Mental Ch. 5

aesthetic qualities and room design

-both counselors and clients will be affected by the room decor at some level 3 variables that can create a healing environment include safety, personalization, and softness -soundproof room can help comfort and safety for the client -personalization = mementos, photographs, diplomas, certificates; ppl prefer texturally complex images of natural settings over posters of ppl, urban life, or abstract works; plants can help as they represent growth -children and young ppl associate light colors with positive emotions and dark with negative; neutral colors are soothing an practical (when sharing space with other counselors) -soft lit rooms help intimate conversation -> lighting that highlights plants/artwork can help and five a softer appearance -keep temperature in a comfortable range esp to fit clients preferences -room should be private and free from distracting sounds/smells -ppl prefer an intermediate distance between the counselor (but background, gender, and nature of relationship may affect that); need to be accessible for those with disabilities -sitting behind a desk can be a barrier between the client -recommendation is that counselors include 2 chairs and a nearby table setting(for tissues) and that chairs be placed at a 90deg. angle from each other so that clients can look straight or at the counselor -softness = soft surfaces/textures, sofas, comfortable chairs, movable furniture, lamps *counselors should not bet interrupted during sessions -> phone calls are held, cell phones off, Do not disturb signs -auditory and visual privacy are mandated by professional codes of ethics and facilitate max self-disclosure

following up

-checking in to see how client is doing with respect to presenting issue, sometime after counseling has ended -positive monitoring process that encourages client growth -important for it reinforces gains clients have made in counseling and helps both the counselor and the client reevaluate the counseling experience -short term follow up = 3-6 months after relationship ends - long term = at least 6 months after termination 4 ways follow ups are conducted: 1. invite client in for a session to discuss any progress the client has continued to make in achieving desired goals 2. telephone call to client 3. send client a letter asking about the client's current status 4. more impersonal - mail or email the client a questionnaire dealing with current levels of functioning (used by public agencies) -personal follow up is more effective but time consuming -talk about methods of follow ups to client in last session

seriousness of the presenting problem

-determines the counseling process and the direction it will take -assessed throughout then counseling process -> degree to which a client is trudging can be determined during initial sessions -intake interview help determines the nature severity, and duration of the issue -clients with more severe issues are likely to need more sessions to make effective life changes (relationship between initial levels of self-reported disturbance and the course of treatment) -clients with serious disorders (BPD, schizophrenia, antisocial) may work better in group sessions -level of functioning, psychosocial stressors and cultural background affect select treatment modalities

premature closing

-if the client reached the end of an HMO-imposed time limit before being ready to end the relationship, the counselor can negotiate with the service provider for additional sessions, refer the client to alternative sources for help, ask the client to pay out of pocket, or provide pro bono services -ACA ethics say counselors should not abandon their clients ACA when it is permissible to discontinue services: 1. no longe benefiting from counseling 2. does not pay designated fees 3. counselor is in jeopardy of harm by the client or another person whom the client has relationship with 4. agency limits do not allow services to continue 5. appropriate referral is made but the client declines the referral

facilitating closing

-individuals need time to prepare for the end of meaningful relationships -counselor and client should agree on when it is time -client signals in time to close = decrease in intensity of work, more humor, consistent reports of imported coping skills, verbal commitments to the future, and less denial, withdrawal, anger, mourning, or dependence -when a relationship has lasted more than 3 months, the final 3-4 weeks should be spent discussing the impact of termination -> help review accomplishments and gains made 1/6 of the time spent should be talking about termination -ask clients for feedback -fading = counseling appointments are spaced over increasing lengths of time

relationship building during initial sessions

-make clients feel comfortable, respected, supported, and heard -> for it to happen you need to set aside their own agendas and focus exclusively on the clients by active listening to their stories and presenting concerns which helps establish rapport -use specific helping skills such as reflective feelings, summarizing, clarifying, and encouraging -> build a repertoire of helping skills and an ability to use them appropriately throughout the counseling process -2 most important skills for rapport building are basic attending behavior and client-observation skills -> focus on what the client is thinking and feeling and behaving -inviting clients to talk about their reasons for seeking help is one way to initiate rapport -door openers = non coercive invitations to talk, which contrast with judgmental or evaluative responses known as door closers -> more likely to talk about priority topics -the amount of talking clients engage in and the insight and benefits derived from the initial interview are enhanced when the counselor appropriately conveys empathy, encouragement, support, caring, attentiveness, acceptance, and genuineness (empathy is most important)

