Stages and Theories of Treatment for the Addiction Counselor & NCMHCE Exam Review

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 hi everybody and welcome to this week's episode of the NCMHCE Review or the NCMHCE Exam Review, whichever you want to call it. Today we're going to be talking about stages and theories of treatment. I AM your host, Dr. Donnelly Snipes. In this episode, we're going to review the stages of treatment and the theoretical approaches for individual counseling, including c behaviorism, humanistic and developmental. So you may be thinking to yourself, okay, how am I going to need this for the exam? Well, you could get a scenario in which you get all the information, you do the assessment, and then they ask you, which approach would you use and why? Generally they don't just say which approach would you use? And you pull out cognitive, behavioral or something. They'll say, would you use cognitive behavioral to address prior psychosomatic trauma? And you know that that's probably not the best use of cbt, so that probably wouldn't be what you would select. So in their responses, not only are you going to have to choose a theoretical orientation, but you're going to have to understand the why you would choose it and understand exactly what those approaches address. If you're talking, if it says you, would you use behaviorism to reduce the target problem behavior? Yes, you would use behaviorism for that. It's really important, and this is true for all of the different theories to know exactly what their purpose is and what their goals are in order to be able to select the best options. We're going to start out by talking about the stages of treatment. This is old hat if you've been doing counseling for a while, but again, when you're taking the exam, you need to pay attention to is this the first time you're seeing the client or have you been seeing them for a while, is this a middle stage of treatment, etc. In order to choose the correct interventions based on the multiple choice questions. The immediate concerns when you first meet a client are to evaluate the risk factors. What's going on? Is there any suicidal or homicidal ideation? Is the person in danger? Domestic violence? What have you? Establish rapport? Well, that goes without saying. Enhance motivation and hope in order to get people to come back, in order to get people to be treatment compliant, so to speak, they need to believe that their efforts are going to have a positive payoff for them. We want to enhance self efficacy, enhance motivation and help them see that recovery as they define it is possible. We want to address administrative and policy issues early on. This is when you go over your informed consent, your confidentiality. If you're dealing with minors, this is when you would set your policies with the parents about what you can and will discuss with them, yada yada. And then you make a preliminary diagnosis and or narrow it to a couple of diagnoses. The initial stages of the vignettes are really very vague most of the time. So you're gonna read through it and you may have a general idea that okay, this person is dealing with grief, or this person has an adjustment disorder or depression, but you're not quite sure. And remember in this test you're not trying to rule out, basically you're trying to rule in, so you think it's depress. So you're going to start looking for things to support your preliminary diagnosis. Then you move on to assessment and goal setting. During the assessment you want to ask questions. Now remember, you're probably going to want to do it from a culturally responsive perspective. Ask the client their perception of the problem. What's causing the problem, how long has it gone on, what makes it worse, what makes it better, when they have recovered, what is their hoped for resolution? What will it look like when their depression is gone? What will it look like when their PTSD is under control? You want to assess the impact on their psychosocial functioning in multiple dimensions. How is it affecting their relationships, their work, their mood, their health, etc. And what are their physical symptoms? Most mental health issues also have some somatic symptoms symptoms with them. So we want to look at the physical symptoms, the fatigue, the irritability, the hypervigilance, gastric distress, increased pain, any of those things. They may not be exactly in the DSM under a diagnostic criteria, but it will give you some information. You want to make observations. So not only are you going to ask questions of the client, but you want to make observations. How are they dressed? Just like you would in any normal assessment. And use collateral sources. The NCMHCE is big on gathering collateral information. Make sure not to gather too much. This can be one of those places they lead you on a wild goose chase. But it is helpful generally to get some third party information and treatment plan development. You want to be as specific as possible. So remember smart, specific, measurable Achievable, related or relevant, and time limited. Those are the characteristics of the goals you want to look for with your clients. When you read the vignette, you're going to prioritize the goals that you may have for that particular client or family. You need to identify the needs and services to meet those goals. Do they need a referral somewhere? Do they need family therapy? What's going on? Do they need interventions at school? Work with the client to select the most appropriate interventions. Now, this is really hard to do on the exam. It's hard for them to ask a