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992 Cards in this Set

  • Front
  • Back
profound changes in the core aspects of the therapist as a result of empathetic engagement with the client's trauma story.
vicarious trauma
shaping behavior by reinforcing behavior in the direction of the desired behavior.
Operant Conditioning
Forms of Reinforcement in Operant Conditioning
positive and negative reinforcement and positive and negative punishment.
Key qualities of reinforcement in Operant Conditioning
Immediacy and Consistency of reinforcement is key.
Criticism vs Complaint
Contempt vs Appreciation
Defensiveness vs Responsibility
Stonewalling vs Self-Soothing
Gottman 4 horsemen
Gottman 6 indicators of divorce
Harsh Start-Up
4 Horsemen
Flooding
Failure of Repair Attempts
Body Language
Bad Memories
Emotional Bids - Towards, Away, Against
Love Maps
Fondness & Admiration System
Emotional Bank Account
The Positive Perspective
Effective Conflict Resolution
Accepting Influence
Creating Shared Meaning
Rituals of Connection
Gottman Terms/Techniques
Content Level
Report Level
Command Level
Process Level
Terms of Cybernetics
Homeostasis - systems endeavor to maintain stability
Positive Feedback - system alters to accommodate novel input
Negative Feedback - system changes to maintain a steady state
First Order Change - change within the system that itself remains invariant
Second Order Change - change in the system itself
Role Theory - too few and too many roles are bad, stereotyped roles exist in groups
Terms of Group Theory
Double-Bind
patterns of communication that are conflictual in that the Content and Command Level messages are contradictory
Multi-Directed Partiality-client=family
Triadic/Circular questions
Table Forward
Targeting the Question: Cognitive, Affective, Behavioral or Interaction Systems
Linking - using client's words
Modulating - reframing to change intensities
Types of questions: Presupposition, Balanced, Normalizing, Validating, Summarizing, Contextual change
Terms of Family Therapy with Complex Families
Express Empathy
Develop Discrepancy
Avoid Argumentation
Roll with Resistance
Support Self-Efficacy
Goals of Motivational Interviewing
Focus on Symbolic Meanings
Increase healthy emotional expression
Free people from unresolved emotion
Acceptance of individual emotional expression
Personal Integrity
Liberate Affect and Impulses
Promote Communication and Interaction
Expand Experiences
Not always too focused on the Presenting Problem
Goals Experiential Family Therapy
Communication Enhancement - Psychodrama, Roleplay, Directing Coaching on Expression
Physical contact - esp Satire
Intuition
Humor
Facilitating Emotional Expression
Softening Family Rules
Sculpting and Spatial Metaphor
Techniques of Experiential Family Therapy
Survival Stances - Congruent, Placator, Blamer, Super-Reasonable, Irrelevant
Observations: Emotional Deadness, Cold Affect, Don't Enjoy the Family, Lack of Warmth, Avoidance by Immersion Elsewhere
Battle Metaphor - Therapist must win battle for Structure of therapy. Client must win battle for Intiative (Therapist should never work harder than client)
Terms of Experiential Family Therapy
core to cultural competency, rather than breadth of knowledge of cultures:
the ability to craft respectful, reciprocal and responsive interactions, both verbally and non-verbally, across diverse cultural parameters.
Joining
Accommodation
Tracking
Family Mapping
Focusing - therapist selection of process area to explore, esp. structural configuration of family
Challenging/Reframing/Intensity
De-IP-ing
Boundary-making
Enactment of the problem
Reframing
Un-balancing
Techniques for STRUCTURAL Family Therapy
Effective Hierarchical Structure
Executive Coalition
Sibling Subsystem
Clear Boundaries
Fostering Differentiation of Individuals
Spouse Subsystem
Goals of STRUCTURAL Family Therapy
Complementarity = unhealthy symbiosis between family members (e.g., pursuer/distancer)
Enmeshment (-) --- Disengagement (-)
Diffuse Boundaries (-) -- Rigid Boundaries (-)
Permeability
Coalition
Memesis
Terms of STRUCTURAL Family Therapy
Engage each member
Elicit each member's view of the problem
Allow family to discuss the problem
Bring problem alive into the room
Define Goals
Assign directives
Techniques of STRATEGIC Family Therapy
No Fishing Expeditions - only presenting problem
Misguided Solutions - 3 kinds: Denial, Fixing a non-problem, repairing inappropriately
Function of the Symptom
Paradoxical Injunctions - 3 Types: Defiance, Compliance, Exposure
Homeostasis
Positive and Negative Feedback
Comfort Zone
Communication Report and Command Levels
Terms of STRATEGIC Family Therapy
Detriangulation
Nonanxious Presence
Genograms
Process vs Content - e.g., Reflective, Connective, Reconstructive or Normative
Supporting Differentiation
Displacement Stories
Coaching
Techniques of SYSTEMS Family Therapy
Intrapsychic - thought vs feeling
Interpersonal - self vs other
Triangles
Nuclear Family Emotional Process
Family Projection Process
Multigenerational Transmission Process
Sibling Position - Firstborn, later-born
Emotional Cutoff
enmeshment/fusion (-) --> differentiation (+)
Terms of SYSTEMS Family Therapy
ordered after hearing. good up to 3 years and then renewable up to 3 years or permanently.
Restraining Order
5 court/7 calendar days, by law enforcement, can determine temporary custody
Emergency Protection Order
3 weeks/until court hearing, must serve other party
Temporary Restraining Order
Restraining Order that is registered in all states DV registry, arrest for violation mandatory, gun and ammunition purchase prohibited
CLETS (vs Non-CLETS) Order
a pattern of abusive behaviors in any relationship that is used by one partner to gain or maintain power and control over another intimate partner
Domestic Violence
repeated, unwanted involvement, explicit or implicit threats, reasonable experience of fear and intention to instill fear
Stalking - types: Intimacy Seeker, Incompetent Suitor, Resentful Stalker, Predatory Stalker
When DO you Report if child = < 14?
partner also < 14 and disparity in chronical age or maturation, or indications of intimidation, coercion or bribery, or indications of exploitative relationship
partner is > 14
lewd and lascivious acts
When DO you Report if Child = 14 or 15
partner is < 14
unlawful intercourse with partner > 21
unlawful intercourse with partner btw >14 and < 21 & there are indications of abuse or of exploitative relationship
lewd and lascivious acts by partner > 10 yrs older
When DO you Report if Child = 16 or 17
partner is < 14
unlawful intercourse with partner btw >14 & there are indications of abuse or of exploitative relationship
Cass's Model of Homosexual Identity Development
Confusion
Comparison
Tolerance
Acceptance
Pride
Synthesis
Coleman's Model of Homosexual Identity Development
Precoming out>Coming out>Exploration>First Relationships>Integration
D'Augell's Model of Homesexual Identity Development
Exiting>Personal status>Social Identity>Becoming offspring>Intimacy Status>Entering Community
Riddle's Homophobia Scale
Repulsion> Pity> Tolerance> Acceptance> Support> Admiration> Appreciation> Nurturance
Downing & Roush's Feminist Identity Development
Passive Acceptance> Revelation >Embeddedness-Emanation> Synthesis> Active Commitment
Kim's Asian American Identity Development
• Ethnic Awareness
• White Identification
• Awakening to Socio-Political Consciousness
• Redirection
• Incorporation
Helm's White Identity Development
Contact> Disintegration> Reintegration> Pseudo-Independence> Immersion/Emersion> Autonomy
Cross's Black Identity Development
Pre-Encounter> Encounter> Immersion/Emersion> Internalization> Internalization-Commitment
Bicultural Identity Development
Personal Identity
Choice of Group Categorization
Enmeshment/Denial
Appreciation
Integration
Bicultural Identity Development
Personal Identity> Choice of Group Categorization> Emmeshment/Denial> Appreciation> Integration
Marcia's Adolescent Identity Development
Diffusion> Foreclosure> Moratorium> Achievement
Allport and DiMonteflores's Strategies for Coping with Oppression
Assimilation
Ghettoization
Specialization (+/-)
Confrontation
McGoldrick & Carter's Family Life Cycle
Single Young Adulthood
Forming Partnerships
Families with Young Children
Families with Adolescents
Families with Adult Children
Families with Adult Children and Grandchildren
Loden's 1st Level Dimensions of Diversity
Age
Race
Ethnicity
Sexual Orientation
Gender
Mental/Physical Ability
Stages of Consciousness of Target/Non-Target Membership
Naive/Unaware
Acceptance/Complacence
Resistance/Anger
Redefinition
Internalization
Bennet's Model of Cultural Competence
Denial
Defense
Minimization
Acceptance
Adaptation
Integration
John Locke (1690) idea that children are neutral and molded by society
Tabula Rasa/mechanistic/Nurture
Jean-Jacques Rousseau (1762) organismic view that children are born good with innate capacities society clear the path
Organismic/Nature
Mahler's Separation Individuation Theory
Hatching 5-9mos
Practicing 9-16mos
Rapprochment 15mos and up
Piaget's Main Concepts
Assimilation
Accommodation
Piaget's Stages of Cognitive Development
Sensory Motor
Pre-Operational
Concrete Operational
Formal Operational
Kohlberg's Stages of Moral Development
Pre Conventional - Obedience/Punishment & Self-Interest
Conventional- Conformity & Authority
Post-Conventional - Social Contract & Universal Ethical Principles
Premak Principle
Any high-frequency activity can be used as a reinforcer for any low-frequency activity
Gender Orientation Dimensions
Self Experience
Disclosed Experience
Perceived Experience
Prescribed Experience
Competency Based Assessment Model
Assess for
Biological Factors
Psychological Factors
Social Factors AND
Competencies
Suicide Evaluation Points
Suicidal Thinking
Suicidal Intent
Suicidal Plans
Future Orientation
Mental Status
Suicide Personal & Demographic Risk Factors
Major Psychiatric Disorder
History of Attempts
Age (particularly Older Adults)
Gender
Never Married
Live Alone
Recent Loss
Unemployment
Certain Professions
Chronic Pain/Disease/Terminal Illness
Recent Surgery
Family History
Access to Means
Active Listening Skills
Minimal Encouragers
Mirroring
Paraphrasing
Summarizing
Silence
Questioning - Open-Ended
Culture ADDRESSING Acronym
Age, Developmental, Disability, Religion, Ethnic, Socioeconomic, Sexual orientation, Indigenous heritage, National origin, Gender
Terms of Foulkes Group Theory
MI from Problems with Interpersonal Relationships
Group as a whole
Matrix = Group/Mother
Hall of mirrors
Resonance
Group Defense
Therapist = Rim of Wheel
Techniques of Foukes Group Therapy
Describe what you see
Notice patterns
Notice themes
Make Interpretations
Terms of Agazarian Systems-Centered Group Therapy
Patterns over content
Attachment theory
Techniques of Agazarian
Systems-Centered Group Therapy
Sub-grouping
Explore, Don't Question
Noise
Here & Now
Stages of Change
Pre-Contemplation
Contemplation
Preparation
Action
Maintenance
Relapse
Principles of Integrated Treatment of Substance ACDC
Concurrence
Comprehensiveness
Long-Term Perspective
Assertive Therapist
Harm Reduction
Motivational Interviewing
In Motivational Interviewing/Motivational Enhancement Therapy, Resistance = ?
Mismatch between Intervention and Clients stage of change or Therapist and Client's Targets
Techniques of Motivational Interviewing/Motivational Enhancement Therapy
Functional Analysis
Payoff Matrix
Functional Assessment
Double-Sided Reflections
Eliciting Change Talk
Non-Confrontational
ACDC HALT Intervention/Skill
Focus on hungry, angry, lonely, tired. 'baby your brain right now” “We took away the superhighway to bliss. We are going to rebuild the roads to happiness”
Predictors increasing likelihood of behavior change
Internal perception of need
Sense of self-efficacy
Stated intention to change
Terms of SOLUTION FOCUSED Therapy
Exception questions
Scaling questions
Formula tasks
Miracle question
Normalizing
Terms of COGNITIVE BEHAVIORAL Therapy
Linear causality, Conditioning, Schema, Reinforcement, Shaping, Cognitive Distortions, Modeling, Automatic Thoughts, Thought Stopping, Stress Inoculation, Contingency Contracting, Cognitive Restructuring
Terms of GESTALT Therapy
Directed Awareness, No Questions, Assuming Responsibility, Enactment, Empty Chair, Reversal, Rehearsal, Exaggeration, Dreamwork
Terms of ROGERIAN/CLIENT-CENTERED Therapy
Unconditional Positive Regard
Accurate Empathy Understanding
Congruence/Genuineness
Murray Bowen is known for ?
Extended Family SYSTEMS/Multigenerational Family Therapy
Terms of NARRATIVE Therapy
Life Stories, Externalizing, Who's in Charge?, Reading btw lines, reauthoring, reinforcing new story, mapping influences, unique outcomes, deconstruction of old story
Terms of Yalom group therapy
Here & Now, Cohesion, Task Leader, Emotional Leader, Scapegoat, Defiant Leader, Installation of Hope, Universality, Imparting Info, Altruism, Corrective Experience, Socializing Skills, Imitative Behavior, Catharsis, Existential, Interpersonal Learning
Etic vs Emic
Etic = emphasis on constructs developed in one culture applying to all others
Emic = Emphasis on culture-specific constructs
3 basic areas of multicultural 'competence'
Awareness
Knowledge
Skill
Recovery/Resilience
Community Integration
Quality of Life
Goals of PsychoSocial Rehabilitation (PSR)
Define Client Plan in PSR therapy
A document, co-created by client and therapist, outlining steps needed to achieve a particular goal or outcome
Elements of PSR Client Plan
Goal
Objectives
Interventions
Duration of Interventions
Signatures
SMART goal =
Simple
Measurable
Attainable
Realistic
Time-framed
Recovery vs Medical Model
Managing symptoms vs none
Meaningful activity vs work
Quality of life vs high functioning
Self-sufficient vs stability
Lowest dosage vs med compliance
Collaboration vs Coercion
Hope vs Motivation
Motivational Interviewing Opening Strategies
Open ended questions
Affirmations
Reflection
Summary
Eliciting Self-Motivational Statements
Principles of PychoSocial Rehabilitation (PSR)
Accessible, Coordinated & Individualized Services
Focus on Outcomes, Wellness, Strengths, Skills, Vocation/Education
Cultural Sensitivity
Environment modification
Maximum involvement of client, community, family, peers
Maslowe Hierarchy of Needs
Physiological
Safety
Love
Esteem
Self-Actualization
PCIT Skils
Attachment Based/Child Directed
Positive Discipline/Parent Directed
PCIT Attachment Based Skills/Child Directied
PRIDE = Praise, Reflection, Imitation, Description, Enthusiasm
Don't
Ignore
Stop
PCIT Positive Discipline/Parent Directed Skills
Limit-Setting
Consistency
Problem Solving
Reasoning
Direct Communication
Effective use of time-outs
Therapeutic holds
Strategies to improve compliance
Narrative Therapy
Elicit Current Story
Name & Externalize Problem
Examine Influence of Problem
Examine Influence of Client
Develop Preferred/Alternative Story
Narrative Therapy Techniques
Deconstruct ideas that maintain problem
Look for Unique Outcomes
Landscape of Action Questions (thicken the story)
Landscape of Identity Questions (Unique Outcomes)
Re-membering Conversations
Narrative Therapy Techniques Continued
Documentation
Therapeutic Letters
Rituals
Celebrations
Definitional Ceremonies
Reflecting Teams
• Began the formal study of Ethology (science of animal behavior).