initiative

-motivation to change -most come to counseling as a voluntary or self-referred basis -> experience tension and concern about themselves or others, and are willing to work hard in counseling sessions -change is hard and ppl don't like to be vulnerable -> takes time to develop trust in counselors and the process -> clients may appear reluctant or resistant to change when they are received about counseling -when clients lack initiative -> counselors may appear impatient, irritated, or sensitive and may end up blaming themselves or clients if not successful -role playing with a colleague can help build empathy and increase personal self-awareness for involuntary clients

initial sessions: building a counseling relationship

-not a linear process that occurs over time 3 stages: initial, working, closing -various tasks are associated with each stage and different client factors including motivation change and responsiveness to treatment need to be considered -initial = focus on building a therapeutic relationship and helping clients explore issues that directly affect them; spend time assessing the seriousness of the concern presented, providing structure tot he counseling process, helping clients take initiate in the change process, developing initial case conceptualizations (informed consesnt, intake interviews, record keeping

cognitive learning

-ppl often come to counseling with distorted or dysfunctional cognitions, making them more susceptible to problems related to life events -distortion affect the way ppl think, feel, and act on multiple levels -counselors can help clients change distorted or unrealistic cognitions by offering them the opportunity to explore thoughts and beliefs within a safe, accepting, and nonjudgmental environment -cognitive distortion def: negative, inaccurate biases that can result in unhealthy misperceptions of events -types of distortions = exaggerating the negative, minimizing the positive, overgeneralizing, catastrophizing, and personalizing -evidenced when ppl engage in all-or-nothing thinking or selective abstraction (taking a detail out of contact and using it to negate an entire experience) -> can result in negative automatic thoughts which then negatively effect emotions and mood states -counselors teach clients to evaluate and challenge the validity of their cognitions -> help them view situations from a more realistic perspective and react accordingly -goal = help clients formulate new cognitions that are more realistic and adaptive HOW? -reframing = offers another probable and positive viewpoint of what a situation is or why an event might have happened -> provides the client with an opportunity to respond differently to the situation

affective experiencing

-recognize and explore emotions clients experience -can use skills and techniques to increase clients' emotional awareness (accurate reflection of feeling, help identify feeling associated with incident, reflecting feeling back to them, encourage them to determine where in their body that feeling is experienced) -many gestalt techniques help with connecting emotions particularly with high levels of distress or are psychotic -catharsis = releasing emotions can have value in counseling, but should not be final goal -> bc counselors need to help the client work through underlying beliefs, thoughts, and patterns of behavior -goal = help clients connect their emotions with cognitions and behaviors in a way that leads to new insights and changed behavior

initial counseling interviews

-set the tone for the counseling process an strongly influence the likelihood of future sessions -first session they determine whether it is reasonable to develop a counseling relationship -> counselor should see if they are capable (clients see if they feel comfortable with and trust the counselor) -clients perceptions of the quality of the relationship tend to stay stable -used to gather into about the client for the purpose of assessment and diagnosis-> formal intake interviews to gather into and form diagnostic impressions -ex of topics = identifying info about the client, presenting concerns and level of distress, history of the presenting concern, family background, personal history, previous counseling experiences, risk assessment, clinical impression or diagnosis, clients goals for counseling *needs rapport for honesty in answers questions in an intake -can ask clients to finish forms and turn in early to give the counselor time to review them -initial meeting the counselor can have the client elaborate -> facilitating case conceptualization -unstructured interviews can meet direct client needs but can have much more room for error and spending too much time on a minor issue but to help can use major headings for something to refer to to make sure nothing is left out -closed and open questions used, request clarification

the physical setting of counseling

-vary in size, comfort, and appearance (control we have over it varies) -environmental factors can influence individuals physically, psychologically and emotionally -there are no universal qualities that compose the "ideal" counseling setting, certain features appear to be more conductive to the counseling process than others

