Counselor Toolbox Podcast

TIP 26: Addiction Treatment in Older Adults Instructor: Dr. Dawn-Elise Snipes PhD, LPC-MHSP, LMHC Podcast Host: Counselor Toolbox & Happiness Isn’t Brain Surgery Objectives ~ Review the data about substance abuse and gambling issues in older adults ~ Review screening for substance use and mental health disorders in the elderly ~ Identify risk factors for SA and MH issues ~ Review placement and treatment issues specific to older adults Introduction ~ Abuse of alcohol and prescription drugs among adults 60 and older; growing fast ~ Estimated 2.5 million older adults have problems related to alcohol ~ Consume more prescribed and over-the-counter (OTC) medications ~ 2006 New Jersey study indicated 23% of citizens over 55 were disordered gamblers (New Jersey Senior Gamblers Study) ~ Seniors are fastest growing group of gamblers between 1974 and 1989 (Gambling Impact and Behavior Study 1999) ~ A 2008 study reveals that they gamble for ~ Extrinsic reasons include winning money, gaining independence, and supplementing income ~ Intrinsic reasons include entertainment/excitement, being around other people, distraction from everyday problems such as loneliness and boredom, and escaping feelings of grief and loss associated with the death of a loved one or close friend. (Arizona Compulsive Gambling Council) Introduction ~ Among adults over 65 years of age gambling is the most frequently identified social activity (McNeilly & Burke 2001) ~ Reduced cognitive capacity can make it difficult for them to make sound decisions. ~ Older adults living on a fixed income with limited savings can’t necessarily afford the financial drain of a gambling disorder. ~ When you’re younger, maybe you’re $100,000 in debt, but you’ve got your spouse, you’ve got your children, your job; you still have some reason to get up in the morning,” Nower says ~ Because older adults tend to have less contact with friends and family, gambling-related problems may go unnoticed. Introduction ~ Gambling should be identified as a problem when it disrupts, damages, or limits a person’s life ~ Signs of problem gambling are spending more money on gambling than intended; feeling bad, sad, or guilty about gambling; not having enough money for food, rent, or bills; being unable to account for blocks of time; experiencing social withdrawal; and experiencing anxiety or depression. ~ Older adults may try to hide or deny a gambling problem, they may feel hopeless or ashamed about the situation, or they may be unaware that help is available. Alcohol and the Older Adult ~ Age-related changes affecting the way an older person responds to alcohol: 1) Normal decrease in body water that comes with age ~ Same amount can now cause intoxication ~ Increased sensitivity and decrease tolerance 2) Decrease in rate of GI metabolism ~ Blood alcohol level remains raised for a longer time ~ Increased hepatic workload Alcohol and the Older Adult Cont… ~ Trigger or worsen serious problems ~ Heart problems ~ Risk of stroke ~ Cirrhosis and other liver diseases ~ Gastrointestinal bleeding ~ Depression, anxiety and other mental health problems Prescription Drugs ~ Medications interact negatively with alcohol ~ Dependence on psychoactive medication ~ Misunderstood directions ~ Multiple prescriptions from different doctors; no coordination ~ Unintentional misuse leading to abuse Screening ~ Psychoactive substance use associated with negative central nervous system effects ~ Indications of problematic psychoactive substance use: ~ Diminished psychomotor performance ~ Impaired reaction time ~ Loss of coordination ~ Falls ~ Excessive daytime drowsiness ~ Confusion ~ Ag

Mental Health and the Elderly Instructor: Dr. Dawn-Elise Snipes PhD, LPC-MHSP, LMHC Podcast Host: Counselor Toolbox & Happiness Isn’t Brain Surgery Objectives ~ Normal Life-Cycle Tasks ~ Cognitive Capacity With Aging ~ Change, Human Potential, and Creativity ~ Coping With Loss and Bereavement ~ Mood Disorders ~ Alzheimer’s Disease ~ Schizophrenia in Late Life ~ Prevention and Helping the Person Live Well ~ Treatment Overview ~ Overview of Services and Service Delivery Settings ~ Issues Facing Families and Caregivers Normal Life Cycle Tasks ~ Normal aging is a gradual process that ushers in some physical decline, such as decreased sensory abilities (e.g., vision and hearing) and decreased pulmonary and immune function ~ Important aspects of mental health include ~ Stable intellectual functioning ~ Capacity for change ~ Productive engagement with life Cognitive Decline ~ It is often partly preventable ~ Slowing or some loss of other cognitive functions takes place, most notably in: ~ Information processing ~ Selective attention ~ Problem-solving ability ~ Prevention and early intervention should focus on ~ Encouraging different problem solving tasks (hobbies, puzzles etc.) ~ Maintaining physical activity to improve blood flow ~ Maintaining a good sleep routine (including addressing bladder issues) Change ~ Capacity to change can occur even in the face of mental illness, adversity, and chronic mental health problems. ~ Older persons display flexibility in behavior and attitudes and the ability to grow intellectually and emotionally. ~ Externally imposed demands upon one’s time may diminish which leaves plenty of time to embark upon new social, psychological, educational, and recreational pathways. Change ~ Ego Integrity vs. Despair can now be seen in two phases ~ Retirement/liberation ~ feelings of freedom, courage, and confidence are experienced. Those at risk for faring poorly are individuals who typically do not want to retire, who are compelled to retire because of poor health, or who experience a significant decline in their standard of living ~ Summing up/swan Song (Cohen) ~ tendency to appraise one’s life work, ideas, and discoveries and to share them with family or society. The desire to sum up late in life is driven by varied feelings, such as the desire to complete one’s life work, the desire to give back after receiving much in life, or the fear of time evaporating Loss and Bereavement ~ Studies on aging reveal that most older people generally do not have a fear or dread of death in the absence of being depressed, encountering serious loss, or having been recently diagnosed with a terminal illness ~ Losses with aging ~ Social status ~ Self-esteem ~ Physical capacities ~ Death of friends and loved ones ~ Other?? Loss and Bereavement ~ Persistent bereavement or serious depression is NOT considered normal. ~ Bereavement is an important and well-established risk factor for depression. At least 10 to 20 percent of widows and widowers develop clinically significant depression during the first year of bereavement. Without treatment, such depressions tend to persist, become chronic, and lead to further disability Overview of Mental Disorders ~ Older adults are encumbered by many of the same mental disorders as are other adults; however, the prevalence, nature, and course of each disorder may be very different ~ Many older individuals present with somatic complaints which amplify physical symptoms, distracting patients’ and providers’ attention from the underlying depression ~ Many older patients may deny psychological symptoms ~ They experience symptoms of depression and anxiety that do