• Famous for theory of imprinting at birth – relationship of infant to caregiver.
Konrad Lorenz
• Studied early infant attachment to their caregiver and developed the early theory of attachment and object relations.

• Believed that attachment disorders could be corrected: ‘earned security’.
John Bowlby
Ethology
Science of Animal Behavior
• Spent time studying mothers and children in Uganda and developed Bowlby’s theory of attachment using the ‘strange situation’ research method whereby a child and mother were temporarily separated and studied.

• Conclusions were that most children were ‘secure’ and able to use mother as a secure base from which to explore.
Mary Ainsworth
Attachment theorist who developed the adult attachment interview. Showed close correlations between child attachment style and subsequent behavioral traits as an adult.
Mary Main
Best known for his Hierarchy of Needs in a triangle starting at the bottom with: Physiological needs, safety, love, belonging, Esteem, Self-actualization (at the top).
Abraham Maslow
Furthered Piaget’s stages by adding stages of moral development:

Pre-conventional (obedience);

Conventional (interpersonal/social morality);

Post-conventional (social contract and universal moral principles)
Lawrence Kohlberg
• Developed early ‘theory of mind” which was organismic (natural unfolding of internal process more than mechanistic).

• Child as the ‘lone scientist’. Believed there were four universal stages of development.
Jean Piaget
Best known for his ‘8 stages of man’ identifying key developmental tasks appropriate to each stage.
Erik Erikson
This refers to Carol Gilligan’s work developing a feminist approach to the ethics of care and the gender differences in approach towards the morality of helping others. Within Social Justice therapy this is reflected in the view that the practices of therapy are held accountable to those who are treated the most unjust in a given society
Theory of Care
Parts of the nervous system:

brain and spine
Central Nervous System
(CNS)
Parts of the nervous system:

complex small nerves branching out across whole body from 12 pairs of Cranial nerves
Peripheral Nervous System
(PNS)
Neurological System:

Runs functions like heart beat without conscious intervention.
Autonomic Nervous System
(ANS)
Parts of the nervous system:

Within the ANS, this SPEEDS UP numerous functions in response to stimulation
Sympathetic Nervous System
(SNS)
Parts of the nervous system:

Within the ANS, this INHIBITS functioning and conserves energy.
Parasympathetic Nervous System
an electrically excitable cell that processes and transmits information by electrical and chemical signaling, via synapses.

Charged ions move down axons and dendrites to the synapse where they cause a neurotransmitter to be released to a receptor site.
Neuron
a junction that permits a neuron to pass an electrical or chemical signal to another cell (neural or otherwise)
Synapse
neurons that respond to touch, sound, light and numerous other stimuli affecting cells of the sensory organs that then send signals to the spinal cord and brain.
Sensory Neurons
neurons that receive signals from the brain and spinal cord, cause muscle contractions, and affect glands.
Motor Neurons
type of neuron that connects neurons to other neurons within the same region of the brain or spinal cord.
Interneurons
Parts of a Neuron
• cell body (often called the soma)
• dendrites
• axon.
Soma
cell body of a neuron
'threads' that arise from the cell body, often branching multiple times
Dendrites
special cellular tissue that arises from the cell and extends as far as 1 yard in humans
Axon
Three Levels
of Neuronal Messaging
• communication across the synapse

• changes in the internal biochemistry of the cell

• activation of MRNA (messenger ribonucleic acid), translating protein into new brain structures.
Ganglion
a mass of nerve cell bodies
Three main parts of the brain
• Forebrain
• Midbrain
• Hindbrain
Lobes of the Cerebral Cortex
• Frontal Lobe
• Parietal Lobe
• Occipital Lobe
• Temporal Lobe
Brain Anatomy:

similar to the cerebrum in that it has two hemispheres and has a highly folded surface or cortex. This structure is associated with regulation and coordination of movement, posture, and balance.
Cerebellum
Brain System:

• often referred to as the 'emotional brain', is found buried within the cerebrum.

• operates by influencing endocrine and autonomic systems
Limbic System
Brain Anatomy:

sensory and motor functions. Almost all sensory information enters this structure where neurons send that information to the overlying cortex.
Thalamus
Brain Anatomy:

regulates homeostasis, emotion, thirst, hunger, circadian rhythms, and control of the autonomic nervous system
Hypothalamus
Brain Anatomy:

important for learning and memory . . . for converting short term memory to more permanent memory, and for recalling spatial relationships in the world about us
Hippocampus
Components of
the Limbic System
• Hippocampus
• Fornix
• Amygdala
Brain Anatomy:

structure responsible for basic vital life functions such as breathing, heartbeat, and blood pressure.
Brain Stem
Components of Brain Stem
• Midbrain
• Pons
• Medulla
Brain Anatomy:

deals with autonomic, involuntary functions, such as breathing, heart rate and blood pressure.
Medulla
Brain Anatomy:

• involved in motor control and initial analysis of sensory input

• It has parts that are important for the level of consciousness and for sleep.
Pons
Brain region involved in functions such as vision, hearing, eye-movement, and body movement.
Midbrain
the ability to sense body position and movement
Proprioception
theory proposed by MacLean which hypothesized that the brain developed in three layers from the bottom up
The Triune Brain
Layers of the Triune Brain
• Reptilian Brain
• Paleo-Mammalian Brain (Limbic)
• Neomammalian Brain (Neocortex)
system which controls glands and the release of hormones. It maintains homeostasis.
Neuroendocrine System
Brain Areas in which language is controlled
• Broca's Area
• Wernicke's Area
Intelligence is primarily driven within the ____ lobes which work very closely with the Parietal lobe which integrates sensory information
Frontal Lobes
the process whereby the brain radically reduces the number of synapses it maintains during adolescent brain growth.

It appears that the rapid brain development in infancy results in activity that can be subsequently discarded in order to achieve greater speed and efficiency in the adult brain.
Pruning
the ability of the brain to change the structure and function of many of its parts to meet different needs over time. The brain is particularly capable of this change when it is in childhood.
Plasticity
Changes in Sleep Patterns
Through the Lifespan
Over a typical lifespan, the amount of time we spend sleeping declines.

• Newborns spend 16-20 hours asleep each day.

• Between ages 1-4, sleep declines to 11 or 12 hours.

• The adolescent will need about 9 hours. Adults through middle age need at least 8 and though the elderly may require up to 8, they struggle to get it in one block.

