Counselor Toolbox Podcast

Improving Cultural Competence Working with Latino/Latina Persons Instructor: Dr. Dawn-Elise Snipes, PhD Executive Director: AllCEUs.com, Counselor Education and Training Podcast Host: Counselor Toolbox & Happiness Isn’t Brain Surgery Objectives A Framework ~ The ecological systems approach provides a structure for understanding the importance of cultural adaptation in social work practice. ~ Macro Level: Culture frames the norms, values, and behaviors that operate on every other level ~ Micro Level represents the individual beliefs and behaviors ~ Mezzo Level represents family customs and communication patterns ~ Exo Level is how that individual perceives and interacts with the larger structures such as the school system or local law enforcement ~ the relationships between individuals, institutions, and the larger cultural context within the ecological framework are bidirectional, creating a dynamic and rapidly evolving system Communication ~ Reading and writing are NOT a common means of communication among those from lower SES ~ Verbal and nonverbal communications from Hispanics usually are characterized by respeto (respect) ~ There is an element of formality in Hispanic interactions, especially when older persons are involved: – ~ Overfamiliarity is NOT appreciated in early relationships. ~ Direct eye contact is less. – ~ It is uncommon for Hispanics to be aggressive or assertive in health care interactions, they usually respond is silence and noncompliance. Communication ~ Early attention must be given to building rapport. ~ Rapport begins through exchange of pleasantries before beginning assessment or treatment for the day ~ Personalismo (politeness and courtesy)is essential ~ Unconditional recognition of the essential value of each individual ~ Confianza: Being “trustworthy” based largely on personal relationships and rapport, the idea that a person “knows us” or “is one of us” far outweighs that person’s credentials or professional accomplishments ~ Hispanics expect health care personnel to be warm and personal and express a strong need to be treated with dignity. Communication ~ Building confianza ~ Take the time to get to know them as individuals – and don’t underestimate the importance of family to one’s individual identity in Latino culture. ~ If Spanish is their primary language, make an effort to communicate with them in Spanish to some degree. ~ Older person should be addressed by their last name. ~ Avoid gesturing, some may have adverse connotations. ~ Encourage the patient to ask questions. Cultural Beliefs ~ Latinos are an ethnic rather than a racial group; Latinos can be of any race. ~ Mexican Americans are the largest group (63 percent), followed by Central and South Americans (13.4 percent), Puerto Ricans (9.2 percent), and Cubans (3.5 percent) Religion ~ Many Latinos place great importance on the practice of Roman Catholicism. ~ Central tenets of Latino Catholicism are sacrifice, charity, and forgiveness. ~ These beliefs can hinder assertiveness, but they can also be a source of strength and recovery ~ Along with Catholicism the use of magicoreligious is common: – Candles with pictures of saints ~ People’s relationship with church is changing ~ Protestant evangelical churches role is increasing Cultural Values ~ Latinos can face somewhat different triggers for relapse relating to acculturative stress or the need to uphold particular cultural values ~ Personalismo is the use of positive personal qualities to accomplish a task. ~ Machismo is the traditional sense of responsibility Latino men feel for the welfare and protection of their families ~ La familia is the collective identity ~ Protective factors: family wa

There are 566 federally recognized American Indian Tribes, and their members speak more than 150 languages, and numerous other Tribes recognized only by states and others that still go unrecognized by government agencies of any sort. Native Americans who belong to federally recognized Tribes and communities are members of sovereign Indian nations that exist within the United States. On lands belonging to these Tribes and communities, Native Americans are able to govern themselves, and health care is provided by the Indian Health Services (IHS), Prevalence of Problems 28.3 percent of American Indians and Alaska Natives report having a mental illness, with approximately 8.5 percent indicating serious mental illness in the past year Native Americans were nearly twice as likely to have serious thoughts of suicide as members of other racial/ethnic populations, and more than 10 percent reported a major depressive episode in the past year. Common disorders include depression, anxiety, and substance use. PTSD comparison rates taken from the AI-SUPER PFP study show that 12.8 percent of the Southwest Tribe sample met criteria for a lifetime diagnosis of PTSD compared with 4.3 percent of the general population American Indians and Alaska Natives have the second highest infant mortality rate in the Nation (National Center for Health Statistics, 1999) and the highest rate of sudden infant death syndrome which contributes to additional trauma, depression and anxiety in families. Native Americans are less likely than other Americans to graduate high school or complete a college degree. This is interesting becaause, American Indian students achieve on a par with or beyond the performance of non-Indian students in elementary school, but show a decline in performance between fourth and seventh grades. It is thought that American Indian children may have a culturally rooted way of learning at odds with teaching methods currently used in public education. For example, they are primarily visual learners, whereas the public education system uses auditory methods of teaching. Poverty is another contributor to stress. The poverty rate for America as a whole is 14.3% (Center for Poverty Research), for Native Americans the rate is about 26%. Native Americans have the lowest employment rate of any racial or ethnic group in the United States (Bureau of Labor Statistics, 2012). In the poorest Native counties, only about 1/3 of men in Native American communities have full-time, year-round employment. Historical reasons for the development of binge drinking among Native Americans include the existence of dry reservations (which can limit the times when individuals are able to get alcohol), high levels of poverty, lack of availability (e.g., In remote Alaskan native villages), a history of trauma (personal and intergenerational), and the loss of cultural traditions. Many Native American children were separated from their families and sent to boarding schools. Due to this separation from their families, when these children become parents themselves, they are not able to draw on experiences of growing up in a family to guide their own parenting which increases the risk for domestic violence, spousal abuse, and family instability, with their attendant negative mental health effects. This is evidenced by the fact that 6 in 10 American Indian and Alaska Native families were headed by married couples vs. 8 in 10 of the Nation's other families https://www.ncbi.nlm.nih.gov/books/NBK44242/ Other health disparities include: Heart disease Cancer Unintentional injuries Diabetes Depression, anxiety, PTSD and suicide Obesity Substance abuse Sudden infant death syndrome (SIDS) Teenage pregnancy Liver disease Hepatitis. 60% higher infant mortality rate than Caucasians 5.8 tuberculosis rate compared to 2.0 for Caucasians (2