question about this. But you do want to remember if you, if you have an opportunity to articulate that you're working in conjunction with the client, you want to articulate that and provide psycho education. During this treatment plan development, you're helping the client understand in general, you know, what might be contributing to their problem. And based on their perceptions, you don't want to contradict them. But you also want to tell them about the different options that are available for treatment. In the middle stages of treatment, you want to consider a systems approach. This is important. Consider a systems approach and involving family, or at least addressing contributions of family to the problem and or the solution. Teach mindfulness. Encourage people to start becoming more aware of their present moment and what their needs are, feelings, identification, so they can identify them and choose the appropriate responses. Distress tolerance skills to reduce their dysregulation when or if it happens. Improve coping skills to reduce core symptoms. You're going to want to improve social support pretty much across the board. There's probably going to be some social support element in there. Enhance self esteem and efficacy and regularly monitor motivation, resistance and unanticipated barriers to change. Just like in counseling, you know, things will come up that you didn't anticipate and they may throw that in in the second or third part of the vignette. When you're working through your test in the late stage, you want to solidify gains and generalize the skills to other areas. For example, mindfulness and coping skills can be used not only for being aware of and addressing depression, but also for being aware of and addressing or preventing anxiety and anger issues. Social support is helpful in again, recovering from depression, but it can also be helpful for behavior change or coping with stress or grief issues that come up. Helping clients see that, okay, you have these tools in your toolbox. How many different ways can you use them to, to help you stay on this right path, so to speak. In the termination stage, you want to consolidate gains by reviewing progress and enhancing efficacy. Ensure a support system is in place, develop a relapse prevention plan. And this is true for mental health too. You want to make sure the person knows what may have precipitated their depressive episode, what may make their depression worse, like staying in bed all day, and how they're going to handle those issues when they come up and identify and address issues related to termination. Sometimes clients are just super excited to be done and cured and fixed and ready to go however they want to see it. Other times, clients are very apprehensive because they feel like they made a lot of progress and they're afraid if they're not coming back in that they may start to backslide. You want to start addressing those issues. You may also need to address abandonment issues depending on the client that may come up as termination looms. Let's move on to theories. Cognitive Theory Cognitive theories are active, directive, and time limited. Cognitive theories are helpful for a huge range of issues that you may deal with, except you don't want to use them. In people who have dementia, are in an active psychotic episode, or have fetal alcohol spectrum issues, or really young children, it's a little bit harder to use. Cognitive Theories There are a lot of different cognitive theories out there. REBT Rational Emotive Behavior Therapy is one of the first ones you learn about in counseling classes. In rebt, the goals are to identify unhelpful thoughts, unhelpful emotions, encourage the person to give themselves unconditional positive regard and help them work on anger management. In rebt, anger is seen as being an unhelpful emotion. In cognitive behavioral therapy, the person focuses less on the emotions and more on identifying unhelpful cognitions that trigger reactions and identifying unhelpful behaviors that keep them from moving towards their goals and help them identify and choose more helpful thoughts and behaviors in order to alter alter the cognitive triad, their view of themselves and their perception of their esteem and their efficacy and all that stuff. Their view of the world, whether it's a safe or a dangerous place or it's against them yada and their view of the future, whether they can have a happy life or not. The cognitions that people hold Think about when people hold pessimistic cognitions, it's going to affect their sense of efficacy, their view of the world, and their view of the future. Therefore, if you can start altering those cognitions and helping them choose behaviors that are going to move them towards their goals, then you can start altering that cognitive triad. In dialectical behavior Therapy People are taught distress tolerance skills, emotion regulation, interpersonal skills and problem solving skills. DBT may or may not be on the exam because it is a newer best practice. Acceptance and commitment therapy is another newer best practice. In act, people practice radical acceptance. They accept how things are in the moment. It is what it is. They use mindfulness to be aware like a fly on the wall of their thoughts, their urges, their feelings, and again, just accept it radically. It is what it is. Then make a commitment to purposeful action. They identify their goals, they identify what's important to them. And from that position of radical acceptance, they say, okay, let me unhook from my feelings so I'm not acting out of an emotion driven place. Make