NCMHCE Review Treatment Planning

Welcome to the NCMHCE Exam Review Podcast. I'm your host, Dr. Donnelly Snipes. This podcast is brought to you by Counselor toolbox podcast and allce.com counselor continuing education, where you can get unlimited on demand CEUs for $59 or or unlimited live webinars for $40. Go to allce.com hey there everybody, and welcome to this episode of the NCMHCE Exam Review. Today we're going to be talking about treatment planning. Now, there are going to be several episodes on treatment planning because there are a lot of issues that NBCC wants you to be able to plan for, but we're going to start out with some of the most common ones. I am Dr. Donnelly Snipes and I will be your host.

In this episode, we're going to review.

Goals and interventions to address anxiety, anger, grief, blended families, and child issues.

And I'm going to give you some.

Hints on things you need to know for the ncmhce as well as a.

Couple of places you might be able.

To go to figure out a little bit more about what might be on the exam so you don't feel like you're just kind of flapping out there in the wind. Let's start by talking about anger and aggression.

Now, unless it's intermittent explosive disorder or.

Something, this person may qualify more in an adjustment disorder diagnosis, but their symptoms are of anger and aggression.

The first thing that you want to.

Do, even if it's not intermittent explosive disorder, is rule out danger to others and potentially the person's self. Making sure that you know how to do those safety evaluations is going to be really important.

You also want to rule out substance use.

Many times, people's anger and aggressive issues come out more strongly when they're under the influence of substances. So if you determine that the person tends to be angry and aggressive when they're under the influence, then that may be a treatment goal.

However, for anger and aggression, your goals.

In general are going to be to increase awareness of the person's angry feelings, triggers, and responses. We're going to talk about interventions to do some of this in a minute, but you want to start thinking about in general, what do I want to do when I see this particular diagnosis to help this person start feeling better?

In almost all cases, the first thing.

Is going to be increase awareness. The answer need to become more aware of what their feelings are, what their automatic responses are, cognitive and behavioral, and start to become aware of what the triggers are for that. Now, if you use a psychodynamic Perspective. You may also go backwards to figure out why is this triggering to you based on prior experiences. But that's depending on your approach.

You're going to want to decrease the.

Frequency and intensity of the dysphoric feelings, in this case, anger.

Well, if somebody's angry 21, 36 times a week, we want to decrease that. And you want to make sure you're.

Setting reasonable, measurable goals. You're not going to say, eliminate it, because that's not realistic. The Average person experiences 15 anger situations per day. Now, how intensely we respond to it is, you know, differs from person to person. But we want to have that person decrease the frequency and intensity of their anger situations and start feeling like they are less on the defensive all the time.

You want to help them increase their.

Awareness of alternatives to aggressive and angry responses. When something happens, you may get angry. Anger is a very reasonable emotional reaction, initial reaction to the fight or flight response. You know, it's part of that threat response, totally normal emotion. It's what you do with that anger that can be constructive or destructive. Encouraging people to start practicing mindfulness and radical acceptance, and those sorts of things are going to help them start identifying their anger feelings and then making better choices about how to respond, whether they just tolerate the distress and move on or what other skills they can use.

And you want to increase the person's.

Ability to use assertiveness skills to address triggers for anger and aggression. When they figure out what triggers their anger and aggression, help them figure out how to use their assertiveness skills or whatever, coping skills, problem solving skills to minimize or mitigate those triggers as much as possible. And then when there are things that happen that are just not preventable, make sure they have the assertiveness skills, the distress tolerance skills, and the communication skills to deal with whatever's going on that's triggering their anger without being aggressive.

Some of the interventions that you can use, well, start out by increasing awareness.

Through daily journaling or logging. Not everybody wants to write in a journal, but they might be willing to keep a little pad with them or keep some something on their. On their mobile device where they can log each time they get angry, what it was about, the intensity of the anger and maybe how long it lasted. Now the last one's a little bit more dicey in terms of getting people to realistically keep up with it. At least you can get a frequency and intensity out of them and that will help you get a better idea. Now, if you can get them to even retrospectively, like at the end of the day, go back and identify how long they stayed upset. That'll be good too, because some people get angry and then it's over with. Other people get angry and they stay ticked off for the rest of the day. And then things keep piling on and increasing their anger. And it's just this snowball effect. We want to look at that. We want to figure out if we can help people figure out how to accept their anger and improve the next moment so they can move out of that angry headspace.

You want to help the client reflect.

Upon and address anger triggers and aggressive behaviors. What things make you angry? And when they're doing their logging, they're going to be identifying what they got angry about. So you can go through that log and identify commonalities, maybe some themes or people that might be triggering to the person and figure out how to help the person better deal with it.

