Counselor Toolbox Podcast

Legal Issues in Adult Mental Health Services Instructor: Dr. Dawn-Elise Snipes Podcast Host: Counselor Toolbox and Happiness Isn’t Brain Surgery Objectives ~ Review common Legal issues in Adult Mental Health ~ Rights ~ Protection ~ Involuntary commitment ~ The ADA ~ Emotional Support Animals Legal and Ethical Concepts ~ Principles of Ethics ~ Beneficence: Duty to act to benefit others ~ Non-Malfeasance: Do no harm ~ Autonomy: Respect rights of others to make decisions ~ Justice: Distribute resources equally ~ Fidelity: Maintain loyalty and commitment to patient ~ Veracity: Duty to communicate truthfully Mental Health Laws: Civil Rights and Due Process ~ Civil rights: people with mental illness are guaranteed same rights under federal/state laws as any other citizen ~ Due process in civil commitment: courts have recognized involuntary commitment to mental hospital is “massive curtailment of liberty” requiring due process protection, including: ~ Writ of habeas corpus: procedural mechanism used to challenge unlawful detention ~ Least restrictive alternative doctrine: mandates least drastic means be taken to achieve specific purpose Mental Health Laws: Admission to the Hospital ~ Voluntary: sought by patient or guardian ~ Patients have right to demand and obtain release ~ Many states require patient submit written release notice to staff ~ Involuntary admission (commitment): made without patient’s consent ~ Necessary when person is danger to self or others, and/or unable to meet basic needs as result of psychiatric condition ~ Some states (i.e. Florida) have a substance abuse provision ~ Emergency involuntary hospitalization ~ Commitment for specified period (1-10 days) to prevent dangerous behavior to self/others ~ Observational or temporary involuntary hospitalization ~ Longer duration than emergency commitment ~ Purpose: observation, diagnosis, and treatment for mental illness for patients posing danger to self/others Patients’ Rights ~ Right to treatment: requires that medical and psychiatric care and treatment be provided to everyone admitted to public hospital ~ Right to refuse treatment: right to withhold or withdraw consent for treatment at any time ~ Issue of right to refuse psychotropic drugs has been debated in courts with no clear direction yet forthcoming ~ Right to informed consent: based on right to self-determination ~ Informed consent must be obtained by physician or other health care professional to perform treatment or procedure ~ Presence of psychosis does not preclude this right Advanced Directives ~ An advance directive is a written document that expresses your wishes in advance about what types of treatments, services and other assistance you want during a personal mental health crisis. ~ What are the benefits of having an advance directive? ~ A psychiatric advance directive can: ~ Promote your autonomy and empowerment; ~ Enhance communications between you, your doctor, treatment team and family; ~ Protect you from ineffective, unwanted or possibly harmful treatment or actions; ~ Help prevent crisis situations and reduce the use of involuntary treatment or safety interventions, such as restraint or seclusion. What to include in an advanced directive ~ You can include: ~ Medications and dosages that you know are most helpful to you and those that you do not wish to receive ~ Names of facilities or healthcare professionals you want involved in your care ~ People who can help you with important activities (such as paying your bills, and taking care of your children, pets or plants). ~ People you do or do not want as visitors if you're hospitalized. ~ One of t

Reducing Stigma and Discrimination Dr. Dawn-Elise Snipes Ph.D., LMHC, LPC-MHSP Podcast Host: Counselor Toolbox and Happiness Isn’t Brain Surgery Objectives ~ Define stigma and discrimination ~ Explore the protections under the ADA ~ List several ways our consumers are stigmatized or discriminated against ~ Identify ways to fight discrimination Data ~ People experiencing mental health conditions often face rejection, bullying and discrimination. This can make their journey to recovery longer and more difficult. ~ Mental health conditions are the leading cause of disability across the United States. ~ Even though most people can be successfully treated, less than half of the adults in the U.S. who need services and treatment get the help they need. ~ The average delay between the onset of symptoms and intervention is 8-10 years. What is Stigma ~ People who have identities that society values negatively are said to be stigmatized ~ Thanks to stigma, people living with mental health conditions are: ~ Alienated and seen as “others.” ~ Perceived as dangerous. ~ Seen as irresponsible or unable to make their own decisions. ~ Less likely to be hired. ~ Less likely to get safe housing. ~ More likely to be criminalized than offered health care services. ~ Afraid of rejection to the point that they don’t always pursue opportunities. Common Stigma Associated with Mental Illness ~ Dangerous ~ The major determinants of violence continue to be ~ Socio-demographic and economic factors ~ Substance abuse, whether it occurs in the context of a concurrent mental illness or not ~ historical (past violence, juvenile detention, physical abuse, parental arrest record)clinical ~ contextual (recent divorce, unemployment, victimization) factors. ~ It is far more likely that people with a serious mental illness will be the victim of violence ~ Research has focused on the person with the mental illness, rather than the nature of the social interchange that led up to the violence STUART, H. (2003). Violence and mental illness: an overview. World Psychiatry, 2(2), 121–124. Common Stigma Associated with Mental Illness ~ Lazy ~ 60 percent of the 7.1 million people receiving public mental health services nationwide want to work NAMI ~ Susan (not her real name) received SSDI and SSI with mental health services covered by Medicare and Medicaid. As her recovery from bipolar disorder progressed, she went back to work part-time. Despite the fact that she enjoyed her job and her employer was pleased with her performance, she resigned after seven months because she did not want to lose the medical benefits that paid for the care she needed. She is no longer seeking paid work. ~ Dirty ~ Diseased ~ Weak willed Mental Illness Myths ~ There's no hope for people with mental illnesses. ~ I can't do anything for a person with mental illness. ~ People with mental illnesses are violent and unpredictable. ~ Mental illnesses don't affect me. ~ People with mental illnesses cannot tolerate the stress of holding down a job. ~ Therapy and self-help are a waste of time. Why bother when you can just take a pill? ~ Children don't experience mental illnesses. Their actions are just products of bad parenting. Addiction Myths ~ Addicts are bad, crazy, or stupid. ~ Addiction is a willpower problem. ~ Addicts should be punished, not treated, for using drugs. ~ People addicted to one drug are addicted to all drugs. ~ Addicts cannot be treated with medications. ~ Addiction is treated behaviorally, so it must be a behavioral problem. ~ Alcoholics can stop drinking simply by attending AA meetings, so they can't have a brain disease. What Perpetu