When working with people with eating disorders, it is important to shift paradigms to one of resourcefulness vs. sickness The therapeutic relationship determines clients willingness to openly discuss and explore behavior patterns, consider altering eating behavior and disclose accurate information. You can improve motivation by creating mutually agreeable goals for treatment, and understanding and tipping the motivational balance regarding the cost/benefit of the current behaviors and attitudes such as ~ Fear of fat vs. desire to be healthy ~ Social pressures vs. desire to change ~ Sense of self-efficacy vs. powerlessness When assessing strengths, it is important to ask What kind and type of therapy did you have in treating your eating disorder What parts of your treatment were helpful, if any? What interventions were helpful and under what circumstances Do you believe you have any other issues such as depression or anxiety? What interventions or strategies that were helpful in the past might be helpful now? Explore Exceptions When has what worked and why? Under what conditions has each activity produced an exception and failed to produce an exception Use scaling questions to help the client stop viewing things in terms of dichotomies Have the client rate on a scale of 1-5 (It is helpful to give verbal anchors) and then explain why she chose her number. ~ How anxious does it make you to think about… ~ How accepted do you feel by… ~ How helpful was therapy/x-intervention in the past? ~ How often have you been successful at going a day without bingeing? ~ Scaling can help therapists highlight ignored exceptions and positives Feedback messages/summary should highlight positive actions or events, restate of the client’s goal (Ex. “You want to get control of your eating so you don’t feel you have to purge to maintain your weight.”) and identify next steps, including homework assignments. Goals of the First Session Attend to present and future with little attention paid to the past Explore a problem free future Enhance exceptions and previous solution patterns Provide feedback and therapeutic compliments Assign homework Second session and beyond Separate the person from the problem Stay focused on client strengths and resources Don’t take a position regarding the client’s situation Constantly check in to see if the client’s specific goals have changed. (i.e. I want to be happy, but have realized that losing weight won’t make me happy it is…) Continually evaluate the client's stage of change…watch for yes buts which indicate… Explain the necessity to focus on small, realistic goals one at a time Develop a plan to tolerate behavioral and attitudinal slips or relapses Food Planning Must be concrete and practical Must be presented as a way to create an “exception” related to a client’s identified goal. That is, how can creating this food plan help you achieve your goal (and prevent the behavior you are trying to eliminate). Generally the food plan will be done in conjunction with a Registered Dietician or a physician. Clients should also maintain a self monitoring journal in the form of a table asking… Time What did you eat? How much did you eat? Were you hungry? If not, what prompted your eating? Were you craving sweet/salty/spicy or a specific food? How did you feel after you ate? Did you purge? If yes, how did you feel afterwards and what could you do differently next time? If no, how did you feel afterwards and what did you do to prevent the purge? What information/exceptions can you derive from this type of table? Remember that many clients coming in are terrified of gaining weight and eating certain “forbidden foods.

Eating Disorders Assessment Part 2 Instructor: Dr. Dawn-Elise Snipes, PhD, LPC, LMHC Podcast Host: Counselor Toolbox & Happiness Isn’t Brain Surgery Objectives ~ Review the prevalence of eating disorders ~ Identify assessment areas ~ Identify risk and protective factors ~ Explore complications ~ Explore potential guidelines for treatment ~ Based on APA Guidelines for Eating Disorders and the NICE Guidelines for Eating Disorder Recognition and Treatment Goals for Treating Anorexia ~ Restore patients to a healthy weight (associated with the return of menses and normal ovulation in female patients, normal sexual drive and hormone levels in male patients, and normal physical and sexual growth and development in children and adolescents) ~ Treat physical complications ~ Enhance patients’ motivation to cooperate in the restoration of healthy eating patterns and participate in treatment ~ Provide education regarding healthy nutrition and eating patterns ~ Help patients reassess and change core dysfunctional cognitions, attitudes, motives, conflicts, and feelings related to the eating disorder Goals for Treating Anorexia ~ Treat associated psychiatric conditions, including deficits in mood and impulse regulation and self-esteem and behavioral problems ~ Enlist family support and provide family counseling and therapy where appropriate ~ Prevent relapse. Anorexia Nutritional Rehabilitation ~ Establish expected rates of controlled weight gain. ~ Realistic targets are 2–3 lb/week for hospitalized patients and 0.5–1 lb/week for individuals in outpatient ~ Registered dietitians can help patients choose their own meals and can provide a structured meal plan that ensures nutritional adequacy and that none of the major food groups are avoided. ~ Formula feeding may have to be added to the patient’s diet to achieve large caloric intake. ~ Encourage patients with anorexia nervosa to expand their food choices to minimize the severely restricted range of foods initially acceptable to them. ~ Caloric intake levels should usually start at ~1,000–1,600 kcal/day. ~ Weight gain results in improvements in most of the physiological and psychological complications of semistarvation. Anorexia Nutritional Rehabilitation ~ It is important to warn patients about the following aspects of early recovery: ~ As they start to feel their bodies getting larger, they may experience a resurgence of mood symptoms, irritability, and suicidal thoughts. ~ Mood symptoms, non-food-related obsessional thoughts, and compulsive behaviors, although often not eradicated, usually decrease with sustained weight gain and weight maintenance. ~ Patients who abruptly stop taking laxatives or diuretics may experience marked rebound fluid retention for several weeks. ~ As weight gain progresses, many patients also develop acne and breast tenderness and become unhappy and demoralized about resulting changes in body shape. ~ Patients may experience abdominal pain and bloating with meals from the delayed gastric emptying that accompanies malnutrition. This may respond to pro-motility agents. ~ Constipation may be ameliorated with stool softeners; if unaddressed, it can progress to obstipation and, rarely, to acute bowel obstruction Anorexia Psychoeducation ~ The goals of psychosocial interventions are to help patients with anorexia nervosa ~ Understand and cooperate with their nutritional and physical rehabilitation ~ Understand and change the behaviors and dysfunctional attitudes related to their eating disorder ~ Improve their interpersonal and social functioning ~ Address comorbid psychopathology and psychological conflicts that reinforce or maintain eating disorder behaviors. ~ During acute refeeding and while weight gain is o

