Methods combo for Kennedy Orals

thought content

-SI? passive, active, plan, intent, means -HI? passive, active, plan, intent, means -delusions -phobias -obsessions/compulsions

attitude

-calm & cooperative -other (describe)

appearance

-causal dress, normal grooming and hygiene -other (describe)

mood

-euthymic -irritable -elevated -anxious -depressed

thought process

-goal-directed & logical -disorganized -other (describe)

Memory/concentration

-short term intact -long term intact -distractible/inattentive

MSE

AA BAPTIST MOM Appearance Attitude Bx Affect Perception Thought process Insight/judgement Speech Thought content Mood Orientation Memory/concentration

How do cognitive distortions contribute to situational anxiety? Automatic thoughts indicate negative schema.

Clients can identify the extent to which such thoughts contribute to situational anxiety by asking themselves, "Do I (1) make unreasonable demands of myself, (2) feel that others are evaluating my performance or actions, and (3) forget that this is only one small part of my life?" The therapist may need to point out that the thoughts are the link between the situation or event and the resulting emotion and ask the client to notice explicitly what this link seems to be.

List the components of cognitive restructuring. P. 370

Cognitive restructuring has its roots in the elimination of distorted or invalid inferences, disputation of irrational thoughts or beliefs, and development of new, healthier cognitions and patterns of responding.

Mind reading

Convinced that one knows what others are thinking, accompanied by assumption that those thoughts are negative.

10 Fundamentals

Don't be a problem solver - client owns the solutions Trust intuition of right path Provide a sense of direction Take care to protect client Have a sense of humor Incorporate self-disclosure - be willing to share Be open minded Believe client is doing the best he/she can Mutual agreement on expectations from therapy Ask for feedback

Evidenced-based Practice (EBP)

EBP:"the conscientious, explicit and judicious use of current best empirical evidence in making decisions about the care of the individual patient. It means integrating individual clinical expertise with the best available external clinical evidence from systematic research." (Sackett , 1996) (1) learn from and work in a collaborative fashion with each of your clients (2) consult and critique empirical research findings (3) understand the standards of professional ethics (4) participate in and contribute to constructive dialogues with your clinical supervisor and other skilled practitioners in your profession and in related professions (5) adapt your therapeutic style over the course of your career based on what you have learned from these various constituents EBP = mostly CBT (most standardized), also MI, SFT, exposure therapy (depression), DBT (borderline) Concerns/Critiques of EBP: Efficacy studies may not easily transfer to actual, everyday performance May not be generalizable to other practitioners, clients, etc. May be confined to single diagnosis Over reliance on treatment manuals EBP changes with time as info acrues: MI originally for Substance Abuse disorder now also for diabetes, high cholesterol, & obesity DBT from borderline personality to now also eating disorders, substance disorder, bipolar, and chronic suicidality Multiculturalism without strong research risks becoming an empty political value, and EBP without cultural sensitivity risks irrelevancy" 1. Explicitly incorporating cultural values/concepts into the intervention (e.g., storytelling of folk heroes to children) 2. Matching the client and helper according to race or ethnicity 3. Providing services in the client's native language (other than English) 4. Providing services in a treatment facility specifically targeting clients from culturally diverse backgrounds (e.g., Africentric programming for African American youth in a substance abuse treatment facility) "Addressing" framework of cultural influences (Hays 2008) Age and generational influences Developmental and acquired disabilities Religion and spiritual orientation Ethnic and Racial Identity Socioeconomic status Sexual orientation Indigenous heritage National origin Gende Expectation of clinical practice, quality care, identify ineffective/harmful treatment, descriptive guide for treatment Efficacy studies = study conducted in ideal experimental conditions Effectiveness studies = does not adhere to strict laboratory research Concerns/critiques of EBP o May not reflect actual practice because it's so controlled o May not be generalizable o Overreliance on clinical/control trials, diagnostics and treatment manuals o Lacking multicultural research

Fortune telling

Foretelling the future in negative outcomes.

What are the instructions for diaphragmatic breathing? p. 446

It may be useful to start training either by describing how a diaphragm works or with a picture that illustrates the diaphragm as a wide, fan-shaped muscle below the lungs that contracts and relaxes, pulling air in or pushing it out, respectively. You can use the following steps as a guide in teaching this exercise: 1. Providing a description of the technique 2. Finding a comfortable body position while reclining or lying on back 3. Breathing through the nose 4. Placement of hands and visualization 5. Simulating movement of the diaphragm 6. Visualizing the diaphragm position and movement while in sitting position 7. Daily practice

Overgeneralizing:

Jumping to conclusions based on a single experience; assumptions of a global negative pattern.

Discounting positives

Minimizing or trivializing the positives (e.g., things you or others do, outcomes).

Emotional reasoning

Over reliance on current feelings as global interpretations of reality; if one is feeling bad, then the situation must be bad.

Person Centered Therapy

P - Permission O - Ownership - client owns treatment W - Well-being - safety, calm balance E - Esteem (self-esteem) R - Resilience R - Responsibility Major Goal: C.U.R.E. -- Congruence -- Unconditional positive Regard -- Empathy - encouraging, clarifying, using silence

paralinguistics

Paralinguistics refers to the vocal cues—or the "how" of the communication. Paralinguistics includes vocal qualities, vocalizations, silent pauses, and speech errors, too.