Substance Abuse Professional CEU Workshop Instructor: Dr. Dawn-Elise Snipes, PhD, LPC-MHSP Podcast Host: Counselor Toolbox and Happiness Isn’t Brain Surgery Objectives ~ Review the function of the SAP and how the SAP and LPC/LCSW may need to function together on an interdisciplinary team or in a co-occurring disorders treatment facility. ~ Review DOT policy on recreational and medical marijuana to ensure all LPCs and LCSWs are familiar with the restrictions on any of their clients who may fall under DOT supervision ~ Review the Final Rule that Changes the Definition of ‘Service Agent' ~ Review the procedures for the Revised Federal Drug Testing Custody and Control Form (CCF) ~ Review the Final Rule: Procedures for Transportation Workplace Drug and Alcohol Testing Programs Function of the SAP ~ The Substance Abuse Professional (SAP) is a person who ~ Evaluates employees who have violated a DOT drug and alcohol program regulation ~ Makes recommendations concerning education, treatment, follow-up testing, and aftercare (up to 60 months). ~ Conducts follow-up evaluation prior to return to work ~ Represent the major decision point an employer may have in choosing whether or not to place an employee back in a safety-sensitive position ~ SAP are advocate for neither the employer nor the employee, their function is to protect the public interest ~ §40.311 What are the requirements concerning SAP reports? ~ (a) As the SAP conducting the required evaluations, you must send the written reports required by this section in writing directly to the DER and not to a third party or entity for forwarding to the DER (except as provided in §40.355(e)). You may, however, forward the document simultaneously to the DER and to a C/TPA. ~ (b) As an employer, you must ensure that you receive SAP written reports directly from the SAP performing the evaluation and that no third party or entity changed the SAP's report in any way. ~ (c) The SAP's written report, following an initial evaluation that determines what level of assistance is needed to address the employee's drug and/or alcohol problems, must be on the SAP's own letterhead ~ (d) The SAP's written report concerning a follow-up evaluation that determines the employee has demonstrated successful compliance must be on the SAP's own letterhead ~ (f) As a SAP, you must also provide these written reports directly to the employee if the employee has no current employer and to the gaining DOT regulated employer in the event the employee obtains another transportation industry safety-sensitive position. ~ (g) As a SAP, you are to maintain copies of your reports to employers for 5 years, and your employee clinical records in accordance with Federal, state, and local laws ~ You must make these records available, on request, to DOT agency representatives (e.g., inspectors conducting an audit or safety investigation) and representatives of the NTSB in an accident investigation. ~ 49 CFR Part 40 Section 40.329 (c) As a SAP, you must make available to an employee, on request, a copy of all SAP reports (see §40.311). However, you must redact follow-up testing information from the report before providing it to the employee. “Let’s cancel the remaining follow-up tests” ~ A SAP can cancel follow-up testing after 12 months. 40.307(f) ~ Follow-up testing is an effective deterrent. ~ If all the follow-up tests are negative, isn’t that what we want? ~ If a driver has had no accidents for a year, would you consider canceling insurance on the bus? ~ Some SAPs require a full 5 years of follow-up testing, and sometimes with only a few tests in the final 2 or 3 years. ~ Critical: The follow-up testing plan is confidential, not to be shared with the employee ~ Critical: An employer’s labor agreement can’t limit the SAP’s a

Strategies for the Prevention of Mental Illness Instructor: Dr. Dawn-Elise Snipes, PhD, LPC-MHSP Podcast Host: Counselor Toolbox and Happiness Isn’t Brain Surgery Objectives ~ Identify strategies for the prevention of mental illness including ~ Community education ~ Early intervention services ~ Community resource development ~ Improving accessibility ~ Improving cultural sensitivity ~ Enhancing protective factors in the environment ~ Drug and domestic violence courts to break the cycle What “causes” mental illness ~ Stress ~ Poor nutrition ~ Poor health ~ Medication side effects ~ Low self-esteem ~ A lack of personal control ~ Isolation and a lack of supportive relationships ~ What else? What is Needed to Be Happy Community Education ~ Educate all individuals in the community about the effectiveness and social and economic benefits of prevention ~ Reduced health care costs ~ Disease ~ Weight ~ Smoking ~ Alcohol ~ Chronic pain ~ Reduced absenteeism ~ Improved productivity ~ Improved energy and mood ~ Improved relationships Principles of Child Education ~ Children are curious and eager to learn. They have an inherent desire to make sense of themselves, the world and others. ~ Children are active participants in their environment and learn through with all of their senses. ~ Children learn and express themselves through play, which is central to their well-being and development. ~ Each child has an individual pattern and timing of growth and development as well as individual styles of learning. ~ Children need to experience challenge, success, positive direction and positive redirection more than failure or criticism to form a positive self-concept. ~ Children learn best when active and interested. When they engage in a meaningful and relevant way, they can experience the joy of learning and feelings of success. Principles of Child Education ~ Children learn best when they experience warm and stable personal relationships with their caregivers. ~ Children develop holistically and benefit from integrated experiences and education. ~ The brain learns best when having fun. ~ When learning happens in a positive emotion environment, it is stored in the hippocampus. This is later transferred to the brain cortex, where long term memory happens- thus affecting our ability to remember. ~ Unpleasant events and fast learning, on the other hand are stored in the amygdala, the part of the brain that stores “what not to do”. ~ Children emulate positive models Principles of Adult Education ~ Adults are autonomous and self-directed ~ Adults are goal and relevancy oriented ~ How does this help me meet my goals and objectives ~ Adults already have a wealth of knowledge ~ How does prior learning impact current learning ~ How does current learning enhance/build off of prior learning ~ Adults are motivated to learn by: ~ Social relationships ~ External expectations ~ Social welfare ~ Personal advancement ~ Escape/stimulation ~ Cognitive interest Principles of Adult Education ~ Barriers to Adult Learning ~ Responsibilities ~ Lack of time ~ Lack of money ~ Lack of confidence or interest ~ Lack of information about opportunities ~ Scheduling problems ~ Problems with childcare or transportation Community Resource Development ~ Case Management ~ Volunteers based at the health department, library, doctors offices or churches ~ State Economic/Workforce Development Boards ~ Jobs ~ Transportation ~ Career One-Stop ~ Job placement ~ Job coaches ~ Bonding ~ Unive

