NCMHCE Exam Review: Recent Episodes

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Body dysmorphic disorder (BDD) is characterized by the belief that some aspects of one’s appearance are ugly, unacceptable, or otherwise deformed, while this is in fact not the case. Those with BDD overfocus on details of visual stimuli rather than global aspects BDD sufferers can become preoccupied with any aspect of appearance, but the most common concerns relate to facial features, including nose, eyes, skin and hair. The development of BDD is associated with past experiences of abuse, violence, and trauma A survey of patients with BDD found high rates of emotional neglect and abuse (68.0%), physical neglect and abuse (34.7%), and sexual abuse (28.0%) Patients are not only more likely to have a history of traumatic experiences but also to experience them as more painful and to be able to recall them clearly. Compared to other diagnoses, little is known about BDD The high rate of trauma/ACEs, frequent comorbidity with mood disorders, OCD and PTSD indicate involvement of the amygdala, the HPA-Axis and DMN Schema A strengths based, trauma informed approach is essential to lay the groundwork for developing safety and empowerment. Information about differences in cortical processing of visual stimulus as well as altered ability to accurately perceive facial expressions may also provide clues to future treatment strategies.

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NCMHCE Adjustment Related to physical loss or chronic illness

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NCMHCE Addiction Counselor Exam Review Biopsychosocial Assessment

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NCMHCE Review Part 2 Screening Brought to you by AllCEUs.com Counselor Continuing Education Unlimited CEUs $59/month or $99/year Live Webinars as low as $4/hour Addiction Counselor Certificate Training $149 Screening Questions -- Anxiety ~ Do you worry about a lot of things most of the time? ~ Do you worry about specific things like germs or getting into a car accident a lot? ~ Do you get so worked up that you cannot eat or sleep?

Screening --PTSD ~ Have you been in really bad situations in which you had no control? ~ Have you been in terrifying situations? ~ Do you ever have memories of those situations that disrupt your day? ~ Do you startle really easily? ~ Do you find yourself being irritable and pessimistic? Anger ~ Do you often get angry? ~ When you get angry, do you feel like you are ready to explode? ~ Do you think you are more irritable than other people? Screening Questions -- Depression ~ Do you feel pleasure or happiness on a regular basis? ~ Have your sleep patterns changed? ~ How is your appetite? ~ Do you often feel guilty? ~ How is your energy throughout the day? ADHD ~ Do you have difficulty finishing tasks? ~ Do you have difficulty getting organized? ~ Do you have difficulty if you have to sit still for a long time? ~ Do you have difficulty staying focused and filtering out distractions ~ Do you have difficulty waiting your turn or not interrupting? OCD ~ Do you sometimes have thoughts you cannot get out of your head? ~ How much time do these thoughts take up on average each day? ~ Do you ever feel like you have to do something over and over or something bad is going to happen? ~ How much time do you spend each day doing these things?

Delusions and Hallucinations ~ Have you ever thought that people could read your mind or control your thoughts? ~ Have you ever felt like your mind was playing tricks on you? ~ Do you ever see or hear things that other people cannot see or hear? ~ Do you ever have difficulty knowing if you are awake or dreaming?

Eating Disorders ~ How would you describe your eating habits? ~ Do you have any concerns about your weight? ~ How do you maintain your weight? Impulsivity ~ Do you ever find yourself doing things without really thinking about the consequences first? ~ Do you ever do things you know you shouldn’t but just cannot seem to stop yourself? ~ Do you buy things that you really don’t need just because they are there? Mania ~ Have you ever had so much energy that you couldn’t sit still ~ Have you ever found yourself not needing sleep or needing much less than usual? ~ Do you have times when you talk a lot more than usual and your brain seems to be going really quickly? Substance Misuse ~ Have you been bothered by “using medicines or drugs without a doctor’s prescription, or in greater amounts or longer than prescribed? ~ Have you used more than intended or spent more time engaging in an activity than intended? ~ Have you spend more time planning, engaging in or recovering from the use of the substance or activity? ~ Have you given up or had difficulty in significant areas of your life as a result of use of the substance or engaging in the activity. ~ CAGE ~ Cutting Down ~ Annoyed ~ Guilt ~ Eye Opener

Summary ~ It is important to screen for a variety of issues ~ Know the diagnostic criteria for the most common mental illnesses ~ Many disorders have overlapping symptoms ~ Anxiety, PTSD, ADHD, Bipolar and Depression for example ~ Psychiatry.org has multiple free Cross Cutting Symptom Measures to be aware of ~ Screening just gives you a launch pad to help guide the in-depth biopsychosocial assessment Test Taking Tip ~ First Priority is identifying the diagnoses for everyone in the scenario. ~ Don’t try to be too broad. ~ If the scenario is about someone who recently underwent a traumatic event and the question asks for what to evaluate to support a provisional diagnosis, think about what you would assess for a provisional PTSD/ASD diagnosis, not a blanket evaluation for every comorbid axis 1 condition.

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011 -NCMHCE Review Treatment Planning Part 1

NCHMCE Review Treatment Planning Dr. Dawn-Elise Snipes PhD, LPC-MHSP, LMHC Executive Director, AllCEUs.com Podcast Host: Counselor Toolbox and NCMHCE Exam Review Objectives ~ Review goals and interventions to address anxiety, anger, grief, blended families and child issues. Anger and Aggression ~ Rule out danger to others and substance abuse. ~ Goals ~ Increased awareness of angry feelings, triggers and responses ~ Decreased frequency and intensity of angry feelings ~ Increased awareness of alternatives to aggressive responses ~ Increased ability to use assertiveness skills to address triggers for anger and aggression Anger Interventions ~ Daily journaling or logging to identify and track frequency, intensity and duration of angry feelings ~ Reflect upon and address anger triggers and aggressive behaviors ~ Use backward chaining to identify antecedents to anger and aggressive behavior ~ Construct a genogram to identify multigenerational triggers for and methods of dealing with anger ~ List prior experiences which have caused hurt and process those experiences to move toward forgiveness and release anger ~ Identify current triggers and targets for anger and address those. ~ Learn at least 5 alternatives to verbally or physically aggressive behavior. ~ Rehearse anger management skills ~ Refer for or teach effective communication skills ~ Bibliotherapy Anxiety ~ Rule out PTSD ~ Goals ~ Increased awareness of anxious feelings and responses ~ Increased awareness of triggers for anxiety ~ Decreased frequency and intensity of anxious feelings ~ Enhanced distress tolerance skills ~ Increased awareness of ways to cope with anxious behavior ~ Improved problem-solving skills ~ Enhanced self-efficacy

Anxiety Interventions ~ Learn mindfulness to identify anxiety when it begins ~ Daily journaling or logging to identify and track frequency, intensity and duration of anxious feelings ~ Reflect upon and address triggers ~ Use backward chaining to identify antecedents to anxious behavior ~ Use cognitive interventions to address prior traumatic or fear-related experiences ~ Learn at least 5 coping skills to deal with anxiety ~ Learn at least 5 distress tolerance skills ~ Bibliotherapy Blended Families ~ Assess the expectations of each family member ~ Contact schools for information about children ~ Goals ~ Develop a new family identity ~ Help each person develop a new identity ~ Redefine roles within the family ~ Identify and resolve losses ~ Develop tolerance and flexibility ~ Create a parent coalition ~ Develop effective conflict resolution skills

Blended families ~ Interventions ~ Normalize ~ Identify and process losses ~ Empower each person to create a new meaningful identity ~ Encourage verbal expression of all emotions including guilt, resentment, and feelings of failure or abandonment ~ Explore parental misperceptions about blending families and the children ~ Educate parents about varying developmental needs ~ Strengthen the identification of the new family unit ~ Identify and address conflicts within the blended family and with extended family members and ex-spouses ~ Ensure all members have personal space and can create a sense of “home.” Child Clients ~ Complete a comprehensive developmental history and refer for psychological testing as needed (i.e. for suspected neurological issues) ~ Interview parents and child. Use behavior rating scales ~ Get ancillary information from school and pediatrician ~ Set clear goals with the parents ~ Goals ~ Decrease maladaptive behaviors ~ Improved interpersonal skills ~ Increased ability to identify and appropriately express feelings ~ Increased use of distress tolerance and coping skills ~ Improved problem solving skills Child Clients ~ Interventions ~ Parent education of skills to model and behavior modification tools ~ Therapeutic play to assist with emotional processing ~ Family meetings and relabeling child’s behavior

Adult Clients with Child Abuse Issues ~ Assess for PTSD, depression, suicidality, substance abuse, dissociation ~ Goals ~ Increased awareness of the impact of the abuse emotionally, cognitively, physically and interpersonally ~ Process the trauma and integrate it ~ Increase awareness of trauma related reactions ~ Enhance the use of effective distress tolerance and coping skills