You can have them use backward chaining.

To identify antecedents to anger and aggressive behaviors. Maybe people tend to be more likely to respond with anger or aggression when they are put on the spot in public, or when they haven't had enough sleep, or if they've had too much caffeine or on the days they're actually at work. Those are some things, you know, we want to look at and identify some of those triggers to figure out how to mitigate them.

You may have them construct a genogram.

To identify multi generational triggers for and methods of dealing with anger. We are social learning creatures. So people who grew up in a household where somebody else was regularly angry could pick up on different triggers. I see it, you know, in my kids, they get triggered by some of the same things that trigger their father and I. And you know, my son will start talking politics or here he hears anything about politics and he starts ranting. And you know, he is definitely triggered by that. By learning from watching his father and his grandfather.

Have the person list prior experiences which have caused hurt and process.

Those experiences to move toward forgiveness and release anger.

Anger comes in a lot of different forms.

It can be resentment, it can be anger, it can be frustration, it can be irritation, it can even be guilt. That's anger at yourself. Helping people figure out all of the different permutations of their anger and deal with it so that energy is not locked up in the past will help them feel liberated and be able to maybe envision things or perceive things a little bit differently in the present.

Have them identify current triggers and targets.

For anger and address those what triggers your behavior in the present and who Are the targets when you get angry, do you typically take it out on somebody? Sometimes people may not like their job and they have a bad day and they get angry at work and they come home and they take it out on the people that they live with. Well, that's worth knowing. So they can figure out a better place to diffuse their anger, like at the gym.

Have them identify at least five alternatives.

To verbally and physically aggressive behavior. What else can they do with that energy when they feel like they're just going to bust? Have them rehearse anger management skills in session. Give them scenarios. You can even use systematic desensitization. Have them imagine themselves in a situation that they've talked about that makes them, you know, wickedly angry and role play it with them with more appropriate anger management skills. You can also have them use guided imagery. Imagine themselves in that situation, maybe dealing with a customer service representative or dealing with their boss or their in laws or whomever. Have them imagine that and imagine themselves using their new skills effectively to deal with that situation.

You may refer to courses for people.

To learn effective communication or assertiveness skills, or you may teach them yourself and bibliotherapy. Bibliotherapy comes up a lot on the ncmhce. So just be aware that it's out there. I realize it's not for everybody and you know, you want to take that into consideration when you're making these assessments. If the person you know, if you're dealing with a 10 year old, bibliotherapy probably isn't going to be the best option. If you're dealing with a teenager or an adult may work really well. If you're dealing with somebody with cognitive impairment may not be the best choice.

Let's move on to anxiety and we're.

Just going to talk in general about mood disorders here. Your anxiety and your depression in general.

You want to rule out ptsd.

Make sure that you're not dealing with trauma.

The goals are to increase awareness of their anxious feelings and responses.

Again, keeping some sort of log, getting some sort of baseline so you can figure out how bad it is, you know, and see visually how often these things are occurring, how intense they are. That way as treatment progresses, the person can actually visually see the effect of treatment.

You want to increase awareness of triggers for anxiety.

What is it that makes you anxious? And you know, people.

Some people may not realize, especially if.

They have generalized anxiety disorder, they may feel like everything makes them anxious.

So we want to start talking about.

What specifically about driving makes you anxious? What specifically about starting a new job or meeting somebody new makes you anxious? And how can you address it?

You want to decrease the frequency and.

Intensity of anxious feelings and enhance distress tolerance skills. There are always going to be occasions where we feel anxiety. Just like anger is a very natural response to the fight or flight reaction, so is anxiety. Anxiety is the flight part. When you get fearful, you want to get the heck out of there. Acknowledging that and not saying that anxiety is bad, just saying, okay, I'm anxious. Now what can I do about it? What is the best strategy for me to use in order to help myself get out of this anxiety loop?

We want to have them increase awareness.

Of ways to cope with anxious behavior when they're, you know, maybe they're waiting for somebody to get out of surgery. And that is, you know, frustrating because you just, you're anxious, you want to find out what's going on, you want to make sure that they're okay and there's nothing you can do. You feel a little powerless. So you can be irritable, you can bite people's heads off, or you can do other things. And what is it that helps that person tolerate distress when they're feeling anxious?

We want to help them improve their problem solving skills.