Trauma Informed Care  Clinical Issues Instructor: Dr. Dawn-Elise Snipes PhD, LPC-MHSP, LMHC Podcast Host: Counselor Toolbox & Happiness Isn’t Brain Surgery Objectives ~ Define Trauma Informed Prevention and Treatment Objectives ~ Highlight Treatment Issues ~ Understand When and How to Make Referrals to Trauma Specific Services ~ Explore Trauma Specific Treatment Models, Integrated Models for Trauma, and Emerging Interventions Prevention and Treatment Objectives ~ Trauma-informed care (TIC) places considerable effort in creating an environment that helps clients recognize the impact of trauma and determine the next course of action in a safe place. ~ TIC also focuses on prevention strategies to avoid retraumatization in treatment, to promote resilience, and to prevent the development of trauma-related disorders Establish Safety ~ Types of Safety ~ Personal Safety ~ Safety from trauma symptoms ~ Strategies ~ Help the client label and gain more control over trauma symptoms when they arise and use grounding techniques when flooded with feelings/memories. ~ Establish some specific routines in individual, group, or family therapy (e.g., have an opening ritual or routine when starting and ending a group session). A structured setting can provide a sense of safety and familiarity. ***Use carefully ~ Facilitate a discussion on safe and unsafe behaviors. Have clients identify, on paper, behaviors that promote safety and behaviors that feel unsafe for them today. ~ Refer to Seeking Safety: A Treatment Manual for PTSD and Substance Abuse (Najavits, 2002a). This menu-based manual covers an array of treatment topics. ~ Encourage the development of a safety plan. Establish Safety ~ Creating Safety ~ Help client feel in control and prepared for the unexpected. ~ Encourage thinking about how supports will respond and connect in the event of another crisis. ~ Encourage thinking about future steps that could help make the client safer/prevent a recurrence. ~ People with histories of trauma and substance abuse are more likely to engage in high-risk behaviors ~ Early treatment should focus on helping clients stop using unsafe coping mechanisms, such as substance abuse, self-harm, and replace them with healthy coping strategies ~ Balance preparation and the realization that one cannot prepare for all possible traumatic events. Establish Safety ~ Scenarios ~ Date rape ~ Home invasion ~ Natural disaster (Fires) ~ House fire ~ Child neglect ~ Car accident Prevent Retraumitization ~ Examples of unintentional trauma ~ Compassionate inquiry into a client’s history can seem similar to the interest shown by a perpetrator many years before. ~ Direct confrontation about behaviors can be seen by someone who has been abused as a sign of impending assault ~ Strategies ~ Be sensitive to the needs of clients who have experienced trauma ~ Do not ignore clients’ symptoms and demands when clients with trauma are triggered and act out; doing so may replicate the original trauma. ~ Walking out of a tense group ~ Avoiding particular clients or topics ~ Be mindful that efforts to control and contain a client’s behaviors remind them of being trapped as part of the trauma. ~ Listen for specific triggers driving the client’s reaction and help the client identify these cues and thereby understand their reactions and behaviors. Provide Psychoeducation ~ Education can play a pivotal role in enhancing motivation, in normalizing experiences, and in creating a sense of safety. ~ Understand the client’s expectations and reasons for seeking help ~ Educate the client and other family members about the program ~ After obtaining acknowledgment of a trauma history, give i