Adult Survivors ~ Interventions ~ Explore family of origin ~ Identify and express feelings and thoughts associated with the abuse ~ Help the client let go of self blame and address unhelpful cognitions ~ Refer for EMDR or hypnosis if appropriate ~ Teach grounding, reorienting and distress tolerance techniques to address dissociation ~ Consider internal family systems theory approaches to help the client integrate fragmented parts of self ~ Enhance the client’s support network ~ Refer for medication for mood symptoms as appropriate ~ Bibliotherapy Grief ~ Rule out depression ~ Assess for substance use and suicidal ideation ~ Goals ~ Increase awareness of the impact of grief on the person ~ Develop vocabulary to describe feelings of grief and loss ~ Develop a short-term action plan for dealing with grief and loss ~ Identify grief and loss issues ~ Identify steps toward moving toward acceptance and integration Grief ~ Interventions ~ Develop support system—Refer to support groups as appropriate ~ Identify current and historical losses and process related feelings and cognitions including guilt, anger, depression ~ Challenge cognitive distortions or maladaptive thinking patterns ~ Refer to physician as appropriate for depressive symptoms ~ Empower clients to integrate the loss(es) into their identities with narrative therapy ~ Make referrals to wrap-around services as needed Summary ~ There are a myriad of issues, not just DSM V diagnoses that NBCC wants to make sure the counselor can address ~ Review the preliminary content outline for an idea of the types of issues you may be asked to deal with ~ In preparing for the exam, consider making your own scenarios that involve not only a diagnosis, but also administrative and ethical issues. Tips--Confidentiality ~ HIPAA permits health care providers to: ~ Communicate with a patient’s family members, friends, or others involved in the patient’s care ~ Communicate with family members when the patient is an adult ~ Communicate with the parent of a patient who is a minor ~ Consider the patient’s capacity to agree or object to the sharing of their information ~ Involve a patient’s family members, friends, or others in dealing with patient failures to adhere to medication or other therapy as long as the patient does not object or, if the patient cannot consent, as long as it is in the patient’s best interest. In making this determination about the patient’s best interests, the provider should take into account the patient’s prior expressed preferences regarding disclosures of their information, if any, as well as the circumstances of the current situation ~ Listen to family members about their loved ones receiving mental health treatment ~ Communicate with family members, law enforcement, or others when the patient presents a serious and imminent threat of harm to self or others ~ Communicate to law enforcement about the release of a patient brought in for an emergency psychiatric hold. Tips--Confidentiality ~ A health care provider is permitted to share patient information with a patient’s personal representative under the Privacy Rule but NOT psychotherapy notes ~ HIPAA defers to state law to determine the age of majority and the rights of parents to act for a child in making health care decisions, and thus, the ability of the parent to act as the personal representative of the child for HIPAA purposes ~ Exceptions…A parent is not treated as a minor child’s personal representative when: ~ State or other law does not require the consent of a parent or other person before a minor can obtain a particular health care service, the minor consents to the health care service, and the minor child has not requested the parent be treated as a personal representative ~ Someone other than the parent is authorized by law to consent to the provision of a particular health service to a minor and provides such consent ~ A parent agrees to a confidential relationship between the minor and a health care provider with respect to the health care service Tips--Confidentiality ~ The Privacy Rule permits a HIPAA covered entity, such as a hospital, to disclose certain protected health information, including the date and time of admission and discharge, in response to a law enforcement official’s request, for the purpose of locating or identifying a suspect, fugitive, material witness, or missing person. ~ If a health care power of attorney is currently in effect, the named person would be the patient’s personal representative ~ HIPAA generally does not require authorizations for disclosures of PHI between health care providers for treatment, case management, and care coordination, EXCEPT for psychotherapy notes. Tips--Confidentiality ~ Other Reasons for Breeching Confidentiality ~ Abuse (state laws vary) ~ Mandated reporter who is otherwise required to report does not have to report if he or she: ~ Does not learn of the suspected abuse or neglect until after the alleged victim of the suspected abuse or neglect is eighteen years of age or older; and ~ Does not have reasonable cause to know or suspect that the perpetrator of the suspected abuse or neglect: ~ has subjected any other child currently under eighteen years of age to abuse or neglect or to circumstances or conditions that would likely result in abuse or neglect; or ~ is currently in a position of trust with regard to any child currently under eighteen years of age.”

Tips--Confidentiality ~ Other Reasons for Breeching Confidentiality ~ Court orders ~ If the therapist is being sued by the client ~ Scenario: An adult client’s father is paying for her treatment and wants to be notified by the therapist of her progress and discharge. The client becomes suicidal and is admitted to the crisis stabilization unit after disclosing a history of abuse by the father. ~ Scenario: A client is referred for involuntary treatment by his department after his Sargent noticed erratic behavior. Can you communicate with the Sargent about progress and discharge without a signed release of information?

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NCMHCE Exam Review Group and Career Counseling Dr. Dawn-Elise Snipes PhD, LPC-MHSP, LMHC Executive Director, AllCEUs.com Podcast Host: Counselor Toolbox and NCMHCE Exam Review Objectives - Review - the indications and contraindications for group therapy - types of groups - stages of group formation - Group curative factors - Therapist’s role in group

Indicators for Group - Indicators for Group - The primary problem involves affective, behavioral, cognitive or social issues - The client is verbally, cognitively and physically able to participate - The client is motivated to change - The client finds peer support and feedback beneficial - The client has a positive view of group therapy

Contraindications for Group Therapy - People who refuse to participate - People who can’t honor group agreements including behavioral (impulsivity) and attendance - People who are unsuitable for group therapy - People in crisis, or who have a low tolerance for anxiety and frustration, or are markedly depressed - People whose defenses would clash with the dynamics of a group. - People who can’t tolerate strong emotions - People who experience severe internal discomfort in groups. Types of Groups - Gender based - Topic based (depression, PTSD, Addiction) - Skill Based (coping, problem solving, interpersonal)

• Support
• Psychoeducational

• Therapy

• Open

• Closed: Short-term, task oriented Forming a Group
• Stages
• Forming
• Storming
• Norming
• Performing
• Adjourning Group Curative Factors
• Social microcosm that allows for multiple transferences
• Hope
• Universality
• Altruism
• Self-understanding and insight Therapist’s Role
• Explain the phases in the group process
• Creating and maintaining cohesion and participation
• Culture building
• Focus on the here and now, illuminating the processes at work.
• Use appropriate self-disclosure
• Facilitate resolution of interpersonal conflict
• Use linking and blocking
• Model giving and receiving of feedback
• Use structured activities
• Identify and discuss group themes and patterns
• Create interventions based on the stage of group development
• Challenge harmful behaviors
• Address interaction of group members outside of group

Career Counseling– Models - Trait and factor model focuses on individual abilities, interests and personalities and work adjustment varies directly with the congruence between characteristics and demands - Client centered model emphasizes self-concept and the existence of choices based on what the client perceives is best in his/her life - Psychodynamic model stresses internal motivations and coping mechanisms and person's belief or knowledge about what he or she is able to do (Efficacy) - Developmental model focuses on career as a developmental, maturational process (Career Maturity Index) Career Counseling– Models - Behavioral career counseling focuses on making realistic career choices (behavior) and eliminating anxiety about making such choices - Values model helps clients choose careers in line with their values - Time: Future, Past, Present, Unconcerned with schedules - Social: Individual, collateral, hierarchical - Activity Value: Active vs. Passive responses - Life Values (Life Values Inventory) Career Choice – Holland/Trait-Factor - Personalities (RIASEC) - Realistic (hands on) - Investigative (problem solving) - Artistic - Social (Helping others) - Enterprising (Leading) - Conventional (Routine/systematic) Career Choice - Holland - Tests - Vocational Preference Inventory (General Holland’s 6-Types by rating 160 jobs) - Self-Directed Search (Identifies competencies, attitudes and self efficacy toward occupations. Hollands 6 types) - Vocational Exploration and Insight (increase occupations for consideration and understand what they want out of careers) - My Vocational Situation (identity and barriers) Other Career Tests - Ashland Interest Assessment for people who have barriers to employment due to disabilities - Career Assessment Inventory focuses on careers that require 0-2 years of post-secondary training - Career Attitudes and Strategies Inventory assesses Job satisfaction, work involvement, career worries, family commitment etc. - Career Beliefs identifies cognitive distortions about themselves and their career. My current career situation, What Seems Necessary for Happiness, Factors that Influence my Decisions, Changes I am willing to make - Career Interest Inventory helps students decide what courses to take and how to prepare for their preferred career Other Career Tests - Career Orientation Inventory assesses biology based careers - Guide for Occupational Exploration explores interest in 12 areas and correlates with the DOT - Vocational Interest Inventory and Strong Interest Inventory help people identify careers based on interests - Differential Aptitude Test identifies job related abilities - DISCOVER Career Planning Program from ACT, inc., is a comprehensive computer-based career guidance system offered on the Internet for Grade 5 through adult. it includes inventories of interest, abilities, and values plus detailed information about occupations - System of Interactive Guidance Information (SIGI) is designed to help university students and adults make informed career decisions via self-assessments and in-depth, current educational and job information - More tests to review Summary - It is important to be aware of the selection criteria for group counseling - In preparing for the exam, review your theories of career counseling and know the most common tests to use Scenario 1 - Tom is a 34-year-old white male who completed 2 years of community college and is married with 3 children. He was referred by his employer due to anger management issues at work. During the assessment you note that Tom is well oriented, verbal but appears to have a lot of anxiety related to finances. - Is group therapy appropriate for him- - What other resources might be helpful- - More study resources Scenario 2 - Julie is a 20 year old student getting her Bachelor’s in liberal arts. She does not yet know what she wants to do for a career. Which of the following assessments would be appropriate- - Ashland Interest Assessment - For people who have barriers to employment due to disabilities - Career Assessment Inventory - For people who want a career that requires 0-2 years of college - Career Attitudes and Strategies Inventory - Assesses Job satisfaction, work involvement, career worries, family commitment etc. - Career Beliefs - Identifies cognitive distortions about themselves and their career. - Career Interest Inventory - Explores interests to narrow career choices - Guide for Occupational Exploration - Explores interest in 12 areas and correlates with the DOT - Vocational Interest Inventory and Strong Interest Inventory - Helps people identify careers based on interests - Differential Aptitude Test - Identifies job related abilities

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NCMHCE Review #9: Stages and Theories of Treatment

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Dr. Dawn-Elise Snipes Executive Director, AllCEUs.com Podcast Host: NCMHCE Exam Review and Counselor Toolbox Objectives ~ Review the stages of treatment ~ Review theoretical approaches for individual counseling including ~ CBT ~ Behaviorism ~ Humanistic ~ Developmental

Stages ~ Immediate Concerns ~ Evaluate risk factors ~ Establish rapport ~ Enhance motivation and hope ~ Address administrative and policy issues ~ Make a preliminary diagnosis or narrow to a couple Stages ~ Assessment and Goal Setting ~ Ask questions about ~ The perception of the problem ~ Duration ~ Mitigating and Exacerbating factors ~ Hoped for resolution ~ Impact on PSF in multiple dimensions ~ Physical symptoms ~ Make observations ~ Use collateral sources

Stages ~ Treatment plan development (specific as possible—SMART) ~ Prioritize goals ~ Identify needs and services to meet those goals ~ Work with client to select interventions ~ Make appropriate referrals ~ Provide psychoeducation Stages ~ Middle stages ~ Consider a systems approach and involving family or at least addressing contributions of family to the problem and/or solution ~ Teach mindfulness, feelings identification, distress tolerance and coping skills to reduce core symptoms ~ Improve social support ~ Enhance self esteem and efficacy ~ Regularly monitor motivation, resistance and unanticipated barriers to change

Stages ~ Late Stage ~ Solidifying gains ~ Generalize skills to other areas ~ Mindfulness and coping skills can be used not only for being aware of and addressing depression, but also anxiety, anger ~ Social support is helpful in recovering from depression, but can also be helpful for behavior change or coping with stress or grief. Stages ~ Termination Stage ~ Consolidate gains by reviewing progress and enhancing efficacy. ~ Ensure a support system is in place ~ Develop a relapse prevention plan ~ Identify and address issues related to termination Cognitive ~ Cognitive theories are active, directive and time limited ~ May include ~ REBT (Identify unhelpful thoughts, unhelpful emotions, UPR, anger management) ~ CBT (Identify unhelpful cognitions, and behaviors and choose more helpful ones and alter the cognitive triad—Self-World-Future) ~ DBT (Distress tolerance, emotion regulation, interpersonal, problem solving) ~ ACT (Radical acceptance, mindfulness, commitment to purposeful action, Unhooking/Defusion) ~ CPT (Challenging questions)