Eating Disorders Assessment Part 1 Instructor: Dr. Dawn-Elise Snipes, PhD, LPC, LMHC Podcast Host: Counselor Toolbox & Happiness Isn’t Brain Surgery Objectives ~ Review the prevalence of eating disorders ~ Identify assessment areas ~ Identify risk and protective factors ~ Explore complications ~ Explore potential guidelines for treatment ~ Based on APA Guidelines for Eating Disorders, the NICE Guidelines for Eating Disorder Recognition and Treatment, and the NEDA Coach and Trainer’s Toolkit Prevalence of Eating Disorders ~ 20% of women struggle with disordered eating ~ 10-15% of people with eating disorders are male ~ 40% of male football players were found to engage in disordered eating ~ Muscle dysmorphia and body fat preoccupation is seen in a majority of bodybuilders and wrestlers ~ 90% of people with eating disorders become symptomatic between 12 and 25 Risk Factors ~ The exact causes of anorexia nervosa are unknown. However, the condition sometimes runs in families; young women with a parent or sibling with an eating disorder are likelier to develop one themselves. ~ People with anorexia come to believe that their lives would be better if only they were thinner. ~ These people tend to be perfectionists and overachievers. ~ The typical person with anorexia is a good student involved in school and community activities. ~ Many experts think that anorexia is part of an unconscious attempt to come to terms with unresolved conflicts or painful childhood experiences. ~ While sexual abuse has been shown to be a factor in the development of bulimia, it is not associated with the development of anorexia. Risk Factors ~ Biological factors may include an abnormal biochemical make up of the brain ~ The hypothalamic-pituitary-adrenal axis (HPA) is responsible for releasing certain neurotransmitters including serotonin, norepinephrine, and dopamine, which regulate stress, mood, and appetite. ~ People with eating disorders tend to have lower levels of serotonin and norephinephrine ~ Starving, bingeing and purging in and of themselves can alter brain chemistry ~ Both undereating and overeating can activate brain chemicals that produce feelings of peace and euphoria, thus temporarily dispelling anxiety and depression. Leading some to conclude that food is used to self-medicate painful feelings and distressing moods. ~ New research suggests that there is a biological link between stress and the drive to eat. Comfort foods — high in sugar, fat, and calories — seem to calm the body’s response to chronic stress. Risk Factors ~ Psychological Risk Factors ~ Low self-worth and low-self esteem /Feelings of inadequacy ~ Obsessive behaviors regarding food and diets and may often also display obsessive-compulsive personality traits in other parts of their life. ~ A strong, even extreme drive for perfectionism. ~ They have unrealistic expectations of themselves and others ~ In spite of their many achievements, they feel inadequate. ~ They see the world dichotomously ~ individuals who develop anorexia are led to think that they are never thin enough regardless of how much weight is lost. ~ Negative affect: depression, anxiety, anger, stress or loneliness ~ A sense of lack of control in life Risk Factors ~ Psychological Risk Factors ~ Wanting to take control and fix things in an unhappy life, but not really knowing how, and under the influence of a culture that equates success and happiness with thinness, the person tackles her/his body instead of the problem at hand. ~ Dieting, bingeing, purging, exercising, and other strange behaviors are not random craziness, but misguided and ineffective, attempts to take charge in a world that seems overwhelming. Risk Factors ~ In