Multicultural Model (Hofstede's)

Power Distance (high vs low) Individualism vs. Collectivism Long-term orientation vs. Short-term orientation Indulgence vs. Restraint Uncertainty Avoidance (High vs. Low) Masculinity vs. Femininty

what is stress inoculation training (SIT)?

Stress inoculation training (SIT) builds on transactional models in viewing stress arising when the perceived demands of a circumstance tax or exceed the perceived capacities and resources of the person (or, by extension, a family or community) to handle these demands, especially when well-being or valued goals are believed to be at risk.

Catastrophizing

anticipating the future in worst scenario terms.

Unfair comparisons

application of standards that are unrealistic, such as focusing on others who do better and seeing oneself inferior in comparison.

In Vitro? 2 ways implemented?

exposure conducted in the treatment setting under controlled conditions Involve simulated stimuli such as role play or virtual technology

countertransference

feelings the therapist has about the client that are in some way atypical reactions either to a particular client or to clients in general. Such reactions may be covert and include thoughts, feelings, and visceral body sensations, or they may be overt behaviors. it negatively impacts the therapy. We manage them by becoming aware of what they are and what they mean to us. be willing to examine and take responsibility for your role in the CT, develop boundaries (feel client's feeling w/o taking responsibility for them) when the therapist projects feelings from their past/present relationships on to the client

congruence

genuineness; being oneself; not playing a role; communicated partially by non-verbal behaviors (appropriate amt of eye contact, mimesis); consistency

kinesics (body motion)

gestures, body movements, posture, touch, facial expressions, and eye behavior. In this area, helpers can listen to messages communicated by clients through such nonverbal behaviors as eye contact, facial expressions, and posture.

Describe the Alternative Goal Attainment Scale and when you would use it? P. 292

goal attainment scaling: scale that identifies a series of increasingly desired outcomes for each area; therapist and client create 5 outcomes for a given issue and arrange them by level or extent of change on a scale: (-2) - most unfavorable outcome (-1) - less than expected outcome (0) - expected outcome (+1) - more or better than expected outcome (+2) - much more than or best possible expected outcome "alternative" goal attainment scale adds a (-0.5) (partially achieved) to indicate partial achievement of the expected level primary purpose is to assess amount of client change good for a variety of setting and goals

Judgment focus

harshly viewing oneself, others, and events in terms of categorical evaluations; finding oneself and others to continually fall short.

Shoulds

hyperfocus on what self, others, or situations should be or do.

Intense (flooding)

involves imaginal or actual stimuli, in short bursts or prolonged contact.

List and describe three categories of non-verbal behavior? P. 117

kinesics - gestures, eye contact, facial expressions paralinguistics - vocal qualities - tone, pitch, volume, pauses, silences proxemics - distance you stand from someone, seating arrangement

proxemics

one's use of personal and social space. In the context of the helping relationship, proxemics involves the size of the room, seating arrangements, the distance between helper and client, and the use of touch.

Regret orientation

preoccupation with losses, missed opportunities, and the idea that one could have done better in the past.

Please list and define the four listening responses. P. 120

reflection, paraphrase, summarization, clarification

Inability to disconfirm

rejection of any evidence or arguments that might contradict one's negative thoughts; resistance to refutation of tenaciously held thoughts.

reflection

rephrasing of the client's feelings or the affect part of the message Goal: help client to express more, become more aware of, acknowledge and manage, & discriminate FEELINGS; help client feel understood

Value? p. 44

something we prize, regard highly, or prefer; core beliefs that influence how we act

empathy

the ability to understand people from their frame of reference rather than your own. Responding to a client empathically may be "an attempt to think with, rather than for or about the client", conveyed thru reflection

summarization

two or more paraphrases or reflections that condense the client's messages or the session. Goal: tie together multiple elements of messages, identify common theme or pattern, interrupt excess rambling, review progress, slow pace of session.

Categories of Nonverbal Behavior:

•Kinesics, or body motion, includes gestures, body movements, posture, touch, facial expressions, and eye behavior. •Paralinguistics refers to the vocal cues - or the "how" of the communication. Includes vocal qualities, vocalizations, silent pauses, and speech errors. •Proxemics - one's use of personal and social space. Involves the size of the room, seating arrangements, the distance between helper and client, and the use of touch.

Possible examples of Reframing? pg 543

•Not making a decision right now = Being careful •Stubborn = Determined •Selfishness = Self-care •"Do not resuscitate"="allow natural death" •Compulsivity = persistence •Nagging = Concerned •Failure = lesson learned •Dinner leftovers = extreme makeover

orientation

- X3 - person, place, time

Dichotomous thinking:

Categorizing events or people in overly simplistic, all-or-nothing, black-and-white terms.

Blaming

Focusing on others as sources of one's negative feelings, externalizing causation, insufficiently accepting responsibility for changing oneself.