informed consent checklist

1. counselor's background and professional affiliations = edu., specialization, licensure/certification, professional affiliations, contact info for appropriate regulatory or certification boards and processional organizations 2. therapeutic process issues = describe the nature of the counseling process and relationship boundaries, theoretical orientation and how that affects the process, clients right t participate in ongoing counseling plans 3. risks, benefits, alternatives = results cannot be guaranteed, limitations, potential risks, benefits; explain clients right to refuse recommended services and to be advised potent consequences of refusal 4. fees = associated with services, cancellation/noshow, arrangements with any manage care organizations, issues related to insurance reimbursement 5. confidentiality and privileged communication = describe it and its limits, info with insurance companies, plans for dealing with any exceptions to confidentiality, clients right to obtain info of their records, info about supervisory or peer consultation arrangements 6. structure of the counseling relationship = freq and length of sessions, duration of counseling, limitations to treatment, procedures for termination 7. diagnostic labels = how long it will be used, how insurances use them to determine reimbursement, potential ramifications of labels (preexisting conditions), limitation to what insurance does with their info 8. emergency situations and interruptions in counseling = normal hours of operation, what is an emergency, and what they should do if we cannot be reached, what happens when you are on vacation, how to handle unexpected interruptions in counseling services 9. involuntary clients = what info will be shared, with whom, and for what purpose, how it affect legal issues (parole), right to refuse treatment but need to be inform dog the consequences of making that choice -disclosure statement = info to clients about the counselor and about the process and defines a counselors qualifications and theoretical orientation as well s purposes, expectations responsibilities, methods, and ethics

recommendations for risk management documentation

1. document what the client said or did that suggested that he or she was engaging in, or considering engaging in high risk activity 2. document the severity of any threat of high-risk behavior based on your clinical expertise 3. record options you considered taking based on your assessment 4. explain what options you ruled out and why, thereby explaining youth clinical rationale 5. consult and document that 6. document the option you chose, including specific actions you took to implement that option 7. document what occurred after that action was taken

8 dimensions that characterize emotions

1. emotional, physical, or a combination = emotions are physically embedded 2. overt, covert, or combo = overt feelings are evident to other ppl, whereas covert feelings are kept inside and are not revealed 3. positive, negative, neutral = curiosity is ex. of neutral; emotions that typically fall into one category may be experienced differently by certain ppl (outward or inward expression of anger in intimidation or fear) 4. in or out of awareness = some are more aware of their emotional states than other; ppl that are unaware can experience problems in relationships; feelings that are considered unacceptable may be particularly hard to deal with 5. level of intensity = intensity with which emotions are felt varies, depending on the person and the circumstances; intense expression of negative emotions can lead to misunderstandings and relationship difficulties 6. appropriateness for contact and stimulus = emotional stimulus that may be appropriate in one contact may not in another 7. congruence = verbal and nonverbal behaviors match; can sabotage communication efforts if incongruent 8. helpfu or harmful = depending on the way and contact they are expressed, they may enhance lives and relationships or contribute to struggles intra- and interpersonally

5 levels of empathy

1. the verbal and behavioral expressions of the counselor either do not attend to or detract significantly from the verbal and behavioral expressions of the client 2. although the counselor responds to the expressed feelings of the client, the counselor does so in a way that does not capture the depth of those feelings 3. the expressions of the counselor in response to the expressions of the client are essentially interchangeable 4. the responses of the counselor add noticeably to the expressions of the client in a way that lets the client feel heard and understood at a deeper level 5. the counselor's responses add significantly to the feeling and meaning of the client's expressions in ways that go beyond what the client was able to verbalize *first two levels are not considered empathetic and inhibit such an environment *level 4 and 5 is where counselors go beyond what the clients say that distinguishes counseling from conversation

Suggestions for record keeping

LOOK AT PAGE 128 -after bullets! - writing notes with the assumption that they will become public information at some later date but not be cautious that insufficient info is recorded -keeping accurate professional records facilitates the provision of quality services to clients and provides self-protection for counselors

support factors, learning factors, action factors

LOOK AT PAGE 131

referring and recycling

Reasons for referral: 1. problem counselor does not know how to handle 2. problem in an area the counselor is inexperienced and does not have necessary skills 3. counselor knows of a nearby expert who would be more helpful 4. incompatible personalities Referral involve a how, when, who how = knowing how to make a referral in a manner that maximizes the possibility that clients will follow through the the process (clients may resist the process and taking a full session in preparation for the process is recommended) when = involves timing; the longer the client works with the counselor the less likely they will want to change who = person you are recommending to a client; check insurance panels recycling = alternative when the counselor thinks the counseling process has not yet worked but has the potential to do so; reexamination of all phases of the therapeutic process -> goals may not have been properly defined or interventions were unhelpful; gives both counselor and client a second chance in positive change