Cognitive ~ Goals are to ~ Increase self monitoring and awareness ~ Identify unhelpful cognitions ~ Clarify and challenge underlying beliefs ~ Replace unhelpful triggers and behaviors with helpful ones ~ Increase adaptive problem solving ~ Counterindications: Psychotic disorders, dementia, FASD Behavioral Approaches ~ Emphasis on changing or replacing current behaviors by altering the antecedents and/or consequences through ~ Positive and negative reinforcement of alternate behaviors and punishment and lack of reinforcement of target behaviors ~ Social/observational learning ~ Focuses on observable, measurable behaviors not thoughts or emotions ~ Always gather baseline data and conduct a functional analysis ~ Interventions are conducted in the person’s natural setting and involve SOs

Behavioral Approaches ~ Techniques in behavioral approaches ~ Systematic desensitization ~ Flooding ~ Assertiveness training ~ Aversion therapy ~ Extinction ~ Token Economy

Humanistic Models ~ Seeks to understand people’s subjective experience ~ UPR for people’s uniqueness, wholeness ~ Belief in people’s natural tendency to move toward self actualization ~ View problems as stemming from incongruence between the self and perceived conditions of worth ~ Overall goal is to achieve congruence between the self and experience and an enhanced ability to cope with future problems ~ Rogerian therapy views assessment and diagnosis as detrimental Gestalt ~ Goals ~ Increase self-awareness ~ Increase sense of responsibility for actions and destiny ~ Help clients gain intrinsic rewards instead of needing extrinsic ones ~ Techniques ~ Encourage awareness of the present moment ~ Using “I” language ~ Adding the phrase “and I take responsibility for it” to statements ~ Empty chair ~ Reversal ~ Rehearsal

Developmental Models ~ When working with children, many times the family is integral to the treatment process ~ General questions for the assessment ~ Has there been any disruption to the homeostatic balance of the family ~ Are members permitted age-appropriate autonomy ~ Which life-cycle transitions have been experienced and how have they been managed? How does this influence current patterns and future transitions? Developmental Models ~ Erikson ~ Trust/mistrust ~ Autonomy/shame ~ Initiative/Guilt ~ Industry/Inferiority ~ Identity/Confusion ~ Intimacy/Isolation ~ Generativity/Stagnation ~ Integrity/Despair Developmental ~ Vygotsky ~ Use scaffolding to encourage cognitive development from the zone of proximal development Family Therapy ~ Goals ~ Defocusing the IP ~ Improving communication in the family unit ~ Increasing awareness of the one’s personal experience and intrapsychic conflicts that influence behavior and interactions ~ Reducing emotional reactivity among individuals and enhance congruent affective interactions ~ Restoring homeostasis ~ Addressing inflexible roles ~ Strengthening the family system ~ Strengthening the executive subsystem ~ Increasing separation/individuation of members ~ Identifying ongoing, repetitive interactions between people (learned responses) ~ Increasing recognition of circular patterns of behavior ~ Restoration of trust, responsibility Family Therapy ~ Beliefs ~ Wholeness and transactionalism ~ The whole is equal to more than the sum of its parts ~ Study of the causes of problems is not important because the same problem may have multiple causes. The process is important. ~ Not why did John become depressed but how is John’s depression impacting family members and their behaviors ~ All behavior is communication General Interventions ~ Empathy ~ Reassurance ~ Normalization ~ Reframing ~ Reflection ~ Interpretation ~ Verbalization/ventilation ~ Simulations/role-plays ~ Letter writing ~ Psychoeducation ~ Bibliotherapy ~ Strengths focus ~ Behavior modification ~ Motivation enhancement ~ Social learning and support ~ Modeling ~ Respite support ~ Resource enhancement Summary ~ In the initial meeting, establish rapport and identify emergent issues ~ During the assessment and treatment planning, use collateral information as well as client self report and testing ~ Develop treatment plans in conjunction with the client ~ Be familiar with basic concepts of the different theoretical approaches in case you are asked to address a problem from a particular perspective. Test Taking ~ Judy and Sam. Judy brings her 9 year old son to counseling based upon a recommendation by the school counselor. Sam has been cutting class and was caught fighting at school. Recently Sam has begun lying to Judy. Sam’s parents recently got divorced and Sam did not want to return to Judy’s after a weekend visit. Judy wants you to testify in court that joint custody is too difficult for Sam and she needs to have sole custody. ~ What would be a preliminary diagnosis ~ Adjustment disorder, rule out ODD, CD ~ What steps should the counselor take? Interventions ~ Observe the interactions between Judy and Sam ~ Ask Judy about the onset of these behaviors ~ Ask Sam to draw pictures of Mom and Dad’s houses ~ Observe Sam alone as he plays with family dolls ~ Ask Sam why he doesn’t want to live with Judy ~ Check with CPS regarding any reports ~ Order a drug test for Sam ~ Get permission to talk to Sam’s dad ~ Interview Judy alone to get more information about the divorce ~ Get permission to talk to Sam’s teachers and school counselor Orientation ~ What theoretical orientation(s) would you use? ~ Family Systems ~ Behavioral ~ Gestalt ~ Narrative ~ Solution Focused*

Treatment Plan Interventions ~ Refer Sam to peer-group counseling ~ Refer Judy to a parenting support group ~ Use behavior modification and reinforce alternate behaviors to reduce cutting class ~ Have Sam and Judy plan fun activities together ~ Teach Judy about the developmental needs of 9-year olds ~ Explore Judy’s parenting style and beliefs about parenting ~ Role play situations to help Sam learn to better manage conflict ~ Encourage Judy to ask Sam about his day at school and help with homework

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NCMHCE Review Human Diversity Dr. Dawn-Elise Snipes, LPC-MHSP, LMHC Executive Director, AllCEUs Counselor Education Host: Counselor Toolbox Podcast, NCMHCE Exam Review Podcast Objectives ~ Explore issues related to the counseling relationships with people who are culturally different ~ Identify approaches to use with culturally diverse clients Explore Cultural Diversity ~ Many of the problems experienced by minorities are related to prejudice and discrimination, cultural differences and other experiences associated with minority group status ~ Clients preferences for ethnically similar counselors depend on ~ Ethnic identity ~ Level of acculturation ~ Gender ~ Trust of therapist’s ethnicity

Cultural Minorities ~ Lack role models ~ May be rejected or discriminated against

Cultural Identify Development Model ~ Conformity: Preference for dominant culture and disavowing personal culture ~ Dissonance: Prefer a minority counselor and perceive their problems as stemming from their minority status ~ Resistance and Immersion: Reject the dominant culture. Prefer a racially similar culture. Perceive most problems as due to oppression ~ Introspection: Conflicts about loyalty and responsibility towards ones group and personal autonomy. More open to counselors of different backgrounds ~ Synergystic awareness: Developed a personalized cultural identity and can objectively evaluate and accept or reject the values of other cultures. Prefer counselors with similar worldviews

Counseling Culturally Diverse Clients ~ Identify the client’s cultural identities and degrees of acculturation ~ Understand the client’s worldview ~ Consider the impact of social, economic and political discrimination and prejudice ~ Remember that clients from a low SES are more concerned with immediate survival than long-range goals ~ Explore their reactions to a culturally different clinician ~ Identify their perception of the problem and role of therapy ~ Explore issues related to cultural discrimination ~ Evaluate positive resources and strengths ~ Identify biopsychosocial issues related to the presenting problem ~ Use a time limited, problem solving approach African Americans ~ Humanitarian, people-oriented view ~ Family is extended past blood relatives ~ Family roles are flexible ~ Church is often important ~ Family therapy approaches are often the treatment of choice

American Indians ~ Begin with small-talk not defending your competence or getting to business ~ Prefer a spiritual, holistic approach ~ Place greater emphasis on the family and tribe than the individual ~ Perceive most problems as a result of disharmony in one’s life ~ Views behaviors as motivated by interconnections with others ~ Treatment often involves helping to heal the community ~ Often prefer the involvement of tribal healers ~ May benefit from fables and lessons from tribal elders which cannot be written

Asians ~ High context communication ~ Extended family often live together ~ Family may expect to participate in assessment and treatment ~ Interdependence ~ Mental illness can be seen as bringing shame on the family ~ Understate feelings and problems ~ Modesty and self-deprecation are often not signs of low S-E ~ Many mental health issues are somaticized ~ PTSD is not uncommon in refugee populations ~ Establish credibility

Hispanics ~ Interdependence ~ Uncomfortable sharing very personal information ~ Concrete, tangible, present-focused approach to life ~ May have a relatively external locus of control ~ Often somaticize ~ Place importance on personal greetings and small talk ~ Family roles are relatively inflexible and patriarchal ~ Avoid insight oriented approaches and focus more on solution-focused approaches Sexual Orientation ~ Dealing with people to whom the client is not “out” ~ Understanding the lifestyles of people who are LGBTQ2IA ~ Help client access resources Coming Out ~ Stage 1 – Identity Confusion: You begin to wonder about your sexual identity and experience denial and confusion. ~ Stage 2 – Identity Comparison: You accept the possibility that you may be LGBTQ2IA and face the social isolation that can occur with this new identity. ~ Stage 3 – Identity Tolerance: Your acceptance of your sexuality increases, but may feel increased isolation and alienation as your self-concept becomes increasingly different from society’s expectation of you. Begin to contact members of the community.

Coming Out ~ Stage 4 – Identity Acceptance: You have accepted your sexuality and have increasing contact with the community ~ Stage 5 – Identity Pride: You begin to feel pride in being part of the community and immerse yourself into the culture sometimes rejecting the heterosexual community. ~ Stage 6 – Identity Synthesis: The rejection of the heterosexual community and the intense pride you may have in your own sexuality decreases and there is congruence between your public self and your private self and in integration of your sexuality with all aspects of your life.