Anger Management 9 Session Protocol Dr. Dawn-Elise Snipes PhD, LMHC Executive Director, AllCEUs.com Objectives ~ Learn about anger and it’s functions ~ Explore events and cues ~ Develop an anger control plan ~ Learn about the aggression cycle and how to change it ~ Review the ABCDEs and thought stopping ~ Assertiveness and conflict resolution skills ~ Alternatives for expressing anger ~ Relaxation Interventions ~ Explore how past learning from your family of origin can influence current behavior Session One: Learn About Anger ~ Anger is an emotion triggered by a threat which prompts the fight (aggression) or flight reaction ~ Hostility refers to a set of attitudes, thoughts and judgments that motivate aggressive behaviors. ~ Aggression is behavior that is intended to protect oneself by causing harm or injury to another person or damage to property. (Fight or Flee) ~ Many times what we initially perceive as a threat is not currently one Session 1 cont. ~ Misperceptions ~ Example: Fire alarm ~ Example: Sean and Elias ~ Initial experience: Brewster perceived a danger ~ Future experiences—Elias is associated with a threat ~ Example: Rescues ~ Initial experience: A man hurt you ~ Future experiences are overgeneralized: All men are dangerous ~ Example: Domestic Violence ~ Initial experience: Raised voices leads to violence ~ Future experiences: Anytime someone raises their voice it is a threat Session 1 ~ Anger becomes a problem when it is felt too intensely, is felt too frequently, or is expressed inappropriately ~ How does anger affect you: ~ Physically: Sleep, pain, GI, immunity ~ Emotionally: Regret, guilt, feeling helpless ~ Socially: Fear vs. respect, negative impact on relationships ~ Occupationally: How you work with others, customer service ~ Spiritually: Your sense of connectedness to and impact within the world, karma ~ Environmentally: Break stuff, holes in walls, throw out things impulsively Session 1… ~ Anger initially has apparent payoffs (e.g., releasing tension, controlling people). ~ In the long-term, however, these payoffs often lead to negative consequences. ~ What benefits/payoffs does anger have for you? ~ Habits are things we do almost automatically. ~ In what ways is anger a habit ~ How can you use mindfulness to start to break that habit? ~ I am angry? ~ What am I angry about? ~ Is this actually a threat to me? ~ What is the best response in this situation to help me achieve my goals Session 1 ~ Identify anger control strategies you have used in the past ~ Which ones worked? Why? ~ Which ones didn’t work? Why? Session 1 ~ Homework: Keep a log of your anger intensity the next week. Keeping a log helps you become more aware of your triggers and cues and see your progress. ~ On the top of the page, put the date (use a different sheet each day) ~ Make 3 columns with the following headers Session 2: Identifying Triggers, Events & Cues ~ When you get angry, it’s because you have encountered an something that has made you feel threatened (provoked you) ~ What are some general situations that make you irritable? Angry or enraged? ~ Many times, specific events touch on sensitive areas. These sensitive areas or “red flags” usually refer to long-standing issues that can easily lead to anger ~ Loss of Control ~ Rejection/Isolation ~ Death/Loss ~ Failure ~ Why does each of these “sensitive areas” make you feel threatened/trigger your anger? Session 2 cont… ~ Cues are indicators that you are getting angry. ~ Cues can be broken down into four cue categories: ~ Physical Cues (how your body responds; e.g.

Live 10 Risk Factors, Warning Signs and Points to Remember About Suicidality Dr. Dawn-Elise Snipes PhD, LPC-MHSP, LMHC Executive Director AllCEUs.com Podcast Host: Counselor Toolbox Objectives ~ Identify general practice points to consider about suicidality ~ Explore/review risk and protective factors for suicidality ~Discuss ways to reduce risk and enhance protective factors ~ Identify suicide warning signs IS PATH WARMED ~ Learn the SPLASH acronym for suicide screening General Practice Points • Clients should be screened for suicidal thoughts and behaviors routinely at intake and at specific points in the course of treatment • Screening for clients with high risk factors should occur regularly throughout treatment. (preferably at each episode) • Counselors should be prepared to develop and implement a treatment plan to address suicidality and coordinate the plan with other providers. • If a referral is made, counselors should check that referral appointments are kept and continue to monitor clients after crises have passed, through ongoing coordination with mental health providers and other practitioners, family members, and community resources, as appropriate. General cont… • Counselors should acquire basic knowledge about the role of warning signs, risk factors, and protective factors as they relate to suicide risk. • Counselors should be empathic and nonjudgmental with people who experience suicidal thoughts and behaviors. • Counselors should understand the impact of their own attitudes and experiences with suicidality on their counseling work with clients. • Counselors should understand the ethical and legal principles and potential areas of conflict that exist in working with clients who have suicidal thoughts and behaviors. General cont. • Suicide risk may increase at transition points in care), especially when a planned transition breaks down. Anticipating risk at such transition points should be regarded as an issue in treatment planning. • Suicide risk may increase when a client is terminated administratively (e.g., because of poor attendance, chronic substance use) or is refused care. ~ It is unethical to discharge a client and/or refuse care to someone who is suicidal without making appropriate alternative arrangements for treatment to address suicide risk. • Suicide risk may increase in clients with a history of suicidal thoughts or attempts who relapse. Treatment plans for such clients should provide for this possibility. General cont. • Suicide risk may increase in clients with a history of suicidal thoughts or attempts who imply that the worst might happen if they relapse (e.g., “I can't go through this again,” “if I relapse, that's it”)—especially for those who make a direct threat (e.g., “This is my last chance; if I relapse, I'm going to kill myself”). • Suicide risk may increase when clients are experiencing acute stressful life events. Treatment should be adjusted by adding more intensive treatment, closer observation, or additional services to manage the life crises. 10 Risk Factors • Mental health conditions ~ Depression ~ Substance use problems ~ Bipolar disorder ~ Schizophrenia ~ Emotional dysregulation ~ Conduct disorder ~ Anxiety disorders • Serious or chronic health conditions and/or pain • Traumatic brain injury 10 Risk Factors • Precipitants/triggering events leading to humiliation, shame, or despair (e.g., loss of relationship, health or financial status – real or anticipated ~ Prolonged stress, such as harassment, bullying, relationship problems or unemployment ~ Stressful life events, which may include a death, divorce or job loss • Exposure to another person’s suicide, or to graphic or sensationalized accounts of suicide includin