Facilitative Conditions

o Heals = -*C*ongruence -*U*nconditional positive regard -*E*mpathy -Managed countertransference -Alliance (therapeutic working alliance)- rapport, trust -Tailoring to the client alliance, empathy, positive regard, congruence, managed countertransference, tailoring to the client (client characteristics to consider when tailoring therapy: resistance level, preferences, culture, religion & spirituality, stage of change, coping style) o Does NOT heal = confrontational style, criticism, blame, verbal attacks, rigidity, inflexibility o Client characteristics: reactance/resistance level, preferences, culture, religion, stage of change, coping style o All helping relationships are cross-cultural *Congruence* or Genuineness - the art of being oneself, be human and collaborate with the client 4 components: supporting nonverbal behaviors -(eye contact, smiling, leaning forward); role behavior - do not overemphasize your role; consistency - helper's words, actions, feelings match; spontaneity - express oneself naturally, tactfully, honestly *Unconditional Positive regard* respect - ability to value the client as a person of worth. Helper must be able to work with, accept, and be interested in the client. Components commitment to the client - willing to work with client, being on time, ensuring privacy, maintaining confidentiality, applying skills; *understanding* - be empathic, ask questions, paraphrase client responses, reflect; *non-judgmental attitude* - suspend judgment, disapproval, or criticism; Components continued... competence and care - get supervision, consultation, continuing education, be principled, use an ethical referral process if necessary, pursue the agenda of the client; *warmth* - warmth begets warmth - voice tone, eye contact, facial expression, gestures, touch, and enhancing statements which must be sincere, accurate and deserved. *Empathy* The ability to understand people from their frame of reference Cognitive empathy*** Intellectual connection to client. Empathy builds rapport, elicits information, may convey the sense of 'team' Non-judgment position, validate responses by mirroring the client's experience, provides a safe environment Limit-setting responses - reflect the client's wish but do not provide gratification. Holding environment - therapist becomes the container for the client to place feelings by conveying an understanding of the client's feelings and experiences and providing a safe environment for the client. *Therapeutic Working Alliance*: partnership between client and counselor to determine goals, tasks, and develop an emotional bond. The alliance is established early in the relationship, may wax and wane, usually affected by the client who may have some issues of attachment. Counselor must not be negative or be a know-it-all. Counselor - get feedback from the client...should feel supported, understood, and hopeful and trust the counselor. *Trust* essential to the relationship and ultimately the responsibility of the counselor. Counselor must behave ethically, make effort to honor commitments, be reliable. These traits and one's reputation are usually what guides the client to a particular counselor. Counselor must prove him/herself. Trust (destroyed by abuse of power, incongruence, judgmental behavior, and apathy) is difficult to rebuild. Counselor: congruent, consistency and dependability of responses to Verbal and NV behaviors, response to client disclosures, confidentiality, openness, honesty, reliable and accurate information giving, non-defensive reflections/reactions to the client's tests of trust.

VBP 3 guiding principles?

(1) all decisions rest on values as well as evidence (the "two feet" principle); (2) often values are noticed only when they cause trouble, including those that prompt ethical conflicts (the "squeaky wheel" principle); and (3) advances in science should promote not only evidence-based practice, but also values-based practice (the "science-driven" principle).

Parts of an Intake Interview

*Identifying information*: Client's name, address, home and work telephone numbers; name of another person to contact in case of emergency *Presenting concerns*: Note the presenting concern (quote the client directly). *Social/developmental history*: Current life situation (typical day/week, living arrangements, occupation and economic situation, contact with other people). *Past psychiatric/counseling history*: Previous counseling and/or psychological/psychiatric treatment *Family, marital, sexual history:* Presence of physical, sexual, and/or emotional abuse from parent, sibling, or someone else *Health/medical history*: Childhood diseases, prior significant illnesses, previous surgeries *Suicidal and homicidal ideation. Assessment* *Educational/job history*: Trace academic progress (strengths and weaknesses) from grade school through last level of education completed *Behavioral observations*: General appearance and demeanor. Client communication patterns *Results of mental status exam (if applicable) and provisional conceptualization* *Goals* for counseling and therapy: *Diagnostic summary (if applicable) and DSM-IV code*

Explain the client practice of the shift? pp. 380-381

-After the client has identified negative thoughts and has practiced alternative coping thoughts, the practitioner introduces the rehearsal of shifting from self-defeating to coping thoughts during stressful situations. Practice of this shift helps the client use a self-defeating thought as a cue for an immediate switch to coping thoughts. -The helper should model this process before asking the client to try it. This gives the client an accurate idea of how to practice this shift. - self defeating thought comes up, cue to cope introduced, then situation oriented or task oriented coping thought placed purposefully into mind instead of negative defeating thought

insight/judgement

-good -fair -poor

perception

-no hallucinations or delusions during interview -other

behavior

-no unusual movements or psychomotor changes -other (describe)

speech

-normal rate/tome/volume/w/o pressure -other (describe)

affect

-reactive -labile -tearful -flat -depressed -normal range....