clients records

accurate and timely documentation is an essential part of clinical mental health counselor's work -most agencies have guidelines -client records def = all client info that is needed for effective service delivery which include written, electronic, video/audio takes -most fall within 6 categories: identifying or intake info, assessment and diagnostic info, treatment plan (initial counseling settings), case nots, termination summary (end of counseling process), other data (consent, copies of correspondence) *protect interests of both parties and promote continuity of care

working phase of counseling

aka action -specific objectives are refined, and interventions for achieving those objectives are implemented (although they overlap some in the initial phase)

case conceptualization

aka case formulation = provides a way for a counselor to link the client's presenting problems to a treatment plan -different definitions on page 125 -developing clinical hypotheses is the heart of case formulation -theoretical orientation influence the hypotheses formed, case conceptualization and treatment planning (but should remain open that our hypotheses may be wrong) -needs to be culturally competent, dynamic, and used to create treatment plans that follow logically from hypotheses -> client-focused rather than theory-focused to match client issues and treatment interventions -very vague and hard to determine -> consulting, supervision, and reading on the topic helps *being able to conceptualize cases, being open and to new client info, and sing those skills to formulate treatment plans are essential for practicing effectively in managed care environments

structure

aka role induction = counselor-client understanding about the conditions, procedures, and nature of counseling and protect rights, define roles, provide direction, and verify obligations of both parties -structure to the process can help clarify expectations and prevent misunderstandings -all throughout counseling but most important in the beg. esp when they come in with crisis and feeling out of control -constructive guidelines= help clients regain stability and find new directions in their lives -based on theoretical orientations, expertise, and personalities and cultural backgrounds of the client -finding a balance can be difficult -> be flexible and negotiate nature of the structure

why closing is important

aka termination = last phase and refers to the decision made by the client, counselor, or both -least researched and most neglected phase of counseling bc many believe it is natural and satisfying for both but is often complex and difficult -produces mixed feelings for both 2 reasons why addressing closing is avoided: 1. associated with loss, which on the surface may seem contradictive to counseling's emphasis on growth and development 2. not directly related to micro skills that facilitate counseling relationships and counselors might not be prepared to attend fully to the ending Important functions of closing: 1. signals that come thing important has been completed 2.gives clients opportunity to maintain changes already achieved and generalize problem-solving skills to new areas and can be empowering 3. serves as a reminder that the client has matured -> ability to handle difficult situations may result in healthier relationships and lives there are more balanced and satisfying

documenting closing

closing statement or summary need to be written and added to client's record she the process is over -2 reasons for documenting termination = client may return for additional services, a client or the legal representative may initiate a malpractice suit (can protect counselors against accusation of abandonment) Info needed in a closing summary: 1. synopsis of initial assessment, treatment plan, interventions, outcomes 2. evaluation of the clients current level of functioning 3. reasons for closing 4. summary of progress toward goals, including final diagnostic impressions 5. follow up plan 6. other pertinent info

empathy

counselors are able to share clients experiences through deep and subjective understanding -culturally sensitive empathy = being able to perceive the cultural frame of reference from which the client operates and which guides the clients perceptions; helps bridge the gap between the counselor and the client Carl Rogers 2 factors of empathy:1. realizing that an infinite number of feelings do not exist 2. having personal security from which you can let yourself go into the world of this other person and still know that you can return to your own world; everything you feel is as if *involves innate skill and intentionality and learned skills -expressed through active listening which is the intentional use of attending abilities that enable the counselor to respond to the clients verbal and nonverbal messages and emotional experiences -can respond at several levels reflecting different degrees of empathy