Elderly ~ Identity transition ~ Sexuality ~ Loss and bereavement ~ Acceptance of death ~ Depression ~ Cognitive decline and dementia ~ Issues in caregivers and family related to guilt, anger, resentment, anxiety

Elderly ~ Treatment ~ Identify current problems ~ Allow the person to express their feelings and thoughts ~ Identify past problem-solving approaches which could be applied here ~ Use a biopsychosocial approach ~ Sleep ~ Nutrition ~ Medications ~ Support ~ Environment ~ Mobility… ~ Reminiscence Therapy may be appropriate

People with Disabilities ~ Identify client's perception of problems ~ If issues related to disability, explore issues of adjustment, grief, pain ~ Make referrals to local support groups as appropriate ~ Help client improve quality of life People Who are Homeless ~ Provide service outreach, engagement and coordination ~ Basic needs (nutrition, sleep, medical care, hygiene) ~ Supportive housing ~ Meaningful daily activities

Summary ~ It is important to be aware of the cultural issues impacting clients ~ Culture is about more than ethnicity ~ People may embrace multiple cultures (gender, sexual orientation, ethnicity, disability, socioeconomic status) ~ Understanding clients’ perceptions of what is causing their problems and how therapy can help is essential ~ It may also be necessary to explore the impact of working with a culturally different clinician ~ Ensure when working with clients from different cultures to use approaches that are appropriate and/or tailored to meet their needs Case Example ~ Betty is 42 years old, a single mother with a 16 year old son. She is an executive at a local company and she has been referred to her EAP due to performance issues. She has insomnia and has been feeling depressed and anxious all the time for about 3 months. She is fatigued and has difficulty getting motivated to go to work. Her son recently was caught smoking marijuana on the school campus, and her mother was diagnosed 2 weeks ago with Parkinson’s disease and will be moving in with them next month. Betty’s mother does not know about her son’s drug issues and Betty is concerned about the responsibilities of caring for her mom. ~ What diagnoses are you thinking exist for Betty? Case Example Case Example

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NCMHCE Exam Review Dangerousness and Abuse Dr. Dawn-Elise Snipes PhD, LPC-MHSP Executive Director, AllCEUs Counseling Education Host: Counselor Toolbox Podcast

Objectives - Identify the characteristics of a dangerousness assessment - Identify factors associated with a high risk for violence - Identify steps in preventing danger to others - Review special cases - Domestic violence - Child Abuse - Elder Abuse - Substance Abuse - Eating Disorders - Emergency calls from nonclients Dangerousness Assessment - Identify the cause of the crisis - Determine the probability the client will hurt someone - Gather information using a mental status exam - Ask the client about a history of violence and current plans - Asses the client’s support system Factors Associated with a High Risk - Male - Alcohol use - History of violence or threats of violence - Antisocial behavior - History of child abuse - Recent provocation - Diagnoses: Substance use disorder, delirium, schizophrenia, mania, personality disorders, intermittent explosive disorder - Agitation - Loud or abusive speech - Poor impulse control - Emotional lability

Duty to Warn - Must involve a reasonably identifiable victim and a credible threat of imminent danger - Contact law enforcement and the intended victim - Divulge only information necessary: You name, the client’s name and the threat (Diagnosis and other information is not necessary and still protected) - Inform the client ahead of time if appropriate

Immediate Intervention - Provide a calm, controlled environment - Allow the client to vent feelings - Build self-esteem - Explore options for addressing the issue - Mobilize support - Help client understand the cause of the crisis* - Make a no violence contract - Ensure the client is calm prior to leaving - If client is unable to regain composure, encourage voluntary commitment - Use involuntary commitment as a last resort

Domestic Violence - Indicators - Injuries at various stages of healing - Depression, anxiety, insomnia, nightmares, ASD - Vague somatic complaints - Complaints of relationship issues - Over-dependence on partner - History of substance abuse - Behavioral problems in children - If kids in the house, assess for child abuse DV Intervention - Use open ended questions - “How did you get that bruise” instead of “Did your spouse do this to you-” - If the perpetrator is present, assess for substance abuse - For victim - Get medical treatment as needed - Help victim protect herself—referral, escape plan - Challenge victim’s denial and self blame - Help client understand the situation (cycle of violence) and their options - Support group referral DV Intervention - For Perpetrator - Break through denial - Get commitment to a no-violence contract - Teach anger management skills - Support group referral Child Abuse Indicators - In Children - Sudden change in behavior - Excessive clinginess - Regression - Suicidal behavior - Antisocial behavior - Fear of adults - Overly sexualized behavior - Sleep disturbances - Childhood pregnancy or STD - School problems - In Adults - Unconcerned about child’s injuries - Provides false explanations - Conceals injuries - Uses harsh discipline - Has overly high expectations for the child - Was abused as a child - Extremely jealous or overprotective - Lacks social support outside the family Child Abuse Interventions - Mandatory reporting - Medical treatment - Ensure safety - Mobilize family support systems - Refer parents to support groups - Clarify events that caused the crisis - Build self esteem, reduce shame and self-blame - Support and validate positive behaviors in the parents - Teach parenting skills or refer - Increase parent’s understanding of the triggers and dynamics of abuse Elder Abuse - Mandatory Reporting - You see the abuse - The client tells you of abuse - You observe physical injuries that clearly indicate abuse - Caregiver won’t let you see client alone - Client appears afraid of caregiver - Types of Abuse - Emotional - Financial - Physical incl. neglect - Sexual

Elder Abuse Interventions - Get medical assistance - Mobilize support system and resources - Be empathetic and validating - Explore events leading up to the current crisis - Help clients and caregivers identify alternate coping strategies an resources which could prevent future problems Severe Eating Disorder or Addiction - Conduct a mental status exam - Assess the client’s support system - Encourage voluntary commitment or involuntary if needed - After the crisis is stabilized, proceed with treatment - Refer the client to a physician for medical evaluation - Consider involving a dietician and psychiatrist - Instill hope

Crisis Call from a Non-Client - Get the phone number and address of the caller - Assess the caller’s level of crisis and ability for self-management - Be directive and advocate for steps to ensure the caller’s safety - Consider offering an appointment as soon as possible Summary - It is imperative for clinicians to be prepared for dealing with clients who may be violent or in abusive situations - Know your ethical imperatives regarding mandatory reporting. - Get additional training on safety practices for working with victims of abuse - If confronted with a call from someone who is in crisis but not your client, it is your responsibility to provide initial triage and assist the individual in getting to safety. Test Taking Tips - Sally is a 25 year old graduate student who was recently raped. She was referred to you by victim services. Her father, a doctor, whom she is estranged from calls your office wondering how Sally is doing - What information do you need to make a diagnosis Test Taking Tips - What are possible diagnoses - GAD, ASD, PTSD, MDD, Adjustment Disorder - What information do you need to make a diagnosis Test Taking Tips - You determine that Sally has Acute Stress Disorder. - Which of the following would be appropriate referrals Test Taking Tips - You determine that Sally has Acute Stress Disorder. - Which of the following would be appropriate to monitor progress-

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NCMHCE Exam Review Crisis Assessment Dr. Dawn-Elise Snipes PhD, LPC-MHSP, LMHC Executive Director AllCEUs Host: Counselor Toolbox Podcast and NCMHCE Exam Review Podcast

CEUs are available for this presentation at https://allceus.com/CE/course/view.php?id=1414 Objectives ~ Review crisis theory and the varying types of crises ~ Describe the stages of crisis ~ Identify the features of a general crisis assessment ~ Differentiate between a crisis and suicide assessment ~ Identify factors associated with a high risk of suicide ~ Review legal and ethical responsibilities (Tarasoff and Bellah vs. Greenson ~ Explore prevention and intervention strategies Crisis Definition ~ Crisis involves ~ A pivotal moment in which a decision must be made which involves facing both peril and promise (Echterling, 2005) ~ “People are in a state of crisis when they face an obstacle to important life goals—and obstacle that is, for a time, insurmountable by the use of customary methods of problem-solving.” (Caplan, 1961) ~ Symptoms of crisis: ~ Emotional distress ~ Physical distress/stress response ~ Cognitive disruption (concentration, problem solving, memory) ~ Behavioral changes Basic Human Needs (CHARGES) ~ When a basic human need has been impacted, it may prompt a crisis ~ Maslow: ~ Air, water, food, sleep, shelter, medical care, safety, love and belonging ~ Elliot (CHARGES) ~ Connection to something bigger than one’s self or a system of meaning to help us understand the world ~ Health and biological needs ~ Acceptance (love and belonging) ~ Relationships (intimate) ~ Goals and Purpose (Identity) ~ Efficacy/Control ~ Safety Types of Crisis ~ Situational crises are not anticipated and usually outside a person’s control ~ Physical (accident, illness, prematurity, birth defects) ~ Interpersonal (death of a person or pet, abuse, divorce) ~ Financial/Environmental/Material (Job loss, Foreclosure, House fire, hurricane, burglary, stock market crash, not getting accepted to …) Types of Crises ~ Cultural/Societal ~ Individuals have less control over these due to the fact that they are perpetuated by the action or inaction of others ~ Political unrest, discrimination and stigma related to gender, race, sexual orientation, violence Types of Crisis ~ Maturational ~ Normal developmental changes produce developmental crises (see Erikson), however, when these crises overwhelm a person’s ability to cope, they may prompt a mental health crisis. ~ To successfully resolve developmental crises, people need support, energy and safety. ~ Examples: Child to adult, empty nest, retirement, child birth, marriage… Types of Crisis ~ Normal developmental reaction or mental health issue? ~ *Determine which symptoms are expected reactions to a normal developmental transition vs. a sign of an emotional or mental health issue ~ Adjustment disorder with depressed mood, anxiety, both or behavior disturbances is conditional upon a particular situation, a life change or a stressor of some sort that precipitates the event ~ Carefully differentially diagnose between adjustment disorder, anxiety, depression, PTSD and personality disorders. ~ Normalize expected reactions to developmental transitions Types of Crisis ~ Normal developmental reaction or mental health issue? ~ The symptoms of adjustment disorder with disturbance of conduct can include: ~ Behaviors that are outside the norms of society ~ Actions that violate the rights of others ~ Outbursts of anger ~ Attempts at revenge ~ Substance use or abuse ~ Emotionality/mood swings that are acted upon

Factors Affecting the Response ~ Demographics (DARES) ~ Age ~ Religion ~ Ethnicity ~ Situational and social supports ~ Perception of the event– How does it impact (BASIC) ~ Biological necessities ~ Acceptance and belonging ~ Similarity to prior traumas or crises ~ Interpretation/world view ~ Control (sense of) ~ Available coping (CRAP) ~ Crises in the past 6-12 months ~ Resources ~ Addiction ~ Psychiatric