Suicide Assessment: 3 step process and intervention

.1 Does the person have thoughts about suicide? A. The more frequent the thoughts during the day (or week), the more likely a suicide attempt might occur. B. The longer the period of time a person thinks about suicide the greater the chance of attempting it. C. Are the thoughts general or specific? General thoughts are only about life ending but not suicide. Specific thoughts imagine the method of death. D. Intervention: if next two levels are not involved i. See if this is a problem to be solved in therapy ii. Determine if this appears to be temporary or is persistent iii. Immediately change treatment plan to focus exclusively on this issue till resolved. iv. Determine if thoughts frequent enough to contact family member. 2. Level #1 is active and has a person developed a plan to commit suicide? A. Example: Kill self with a gun. But if there is no idea of which gun, where to find a weapon then somewhat less danger. B. Have they rehearsed the plan in their mind? More dangerous. C. Have they tried this plan before but were prevented in some way from completing it. Very dangerous. D. Intervention: all of above intervention plus i. No-suicide contract ii. Definitely contact family member about concerns. Yes, this does break confidentiality. 3. Levels #1 and #2 are active and is there access to the method by which a person will kill themselves? A. Determine if an immediate threat or highly potential one B. If a potential threat, call a family member to come to the office. Instruct the family member to commit person to a psychiatric hospital C. If an immediate threat i. Call family member to take to hospital or ii. Or call police to take to hospital. Do not take yourself unless absolutely necessary (police won't arrive)

What are the three parts of a working alliance with a client? P. 96

1. Agreement on therapeutic goals 2. Agreement on the therapeutic tasks 3. An emotional bond between client and therapist

Nine Ideal features of a mental health intervention

1. Be well defined. 2. Reflect client goals. 3. Be consistent with societal goals. 4. Demonstrate effectiveness. 5. Have minimum side effects. 6. Have positive long-term outcomes. 7. Have reasonable costs. 8. Be relatively easy to implement. 9. Be adaptable to diverse communities and client subgroups.

Specific strategies of MI that cultivate positive change?

1. Being collaborative 2. Being client centered 3. Being nonjudgmental 4. Building trust 5. Reducing resistance 6. Increasing readiness for change 7. Increasing self-efficacy 8. Increasing perceived discrepancy 9. Engaging in reflective listening Cormier, Sherry; Nurius, Paula S.; Osborn, Cynthia J.. Interviewing and Change Strategies for Helpers (HSE 123 Interviewing Techniques) (Page 537). Cengage Textbook. Kindle Edition.

List the components of stress inoculation?, p 425.

1. Treatment rationale (overview and purpose) 2. Information giving (psychoeducational component) 3. Acquisition and practice of direct-action coping skills 4. Acquisition and practice of cognitive coping skills 5. Application of all coping skills to problem-related situations 6. Application of all coping skills to potential problem situations 7. Homework and follow-up

transference (2 components)

1. client's projection of feelings and fantasies that are reactions to significant others in the client's past onto the helper. 2. interpersonal dynamic between the helper and client - "here-and-now experience of the client with the therapist who has a role in eliciting and shaping the transference" when the client projects feeling from other past/present relationships on to you. Part of contemporary relational theorists.

4 stages of the helping process

1. establishing an effective therapeutic relatinship 2. assessment and goal setting 3. strategy selection and implementation 4. evaluation and termination

how to manage countertransference

1. gaining *awareness* (be aware of your responses & covert feelings/biases) a clue we may be experiencing countertransference: having strong emotions self-insight: intentional attention to what is going on inside us countertransference is inevitable so you should consult and seek supervision & counseling 2. develop conceptual *understanding*: hunches about what is occurring in the moment in the relationship w/ client (helps prevent automatic response) 3. helper needs to be willing to *examine* and take responsibility for her possible contributions to the issues that are emerging between you and client. (mindfulness helpful) 4. develop and use *boundaries*- don't let what the client says get to you (feel client's feelings w/o acting as if they belong to you) & don't share too much w/ client

List the 3 types of immediacy and give an example of each? P. 166

1. helper immediacy - therapist reveals own thoughts/feelings - im glad to see you today; can you please repeat that I was having trouble following 2. client immediacy - therapist provides feedback to client about some client behavior or feeling as it is occurring - you smiling, you seem very happy about this; 3. relationship immediacy - therapist reveals feelings or thoughts about how she experiences the relationship - im glad that you're able to hare that w/ me.

List the three steps in developing effective confrontations? Pp. 177-178

1. listen & observe discrepancies; detect several before jumping in. 2. assess purpose of confrontation. make sure its for the client's benefit, not your own; asses whether it's appropriate based on relationship and client's culture 3. summarize the discrepancies - use "and" instead of "but" ex. "on one hand you _______, and on the other hand ______" make sure your tone is nonjudgemental (4) assess the effectiveness of confrontation

According to the chapter 9, what are the five components of a treatment plan? P. 344

1. presenting concerns 2. strengths/resources 3. goals & measures 4. therapist interventions and client implementations 5. duration

What specifically helps with the alliance?

1. the helper-client interactions are not hostile or negative. 2. revisiting the strength of the alliance throughout the entire helping process, making sure that agreement on the therapeutic tasks and goals remains consistent, and that the emotional connection between the helper and client remains strong. 3. A critical element in the efficacy of the therapeutic alliance appears to involve client feedback to helpers about the way clients are experiencing the alliance. 4. Clients report that feeling understood, supported, and hopeful is connected to the strength of the working alliance, particularly in the early part of the helping process. In addition, the working alliance is also impacted by the client's trust in the helper. at the most basic level the client's ability to trust and have faith in the helper plays a pivotal role in the change process.