a purposeful choice to do something that will help me move towards my goals in order to respond to the situation. Basically, how can I improve the next moment and start working back towards my goals instead of choosing something like drinking or sleeping or smoking or throwing a temper tantrum. That is not going to get me towards my goals, but it's going to use a lot of energy. Cognitive processing therapy is another new or best practice. But being aware of these things is important. And in cognitive processing therapy, one of the key things is the challenging questions worksheet. And it is heavily cognitive behavioral in its approach, but it helps people separate fact based reasoning from emotion based reasoning and really evaluate their thought patterns in an in depth way. Goals of cognitive therapies in general are to increase self monitoring and awareness, to identify unhelpful cognitions, to clarify and challenge underlying beliefs, to replace unhelpful triggers and behaviors with helpful ones. When they start noticing things that may prompt a cascade of unpleasant or unhelpful thoughts or urges, identifying those triggers and behaviors and replacing them. And when they start identifying unhelpful reactions, replacing those with helpful reactions, and to increase adaptive problem solving. Rarely is a problem going to be solved the exact same way every single time. People need to be able to adapt based on the context and the setting. Those are the general goals of cognitive therapy, which you know, as the name implies, it's cognitive. You're addressing people's thought patterns in order to help them feel better emotionally and change their unhelpful behaviors. Behavioral approaches have an emphasis on changing or replacing current behaviors by altering the antecedents, what comes before, what triggers the behavior and or the consequences, or the punishments or rewards through manipulation of reinforcement and punishment. Now remember, reinforcement can be positive. You give somebody something like money or a prize or affection, that's positive reinforcement, negative reinforcement. Now if it's reinforcement. It's going to have make somebody do it again. Negative reinforcement means taking away something unpleasant. So a parent might say, if you eat your main course, then you don't have to eat your vegetables. That's negative reinforcement. They're taking away the eating of the vegetables, which is seen as unpleasant. Or if you have a good behavior day today, then you don't have to go to bed at 8 o'. Clock. You can stay up till 9. Punishment reduces the likelihood that the behavior is going to occur. And there's positive and negative punishment. Positive punishment is adding a punishment, such as a spanking or getting yelled at. You know, that's really unpleasant stuff. Negative punishment is taking away something somebody wants, like taking away their. Their phone and putting the phone in timeout. That's. Oh my gosh, that's really punishing for a lot of people. I think it's punishing for me too. So remember, positive means the addition of negative means the subtraction of. But reinforcement always increases the likelihood of a behavior, and punishment always decreases the likelihood of a behavior. Behavioral approaches focus on observable, measurable behaviors, not thoughts or emotions. So if they suggest that you may choose a behavioral approach to alter Sally's feelings about her teacher, that's not going to be an accurate response. Behavioral approaches don't. If it can't be seen and measured, it pretty much doesn't exist. In behavioral approaches, you always gather baseline data and conduct the functional analysis. Baseline data means how often is it occurring, to what degree is it occurring before the intervention. And the functional analysis looks at what things might prompt this behavior, what triggers it, and what are the rewards that are maintaining this behavior, and what function does the behavior serve for the person? Interventions and behavioral approaches are conducted in the person's natural setting. You're not going to do something in your office. You're going to go to the child's classroom, if that's where they're acting out at, or to the child home, wherever the behavior naturally occurs. And the intervention is going to be implemented there, preferably by their significant others, because it has a lot more weight and it can be implemented a lot more consistently if it is implemented by somebody in that person's immediate lifestyle or immediate family group. A therapist is not going to be there 24, 7. A primary caregiver is, a spouse is. There are a lot of different ways to implement these things. Techniques and behavioral approaches include systematic desensitization. Remember, back to counseling 101. You are helping somebody deal with something like a fear of flying by first learning how to relax, then imagining an airplane or imagining flying and getting to the point where they can imagine flying and get themselves relaxed. So when they imagine flying, they aren't stressed anymore. And then move up to the next step, which may be going to the airport, not to fly, but just going to be in the airport and getting to the point where they can be in the airport and relax themselves so they don't get stressed out just being in the airport. The next step may be boarding a plane. Again, not to fly, just to sit in the seat and smell the smells and all that kind of stuff is a step by step process where a person does something that's anxiety provoking and relaxes themselves until the point that they can do it without it triggering