reluctant and resistant clients

def: someone who has been referred by a 3rd party and is usually unmotivated to seek help (children, adolescents, court-referred clients) -do not wish to be in counseling or talk about themselves and may terminate prematurely and report dissatisfaction with the process Resistance can be displayed: 1. noncompliance = not following through with hw, not showing up, or showing up late) 2. avoidance = extremes expressed as outbursts against the counselor, debating, derailing conversation (idk) or by changing the subject, manipulating the session by waiting until the end to bring up important info 3. ambivalence = having mixed feelings about change Motivation interviewing = helps resistant or ambivalent clients; encourages counselors to role with client resistance rather than confront it; mostly in addictions counseling but can help in any change-related issue Transtheoretical model of change = directly related with MI; 5 different levels of readiness for change -precontemplative (unaware of problem), contemplative (aware of it but doesn't want treatment), preparation (takes small steps toward change), action (commitment to change through overt behaviors), maintenance (make positive changes and change lifestyle to keep changes) *reluctant clients are helped in processes that increase emotional arousal and provide support are more likely to be effective than are approaches that focus on tasks or behavioral schedules -can also make a chart of pros and cons of current behavior and pros and cons of changing behavior to help facilitate change

case of anne

depressed, doesn't like work, doesn't like her regular hobbies anymore, can't sleep, mostly aggitated

case notes

documenting the activity in the session -aka case note, clinical entry, staff note, progress note, group note, service log -purpose = ensure counselors to record info about the content of the counseling session and to guide professional practice and the content may be used for reimbursement for services and are required by the ACA Code of ethics (protect counselors from litigation issues) General info included in most case notes: 1. confirmation of service = what did the counselor and client do during session ? use verbs to describe service rendered 2. verification of the info implied within the billing code = content of the case should confirm the date of service, length of session, and type of service provided 3. an original, legible signature = some need cosignatories -> depending on state licensure and funding source regulations 3 FORMATS ON PG 135 -agency typically has a predetermined outline -primary purpose of case notes are to provide quality serviced to clients and to document decision made and actions taken by counselor (remley)

rehearsal

focuses on client behavior -can help maximize the possibility of accomplishing their goals by giving them opportunities to rehearse or practice new behaviors such as assertiveness and social skill deficits -2 ways of rehearsing = overtly and covertly -overt = requires clients to verbalize or act out what they are going to do -covert = imaging and reflecting on the desired course of action; can alleviate unnecessary anxiety and help improve performance -may need coaching as they rehearse which may include helping clients create written or visual aids to help them remember what to do next in a given situation (oral or written corrective feedback) -helps to talk about the feedback process ahead of time and share observations in a nonthreatening, objective manner -another way to help clients practice is by assigning hw Advantages of hw: 1. keeping clients focused on relevant behavior between sessions 2. helping them to see clearly kind of progress they are making 3. motivating clients to change behaviors 4. helping them evaluate and modify their activities 5. heling clients assume more responsibility for their own behaviors 6. celebrating a breakthrough achieved in counseling -helps them to help themselves but needs or be relevant to the situation and specifically tied to some measurable behavior change to be effective -> need to follow up with their hw *important taks that accompanies all phases of counseling is documenting counselor-client interactions -> after each session, counselors ned to write case notes to record what occurred

documenting work with high-risk clients

high risk = clients who are potentially violent, suicidal, homicidal, or engaged in criminal behavior; those who have experienced or committed abuse -3 things to be done if a client is potentially dangerous: 1. explain how the conclusion was reached, 2. take action, 3. document the action -counselors should involve clients in the doc process when feasible bc it can enhance the service relationship and promote empowerment -if counselors suspect abuse, neglect, or current criminal behavior, it is advisable to discuss the case with a lawyer and contact the proper authority if a report is required -when documenting any concerns about abuse, be sure to record the client's words and behaviors rather than express unsubstantiated opinions -> maintain objectivity -be precise and specific in all docs

timing of closing

if ended to soon -> clients may lose the ground they gained in counseling and regress to earlier behaviors if never addressed -> clients can become dependent and fail to resolve difficulties and to grow as a person Considerations when closing: 1. have the clients achieved behavioral, cognitive, or affective goals? 2. has the client developed better coping skills? 3. is the counseling relationship no longer helpful? 3. has the contact of the initial counseling arrangement changed?

