLINICAL FOCUS REACH MANY KIDS WHO DON’T NORMALLY GET HELP TREATMENT DELIVERED BY SCHOOL COUNSELLORS TENDS TO BE BRIEFER SCHOOL INTERVENTION FOR CHILD ANXIETYMIFSUD & RAPEE, 2006:  SCHOOL INTERVENTION FOR CHILD ANXIETY MIFSUD andamp; RAPEE, 2006 YEARS 4 andamp; 5 FROM 9 SCHOOLS SCHOOLS SELECTED FROM LOW SES INDICATORS SCREENED WITH RCMAS + TEACHER NOMINATION (EXCLUDE EXTERNALISING) OVER 90 KIDS – ONLY 2 HAD PREVIOUS TX MEAN AGE 9.5; 59% FEMALE INTERVENTION DELIVERY:  INTERVENTION DELIVERY 8 SESSIONS / 8 WEEKS APPROX. 45 MIN - 1 HOUR GROUPS ~ 10 ALL ANXIETY COMBINED SCHOOL COUNSELLOR + MENTAL HEALTH TWO PARENT EVENINGS PARENT AND CHILD MANUALS SCAS – CHILD REPORT :  SCAS – CHILD REPORT TEACHER REPORT FORM (Int) :  TEACHER REPORT FORM (Int) BENEFITS OF SCHOOL-BASED DELIVERY :  BENEFITS OF SCHOOL-BASED DELIVERY IT WORKS ACCESS CHILDREN WHO DON’T GET HELP PERHAPS MORE ACCEPTABLE BECAUSE DELIVERED TO THEM MORE EASILY ACCESSIBLE – BROADLY DISSEMINABLE (LOTS OF SCHOOLS) BRIEFER - CHEAPER ALTERNATE #3OUTREACH DELIVERY:  ALTERNATE #3 OUTREACH DELIVERY CAN WE DELIVER PARENT PROGRAM TO THOSE WHO CAN’T ACCESS CLINIC? MANY PEOPLE CANNOT ACCESS CLINICS DUE TO DISTANCE, ILLNESS, OR STIGMA USE OF WRITTEN MATERIALS PROVIDES A PLATFORM FOR AUGMENTATION THROUGH VARIOUS MEANS OUTREACH PROGRAM FOR ANXIOUS CHILDRENLYNEHAM & RAPEE, 2006:  OUTREACH PROGRAM FOR ANXIOUS CHILDREN LYNEHAM andamp; RAPEE, 2006 Identical content and materials to parent-delivered tx Suitable for children in primary school Augmented with 1 of 3 methods Telephone: 9 SCHEDULED 30 MIN. SESSIONS (average 24min) – 12 WEEKS Email: WEEKLY EMAIL RE PROGRESS – THERAPIST AVAILABLE BY EMAIL AS NEEDED (average 21 times) Self-Initiated: THERAPIST AVAILABLE AS NEEDED – PHONE OR EMAIL (av 8 min/S) Evaluation:  Evaluation N= 100; 51% male Principal diagnosis of anxiety Comorbid externalising disorder 11% Mean age of 9.4 years Randomisation to the three methods or waitlist DIAGNOSIS FREE:  DIAGNOSIS FREE SCAS – MOTHER REPORT:  SCAS – MOTHER REPORT BENEFITS OF OUTREACH DELIVERY :  BENEFITS OF OUTREACH DELIVERY IT WORKS WELL PROVIDES ACCESS TO FAMILIES WHO CANNOT REACH TRADITIONAL HELP CAN FIT AROUND BUSY FAMILY LIVES BRIEFER – CHEAPER; THERAPISTS STRETCH FURTHER ALTERNATE #4aPURE SELF HELP (BIBLIOTHERAPY):  ALTERNATE #4a PURE SELF HELP (BIBLIOTHERAPY) CAN WRITTEN MATERIALS BE REDUCED TO PURE SELF HELP? ACCESS THE MANY WHO PREFER TO 'MANAGE THEMSELVES' SELF HELP BOOKS ARE WIDELY USED – CAN THEY WORK? BIBLIOTHERAPY:  BIBLIOTHERAPY WEALTH OF RESEARCH ACROSS MANY YEARS FOR MANY PROBLEMS TO DATE, NONE IN CHILDHOOD ANXIETY EXTREMELY CHEAP VERY EASILY ACCESSIBLE TOTAL ANONYMITY FOR CHILDREN – PARENT AS THERAPIST MODEL BIBLIOTHERAPY FOR ANXIOUS CHILDRENRAPEE, ABBOTT & LYNEHAM, 2006:  BIBLIOTHERAPY FOR ANXIOUS CHILDREN RAPEE, ABBOTT andamp; LYNEHAM, 2006 ANXIOUS CHILDREN AGED 7-11 YEARS ANY PRINCIPAL ANXIETY DISORDER 27% COMORBID EXTERNALISING EXCLUSIONS - CURRENTLY SUICIDAL; CURRENT SEVERE SCHOOL REFUSAL PARENT ABLE TO READ ENGLISH PAPER ~200 AT POST-TX; ~130 AT 3 MO F/U 60% MALE; M. AGE APPROX. 