Stages of Crisis ~ The event that disrupts the persons ability to maintain homeostasis (balance) ~ The vulnerable state in which the person tries to cope with given resources and strategies ~ The active crisis state Crisis Assessment ~ Emergent assessment conducted when the client expresses a sense of disequilibrium ~ Identify the precipitating factor ~ Identify the client’s responses ~ Identify all the ways the event has disrupted the client’s life (BASICS (Echterling, 2005) ) ~ Behavioral—what they do ~ Affective—How they feel ~ Somatic—Physiological reactions and impact ~ Interpersonal—How they relate to others and their support system ~ Cognitive—Problem solving, memory, perceptions ~ Spiritual—Sense of belonging and system for understanding the world Crisis Assessment ~ Emergent assessment conducted when the client expresses a sense of disequilibrium ~ Explore coping strategies client has used in the past ~ Explore current resources and supports ~ Identify specific goals ~ Assess client’s mental status and sobriety ~ Assess for suicidality and homicidality Suicide Assessment ~ Crisis assessment determines the cause of the situational disequilibrium and resources needed to help the client cope ~ Suicide assessment is ~ Designed to determine the probability of a suicide attempt in the near future ~ Ongoing since suicide risk changes over time ~ Comprised of input from collateral sources ~ Direct (asking the client) and indirect (general risk factors) Suicide Assessment ~ Risk Factors ~ Gender: ~ Male: 75+ although age 45-60 has increased 43% since 1997 ~ Female: 45-64 ~ Adolescents: 15-24 ~ Prior suicide attempt(s) ~ Misuse and abuse of alcohol or other drugs ~ Mental disorders, particularly depression and other mood disorders ~ History of abuse ~ Access to lethal means ~ Exposure to someone who died by suicide, particularly a family member ~ Social isolation or lack of social support ~ Chronic or major disease and disability, recent childbirth or major surgery ~ Lack of access to behavioral health care ~ Recent medication changes ~ Stressful (crisis) life events or anniversary therein Suicide Assessment ~ Risk Factors ~ Motivation: if it is to escape it is high.  If it is to impact another person it is lower ~ Ethnicity and Culture ~ Highest rates across the life span occurring among non-Hispanic American Indian/Alaska Native and non-Hispanic White populations. ~ Veterans, military personnel and workers in certain occupational groups. ~ Sexual minority youth: Prolonged stress resulting from prejudice and discrimination Direct Assessment ~ Communicated intent ~ Frequency, intensity and duration of suicidal thoughts ~ Prior attempts? ~ Family history? ~ What might prevent you from killing yourself? ~ Plan? Specificity? Time? ~ Means? ~ Level of lethality? Things to listen for ~ Desire to die ~ Hopelessness ~ No reason to live ~ Feels like a burden ~ Feels trapped ~ Unbearable pain ~ Increased use of substances ~ Learning about suicide methods ~ Withdrawal/Isolation ~ Sleeping changes (esp. waking up in the middle of the night) ~ Saying goodbye ~ Tying up loose ends ~ Fatigue ~ Depression/Anxiety ~ Sudden improvement or sense of calm American Foundation for Suicide Prevention Legal and Ethical Responsibilities ~ Tarasoff, the California Supreme Court held that, under certain circumstances, a therapist had a duty to warn others that a patient under the therapist's care was likely to cause personal injury to a third party. where a therapist knows that his patient is likely to injure another and where the identity of the likely victim is known or readily discoverable by the therapist, he must use reasonable care to prevent his patient from causing the intended injury. Such care includes, at the least, informing the proper authorities and warning the likely victim. Legal and Ethical Responsibilities ~ Bellah vs. Greenson ~ Outpatient client committed suicide.  The court ruled that the Tarasoff decision did NOT apply to threatened self-harm but established a legal duty for therapists to take reasonable steps ~ Breaching confidentiality in this case requires that you determine the client is an imminent threat to self AND  a breach of confidentiality will prevent the danger Indications for Hospitalization (LIMPS) ~ Lack of available support system ~ Medical issue causing suffering or symptoms ~ Intoxication ~ Psychiatric comorbidity ~ Suicide risk high Indications for OP Management ~ Risk is low ~ Precipitating crisis averted ~ Adequate supports ~ Client agrees to a safety contract Interventions ~ American Counseling Association Guidelines (PIECED-Med) ~ Provide emergency numbers ~ Increase frequency of counseling sessions, possible phone check-ins ~ Explore and mobilize available resources, e.g. family support, friends, support groups, community resources, crisis team etc ~ Contract (Safety) ~ Encourage voluntary commitment, but get the client hospitalized if necessary ~ Develop a plan to deal with potential weapons, medications, drugs, etc ~ Medication Assessment (decide)

Interventions ~ Tell the client you don’t want them to ham themselves ~ Consult and document ~ Encourage client to wait until the crisis has passed to make a decision about suicide Summary ~ People generally come to counseling when they are experiencing some level of crisis ~ Crisis is often caused when people cannot meet their basic needs (CHARGES) ~ There are many factors that contribute to a person’s reaction to a precipitating event (Who DARES to Perceive BASIC Coping CRAP) ~ Hospitalization may be indicated in some circumstances (LIMPS) ~ When conducting a suicide screening, remember the mnemonic PIECED-Med Test Taking Tips ~ An answer choice may be wrong simply because it leaves no room for exception. ~ Accept the situation in the problem at face value. Don’t read too much into it. ~ Don’t be distracted by an answer choice that is factually true but doesn’t answer the question ~ Sally is a 30-year-old woman who has never been married and is estranged from her family.  She has been living in a supported living home for the past 2 years due to a diagnosis of disorganized schizophrenia.  Her intellect is normal and her daily functioning is high.  She has held a job at the local supermarket for 1 year. You are to evaluate her continued eligibility for services in the facility. There have been at least 5 episodes of decompensation in the past 3 years, but she has had no psychotic episodes in the past 22 months ~ Which of the following would you need to assess to determine if she still met the criteria for disorganized schizophrenia and continued services? What to Assess • Current Stressors– Yes, because stressors could contribute to decompensation • Quality of Existing Family Relationships—No.  Vignette stated she was estranged • Employment History—No. Stated in the vignette. • Educational History—No.  Irrelevant. • Current and Past Addictive Behaviors—No. Irrelevant. • Family History of Psychosis—No.  You are not deciding IF she has schizophrenia, rather if it is in remission • Past/Current Medications—Yes. • Medication Compliance—Yes.  Evaluating whether client will reliably take her medications in independent living. • Mental Status—No. Vignette indicates she is currently high functioning. • Frequency and nature of psychotic episodes– Yes to determine precipitating factors for prior episodes and the 22 month remission. ~ The NCMHCE Exam Review Podcast will no longer be in the Counselor Toolbox Feed.  Subscribe to the NCMHCE Exam Review Podcast for future episodes

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NCMHCE Assessment Review Part 3 Brought to you by AllCEUs.com Counselor Continuing Education Unlimited CEUs $59/month or $99/year Live Webinars as low as $4/hour Addiction Counselor Certificate Training $149 Assessment - Categories of information - Presenting issue - Mental Status Exam - Emotional - Behavioral - Physical - Personality - Coping Skills - Family of Origin - Culture - Social Supports and interpersonal relationships - Environment live and work - Developmental stage - Activities of daily living and ability for independence - Motivation Assessment - Categories of Information - Emotional Signs and symptoms - Degree of emotional control - Ability to feel and express a range of emotions - Emotional appropriateness - Emotional issues which may be a focus of clinical attention - Anger - Anxiety - Depression - Grief - Guilt Assessment - Categories of information - Psychiatric signs - Looking for diagnostic criteria for disorders - Affective, behavioral/physical, cognitive, social indicators of mood disorders - Changes in thinking behavior associated with cognitive impairments - Signs of a substance use disorder - Discussing with client - Exacerbating factors and triggers - Mitigating factors and effective interventions Assessment - Categories of information - Medical and Physical Symptoms and Issues - Consider the possibility that symptoms are caused by a medical condition and refer for an evaluation - Evaluate current medications and consider medication side effects - Is the client intoxicated or in withdrawal from a substance - Vegetative symptoms: Persistent problems with appetite, weight control, sleep, energy, sexual desire and function Assessment - Categories of information - Medical and Physical Symptoms and Issues - Somatoform Disorders: Physical symptoms with no detectable physiological cause - Includes pain disorder and body dysmorphic disorder - When tests and physical exams do not support the patient’s symptoms consider malingering of factitious disorders Assessment - Categories of information - Personality Traits - Patterns of behavior, thinking and perception that are pervasive can indicate a personality style such as aggressive, addictive, Type A or co-dependent or a personality disorder such as antisocial, histrionic, or borderline - Ego functioning - Self regulation/impulse control/frustration tolerance - Defense mechanisms - Healthy use limits dysphoric emotions without significantly disrupting a persons life

Assessment - Categories of information - Coping skills - Coping abilities, resources and deficits - Current coping strategies that are and are not effective - Ways the client has responded to similar problems in the past (adaptive and maladaptive) - Specific individual characteristics that impact coping ability such as developmental level, cognitive functioning, locus of control and sense of self-efficacy - Family of Origin - Cultural background - Socioeconomic background

Assessment - Categories of information - Interpersonal Relationships and Social Supports - Type, quality and effectiveness of current relationships - If isolated, evaluate for voluntary withdrawal, poor social skills, alienation, shyness/social anxiety, substance misuse or compulsive behaviors, low self-esteem, PTSD - Capacity for healthy interpersonal relationships (boundaries)

Assessment - Categories of information - Social Roles and Role Functioning - Each role holds a set of role expectations - What roles does the person fulfill (child, parent, spouse, employee, friend…) - Is there role ambiguity or role conflict (parent/friend; parent/employee) - Has there been a loss of an important role (empty nest, divorce) - Is the client overwhelmed or ambivalent about the responsibilities associated with a role (parenting, employee, spouse) - Are client’s normal dependency/affiliation needs being met in an appropriate way (boundaries) - Is the client being victimized/manipulating or victimizing/manipulating someone else Assessment - Categories of information - The Environment - Living and working environment (safety, security, stressors) - Maslow+: Shelter, food, economic resources, education, job opportunities, legal resources, transportation, religious and community groups (assistance, affiliation and support), sources of social support and affiliation (a farm in rural area vs. an urban environment) - Developmental Stage - Child development issues - Current developmental tasks and issues Assessment - Categories of information - Activities of Daily Living / Personal Independence (safety, effectiveness and ability to complete independently) - Self-care skills - Health care (exercise, sleep, nutrition/cooking, medications) - Environmental skills (cleaning, laundry) - Financial Skills - Child care/parenting skills(if needed) - Transportation

Assessment - Categories of information - Client’s motivation level - What are the clients goals and expectations - Help set SMART goals - How does the client view his/her role (active, or passive)

Assessment - Sources of Information - Client self-report - Provides the current, salient factors for the client - May not include underlying issues - May not be complete if client is not comfortable - Observations of verbal and nonverbal behavior - Observations of interactions with therapist, others - Do observations match client reports? - Has there been a physical workup to rule out medical causes of symptoms?