anxiety. Flooding, on the other hand, is when you take somebody and you say, all right, you're going to learn that this is not as scary as you think. And they are put in the midst of it. If they're afraid of flying, they're put on an airplane to fly. If they are afraid of spiders, they are asked to hold a spider. You know, flooding is a really intensive, you know, episode, if you will. Assertiveness training is another behavioral approach in which people are trained to use assertiveness skills. Aversion therapy. The most common example of aversion therapy is when people take ant abuse for alcohol. So when they drink, they get violently ill. That's aversion therapy. Extinction is when somebody does a behavior and there is no reward for it. If, for example, you did your chores, you cleaned the house just super well every single day, and it was spic and span and sparkling clean, but there was no reward for it, or you went to work every single day for a month and you didn't get paid. At a certain point when there's no reward, you're not going to go back to work again, you're not going to keep doing that behavior, and that's when the behavior is said to be extinguished. Token economies are frequently used with children in order to manage behavior. They get tokens based on positive behaviors, and they can cash in those tokens for privileges or rewards of some sort. Be aware of these different behavioral approaches now in systematic desensitization and flooding. When we talk about relaxation, we're not talking about necessarily feeling calm. We're talking about monitoring people's blood pressure and heart rate and their respiration rate. Those are all observable and measurable signs that their threat response system, their HPA axis, is calming down in humanistic models. We are seeking to understand people's subjective experience. Humanistic and behavioral are kind of polar opposites of one another. In humanistic models, there's unconditional positive regard for people's uniqueness and their wholeness. They are needing to be recognized and encouraged to recognize themselves for being awesome for just who they are. This kind of sounds similar to REBT in that respect. There's a belief in people's natural tendency to move towards self actualization and growth when obstacles are removed from their path. Humanistic models view problems as stemming from an incongruence between the self perceived conditions of worth. If I feel like I am not good at math and sciences and I feel like my family puts a high priority on math and sciences, then I may feel that I am letting them down or I am unworthy. If I feel that the characteristics and values that I hold and I embody are not worthy of love, if the people in my life are not rewarding those behaviors and they're not communicating that those behaviors or characteristics are valuable, then there's an incongruence. I'm feeling like I don't fit, like I am not enough. That is the basis for distress in most humanistic models. The overall goal in humanistic models is to achieve congruence between the self and the experience. Recognizing who are you and being checking some of those beliefs. Because you may think, you know, my daughter's going through this period right now where she doesn't see herself as being competent and capable with the math and sciences and she's actually far more skilled in math and sciences than she really perceives herself to be. In humanistic models, the person would be encouraged to look at the evidence of what their belief is about their capabilities or who they are versus the evidence, you know, are they perceiving reality in this accurately, so to speak. And they're going to encourage people to enhance their ability to cope with problems. Sometimes you aren't going to be in congruence with your environment. Your environment may want something from you that you just can't give it, how do you deal with that? Rogerian therapy views assessment and diagnosis as detrimental. We know we have to do it for insurance purposes, but I just figured I'd throw that in there. Gestalt therapies are designed to increase self awareness. Now you remember the videos with Fritz Pearls increasing self awareness. If somebody's sitting in their chair and they're shaking their foot rapidly asking them what that foot is trying to say, making them aware of their verbals and nonverbals increase the sense of responsibility for their actions and their destiny and to help clients gain intrinsic rewards instead of needing extrinsic ones, they can basically self reward behaviors and whatever else. Techniques in Gestalt therapy include encouraging awareness of the present moment using I language instead of you make me feel I feel when you blank adding the phrase to and I take responsibility for it to statements. So instead of saying you make me feel unworthy when you do this, saying I feel unworthy when you do this and I take responsibility for it. In order to encourage people to start identifying that they do have the responsibility for their feelings and their cognitions, you can also use the empty chair technique. I think most of us have used it at least once. Reversal is when you swap places. If you're having a talk with a client who is saying their spouse is just not being sensitive or doesn't understand having them reverse roles and have them pretend to be the spouse and role play it from their shoes and rehearsal is just like it sounds. If somebody is getting ready to do something, rehearsing it in session so they don't feel as anxious about doing it. Developmental Models when working with children, many times the family is integral to