• Age related sleep problems are reported in women due to menopause and insomnia and interrupted sleep are common problems due to chronic medical conditions.

• The elderly suffer disproportionately from chronic sleep deprivation because most older adults are less able to maintain sleep than their younger counterparts.
Coping with Oppression:

adopting styles that conform. May be “passing” in the workplace for example
Assimilation
Ghettoization
retreat into the community with others that are like you. It may be an adaptive response, but may not be a healthy place to stay. This can be geographical or psychological and may be a function of survival.
Cass Model of Coming Out
--Stages--
• Identity Confusion
• Identity Comparison
• Identity Tolerance
• Identity Acceptance
• Identity Pride
• Identity Synthesis
Helm’s White Racial Identity Development Model
--Stages--
• Contact
• Disintegration
• Reintegration
• Pseudo-Independence
• Immersion/Emersion
• Autonomy
Two Phases of Helm's White Racial Identity Development Model
• Abandonment of Racism
• Defining a Non-Racist Identity
Cross: Black Racial Identity Development Model
--Stages--
• Pre-encounter
• Encounter
• Immersion/Emersion
• Internalization
• Internalization-Commitment
Coleman Model of Coming Out
--Stages--
• Precoming out
• Coming out
• Exploration
• First relationships
• Integration
Social Identity
Development Model
--Stages--
• Naïve/ No Social Consciousness (Curiosity)
• Acceptance (Complacence/ Resignation)
• Resistance (Anger/Shame)
• Redefinition
• Internalization
The process by which an oppressed person comes to believe, accept, or live out the inaccurate stereotypes and misinformation about their group. The oppressed person comes to use against herself (and/or against her co-members) the methods of the oppressor, holds an oppressive view toward her own group, or starts to believe in negative stereotypes of herself.
Internalized Oppression
members of the oppressed group (“Target Group”) collude with the oppression (“Non-Target Group”) and think/feel/act in ways that confirm their devaluation
Internalized Subordination
Riddle Homophobia Scale
• Repulsion
• Pity
• Tolerance
• Acceptance
• Support
• Admiration
• Appreciation
• Nurturance
Downing and Roush Feminist Identity Model
--Stages--
• Passive Acceptance of trad. sex roles

• Revelation – open questioning of self – men perceived as negative

• Imbeddedness–Emanation – connectedness with select women

• Synthesis – development of authentic, positive feminist identity

• Active commitment to meaningful action, men considered equal, different
Kim's Asian-American Identity Development Model
--Stages--
1. Ethnic Awareness

2. White Identification Stage – realization of differentness

3. Awakening to Social Political Consciousness

4. Redirection – reconnection with one’s Asian American heritage and culture

5. Incorporation – development of comfortable identity as Asian American.
Term describing process by which:

targets collude in their own oppression, think, feel, act in ways that confirm their devaluation.
Internalized Subordination
Term describing process by which:

Non target group members internalize and unconsciously express internalized notions of entitlement and privilege.
Internalized Domination
Family Life Cycle Model
--Key Theorists--
• Monica McGoldrick
• Betty Carter
Family Life Cycle Model
Our first relationships, our first experience of the world are with and through families. Within the larger sociopolitical culture, the individual life cycle takes shape as it moves and evolves within the matrix of the family life cycle. Families comprise people who have shared history and a shared future. Relationships with parents, siblings, and other family members go through transitions as they move along the life cycle.
Family Life Cycle Model
--Stages--
• Leaving Home
• Single Young Adults
• Forming Partnerships
• families w/young children
• families w/adolescents
• families w/adult children
• families in later life
is an individual's identification with a gender inconsistent or not culturally associated with their biological sex.
TRANSSEXUAL

Transsexualism is stigmatized in many parts of the world but has become more widely known in Western culture in the mid to late 20th century, concurrently with the sexual revolution and the development of sex reassignment surgery (SRS).
a general term applied to a variety of individuals, behaviors, and groups involving tendencies to vary from culturally conventional gender roles.
TRANSGENDER

Transgender is the state of one's 'gender identity' (self-identification as woman, man, neither or both) not matching one's 'assigned sex' (identification by others as male, female or intersex based on physical/genetic sex). 'Transgender' does not imply any specific form of sexual orientation; transgender people may identify as heterosexual, homosexual, bisexual, pansexual, polysexual, or asexual; some may consider conventional sexual orientation labels inadequate or inapplicable.
the practice of cross-dressing, which is wearing clothing traditionally associated with the opposite sex.
TRANSVESTITE

refers to a person who cross-dresses; however, the word often has additional connotations
in humans and other animals, is the presence of intermediate or atypical combinations of physical features that usually distinguish female from male. This is usually understood to be congenital, involving chromosomal, morphologic, genital and/or gonadal anomalies, such as diversion from typical XX-female or XY-male presentations, e.g., sex reversal (XY-female, XX-male), genital ambiguity, or sex developmental differences.
INTERSEX

An intersex individual may have biological characteristics of both the male and the female sexes. Intersexuality as a term was adopted by medicine during the 20th century, and applied to human beings whose biological sex cannot be classified as clearly male or female. Intersex was initially adopted by intersex activists who criticize traditional medical approaches to sex assignment and seek to be heard in the construction of new approaches
the German name for a condition which affects a woman's ability to engage in any form of vaginal penetration, including sexual intercourse, insertion of tampons, and the penetration involved in gynecological examinations. This is the result of a reflex of the pubococcygeus muscle, which is sometimes referred to as the 'PC muscle'. The reflex causes the muscles in the vagina to tense suddenly, which makes any kind of vaginal penetration—including sexual intercourse—painful or impossible.
VAGINISMUS

A woman suffering from vaginismus does not consciously control the spasm. The vaginismic reflex can be compared to the response of the eye shutting when an object comes towards it. The severity of vaginismus and the pain during penetration, including sexual penetration, varies from woman to woman.
Translated as “large lips,” this flap of skin protects the vagina from foreign particles.
LABIA MAJORA
The “small lips” also surround and protect the vaginal opening and are located inside the labia majora.
LABIA MINORA
The fatty mound of tissue that covers the pubic bone in females. Often called the 'mons.'
MONS PUBIS
ACCESSORY GLANDS
There are several glands that work together to produce semen, or seminal fluid. Sperm can live inside the female reproductive system for up to 48 hours, and seminal fluid helps the sperm move around and stay nourished. The seminal vesicle produces a fluid that provides energy to the sperm as they seek out the female sex cell, or the egg. The prostate gland makes a different fluid that helps the sperm move more quickly through the female reproductive system. Another set of glands, called bulbourethral or Cowper's glands, makes a small quantity of fluid that helps protect the sperm on its way through the urethra by neutralizing any leftover traces of acidic urine.
a gynecologist who invented the Kegel Perineometer (used for measuring vaginal air pressure) and Kegel exercises (squeezing of the muscles of the pelvic floor) as non-surgical treatment of genital relaxation.

First published his ideas in 1948. He was Assistant Professor of Gynecology at the University of Southern California School of Medicine.
ARNOLD KEGEL

Today pelvic floor exercises are widely held as first-line treatment for urinary stress incontinence and female genital prolapse, with evidence supporting its use from systematic reviews of randomized trials in the Cochrane Library amongst others.
Research team that pioneered research into the nature of human sexual response and the diagnosis and treatment of sexual disorders and dysfunctions from 1957 until the 1990s.
MASTERS & JOHNSON

Their findings, particularly on the nature of female sexual arousal (for example, describing the mechanisms of vaginal lubrication and debunking the earlier widely-held notion that vaginal lubrication originated from the cervix) and orgasm (showing that the physiology of orgasmic response was identical whether stimulation was clitoral or vaginal, and proving that some women were capable of being multiorgasmic), dispelled many long standing misconceptions.
A pioneer in the field of sex therapy and founder of the country's first clinic for sexual disorders established at a medical school.

She was noted for her efforts to combine some of the insights and techniques of psychoanalysis with behavioral methods.
She agreed with others in the field that sexual difficulties often had superficial origins. But she held that, in case an unconscious conflict lay at the root of the disorder, it could indicate deep emotional problems and require the therapist to resort to more analytical means.
HELEN SINGER KAPLAN
Developer of The Kinsey Scale, which attempts to describe a person's sexual history or episodes of his or her sexual activity at a given time. It uses a scale from 0, meaning exclusively heterosexual, to 6, meaning exclusively homosexual. In both the Male and Female volumes of the Kinsey Reports, an additional grade, listed as 'X', was used for asexuality.
Alfred Kinsey
Masters and Johnson: Four Phase model of sexual response
• Excitement (initial arousal)
• Plateau (full arousal, not orgasm)
• Orgasm
• Resolution (after orgasm)
the tendency to be sexually attracted to persons of the same sex, the opposite sex, both sexes, or neither sex. Includes: erotic attraction, sexual behavior, emotional attachment, and definition of self.
Sexual Orientation
the way in which an individual identifies with a gender category

also influenced by the social learning theory, which assumes that children develop their gender identity through observing and imitating gender-linked behaviors, and then being rewarded or punished for behaving that way.
GENDER IDENTITY
the “aversion to some or all of those physical characteristics or social roles that connote one’s own biological sex”
GENDER DYSPHORIA
PLISSIT Model
of Sex Therapy
• P = permission: give clients permission to discuss sexual issues, normalize thoughts, feelings, Bx
• LI= limited information: involves psychoeducation i.e., impact of medical or medications on sexual functioning
• SS= specific suggestions: homework assignments
• IT = Intensive Therapy: used if the first three levels don’t work
a state of responsiveness to sensory stimulation or excitability.
AROUSAL
Kaplan's Three-Stage Model of the Human Sexual Response Cycle
• Desire: Neuro- and psychological sensation for initiating sexual activity and upon which sexual stimulation then builds.