Sometimes anxiety comes from problems that are not effectively solved. So looking at what are the things that make me anxious and is there something that I can do to have them make me less anxious? My daughter is starting to drive now and that makes me really anxious. So I can be anxious the entire time she's not in my sight. That wouldn't be helpful for anybody. Or when she's driving. When she goes out, she lets me know when she arrives at her destination, she sends me a text, she lets me know when she's on the way home and, and then obviously I know when she gets home. Now as she gets older, I won't need her to check in that much. But she just got her license and you know, it's a little nerve wracking, so it makes me feel better and she's okay with it. So that's a problem solving skill where we're both okay with it.

You also want to enhance people's self.

Efficacy when they feel anxious. Anxiety is fear. That's a fear that you won't be able to handle what's coming towards you or a fear that you won't be able to survive somehow. It's a fear when you feel efficacious. You feel like you have the strength and the resources and the abilities to Deal with whatever life throws at you. We want to increase people's self efficacy by increasing their successes and helping them see ways that they have.

Gotten through.

Challenging situations in the past.

Interventions, you know, again, they can run.

Their gamut depending on your theoretical approach, but in general you want to have them identify anxiety when it begins instead of waiting until they're in full, full blown crisis. Mindfulness can be helpful here. Encourage daily journaling or logging to identify and track frequency, intensity and duration of anxious feelings.

Have them reflect upon and address triggers to their anxiety.

Use backward chaining to identify the antecedents to anxious behavior, what led up to it, and use cognitive interventions to address prior traumatic or fear related experience experiences. When my grandfather got older and his Parkinson's really took hold, he would get frantic when my grandmother would leave the house. Whether it was to go to bingo or to go up to the grocery store. He would pace around like a caged cat and get angry and irritable and just frantic when she was gone.

If I were his therapist, we would.

Reflect upon and address triggers, talk about what he might be concerned about. And basically he was concerned that if she didn't return he wouldn't be able to survive. They were kind of enmeshed and likewise he felt guilty because he wouldn't, you know, if something happened to her then and he wasn't there to protect her, then somehow it would be his fault. And some of that comes from the generational teachings. But processing that with the person and helping them reflect on, for example, how many times my grandmother went to bingo and went to the grocery store and came home and you know, there was no problem, that might be something that you would do. Again, it's important to identify what's going on with them and if there's any prior traumatic or fear related experiences that may be triggering this current reaction to the present situation.

Have them learn at least five coping.

Skills to deal with anxiety and five distress tolerance skills. Remember, distress tolerance just helps people ride out the emotional turmoil until they can get back into their their wise mind. As Linahan would say, coping skills help them deal with the situation. And again, bibliotherapy is an option.

Blended families is another issue that you.

May see on the exam. Obviously that's not a DSM 4 DIA 5 sorry, DSM 5 diagnosis, but it may occur. And I can tell you when I took my test, I think only one of the scenarios was actually a diagnosable DSM 4 back then condition. So a lot of these issues are going to be common issues that Are seen in practice, that may not actually rise to the level of a clinical diagnosis. Maybe adjustment disorder, I don't know. You have to be able to make that call Anyhow. If you're dealing with blended families, one.

Of the first things to do is.

Assess the expectations of each family member. And depending on your approach, you may do that individually, you may do that as a group.

You want to contact the schools for.

Information about the children to figure out, you know, if there are any issues going on with them behaviorally at school.

And I put that in there just.

Because if they ask you, are you going to contact any collateral sources?

When you're dealing with kids, it's always.

Helpful to have some collateral information. You obviously, you have the parents there, you have the children there. Then if you can get the school and maybe the pediatrician, if it seems appropriate, then that would be helpful.

The goals with blended families in general.

Include developing a new family identity. What does this new family look like? Help each person develop a new identity as it relates to that family. It doesn't mean, you know, if Sally is, you know, Sally Smith, it doesn't mean that she has to quit being a Smith. Her father is, you know, John Smith. Her father will always be her father. But what is this new identity she's taking on in addition to that old identity of being John Smith's daughter? Now she is part of this new.

Family, and encourage them to.

Recognize the new identity that needs to be formed in addition to, not instead of in addition to the old identity. And maybe different ways that those identities might need to morph a little bit or adjust.

You're going to have to redefine roles within the family.

You often have, you know, kids coming in and, you know, each family may have a dominant child, and each family may have some more subordinate children, and each family may have some the smarter, smart child. And each family may have the athletic child or however you want to label them. But once they come together in a blended family, they're going to jockey for position to figure out who takes what role. And it's going to be important to define those roles, hopefully healthy roles within the family, and make sure each person feels like they have a place.

You're going to work with each person.