the treatment process. General questions that you want to answer in an assessment when you're working with children, has there been any disruption to the homeostatic balance of the family? It could be a divorce, it could be a separation, it could be a marriage, it could be a new baby. It could be, you know, a blended family. It could be somebody went into the hospital. Anything like that could disrupt the homeostatic balance of the family. You want to look further than just the nuclear family. For example, after my mom died, you know, she was not in the nuclear family, so to speak, but it did disrupt the homeostatic balance for a while because I was off my A game which altered what was going on in the family. Our members permitted age appropriate autonomy. A five year old is going to have less Autonomy than a 15 year old. We want to make sure that they have the ability to grow and have appropriate levels of autonomy. Which life cycle transitions have been experienced and how have they been managed for kids? And you know, I have teenagers now, so we've gone through some life cycle transitions from going from middle school to high school, from high school to college, beginning dating, beginning driving. All of those things are life cycle transitions. And if you manage them well, then future transitions are often not difficult. If those transitions are not managed well, then it can cause some difficulty and friction within the family system. How does this influence how prior life cycle transitions were managed. How does this influence current patterns and future transitions? Another transition, if you will. It's not really a life cycle transition, but another thing that I often see when I work with families that have person with an addiction in it. One family member may feel like that person needs tough love, they need to be cut off, they need to be sent to treatment, whatever. And other family members might not agree. And if that starts causing, if how to handle this problem starts causing friction within the family, then it could lead to the people who don't think the person needs to go to treatment, enabling that person and the person who thinks that treatment is necessary. Feeling very ganged up upon, so to speak. When you're talking about developmental models, Erikson and Piaget kind of come to the forefront of your mind when you're thinking about age. Now remember, Erikson is not just childhood. Piaget kind of stops at late adolescence because that's. He's talking about your cognitive development, so to speak. Erikson's trust and mistrust, that's that infancy stage where children learn to trust in their caregivers. That corresponds roughly with Piaget's sensory motor stage. Erikson's autonomy and shame. The toddler years corresponds roughly to the pre operational stage of Piaget. Initiative versus guilt. And this is, you know, three to five year olds, they're starting to dress themselves, that sort of thing. They're not quite in school yet. This is still pre operational according to Piaget. Industry versus inferiority is your middle school age, if you will, your elementary and middle school concrete operational thought. When you're talking with children at this age, they need concrete examples. They have a hard time hypothesizing and thinking outside the box. This is one of the reasons we generally don't teach things like algebra until later in, later in school. Because children just have a real hard time conceptualizing things that aren't concrete and then identity versus identity confusion. This starts happening in adolescence and it also corresponds with the formal operational period when adolescents are starting to be able to hypothesize, to think about multiple options, etc. The next stage is intimacy versus isolation. This is during that period of young adulthood when people are typically coupling up. Maybe not getting married, but coupling up and finding a life partner. Generativity versus stagnation is later in life when people reflect and they need to feel like they're making a difference in the world. And then integrity versus despair is old age, when people look back over their life and they'll either feel like they used their energy and their time on this. On this earth wisely. And they will feel a sense of integrity or they will feel great sense of despair and regret. Why do we care? Because on the test again, if you're dealing with somebody who is 78, then you're going to be dealing with some of those integrity versus despair issues. Potentially, if you're dealing with somebody who is a teenager, then you may be dealing with some identity versus role confusion issues. It is important to understand what kind of psychosocial crises are common for that person at or for people at that particular age group. Vygotsky I'm just going to throw him out there in case you need to remember him. He proposed the zone of proximal development. And that's the difference between somebody's current capabilities and their next level of capabilities. Zone of proximal development is kind of that no man's land in the middle. They're really good and they're super confident at what they can do. They just need a little nudging to get to the next level of development. Vygotsky encouraged the use of scaffolding in order to encourage cognitive development from the zone of proximal development. Scaffolding is when you let the person do as much as they can do until they get to a stage stuck point. And then you provide as little help as possible, but just enough to keep them moving forward to help them complete the task. Think about if you've ever taught a child to tie