guidelines

include time limits (50 minutes), action limits (for the prevention of destructive behavior), role limits (what will be expected of each participant), and procedural limits (the clients responsibility to work on specific goals or needs), fee schedules, informed consent

interventions, skills, techniques

interventions = outlined in treatment plan and are determined by several factors, including the nature of the presenting problem, client characteristics (culture, age, gender, personality), counselor characteristics, theoretical orientation, training, and the organization in which the counselor works -has been a push for using interventions wit best outcomes for specific conditions, professionals need to provide empirical evidence of the efficacy, pressures from managed care companies also focus on evaluating treatment outcomes -outcome research indicates, in general, counseling is effective across setting and theoretical orientation -> what leads to a successful outcome is determined by client variables, a set of common curative factors, and specific interventions applied to particular problems *important for counselors to provide the most effective treatments possible by selecting interventions and techniques that have been demonstrated as effective -APA, psychiatric nursing profession, and ACA have independently made strong efforts to summarize outcome research to guide mental health practices -it is important to know that not all clients experience the ams problem in the same way, and focusing too much on immediate problem resolution rather than taking a more broad-based approach to healthy emotional functioning may be counter indicated -common curative factors of effective counseling = support factors (therapeutic alliance, trust, empathy, catharsis), learning factors (cognitive learning, affective experiencing, feedback), action factors (reality testing, rehearsal, mastery efforts) *all can be used in the working phase but mainly learning factors are emphasized

reasons for careful record keeping

organized, accurate records are the most effective tool counselors have for establishing client treatment plans, ensuring continuity go care in the event of absence, and providing that quality care was provided LOOK AT PAGE 126-127 for more reasons

treatment plans

set the course for further counseling interventions =-required by managed care organizations and many insurance companies for service approval and reimbursement -explains why the client is receiving services and what is going to take place in counseling -lists measurable and desired outcomes of treatment and is sometimes called plan of care, service plan, habitation plan, residential plan, case management plan (depends on the type of services provided and the agency) Components in Treatment Plan: 1. problem statement = ex. depression due to marital problems 2. goal statement and expected date of achievement = list goals that relate to the problem and timing 3. treatment modality = describe intervention used; to be billable the intervention must be provided by a professional who is considered qualified by the funding source 4. clinical impression or diagnosis = accurate reflection of the client's mental health as described in assessment; diagnostic terms should be listed according to the DSM; clients condition must not be overstated or understated 5. Names and credentials = list names and credentials of ppl who participated in the development of the treatment pan as well as the assigned clinician and the person who writes the plan needs to sign and date it *this represents a collaborative, ongoing effort between the client and counselor

winning the battle for initiative

ways counselors can help clients in the battle for initiative and achieve success in counseling 1. anticipate anger, frustration, defensiveness, or ambivalence -> help better prepare to effectively deal with it when it happens 2. show acceptance and patience and strengthen the relationship, which is the most powerful predictor of successful client outcome; empathetic, nonjudgmental approach helps trust and open communication -> clients are more likely to be honest with themselves and are able to better recognize and express reasons for what manifests as resistance or noncompliance 3. use of persuasion = aka social influence; process of encouraging clients to take reasonable and growth-producing risks to make thoughtful decisions and healthy choice to disclose and process feelings and experiences and to move forward toward their goals; when clients see the counselors as relaible, credible, and competent they are more likely to respond positively 4. therapeutic confrontation = pointing out discrepancies i clients beliefs, actions, words, or nonverbal behaviors; used in a gentle and therapeutic way -3 ways clients respond = denying confrontation, accepting some aspect of the confrontation as true, fully accepting the confrontation and agreeing to try to resolve inconsistency -beneficial results = doing something differently, gaining a new perspective 5. using metaphors = help reduce threat levels by providing images, offering fresh insights, challenging rigidity, overcoming tension *source of resistance can come from the client OR the counselor and timing of resistance can occur at any time

confidentiality and access to client records

we are responsible for ensuring safety and confidentiality of any client records they create, maintain, or destroy -make sure the are secured in locked files or saved in protected computer programs -> needs to be a security component that ensures the protection of info -ensure al client charts and info remain in the agency or office -need to be shredded when invalid or outdated -know HIPPA and the controversy with electronic storage -need to be able to provide clients access to their records if requested and demand that copies of clinical records be transferred to other professionals unless the content would be detrimental to client welfare -written consent should be obtained when giving info to third parties -> preferred to mail rather than fax unless situation is critical -> if faxed, must have a cover letter that says confidential, intended for use only by the designated person, and that receipt must be acknowledged -client records may be subpoenaed in litigation situations and counselors should consult with a lawyer before turning over records or appearing in court