History Taking Intake interview. How many assessment categories are there? Describe the person-in-environment (PIE) classification? Pp. 213, 194

14 assessment categories 1. identifying information 2. presenting problem/sxs (include hx related to presenting problem) 3. past psychiatric/counseling/treatment and previous dx 4. educational & job hx 5. health & medial hx 6. social/developmental hx (developmental delays, culture) 7. family, marital, relationship, sexual hx. 8. substance abuse and legal hx 9. military hx 10. SI/HI 11. behavioral observations (speech, appearance, MSE possibly) 12. goals for therapy 13. DSM dx 14. person-in-environment (PIE) classification -PIE - tool to help therapist understand the relationship between the client and the system or environment in which client resides factor 1 - social fx problems & strengths factor 2 - environmental problems & strengths factor 3 - mental health problems & strengths factor 4 - physical health problems & strengths 4 additional assessment indices for each factor: severity, duration, coping, and strengths 1 & 2 make up the bulk. notes: system avoids classifying social roles in a culturally specific context - factor one is limited in clarifying some problems of certain groups but factor 2 addresses this. judgements are based on therapist's perception; not client's. based on the notions that clients are embedded w/I cultural, environmental, and social systems. movement is to focus on strengths & coping skills.

Define SUDS and give an example of it. p. 483

A *Subjective Units of Distress Scale (SUDS; Wolpe, 1969) Ultimate purpose: enable client to notice improvements! SUDS is a scale of 0 (no fear) to 10 (most severe distress) measuring the subjective intensity of disturbance or distress currently experienced by an individual. The individual self assesses where they are on the scale. In desensitization-based therapies, the patients' regular self assessments enable them to guide the clinician repeatedly as part of the therapeutic dialog. In CBT for anxiety disorders (exposure hierarchy) The intensity recorded must be as it is experienced now. Constriction or congestion or tensing of body parts indicates a higher SUDS than that reported.

What are the 7 specific strategies used in motivational interveiwing? pg 538-544

Affirmations Emphasizing personal choice and control Open ended questions & reflective listening: Reflections (complex reflections and double sided reflections) - reflective or empathic statements Reframing Supporting MODEL DIALOGUE: AFFIRMING, EMPHASIZING AUTONOMY, AND ADVISING ONLY WITH PERMISSION

List the components of cognitive modeling and why they are used in this sequence. Pp. 363- 365

Cognitive modeling is a procedure in which practitioners demonstrate to clients what to say to themselves while performing a task, in countering a person's negative self-talk that can impede change efforts. This is a self-instructional strategy that starts out with active roles performed by the helper (to model the desired behavior, to prompt and reinforce), with the balance progressively shifting to the client to provide his or her own self-coaching and reinforcement. 7 steps: Helper Groundwork 1. Treatment rationale 2. Cognitive modeling of the task and of the self-verbalizations: The helper serves as the model (or a symbolic model can be used) and first performs the task while talking aloud to himself or herself. Client Practice 3. Overt external guidance: The client performs the same task (as modeled by the helper) while the helper instructs the client aloud. 4. Overt self-guidance: The client is instructed to perform the same task again while instructing himself or herself aloud. 5. Faded overt self-guidance: The client whispers the instructions while performing the task. 6. Covert self-guidance: The client performs the task while instructing himself or herself covertly. 7. Homework and follow-up

Cognitive Change and Cognitive Restructuring Strategies

Cognitive restructuring (cognitive replacement) can affect 3 levels of cognition that play a significant role in emotional and behavioral difficulties (1) automatic thoughts (2) schemas or underlying assumptions (3) cognitive distortions. Cognitive restructuring is considered an essential component of cognitive behavioral procedures. Be aware of cultural issues...and remember that so much of the research and the "standards" are based in Euro-centric values.

4 primary stages of helping.

Establishing an effective therapeutic relationship. Assessment and goal setting. Strategy selection and implementation. Evaluation and termination.

Exposure Therapy

Exposure Therapy Treatment strategies involving some form of contact between the client and what he/she finds anxiety-provoking, frightening, or distressing. Well-supported empirically and clinically in treating anxiety/fear-related concerns When effective, the extinction of the distress occurs after repeated or prolonged contact with the stimulus that evokes fear. (Habituation to fear til it doesn't trigger you) Cue desensitization - individuals are exposed to the sights, sounds, smells, and other aspects of addiction so that new associations can be learned. Phobias - persistent and irrational fears of specific situations, objects, or activities. The greater the duration of the exposure, the more the fears tend to be reduced (Marks, 1975). Components and process of ET Gradual exposure - increasing fear or anxiety-provoking stimuli in a steady, incremental fashion over several or many shorter sessions Intensive exposure - contact with more intense fear - or anxiety-provoking stimuli - almost immediately, for an extended period of time, during only one or very few sessions. Put greater focus on preparing client and informed consent with IE General sequence of Exposure Therapy Treatment rationale for exposure Address questions and obtain informed consent Identify fear-provoking stimuli Constructing an exposure hierarchy (SUDS -see next slide*) Relaxation Response Training Initial exposure Discussing the experience Disconfirming maladaptive thoughts Identifying and addressing avoidance and safety-seeking behaviors. 7. Continuing exposure through the hierarchy 8. Homework When designing an exposure hierarchy, therapists first conduct a thorough assessment of their client's fear with particular attention to the (a) feared object or situation, (b) feared consequences of confronting the object, (c) fear-related avoidance or safety behaviors, and (d) triggers and contexts of the fear Systematic and Controlled for the purpose of Systematic Desensitization: When exposure to an item at the bottom of the hierarchy leads to moderately reduced distress or increased tolerance, a client progresses up the hierarchy to more and more difficult exposures. Assessment tool of the client's progress and their increasing ability to habituate to fearful situations further up in their hierarchy Possibility that in some forms of therapy, the patient will want to see progress and will therefore report progress that isn't objectively present— type one error. Clinical utility: provide an indirect opportunity for positive autosuggestion (indirect suggestions in Ericksonian hypnosis).