Improving Cultural Competence SAMHSA TIP 59 Instructor: Dr. Dawn-Elise Snipes, PhD, LPC-MHSP, LMHC Executive Director: AllCEUs.com Counselor education Podcast Host: Counselor Toolbox, Happiness Isn’t Brain Surgery Objectives ~ Define assumptions about cultural competence ~ Define Race, Ethnicity and Culture ~ Explore the problems with limited cultural competence ~ Explore ways in which culture impacts ~ Choice of therapeutic approaches and modalities ~ Involvement of family ~ Appropriateness of self-help and/or group counseling Assumptions ~ Assumption 1: Counselors will not be able to sustain culturally responsive treatment without the organization's commitment to it. ~ Assumption 2: An understanding of race, ethnicity, and culture (including one's own) is necessary to appreciate the diversity of human dynamics and to treat all clients effectively ~ Assumption 3: Incorporating cultural competence into treatment improves therapeutic decision-making and offers alternate ways to define and plan a treatment ~ Assumption 4: Consideration of culture is important at all levels of operation—individual, programmatic, and organizational ~ Assumption 5: Culturally congruent interventions cannot be successfully applied when generated outside a community or without community participation. ~ Assumption 6: Public advocacy of culturally responsive practices can increase trust among the community, agency, and staff. Cultural Identification ~ Not all clients identify with or desire to connect with their cultures ~ Culturally responsive services offer clients a chance to explore the impact of culture, acculturation, discrimination, and bias, and how these impacts relate to or affect their mental and physical health. ~ Stereotypes are endpoints in which a decision has been made ~ Generalizations are beginning points from which to explore. ~ The Affordable Care Act, (HHS 2011b) necessitates enhanced culturally responsive services and cultural competence among providers. Problems with Limited Cultural Competence ~ Limited cultural competence is a significant barrier that can translate to: ~ Ineffective provider–consumer communication ~ Delays in appropriate treatment and level of care ~ Misdiagnosis ~ Lower rates of treatment compliance ~ Clients feeling misunderstood ~ Clients feeling judged ~ Clinicians making inappropriate treatment recommendations ~ Poorer outcome Culturally Responsive Practice ~ Culturally responsive practice reminds counselors that a client's worldview shapes his or her: ~ Perspectives (How things “should be,” What goals to strive for) ~ Beliefs (ex. Just world, why things happen) ~ Behaviors surrounding addictive behaviors (Alcohol, illicit drugs, sex, gambling, eating disorders) ~ Beliefs about illness and health (East vs. West, God’s punishment vs Natural progression) ~ Seeking help (Airing “dirty laundry,” participation in face to face vs virtual treatment, LEO/Military, elderly) ~ Counseling expectations (LEO/Military, criminally involved) ~ Communication (Openness, methods) Continuum of Cultural Competence ~ Stage 1. Cultural Destructiveness ~ Organizational Level: At best, the behavioral health organization negates the relevance of culture in the delivery of behavioral health services. ~ Individual Level: Counselors can also operate from this stance, holding a myopic view of “effective” treatment. ~ Stage 2. Cultural Incapacity ~ Organizational Level: Organizational culture may be biased, and clients may view them as oppressive. An agency functioning at cultural incapacity expects clients to conform to generalized services ~ Individual Level: Counselors ignore the relevance of culture while using the dominant c

Enhancing Motivation for Change in Substance Abuse Treatment Part 2 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 the nautre of change ~ Explore the different stages of readiness for change ~ Learn about goals and interventions for each stage fo readiness for change ~ Identify ways to identify a clients change in readiness for chage ~ Explore ways to identify barriers to recovery ~ Learn how to explore expectations regarding recovery and how to use that to enhance motivation ~ Briefly review how to develop a relapse prevention plan Change ~ Is Constant ~ Occurs all the time ~ In the natural environment ~ Among people ~ In relation to behaviors ~ Occurs without professional intervention ~ The change process is cyclical, and people typically move back and forth between the stages and cycle through the stages at different rates. ~ It is not uncommon for people to linger in the early stages. ~ Recurrence of at least some symptoms or old behaviors is a normal event, and many clients cycle through the different stages several times before achieving stable recovery. Nature of Change ~ 6 basic stages in the process of change: ~ Precontemplation ~ Contemplation ~ Preparation ~ Action ~ Maintenance ~ Recurrence ~ People typically vacillate between the stages and cycle through the stages at different rates. (Pool) Precontemplation ~ The client is unaware, unable, or unwilling to change. ~ Establish rapport ~ Raise doubts about patterns of use ~ Give info on risks, pros and cons of use ~ Explore reasons for unwillingness to change (.i.e fear of failure) ~ The client is likely to be wary of the counselor and of treatment. ~ Should not rub the client the wrong way ~ Should try to keep the interview informal. Goals/Actions ~ Explore the meaning of events that brought the client to treatment or the results of previous treatments. ~ Elicit the client's perceptions of the problem. ~ Offer factual information about the risks ~ Provide personalized feedback about assessment ~ Explore the pros and cons of substance use. ~ Help a significant other intervene. ~ Examine discrepancies between the client's and others’ perceptions of the problem behavior. ~ Express concern and keep the door open. Ambivalence ~ Many clients are ambivalent about change. ~ Change is hard ~ Ambivalence is expressed in several ways. ~ Argue: Challenge or discount statements ~ Interrupt: Take over or cut off conversation ~ Deny: Blame, disagree, excuse, minimize ~ Ignore: Not responding, not paying attention Contemplation ~ The client is ambivalent or uncertain, considering the possibility of change. Counselor can ~ Discuss and weigh pros/cons of change (Decisional Balance) ~ Emphasize client's free choice and responsibility ~ Elicit self-motivational statements ~ Reassure the client that no one can force him to change and he is in charge. ~ Ask questions that prompt motivation. For example, “When you want to keep up your motivation for doing something, what are some of the things you say to yourself?” Goals/Actions ~ Help the client recognize the problem(s) contributing to the current situation ~ Help the client acknowledge concern ~ Help the client generate intention to change ~ Help the client develop optimism ~ Convey feedback ~ Help clients see a difference ~ Show curiosity about client strengths. Explore how those skills and competencies may be negated by their curr