Trauma-Informed Care Impact of Trauma Instructor: Dr. Dawn-Elise Snipes, PhD, LPC-MHSP Podcast Host: Counselor Toolbox and Happiness Isn’t Brain Surgery Objectives ~ Learn About The Sequence of Trauma Reactions ~ Explore Common Immediate and Delayed Experiences and Responses to Trauma (Emotional, Physical, Cognitive, Behavioral and Existential) ~ Identify Specific impacts of Trauma ~ Explore the Impact of Trauma on the Family Delayed Traumatic Response ~ There can be a delay of months or even years before symptoms appear ~ Trauma symptoms can appear suddenly, even without conscious memory of the original trauma or without any overt provocation ~ Clients who are experiencing a delayed trauma response can benefit if you help them to: ~ Create an environment that allows acknowledgment of the trauma. ~ Discuss their initial recall or first suspicion that they were having a traumatic response. ~ Draw a connection between the trauma and presenting trauma-related symptoms. ~ Explore their support systems and fortify them as needed. ~ Identify their triggers. ~ Develop strategies to navigate and manage symptoms and triggers. Biology of Trauma ~ Changes in limbic system functioning. ~ Hypothalamic–pituitary–adrenal axis activity changes with variable cortisol levels. ~ Neurotransmitter-related dysregulation of arousal and endogenous opioid systems. Emotional Reactions to Trauma ~ Immediate ~ Numbness and detachment ~ Anxiety/fear/ helplessness ~ Guilt (including survivor guilt) ~ Exhilaration as a result of surviving ~ Anger ~ Sadness ~ Feeling unreal; depersonalization ~ Disorientation ~ Feeling out of control ~ Denial ~ Constriction of feelings ~ Feeling overwhelmed Cognitive Reactions to Trauma ~ Immediate ~ Difficulty concentrating ~ Rumination or racing thoughts ~ Distortion of time and space ~ Memory problems ~ Strong identification with victims Behavioral Reactions to Trauma ~ Immediate ~ Startled reaction ~ Restlessness ~ Sleep and appetite disturbances ~ Difficulty expressing oneself ~ Argumentative behavior ~ Increased use of alcohol, drugs, and tobacco ~ Withdrawal and apathy ~ Avoidant behaviors Specific Impacts of Trauma ~ Attachment and Relationships ~ Trauma can impacts people’s ability to develop a strong healthy attachment to caregivers. ~ People who do not have healthy attachments and relationships have been shown to ~ be more vulnerable to stress ~ have trouble controlling and expressing emotions ~ may react violently or inappropriately to situations. Specific Impacts of Trauma ~ Physical Health: Body and Brain ~ When a child grows up afraid or under constant or extreme stress, the immune system and body’s stress response systems may not develop normally. Later on, when the child or adult is exposed to even ordinary levels of stress, these systems may automatically respond as if the individual is under extreme stress. ~ Stress in an environment can impair the development of the brain and nervous system. ~ An absence of mental stimulation in neglectful environments may limit the brain from developing to its full potential. Specific Impacts of Trauma ~ Physical Health: Body and Brain ~ People with trauma histories may develop chronic or recurrent physical complaints, such as headaches or stomachaches. ~ Trauma survivors may suffer from body dysregulation, meaning they over-respond or underrespond to sensory stimuli. For example, they may be hypersensitive to sounds, smells, touch or light, or they may suffer from anesthesia and analgesia. As a result they may injure themselves without feeling pain, or, ma

Etherapy Clinical Principles & Treatment Modalities Instructor: Dr. Dawn-Elise Snipes Podcast Host: Counselor Toolbox and Happiness Isn’t Brain Surgery Objectives ~ Review the different modalities and most common usages in counseling ~ Identify potential clinical and ethical issues ~ Learn about at least 3 unique ideas for doing online counseling ~ Define Treatment Structure Text Reading ~ Review Online Counseling: A Handbook for Mental Health Professionals ~ http://www.netlingo.com/ Modalities ~ Emails ~ Blogs ~ Secure Forms ~ Forums ~ Chat rooms ~ IM/Tweets ~ Video Chat ~ Second Life ~ Good ole telephone Tweets ~ This is a great way to push out positive thoughts for the day. ~ I have used this for morning focus meditations and evening roundup meditations. ~ It is NOT secure, so no PHI here. This includes graduation announcements or congrats. ~ Good way to get the word out about you and your approach. ~ This is not a therapy approach. Emails ~ Technical ~ Use a secure service. ~ If you are not using a secure service, then make sure your email address does not give away who you are. ~ Services offering Secure Email: Hushmail, ZixMail, ~ Are considered part of the clinical record and can be subponeaed just like progress notes. ~ Provide clients with a response time frame ~ Benefits ~ Can provide a running “diary” of progress ~ Are excellent for people who like to write and ponder. (Introverts and Reflective learners) Email Cont… ~ Drawbacks ~ Can miss a lot when you do not see the rate of responding (increase in rate or errors in typing etc) ~ Gives patients time to go back and edit which may remove some of the underlying meanings ~ Not appropriate for patients in crisis ~ Formats ~ Diary—freeform ~ Diary—Structured ~ Worksheet completion (i.e. CBT, relapse prevention) ~ Questions to ponder (i.e. Miracle Question) ~ Activities to do (digital collage) Blogs ~ Provide information to people ~ Not secure or HIPAA compliant unless you make them that way ~ A secure blog can be a good place for clients to journal as an option to daily emails. ~ Excellent activity to inform patients about conditions, new treatments and new programs ~ Excellent for patients who have something to say to the world—Awareness/Advocacy Campaigns Blogs cont… ~ Secure Blog Formats ~ Video Blog: ~ Can be used for daily check-ins for clients—excellent for addictions, eating disorders and major depression ~ Blog with pictures ~ Can be used to as a means of creative and therapeutic expression for some clients ~ Can also be created like an online scrap-book with pages for: What means the most to me, My Goals, My accomplishments, About Me (Best with teens) ~ Text Blog ~ Can be used as a running diary ~ Blogs must be regularly checked ~ Rules for appropriate use of blogs must be set forth Forums ~ Forums are a good place to ask a question to a group and let them provide answers ~ Forums must be moderated ~ Appropriate forum behavior must be communicated and maintained ~ Group members can see each others responses and comment and/or learn ~ More than some other modalities, it is imperative to be clear about appropriate behavior in the forums. ~ If you do not have something nice or constructive to say, don’t say anything at all ~ This is not a place for Borderline behavior Secure Forms & Worksheets ~ Useful to get information quickly such as intakes, client’s week in review and CBT or DBT worksheets ~ Can be created as fillable PDFs and securely emailed to you. ~ Used as an adjunct to therapy for people who like