In vivo? Advantages? Limitations?

In vivo exposure therapy involves exposure to the actual stimuli and situations that provoke anxiety and fear for a client. Advantage = in vivo exposure involves exposure to tangible stimuli that can objectively be quantified to document the client's treatment gains. limitation = 1. unforeseen events will cause a temporary setback in the client's progress. 2. behavioral experiment homework assignments can be an aversive experience for a client who meets with a high degree of perceived failure, 3. the primary anxiety-provoking stimuli for some clients can be imaginal in nature, which in vivo can't help

facilitative conditions pp. 86-95

List and define the 3 conditions necessary to conduct effective counseling according to client-centered therapy: congruence, empathy, unconditional positive regard,

6 faces Theories/Fields

Psychodynamics Behaviorists Person Centered Existentialists Cognitive Humanists

Six Influencing Responses

Questions- open-ended or closed query or inquiry Goal: (open-ended)- begin interview, encourage elaboration or obtain info, elicit specific examples of client's behaviors, feelings, or thoughts. (closed)- narrow topic of discussion, obtain specific info, elicit specific examples of client's behaviors, feelings, or thoughts, motivate client to communicate. Information giving- communication of data or facts Goal: identify & evaluate alternatives, dispel myths, motivate client to examine issues they have been avoiding, provide structure at outset and major transition points in helping process Interpretation*** (advanced or additive empathy)- mirroring of client's behaviors, patterns, and feelings, based on implied client messages and the helper's hunches Goal: identify client's implicit messages; examine client behavior from an alternative view; add to client's self-understanding and influence client action Confrontation**- description of discrepancy/distortions Goal: identify client's mixed messages or distortions; explore other ways of perceiving client's situation or self; influence client to take action. Self-disclosure- purposeful revelation of info about oneself through verbal and nonverbal behaviors Goal: build rapport, safety, and trust; convey genuineness; model self-disclosure; instill hope & promote feelings of universality; help clients consider other alternatives and views Immediacy- description of feelings or process issues as they are occurring w/i the helping interview; self-disclosure of current feelings or what is occurring at the present time in the relationship or session Goal: open up discussion about covert or unexpressed feelings or issues; provide feedback about process or interactions as they occur; help client self-disclose QII CSI

4 steps in the rehearsal of the shift?

Rehearsal of this shift involves four steps: 1. The client imagines the stressful situation or carries out his or her part in the situation by means of a role play. 2. The client is instructed to recognize the onset of any self-defeating thoughts and to signal this by raising a hand or finger. 3. The client is told to stop these thoughts or to reframe these thoughts. 4. After the self-defeating thought is stopped, the client immediately replaces it with the coping thoughts. The client should be given some time to concentrate on the coping thoughts. Initially, it may be helpful for the client to verbalize coping thoughts; later, this can occur covertly.

3 phases of SIT?

SIT is made up of three overlapping phases: (1) a conceptual educational phase (helping the client better understand the nature of stress and stress effects), (2) a skill acquisition and skill consolidation phase (developing and practicing a repertoire of coping skills), and (3) an application and generalization phase (using coping skills in conditions approximating problem situations as well as those with potential stress effects).

Self Care = Stamina

Selectivity: intentionally choosing setting, supervisor, clients, your battles, etc. Temporal sensitivity: be mindful of clients' time, your own time (on and off the job), using time effectively Accountability: practice ethically and engage with others who have the same values, be willing to be scrutinized Measurement/Management: the second half of selectivity, maintain your boundaries, continue building skills in your area, manage your resources Inquisitiveness remember your fascination, be engaged in new learning Negotiation: be flexible, reframe your "negative" experience, adapt, learn new skills Acknowledgement of Agency: of your clients, focus on their strengths, believe in them Osborn's Preventative S - Selectivity - focus activities, pick fights wisely T - Temporal sensitivity - mindful of constraints on time A - Accountability - Ethical, informed, qualified M - Measurement & Management of one's skills, resources, strengths I - Inquisitiveness - Curiosity, intrigue, motivation N - Negotiation - ability to be flexible - give & take A - Acknowledging agency - Other's ability for positive change Ethical imperative Not simply a personal matter Not an indulgence Not optional Not automatic Burnout = emotional depletion Foundation: Self-kindness Common humanity Mindfulness

silence in/of paralinguistics

Silence and pauses in communication are important in the helping process for several reasons. First, they help regulate the course of the conversation. Unfilled pauses, or periods of silence, serve various functions in a helping interview. The purpose of silence often depends on whether the pause is initiated by the helper or by the client. Clients use silence to express emotions, to reflect on an issue, to recall an idea or feeling, to avoid a topic, or to catch up on the progress of the moment.