Motivation is positive and a key to change. It “harnesses” energy to use to accomplish a task. It is important to realize that motivation is multidimensional including what will make the client feel happy, have more energy, reduce pain, improve health, improve relationships, earn more money, or be more successful. However, motivation can fluctuate over time and in relation to different situations. People may be motivated to get healthier and start exercising, but not motivated to address their eating or sleeping habits. To achieve their goals they will need to do all three, exercise, eat healthfully and get quality sleep. It is important to help people see all of the components of their goal. Another example would be getting a promotion. If a person wants to get a promotion and starts working extra long hours, but is not a team player, they may not succeed. They need to maintain their motivation to put in the hours, but also increase awareness of how their interpersonal behaviors may be hindering their ability to get the promotion. Additionally, motivation may falter in response to doubts. If Therefore, as doubts are resolved and goals are envisioned more clearly motivation will return. Motivation is Dynamic ~ Motivation can be modified/changed ~ Social Influences ~ Environmental Pressures ~ Distress Levels ~ Critical Life Events ~ Motivation is influenced by clinician's style ~ Nonpossessive warmth & Friendliness ~ Genuineness ~ Respect ~ Ability to affirm ~ Empathy ~ Motivation is purposeful and intentional Why Enhance Motivation? ~ Inspiring motivation to change ~ Preparing clients to enter treatment ~ Engaging and retaining clients in treatment ~ Increasing participation and involvement ~ Improving treatment outcomes ~ Encouraging a rapid return to treatment if symptoms recur ~ Creates a therapeutic partnership Help Increase Motivation ~ Counselor Techniques OARS ~ Open ended questions ~ Respect the client's autonomy ~ Affirm their ability to succeed ~ Recognize co-occurring disorders, acknowledge difficulties ~ Employ client centered treatment ~ Reflective listening ~ Using empathy more than authority, Validate client experience ~ Summarize ~ Focus on client strengths, successes and personal power Help Increase Motivation ~ Help clients ~ Recognize behavior that is not in their best interest ~ Regard positive change to be in their best interest ~ Feel competent to change ~ Developing a plan for change ~ Begin to take action ~ Continue to use strategies that discourage a return to the old behavior 3 Critical Elements of Motivation ~ Ability refers to the extent to which the person has the necessary skills, resources, and confidence to carry out a change. ~ Willingness involves the importance a person places on changing—how much a change is wanted or desired. ~ Readiness represents a final step in which the person decides to change a particular behavior. Elements Of Current Motivational Approaches ~ The FRAMES approach ~ Decisional balance exercises ~ Discrepancies between personal goals and current behavior ~ Flexible pacing ~ Personal contact with clients in treatment FRAMES ~ Feedback regarding personal risk or impairment ~ Responsibility for change is placed squarely and explicitly on the client ~ Advice is clearly given to the client by the clinician in a nonjudgmental manner. ~ Menus of self-directed change options and treatment alternatives are offered to the client. ~ Empathic counseling ~ Self-efficacy is engendered in the client to encourage change. Feedback ~ Should be straightforward, respectful, easy-to-understand, and culturally appropri

Providing Feedback, Addressing Anxiety and Overcoming Biases Instructor: Dr. Dawn-Elise Snipes, PhD Executive Director: AllCEUs.com, Counselor Education and Training Podcast Host: Counselor Toolbox & Happiness Isn’t Brain Surgery Objectives ~ Review types of supervisory intervention ~ Identify types of biases and ways to overcome them ~ Identify types of anxieties and how to address them Feedback and Intervention ~ Can be triaged into three levels: ~ Immediate intervention ~ Non-immediate intervention ~ Suggestions ~ Designed to enhance counselor competencies ~ Personal characteristics (self awareness, cultural competence) ~ Philosophical foundations ~ Communications (verbal and nonverbal) ~ Counseling skills ~ Adjunctive or administrative activity ~ Ethical behaviors 5 Types of Supervisory Intervention ~ Facilitative: Brings about discussion through nondirective questions ~ What might the next step be? ~ What other interventions might you have used? ~ What other explanations exist? ~ Confrontive: Addresses specific action or behavior and requires the counselor to answer a question about it ~ Why did you choose to pursue that avenue with the client? ~ What was your intent when you asked… ~ What is your timeline for preparing for the audit on January 25? Cont… ~ Conceptual: Contributes new information and a different way of visualizing the case ~ Sally is a 27 year old female with a 7-month old child and presents with symptoms of depression ~ Depression? ~ Grief? ~ Hormone changes? ~ Stress and sleep deprivation? ~ Prescriptive: Directs the counselor to respond in a particular manner the next time a certain set of circumstances occurs ~ The next time the client begins blaming his wife for things… ~ The next time a client calls at the last minute to cancel… Cont… ~ Catalytic: Moves the process along by asking provocative, or what if questions ~ What if the client were to gather baseline data for a week ~ What if you used the empty chair technique ~ What if the client were to try [x intervention] for 1 week ~ What if you held the client on point for X-topic ~ What if you helped the client reconceptualize the problem ~ In later practice this is often the feedback you get from colleagues when you ask for suggestions. ~ Good type of intervention for ethical issues Feedback is ~ Supervisor's response to the data presented ~ Lack of data leads to ineffective feedback ~ Designed to: ~ Help the supervisor understand (get inside the head of) the supervisee ~ Bring about a positive change in the professional life of the counselor ~ Supportive, challenging and pragmatic ~ Not “It was a good session” ~ But “It was a good session. I liked how you… And …. I am wondering… If I had to give one suggestion or area to work on it would be….” Effective Feedback ~ Is elicited rather than imposed ~ Supervisees should be seeking feedback ~ Is timely ~ Is communicated clearly, directly and with regard to specific issues ~ Is constructive and descriptive rather than critical or judgmental ~ When the client revealed his concern about his anger issues and you responded by saying, “well, once we get your anxiety under control, your anger will probably not be a problem” he seemed to shut down. I am wondering what you intended to communicate and what your rationale was ~ Not: “Your response to the client was totally inappropriate” Cont… ~ Is directed toward changeable behavior ~ Stay on task ~ When clients… then you should … ~ Is not used as a disciplinary weapon ~ Constructive feedback is presented with positive feedback and/or recogniti