Assessment - Sources of Information - Collateral sources - Medical referral/report - Prior treatment history - Relatives - Caretakers - Case workers - Employers

Summary - A comprehensive assessment should provide the factual evidence supporting your diagnosis - The symptoms identified in the assessment will form the basis for the treatment plan - Assessments should always involve collaboration with other professionals when permitted to rule out biological or other social/environmental causes (i.e. domestic violence, trauma, detox) - No one person’s account will be truly unbiased. Test Taking Tip - In the initial question you are trying to uncover more clues to help you verify your hypothesis about the client’s diagnosis - Do not get distracted by questions which would reveal interesting information but not relevant to the case. - If you suspect the client has PTSD, gathering information about substance use will not provide you any additional information about that particular diagnosis. It may be a comorbid diagnosis, but the scenario is focused on the PRIMARY diagnosis. NCMHCE Exam Review Podcast Brought to you by Counselor Toolbox Podcast and AllCEUs.com Counselor Continuing Education where you can get Unlimited on demand CEUs for $59 or unlimited live webinars for $40 NCMHCE Review Part 4 Brought to you by AllCEUs.com Counselor Continuing Education Unlimited CEUs $59/month or $99/year Live Webinars as low as $4/hour Addiction Counselor Certificate Training $149 Objectives - Define assessment - Review acronyms to help you remember what to look for when assessing for a problem. What is Assessment - Assessment is the process of gathering, analyzing and integrating information into a comprehensive picture that describes - The nature, frequency, intensity and duration of the client’s problems - The roles the client, significant others and the environment/community play in the current issues - The functioning of the client and significant others - Client motivation to address presenting issues - Resources needed to resolve problems and effectively participate in treatment. Presenting Issue - Represents the problems that are foremost in the client’s mind - Denial of any problems may also provide information into client insight, judgement and motivation Evaluating the presenting issue - When did it begin? - What makes it worse? Better? - How often does it occur and to what intensity? - If the client is reporting multiple symptoms, assess the above for each and identify which symptom presented first. - What are the antecedents of (triggers/precipitants) the problem? - How do you feel when the problem occurs? What are you thinking? - Describe what happens right after the problem (reinforcers), habitual responses. Stressors - What stressors are occurring and what is their frequency, intensity and duration? - How does the client deal with the stressors? - Are the stressors impacting the course of the presenting problem? Emotional Range - Emotional control (dysregulation or flattening) can impact the client’s health, relationships and functioning at work or school. - People who avoid dealing with emotions may develop depression, anger or anxiety - People who experience dysregulation may also develop depression, anger or anxiety - Trauma-induced changes in emotional range may also impact the client’s ability to function - Remember that affect is the current, transient state. Always assess affect. Mood Disorders - When the client presents with mood symptoms, inquire about - Previous episodes of the same symptoms - How he or she has dealt with them before - If there was a previous episode, was there full remission?

Depression - What to look for - Anhedonia - Dysphoria - Sleep changes - Appetite changes - Changes in psychomotor behavior - Reduction in libido - Reduced energy - Nonverbals indicating any of the above

• Highly self-critical
• Cognitive distortions
• Hopelessness/pessimism
• Irritability
• Guilt/shame
• Difficulty concentrating
• Withdrawal from relationships

Depression Mnemonic A SAD FACES - A = Appetite (Weight Change) - S = Sleep (Insomnia / Hypersomnia) - A = Anhedonia - D = Dysphoria - F = Fatigue - A = Agitation / Retardation - C = Concentration Diminished - E = Esteem (Low) / Guilt - S = Suicide / Thoughts of Death

Mania - What to look for - Elevated mood - Grandiosity - Irritability/aggression - Pressured speech - Flight of ideas - Restlessness - Hypersexuality - Impulsivity

• Limited insight
• Poor concentration
• Impatience
• Gregariousness
• Provocativeness

Mania Mnemonic DIG FAST - Distractibility - Indiscretion - Grandiosity - Flight of ideas - Activity increase - Sleep deficit - Talkativeness Anxiety - What to look for - Irritability/edginess - Uneasiness/worry - Panic - Hypervigilance - Psychomotor agitation/Nervous habits - Nonverbals indicative of worry

• Ruminating
• Persistent worrying about a variety of things
• Difficulty concentrating
• Withdrawal from relationships
• Highly critical of self
• Sleep problems
• Clinginess/dependency Anxiety Mnemonic: Worry WARTS

• Worry

• Worn out

• Absentminded
• Restless
• Touchy
• Sleepless PTSD
• What to look for:
• Exposure to a traumatic event
• Re-Experiencing (Dreams, memories, flashbacks)
• Avoidance of reminders
• Negative thoughts or feelings that began or worsened after the trauma and/or difficulty experiencing positive emotions
• Trauma related arousal and reactivity PTSD
• Disinterest in usual activities
• Re-experience
• Event preceding symptoms
• Avoidance
• Month or more of symptoms
• Sympathetic arousal Substance Abuse – SAD CLIPS
• Signs of intoxication or withdrawal
• Slowed reflexes
• Aroma of drugs

• Difficulty concentrating

• Confusion

• Lowered inhibitions
• Impaired Coordination
• Pupils
• Slurred speech

Physical Symptoms – CLASSED - Is the client under a doctors care? If so why? - If there are obvious long-standing physical/developmental issues, how have they impacted the client? - Convulsions or seizures - Libido - Appetite - Sleep - Sex hormones - Energy - Dizziness or fainting - Describe childhood health

Medical Referral- EAT LOADS - Eating Disorder - AIDS/HIV - Tuburculosis

• Long standing depression
• Ongoing physical complaint (chest pain, dizziness, abdominal pain, chronic cough, fatigue)
• Abrupt personality or behavioral change
• Delirium/Dementia
• Substance abuse

Test Taking Tip - Everything in the NCMHCE has one clear diagnosis and assumes a mutual respect between client and counselors. Thus, the test is measuring for ideal questions and treatments, even if those might not be appropriate or applicable in some real-world situations. - In reading the initial scenario, focus on the symptoms and all components of the question. - Does the question indicate the client is grieving and withdrawn? Then you would look for remedies that target that area such as support groups - Consider whether the information that is being requested is actually beneficial and whether it will narrow down the diagnosis. Asking too many questions will lower your score - Gather support FOR your diagnosis NOT to rule out other things. NCMHCE Review Episode 5 Assessment Part 3 Brought to you by AllCEUs.com Counselor Continuing Education Unlimited CEUs $59/month or $99/year Live Webinars as low as $4/hour Addiction Counselor Certificate Training $149 Objectives - Continuation of the assessment review Developmental Stage (and Unresolved Crises) - Trust/Mistrust: Get needs met - Autonomy: Control my own body and make choices - Temper tantrums - Initiative: Ability to make and carry out plans - Stuttering/cluttering and speech problems should abate by 5years. Sudden onset after this point may indicate an emotional issue - Bedwetting stops by the end of this phase - Industry: Identify what they are good at - Identity: Individuation - Intimacy: Creation of new secure attachments - Generativity: Commitment to wellbeing of future generations via work and activities - Integrity: Acceptance of mortality Self-Esteem - Self efficacy - Confidence - Vindictiveness - Argumentativeness - Willing to accept responsibility or blames others - Social anxiety - Self-perception including body image

Social Functioning - Information about social functioning can help you - Determine what client’s behaviors are like outside of the session - Identify the source of current problems - Family History - Childhood family - Who was there - How did they get along - How frequent were moves - History of abuse, neglect, DV, or MH issues - Childhood friends - School performance - History of childhood trauma

Social Functioning - Current Living Situation - Where? - Safety? - Transportation? - With whom? - Quality of relationships with co-habitants? - Financial Status - Can client pay bills? - Sources of income? - Is client employed? How long? Work history?

Social Functioning - Social Network - Perception of support? - Quality of relationships? - Relationship with family? - Relationship with adult children? - Hobbies and leisure activities - Sexual and Romantic Relationships - What is the client’s sexual orientation? - How has the client integrated his/her/their sexual orientation?

Social Functioning - Sexual and Romantic Relationships - Is the client in a LTR/marriage/partnership? - Have there been previous LTR/m/ps? Why did they end? - How do partners support each other? - Has/have the partnership(s) contributed to the current problems? - How have the current difficulties impacted the partnership(s)? - How is the client’s current sex life and sexual functioning? - Have there been relationships outside the partnership? - Were these relationships CNM?

Social Functioning - Children and Step Children - Does the client have children/step? Ages? - Relationships with children/step? - Does the client agree with partner(s) about care of children? - With step-children and children from a previous relationship, how does the client get along with the other caregiver?

Social Role Functioning - Social role problems negatively impact clients’ abilities to fulfil expectations of their social roles - Role ambiguity - Role conflict - Role loss - Role incompetence - Lack of knowledge - Isolation - Lack of role resources - Power: Misuse or abuse or learned helplessness - Ambivalence about role expectations - Inability to fulfil role responsibilities (overwhelmed) - Enmeshment (blocked) or detatchement (lack of support)

Environment - Economic and basic needs - Education and training - Legal assistance (civil and criminal) - Health and social services - Community engagement - Social supports Distress Tolerance and Coping Abilities - Coping Skills and Strengths - Problem focused - Emotion Focused (Distress Tolerance) - Current strategies to cope with the presenting issue. What works? What doesn’t? - How has client coped with similar problems in the past? - If the client coped in the past, but not now, what is different? - Dysfunctional Coping abilities include - Ineffective coping skills (general or situational) - Rigid coping skills - Power-based coping/violence/NSSI - Addictive behaviors Personality Patterns - What was the clients like before the onset of the current problems? - Type A: Achievement oriented, impatient, competitive, workaholic, aggressive, stressed - Addictive: Thrill seeker, impulsive, inability to set limits on pleasure - Codependency: Difficulty identifying and communicating needs, need approval of others, low self esteem, unhealthy need to be in a relationship - Schizoid: lack of interest in social relationships, a tendency towards a solitary or sheltered lifestyle, secretiveness, emotional coldness, detachment, and apathy. - What is their normal mood? - What were they like in adolescence? - How do clients perceive others view them?