Trauma-Informed Care Trauma Awareness Instructor: Dr. Dawn-Elise Snipes, PhD, LPC-MHSP Podcast Host: Counselor Toolbox and Happiness Isn’t Brain Surgery Objectives ~ Define and differentiate between the different types of trauma (individual, group, mass, natural or human caused) ~ Explore how trauma effects communities and cultures ~ Identify staff and agency issues that could cause retraumatization ~ Explore the objective and subjective characteristics of trauma and their biopsychosocial impact. ~ Identify characteristics that nurture resilience among individuals from diverse groups. Types of Trauma ~ Individual ~ An individual trauma occurs to one person. ~ It can be a single event or multiple or prolonged events (e.g., a life-threatening illness, multiple sexual assaults, first responders, war). ~ Although the trauma directly affects just one individual, others who know the person and/or are aware of the trauma will likely experience emotional repercussions ~ Survivors of individual trauma may not receive the environmental support and concern that members of collectively traumatized groups and communities receive. ~ They are less likely to reveal their traumas or to receive validation of their experiences. ~ Shame distorts their perception of responsibility for the trauma. ~ They struggle with issues of causation ~ They feel isolated by the trauma Types of Trauma ~ In working with clients who have histories of individual trauma, counselors should consider that: ~ Empathy, or putting oneself in the shoes of another, is more potent than sympathy (expressing a feeling of sorrow for another person). ~ Some clients need to briefly describe the trauma(s) they have experienced, particularly in the early stages of recovery. ~ Intensive exploration should wait until the client is more prepared ~ Understanding the trauma should begin with educating the client about and normalizing trauma-related symptoms, creating a sense of safety within the treatment environment, and addressing how trauma symptoms may interfere with the client’s life in the present. ~ It is helpful to examine how the trauma affects opportunities to recover(e.g., by limiting one’s willingness to share in in group). ~ Identifying and exploring strengths in the client’s history can help the client apply those strengths to his or her ability to function in the present. Types of Trauma ~ Group ~ “Group trauma” refers to traumatic experiences that affect a particular group of people ~ Groups often share a common identity and history, as well as similar activities and concerns. (vocational groups who specialize in managing traumas or who routinely place themselves in harm’s way) ~ examples of group trauma include crews and their families who lose members from a commercial fishing accident, a gang whose members experience multiple deaths and injuries, teams of firefighters who lose members in a roof collapse, responders who attempt to save flood victims, and military service members in a specific theater of operation. ~ Group members who have had traumatic experiences in the past may not actively support traumatized colleagues for fear that acknowledging the trauma will increase the risk of repressed trauma-related emotions surfacing. Types of Trauma ~ Group ~ Survivors of group trauma can have different experiences and responses than survivors of individual or mass traumas. ~ Likely to experience repeated trauma. ~ Tend to keep the trauma experiences within the group, feeling that others outside the group will not understand ~ Members may encourage others in the group to shut down emotionally and repress their traumatic ~ Group members may not want to seek help and may discourage others from doing so out of fear that it may shame t

Trauma-Informed Care A Sociocultural Perspective Instructor: Dr. Dawn-Elise Snipes, PhD, LPC-MHSP Podcast Host: Counselor Toolbox and Happiness Isn’t Brain Surgery Objectives ~ Define “What is Trauma” ~ Explore why trauma informed care is important ~ Learn the 3 key elements to a trauma informed approach: Realizing, recognizing and responding ~ Identify trauma informed intervention and treatment principles ~ Learn how to anticipate the interplay between treatment elements and clients' trauma histories ~ Identify the cross-cutting factors of culture What is Trauma ~ Traumatic events are those which the person experiences a threat of death, serious injury to self or self concept or threat to the physical integrity to self or another. ~ Events may be: ~ Human-made, such as a mechanical error that causes a disaster, war, terrorism, violence or neglect ~ “Traumatization can also occur from neglectwhich is the absence of essential physical or emotional care, soothing and restorative experiences from significant others,particularly in children.” (International Society for the Study of Trauma and Dissociation, 2009) ~ Products of nature (e.g., flooding, hurricanes, tornadoes). What is Trauma ~ Trauma can occur at any age or developmental stage, and often, events that occur outside expected life stages are perceived as traumatic (e.g., a child dying before a parent, cancer as a teen, personal illness, job loss before retirement). ~ Individuals may experience the traumatic event directly, witness an event, feel threatened, or hear about an event that affects someone they know. ~ It is not just the event itself that determines whether something is traumatic, but also the individual’s experience of the event. What is Trauma ~ Just because something does not DSM V criteria for ASD/PTSD does not mean it wasn’t traumatic ~ Trauma is something that: ~ Overwhelms our coping capacity ~ Affects the whole self ~ Physical ~ Emotional ~ Intellectual/Cognitive ~ Spiritual ~ Interpersonal Why Is Trauma Informed Care Important ~ National Comorbidity Study 61 percent of men and 51 percent of women reported experiencing at least one trauma in their lifetime ~ National Epidemiologic Survey on Alcohol and Related Conditions, 71.6 percent of the sample reported experiencing trauma ~ In a survey at the Alachua County Jail, 99% of female inmates reported having experienced trauma Why Is Trauma Informed Care Important Why Is Trauma Informed Care Important ~ Improve screening, assessment, treatment planning, ~ Decrease the risk for retraumatization. ~ Enhance communication between the client and treatment provider, thus decreasing risks associated with misunderstanding the client’s reactions and presenting problems or underestimating the need for appropriate referrals ~ Improved cost effectiveness because services are more appropriately matched to clients from the outset. ~ Ensures the implementation of decisions that will optimize therapeutic outcomes and minimize adverse effects on the client and, ultimately, the organization. ~ Clients and staff are more apt to be empowered, invested, and satisfied if they are involved in the ongoing development and delivery of services. Why Is Trauma Informed Care Important ~ To increase clinician self-awareness of trauma triggers ~ To increase clinician awareness of the variety of emotional, behavioral, interpersonal and physical symptoms of trauma ~ To provide appropriate responses to trauma related reactions or symptoms ~ To prevent the clinician from delving too deeply too quickly and unwittingly harming the client ~ To aid the client in developing a safety net to prevent further trauma ~ To provide clinicians w