Describe the steps for muscle relaxation? pp 448-451

Tension is incompatible with relaxation. Tension and relaxation can affect blood pressure, heart rate, and respiration rate and also can influence covert processes—how we think and feel—and the way a person performs or responds overtly. One goal of muscle relaxation is that of heightening sensitivity to our bodily experience "under our skins," learning to monitor our muscular signals, and automatically relieving tensions that are not desired 1. Treatment rationale (skill built with practice) 2. Instructions about client dress 3. Creation of a comfortable environment (padded reclining chair) 4. Helper modeling of relaxation exercises 5. Instructions for muscle relaxation (not too tense). When the client can alternately tense and relax any of the 16 muscle groups on command, you may shorten the procedure by gradually reducing the number of muscle groups involved to seven. and then 4. 6. Posttraining assessment 7. Homework and follow-up

Why cognitive restructuring?

The last part of the rationale for cognitive restructuring should be an explicit attempt to point out how self-defeating thoughts or negative self-statements are unproductive and can influence emotions and behavior. people don't literally tell themselves something. Often, our thoughts are so well learned that they reflect our core beliefs or schemas and are not made explicit. One way to prevent implementation difficulty is to enhance the client's self-efficacy. Repeated practice helps loosen the grip on self-defeating thoughts, enables the client to formulate experiences more realistically, and gain enough experience that the self-enhancing thoughts become almost as automatic as the self-defeating ones. Additionally, repeated practice can enhance the client's self-efficacy with the procedure. what automatic thoughts does the client tend to have, do these thoughts contain distortions, and, if so, do these distortions appear to be linked to broader conceptualizations of or beliefs about self or others (schemas)?

What are the 7 specific strategies/techniques of Solutions-Focused Therapy that are used to stimulate 'possibility' thinking? pp 526-527, 529

The practice of SFT is known for its creative use of questions (questions for both client and helper to consider, intended to stimulate possibility thinking) and for the attention given to the language used by both client and helper. The conversations between client and helper are therefore fluid, not scripted, and reflect a mutual inquisitiveness about alternative perspectives and realities. 1. Use of the miracle question 2. Use of scaling questions 3. Taking a consulting break and providing clients with a set of compliments 4. Assigning homework tasks 5. Looking for strengths or solutions 6. Setting goals with the client 7. Looking for exceptions to the problem. Possibility thinking: identify strengths, scaling questions. resistance—or what Shilts and Thomas (2005) regard as curiosity—is the intended recipient or target of constructive questions as well as the germination or yeast for such questions. The questions described are intended to engage clients in the helping process by tapping into client resources and strengths.

What are the advantages of relaxation training when used with an exposure hierarchy?

Treatment strategies involving some form of contact between the client and what he/she finds anxiety-provoking, frightening, or distressing. Well-supported empirically and clinically in treating anxiety/fear-related concerns

Four Listening Responses

WHY? help client feel understood and that you are listening. keep conversation going. **** Reflection- rephrasing of the client's feelings or the affect part of the message Goal: help client to express more, become more aware of, acknowledge and manage, & discriminate FEELINGS; help client feel understood. Paraphrase- rephrasing of the content part of the message (the part that describes a situation, event, person, or idea). Goal: help client focus on content, to *highlight content when attention to feelings is premature/self-defeating*. Summarization- two or more paraphrases or reflections that condense the client's messages or the session. Goal: tie together multiple elements of messages, *identify common theme or pattern*, interrupt excess rambling, *review progress*, slow pace of session. Clarification- often begins with a question, often posed after an ambiguous client message Ex. "Do you mean that...:" or "Are you saying that..." then followed by a repetition or rephrasing of all or part of the client's previous message. Goal: encourage elaboration, check accuracy, clear up vague or confusing message

Give a summary of the Brief Mental Status Exam? P. 209

a model that allows the therapist to assess current mental fx of the client as pathology increases appearance, attitude, bx, orientation, memory, judgement, SI/HI, active psychosis 1) client's physical appearance (including dress, posture, gestures, and facial expressions) 2) client's attitude and response to you (including alertness, motivation, passivity, distance, and warmth) 3) any client sensory or perceptual behaviors that interfered with the interaction. Note the general level of information displayed by the client, including vocabulary, judgment, and abstraction abilities. 4) Note whether the client's stream of thought and rate of talking were logical and connected. 5) Note the client's orientation to four issues: people, place, time, and reason for being there (sometimes this is described as "orientation by four"). 6) Note the client's ability to recall immediate, recent, and past information.

Values-based Practice

a multidisciplinary treatment team approach that respects different values. Specifically, values-based practice begins with prioritizing or centralizing the values of the service user or client, respects the diversity of values represented by other professionals on the treatment team, and is consistent with and is intended to complement evidence based practice.