To identify and resolve losses. When families blend, it often means at least one of the families is moving. So they are moving out of their house. They're losing the house that they lived in. They're losing the neighbors they had. They may even be going to a different school. That can be really traumatic for A lot of people identifying any losses that are occurring on a more abstract level. If one of the families or both of the families, the children used to have their own bedroom, now they have to share bedrooms. They're losing privacy. There are a lot of different losses that may occur that it's important to identify and help the person work through any resentment or frustration.

Help them develop tolerance and flexibility as a family.

Be tolerant of one another, understanding, you know, every person has their own unique quality, quirks and characteristics. Create a parent coalition so the children don't split the parents. You don't want Jane's children always going to Jane and saying, you know, I want to see this happen and then Bill's kids always going to him and pretending or acting as if the non biological parent has no power. It's important that both parents form a coalition and present a unified front.

And everybody in the family, not just the parents, everybody is going to need.

To develop effective conflict resolution skills.

Interventions. Well, the first step is to normalize. Blending a family is tough for everybody.

Feelings of anxiety, anger, resentment, curiosity. Any feeling somebody has is a normal feeling. And we want to normalize how challenging this can be.

You want to identify and process the.

Losses with people and empower each person to create a new meaningful identity. Encourage verbal expression of all emotions, including guilt, resentment and feelings of failure or abandonment, especially younger children. But it can happen in older children where they may feel guilty, they may feel like it's their fault that their parents split up.

They may fear or feel like they've.

Been abandoned by the parent who is no longer the custodial parent. The parents may have feelings of guilt about the breakup and the turmoil that's being caused. We want to understand how every person feels and really get those feelings out there. This area is good. Verbal expression is helpful, but sometimes you need to start slower with maybe some art therapy projects and start getting it out there visually and then having the person explain their project in order to really highlight those feelings.

Explore parental misperceptions about blending families and.

Misperceptions about the children. A lot of times parents misunderstand children's behavior and they think it is oppositional or uncaring or hateful or spiteful, when in reality the child is probably trying to communicate something. Helping parents look at behavior as a form of communication and evaluate what reinforcers might be maintained that behavior.

Educate parents about varying developmental needs of children.

Depending on the child's developmental age, they may understand the divorce and the blending very differently. Younger children tend to think very dichotomously very all or nothing, and very egocentrically, it's all about me, and I must have caused this or I should have prevented this. Older children tend to be more egocentric in terms of how can you do this to me? But we want parents to be able to understand how children are conceptualizing what's going on and developmentally, what they need to feel safe and secure.

You want to strengthen the identification of.

The new family unit. I talked about creating a parent coalition, but also strengthening the new family unit. And again, art therapy projects can be really awesome here. Encourage them to do things that are fun together, but maybe create a family flag. There are a lot of different things that people can do to open discussion and create a sense of cohesiveness.

Identify and address conflicts within the blended.

Family and with extended family members, including ex spouses. When we think of blended families, we tend to think of conflict within the family and maybe conflict with the ex spouses, you know, who gets visitation when, and all the responsibilities, and what do you say when the child's not, you know, with me and all that kind of stuff. But we often don't pay enough attention to the conflicts or reactions of extended family members. So the step grandparents, how do the children interact with the step grandparents, and how are they received by the step grandparents, etc.

And ensure all members have personal space.

And can create a sense of home. It's not just a house. You want each person to be able to feel like it's a home. They need to have a sense of security and safety. They need to have a place where they can put their stuff, where their siblings aren't going to rifle through it all the time. All of those things that you would normally want to make sure in a.

Non blended family are true.

In a blended family, everybody needs to have a sense of control over their personal environment.

Another issue that may come up is.

Working with child clients.

And this one always frustrated me because.

I know in the setting that I.

Work in, I'm not going to work with child clients. However, you have to be aware of.

It for the ncmhce. Therefore, you also need to be aware of all of the confidentiality issues and everything else that we're going to get into a little later.

When you're working with a child client, the first thing to do is complete.

A comprehensive developmental history and refer for psychological testing as needed for any suspected neurological issues like adhd. If you don't do that testing or fetal alcohol spectrum disorders, anything you think may need to be assessed that fits with the client's presentation. Interview the parents and the child and encourage the parents to use behavior rating scales. This will give you two bits of information. Number one, how the parents rate the child. Well, three, I guess how the parents rate the child in comparison with how you rate the child on those behaviors. When you're interacting with the child will give you an idea of how the parents perceive things and whether they're seeing tragedy. When you know there's a little bit of disruption but it's not tragic, or if they're not seeing enough disruption.

It will also give you an idea.