Other Things … - Beliefs - Listen for cognitive distortions and irrational beliefs - Legal Issues - Convictions/pending/arrest history: Criminal - Any civil matters: Divorce, bankruptcy, civil lawsuits - Culture - Nationality - Racial or ethnic identification - Cultural identification (soldier, deaf, blind, “addict”) - Religious identification - Level of acculturation - Cultural expectations and beliefs

Other Things … - Motivation - Precontemplation - Contemplation - Preparation - Action - Maintenance - Dimensions - Who are they changing for? - Who is responsible for the change? - What do they hope to get out of it? - What obstacles do they anticipate? - When do they envision making a change?

Integration - Primary focus in the person-in-system (contextual) - Recognize that a change in one area will impact all other areas - Explore the reciprocal dynamics between the clients’ environments and their problems - Clients’ actions and reactions impact the environment which in turn impact the client’s actions and reactions. - The environment affects clients which impact their reactions which impact the environment - The goal is to improve the person-environment fit Interactions - Anxiety can lead to depression and isolation which can reduce self efficacy and esteem - Depression can impact social functioning, work functioning, pain, physical health, sleep - Grief can impact people’s abilities to function at work and as a parent - Addictive behaviors may be used to “self-medicate” environmental, social or occupational issues yet often make those issues worse… Summary - Self Esteem and efficacy - Developmental stage and unresolved crises - Current social relationships - Social relationship patterns - Personality styles and traits - Environmental factors (housing, finances, community attachment etc.) - https://www.americanmentalwellness.org/prevention/risk-and-protective-factors/ - https://youth.gov/youth-topics/youth-mental-health/risk-and-protective-factors-youth - Integration using an interactive person in situation approach.

Test Taking Tips - Assessment - Integrate client assessment and observational data - Identify precipitating problems or symptoms - Identify individual and/or relationship functioning - Identify relevant family issues. - Make it Relevant - Analyze the person-environment fit in the child throwing a tantrum in the store - Think about the developmental stage children are at - When you see conflict IRL or on TV, explore the potential factors that contributed to it

Test Taking Tips - When Assessing Children - Use descriptive statements to support and encourage the child. - Encourage children to think about what they are doing, thinking, feeling, saying. - Provide positive reinforcement for participation. - Ask age appropriate questions - When assessing adults look for common themes either across time or across situations

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NCMHCE Exam Review Podcast Assessment Part 2 Brought to you by Counselor Toolbox Podcast and AllCEUs.com Counselor Continuing Education where you can get Unlimited on demand CEUs for $59 or unlimited live webinars for $40

Objectives ~ Define assessment ~ Review acronyms to help you remember what to look for when assessing for a problem. What is Assessment ~ Assessment is the process of gathering, analyzing and integrating information into a comprehensive picture that describes ~ The nature, frequency, intensity and duration of the client’s problems ~ The roles the client, significant others and the environment/community play in the current issues ~ The functioning of the client and significant others ~ Client motivation to address presenting issues ~ Resources needed to resolve problems and effectively participate in treatment. Presenting Issue ~ Represents the problems that are foremost in the client’s mind ~ Denial of any problems may also provide information into client insight, judgement and motivation Evaluating the presenting issue ~ When did it begin? ~ What makes it worse? Better? ~ How often does it occur and to what intensity? ~ If the client is reporting multiple symptoms, assess the above for each and identify which symptom presented first. ~ What are the antecedents of (triggers/precipitants) the problem? ~ How do you feel when the problem occurs? What are you thinking? ~ Describe what happens right after the problem (reinforcers), habitual responses. Stressors ~ What stressors are occurring and what is their frequency, intensity and duration? ~ How does the client deal with the stressors? ~ Are the stressors impacting the course of the presenting problem? Emotional Range ~ Emotional control (dysregulation or flattening) can impact the client’s health, relationships and functioning at work or school. ~ People who avoid dealing with emotions may develop depression, anger or anxiety ~ People who experience dysregulation may also develop depression, anger or anxiety ~ Trauma-induced changes in emotional range may also impact the client’s ability to function ~ Remember that affect is the current, transient state. Always assess affect. Mood Disorders ~ When the client presents with mood symptoms, inquire about ~ Previous episodes of the same symptoms ~ How he or she has dealt with them before ~ If there was a previous episode, was there full remission?

Depression ~ What to look for ~ Anhedonia ~ Dysphoria ~ Sleep changes ~ Appetite changes ~ Changes in psychomotor behavior ~ Reduction in libido ~ Reduced energy ~ Nonverbals indicating any of the above

~ Highly self-critical ~ Cognitive distortions ~ Hopelessness/pessimism ~ Irritability ~ Guilt/shame ~ Difficulty concentrating ~ Withdrawal from relationships

Depression Mnemonic A SAD FACES ~ A = Appetite (Weight Change) ~ S = Sleep (Insomnia / Hypersomnia) ~ A = Anhedonia ~ D = Dysphoria ~ F = Fatigue ~ A = Agitation / Retardation ~ C = Concentration Diminished ~ E = Esteem (Low) / Guilt ~ S = Suicide / Thoughts of Death

Mania ~ What to look for ~ Elevated mood ~ Grandiosity ~ Irritability/aggression ~ Pressured speech ~ Flight of ideas ~ Restlessness ~ Hypersexuality ~ Impulsivity

~ Limited insight ~ Poor concentration ~ Impatience ~ Gregariousness ~ Provocativeness

Mania Mnemonic DIG FAST ~ Distractibility ~ Indiscretion ~ Grandiosity ~ Flight of ideas ~ Activity increase ~ Sleep deficit ~ Talkativeness Anxiety ~ What to look for ~ Irritability/edginess ~ Uneasiness/worry ~ Panic ~ Hypervigilance ~ Psychomotor agitation/Nervous habits ~ Nonverbals indicative of worry

~ Ruminating ~ Persistent worrying about a variety of things ~ Difficulty concentrating ~ Withdrawal from relationships ~ Highly critical of self ~ Sleep problems ~ Clinginess/dependency Anxiety Mnemonic: Worry WARTS ~ Worry

~ Worn out ~ Absentminded ~ Restless ~ Touchy ~ Sleepless PTSD ~ What to look for: ~ Exposure to a traumatic event ~ Re-Experiencing (Dreams, memories, flashbacks) ~ Avoidance of reminders ~ Negative thoughts or feelings that began or worsened after the trauma and/or difficulty experiencing positive emotions ~ Trauma related arousal and reactivity PTSD ~ Disinterest in usual activities ~ Re-experience ~ Event preceding symptoms ~ Avoidance ~ Month or more of symptoms ~ Sympathetic arousal Substance Abuse – SAD CLIPS ~ Signs of intoxication or withdrawal ~ Slowed reflexes ~ Aroma of drugs ~ Difficulty concentrating

~ Confusion ~ Lowered inhibitions ~ Impaired Coordination ~ Pupils ~ Slurred speech

Physical Symptoms – CLASSED ~ Is the client under a doctors care? If so why? ~ If there are obvious long-standing physical/developmental issues, how have they impacted the client? ~ Convulsions or seizures ~ Libido ~ Appetite ~ Sleep ~ Sex hormones ~ Energy ~ Dizziness or fainting ~ Describe childhood health

Medical Referral- EAT LOADS ~ Eating Disorder ~ AIDS/HIV ~ Tuburculosis

~ Long standing depression ~ Ongoing physical complaint (chest pain, dizziness, abdominal pain, chronic cough, fatigue) ~ Abrupt personality or behavioral change ~ Delirium/Dementia ~ Substance abuse

Test Taking Tip ~ Everything in the NCMHCE has one clear diagnosis and assumes a mutual respect between client and counselors. Thus, the test is measuring for ideal questions and treatments, even if those might not be appropriate or applicable in some real-world situations. ~ In reading the initial scenario, focus on the symptoms and all components of the question. ~ Does the question indicate the client is grieving and withdrawn? Then you would look for remedies that target that area such as support groups ~ Consider whether the information that is being requested is actually beneficial and whether it will narrow down the diagnosis. Asking too many questions will lower your score ~ Gather support FOR your diagnosis NOT to rule out other things.

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NCMHCE Review Part 3 Assessmemt Brought to you by AllCEUs.com Counselor Continuing Education Unlimited CEUs $59/month or $99/year Live Webinars as low as $4/hour Addiction Counselor Certificate Training $149 Assessment ~ Categories of information ~ Presenting issue ~ Mental Status Exam ~ Emotional ~ Behavioral ~ Physical ~ Personality ~ Coping Skills ~ Family of Origin ~ Culture ~ Social Supports and interpersonal relationships ~ Environment live and work ~ Developmental stage ~ Activities of daily living and ability for independence ~ Motivation Assessment ~ Categories of Information ~ Emotional Signs and symptoms ~ Degree of emotional control ~ Ability to feel and express a range of emotions ~ Emotional appropriateness ~ Emotional issues which may be a focus of clinical attention ~ Anger ~ Anxiety ~ Depression ~ Grief ~ Guilt Assessment ~ Categories of information ~ Psychiatric signs ~ Looking for diagnostic criteria for disorders ~ Affective, behavioral/physical, cognitive, social indicators of mood disorders ~ Changes in thinking behavior associated with cognitive impairments ~ Signs of a substance use disorder ~ Discussing with client ~ Exacerbating factors and triggers ~ Mitigating factors and effective interventions Assessment ~ Categories of information ~ Medical and Physical Symptoms and Issues ~ Consider the possibility that symptoms are caused by a medical condition and refer for an evaluation ~ Evaluate current medications and consider medication side effects ~ Is the client intoxicated or in withdrawal from a substance ~ Vegetative symptoms: Persistent problems with appetite, weight control, sleep, energy, sexual desire and function Assessment ~ Categories of information ~ Medical and Physical Symptoms and Issues ~ Somatoform Disorders: Physical symptoms with no detectable physiological cause ~ Includes pain disorder and body dysmorphic disorder ~ When tests and physical exams do not support the patient’s symptoms consider malingering of factitious disorders Assessment ~ Categories of information ~ Personality Traits ~ Patterns of behavior, thinking and perception that are pervasive can indicate a personality style such as aggressive, addictive, Type A or co-dependent or a personality disorder such as antisocial, histrionic, or borderline ~ Ego functioning ~ Self regulation/impulse control/frustration tolerance ~ Defense mechanisms ~ Healthy use limits dysphoric emotions without significantly disrupting a persons life

Assessment ~ Categories of information ~ Coping skills ~ Coping abilities, resources and deficits ~ Current coping strategies that are and are not effective ~ Ways the client has responded to similar problems in the past (adaptive and maladaptive) ~ Specific individual characteristics that impact coping ability such as developmental level, cognitive functioning, locus of control and sense of self-efficacy ~ Family of Origin ~ Cultural background ~ Socioeconomic background