TIPs 31 and 32 Screening, Assessment and Treatment of Adolescents Dr. Dawn-Elise Snipes, PhD, LMHC Objectives ~ Identify 10 Unique Issues to the Assessment and Treatment of Adolescents Not Little Adults ~ Adolescent treatment requires an awareness of: ~ Developmental stages ~ Adolescent culture Adolescent Development ~ Cognitive ~ Early Adolescence ~ Emphasizes immediate reactions to behavior ~ May not be fully aware of later consequences ~ Impulse control areas of brain are not fully developed ~ Late Adolescence ~ Greater use of inductive/deductive reasoning ~ More introspective and more sensitive to later consequences Developmental Tasks ~ Family Independence ~ Beginning rejection of parental guidelines ~ Ambivalence about wishes ~ Insistence on independence, privacy ~ May have overt rebellion, limit testing, withdrawal ~ Peers ~ Early: Most often “best” friend is same sex ~ Late: Dating, risk taking, need to please peers Developmental Tasks cont… ~ School and Vocation ~ Beginning to identify skills, interests ~ Starting part-time job ~ Self Identity and Esteem ~ Am I normal? ~ Conformity–behavior that meets peer group values ~ Some continue to pursue group/peer acceptance ~ Some are able to reject group pressure if not in self-interest Professional Approach ~ Early Adolescents ~ Provide firm, direct support ~ Convey limits–simple concrete choices ~ Do not align with parents, be an objective caring adult ~ Help the client explore dialectics ~ Sexual decisions–directly encourage to wait ~ Encourage parental presence in clinic, but interview teen alone Professional Approach cont… ~ Late Adolescence ~ Be an objective sounding board (but let adolescents solve own problems) ~ Negotiate choices ~ Be role model ~ Don't get too much history (“grandiose stories”) ~ Confront gently–about consequences, responsibilities ~ Consider “What gives them status in the eyes of peers?” ~ Use peer group sessions ~ Adapt systems to crises, walk-ins, impulsiveness, testing ~ Ensure confidentiality ~ Allow teens to seek care independently Screening and Assessment Screening and Assessment ~ Selection of instruments is guided by: ~ Reliability and validity of the tool ~ Its appropriateness to an adolescent population ~ Type of settings in which the instrument was developed ~ Intended purpose of the instrument Features of Instruments ~ Short in duration ~ High test-retest reliability ~ Evidence of convergent validity (i.e., the instrument is strongly correlated with other instruments that purport to measure similar constructs) ~ Predictive validity (i.e. school performance, relapse) ~ Normed on adolescents ~ Ability to measure meaningful behavioral and attitude changes over time ~ Sample Screening Forms ~ Depression Screening Tools ~ Drug & Alcohol Use Screening Tools ~ Bipolar Disorder Screening Tools ~ Suicide Risk Screening Tools ~ Anxiety Disorders Screening Tools ~ Trauma Screening Tools Family Assessment ~ Adolescents may define family in nontraditional ways. ~ The law and society may define family in ways that differ from the actual experiences of youth. ~ Cultural and ethnic differences in family structures should be respected. ~ The core problem may reside outside the adolescent and the substance use is a symptom. Screening Indicators ~ Problems during childhood or early adolescence ~ School issues ~ Peer involvement in delinquent behaviors ~ Daily use of one or more s

Bipolar and Depression Dr. Dawn-Elise Snipes PhD, LMHC Executive Director, AllCEUs.com Objectives ~ Differentially Diagnose Bipolar Disorder and Depression ~ Recognize general medical conditions and drugs that may mimic depression or mania ~ Understand the goals of psychiatric management of bipolar disorder and depression ~ Identify bipolar patients at increased risk of suicide ~ Understand the link between bipolar disorder and substance abuse ~ Identify key areas of consideration when making a treatment placement decision ~ Learn about the areas which patients with bipolar disorder and their families may need education ~ Familiarize with the most common psychopharmacological interventions for bipolar disorder Bipolar I and II ~ Bipolar I disorder: at least one episode can be characterized as mania ~ Episodic, lifelong illness with a variable course ~ The first episode may be manic, hypomanic, mixed, or depressive ~ Patients may experience several episodes of depression before a manic episode Differential Diagnosis ~ Ask about a history of depression accompanied or followed by manic or hypomanic symptoms ~ Assess for substance use disorder, other general medical conditions or medications ~ Medical conditions associated with manic-like symptoms include: ~ Multiple sclerosis ~ Lesions closely linked to the limbic system ~ Hyper or hypothyroid ~ Head injuries ~ Encephalitis Medications Associated with Manic-like Symptoms ~ L-Dopa ~ Corticosteroids ~ High-dose decongestants ~ Stimulants (weight loss, ADHD) ~ Antidepressants may trigger a manic episode Substance Use ~ May cause manic-like episodes ~ May help patient self-medicate ~ Stimulants (manic like symptoms) ~ Cocaine ~ Methamphetamines/Amphetamines ~ Ephedrine ~ Ecstasy/MDMA ~ Caffeine Patients with Bipolar ~ Seek treatment during depressive episodes ~ Rarely volunteer information about manic or hypomanic symptoms ~ Do not see the symptoms of hypomania to be distressing Suicide ~ Completed suicide rates 10% to 15% ~ Suicide attempts associated with depressive episodes or depressive features of mixed episodes ~ Ask every patient about suicidal ideation Increased Risk Factors ~ Factors associated with increased risk: ~ Means ~ Lethality ~ Family history of suicide ~ Pervasive insomnia ~ Impulsiveness ~ Psychiatric comorbidity ~ Psychosis ~ Personality disorder ~ Lack of social support Hospitalization ~ Patients who: ~ Pose a serious threat of harm to themselves ~ Are severely ill ~ Lack adequate social support ~ Demonstrate significantly impaired judgment ~ Have complicating psychiatric or general medical conditions ~ Have not responded adequately to outpatient treatment. ~ Re-evaluate treatment setting regularly Education ~ Should introduce facts about the illness and its treatment ~ Use printed, verbal and videotaped material ~ Present in an ongoing gradual and consistent process ~ Use psychoeducational groups Stressors ~ Commonly precede episodes ~ Disrupted sleep-wake cycles may specifically trigger manic episodes ~ Physical illnesses that cause changes in eating and/or dehydration ~ Alter blood plasma levels ~ May require dose adjustment ~ Regular patterns should be promoted Counselor Activities ~ Preplanning ~ Plan for impairments in functioning ~ Assisting patient in scheduling absences from work ~ Avoid major life changes ~ Plan for the needs of their children while the patient is in an acute state ~ Assist the patient who is able to work in contacting