Creative Methods of Supervision Creative ways to use video and audio tapes Run the video in fast-forward to convey a heightened image of the counselors and clients body movements On a video, turn down the audio to try to fill in what is being said on the basis of nonverbals On a video, cover the counselor and observe the client to guess what the counselor is doing and vice versa. On a video, focus on the counselor’s nonverbals While reviewing the audio or video tape prior to supervision, the supervisor can do a voiceover, inserting questions for the supervisee onto the tape. Review the tape and stop after a client statement. Ask the counselor to respond. Co-facilitation and live Observation via closed-circuit video and one-way mirror supervision provide the ability to observe in real-time. They are time consuming, but less obtrusive than observing by sitting in the session or co-facilitating. Case presentations are useful in groups and individual supervision. Should be built around problems and solution-oriented questions to be answered, and should move from client information to dynamics, prognosis, and treatment plan Allow the supervisor to observe the counselor's actions, determine their impact on the client, assess the counselor's clinical reasoning process, and help the counselor improve treatment delivery Role playing is an alternative to observing the clinician in an actual counseling session. It is ideal for practicing skills, and an opportunity to learn-by-doing in a safe environment where they can receive helpful feedback Process recording provides a written account of everything that was said and done in session. It is only from supervisee point of view which can result in intentional and unintentional errors and omissions. To improve accuracy, it can be used with video to compare salient points.

12 Things Counselors Need to Learn and How Supervisors Can Facilitate Them Instructor: Dr. Dawn-Elise Snipes, PhD Executive Director: AllCEUs.com, Counselor Education and Training Podcast Host: Counselor Toolbox & Happiness Isn’t Brain Surgery Objectives ~ Define 12 things counselors need to learn and discuss how supervisors can facilitate them What Counselors Need to Learn ~ How to attend themselves to the client's feelings, establish rapport, to demonstrate caring, compassion, and empathy ~ How to find a collaborative, instead of combative, metaphor for treatment ~ How to develop and monitor the therapeutic alliance ~ How to marshal and enhance the potential for success through the use of ~ social support networks ~ community services ~ family and community resources What Counselors Need to Learn ~ How to avoid falling into conventional wisdom that when treatment does not meet the desired outcome it is the client's fault ~ How to promote the client’s sense of personal control and empowerment ~ How to focus on the future and the client's ability to overcome the past ~ How to engage in brief therapy What Counselors Need to Learn ~ How to establish the affective qualities essential to counseling before launching into diagnostics ~ How to adapt a relationship to different clients and their needs ~ The earlier change happens in treatment the more likely will be a positive outcome ~ How to identify not what the person needs, but what the person already has to work with How Can Supervisors Help ~ Help is when the mind is present in the heart, when mind, body and spirit are integrated and when an individual is at peace with his mind body and spirit even if one of those elements is experiencing pain or suffering Supervisors need to ~ Offer mystery, compassion, openness, and a simple presence instead of answers or being the expert ~ Learn contemplative listening which means ~ Being receptive to visual, auditory, kinesthetic and intuitive cues ~ Without an agenda ~ Without a compulsion to help ~ The most important phrases a supervisor can learn are “I don't know” and “I could be wrong” Establishing Supervisory Relationships ~ Creating a contract involving mutually defined goals for both parties that allow for realistic accountability ~ Establishing a working relationship which includes laying groundwork of trust and respect ~ Assessing the counselor's clinical knowledge and skills and training needs using standardized instruments, transcripts and other methods of observation ~ Setting learning goals for the supervision and a form of supervision training plan Goals of Supervision should be ~ Clearly stated, attainable, specific, measurable and observable ~ In writing (individual development plan, IDP) and agreed upon by the supervisor and supervisee ~ Contain specific action steps to bring about the outcome ~ Contain specific procedures to evaluate the outcome Individual Development Plans ~ Include the following ~ Expectations for supervision including ~ the model of therapy ~ the number and types of patient to be seen ~ the number and duration of supervision sessions ~ the techniques and interventions to be used ~ The counselor's experience and readiness for the position including ~ the counselor's base of knowledge ~ his or her strengths and areas for growth IDPs cont… ~ Procedures to be used to observe the counselor and practice ~ Procedures to be used to determine the counselor's reasoning, conceptualization, and decision-making skills ~ Procedures to be used to evaluate the counselor ~ Procedures to be used to intervene to help the counselor achieve supervision goa