Potentially of how the child behaves at home because the parents may be rating the child at home versus in your office, which might indicate that there are certain reinforcers and stimuli in the home that may be prompting maladaptive behavior.

And the behavior rating scale also gives you a baseline.

This is what the parent perceives as the child's level of misbehavior or maladaptive behavior right now, as well as good behaviors, their strengths and let's use that information to develop a treatment plan and start enhancing the strengths and reducing the maladaptive behaviors.

Get ancillary information from the school and the pediatrician.

Find out if there are any developmental issues that the pediatrician may have noted and if there are any problems in academics or getting along with others. Anything that the teachers or school counselor may have noticed. Set clear goals with the parents. Especially if you're dealing with young children.

Treatment planning with them is going to.

Be a little dicey. You're not going to really make a treatment plan with a four year old, so you're going to set clear goals with what the parents want to see change. Some of the goals are going to include decreasing maladaptive behaviors, improving interpersonal skills, increasing the child's ability to identify and appropriately express feelings, increase the child's use of distress tolerance and coping skills and improve the child and parents problem solving skills.

Interventions can run the gamut. One of the first things that you're.

Going to want to do or one of the things that's common to just about every treatment plan is parent education of skills to model and behavior modification tools. If you're going to teach the child distress tolerance skills, for example, then the parents need to understand distress tolerance skills and be able to model them. So when Junior gets upset at home, then the parent can point to the chart on the wall that has the distress tolerance skills and say, okay, let's.

Pick one that we're going to do.

Right now and let's practice that. That will help Both the parent and the child work on the presenting issues.

The other thing that you're going to.

Work on with parents is behavior modification tools. We know that behaviors that are rewarded are going to be more likely to recur, and behaviors that are either not rewarded or are punished are going to be less likely to occur. Ideally, we reward pro social adaptive behaviors and the other behaviors will extinguish. Depending on the child and the situation, you're going to look at different behavior modification tools and you might also start talking with the parent to identify some of the reinforcers that might be inadvertently maintaining the behavior, such as, you know, Johnny may act out and throw a tantrum at home and mom may not react to it, but it may get him a lot of attention from his siblings or vice versa. But we do want to look at potentially potential reinforcers that may not be being noticed.

Therapeutic play may assist children with emotional.

Identification and processing, and it's up to the therapist to set clear limits about what's acceptable in terms of ways to deal with emotions and help the child model that through play and family meetings and relabeling of a child's behavior are also effective interventions. Similarly, but not quite, are adult clients that you may see that have child abuse issues. Whether it's emotional abuse, sexual abuse, physical abuse, some kind of abuse. This is an adult client, so the person's over 18, the abuse occurred when they were under 18.

The first thing that you're going to do is assess for ptsd, depression, suicidality.

Substance abuse and dissociative symptoms. Figure out what's going on in all those areas. Your goals with this client are going.

To be to increase awareness of the.

Impact of the abuse, emotionally, cognitively, physically and interpersonally. Help them understand how it has shaped their life till now.

Help them process the trauma and integrate it.

Increase awareness of trauma related reactions. Help them understand, you know, why sometimes they get a twinge in the pit of their stomach sometimes, or why certain people may elicit certain reactions from them.

And enhance the use of effective distress.

Tolerance and coping skills to mitigate those trauma related reactions.

Interventions for adult survivors can include exploring the family of origin and identifying and.

Expressing feelings and thoughts associated with the abuse. Ultimately, we want to help the client let go of self blame and address unhelpful cognitions where they think it's their fault that it happened, and they may have been told that for many, many years by the abuser, helping them reclaim their power.

You may refer to a therapist that.

Is certified in EMDR or hypnosis if that's appropriate. That can help some clients work through trauma.

You're going to want to teach grounding.

Reorienting and distress tolerance techniques to address dissociation. When the person starts feeling anxious, when they start feeling hyper vigilant, help them get regrounded so they don't dissociate. And any of the grounding techniques that you know are good, the 5, 4, 3, 2, 1, or just focusing, finding all the things in the room that are green, whatever it is that helps them is going to be appropriate. I tend to have them write down a list of grounding techniques and keep it with them just in case they start feeling, as we call it in my practice, wonky and they can't remember. Okay, what am I supposed to do? What can I do to get a grip on this?

Consider internal family systems theory approaches to.