10 Useful Brief Interventions and Brief Therapies Instructor: Dr. Dawn-Elise Snipes, PhD, LPC-MHSP, LMHC Objectives ~ We will review: ~ Stages-of-Change Model ~ Goals of Brief Intervention ~ Components of Brief Interventions and Effective Brief Therapy ~ Essential Knowledge and Skills for Brief Interventions ~ When To Use Brief Therapy ~ Approaches to Brief Therapy ~ Components of Effective Brief Therapy ~ Cognitive Behavioral (CBT) ~ Cognitive Processing ~ Trauma Focused CBT ~ Brief Strategic/Interactional ~ Brief Humanistic/Existential ~ Brief Psychodynamic ~ Brief Family therapy ~ Time Limited Group Therapy Who Can Use Brief Interventions ~ Primary care physicians ~ Substance abuse treatment providers ~ Emergency department staff members ~ Nurses ~ Social workers ~ Health educators ~ Lawyers ~ Mental health workers ~ Teachers ~ EAP counselors ~ Crisis hotline workers, student counselors ~ Clergy Benefits ~ Reduce no-show ~ Increase treatment engagement ~ Increase compliance ~ Increase self-efficacy ~ Reduce aggression and isolation ~ Provide an interim for clients on waiting lists Goals of Brief Interventions ~ Making a measurable change in specific target behaviors ~ Helping the client demonstrate a new understanding and knowledge of problems and issues ~ Improving the client's personal relationships ~ Resolving other identified problems Characteristics of Brief Interventions ~ They are either problem focused or solution focused; they target the symptom and not what is behind it. ~ They use interventions appropriate to the stages of change model ~ They clearly define goals related to a specific change or behavior. ~ They should be understandable to both client and clinician. ~ They should produce immediate results. ~ The therapeutic style is highly active, empathic, and sometimes directive. ~ Responsibility for change is placed clearly on the client. ~ Early in the process, the focus is to help the client have experiences that enhance self-efficacy and confidence that change is possible. ~ Termination is discussed from the beginning. ~ Outcomes are measurable. Objectives for Brief Interventions ~ It is important to extract at least one measurable change in the client's behavior ~ Time management ~ Expanding a support system ~ Improving social skills ~ Changing unhelpful thoughts ~ Improving health behaviors ~ Vulnerability awareness and prevention ~ Vocational issues ~ Support group attendance ~ Forgiveness and acceptance ~ Staying in the “here and now” ~ Identifying triggers for the mood or behavior ~ Coping with high risk or triggering situations Goals Setting Within Brief Interventions ~ Goals should be… ~ Specific ~ Measurable ~ Achievable in 8-10 weeks ~ Realistic ~ Time Limited ~ Purpose: Reduce the likelihood of damage/additional problems from the current issue. (i.e. family, work, health, self-esteem, guilt, anger) Components of Brief Interventions ~ FRAMES ~ Feedback ~ Responsibility ~ Identification of future goals for health, activities, hobbies, relationships ~ Identification of the pros and cons of current behavior in terms of self or family/community ~ Consequences of staying the same ~ Reasons to change ~ Sensible strategies for change ~ Advice ~ Menu ~ Empathy ~ Self-Efficacy Stages of Change ~ Precontemplation: “I’m okay” ~ Provide ~ Information linking problems with current behaviors (thoughts, reactions) or issues (health, environment, soci

16 Principles for Trauma Informed Assessment and Treatment ~ Promote Trauma awareness and understanding ~ Recognize That Trauma-Related Symptoms and Behaviors Originate From Adapting to Traumatic Experiences ~ View Trauma in the Context of Individuals’ Environments ~ Minimize the Risk of Retraumatization or Replicating Prior Trauma Dynamics ~ Create a Safe Environment ~ Identify Recovery From Trauma as a Primary Goal ~ Support Control, Choice, and Autonomy ~ Create Collaborative Relationships and Participation Opportunities ~ Familiarize the Client With Trauma-Informed Services ~ Incorporate Universal Routine Screenings for Trauma ~ View Trauma Through a Sociocultural Lens ~ Use a Strengths-Focused Perspective: Promote Resilience ~ Foster Trauma-Resistant Skills ~ Demonstrate Organizational and Administrative Commitment to TIC ~ Develop Strategies To Address Secondary Trauma and Promote Self-Care ~ Provide Hope—Recovery Is Possible Screening ~ The most important domains to screen among individuals with trauma histories include: ~ Trauma-related symptoms. ~ Depressive or dissociative or intrusive symptoms, sleep disturbances ~ Past and present mental disorders ~ Severity or characteristics of a specific trauma type (e.g., forms of interpersonal violence, adverse childhood events, combat experiences). ~ Substance abuse. ~ Social support and coping styles. ~ Availability of resources. ~ Risks for self-harm, suicide, and violence. ~ Health screenings. Advice About Screening Discussing the occurrence or consequences of traumatic events can feel as unsafe and dangerous to the client as if the event were reoccurring. Don’t encourage avoidance of the topic or reinforce the belief that discussing trauma-related material is dangerous. Initial questions about trauma should be general and gradual. Ask all clients about any history of trauma; use a checklist to increase proper identification of such a history. By going over the answers with the client, you can gain a deep understanding of your client. Do not require clients to describe emotionally overwhelming traumatic events in detail. Focus assessment on how trauma symptoms affect clients’ current functioning. Talk about how you will use the findings to plan the client’s treatment, and discuss any immediate action necessary, such as arranging for interpersonal support, referrals to community agencies, or moving directly into the active phase of treatment. It is helpful to explore the strategies clients have used in the past that have worked to relieve strong emotions. Finally, make sure the client is grounded and safe before leaving. Readiness to leave can be assessed by checking on the degree to which the client is conscious of the current environment, what the client’s plan is for maintaining personal safety, and what the client’s plans are for the rest of the day. ~ Elicit only the information necessary for determining a history of trauma and the possible existence and extent of traumatic stress symptoms and related disorders. ~ Even if a client wants to tell his or her trauma story, it’s your job to serve as “gatekeeper” and preserve the client’s safety. ~ Your tone of voice when suggesting postponement of a discussion of trauma is very important. Avoid conveying the message, “I really don’t want to hear about it.” Grounding Techniques ~ Ask the client to state what he or she observes. ~ Guide the client through this exercise by using statements like, “You seem to feel very scared/angry right now. You’re probably feeling things related to what happened in the past. Now, you’re in a safe situation. Let’s try to stay in the present. Take a slow deep breath, relax your shoulders, put your feet on the floor; let’s talk about what day and time it is, notice what’s on the wa