3 Stages of Supervisor & Supervisee Development Instructor: Dr. Dawn-Elise Snipes, PhD Executive Director: AllCEUs.com, Counselor Education and Training Podcast Host: Counselor Toolbox & Happiness Isn’t Brain Surgery Objectives ~ Review the stages of supervisor and supervisee development ~ Forming ~ Storming ~ Norming Supervisor and Supervisee Development The supervisor provides: ~ Nonjudgmental support ~ Uses a counseling, therapeutic approach addressing feelings thoughts and actions that may impede the supervisees professional performance ~ Is consultative with self-evaluation an exploration ~ Employs self supervision Structures Underlying Development ~ Autonomy ~ Self and other awareness ~ Motivation Development ~ Phase 1: Childhood: supervisor creates a safe place for supervisee to explore new techniques ~ Phase 2: Adolescence: alternating between exploration into new areas and retreating to the safety of home ~ Phase 3: Adulthood: mutual interdependence between supervisor and supervisee built on the foundation of basic universal values such as faith, hope, love, peace and respect Developmental Stages ~ Counselor Level 1 “Forming” ~ Characterized by: high dependence on others, lack of self and other awareness, categorical thinking, high motivation and commitment to work ~ Plagued by feelings of anxiety and driven by the desire to do it right ~ And formulate clinical concepts on the basis of a single aspect of the client history ~ Practice by formulas such as “All clients in early recovery are __________” Developmental Stages ~ Do not know how to formulate treatment plans ~ Cannot visualize and articulate therapeutic process from intake through intervention to termination ~ The supervisor environment is one that encourages autonomy of providing instruction support and modeling within a structured setting ~ The primary responsibility of supervisors for level 1 counselors is to protect client needs at all times while encouraging risk-taking by the counselor ~ To facilitate growth a supervisor should introduce the counselor to ambiguity and conflict ~ It is imperative that supervisors working with level 1 counselors take into account the supervisees learning style Developmental Stages ~ Counselor Level 2 “Storming” ~ Realizing that cannot save the world, level two counselors become frustrated by their inability to solve difficult problems ~ Characterized by: Vacillating between autonomy and dependence, more self-aware of self and others, and consistently motivated ~ Although level 2 counselors have more skills and tools, they often do not know which tools to use with which client or why ~ Often vacillates between rejecting advice and assistance to desperately wanting to be comforted and protected ~ Level 2 counselors can empathize excessively with the client ~ Level 2 counselors progress in a cyclical rather than linear fashion regressing at times to earlier developmental issues Developmental Stages ~ Counselor Level 3 “Norming” ~ Involves establishing one's own therapy model and normalizing that approach in a range of clinical situations ~ Characterized by: secure autonomy, awareness and acceptance of self and others, stable motivation Developmental Stages ~ Supervisors: Level 1 “Forming” ~ Displays a mechanistic approach ~ Place a strong expert role ~ Depends on own supervisor ~ Is moderately to highly structured ~ Is invested in trainees adopting their own model ~ Has trouble with level 2 counselors Developmental Stages ~ Supervisors: Level 2 “Storming” ~ Displays confusion, conflict issues ~ Sees supervision a

5 Main Influences in Clinical Supervision 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 the 5 Main Influences in Clinical Supervision ~ Philosophical foundation ~ Descriptive dimensions ~ The supervisor’s stage of development ~ The supervisee’s stage of development ~ Contextual factors including personal characteristics and setting/environment Answer The Following Questions ~ How do I believe change occurs? ~ What are the crucial variables in training and supervision? ~ How do I measure success in supervision? ~ How do I contribute to that success? ~ What learning objectives do I have for supervision? ~ What techniques will I apply to measure/ensure learning objectives are met? 4 Factors That Affect Change ~ Extra therapeutic factors which are all factors related to client (supervisee) and not the actions of the therapist (supervisor) ~ Relationship factors, the single most significant issue in the therapy outcome, including caring, empathy, warmth, acceptance, mutual affirmation, and encouragement of risk taking ~ Placebo factors, such as hope and expectancy ~ Technique factors, account for only 15% of therapeutic change Supervision Layers ~ Supervision will be impacted by 5 main influences: ~ Philosophical foundation ~ Descriptive dimensions ~ The supervisor’s stage of development ~ The supervisee’s stage of development ~ Contextual factors including personal characteristics and setting/environment The Philosophical Layer ~ Basic beliefs about how we know what we know, what motivates people and how people change ~ How do you know what you know? ~ Where does mental illness come from? ~ What do you believe motivates people? ~ How does change occur? Descriptive Layer: 10 Dimensions ~ Influential ~ Symbolic ~ Structural ~ Replicative ~ Counselor in treatment ~ Information gathering ~ Jurisdictional ~ Relationship ~ Strategy Descriptive Layer cont…Influential ~ Determines whether the client and supervisee are influenced at an affective or cognitive level ~ What does this mean? (Thinking vs. Feeling) ~ What does it look like/sound like if they are being influenced at an affective level? Cognitive? ~ Are you typically influenced at an affective or cognitive level? ~ How do you keep supervisees motivated who are influenced at an affective level? Cognitive? Descriptive Layer cont…Symbolic ~ Deals with whether latent or manifest content is addressed in counseling and supervision ~ What do you typically focus on—the seen or the unseen ~ When Sue gets frustrated with a client it manifests in lack of attention and irritability. ~ Do you help Sue learn to deal with her frustration and identify it as possibly a projection? ~ Do you teach Sue that she will get frustrated, but she has to learn to control how it manifests ~ Do you do something else? Descriptive Layer cont…Structural ~ Describes whether therapy and supervision are spontaneous or planned ~ Discuss the benefits and drawbacks of daily, brief supervision ~ Discuss the benefits and drawbacks of weekly hour-long supervision Descriptive Layer cont…Replicative ~ Refers to the extent to which the supervisor sees observed interactions as representations of isomorphic processes ~ What the client does in counseling, she does in “real life” ~ What the supervisee does in supervision represents what she does in session and in real life Descriptive Layer cont…Counselor in Treatment ~ Has to do with whether training and personal therapy are v