• Excitement phase: Similar to Masters and Johnson

• Orgasm Phase: Similar to Masters and Johnson’s model orgasm + resolution phase eg. reversal of vasocongestion, release of muscular tension
Psychologist Jack Annon developed this model (1976) illustrating the fact that most people with sexual problems do not need an intensive course of therapy.
PLISSIT Model
The vulva consists of:

(a) Labia, fallopian tubes, and ovaries.
(b) Clitoris, labia, mons veneris, vagina.
(c) Mostly external female sexual structures and a few internal ones.
(d) The external female sexual structures.
The External Female
Sexual Structures
Dyspareunia
Genital pain during intercourse
CERTS: Necessary Conditions for Positive Sexual Experiences for Survivors of Sexual Abuse
Consent
Equality
Respect
Trust
Safety
True or False:

Disparity in desire levels between partners is an indicator that their relationship has failed.
FALSE

The tension caused by this disparity can subside when partners learn to tolerate anxiety about the relationship and take the opportunity to grow.
developer of first systematic nosologic system for diagnosis
Emil Kraepelin
early pioneer in neurology, connecting bx symptoms with brain functioning.
Jean-Martin Charcot
developed early concept of the synapse as site of electrical transfer between neurons.
C.S. Sherrington
Pro-medication Assumptions
(anti-psychotherapy)
• quantifiable effects
• fast acting
• quick response increases hope
• systematic treatment, less error
• facilitate Pt. engagement in Tx
• effective where Tx is not
• cost-effective
• available to public
Pro-psychotherapy Assumptions
(anti-medication)
• meds not address complex human
• autonomy vs. dependency
• Rx may reduce Tx-motivation
• side-effects
• meds cannot heal emo. wounds
Types of biologically based psych disorders
• due to medical illness (i.e., hyperthyroidism
• due to drugs (Rx, OTC, rec.)
• Endogenous mental illness
specific and highly predictable response to a stimulus. (Rarely applicable to psychotropic meds)
Stimulus-Response Specificity
Generic meanings of Pharm. Tx
• Rx as punishment
• sign of sick/crazy/deranged
• therapist not hopeful?
• fear that can lead to addiction
• bad/weak for taking drugs
• assault on free will/autonomy
Personal Meanings of Pharm. Tx
• may convey a need to be 'fed'
• might spark anxiety, fear, paranoia
• side-effects may exacerbate depression
Pharmacokinetics
effect of the body on a drug; impacts effectiveness
Components of a Neuron
• cell body
• dendrites
• axon
• terminal bouton
short, branched structures projecting out from cell body of a neuron; receives and conducts information TO cell body
Dendrite
long fiber that ends in terminal bouton; conducts impulses AWAY FROM cell body
Axon
molecule binding to and activating receptors; includes neurotransmitters, hormones, certain drugs, chemicals in foods
Ligand
brief change in electrical potential from cell's resting state
Action Potential
type of neuron that releases neurotransmitters
Presynaptic Neuron
type of neuron that receives neurotransmitters
Postsynaptic Neuron
process of impulse movement along axon
Conduction
Transmission
passage of impulse across synaptic space
manufactured in cell body, transported via axon to vesicles for storage in Terminal Bouton
Neurotransmitter Molecules
areas of presynaptic terminal bouton enclosing neurotransmitters to protect from enzymes in cellular fluid
Vesicles
Primary means of nerve cell influence on functioning of another neuron
Binding of Neurotransmitters to Receptors
protein structure allowing neurotransmitter molecules to reenter nerve cell for re-use
Reuptake Transporter Pump
Life span of receptors
12-24 hours
'Functional' Categorization of Receptors
inhibitory vs. excitatory effect of neurotransmitter-receptor coupling
'Mechanistic' Categorization of Receptors
signaling mechanisms by which neuronal activities occur (i.e., ionic, metabotropic)
rapid, transient changes in nerve cell activity
Ionic Neuronal Actions
gradual changes in neuronal functioning (i.e., over hours, days, weeks, months); changing/regulating cellular activity
Metabotropic Neuronal Actions
• inhibited neurotransmitter production
• enzymes degrading neurotransmitters
• bio-based disorders facilitate or inhibit release of neurotransmitters
• altered reuptake absorption process
• pathological alterations in genetics
Neuronal Malfunction
apoptosis
cell death
Central Nervous System
brain, spinal cord
Peripheral Nervous System
nerves extending through body (i.e., autonomic, somatic)
Somatic Nervous System
controls voluntary action of skeletal muscles, carries sensory information to CNS
Autonomic Nervous System
supplies nerves to involuntary organs (i.e., heart, glands, etc); includes Sympathetic & Parasympathetic Nervous Systems
Sympathetic/Parasympathetic Nervous Systems
involved in maintaining autonomic homeostasis, mediated primarily by norepinephrine, involved in fight/flight response
• Functions: higher cognitive processing
• Pathology: dementia, confusing states
Cortex
• Functions: impulse control, attention, behavioral monitoring, organization of complex information processing
• Pathology: ADD, schizophrenia, OCD, depression
Prefrontal Cortex
Components of Diencephalon
• Thalamus
• Hypothalamus
• Functions: many nerves pass through this structure
• Pathology: not implicated in major psychiatric DO's
Thalamus
Components of Limbic System
• amygdala
• septum
• cingulate
• hippocampus
• Functions: elicits/controls aggression, primitive threat appraisal, initiates fight/flight
• Pathology: impulse control disorders, depression, borderline PD(?), anxiety disorders
Amygdala
• Functions: emotional/stimulus 'gate,' pleasure centers
• Pathology: schizophrenia, impulse control disorders, addictive disorders
Septum
• Functions: neuronal pathways connecting limbic system w/prefrontal lobes; affect regulation
• Pathology: OCD, anxiety disorders
Cingulate
• Functions: recent memory, new learning, impulse & emotional control, reduces stress arousal
• Pathology: Alzheimer's disease, postconcussion syndrome, depression
Hippocampus
• Functions: controls aspects of motor behavior; OCD
• Pathology: Parkinson's disease, antipsychotic med. side effects)
Basal Ganglia
• Functions: Neuronal pathways connecting limbic system & prefrontal lobes; stimulus filter or 'gate'
• Pathology: ADD, schizophrenia
Brain Stem, reticular system
effect of a drug on the body
Pharmacodynamics
Basic Pharmacokinetic Factors
• absorption
• distribution
• biotransformation
• excretion
in pharmacokinetics, process by which a drug is absorbed into the blood (often via digestive tract)
Absorption
system protecting Central Nervous System from exposure to toxins by allowing only certain molecules into brain. Penetration is restricted but not impossible.
Blood-Brain Barrier
in pharmacokinetics, process by which a drug is spread throughout the bloodstream to various organs/sites throughout the body for biotransformation and/or storage in fat/muscle cells
Distribution
in pharmacokinetics,metabolism; occurs primarily in liver via enzymes changing original chemical into compounds more easily excreted by kidneys (metabolites)
Biotransformation
in pharmacokinetics, chemical by-products of biotransformation/metabolism; can be useful/desirable (i.e., reduction of Sx) or harmful (i.e., side-effects)
Metabolites
in pharmacokinetics, poisoning due to excessively high levels of a drug; failure to metabolize (ex. impaired liver functioning)
Toxicity
in pharmacokinetics, process by which drugs are eliminated from the body, primarily via kidneys
Excretion
• time required for serum concentration to be reduced by 50%
• used to determine dosage amt/intervals
• used to estimate time required for drug to reach 'steady state'
Drug Half-life
Primary Sites of Drug Excretion
• kidneys
• gastrointestinal tract
• respiratory system
• sweat
• saliva
• breast milk
Steady State
• when concentrations of a drug in the bloodstream have reached a plateau (i.e., amt administered is equal to amt being eliminated)
number of half-lives after which Steady State is generally attained
four (4) half-lives for most drugs
Primary Types of Medication Effects
• pharmacological effects
• side effects
• idiosyncratic effects
• allergic reactions
• discontinuance syndrome
desired therapeutic effect of a drug
Pharmacological Effects
• typically undesirable
• occasionally beneficial (i.e., sedative qualities as sleep aide)
• account for 70-80 percent of adverse drug events
Side Effects
• extremely rare, adverse effects
• difficult to predict
• often specific to individuals, or to groups sharing genetic/bio features
Idiosyncratic Effects
• immunological response (generally skin rash or hypersensitivity) to drug as if it were foreign substance/organism
• in extreme, 'anaphylaxis' can occur
Allergic Reactions
Anaphylaxis
• difficulty breathing
• fever
• irregular heart beat
• potentially fatal
• response to stopping or interrupting medication Tx
• examples include: narcotic withdrawal, 'cholinergic rebound' re: tricyclics
Discontinuance Syndrome
Drug Interactions
effects of coadministered meds on absorption, distribution, biotransformation, excretion
Time-Course Pattern of Drug Interactions
• immediate vs. delayed
• several weeks may pass before interaction effects are evident
Blood-Brain Barrier
• dense membranes & tightly packed capillaries protecting CNS
• controls chemical access to brain, preventing entry of toxins
Beta-Blocker
psychiatric medication that primarily effects peripheral nervous system, does not cross blood-brain barrier
Lipophilic Drugs
• able to penetrate blood-brain barrier
• effective psychiatric meds often lipophilic
Prerequisite to Ligand-Receptor Binding
ligand must have highly specific molecular shape to fit precisely
ligand binding activates receptor
Agonist Effects
• ligand occupies a receptor site but does not activate it
• prevents other molecules from activating that receptor site
• a.k.a. 'blocking'
Antagonist Effects
Problems in Drug Development
• molecules inadvertently bind to more than one receptor
• molecules bind to similar receptors in undesired brain regions
• molecules effect multiple subtypes of receptor classes (ex. seratonin)
Hopes for Future Drug Development
• highly selective molecules, targeting only particular receptor subtypes
Reactive dysphoria
• normal, appropriate, low-grade mood changes in response to minor losses
• transient, do not interfere with functioning
• normal prolonged/intense response to major losses
• initially 6-12 months
• continued up to 1-3 yr.
• some impact on functioning
Grief (Uncomplicated bereavement)
When grief becomes Clinical Depression
• marked erosion in self-esteem
• agitation
• early morning awakening
• major weight loss
• suicidal ideation/attempts
• anhedonia
• clinically significant impairment in functioning
loss of ability to experience pleasure
anhedonia
Reactive Depressions
• mild, moderate, severe
• response to identifiable stressors
• physiological functioning relatively unaffected
Types of Stressors in Reactive Depressions
• acute/intense (i.e., loss/death)
• insidious (i.e., gradual change in relationships)
• distant past (i.e., early abuse)
Biological Depressions
• in pure form, not reaction to stressors
• can emerge apparently spontaneously
• resulting from altered neurotransmitter functions in key limbic system areas
Conditions Responsible for Biological Depressions
• Medical illnesses affecting brain functioning
• Female sex-hormone fluctuation
• Medications & recreational drugs
• Endogenous biological depressions
originating spontaneously from within (i.e., genetically transmitted mental illness)
Endogenous
physiological symptoms of depression emerging in the absence of identifiable psychosocial stressors
(Neuro)Vegetative Symptoms
a reactive depression which progresses to exhibit physiological features
Reactive-biological depression
(endogenomorphic)
• subtype of major depression characterized by particular symptom set
Atypical Depression
• Reactive dysphoria (i.e., positively correlated to stressors)
• Profound fatigue, low energy
• Hypersomnia
• Increased appetite & weight gain
• Marked sensitivity to interpersonal rejection/separation
Symptoms of Atypical Depression
Suicide Rate for Major Depression
(quoted from textbook)
9 percent suicide rate
Most reliable behavioral markers of underlying biological dysfunction
Physiological symptoms
Primary focus of med. Tx for depression
restoring normal bio. functioning (i.e., effects on mood, self-esteem, etc. are secondary)
Psychotic Depressions
severe depression with (typically) 'mood congruent' hallucinations/delusions
Recurrent major depressions
usually involve 2-6 episodes in a lifetime
Highly Recurrent major depressions
often 15 or more episodes in a lifetime
Core Psychological Symptoms of Dysthymia
• chronic low-grade sadness
• irritability
• negative thinking
• low self-esteem
Biological Symptoms of Dysthymia
• low energy
• decreased capacity to experience pleasure, enthusiasm, motivation
'Double Depression'
instances of dysthymic patients experiencing a major depressive episode
Theories of Dysthymia Etiology
• characterological
• chronic low-grade biologic depression
Seasonal Affective Disorder
• a specifier of major depression
• depressive symptoms brought on by reduced exposure to bright light
• resembles 'atypical depression'
Mania
• extreme agitation
• hyperactivity
• racing thoughts
• (psychotic symptoms)
Hypomania
• milder episodes
• increased energy
• euphoric mood
• irritability
• decreased need for sleep
Screen depressive presentations for Bipolar DO because
antidepressant Rx is contraindicated, can facilitate mania
Risk factors for Bipolar DO
• symptoms of atypical depression
• psychotic symptoms
• family Hx of Bipolar DO
Symptom vs. Etiology
'common symptoms should not automatically lead to conclusions regarding common etiologies'
Monoamine hypothesis
theory holding that depressive symptoms result from malfunction of norepinephrine, serotonin, dopamine neurons in limbic system and hypothalamus
According to Monoamine Hypothesis
'what can go wrong'
• excessive reuptake
• decreased neurotransmitter release
• neurotransmitter degradation due to excessive monoamine oxidase (MAO)
• disruption of neuroproductive protein synthesis
• abnormalities in receptor numbers/sensitivity
Types of Antidepressant Drugs
• Tricyclic (most side-effects)
• Selective Serotonin Reuptake Inhibitors (SSRI)
• Serotonin and Norepinephrine Reuptake Inhibitors (SNRI)
• Norepinephrine Reuptake Inhibitors (NRI)
• Atypical Antidepressants
• Monoamine Oxidase Inhibitors (MAOI)
• Stimulants
Side-Effects of Lithium Rx for Bipolar DO
• Gastrointestinal
• Nervous System
• Neuromuscular
• Endocrine
• Renal
• Hematological
• Cardiovascular
• Dermatological
• Weight Gain
• Teratogenicity
Neuroprotective features of pharmacological Tx.
medication may either protect against brain damage or promote normal neuromaturation
Drug Administration Methods
* Pills
* Injection/inhalation
* Skin patches
* Intra-muscular injections
measure of how efficiently drug is reducing target Sx, regardless of dose
Drug Efficacy
dose of a drug needed to achieve a given level of Sx reduction
Drug Potency
• a measure of drug toxicity
• ratio of therapeutic to lethal dose
• inverse relationship
Therapeutic Index
anticholinergic effects
• dry mouth
• constipation
• urinary retention
• blurred vision
• memory impairment
• confusional states
Extrapyramidal Symptoms
• parkinson-like effects
• dystonias/tardive dyskinesia
• akathisia
Parkinson-like Side Effects
• rigidity
• shuffling gait
• tremor
• flat affect
• lethargy
Akathisia
intense, uncomfortable sense of inner restlessness
Dystonias
spasms in neck and other muscle groups
Tardive dyskinesia
persistent, permanent movement disorder including involuntary:
• lip smacking
• writhing/jerky movements
Metabolic Syndrome
• common side effect for 2nd generation anti-psychotic drugs
• weight gain
• increased hunger
• increased glucose intolerance
• risk of type 2 diabetes
ADHD Diagnostic Criteria
6 symptoms
for 6 months
before the age of 6 years
in 2 settings
6 for inattentive
6 for hyperactive
or 6 each for both
Lithium Pregnancy Risk
• minor cardiac abnormalities in newborn (dose dependent)
• synergistic effect, harmful to fetus
Tegretol Pregnancy Risk
• congenital defects
• neural tube defects
• developmental delays
Advantages to Anti-Psychotic meds while pregnant
active psychosis can lead to:
• poor nutrition/prenatal care
• preterm/precipitous births
• fetal abuse or infanticide
'Floppy Baby' Syndrome
associated with benzo withdrawal
• lethargy
• difficulty sucking
• poor respiration
• difficulty maintaining temperature
Avg. # meds for ppl over 70 yrs
7 medications
Safety Considerations in Older Patients
• Medical comorbidity / differential dx
• drug interactions more common
• cognitive impairment more of an issue
• greater risk of side effects
• fall risks
Three central components of Psychosis
• Delusions
• Hallucinations
• Disorganized Bx
Phases of Schizophrenia
• Prodromal: mostly negative Sx
• Active: increased positive Sx
• Residual: return to negative Sx
Psychosis Types
• Delusional Disorder
• Mania
• Depression w/psychotic feat.
• Schizoaffective DO
• Brief Psychotic
• Shared Psychotic
• Due to General Med. Condition
• Schizophrenia
Chloride Ion Channel
brain structures opened by GABA, allow chloride ions to slow physiological anxiety/fear response
Positive Sx of Schizophrenia
(Neurology)
over-firing in limbic system
experiences not normally present:

• delusions
• disordered thoughts and speech
• tactile, auditory, visual, olfactory and gustatory hallucinations
Negative Sx of Schizophrenia
(Neurology)
under-firing in pre-frontal cortex
normal experiences absent
Examples of Benzodiazepines
• Valium
• Klonopin
• Ativan
• Xanax
Examples of Benzodiazepines
• Valium
• Librium
• Klonopin
• Ativan
• Xanax
Examples of Medications
with HIGHER risk of abuse
• Benzodiazepines
• Seroquel
• Stimulants
Major Mental Disorder
including symptoms of:
sleep disturbances, listlessness, fatigue, agitation, decreased sex drive
Major Depressive Disorder
Major Mental Disorder
including symptoms of:
low-grade chronic depression, low self esteem
Dysthymia
Major Mental Disorder
including symptoms of:
elation, labile mood, sleeplessness, racing thoughts, lack of insight
Bipolar Disorder
Major Mental Disorder
including symptoms of:
presence of 2+ panic attacks, significant anticipatory anxiety
Panic Disorder
Major Mental Disorder
including symptoms of:
disrupted function due to sustained hyperactivity and/or inattention, probs with self-regulation, impulsivity
ADHD
Pharmacological interventions for children may:
• Reduce the risk of suicide
• Decrease risk of substance abuse
• Prevent loss of brain tissue
All of the following medications have a high therapeutic index EXCEPT:

• Prozac
• Thorazine
• Lithium
• Zyprexia
Lithium
Which of the following disorders is LEAST associated with possible progressive neurobiological impairment?

• Bipolar disorder
• Specific Phobia
• Major depression recurrent
• Schizophrenia
Specific Phobia
Which class of drugs poses the greatest potential for abuse:

• Benzodiazepines
• Mood stabilizers
• Anti-psychotics
• Anti-depressants
Benzodiazepines
Additional common symptoms in children with depression include all but the following:

• Irritability
• Social Withdrawal
• Delusions
• School failure
Delusions
The SSRI is most associated with the side effect of activation is...
Fluoxetine (Prozac)
The SSRI is most associated with the side effect of sedation is...
Paroxetine (Paxil)
Which of the following is an SNRI:

• Atomoxetine (Strattera)
• Buproprion (Wellbutrin)
• Duloxetine (Cymbalta)
• Escitalopram (Lexapro)
Duloxetine (Cymbalta)
Potential side effects of SSRI anti-depressants
• Activation
• sedation
• nausea,
• gastrointestinal symptoms
• sexual dysfunction
A serious rash that requires medical attention may be a side effect of which mood-stabilizing drug?
Lamotrigine (Lamictal)
Which drug is LEAST likely to be prescribed for mood stabilization?

• Divalproex (Depakote)
• Trazadone (Desyrel)
• Lamotrigine (Lamictal)
• Carbamazepine (Tegretol)
Trazadone (Desyrel)
In diagnosing children, differentiating between bipolar disorder and ______ is most challenging?
ADHD
Generally, when using an SSRI to treat OCD, the dose is ______ than the recommended treatment dose for depression
higher
most common medication for the treatment of OCD
SSRI
True or False:

Schizophrenia often starts in childhood.
FALSE

While this can happen, it is quite rare.
In the prodromal phase of schizophrenia, common symptoms include:
deterioration in functioning and/or marked social withdrawal
Negative symptoms of schizophrenia
• anhedonia
• apathy
• blunted affect
• poverty of thought
• amotivation
Psychotic symptoms may be the result of:
• Major depression or Dipolar DO
• schizophrenia
• substance use or withdrawal
Akathisia is a side effect of some medications. It causes:
an intense feeling of restlessness
Tardive dyskinesia may persist for ________ after discontinuation of some antipsychotic medications:
Years
An excessive amount of which neurotransmitter is most associated with causing schizophrenia:
Dopamine
Which neurotransmitter/s is most associated with mood symptoms?
Serotonin & Norepinephrine
EPS, or extrapyramidal side effects of antipsychotic medications
• Acute dystonic reactions (muscle spasms in neck & shoulder)
• Akathisia
• Pseudoparkinsonism
Signs of Pseudoparkinsonism
• slowed movements
• decreased facial expression
• resting tremor
• shuffling gait
Class of medications associated with a change in metabolism that tends to lead to weight gain
Atypical Antipsychotics
Patients taking _____ should have their weight, blood sugar, and lipid levels monitored
Olanzapine (Zyprexa)
Class of medications shown to be effective in tx of ADHD
• stimulants
• some anti-depressants
• alpha-2 adrenergic agonists
Class of psychiatric drugs considered to be safest and have mildest side-effects
SSRIs
True or False:

It is within MFT Scope of Practice to recommend that a client take vitamin B1 to relieve his stress.
FALSE
Common side effects of stimulants include:
• Insomnia
• reduced appetite
• stomach aches
• nervousness
• mild dysphoria
• lethargy
What is the most likely severe consequence of misdiagnosing a child with ADHD and treating with a stimulant if the child really has bipolar disorder?
increased manic symptoms and cycle acceleration
Which anti-depressant is most appropriate for the treatment of ADHD with co-occurring depression?
Bupropion (Wellbutrin)
Medications that may help control some of the symptoms of autism spectrum disorders:
• SSRIs
• antipsychotics
• mood-stabilizers
• beta-blockers
Autism spectrum disorders are best treated with:
Behavioral interventions and medications that target the most problematic symptoms of the disorder
Which anti-depressant is contra-indicated in the treatment of bulimia nervosa because of the increased risk of seizures?
Bupropion (Wellbutrin)
Patients with bulimia nervosa often benefit from treatment with which class of medications?
SSRIs
Medications most impact which part of the nervous system:

• The blood brain barrier
• The axon of a neuron
• The dendrite of a neuron
• The synapse
The synapse
Manic switching
When a person taking an antidepressant spirals into a manic episode
What is the first thing to do after making a referral for medication?
Get a release signed to talk to the MD about the medication treatment
An example of a medication that is an antagonist is:

• Paxil
• Valium
• Thorazine
• MAO inhibitor
Thorazine
The black box warning on antidepressants was issued to:
Warn parents about the possible side effect of suicidality as in kids and teens
Panic Disorder has been effectively treated with ______
antidepressants augmented with a benzodiazepine
Prescriptions are described as 'Off label' when:
• The medication is prescribed to populations that have not been tested on the medication

• The medication is prescribed in larger or smaller dosages than recommended by the FDA guidelines

• The medication is prescribed for conditions and target symptoms not recommended by FDA guidelines
Side Effects of Lithium
• Increased thirst, urination
• nausea, diarrhea
• headache
• tremor
• weight gain
Anti-cholinergic side effects found in tricyclic antidepressants and some 1st generation antipsychotics
• Dry mouth
• blurry vision
• constipation
• memory problems
Elderly clients be treated with great care when given psychotropic medications because...
• They metabolize medications less efficiently and so need lower doses

• They often take multiple additional prescribed medications leading to increased interaction effects
What must you keep in mind when a client of yours is placed on a 2nd generation atypical antipsychotic?
They could get Metabolic Syndrome.
What should we be aware of when a client of color is placed on psychotropic medications?
He or she may be a slow metabolizer and need much lower doses than is generally prescribed
What complicates prescribing with kids?
• Can metabolize drugs faster
• They're smaller, may need lower doses
• They may be more prone to suicidality when taking medications than adults
Which of the mood stabilizers is NOT FDA approved for acute mania?
lamotrigine (Lamictal)
Which brain structure has a primary role in the rapid response to threatening stimuli?
Amygdala
Although not accepted as a complete explanation of the etiology of bipolar disorder, the Kindling Hypothesis nevertheless correctly predicts that...
Some anticonvulsant medications help stabilize mood and prevent recurrent mood episodes
Associated features or symptoms of depression in children include all except:

• School failure
• Bullying behavior
• Social withdrawal
• Irritability
Bullying Behavior
Which of the following medications is NOT classified as an SSRI antidepressant?

• venlafaxine (Effexor)
• citalopram (Celexa)
• fluvoxamine (Luvox)
• fluoxetine (Prozac)
venlafaxine (Effexor)
Children with Tourette’s Syndrome have a higher incidence of ...
• ADHD
• OCD
• Learning disabilities
Which of the following is a pharmacokinetic process?

a) Neurotransmitter reuptake inhibition
b) Enzyme inhibition
c) Receptor-specific occupancy
d) Drug absorption
Drug absorption
Which of the following discoveries was NOT an important precursor to today’s understanding of the mechanism of action of many psychotropics:

a) The Neuron Doctrine
b) Chemical neurotransmission
c) The synapse
d) Genotyping of CYP450 enzyme variants
Genotyping of CYP450 enzyme variants
True or False:

Bupropion (Wellbutrin) is a primarily serotonergic medication.
FALSE

Bupropion (Wellbutrin) does not primarily enhance serotonin transmission.
Which of the following medications is/are (a) first-generation antipsychotic(s)?

a) haloperidol (Haldol)
b) perphenazine (Trilafon)
c) atomoxetine (Strattera)
d) fluvoxamine (Luvox)
• haloperidol (Haldol)
• perphenazine (Trilafon)
Which of the following medications is LEAST likely to be prescribed to assist with maintaining sobriety from alcohol?

a) acamprosate (Campral)
b) benztropine (Cogentin)
c) disulfiram (Antabuse)
d) lithium carbonate
benztropine (Cogentin)
Which of the following medications carries the greatest risk for fetal malformation (i.e. is most teratogenic)?

a) fluoxetine (Prozac)
b) divalproex (Depakote)
c) desipramine (Norpramine)
d) citalopram (Celexa)
divalproex (Depakote)
Which of the following medications is LEAST likely to be used for the treatment of ADHD?

a) atomoxetine (Strattera)
b) guanfacine (Tenex)
c) mixed amphetamine salts (Adderall)
d) buspirone (Buspar)
buspirone (Buspar)
The hippocampus is known to be involved with ...
• consolidation of memories
• regulation of the stress response
Which of the following is NOT a frequently prescribed hypnotic medication (or prescribed as a hypnotic)?

a) zolpidem (Ambien)
b) trazodone (Desyrel)
c) ramelteon (Rozerem)
d) fluvoxamine (Luvox)
e) clonazepam (Klonopin)
fluvoxamine (Luvox)

This is an SSRI
True or False:

Second-generation Antipsychotics are substantially more effective at reducing positive symptoms than first generation antipsychotics.
FALSE
True or False:

Stimulant medications may increase agitation in children with Bipolar DO
TRUE
Neurotransmitter most frequently associated with the pathophysiology of schizophrenia
dopamine
Warning signs of a medical condition being primarily responsible for emotional or behavioral disturbances include all of the following EXCEPT

a) Visual hallucinations
b) Onset after age 55
c) Patient is taking several medications
d) Denigrating auditory hallucinations
e) Lack of precipitating factors
Denigrating Auditory Hallucinations
True or False:

Bulimia responds more frequently than anorexia to SSRI medications
TRUE
Which of the following factors helps to discriminate best between childhood bipolar disorder and ADHD?

a) hyperactivity
b) grandiosity
c) distractibility
d) impulsivity
Grandiosity
True or False:

The cell bodies of the neurons that produce serotonin, norepinephrine, and dopamine are ubiquitous (found everywhere) throughout the nervous system
FALSE

The neurons that produce these neurotransmitters are primarily found only in particular brain areas.
Which medication would NOT be appropriate for the initial treatment of generalized anxiety or anxiety associated with other psychiatric conditions?

a) hydroxyzine (Vistaril)
b) selegiline (Emsam)
c) lorazepam (Ativan)
d) clonazepam (Klonopin)
selegiline (Emsam)
Which substance abuse disorder has the LEAST number of FDA-approved medication treatments?

a) cocaine dependence
b) nicotine dependence
c) opiate dependence
d) alcohol dependence
cocaine dependence
True or False:

Irritability, anger and temper tantrums are particularly important diagnostic features that distinguish childhood bipolar disorder from other conditions.
FALSE
Which of the following is true regarding 'postpartum blues'?

a) It is defined as a major depressive episode that starts within 4 week after delivery
b) It is rare, affecting less than 1% of new mothers
c) It may have prognostic significance in predicting later postpartum depression
d) Despite the complications of breast feeding, antidepressant medications should strongly be considered
It may have prognostic significance in predicting later postpartum depression.
True or False:

SSRI’s have not been found effective for OCD and other anxiety disorders in children
FALSE
Which of the following is NOT an advantage of lamotrigine (Lamictal) over other mood stabilizers?

a) No need for blood monitoring
b) Quickly effective for bipolar mania
c) Relatively few side effects
d) More effective for bipolar depression
Quickly effective for bipolar mania
Which of the following is NOT one of the “Five Rs” that describe possible events in the course of treatment of major depressive episodes?

a) Remission
b) Recuperation
c) Relapse
d) Response
Recuperation
Which of the following is NOT a factor to weigh when considering psychiatric medications during pregnancy?

a) Teratogenesis (fetal malformation)
b) Effects on newborn’s immune system
c) Pharmacokinetic complications
d) Behavioral teratogenesis
Effects on newborn's immune system
After an acute traumatic event, the Stress Response syndrome often includes an alternation between states of denial and states of ______.
Intrusion
Movement disorders that may be caused by antipsychotic medications include all of the following EXCEPT

a) Neuroleptic Malignant Syndrome
b) EPS (extrapyramidal symptoms)
c) Akathisia
d) Tardive dyskinesia
Neuroleptic Malignant Syndrome
Knowing a drug’s half-life allows one to ascertain:
• How long it will take for a drug’s concentration in serum to be reduced to 50% of its peak level, after it’s discontinued

• How long it will take a drug to reach steady state when taken repeatedly

• How long it will take a drug to be practically eliminated from the body
Which of the following is true regarding cyclothymia?

a) Frequently diagnosed variant of dysthymia
b) May be a precursor of bipolar DO
c) Characterized by hypomanic episodes and episodes of major depression
d) Characterized by manic and hypomanic episodes
May be a precursor of bipolar DO
True or False:

The use of benzodiazepines may nullify behavioral desensitization techniques in the treatment of agoraphobia (without panic).
TRUE
Which of these medications is LEAST likely to have any therapeutic effect in the treatment or prevention of PTSD?

a) sertraline (Zoloft)
b) lamotrigine (Lamictal)
c) prazosin
d) morphine
e) propranolol
lamotrigine (Lamictal)
The differential diagnosis of hyperactivity and inattention in childhood does NOT typically include:

a) Attention Deficit Hyperactivity Disorder
b) Anxiety Disorders
c) Fetal Alcohol Syndrome
d) Obsessive Compulsive Disorder
e) Situational stress
Obsessive Compulsive DO
True or False:

Tricyclic anti-depressants (TCAs) are not effective in medication treatment of childhood depression.
TRUE
True or False:


FDA Pregnancy categories offer a reliable and fairly comprehensive guide to treatment decisions in regards to adverse effects of psychiatric medications during pregnancy or shortly after the birth of the infant.
FALSE
The concept that Axis II disorders may reflect mild or attenuated versions of Axis I conditions (and thus may respond to medications) applies LEAST to

a) Schizotypal Personality Disorder
b) Borderline Personality Disorder
c) Narcissistic Personality Disorder
d) Avoidant Personality Disorder
Narcissistic Personality Disorder
Which of the following is true regarding benzodiazepine drugs?

a) Their mechanism of action is understood to involve serotonin at the synapse
b) They are used almost exclusively in the treatment of psychiatric conditions
c) They have fallen into disuse, because of their addictive potential
d) Their therapeutic effect is almost immediate
Their therapeutic effect is almost immediate
Which of the following treatment options is NOT generally recognized as effective for OCD?

a) clomipramine (Anafranil)
b) Interpersonal psychotherapy
c) CBT; exposure & response prevention
d) Various SSRI antidepressants
Interpersonal psychotherapy
True or False:

The Fight or Flight response may be effectively stopped by a single dose of a high potency serotonergic medication.
FALSE
Dementia: Signs & Symptoms
Increased Difficulty with:
• Learning & Retaining new info
• Handling complex tasks
• Reasoning ability
• Sense of direction
• Language
• Behavior
Dementia: Modes of Onset
• Abrupt
• Gradual
Dementia: Progression
• Stepwise vs. Continuous
• Worsening vs. Fluctuating
or improving
• Disturbance of consciousness—reduced awareness
• Reduced ability to focus, sustain, or shift attention
• Cognitive changes such as orientation, memory deficit, language disturbances
• Fluctuate throughout the day
• Develops over a short period
Delirium

Also known as Acute Confusional State is a reversible disorder of cognitive function and is defined as an acute disturbance of attention and cognition. Delirium affects up to 56% of older people admitted to the hospital.
A loss of brain function that occurs with certain diseases. It affects memory, thinking, language, judgment and behavior.
Dementia

Alzheimer’s disease is the most common dementia-related disorder (50%). Other causes include vascular disease/stroke, other diseases such as Huntington’s, Pick’s and Parkinson’s., ETOH (Alcohol abuse dementia).
Age Range for Early-Onset
Alzheimer's
Before age 60
Age Range for Late-Onset
Alzheimer's
Age 60 and above
Estimates show that ___% of all reported suicides occur with persons 65 and older.
17-25%
Older ____ are the highest rates for suicides in the US with older ______ being the second highest risk.
white males, men of color
Older white males and older men of color account for ___% of all suicides among American older adults.
81%
Risk factors for suicide among older adults
• serious physical illness
• severe pain
• sudden death of a loved one
• major loss of independence
• financial problems
• major loss of interest in activities.
A syndrome in later life manifested by weight loss greater than 5% of baseline, decreased appetite, poor nutrition, inactivity, often accompanied by dehydration, depressive symptoms, impaired immune function and low cholesterol levels.