Culturally Responsive Services with Persons Who Are LGBTQ2IK Dr. Dawn-Elise Snipes, PhD, LPC-MHSP, LMHC Executive Director, AllCEUs.com Podcast Host: Counselor Toolbox Objectives ~ Learn terminology specific to the LGBTQ2IK community ~ Explore specific verbal and nonverbal communication issues ~ Learn the stages of the coming out process ~ Review Neisen's 3-Phase Model for Recovery From Shame and counselor tasks ~ Identify LGBTQ2IK Cultural Issues ~ Identify how race, culture and ethnicity impact identity development and acculturation ~ Identify specific treatment issues which may be unique to this population ~ Learn about the Family Acceptance Project Terminology ~ Sex: Genetic and anatomical characteristics with which people are born ~ Intersex: Some individuals are born with a reproductive/sexual anatomy that does not fit typical definitions of male or female. Not all of these individuals identify as intersex. ~ Sexual orientation: A person’s emotional, sexual, and/or relational attraction to others including heterosexual, gay/lesbian, bisexual ~ Gender identity: Our internal sense of being male, female Because gender identity is internal, it is not necessarily visible to others. ~ “transgender” describes people whose gender identity/expression is different from that typically associated with their assigned sex at birth. gender identity, in many cases, is independent of sexual orientation ~ A transgender person “transitions” to express gender identity through various changes including wearing clothes and adopting a physical appearance that aligns with their internal sense of gender. Terminology ~ Gender expression: The manner in which people represent their gender to others individual through mannerisms, clothes, and personal interests. ~ Two-Spirit: An inclusive term created specifically by and for Native American communities. It refers to American Indian/Alaskan Native American people who (a) express their gender, sexual orientation, and/or sex/gender roles in indigenous, non-Western ways, using tribal terms and concepts, and/or (b) define themselves as LGBTQI in a native context. ~ Heterosexism resembles racism or sexism and denies, ignores, denigrates, or stigmatizes nonheterosexual forms of emotional and affectional expression, sexual behavior, or community. ~ Homophobia is defined as the irrational fear of, aversion to, or discrimination against LGBT behavior or persons. ~ Internalized homophobia describes the self-loathing or resistance to accepting an LGBT sexual orientation and is an important concept in understanding LGBT clients Terminology ~ Lesbians are people who identify as female, who are attracted to others who identify as female ~ Gay: means anyone who’s attracted to people of the same sex ~ Bisexuals are attracted to both the male and female sex ~ Transgender born a certain sex but identify as a different gender ~ Queer: a very inclusive term for anyone in the LGBT+ community. Choosing to identify as ‘queer’ can mean individuals don’t have to belong to a more specific category if they aren’t sure of their sexuality/ gender or simply don’t want any other label ~ Intersex: intersex it means they are born a certain gender but their sexual or reproductive anatomy is from the opposite sex Terminology ~ Asexual: When a person is asexual it simply means that they aren’t very sexually attracted to either sex and have a generally low level of interest and desire to take part in sexual activities. ~ Pansexual: When someone is pansexual it means they are attracted to people regardless of their gender. They are attracted to individuals rather than one particular gender or sexuality ~ Polygamous/ polyamorous: People who identify as polygamous/ polyamorous have consenting open relationships with more

15 Principles of Client Centered Care Dr. Dawn-Elise Snipes, PhD Executive Director: AllCEUs.com Podcast Host: Counselor Toolbox and Happiness Isn’t Brain Surgery Definition and Benefits ~ Client Centered Care empowers the client to actively participate in his/her care and develop an understanding of the interaction between his/her environment and self. ~ Improves treatment compliance ~ Leads to more rapid and enduring improvements ~ Starts with caring Characterize caring ~ Listening to and empathizing with clients’ points of views ~ Recognizing clients as unique individuals ~ Never allowing your values to interfere with clients’ right to receive care Client Centered Care ~ An approach in which ~ Clients are viewed as whole persons ~ It is not merely about delivering services where the client is located ~ It involves advocacy, empowerment, and respecting the client’s autonomy, voice, self-determination, and participation in decision-making. Empowerment ~ Empowerment is “the participation of individuals and communities in a social action process that targets both individual and community change outcomes.” A concept that is crucial is that community workers and professionals must “start where the people are” ~ Initial and ongoing assessment of clients’ values, feelings, actions are integral to any community work. Humanistic Approach ~ Based on knowing the client and the client’s perspective through continuous dialogue. ~ Views the client as a whole, and recognizes the interconnectedness and interrelationship between the client and the environment. ~ Focuses on restoring health, harmony and enhanced quality of life. Participatory Management ~ Participatory Management is the extent to which managers involve staff in decisions regarding their work and aspects of the work environment, ~ Characterized by ~ the manager seeking staff input and feedback about the work environment ~ involving staff in decision making about their own work ~ providing recognition and support and taking action on the input Reflective Practice ~ An ongoing process that the counselor utilizes in order to examine his/her own nursing practice, evaluate strengths, and identify ways of continually improving practice to meet client needs. ~ Questions useful in framing the reflective process include: ~ “What have I learned?” ~ “What has been most useful?” ~ “ What else do I need?” Respect ~ Respect clients’ wishes, concerns, values, priorities, perspectives, and strengths. Clients Are Experts for Their Own Lives ~ Clients know themselves the best or they would not be in this situation. ~ You should follow your client’s lead with respect to information giving, decision making, care in general and involvement of others. ~ Clients define the goals that coordinate the practices of the health care team. Identifying Concerns/Needs ~ Initiate discussion or strategies (i.e. Focus groups and surveys) in order to understand the client’s perspective regarding his/her health and quality of life. ~ Seek to clarify the hopes, wishes, preferences, strengths, needs, and concerns of the client, from his/her perspective. ~ Seek to build the client’s capacity (ability to reach independence) based on the client’s goals. ~ ~ Represent the client’s/community’s perspective of health, goals in life, as well as their concerns when making recommendations to others ~ Follow the client’s lead when providing information or teaching what the client wants with respect to his/her health/illness situation ~ Document the client’s/community’s perspective with regard to health and quality of life, goals, wishes, choices regarding information, and concerns Making Decisions ~ Identify prio