12 Common Errors in Supervision Instructor: Dr. Dawn-Elise Snipes, PhD Executive Director: AllCEUs.com, Counselor Education and Training Podcast Host: Counselor Toolbox & Happiness Isn’t Brain Surgery Objectives ~ Error 1: Doing Harm to the Counselor ~ Error 2: Failing to Observe ~ Error 3: Passive Supervision ~ Error 4: Failure to Focus on Reciprocal Effects ~ Error 5: Failure to Ask Socratic Questions ~ Error 6: Terminating supervision upon licensure ~ Error 7: Undisciplined ~ Error 8: Failure to Individualize Training Plans ~ Error 9: Failure to Set Boundaries ~ Error 10: Not Practicing What You Preach ~ Error 11: Failure to provide adequate support ~ Error 12: Blurring the line between supervision and counseling Reflection ~ Think about your supervisor. ~ What things did he/she do that you liked? ~ What do you wish he/she would have done? ~ What is one thing you will do differently as a supervisor? The Purpose of Supervision ~ Bring about change in the knowledge, skills and behavior of another ~ Assist the counselor in self observing, self-correcting, self reinforcing, and self soothing ~ Ensure counselors remaining in the field are competent with regard to personal characteristics, philosophical foundations, communication abilities, counseling skills, administrative skills, and ethical behaviors What Shapes Clinical Supervision ~ The theoretical model from which it is derived ~ Therapy ~ Education ~ How do these differ? Traits of an Effective Supervisor The 4 “A’s” ~ Available ~ Accessible ~ Able ~ Affable Discussion: In what ways are you available, accessible, able and affable? How could you improve in any of these areas? Errors 1 & 2: Doing Harm to the Counselor and Failing to Observe ~ 5 Main Components of Supervision ~ An experienced supervisor ~ Clients in clinical settings ~ A primary concern to “do no harm” with regard to both the client and supervisee ~ Monitoring counselor performance through observation ~ General ~ In session ~ The goal of changing the counselors behavior ~ How are you going to change a counselor’s behavior? Error 3: Passive Supervision Fails to Develop Skills and Competencies ~ Supervision Through Leadership ~ Promote measurable development of skills and competencies ~ Raise the level of accountability and effectiveness in counseling services and programs Leadership Is based in a set of core values, and involves: ~ Teaching (Explaining, educating) ~ Mentoring (Practicing, showing) ~ Coaching (Cheerleading, encouraging, processing) ~ Emphasizes ~ Observing the client, counselor and organization (needs and interactions) ~ Doing no harm to client, counselor or organization 10 Principles for Leadership • Take full responsibility for the decisions you make • Put subordinates wellbeing above your own • Give subordinates full credit for successes • Take risks when they are in the best interest of the organization or the client • Protect, support, defend subordinates to senior management Leadership cont… • Take a personal interest in the welfare of your staff • Make decisions promptly • Be a teacher ~ Learning Styles ~ Auditory, Kinesthetic, Visual ~ Active, Reflective • Do not play favorites • Do not give orders just to show who is boss 3 Roadblocks to Effective Evaluation ~ Lack of supervisor skills in evaluating supervisee performance (i.e. lack of understanding regarding setting measurable goals/objectives) ~ Confusion about the compatibility of evaluation and supervision ~ Anxiety evoking aspects of evaluation Discussion:

10 Issues in the Diagnosis of Developmental and Neurocognitive Disorders Instructor: Dr. Dawn-Elise Snipes, PhD Executive Director: AllCEUs.com, Counselor Education and Training Podcast Host: Counselor Toolbox & Happiness Isn’t Brain Surgery Objectives ~ Autism Spectrum Disorder ~ ADHD ~ Oppositional Defiant and Conduct Disorder ~ Dementia (Vascular, Lewy Body) ~ Mystery Dx Autism Spectrum Disorder ~ A. Persistent deficits in social communication and social interaction across multiple contexts, as manifested by the following, currently or by history ~ 1. Deficits in social-emotional reciprocity: abnormal social approach, failure of normal back-and-forth conversation, reduced sharing of interests, emotions, or affect; failure to initiate or respond to social interactions. ~ 2. Deficits in nonverbal communicative behaviors: Poorly integrated verbal and nonverbal communication; abnormalities in eye contact and body language; deficits in understanding and use of gestures; to a total lack of facial expressions and nonverbal communication. ~ 3. Deficits in developing, maintaining, and understanding relationships, ranging, for example, from difficulties adjusting behavior to suit various social contexts; to difficulties in sharing imaginative play or in making friends; to absence of interest in peers. Autism Spectrum Disorder ~ B. Restricted, repetitive patterns of behavior, interests, or activities (2+) ~ Stereotyped or repetitive motor movements, use of objects, or speech (e.g., simple motor stereotypies, lining up toys or flipping objects, echolalia, idiosyncratic phrases). ~ Insistence on sameness, inflexible adherence to routines, or ritualized patterns or verbal nonverbal behavior (e.g., extreme distress at small changes, difficulties with transitions, rigid thinking patterns, greeting rituals, need to take same route or eat food every day). ~ Highly restricted, fixated interests that are abnormal in intensity or focus ~ Hyper- or hyporeactivity to sensory input or unusual interests in sensory aspects of the environment Autism Spectrum Disorder ~ Symptoms must be present in the early developmental period (but may not become fully manifest until social demands exceed limited capacities, or may be masked by learned strategies in later life). ~ Symptoms cause clinically significant impairment in social, occupational, or other important areas of current functioning. ~ These disturbances are not better explained by intellectual disability (intellectual developmental disorder) or global developmental delay. ~ Individuals with a well-established DSM-IV diagnosis of autistic disorder, Asperger’s disorder, or pervasive developmental disorder not otherwise specified should be given the diagnosis of autism spectrum disorder. ~ Individuals who have marked deficits in social communication, but whose symptoms do not otherwise meet criteria for autism spectrum disorder, should be evaluated for social (pragmatic) communication disorder. Autism Spectrum Disorder ~ 4. Avoid using the exact same behavioral exemplar to satisfy two criteria. ~ For example, ‘repetitively putting hands over ears’ may be considered a repetitive motor movement, or it may be considered hyper-reaction to stimuli/adverse reaction to sounds. ~ 5. One example of a specific criterion may not be sufficient to assign the criterion as being present. ~ Is the example behavior clearly atypical? ~ Is the example behavior present across multiple contexts, or rarely occur/occur in only one context. ADHD –Children and Adults ~ For children, six or more of the symptoms (5+ for adolescents or adults) have persisted for at least 6 months, in two or more settings to a degree that is inconsistent with developmental level ~ Symptoms do not occur exclusively during the course o