their shoes. Scaffolding is very common. During this, you teach them first how to put the shoe on, and then you teach them how to cross the laces and tie it the first time. And then they get to the. Generally they go from there to making the first bow really quickly. But once you start wrapping the strings and pulling the bow through and actually tying, it gets a little bit more dicey. So with scaffolding, you would let the child do every step up until the point that they started getting stuck. And then you might stop them and say, okay, you got the bow. Now what's the next thing you need to do? Which is why you have the. The rabbit that runs around the Tree or whatever story you use to help people remember what they're doing when they're tying their shoe. In family therapy. Now, there are lots of schools of family therapy, and it is likely going to be important to know what in general, the goals are for the main groups of family therapy. Strategic family therapy is being one of them. The goals of family therapy in general are to defocus the problems from the identified patient. They view the problem as systemic within the family and being maintained and may be caused by things that are going on in the family. Improving communication in the family unit, increasing awareness of one's personal experience and intrapsychic conflicts that influence their behavior and interactions. People need to become aware of how they're perceiving the interactions from their family, how they're interpreting them, their phenomenological reality, so to speak, and how that influences their behavior and how prior experiences influence their behavior in the family. So they start understanding the reciprocal interaction. You want to reduce emotional reactivity among family members and enhance congruent affective interactions. Instead of getting into yelling matches, Encouraging the use of assertiveness and identify identifying emotions in order to discuss what's going on. So going from screaming at each other all the time to having meaningful discussions about affective states. What you want to restore homeostasis to the family unit and address inflexible roles. If one person just holds on to a particular role for dear life addressing where, you know, sometimes there may need to be some flexibility. For example, when I was sick a couple of years ago and I had surgery, you know, normally I cook the dinner, I do the laundry, I mow the enclosed backyard. There are things that I do in my role as mom, as a general. As a general rule. But during that period when, you know, I wasn't allowed to lift more than five pounds, other people had to step up and take on some of those roles that are not necessarily what they normally do. So we want to address inflexible roles and help people see that the family is kind of like a rubber band. And when you hold it out, it's a circle. But if one person gives or takes a little bit, that alters the shape of the rubber band. So everything else has to move in order to keep that rubber band a perfect circle. You want to strengthen the family system and strengthen the executive subsystem, which is generally the primary caregivers increased separation and individuation of members. That sounds counterintuitive, but you don't want people who are like totally enmeshed people need to be allowed to have their own thoughts, their own opinions, be able to assertively state what their goals and ideals are and still remain part of that system. So the system needs to be able to handle individuality. Identify ongoing repetitive interactions between people. Those learned responses. If a child regularly approaches one caregiver and gets their own way and regularly approaches the other caregiver and gets told no, then what's the child going to do? Child's probably going to go to the caregiver that always says yes. That would as one of those interactions that may be identified because not only is that splitting parents, but it's sending different messages. Increase recognition of circular patterns of behavior. When I do this, it makes you angry, so you do something in response. This comes up with couples. Sometimes one couple, one person will say, I need to have physical contact in order to have emotional connection. And another partner will say, I need to have emotional connection before I want you to come anywhere near me. And it gets into this standoff where one partner will say, well, I can't do that unless you. And it just goes back and forth. And it's this tug of war and restoration of trust and responsibility in the family unit. Not just one person, not the identified patient, but everybody. They can trust each other with their thoughts, with their feelings, with their lives. The beliefs of family therapy surround wholeness and transactionalism. That is that when I do something, it affects the whole system, and the status of the whole system affects me. I'm not operating in a vacuum. The whole is equal to more than the sum of its parts. And it studies the causes of problems and as being unimportant, you know the cause. What causes a problem? Really not important, because there's a lot of things that could cause friction between kids and parents. So for example, but the process is important. Why is it that problems cause friction in the family or not? You don't want to look at, why did John become depressed? There's a lot of things that could make John become depressed. But how is John's depression impacting family members and their behaviors? And how is that change in the family system impacting John? Family therapy believes that all behavior is communication, whether