May result from several issues including chronic disease, functional decline.
GERIATRIC FAILURE TO THRIVE

Adverse outcomes include malnutrition, depression, cognitive impairment and impaired physical function.
_____ affects from 5-35% of community dwelling elders and 25-40% of nursing home residents.
Failure to Thrive
Syndrome associated with increased rates of infection, incidence of hip fractures, pressure ulcers, surgical mortality, mortality rates and medical costs.
Failure to Thrive
Main areas of Assessment
with Older Adults
• Impaired physical status or function
• Undernutrition or malnutrition (including unintentional or significant weight loss)
• Depression or depressive symptoms
• Cognitive impairment or decline
Effective Treatment of Older Adults is best achieved through...
a team approach: physician, nurse, dietitian, physical therapist, social worker, mental health professional and/or speech pathologist.
The excessive loss of muscle associated with aging.
Sarcopenia

Generally, people start losing muscle at 45 years of age and tend to lose 1% per year. Muscle loss leads to reduced strength and ability to perform everyday tasks. Unsteadiness may result in falls.
Highest rates of completed suicide are among:
elderly age 80 and up
Leading causes of injury among older adults
• elder abuse or maltreatment
• falls
• driving related accidents
• sexual abuse
• suicide
• traumatic brain injury
Types of Elder Abuse
• Physical
• sexual
• financial (undue influence)
• abandonment
• isolation
• neglect
• self-neglect
Signs of Elder Abuse
o Sudden changes in financial matters (new gifts, bank accounts, loans)
o Sudden isolation by caregiver
o New sources of power & authority
o Sudden increase in debt
o Altering estate planning
o Loss of valuable personal property
o Parasitic child/grandchild
o Caregiver offer of lifetime care in exchange for $/inheritance
the act of making the terminally ill patient more comfortable; to relieve pain
Palliative Care
the program which delivers palliative care
Hospice
naturally occurring retirement communities
Aging in Place

• Older adults remain in their homes being around family and friends
• Elder cohousing communities or Green Houses—neighborhood based retirement programs.
Average Monthly Cost
for Assisted Living
Approx $3000
Psychological Affects of Stroke
• Depression
• Apathy
• Memory Loss
• Dysphasia/Aphasia
• Frustration
• Apraxia
• Dependency Issues
Focal Seizure Psychosis
Symptoms by Brain Region
• Frontal: depersonalization, olfactory hallucinations

• Parietal: perceptual distortions

• Temporal: hyper-religiosity, hyper-orality

• Occipital: visual distortions
Common Causes of Delirium
• ETOH withdrawal
• Infections, including UTI
• Pulmonary Diseases
• Cardiovascular Diseases
• Neuro. Diseases
• Medications
• Environmental: lead/insecticide
Medication Problems in Elderly
• Multiple healthcare providers
• OTC meds, friend's meds, herbal
• Non-compliance b/c side effects, cost, memory loss
• Guarded re: disclosing info about self-directed med changes
• Hoarding of medications
• Synergistic effects: 8-12 meds/day
Sundowning
In Alzheimer's patients, increase in delirious/psychotic Sx occurring late in the day due to sensory deprivation
Types of Dementia
• Vascular dementia
• Alzheimer's
• Parkinson's
• Creutzfeldt-Jacob
• Pick's disease
• Brain Infection (AIDS, meningitis, syphilis)
• Lewy-Body
• Fronto-temporal
Features of Vascular Dementia
• 20% of all dementias
• rapid onset, stepwise decline
• some recovery of function
• often with history of Hypertension
Features of Lewy-Body Dementia
• diffuse Lewy-Body disease
• hallucinations
• parkinsonian movements
Features of Fronto-temporal Dementia
• marked personality changes
• impaired executive function
Six Domains of Potentially Limited Civil Capacity
• Medical Consent
• Sexual Consent
• Financial
• Testamentary
• Driving
• Independent Living
A brief neurocognitive battery with alternate forms, measuring immediate and delayed memory, attention, language, and visuospatial skills.

Used primarily for detection and characterization of dementia in elderly and other disorders.

Can be used for repeat evaluations when an alternative form is desirable to control for practice effects.
Repeatable Battery for the Assessment of Neuropsychological Status (RBANS)
Test of mild cognitive impairment (MCI) and dementia, developed by Z. Nasreddine MD

Measures exec. function, visuoconstructional skills, language, memory, attention, conceptual thinking, orientation, calculations
Montreal Cognitive Assessment Test (MOCA)
Assessment Tools Used
with Elderly Persons
• RBANS
• MOCA
• Clock Drawing
A quick screening test for cognitive dysfunction secondary to mild cognitive impairment, dementia, delirium, or a range of neurological and psychiatric illnesses
Clock Drawing Test
Potential Errors in Clock Drawing
• Impaired spacing of numbers
• Perseveration
• Organizational problems
• Etc.
Services offered by APS
• Home visit to assess & follow patient/family
• Case Management
• Tx recommendations, coordination of services
• Interface with police/DA services
Legal Issues: Capacity
ability to make intelligent choices, understand the nature and effects of one's decisions

psychological evaluation is one method of determining capacity
term used to describe the strategic use of manipulation through fraud, misrepresentation, or physical intimidation for the purpose of taking advantage of an elderly person's vulnerability
Undue Influence

REPORT MANDATED!
Factors that set the stage for Undue Influence
• Isolation: manipulator controls all communication

• Dependency: perpetrator convinces pt. that they cannot survive alone

• Stockholm Syndrome: patient bonds to abuser b/c dependent
Gives directions for how an individual wants to be treated in the event of a catastrophic illness or accident
Advance Directive
Healthcare providers including paramedics are mandated to try and resuscitate you and use all measures to keep you alive without this document
Do Not Resuscitate (DNR)
Examples of IADLs
(Instrumental Acts of Daily Living)
transportation, banking, taking meds, shopping, cooking, housekeeping
Examples of ADLs
(Acts of Daily Living)
bathing, grooming, dressing, feeding, continence, ambulation/transfers
Time-frame for reporting elder abuse to APS
Phone call: ASAP
Written: 48 hrs.
True or False

A therapist should be sure abuse and/or neglect has occurred before making a report of suspected abuse/neglect.
FALSE
True or False

lf a therapist learns, in her/his professional capacity, of abuse which occurred in another state, the report of suspected abuse must be made to a law enforcement or social service agency in the state where the abuse occurred.
FALSE
True or False

If, after investigation, a report of suspected abuse/neglect is unfounded it means the investigating agency has not been able to determine whether or not abuse/neglect occurred.
FALSE
True or False

Unlawful intercourse/statutory rape is a crime and therapist must report it to police.
FALSE
True or False

Lack of information about and insensitivity to multiple cultures has, in some cases, led to unfair/discriminatory treatment of children and families regarding the reporting and investigation of suspected child abuse/neglect.
TRUE
True or False

Although therapists do not report domestic violence, it is likely a child living in such a situation experiences mental suffering/emotional abuse which may be reported as suspected abuse.
TRUE
True or False

lf a therapist learns about the abuse of a child in their extended family or neighborhood from communications outside of their professional capacity, the therapist must report but may remain anonymous.
FALSE
True or False

The principal of a private school may require all pre-licensed employees, including MFT trainees, to have his/her approval before making a report of suspected abuse/neglect.
FALSE
True or False

ln a government agency, a supervisor who is a licensed therapist or social worker may have final authority as to whether a report of suspected abuse/neglect may be made by an employee of that agency.
FALSE
True or False

lf an MFT intern makes his/her supervisor aware of suspected child abuse/neglect, the intern’s obligation under the law has been met.
FALSE
True or False

Children of color are disproportionately represented in the nation's foster care system.
FALSE
True or False

An MFT trainee may provide therapy to a minor who qualifies to consent to their own therapy.
FALSE
True or False

lf minors discuss their sexual activity with a therapist, the therapist is not required to determine whether the activity involves sexual behavior other than intercourse.
TRUE
True or False

A minor aged 10 or over may consent to their own treatment if the child is an alleged victim of abuse/neglect suicidal or a danger to others.
FALSE
True or False

According to CAMFT, mandated reporters have a right to know whether their report of suspected abuse was substantiated and what action(s) the investigating agency took/will take.
TRUE
True or False

Consensual sexual intercourse between a minor aged 15 and an adult 21 need not be reported.
FALSE
True or False

Under current law, oral copulation among minors must only be reported as suspected abuse if there is reason to believe it was non-consensual.
FALSE
True or False

A therapist must answer any question from a CFS worker about a report of suspected abuse made by the therapist.
FALSE
True or False

The BBS may take disciplinary action against a therapist for failure to report suspected abuse, depending on circumstances.
TRUE
True or False

As a therapist, you are required to report suspected abuse you learn about in your professional capacity, even if it does not involve your client as the victim or perpetrator.
TRUE
True or False

According to law, mandated reporters are to sign statements acknowledging their awareness of the child abuse law and agreeing to comply with the law prior to beginning employment or practicum.
TRUE
True or False

Children who have been abused may deny the abuse in order to protect the abuser.
TRUE
True or False

Generally speaking, drug abuse on the part of parents is reason, in and of itself to report suspected abuse.
FALSE
True or False

Spanking a child with a wooden spoon should be reported by a therapist as suspected abuse.
FALSE
True or False

A therapist who makes a report of suspected abuse, with their client as the suspected perpetrator, is not required to inform the client of the report.
TRUE
True or False

Most of the time, when a report of suspected abuse is investigated, the children are removed from the home.
FALSE
True or False

Most reports of abuse by teens are fabricated.
FALSE
True or False

Therapists are required by law to report suspected abuse in a childcare facility only if the facility is licensed by the state.
FALSE
True or False

If a minor aged 17 tells the therapist s/he was abused at age 5, no report is needed because 10 years have passed since the abuse.
FALSE
True or False

Written reports of suspected abuse may be faxed.
TRUE
True or False

An alleged victim of child abuse who is at least 12 and mature enough to participate in and benefit from therapy may consent to their own therapy.
TRUE
True or False

Because emotional abuse is difficult to prove, a therapist is discouraged from reporting suspected emotional child abuse.
FALSE
True or False