12 Errors in Addiction and Eating Disorder Diagnosis Instructor: Dr. Dawn-Elise Snipes, PhD Executive Director: AllCEUs.com, Counselor Education and Training Podcast Host: Counselor Toolbox & Happiness Isn’t Brain Surgery Objectives ~ Avoidant/Restrictive Food Intake Disorder ~ Anorexia ~ Bulimia ~ Binge Eating Disorder ~ Substance Use Disorder ~ Internet Gaming Disorder ~ Gambling Disorder ~ Sex Addiction and Gambling Avoidant/Restrictive Food Intake Disorder (ARFID) ~ An Eating disturbance as manifested by persistent failure to meet appropriate nutritional and/or energy needs associated with 1+ of the following: ~ Significant loss of weight (or failure to achieve expected weight gain or faltering growth in children). ~ Significant nutritional deficiency ~ Dependence on enteral feeding or oral nutritional supplements ~ Marked interference with psychosocial functioning ~ Note: There is no body dysmorphia or fear of becoming fat Avoidant/Restrictive Food Intake Disorder (ARFID) ~ The behavior is not better explained by lack of available food or by an associated culturally sanctioned practice. ~ The behavior does not occur exclusively during the course of ~ Anorexia nervosa ~ Bulimia nervosa ~ Body dysmorphic disorder ~ The eating disturbance is not attributed to a medical condition, or better explained by another mental health disorder. ~ Depression ~ Anxiety ~ Psychotic disorder ~ Chron’s Disease Anorexia ~ Persistent restriction of energy intake leading to significantly low body weight (in context of what is minimally expected for physical health) ~ Either an intense fear of gaining weight or of becoming fat, or persistent behavior that interferes with weight gain (even though significantly low weight). ~ Disturbance in the way one's body weight or shape is experienced ~ Undue influence of body shape and weight on self-evaluation ~ Persistent lack of recognition of the seriousness of the current low body weight. Subtypes: Restricting type Binge-eating/purging type Anorexia Differential and Confounds ~ Obsessive Compulsive tendencies common (R/O OCD) ~ Can occur in males (3.6% males have an ED) ~ Onset during puberty up to age 40 ~ Depressive symptoms (primary or secondary) ~ Anemia ~ Low estrogen/testosterone ~ Reduced thyroid hormones ~ Potassium imbalances and arrhythmias ~ Common Co-Occurring Disorders ~ Depression ~ Anxiety Binge Eating Disorder ~ Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following: ~ Eating, in a discrete period of time (e.g. within any 2-hour period), an amount of food that is definitely larger than most people would eat during a similar period of time and under similar circumstances. ~ A sense of lack of control over eating during the episode (e.g. a feeling that one cannot stop eating or control what or how much one is eating). Binge Eating Disorder ~ The binge eating episodes are associated with 3+ of the following: ~ Eating much more rapidly than normal ~ Eating until feeling uncomfortably full ~ Eating large amounts of food when not feeling physically hungry ~ Eating alone because of feeling embarrassed by how much one is eating ~ Feeling disgusted with oneself, depressed or very guilty afterward Binge Eating Disorder ~ Marked distress regarding binge eating is present ~ Binge eating occurs, on average, at least once a week for three months ~ Binge eating not associated with the recurrent use of inappropriate compensatory behaviors ~ Note: ~ Binge Eating Disorder is less common but much more severe than overeating. ~ Binge