REFRAMING

also called relabeling exploring how something is perceived and offering another view; helps client change emotions, meaning, or options; change perceptions of limitations. Opens a window of hope. Helps client understand multiple meanings of situations, search for understanding that is impeding the client, and search for useful ways to deal with situation. Useful in family therapy to shift focus from "scapegoat" and see how entire family is affected by issue. With individuals, useful to help client reduce defensiveness and move toward change, useful to shift focus from "simple" behavior traits to looking at cues associated with the behavior, and helps clients achieve self-efficacy. Clients realize the conflicts at the root of the issue. For reframing to be effective, must be acceptable to client, and helper must be aware of cultural factors. Reframing Meaning when this is done with a client, the helper is challenging the meaning the client has given to a situation. If the meaning has been in place for a long time, that is the only way the client views the situation. Reframing helps client view the situation differently. Does not necessarily change behavior at first. Six steps to reframe meaning: (1) Treatment rationale - attempts to strengthen client's beliefs that perceptions about a situation can cause distress (2) Identification of client perceptions and feelings - help client become aware of automatic responses to problem. Responses may be a feeling of anxiety or lack of confidence and can lead to impaired performance or avoidance of a situation. Can role play or use imagery and ask questions to help client develop awareness (3) Deliberate enactment - client reenacts situation and attends to those automatic responses. This helps client become more aware...and awareness can bring about control of responses (4) Identification of alternative perceptions - look at another feature of situation rather than ignoring it. The feature and its link to the situation must be agreeable/valid to the client. Helper's delivery of reframe - nonverbal behavior must be congruent with tone, emphasis on certain words, and content of reframe (5) Modifications of perceptions in area of concern - role play and imagery useful - client can look at other features of the situation so client can gradually experience relief, optimism, hope (6) Homework and Follow-up - in vivo client is to be aware of features of a stressful situation, be aware of uncomfortable feelings, engage in practice activities, and try to make the changes sought.

Personalizing

assigning disproportionate self-responsibility or self-blame for negative events; perceiving events as linked to oneself without evidence.

Labeling:

attaching global traits to oneself and others that typically are negative.

What is a micro-aggression? p. 85

brief, everyday exchanges that send denigrating (belittle, criticize) messages to a target; sender often unaware; has to be assumption on part of sender; not intending to offend; impact is offensive b/c of assumption; assumption is clear; form of condecension

examples of physical relaxation? p 425

direct action coping methods (modeled first): breathing techniques, muscle relaxation, meditation, and exercise.

Explain how to draw and use an ecomap? Pp. 238-239 (see Learning Activity 7.1)

ecomap- tool for assessing context and environment. client writes his name or "me" in the middle of the paper and draws a circle around it. then around it writes things like friends, family work, religion, community. then draw circles around each thing...the bigger the circle the more influence this has on client. then draw lines and define those lines. ex. dotted line could mean there's stress. then talk about it.

give examples of mental relaxation? p 425

mental relaxation: 1) attention diversion tactics which may build on early introduction of escape route strategies - concentrating on a problem to solve, counting floor tiles in the room, recalling a funny joke, or thinking about something positive about themselves. 2) Imagery

Gradual (Systematic desensitization)

method of gradual exposure over time. Initially conducted using imagery/visualization.

What are the basic guidelines a counselor gives to a client for mindfulness meditation? pg 458

mindfulness meditation therapy focuses more on altering the client's attitude or relationship to the thought. Mindfulness Meditation Attitude of acceptance of "what is," nonjudging of one's experiences in the present moment Effective in working with pain, anxiety, and sleep disturbance; terminal disease, addictions Steps: Rationale Instruct client about attitudinal foundations for mindfulness practice Instruct about commitment, self-discipline, and energy Instruct about preparations for meditation Do a quick body scan to relax client's muscles Provide instructions for breathing Instruct about a wandering mind, focus on breathing to control the mind. Instruct client to sit quietly, close eyes, be present in the moment, 10 to 20 min. Come out slowly. Inquire about the just-completed meditation experience. Homework.

clarification

often begins with a question, often posed after an ambiguous client message Ex. "Do you mean that...:" or "Are you saying that..." then followed by a repetition or rephrasing of all or part of the client's previous message. Goal: encourage elaboration, check accuracy, clear up vague or confusing message

Negative filtering

paying disproportionate attention to negative information, not allowing competing positive content to filter in

What if?

persistent worrying about possible negative outcomes,"yes, but"blocking of others'suggestions, failing to be satisfied with answers and explanations

paraphrase

rephrasing of the content part of the message (the part that describes a situation, event, person, or idea). Goal: help client focus on content, to highlight content when attention to feelings is premature/self-defeating.

Core attributes & skills

skills & attributes: qualities, traits, learned behavior SKILLS? Self-awareness & self-reflection Mindfulness Self-care & self-compassion Promote stamina & resilience Avoid burnout, compassion fatigue, empathy fatigue STAMINA = Selectivity, Temporal Sensitivity, Accountability, Measurement/Management, Inquisitiveness, Negotiation, Acknowledging Agency Resilience - develops from social support (DOVE = desire, opportunities, values, education) Clinical competence Commitment to: lifelong learning, collaboration, values-based practice, beneficence *Self-compassion - balance concern for self with concern for others · ATTRIBUTES? Warm, Calm, Patient · Empathetic · Genuine/Authentic · Confident, Sense of Humor · Positive, Hopeful, Trustworthy · Values/Ethical Professional · Able to Set Boundaries Knowledgeable/Credentialed · Eye contact, Observant · Clear, Good Communicator, Good listener Culturally competent

Briefly describe the process of formulating a Goal Pyramid. P. 292

ultimate outcome goal - end point of therapy; directly related to presenting problem. ex. to think, feel, and look like a healthy person by losing 40 lbs in a year instrumental AKA intermediate outcome goals - goals that are achieved along the way and are instrumental to ultimate outcome goal; "stepping stones" steps to take to get to the outcome goal. goal pyramid: draw it... make subgoals: easiest and quickest to achieve at bottom (walking one mile per day) to the top goal (maintain previous 6 subgoals over the year)

unconditional positive regard

value the client as a person; commitment to working w/ client; nonjudgemental attitude; warmth