Alzheimer's and Dementias Instructor: Dr. Dawn-Elise Snipes, PhD Executive Director: AllCEUs.com, Counselor Education and Training Podcast Host: Counselor Toolbox & Happiness Isn’t Brain Surgery Objectives ~ Explore symptoms of cognitive impairment in ~ Alzheimer’s ~ Dementias ~ Review APA Treatment Guidelines for counselors working with persons with Alzheimer’s ~ Identify methods for effective communication ~ Learn how to handle difficult behaviors Symptoms of Cognitive Impairment ~ Patients with dementia display a broad range of cognitive impairments, behavioral symptoms, and mood changes ~ The development of multiple cognitive deficits manifested by both ~ (1) Memory impairment (impaired ability to learn new information or to recall previously learned information) ~ (2) One (or more) of the following cognitive disturbances: ~ (a) Aphasia (language disturbance) ~ (b) Apraxia (impaired ability to carry out motor activities despite intact motor function) ~ (c) Agnosia (failure to recognize or identify objects despite intact sensory function) ~ (d) Disturbance in executive functioning (i.e., Planning, organizing, sequencing, abstracting) Symptoms of Cognitive Impairment ~ Other Symptoms ~ Attention ~ Perception ~ Insight and judgment ~ Organization ~ Orientation ~ Processing speed ~ Problem solving ~ Reasoning ~ Metacognition: processes used to plan, monitor, and assess one’s understanding and performance Symptoms of Cognitive Impairment ~ Prominent memory symptoms include all EXCEPT: ~ Difficulty learning new material ~ May lose valuables or forget food cooking on the stove ~ Forget previously learned material, including the names of loved ones ~ Difficulty with spatial tasks, such as navigating around the house or in the immediate neighborhood ~ Agitation, within the context of a diagnosis of dementia, is an umbrella term that can refer to a range of behavioral disturbances, including aggression, combativeness, hyperactivity, and disinhibition ~ Individuals with questionable cognitive impairment have Borderline functioning in several areas but definite impairment in none. Such individuals are not considered demented, but they should be evaluated over time Causes of Cognitive Impairment ~ Vascular Dementia ~ Stroke ~ Impeded blood flow to brain ~ Alzheimer's ~ Brain Injury from a fall ~ Primary or secondary brain tumor ~ Endocrine conditions (hypothyroidism, hypercalcemia, hypoglycemia) ~ Nutritional conditions (deficiency of thiamin, niacin, or vitamin b12 (Wernike-Korsakoff’s Syndrome)) ~ Infectious conditions (HIV, neurosyphilis, cryptococcus) ~ Problems with renal and hepatic function ~ Effects of medications (e.g., benzodiazepines) ~ The toxic effect of long-standing substance abuse Diagnostic Criteria ~ Mild or Major Neurocognitive Disorder Due to Alzheimer's ~ Criteria adapted from the National Institute of Neurological and Communicative Disorders and Stroke and Alzheimer’s Disease and Related Disorders Association (NINCDS-ADRDA) include: ~ Dementia established by examination and objective testing ~ Deficits in two or more cognitive areas ~ Progressive worsening of memory and other cognitive functions ~ No disturbance in consciousness ~ Onset between ages 40 and 90 Diagnostic ~ Alzheimer’s cont… ~ Some individuals may show personality changes or increased irritability in the early stages ~ In the middle and later stages of the disease ~ Psychotic symptoms are common ~ Patients develop incontinence and gait and motor disturbances, eventually becoming mute and bedridden. Diagnostic ~ Parkinson's ~ Insidious onset

You Don’t Know What You Don’t Know Interview with Cecilia Briseno, LCSW Intro ~ Cecilia Briseno is a bilingual Licensed Clinical Social Worker at Bright Side Family Therapy, in Arlington, TX. ~ Following the completion of her Master’s program, Cecilia went on to study Marriage and Family Therapy in a doctoral program at Texas Woman’s University, which helped her to broaden her knowledge of SFT and family systems. ~ Cecilia has found her niche in working with families navigating through the immigration process. Cecilia provides evaluations explaining the hardships they face when separated from their loved ones. She is now also providing training for clinicians interested in working with immigrants. Path to your LCSW ~ How can this help someone who has recently graduated or will be graduating in the Spring? ~ What types of topics do you usually cover in this workshop? ~ What things do you wish someone would have told you after your graduated? ~ Is this ever offered online as a webinar? Hardship evaluations ~ What are hardship evaluations and who needs them? ~ How did you get into doing them? ~ How does the average therapist get into doing them? ~ Do you have to be bilingual or can you use an interpreter? ~ What is the demand like for these evaluations? ~ How much do they pay, on average? ~ What do you cover in your webinar? ~ Is the process the same for people in other states? ~ What if you know someone who needs a hardship evaluation…how do you get them in touch with the right people? Concluding Remarks Cecilia Briseno, LCSW-S Bright Side Family Therapy ~ Path to Your LCSW ~ https://www.allceus.com/BrightSide ~ Hardship Evaluations ~ https://www.allceus.com/Hardship