10 Principles of Crisis Intervention Dr. Dawn-Elise Snipes Ph.D., LMHC, LPC-MHSP Executive Director, AllCEUs.com Objectives ~ Define crisis ~ Identify the 6 basic threats and how they relate to crisis ~ Discuss characteristics of crisis ~ Examine cultural influences in behaviors ~ Explore the SAFERR model ~ Identify 10 principles of crisis intervention Definition of Crisis ~ People are facing an untenable obstacle to goals ~ People’s life cycles are significantly disrupted AND ~ The person has no appropriate response to deal with a situation Temperament ~ Defines how we tend to prefer to act and interact. ~ Extrovert/Introvert (Awareness/Socialization) ~ Sensing/Intuitive (Problem Conceptualization) ~ Thinking/Feeling (Meaning) ~ Judging/Perceiving (Structure/Spontaneity) Characteristics of Crisis ~ Presence of opportunity and danger ~ Change causes crisis and crisis causes change ~ Increasing anxiety can lead to violent reactions Characteristics of Crisis ~ Complicated ~ Generally does not have one simple cause ~ Beliefs may be operating when an emotion or reaction seems out of proportion ~ Precipitating events may impact many different areas of life ~ No Panaceas or Quick Fixes ~ May provide temporary, immediate relief ~ Ensure they do not make problem worse ~ Necessity of Choice ~ Making a choice requires action ~ Choosing not to act is a still a choice Types of Crisis ~ Developmental ~ Identity formation ~ Empty nest ~ Mid-life ~ Medical/Physical ~ Chronic Illness/Pain (HIV, Fibro, Paralysis) ~ Spouse chronic illness ~ Situational ~ Death ~ Relationship ~ Job Loss ~ Homelessness* ~ Cabin Fever Exacerbating & Mitigating Factors/Vulnerabilities ~ Emotional: Pre-existing mood issues ~ Mental/Cognitive ~ Critical inner voice ~ Negative perceptions ~ Unhelpful thoughts (Cognitive distortions) ~ Physical ~ Pain/illness ~ Sleep deprivation ~ Low blood sugar/dehydration ~ New meds or med change Exacerbating & Mitigating Cont… ~ Social: ~ Lack of healthy, supportive social environment ~ Spiritual ~ Sense of interconnectedness and connection to something bigger than ourselves ~ What gives hope, faith, meaning and courage ~ What are a person’s values ~ Environmental ~ Visual triggers ~ Auditory triggers ~ Audience 6 Basic Threats ~ Fear and anger represent responses to a threat ~ Threats to consider in assessment ~ The unknown ~ Loss of control or power ~ Rejection ~ Isolation ~ Failure ~ Death Models of Crisis Intervention ~ Equilibrium/Stabilization ~ Remove reinforcers for aggressive behavior ~ Identify reasons to calm down ~ Cognitive ~ Gain control by changing thinking ~ Psychosocial ~ Assess internal and external exacerbating and mitigating factors ~ Choose workable alternatives Cultural Competence ~ There is no one “normal” range of behaviors ~ Individualistic vs. collectivistic society ~ Language is not always interpreted in the same way ~ We must accommodate the client’s needs ~ Past history certainly impacts current events ~ Be aware of personal assumptions Crisis Intervention-SAFERR ~ Basic Steps ~ Stabilize ~ Acknowledge ~ Facilitate understanding ~ Encourage adaptive coping ~ Restore functioning ~ Refer as needed Stabilize ~ Ensure Safety ~ Physical ~ Remove the client from the situation (if possible) ~ Inform client you want to help, but it is hard for you to focus

Relapse Prevention Dr. Dawn-Elise Snipes PhD, LPC-MHSP, LMHC Executive Director AllCEUs Objectives ~ Define relapse in terms of addiction as well as mental health ~ Examine relapse prevention techniques ~ Explore needs of the person: Psychosocial and Maslovian What is Relapse ~ Relapse is the return to addictive behaviors or the recurrence of mood symptoms ~ Relapse often starts long before the person uses again ~ Get caught up in day-in-day-out ~ Start acting “mindlessly” ~ Stop going to meetings/counseling/church/lifeline ~ Begins running out of energy to do new behaviors ~ Frustration, irritability and exhaustion set in ~ Caveat…an extreme stressor can prompt “immediate relapse” Relapse Definition ~ Relapse is the return to something that has been previously stopped ~ Relapse is multidimensional ~ Emotional ~ Mental ~ Physical ~ Social ~ A relapse is when you start returning to any of these people, places, things, behaviors or feeling states. Extreme Stressors ~ Those things that overwhelm an individuals ability to cope ~ Thrust them into the fight or flight ~ New coping skills and support resources may not even be considered, or only half-heartedly ~ Have clients identify or practice dealing with these types of situations in group ~ Divorce ~ Death ~ Job Loss ~ Diagnosis of a terminal or chronic illness (Cancer, ALS, HIV) Beginner Tools for Extreme Stress ~ Get support… You are outnumbered! ~ Self-soothing/De-Escalation ~ Systematic Desensitization ~ Cognitive Behavioral Therapy ~ CPT Note Card ~ I feel… because …… ~ What am I upset about ~ What are the FACTS for and against this belief ~ Am I using all or nothing thinking or jumping to conclusions ~ I need to call _______ to get an objective perspective or what would _____ do The 4 Ds ~ Delay – Most urges, feelings and cravings rise and fall like waves in about 20 minutes if you do not “feed” them ~ Distract – Craving time passes more quickly when engaged in a distracting activity for a few minutes. ~ Use Distress Tolerance Skills to IMPROVE the moment and ACCEPT reality. DBT Video ~ De-Stress – By reducing your stress and distress, you are allowing your body to maintain higher levels of calming and “happy” chemicals. ~ For more tips, listen to the Happiness Isn’t Brain Surgery Podcast on preventing vulnerabilities. ~ De-Catasrophize – Challenge your thoughts and when necessary, reframe them into more accurate notions, like, “This is really uncomfortable, but I can manage.“ ~ Video on thinking errors Relapse Prevention Card ~ Fold a paper into four squares: ~ On the first square, write: “Delay, Distract, De-Stress, De-Catastrophize ~ On the second square, write out 5 personally relevant distraction ideas ~ On the third square, write out 3 of your most significant reasons for wanting to recover ~ On the fourth square, write out some negative expectations – accurate predictions for what will happen if you slip (over eat, smoke, drink, say “yes” when you need to say “no”) Creating a Relapse Prevention Plan ~ Triggers and Vulnerabilities are multidimensional ~ Emotional ~ Mental ~ Physical ~ Social ~ Environmental ~ Cravings: Compile a list of who you can call, what you can do to distract yourself from a craving and how you could stop a craving altogether. (gambling, smoking, sex, over eating) ~ Healthy tools: Think about what new and old behaviors/tools you can use to keep you on the right track. Some examples include writing a list of consequences should you relapse, attending a support meeting, exercising, journaling, or writing a gratitude list.