9.5 YEARS DESIGN:  DESIGN RANDOM ALLOCATION – TRADITIONAL (10 SESSIONS/ 12 WEEKS); WAITLIST (12 WEEKS); PURE BIBLIOTHERAPY (12 WEEKS). BIBLIOTHERAPY – HELPING YOUR ANXIOUS CHILD TOLD TO READ AND APPLY – NO OTHER CONTACT CONTENT WAS SIMILAR TO COOL KIDS DIAGNOSIS FREE (completers):  DIAGNOSIS FREE (completers) % SCAS (parent):  SCAS (parent) BENEFITS OF BIBLIOTHERAPY :  BENEFITS OF BIBLIOTHERAPY AROUND 20% OF ANXIOUS CHILDREN NO LONGER MEET CRITERIA WITHIN 3-6 MONTHS VERY INEXPENSIVE BROADLY ACCESSIBLE AND ACCEPTABLE TO MANY REDUCES BURDEN ON BUSY THERAPISTS BY 20+% ALTERNATE #4bPURE SELF HELP (COMPUTERS):  ALTERNATE #4b PURE SELF HELP (COMPUTERS) PARENT AS THERAPIST MODEL IS NO GOOD FOR ADOLESCENTS ADOLESCENTS ARE ESPECIALLY CONVERSANT WITH COMPUTER DELIVERY ONE ACCEPTABLE METHOD FOR ADOLESCENTS MAY BE COMPUTER-BASED DELIVERY OF SELF HELP BECOMING WIDELY USED FOR SEVERAL PROBLEMS – NONE YET FOR ADOLESCENT ANXIETY Cool Teens Program Summary(Cunningham et al, 2006):  Cool Teens Program Summary (Cunningham et al, 2006) 8 modules (20-30 minutes each) Adapted from Cool Kids and existing group therapy techniques Information, interactive exercises, examples, practice tasks Track anxiety levels andamp; achievements Motivational boosts/feedback Multi-media components:  Multi-media components Text Audio Illustrations Cartoons Live video Feedback on Prototype:  Feedback on Prototype BENEFITS OF COMPUTER DELIVERY :  BENEFITS OF COMPUTER DELIVERY EASILY andamp; WIDELY DISSEMINABLE AFTER DEVELOPMENT, INEXPENSIVE BROADLY ACCESSIBLE AND ACCEPTABLE TO MANY, POSSIBLY ESPECIALLY TO ADOLESCENTS CAN INCORPORATE MOTIVATIONAL BOOSTS AND FEEDBACK SUMMARY:  SUMMARY SEVERAL METHODS BEING EVALUATED AS ALTERNATES TO TRADITIONAL, CLINIC-BASED THERAPY FOR ANXIOUS KIDS PARENT-ONLY TX (BRIEFER, CHEAPER) SCHOOL-BASED DELIVERY (CHEAPER + ACCESSIBLE) OUTREACH BIBLIOTHERAPY (CHEAPER, VERY ACCESSIBLE, SOMEWHAT ANONYMOUS) SELF HELP (MUCH CHEAPER, VERY ACCESSIBLE, ACCEPTABLE, ANONYMOUS) ABOVE ALL:  ABOVE ALL THE BURDEN OF UNMET NEED IS LARGE AND TRADITIONAL THERAPY CANNOT COPE THESE ALTERNATIVES ARE NOT DESIGNED TO REPLACE THERAPISTS A FLEXIBLE AND EFFECTIVE PUBLIC HEALTH SYSTEM MUST CONTAIN A VARIETY OF DELIVERY METHODS TO SUIT DIFFERENT NEEDS. Slide103: 

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