Help the client integrate the fragmented parts of the self. Enhance the client support network. Obviously, if their abuser was someone who might normally be in their support network, then that person is not going to be in the network. If for example, they were abused by a parent or a caregiver and the other parent or caregiver did nothing to stop it, then neither parent or caregiver is probably going to be appropriate for the support network, at least initially, maybe never. It's important for them to identify a supportive group of people. This also could include referring out to support groups once the person is stable enough in their recovery. Referring people to trauma support groups the minute they identify a trauma can be very triggering. And if they don't have the skills to deal with being triggered, then the support group might do more harm than good.

Refer to a psychiatrist or physician for.

Medication for mood symptoms as appropriate. And again, bibliotherapy. And finally, I think grief, the first.

Thing you want to do is rule.

Out depression or rule it in.

Remember in the DSM 5 they took.

Out the bereavement exception for major depressive disorder. So now you can have bereavement and major depression concurrently.

Assess for substance use and suicidal ideation.

When somebody is experiencing grief, it is not uncommon for them to self medicate with substances. And especially in cases when a spouse or a child dies, suicidal ideation may not be very surprising. So we do want to rule out those.

The goals are to increase awareness of.

The impact of the grief on the person. Help them recognize how their grief is impacting them. Is it? You know, some people get so caught up in their grief they forget to eat, they're not sleeping, they aren't able. Sometimes they don't shower, they forget they have cognitive dysfunction because they're so just overwhelmed and flummoxed with everything. Help them identify these symptoms that came on as a result of their grief.

Help them develop develop a vocabulary to.

Describe feelings of grief and loss and develop a short term action plan for dealing with grief and loss.

Short term action plans are not going.

To resolve the grief and loss. What the short term action plan is designed to do is help the person keep going and not develop secondary problems such as malnutrition, depression, etc. Help them identify ancillary grief and loss issues. They may present with a single grief issue such as a death, but it may also be triggering prior grief issues. So we may need to look at historical losses and identify if there's any grief issues that need to be resolved there and identify steps for moving toward acceptance and integration of these grief experiences or of these losses in the person's life.

Interventions include developing a support system. Refer people to support groups as appropriate.

If somebody is a survivor of suicide, then send them to a survivors of suicide group. If somebody is a survivor of, you know, their loved one died of cancer, you know there's a support group for that. If somebody's spouse just passed away of old age, you know, there's a support group for that. Help them find an appropriate support group with people who kind of have been there.

Help them identify current and historical losses.

Losses and process related feelings and cognitions including guilt, anger and depression. Guilt is a big one that we often overlook.

Challenge cognitive distortions or maladaptive thinking patterns.

Especially as they relate to guilt and hopelessness and helplessness. Refer to a physician as appropriate for depressive symptoms. Some people, when they are experiencing grief, are so completely overwhelmed in their bereavement reaction that they may benefit from some short term or PRN medications.

Empower clients to integrate the loss or.

Losses into their identities with narrative therapy. When I work with clients who've gone through losses and all of us have.

I encourage them to think of it.

Like writing a mini series or writing a novel or where you have clients or where you have characters that come into the story and they play a role. And then in this chapter right now they are leaving the story. Yet they they informed the book or the miniseries up until now, you know, and you won't forget that because that will always be written into those prior chapters. But how are you going to basically write that person out of the script and move on with the story? And just like in miniseries or series, on television and books, it's not uncommon to have flashbacks where you remember the person and their influence continues to affect you even after they're gone. I'm not saying with narrative therapy that you write them out of the script and you never talk about them again. What I want people to do is figure out how they're going to integrate this loss and how that person or being or whatever it is is going to influence them in the future.

And not all losses are people.

You can lose jobs, you can lose money. There are a lot of things that you can lose that you may grieve. You can lose relationships, not just to death, but to breakups. You can lose your health. Helping people grieve any of the losses that they may be experiencing, and then.

Make referrals to wraparound services as needed.

After my mother passed away, my stepfather didn't cook, never cooked, and he was now, you know, almost 90 years old and living by himself in this great big house and had no idea how to cook for himself and barely could do microwavable meals and those sorts of things. And it was important to make sure that we had somebody coming around not only to help him with that, but his mobility was getting kind of limited. So somebody to help him with the cleaning and also to make sure that he was eating. Even if somebody was bringing him his food, you couldn't guarantee he was going to eat because he was pretty overwhelmed with her passing wraparound services. In those cases, the hospice social worker came by regularly making sure that meals were delivered, and she made sure that he ate them and she monitored his weight and all those kinds of things. Transportation might be another wraparound service that the person needs. We want to make sure that the person doesn't, again, develop any secondary complications as a result of the primary issue.

As I said earlier, there are a myriad of issues, not just DSM 5.