8 Useful Brief Interventions and Brief Therapies 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 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 ~ 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) 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 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, social etc.) ~ Education ~ Motivational Interviewing: “List 5 ways substances use has impacted….” ~ Family/Peer commentary specifically about the client ~ Types ~ Reluctant ~ Increase knowledge of the problem, and the personal impact ~ Rebellious ~ Shift energy from fear of losing control to improving the next moment ~ Resigned ~ Rekindle hope/optimism by highlighting successes, strengths Stages of Change ~ Contemplation: “It’s getting a little hot, but I’m okay” ~ Increase awareness of the consequences of the current problem ~ Explore/address ambivalence by tipping the decisional balance scales ~ Address anxiety and grief about change ~ Help clients visualize change Treatment Needs: Preparation ~ Preparation: “I’ll just stick my toe in and see.” ~ Identify benefits of treatment ~ Identify/address fears/apprehensions about treatment ~ Give the client a list of options for treatment ~ Clarify goals and strategies ~ Identify and address barriers to change ~ Highlight strengths and past successful strategies ~ Garner social support ~ Envision change and find motivating stories from others ~ Identify motivations in each area and create small successes for components of the goal ~ Increase self efficacy and hardiness (C3) ~ Strengthen commitment ~ Begin learning about the issues Stages of Change ~ Action: “I’m tired of being hot.” ~

Culturally responsive Service with African American Clients Objectives ~ African Americans or Blacks are people whose origins are “in any of the black racial groups of Africa” ~ The term includes ~ Descendants of African slaves brought to this country against their will ~ More recent immigrants from Africa, the Caribbean, and South or Central America ~ many individuals from these latter regions, if they come from Spanish-speaking cultural groups, identify primarily as Latino Treatment Issues/Barriers ~ African Americans are less likely than White Americans to receive treatment for anxiety and mood disorders ~ African Americans are more likely to be diagnosed with schizophrenia and less likely to be diagnosed with affective disorders than White Americans, even though multiple studies have found that rates of both disorders among these populations are comparable ~ African Americans are about twice as likely to be diagnosed with a psychotic disorder as White Americans and more than three times as likely to be hospitalized for such disorders. ~ For an overview of mental health across populations, refer to Mental Health United States, 2010 (SAMHSA 2012a). Treatment Issues ~ Blacks were much more likely to receive mental health services from general practitioners than from mental health specialists (Outreach) ~ Were significantly more likely than White Americans to have an undetected co-occurring mental disorder, and, if detected, they were significantly less likely than White Americans or Latinos to receive treatment for that disorder ~ African Americans are more likely to be referred to treatment from criminal justice settings rather than self-referred or referred by other sources Treatment Issues/Barriers ~ Lack of familiarity with the value and use of specialized behavioral health services may limit service use. ~ An essential step in decreasing disparity in behavioral health services among African Americans involves using culturally sensitive instruments and evaluation tools ~ African Americans were more likely than members of other major ethnic/racial groups to state that they lacked transportation to the program or that their insurance did not cover the cost of such treatment ~ Longstanding suspicions regarding established healthcare institutions can also affect African Americans' participation in, attitudes toward, and outcomes after treatment Treatment Issues/Barriers ~ Attitudes toward psychological services appear to become more negative as psychological distress increases (Early intervention) ~ In many African American communities, there is a persistent belief that social and treatment services try to impose White American values ~ African Americans, even when receiving the same amount of services as White Americans, are less likely to be satisfied with those services Approaches ~ African American clients generally respond better to an egalitarian and authentic relationship with counselors ~ Request personal information gradually rather than attempting to gain information as quickly as possible ~ Avoid information-gathering methods that clients could perceive as an interrogation ~ Be willing to validate African American clients' experiences of racism and its reality in their lives ~ Racism and discrimination can lead to feelings of anger, anxiety, or depression. ~ These feelings are pervasive ~ Counselors should explore with clients the psychological effects of racism and develop approaches to challenge internal negative messages that have been received or generated 6 Core Principles ~ Discussion of clients' issues should be framed in a context that recognizes the totality of life experiences faced by clients as African Americans. ~ Equality is sought in the therapeutic counselor–client relationship, and coun