Assessment ~ Categories of information ~ Interpersonal Relationships and Social Supports ~ Type, quality and effectiveness of current relationships ~ If isolated, evaluate for voluntary withdrawal, poor social skills, alienation, shyness/social anxiety, substance misuse or compulsive behaviors, low self-esteem, PTSD ~ Capacity for healthy interpersonal relationships (boundaries)

Assessment ~ Categories of information ~ Social Roles and Role Functioning ~ Each role holds a set of role expectations ~ What roles does the person fulfill (child, parent, spouse, employee, friend…) ~ Is there role ambiguity or role conflict (parent/friend; parent/employee) ~ Has there been a loss of an important role (empty nest, divorce) ~ Is the client overwhelmed or ambivalent about the responsibilities associated with a role (parenting, employee, spouse) ~ Are client’s normal dependency/affiliation needs being met in an appropriate way (boundaries) ~ Is the client being victimized/manipulating or victimizing/manipulating someone else Assessment ~ Categories of information ~ The Environment ~ Living and working environment (safety, security, stressors) ~ Maslow+: Shelter, food, economic resources, education, job opportunities, legal resources, transportation, religious and community groups (assistance, affiliation and support), sources of social support and affiliation (a farm in rural area vs. an urban environment) ~ Developmental Stage ~ Child development issues ~ Current developmental tasks and issues Assessment ~ Categories of information ~ Activities of Daily Living / Personal Independence (safety, effectiveness and ability to complete independently) ~ Self-care skills ~ Health care (exercise, sleep, nutrition/cooking, medications) ~ Environmental skills (cleaning, laundry) ~ Financial Skills ~ Child care/parenting skills(if needed) ~ Transportation

Assessment ~ Categories of information ~ Client’s motivation level ~ What are the clients goals and expectations ~ Help set SMART goals ~ How does the client view his/her role (active, or passive)

Assessment ~ Sources of Information ~ Client self-report ~ Provides the current, salient factors for the client ~ May not include underlying issues ~ May not be complete if client is not comfortable ~ Observations of verbal and nonverbal behavior ~ Observations of interactions with therapist, others ~ Do observations match client reports? ~ Has there been a physical workup to rule out medical causes of symptoms?

Assessment ~ Sources of Information ~ Collateral sources ~ Medical referral/report ~ Prior treatment history ~ Relatives ~ Caretakers ~ Case workers ~ Employers

Summary ~ A comprehensive assessment should provide the factual evidence supporting your diagnosis ~ The symptoms identified in the assessment will form the basis for the treatment plan ~ Assessments should always involve collaboration with other professionals when permitted to rule out biological or other social/environmental causes (i.e. domestic violence, trauma, detox) ~ No one person’s account will be truly unbiased. Test Taking Tip ~ In the initial question you are trying to uncover more clues to help you verify your hypothesis about the client’s diagnosis ~ Do not get distracted by questions which would reveal interesting information but not relevant to the case. ~ If you suspect the client has PTSD, gathering information about substance use will not provide you any additional information about that particular diagnosis. It may be a comorbid diagnosis, but the scenario is focused on the PRIMARY diagnosis.

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NCMHCE Review Part 2 Screening Brought to you by AllCEUs.com Counselor Continuing Education Unlimited CEUs $59/month or $99/year Live Webinars as low as $4/hour Addiction Counselor Certificate Training $149 Screening Questions -- Anxiety ~ Do you worry about a lot of things most of the time? ~ Do you worry about specific things like germs or getting into a car accident a lot? ~ Do you get so worked up that you cannot eat or sleep?

Screening --PTSD ~ Have you been in really bad situations in which you had no control? ~ Have you been in terrifying situations? ~ Do you ever have memories of those situations that disrupt your day? ~ Do you startle really easily? ~ Do you find yourself being irritable and pessimistic? Anger ~ Do you often get angry? ~ When you get angry, do you feel like you are ready to explode? ~ Do you think you are more irritable than other people? Screening Questions -- Depression ~ Do you feel pleasure or happiness on a regular basis? ~ Have your sleep patterns changed? ~ How is your appetite? ~ Do you often feel guilty? ~ How is your energy throughout the day? ADHD ~ Do you have difficulty finishing tasks? ~ Do you have difficulty getting organized? ~ Do you have difficulty if you have to sit still for a long time? ~ Do you have difficulty staying focused and filtering out distractions ~ Do you have difficulty waiting your turn or not interrupting? OCD ~ Do you sometimes have thoughts you cannot get out of your head? ~ How much time do these thoughts take up on average each day? ~ Do you ever feel like you have to do something over and over or something bad is going to happen? ~ How much time do you spend each day doing these things?

Delusions and Hallucinations ~ Have you ever thought that people could read your mind or control your thoughts? ~ Have you ever felt like your mind was playing tricks on you? ~ Do you ever see or hear things that other people cannot see or hear? ~ Do you ever have difficulty knowing if you are awake or dreaming?

Eating Disorders ~ How would you describe your eating habits? ~ Do you have any concerns about your weight? ~ How do you maintain your weight? Impulsivity ~ Do you ever find yourself doing things without really thinking about the consequences first? ~ Do you ever do things you know you shouldn’t but just cannot seem to stop yourself? ~ Do you buy things that you really don’t need just because they are there? Mania ~ Have you ever had so much energy that you couldn’t sit still ~ Have you ever found yourself not needing sleep or needing much less than usual? ~ Do you have times when you talk a lot more than usual and your brain seems to be going really quickly? Substance Misuse ~ Have you been bothered by “using medicines or drugs without a doctor’s prescription, or in greater amounts or longer than prescribed? ~ Have you used more than intended or spent more time engaging in an activity than intended? ~ Have you spend more time planning, engaging in or recovering from the use of the substance or activity? ~ Have you given up or had difficulty in significant areas of your life as a result of use of the substance or engaging in the activity. ~ CAGE ~ Cutting Down ~ Annoyed ~ Guilt ~ Eye Opener

Summary ~ It is important to screen for a variety of issues ~ Know the diagnostic criteria for the most common mental illnesses ~ Many disorders have overlapping symptoms ~ Anxiety, PTSD, ADHD, Bipolar and Depression for example ~ Psychiatry.org has multiple free Cross Cutting Symptom Measures to be aware of ~ Screening just gives you a launch pad to help guide the in-depth biopsychosocial assessment Test Taking Tip ~ First Priority is identifying the diagnoses for everyone in the scenario. ~ Don’t try to be too broad. ~ If the scenario is about someone who recently underwent a traumatic event and the question asks for what to evaluate to support a provisional diagnosis, think about what you would assess for a provisional PTSD/ASD diagnosis, not a blanket evaluation for every comorbid axis 1 condition.

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NCMHCE Review Part 1 Brought to you by AllCEUs.com Counselor Continuing Education Unlimited CEUs $59/month or $99/year Live Webinars as low as $4/hour Addiction Counselor Certificate Training $149 Mental Status Exam ~ Evaluation of a clients current mental functioning ~ Combined with other information to arrive at formal diagnosis ~ Behavioral Aspects ~ Physical characteristics (ethnicity, cleanliness, weight, dress--age and setting appropriateness) ~ Communication barriers ~ Alertness ~ Movement and activity (tension, perseverative movements, non-goal-directed behaviors, itching/picking) ~ Facial expressions and continuity with words ~ Eye contact ~ Speech patterns (articulation, stuttering, mumbling, baby-talk, use of cultural dialects) ~ Attitude toward therapist

Mental Status Exam ~ Mood and Affect ~ Mood: How they feel most days ~ Affect is more variable--- How do they feel right now or at a specific time ~ Type, quality, appropriateness ~ Bland---nothing affects him may indicate dementia ~ Affective flattening is a negative symptom of schizophrenia

Mental Status Exam ~ Flow of Thought ~ Spontaneous or only in response to questions ~ Incoherent rambling: Intoxication ~ Common in mania or schizophrenia ~ Flight of ideas ~ Tangential speech (answers unrelated to questions) ~ Loose associations (I got up and it was sunny today. I had oatmeal for breakfast. My dog died last Thursday)

Mental Status Exam ~ Flow of speech ~ Rate of speech: pressured (hypomania) or too slow (depression or intoxication) ~ Suicidal/Homicidal Ideation and risk for violence

Mental Status Exam ~ Cognitive Aspects ~ Thought content (logical, deluded) ~ Perception (Accurate, hallucinations) ~ Consciousness and cognition ~ Awareness of, ability to process and communicate information and attention span ~ Orientation to person, place, time and situation, also may include familiar object identification and other people identification

Mental Status Exam ~ Cognitive Aspects ~ Language comprehension and fluency ~ Memory ~ Types ~ Immediate (5-10 seconds) ~ Short Term (5-10 minutes) ~ Long Term – ability to provide autobiographical hx ~ Deficit Indicators ~ Dementia ~ Amnesia ~ Mental disorder due to a medical condition (stroke, chronic fatigue) ~ Substance Induced Mental Disorder (Korsakoff’s Syndrome) ~ Depression ~ Anxiety

Mental Status Exam ~ Cognitive Aspects ~ General Intelligence ~ Poor intelligence despite a good educational background can indicate a neurological problem ~ Must consider age, education level, culture and degree of depression and anxiety when assessing performance (29% of Americans can’t name the vice president) ~ Abstract Thinking: Interpret a proverb ~ Don’t count your chickens before they hatch

Mental Status Exam ~ Insight and Judgement ~ Insight about problem severity and what needs to happen ~ Poor insight is associated with cognitive disorders, depression, psychosis and mania. ~ Poor judgement is often associated with mania, hypomania or FASD

Summary ~ A mental status exam should be done at admission to aid in assessment and treatment plan development ~ A mini mental status exam should be done at each contact. ~ Orientation to person, place, purpose and time ~ Sign in ~ Thought content and perception ~ What were 2 things you got out of group/session ~ Fund of information / memory ~ How did you apply the tools/homework from last week ~ Future plans ~ What do you plan to do over the next week to improve your recovery ~ Mood ~ What is your mood? Happy Anxious Angry/Irritable Depressed ~ Judgement ~ If you start having a bad day, what will you do?

Test Taking Tip ~ For ethics related questions your best guess is the answer that is best for the client. ~ When eliminating response options, eliminate answers which: ~ Don’t answer the whole question ~ Are true, but not relevant to the presenting problems and situation ~ Use extreme words like always or must ~ Represent a common misconception or a lay-persons view ~ Check each answer against every part of the clinical simulation especially the diagnoses ~ If two options are similar, Choose the one that is more case-specific. The best answer is relevant to both the case and the question being asked.