Diagnoses, that NBCC wants to make sure that the counselor can address. So here's one of the little tips. Review the preliminary content outline, and it's hyperlinked here, or you can just search online for NBCC NCMHCE Preliminary Content Outline. And it's a PDF. It'll pop right up and it gives you an idea of the types of issues you may be asked to deal with. And the outline, I believe, is like 12 pages long. So don't be surprised when you use a fair amount of paper, but it breaks it down and you can go through bullet point by bullet point and go, yes, I know how to do this. Yes, I know how to do this. And maybe, no, I have no clue how to do this. I need to research it.

In preparing for the exam, consider making your own scenarios that involve not only.

A diagnosis like depression or adjustment disorder or bullying or something, but also administrative and ethical issues that may occur surrounding it. So if you're seeing a child who is being bullied at school and has developed some anxiety as a result, what are the ethical issues that you may face in terms of helping that child and that family in that situation? How much contact, if any, would you have with the school? You know, how's that going to be handled? So there's lots of ethical issues that you can probably come up with in your mind. I encourage you to think about cases that you've worked with that in your internships, as well as talk to your colleagues about.

Particularly cases that they've worked.

On that have had some sort of ethical or legal quandary associated with them where they had to think or seek consultation. Those are the best ones to try to brainstorm and work together as a team to figure out what the right answers would be.

So tips today we're going to talk.

A lot about confidentiality because this is a big bugaboo for a lot of people and I know it comes up on the ncmhce.

So HIPAA permits healthcare providers to communicate.

With patients, family members, friends or others involved in the patient's care under certain circumstances. And generally the circumstances are if the patient consents. If they sign a release of information, well, that's kind of a no brainer. If they are unable to affirm or deny consent because of incapacity, you may be able to communicate with those people to a limited extent. In order to facilitate the patient's care.

You may be able to communicate with the parent of a patient who is a minor.

And there are some exceptions to that. We're going to talk about that in a few minutes.

You do need to consider the patient's.

Capacity to agree or object to the sharing of their information and take into account the patient's prior expressed preferences regarding disclosures. If the patient has, in prior sessions when they were able to consent, said no, I don't want my dad knowing about this, I don't want to have him involved in any way. And then the patient becomes incapacitated, unable to consent or deny consent, and dad wants to know what's going on, do you do it? Well, unless there is some glaring reason why the client has already expressed her preferences that her dad not be involved in treatment, therefore you probably wouldn't.

You.

Are always able through HIPAA to Listen to family members about their loved ones that are receiving mental health treatment. You don't have to confirm or deny that you're treating that patient, yada yada, you can just say, I can't confirm.

Or deny that I'm treating that patient.

But if you want to, you know, tell me the story, I am happy to listen.

You can communicate with family members, law enforcement or others when the patient presents.

A serious and imminent threat of harm to self or others. And communicate with law enforcement about the release of a patient brought in for an emergency psychiatric hold. Typically, this just involves the informing the law enforcement officer that you've taken the client in and Baker acted them or whatever you call it in your state. Now, let's talk about some specifics here.

The Privacy rule permits a HIPAA covered.

Entity, such as the 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.

So you're not just going to call.

Up Jim Bob, Sergeant Jim Bob, when a client is going to be discharged after a 72 hour hold, unless that person was a suspect, fugitive, material witness or missing person. Once Sergeant Jim Bob drops the client off at the stabilization unit, if it's just any old client, then you're probably going to not have contact with that officer again. You may have contact with the patient's family depending on how who they're being discharged to.

If a health care power of attorney is currently in effect, the named person.

Is the patient's personal representative. Always know about health, healthcare power of attorney, and maybe you're working with a client who hasn't had prior psychiatric issues but has a healthcare power of attorney signed because they are undergoing treatment for end stage renal disease or stage four cancer and they may not be able to consent to certain types of treatment or something, then you can talk to the personal representative.

HIPAA generally does not require authorizations for.

Disclosures of protected health information between healthcare.

Providers for the treatment, for the treatment.

Case management and care coordination of the patient. If you are working with a team, even a team that's not all within your agency, you, you're working with a social worker at hospice, you are a mental health counselor. You're also working with the oncologist over here at the hospital and somebody else if you are doing it with them, and they are all covered entities.

In.

The auspices of coordinating care and coordinating treatment. You don't need a release of information for each one of Those people, the release of information is implied by the client seeking treatment. Except you're not going to release psychotherapy notes. HIPAA typically views psychotherapy notes as notes that the clinician uses to help them formulate case. Formulate the case treatment planning and figuring out what to do next. So basically, HIPAA views psychotherapy notes as your own personal little sketchpad, and that is not admissible. Even when your charts are subpoenaed, there has to be a separate subpoena for the case notes. And when people sign a release of information, they have to sign a separate release of information for psychotherapy notes. Very important to know that.