it's withdrawing or throwing a temper tantrum or being enmeshed or detached, or any of these behaviors are communicating something about how people feel in the system, whether they feel safe, whether they feel they can express themselves, whether they feel secure or abandoned. General interventions. Regardless of your theory that you may want to consider using empathy. Go figure. Reassurance, normalization. Most people come in and they think they're the only person or nobody else has experienced this or not. Many people, they feel like they're weird in some way. We want to normalize this experience, help them understand how many people in the US Are experiencing depression, how many people in the US unfortunately, have been victims of sexual violence. Normalize what's going on for them so they feel they don't Feel isolated. Reframe what's going on in substance abuse. We do this a lot. Instead of saying that the substance abuse was, you know, a horrible, awful thing, yada yada, we sometimes reframe it as it was a way you coped up until now. It was not a helpful way, but it shows me that you wanted to survive and it was your way of trying to survive until now. That's reframing it in a way to help a person see that there are options. Reflection, reflecting back what people are saying and identifying differences between what they say and what they do. You know, developing those discrepancies, interpretation of things. Sometimes, you know, and that's the counseling 101. We're going to interpret what we hear people saying, and they're either going to say, yeah, that actually makes sense, or no, you're way off, doc. Allow for verbalization and ventilation. Sometimes people just need to be heard and to get it out there. Use simulations and role plays when appropriate. Letter writing can be really helpful. And generally these letters are not letters to be sent. They're just letters to get stuff out. Psychoeducation about the condition, whatever the condition is, and potential treatments. Bibliotherapy, to help people learn more about their condition, to learn more about treatments, or even just to learn about more people that are like them. After I had my son, he was a micro preemie, I did a lot of reading about other families who had had micro preemies. And it provided a sense of hope and connection. And, you know, when things went bad, I had read about other families who had had things that went bad. And it gave me a foundation to build on so I could see that, you know, these, these bumps in the road are normal. Use a strengths based focus. What skills and tools do they currently have? What things have they dealt with before that you can take those tools and apply them to the current situation. What resources do they have at their disposal that you can take advantage of? Behavior modification, motivation enhancement, social learning and support and modeling. I'm going to put all three of those together, depending on the situation. Sometimes social learning takes place in a variety of situations where people can observe the behavior being done correctly. You can watch it on tv, you can have social learning in group therapy, you can have support groups and social learning. And the therapist is very effective at modeling certain behaviors such as assertive communication and appropriate boundaries and those sorts of things. Respite support. I know on my exam way back when there was one where respite support was important, the person needed A break from dealing with the chaos that was in their family and resource enhancement. Looking at what the person may need in terms of resources in order to achieve their goals. Do they need somebody to come in? Maybe it's a mother with postpartum depression. Do they need somebody to come in to help watch the baby overnight or to help with cleaning and doing laundry so they can get a little bit more rest or follow their treatment plan, whatever that may be. All of these are general interventions that you do want to consider. You probably consider these anyway. These are all pretty basic interventions, but resource enhancement is definitely something you're going to come across on the exam in the initial meeting. Establish rapport and identify emergent issues during the assessment and treatment planning. Use collateral information as well as client self report and testing in order to get a dimensional picture about what's going on with the client. Develop treatment plans in conjunction with the client and be familiar with basic concepts of the different theoretical approaches in case you are asked to address a problem from a particular perspective. I cannot emphasize this enough. Go back over your main theories of family therapy and know how they perceive, what they perceive causes problems and how they perceive to solve them. You know, that's a pretty simple question right there. And be familiar with that. Even if you're not a family therapist, you're going to be expected to know those things for the exam. As always, we're going to go through a little test taking tip, so to speak. So this scenario Judy and Sam. Judy brings her nine year old son to counseling based upon a recommendation by the school counselor. Sam has been cutting class and was caught fighting at school recently. Sam has begun lying to Judy. And Sam's parents recently got divorced last weekend. Sam did not want to return to Judy's after a visit with his dad. Judy wants you to testify in court that joint custody is too difficult for Sam and she needs to have sole custody. Okay, so the first thing my mind jumps to is interventions, but that's not where we go