8 Errors in Effective Differential Diagnosis of Personality Disorders Instructor: Dr. Dawn-Elise Snipes, PhD Executive Director: AllCEUs.com, Counselor Education and Training Podcast Host: Counselor Toolbox & Happiness Isn’t Brain Surgery Objectives ~ Review the criteria for ~ Paranoid ~ Schizoid ~ Schizotypal ~ Antisocial ~ Borderline ~ Histrionic ~ Narcissistic ~ Avoidant ~ Dependent ~ Obsessive Compulsive ~ Identify 8 common errors in diagnosis Overview of Personality Disorder Diagnosis ~ Enduring pattern of inner experience and behavior that deviates markedly from cultural expectations in 2 or more areas ~ Cognition ~ Affectivity (range, intensity, lability, appropriateness) ~ Interpersonal functioning ~ Impulse control ~ Behavior is inflexible and pervasive ~ Behavior is stable and can be traced back to adolescence or early adulthood ~ Not better explained as a manifestation of consequence of another mental disorder or attributable to medical conditions or substances: (Mania, Addiction, Autism Spectrum, FASD) ~ Dx of a PD in someone under 18 requires a duration of at least 1 year ~ Adopted as well as biological children have similar chances of developing a PD indicating the influence of environment Issue 1: Acculturation ~ Do not confuse with problems with acculturation ~ Take into account individual’s cultural background (ethnicity, country, urban/rural, high/low SES, religion) ~ Common intergenerational heritage ~ Shared values, beliefs, customs, behaviors, traditions, institutions, arts, folklore, and lifestyle. ~ Similar relationship and socialization patterns. ~ A common pattern or style of communication or language. ~ Geographic location of residence (e.g., country; community; urban, suburban, or rural location). ~ Patterns of dress and diet Issue 1: Acculturation cont… ~ Cultural Issues ~ Minority groups, immigrants, individuals from different ethnic backgrounds and those with physical handicaps may display suspiciousness, guarded or defensive behaviors resulting from perceived neglect or indifference by the majority society ~ Some ethnic groups also display culturally related behaviors which should not be confused with ~ Paranoia ~ Avoidance ~ Dependence Issue 2: Stereotyped Gender Roles ~ Do not misdiagnose based on stereotypical gender roles ~ Females: Borderline, histrionic, dependent ~ Males: Antisocial, narcissistic ~ Personality traits are only personality disorders when inflexible, maladaptive, persistent and cause functional impairment or subjective distress Issue 3: Differentiate from Mood Disorders with Psychotic Features ~ Paranoid, schizoid and schizotypal must not have occurred exclusively within ~ Schizophrenia ~ Bipolar ~ Depressive disorders with psychotic features Issue 4:Personality Changes from PTSD ~ Personality changes as the result of PTSD ~ Lack of interest in social relationships ~ Solitariness ~ Affect flattening/emotional numbing ~ Irritability ~ Lack of trust/paranoia ~ Avoidance of reminders of the event Issue 5: Addictions ~ Differential diagnosis with addictive disorders (~47%) ~ More time spent getting, using, recovering from the substance than intended ~ Irritability, grudging during withdrawal ~ Paranoia or irritability while under the influence ~ Histrionic behaviors to manipulate getting the substance ~ Inability to stop or cut down ~ Dependence on dealers ~ Failure to meet important role obligations ~ Reduction in hobbies and important activities ~ Continued use despite 2 or more problems ~ Sensitive to perceived attacks on character

Assessment and Patient Placement Tools ASAM, FARS, LOCUS Instructor: Dr. Dawn-Elise Snipes PhD, LPC-MHSP, LMHC Executive Director, AllCEUs Counselor Education Podcast Host: Counselor Toolbox and Happiness Isn’t Brain Surgery Objectives ~ Differentiate between level of care guidelines and patient placement criteria ~ Learn about the Functional Assessment Rating Scale (Required in some states) ~ Learn about the ASAM (Required by most insurers) ~ Learn about the LOCUS (Often an alternate to the ASAM ~ Discuss why these tools are used and how they can benefit clinician and client Patient Placement vs. Level of Care ~ Patient placement criteria suggests a treatment intensity level that meets the needs of the client ~ Level of Care Guidelines are defined by: ~ Insurance Providers ~ State Law (in some states) Why Use Them ~ Provides a biopsychosocial approach to care management ~ Assists in defining potential strengths and obstacles to the recovery process as the client sees them ~ Helps guide treatment planning for ~ Biomedical Issues ~ Cognitive/Emotional/Behavioral Issues ~ Motivational Issues ~ Recovery Environment (including social supports) ~ Assists in providing Specific, Measurable, Achievable, Realistic, Time Limited Goals FARS ~ Functional Assessment Rating Scale ~ Not a placement guideline per se ~ Helps more clearly define anchors for behavioral observations FARS FARS FARS ASAM– Assessment, Reassessment & Discharge ~ Physical ~ Acute Intoxication/Withdrawal Potential ~ Biomedical Conditions ~ Emotional/Cognitive ~ Emotional/Behavioral Conditions ~ Treatment Acceptance/Resistance (Readiness for change) ~ Behavioral ~ Relapse or Continued Use Potential ~ Social/Environmental ~ Recovery Environment ASAM Levels ~ Level .05: Early Intervention (Relapse Prevention) ~ Level I: Outpatient (<9 hours per week) ~ Level II: IOP (9-19 hours per week) ~ Level II.5: PHP (20+ Hours per week) ~ Level 3: Residential ~ Level 4: Medically Managed Intensive Inpatient Services LOCUS Dimensions ~ Risk of Harm ~ 1-Minimal ~ 2-Low ~ 3-Moderate ~ 4-Serious ~ 5-Extreme ~ Functional Status ~ 1-Minimal Impairment ~ 2-Mild Impairment ~ 3-Moderate Impairment ~ 4-Serious Impairment ~ 5-Severe Impairment LOCUS Dimensions ~ Medical, Addictive and Psychiatric Comorbidity ~ 1-No Comorbidity ~ 2-Minor Comorbidity ~ 3-Moderate Comorbidity ~ 4-Major Comorbidity ~ 5-Severe Comorbidity Recovery Environment ~ Level of Stress (A) ~ 1-Low ~ 2-Mild ~ 3-Moderate ~ 4-High ~ 5-Extremely Stressful ~ Level of Support (B) ~ 1-Highly supportive ~ 2-Supportive ~ 3-Limited Support ~ 4-Minimal Support ~ 5-No Support LOCUS Dimensions ~ Treatment and Recovery History ~ 1-Fully Responsive ~ 2-Significant Response ~ 3-Moderate or Equivocal Response ~ 4-Poor Response (goals not achieved or gains not maintained) ~ 5-Negligible Response LOCUS Dimensions ~ Engagement ~ 1-Optimal (Action) ~ 2-Positive (Preparation/Determination) ~ 3-Limited (Contemplation) ~ 4-Minimal (Contemplation) ~ 5-Unengaged (Precontemplation) EXAMPLE Guidelines LOCUS Placement ~ Level 1 LOCUS Placement (up to 3h/week) ~ 1. Risk of Harm – clients with a rating of two or less ~ 2. Functional Status – clients should demonstrate ability to maintain a rating of two or less ~ 3. Co-morbidity – a rating of two or less ~ 4. Recovery Environment – a combined rating of no more than four on