Other reasons that you may breach confidentiality.

We talked earlier about adult survivors of childhood abuse. Now, it's important to know that state laws vary widely. So you need to know the laws in your own state, which means this may not be an issue on the exam. But it's good to just kind of be aware that a state laws vary. And a 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 is 18 years of age or older. So if you have an adult survivor who said, this happened to me when I was 16 or when I was 6, however old, you don't necessarily have to report. But if the adult victim is an adult and the abuse occurred when the person was a child, and the therapist has reasonable cause to suspect that the perpetrator has subjected any other child that is currently a minor to abuse or neglect, or that this person is currently in a position of trust with regard to any child under the age of 18, then the therapist has to report. So if Sally is 22 and reports that when she was 14, she was abused by her uncle, who happens to be a middle school teacher, well, that changes the face of things a little bit because now Sally's uncle is currently in the position of trust with regard to minors and there is an allegation of abuse. Yes, Sally is an adult. So, you know, her being an adult and experiencing abuse alone is not enough. But since she's an adult and the alleged perpetrator is basically in a position where he can continue to abuse children, then a mandated report is generally called for. Again, state laws vary depending. One of the things I found when I was working in community mental health in the state that I was in, the abuse hotline was really helpful if there was a questionable, you know, do I call this in? Do I not call this in? We would call the hotline. We would get the person's number or badge number, and we would say, okay, hypothetically, if this situation occurred, would it be a report? And if they say yes, then you make the report. And if they say no, we're not going to take that report, then? No. Other people that I've worked with, clinicians, have said, if there's any doubt in my mind, I call, I make the report, I get documentation of it, and if the department decides not to do anything with the report, so be it. If you have questions and you don't have an attorney on hand, you know, like right there, then, you know, my suggestion would be to make a report. But do know that if the perpetrator continues to have access to his or her preferred victims, then you're probably mandated to make a report.

Other reasons for breaching confidentiality? Court orders. Now, this doesn't mean Sergeant Jim Bob showing up at your facility and going.

And asking if somebody is there. It means Sergeant Jim Bob showing up with a signed court order from a judge which says that you have to breach confidentiality. If you're being sued by the client, especially for breach of duty, then all bets are off. And case notes are going to be open, at least the chart, maybe not your progress notes.

So here's a 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. The client is not in the state of mind to consent or deny letting the father know. What's your best judgment? Now, this one's pretty obvious. The best judgment is not to notify the father. The father has. Just because he's paying the bills doesn't mean he has any right to have access to privileged health information. And, you know, obviously, assuming she hadn't given him sign sign a release of information, but in this case, we're going to assume she hadn't.

Another scenario. A client is referred for involuntary treatment.

By his department after his sergeant noticed erratic behavior.

Can you communicate with his sergeant about.

Progress and discharge without a signed release of information? This is an involuntary client. We're assuming that the EAP is paying for services, not the client. So can we talk to the sergeant? And the answer is no, unless the client represents some imminent threat to himself or public safety. And in that case, you would be, you know, operating under the Tarasoft mandate. But in general, the organization that referred the person for involuntary treatment does not have the right to be kept updated on protected health information unless the client signs a form. When I worked in Probation and Parole, I had all my clients were involuntary as part of their probation, it was written into their orders that they needed to participate in involuntary treatment and that the court would be notified of their progress and if they revoked the right for the court to be notified that they would have other consequences. Did I like that? No. But I didn't have any say over that. That's what the court did.

In the case of, you know, a.

Law enforcement officer, if he or she is referred for fitness for duty, the assumption is that a report is going to be made to someone but still get a release of information so you can share confidently your results. Again, unless you're doing this fitness for duty and you realize that the officer or whomever is a imminent threat to themselves or others, then obviously other rules kick in.

All right, those are some of my quick and dirty tips for the ncmhce.

Again, you can look for, and I've got it right here, the PDF online from nbcc. It's called the Preliminary Content Outline for the National Clinical Mental Health Counselor Exam, and it shows you the weight of each domain and the specific functions that they're actually wanting to make sure that you can do.

Remember, when you're doing these things, this.

Is a national test, so any.

Scenarios.

They give you are probably going to be things that are applicable nationally and not going to be affected by particular state laws.

All right, have a good day.

I will see you in the next episode. Thank you for joining me today. Subscribe to the NCMHCE Exam Review Podcast to be notified when new episodes are released.

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