on the test. The first thing that you need to have your mind jump to is what are the preliminary diagnoses for both Judy and Sam. And right now we're just going to primarily talk about Sam. Adjustment disorder is one. And you want to rule out oppositional defiant and conduct disorder. Now remember, Sam is nine, so you've got some age ranges here. There's been some disruption in the homeostasis of the family unit, you know that. So there's some stuff that's going on because they, quote, recently got divorced. So we're not exactly sure what's going on here. I wouldn't at this point think about testing for substance abuse because again, Sam's nine. I don't see him smoking in the boys room in second grade. Or I guess he would be in third grade at nine years old. What steps should the counselor take next? After there's a preliminary? You think it may be adjustment disorder? What might we do? Observe the interactions between Judy and Sam. Well, Sam didn't want to go back to Judy's house, so let's figure out what's going on. Could be that dad lets him get away with everything because dad feels guilty. We don't know, but we want to observe the interactions between them. Ask Judy about the onset of these behaviors. Did it start. Did all this coincide with, you know, the divorce or just before the divorce? Or has this been going on for three years? You may ask Sam to draw pictures of his mom and dad's house in order to get an idea of what's there and how he perceives those places. You may observe Sam alone as he plays with family dolls. I didn't know what else to call them besides dolls, the little plastic action figures to see what he does with them. You may ask Sam why he doesn't want to live with Judy. You know, he said he didn't want to go home. What's that about? You may think that checking with Children Protective Services regarding any reports would be necessary, but it's not. The divorce just recently happened. There's been no evidence of any bruising or anything that you're looking at. School hasn't called and the attorneys are already involved in this. And the custody hearing just took place. So likely anything that would have caused a CPS report would have been caught during those things. So that's not something you want to look at right now. You wouldn't order a drug test for Sam primarily because of his age. Right now you want to look at what's going to be too invasive. And again, a nine year old is probably not smoking pot in the bathroom. Get permission to talk to Sam's dad, see what's going on there. You know, let's get the family unit involved. You may interview Judy alone to get more information about the divorce. Was it amicable? Was there a lot of animosity? How long were they separated? Yada yada. And collateral information, you want to get permission to talk to Sam's teachers and school counselor. Remember, the school counselor made the referral to understand a little bit more about why this referral was made and get A better vision of the timeline of Sam's behavior changes. What theoretical orientations would you use? Family systems theory would be something that you might choose to use because obviously there's some disruption in the family system. Behavioral approaches. Yeah, we want him to stop cutting class so we can reinforce class attendance and solution focused. You know, what are the solutions that we're looking for in this particular situation and how can we make those happen? Gestalt would not be appropriate to use with a nine year old in general. And narrative therapy, again, a nine year old is not reading that well. There may be a couple little books here and there, but that's not going to be your first choice. You. You're really going to be working with Judy in order to help her alter Sam's behaviors and understand what's going on, and working with Sam to help him be assertive and articulate what's going on and strengthen that family unit in the treatment plan. There are a lot of options that you might consider. Referring Sam to peer group counseling is not age appropriate. Referring Judy to a parenting support group is not probably necessary or appropriate because we have no indication that these problems are because of Judy's parenting. It may be an adjustment to the divorce. Use behavior modification and reinforce alternate behaviors to reduce cutting class. Yep. Have Sam and Judy plan fun activities together. Yep. Teach Judy about the developmental needs of a nine year old, possibly, you know, if she indicates that she doesn't know about that. Explore Judy's parenting style and beliefs about parenting. Since there's a chance that Judy and the dad have very different parenting styles. You know, understanding what those differences are could be helpful role play situations to help Sam learn to better manage conflict. So he's not getting in fights. He has potentially a lot of anxiety and anger and frustration over the divorce, maybe. And some of that may be coming out in his interactions at school, which is why he got into a fight. So we want to help him learn how to better handle those situations. And encourage Judy to ask Sam about his day at school and help with homework. If she's helping him with homework, she's going to know if he is cutting class. And this also may give us an idea about if there are any learning issues that may be happening which are prompting him to cut class. I hope that was helpful and I'll 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. And while you're at it, subscribe to Counselor Toolbox podcast to stay up to date on current trends in counseling and earn your continuing education on the go.