Attachment Theory: Implications for Treatment Instructor: Dr. Dawn-Elise Snipes Executive Director, AllCEUs Counselor Education Objectives ~ Review Attachment Theory ~ Identify stages of distress ~ Discuss the benefits of secure attachment ~ Explore the effects of insecure attachment ~ Learn about different attachment styles and their associated problems ~ Hypothesize interventions to create secure attachment regardless of age. Infancy and Attachment ~ Attachment ~ Attachment is the quality of the relationship with the caregiver characterized by trust, safety and security. ~ The quality of the infant-parent attachment is a powerful predictor of a child’s later social and emotional outcome ~ Determined by the caregiver’s response to the infant when the infant’s attachment system is ‘activated’ ~ Beginning at six months old, infants come to anticipate caregivers’ responses to their distress and shape their own behaviors accordingly (eg, developing strategies for dealing with distress when in the presence of that caregiver) ~ Sensitive, Responsive, Loving = Secure ~ Insensitive, Rejecting or Inconsistent = Insecure Attachment cont… ~ The primary attachment figure remains crucial for approximately the first two years of life ~ Forming this attachment is almost useless if delayed until after two and a half to three years ~ If the attachment figure is broken or disrupted between ages 1 and 5, the child may suffer irreversible long-term consequences. ~ Bifulco (1992) Women who had lost their caregiver through separation or death doubled their risk of depressive and anxiety disorders. The rate of depression was the highest in women whose caregivers had died before the child reached the age of 6. Internal Working Model ~ Children’s attachment with their primary caregiver leads to the development of an internal working model which guides future interactions with others. ~ 3 main features of the internal working model ~ a model of others as being trustworthy ~ a model of the self as valuable ~ a model of the self as effective when interacting with others Adult Attachment ~ Adult attachment style refers to systematic patterns of expectations, beliefs, and emotions concerning the availability and responsiveness of close others during times of distress ~ Often among multiple people with one primary attachment ~ Provide a bidirectional attachment relationship which provides adults with a secure base that they are able to depend on a daily basis. Attachment ~ Psychological problems can increase attachment insecurity. ~ Davila et al found that late adolescent women who became less securely attached over periods of 6 to 24 months were more likely than their peers to have a history of psychopathology ~ Among soldiers with PTSD Attachment anxiety and avoidance increase over time, and the increases are predicted by the severity of PTSD symptoms Three Progressive Stages of Distress ~ Protest: The child cries, screams and protests angrily when the caregiver leaves. They will try to cling on to the caregiver to stop them leaving. ~ Despair: The child’s protesting begins to stop, and they appear to be calmer although still upset. The child refuses others’ attempts for comfort and often seems withdrawn and uninterested in anything. ~ Detachment: If separation continues the child will start to engage with other people again. They will reject the caregiver on their return and show strong signs of anger. Effects of Secure Attachment ~ Learn basic trust, which serves as a basis for all future emotional relationships ~ Develop fulfilling intimate relationships ~ Maintain emotional balance ~ Feel confident and good about themselves ~ Enjoy being with others ~ Rebound from d

Improving Cultural Competence Working with Asian People Instructor: Dr. Dawn-Elise Snipes, PhD Executive Director: AllCEUs.com, Counselor Education and Training Podcast Host: Counselor Toolbox & Happiness Isn’t Brain Surgery Objectives ~ Learn about Asian cultures, traditions and values as they relate to mental health ~ Learn about communication styles to help the counselor more effectively communicate with culturally different clients ~ Explore health disparities ~ Explore appropriate approaches to counseling General Information ~ Asian Americans have a 17.30 percent overall lifetime rate of any psychiatric disorder and a 9.19 percent 12-month rate, yet Asian Americans are three times less likely to seek mental health services than Whites ~ Cultural factors, such as language, age, gender, and others, can influence the mental health of Asians, particularly immigrants ~ Asians place great value on the family as a unit. Each individual has a clearly defined role and position in the family hierarchy and is expected to function within that role, submitting to the larger needs of the family. ~ Social stigma, shame, and saving face often prevent Asians from seeking behavioral health care ~ Asian patients are likely to express psychological distress as physical complaints General cont… ~ Language Knowledge of English is one of the most important factors influencing access to care. ~ Level of acculturation Typically, it takes three generations for immigrants to fully adopt the lifestyle of the dominant culture. ~ Age In general, the younger people are when they migrate, the more readily they adapt ~ Gender Historically, men have acculturated more rapidly than women ~ Occupational Issues: Sometimes, women earn more than men, thereby disrupting family expectations and traditional values Religion and Spirituality ~ Christianity ~ Muslim ~ Buddhism which promotes spiritual understanding of disease causation ~ Confucianism, an ethical belief system that stresses respect for authority, filial piety, justice, benevolence, fidelity, scholarship, and self-development ~ Taoism, which is the basis for yin and yang theory ~ Animism, which is the belief that human beings, animals, and inanimate objects possess souls and spirits. Beliefs About Mental Health ~ Traditional beliefs about mental health: ~ Mental illnesses are caused by a lack of harmony of emotions or by evil spirits. ~ Mental wellness occurs when psychological and physiologic functions are integrated. ~ Buddhist belief that problems in this life are most likely related to transgressions committed in a past life. ~ In addition, our previous life and our future life are as much a part of the life cycle as our present life. Traditional Beliefs Beliefs About Health ~ Health is seen as a state of balance between the physical, social, and super-natural environment ~ The Eastern approach assumes that the body is whole, and each part of it is intimately connected. Each organ has a mental as well as a physical function. ~ Heart, lungs, spleen, liver, kidney are Yin organs ~ Large intestine, gall bladder, bladder and stomach are Yang organs ~ Think about how the symptoms of the Western diagnoses of depression and anxiety are physiologically manifested ~ TKM emphasizes specific characteristics of the individual who suffered from the disease, rather than single symptom as is common in TCM Historical difference between traditional Korean medicine and traditional Chinese medicine Traditional Asian Health Beliefs and Healing Practices Beliefs cont… ~ Uncertainty is inherent in life and each day is taken as it comes. ~ A fatalistic attitude about sickness (belief that all events are predetermined and therefore inevitable