While child abuse occurs in all demographics of the population, poor people are more likely to be reported to authorities.
TRUE
True or False

Having extremely unrealistic expectations of a child’s capabilities is one of the common indicators a parent may be abusive.
TRUE
A phone report of suspected abuse and/or neglect must be made within what period of time?
As Soon As Possible
A written report of suspected child abuse/neglect must be sent within what period of time?
36 hours of the phone report
Childhood abuse/neglect disclosed by an adult client should be reported if...
If there is reason to believe perpetrator has abused someone currently a minor
The critical factor to be evaluated in deciding whether corporal punishment must be reported as suspected abuse is:
Whether the child sustained an injury (including bruises)
lf a therapist is unable to make a report of suspected abuse/neglect by phone because the agency refuses to accept the report, the therapist:
Should send in a written report and state the reasons no phone report was made.
If one sibling repeatedly assaults another, this:
May be reportable as suspected abuse depending on circumstances
When evaluating whether sexual activity between two minors of the same chronological age needs to be reported as suspected abuse, the therapist should primarily consider:
Power differential in the relationship
If an MFT intern is a member of an agency’s multidisciplinary team and another member of that team is chosen to make the report of suspected abuse/neglect, the intern...
Has met their reporting obligation
Reportable neglect includes:
Omissions and acts
The California Child Abuse and Neglect Reporting Act (CANRA) is found in:
California Penal Code
The most common barrier for therapists in being willing to report suspected abuse is:
Countertransference
If a minor tells the therapist they are afraid of being hurt by the suspected abuser once the report of suspected abuse is made, the therapist should:
Inform CFS/law enforcement of this when making the report
For families, a report of suspected abuse can be:
The beginning of getting help.
When working with clients from a different cultural background than the therapist, it is important to:
Be aware of how the therapist’s cultural limitations may effect decision-making
While therapists do not have an obligation to investigate child abuse, we do have an obligation to:
Be willing to form a reasonable suspicion if it is warranted
Unlawful corporal punishment
• cruel/inhuman
• leaves a mark
True or False

When reporting child abuse:
Legal custody
determines jurisdiction
TRUE
True or False

Drunk driving with a child in the car constitutes abuse/neglect
TRUE
CFS Terminology:

Unfounded
It was determined that no abuse occurred
CFS Terminology:

inconclusive
Cannot be determined whether or not abuse has occurred
CFS Terminology:

Substantiated
It was determined that abuse has occurred.
'... a continuing, deeply personal, individual effort that leads to growth, discovery, and the changes of attitude, values, goals, and perhaps roles.'
Recovery
Managing Symptoms
Meaningful Activity
Quality of Life
Self-Sufficiency & Independence
Lowest Dosage Necessary
Coloration
Rekindling Hope
Self-Motivated & Collaborative
Family Centered
Skills focus
Recovery
Definition of 'Recovery'
as Used in Research
• No enduring symptoms
• No odd behaviors
• No further medication
• Living in the community
• Working and relating well to others
Recovery Principles
• Recovery can occur with a mental health provider
• Support person and belief in recovery are crucial
• Focus on Consumer Choice
Potential Barriers
to Recovery
• Lack of hope
• Externalized stigma
• Internalized stigma
• Professional stigma—unconsc. neg. feelings of therapist
• Language used—“unmotivated”, “non-compliant”
A culturally sensitive, recovery-oriented approach to helping individuals (as defined by culture) live successfully in the community.
Psychosocial Rehabilitation (PSR)
Four W's
of Psychosocial Rehabilitation
• Who does it? (Anyone with the values)
• What they do? (Whatever it takes.)
• Where? (Anywhere.)
• Why? (Because it works.)
Supported as best practice by 1999 Surgeon General’s Report, SAMHSA, and the President’s New Freedom Commission Report on Mental Health.
Psychosocial Rehabilitation (PSR)
Goals of Psychosocial Rehabilitation
• Recovery/resilience
• Community integration
• Quality of life
Values of Psychosocial Rehabilitation
• Dignity & worth of every person
• respectful of indiv, cultural, ethnic diffs
• everyone has capacity to learn, have meaningful role in community
• right to self-determination;
• optimism in the recovery of individuals with psychiatric disabilities.
Guiding Principles
of Psychosocial Rehabilitation
• Individualization of all services
• Focus on health and wellness
• Focus on strengths
• Cultural sensitivity
• Maximum client/family involvement
• Preference for choice.
• Community participation
• Partnership with Family
• Vocational /educational focus
• Skills focus
• Environmental modifications, supports
• Outcome-oriented focus
• Involvement of peer support
• Accessible, coordinated services
Case Formulation
for Psychosocial Rehabilitation
• Brief history (include cultural ID)
• Strengths
• Risk Factors
• Predisposing Factors (trauma hx?)
• Precipitating factors (why now?)
• Perpetuating Factors (cultural factors, stigma, discrimination)
• Present condition/Presenting problem (cultural explanation; symptoms that support a diagnosis)
• 5 axis dx (establish med. necessity)
• Previous treatment and response
• Preferences of person served
• Resources
• Preliminary plan
Strengths Assessment
in Psychosocial Rehabilitation
EXPLORES THE FOLLOWING:
• qualities/personal characteristics
• talents and skills
• environmental strengths
• cultural traditions and values
• interests and aspirations

IN THESE AREAS:
• daily living
• financial
• vocational/educational
• social supports
• health
• leisure/recreation
• spirituality
• culture
Treatment Planning
in Psychosocial Rehabilitation
• document co-created by the person receiving the services and provider to outline the steps needed to achieve a particular goal/outcome.

• Comprised of client’s goal, objectives, proposed types of interventions, duration of interventions, and signatures.

• Demonstrates medical necessity and outlines how symptoms, barriers, and functional impairments to achieving goals will be reduced/eliminated
Goals in Psychosocial
Rehabilitation
• Express hopes/dreams of client; big; written in positive terms; inspirational; linked to discharge and transition criteria

• Should include cultural consideration and involve client’s strengths
Objectives in Psychosocial
Rehabilitation
• Significant or meaningful change individual can see; milestones

• Maximum of 2-3 objectives per goal; but personalized for each individual

• Comprised of Subject, Verb/action word, What, When it will be done, How it will be measured (e.g. “Client will demonstrate ability to use three coping techniques within one month as measured by therapist observation.”)

• SMART: Simple, Measurable, Attainable, Realistic, Time-framed
Interventions used
in Psychosocial Rehabilitation
• Action by staff, family peers, etc. that supports a specific objective.
• 5 Ws of interventions: who, what, when, where, and why
• Respect consumer choice and specific to the stage of change/recovery
Risk Factors
(definition)
Potential harms or immediate vulnerabilities for the health and safety of the individual, including physical health risks, suicidal ideation, etc.
Perpetuating Factors
(definition)
Factors or situations that are contributing to the continuation and/or worsening of the problem
Precipitating Factors
(definition)
Events or factors that led to the onset of the behaviors or problems
Predisposing Factors
(definition)
Historical or genetic factors that contribute to the current problem
Assumptions of
Narrative Therapy
a. Respectful, non-blaming approach which centers people as the experts in their own lives

b. Views problems as separate from people

c. Views people as having many untapped or unrecognized resources and competencies

d. Therapist stance is one of genuine curiosity

e. Use of “Narrative Metaphor”

f. Particular interest in culturally laden stories (e.g. woman as caretaker)
Narrative Therapy
--Externalizing the problem--
i. Shifts from adjectives that locate problem inside individual to nouns that are located outside of individual; separates the problem from the individual; often seen as personifying the problem.

ii.Once problem is externalized, the person can push back.

iii.Reduces guilt and blame, yet leaves room for accountability and collaboration in finding options. Also allows to understand the context of the problem, its influence (and the person’s influence on it), and the problem’s allies
Narrative Therapy
--Thick vs. Thin Narratives--
i. Thin descriptions allows little space for the complexities and contradictions of life. It allows little space for people to articulate their own particular meanings of their actions and the context within which they occurred.

ii.Thin descriptions are created by others, particularly those in power. Thin descriptions lead to thin conclusions, which are usually drawn from problem-saturated stories.

iii. Thick narratives are those that can be ‘richly described’. Alternate stories can be thickened through questions that draw greater attention (landscape of action, landscape of identity, and re-membering) to the details around the unique outcomes.
Basic Structure
of the Narrative Interview
• Eliciting the current (problem) story

• Naming/externalizing the problem

• Examining the influence of the problem on the person

• Examining the influence of the person on the problem

• Developing a preferred/alternative story about how to move forward
Narrative -- Unique Outcomes
(definition)
times in the life of the person when the problem has not been or has been the least influential; sparkling events; instances/ events that do not fit with problem story
Relative Influence Questioning
(Narrative)
sed to determine times when the problem had greater or less influence on a person’s life (usually done by ranking influence as a scaling number, fraction, percentage, or spatial scale represented by a mark on a line). Allows for the tracing of the history of the problem that opens space for the consideration of other stories about the problem, including non-problem-saturated conversations. Asks when the problem was not a problem.
Landscape of Action Questions
(Narrative)
thickens the story connected to unique outcomes (things the problem wouldn’t like) by linking to other people, places, actions, experiences
Landscape of Identity Questions
(Narrative)
i. Explores the meaning of the unique outcome in a way that lays the foundation for noticing more unique outcomes, and paves the way for productive re-storying

ii. Indicates what landscape of action questions reflect about their desires, intentions, preferences, beliefs, hopes, personal qualities, values, and commitments, and those of others in their social networks
In Narrative Theory,

the problem-laden story that is often built off of thin conclusions (impacted by messages given to individuals).

For clients seeking help, it is often the dominant story.
Tragic Narrative
In Narrative Theory,

the alternate story built off a client’s preferred story about themselves, thickened through rich descriptions. It can be built through finding unique outcomes and re-storying the alternate story.

It may be understood within the context of the externalized problems, including deconstructing the larger context of the problem.
Heroic Narrative
Central Dialectic of DBT
Balancing Acceptance
with Change
Core Assumptions of DBT
i. Escape/avoidance of affect is central to distress

ii.Acceptance of painful emotions actually decreases pain

iii. Therapy is both supportive & didactic
DBT Skills Modules
• Mindfulness
• Distress tolerance
• Interpersonal effectiveness
• Emotion regulation
Essential Components
of DBT Treatment
• Individual Tx
• Group Skills Training
• Consultation/Supervision
DBT was originally designed
for: _______
Borderline Presentatons
Stages of Treatment
in DBT
• Stabilize Client, Achieve Bx Control
• Achieve Non-Traumatic Emo. Exper.
• Achieve Ordinary Happiness
• Overcome Emptiness, Achieving Joy
Primary Emotions
(DBT)
a direct and immediate reaction to what happened
Secondary Emotions
(DBT)
judgments, reactions, and reflections upon the first feeling
DBT vs. Psychoanalytic Theory
We make compromises with unconscious behaviors, especially emotional trauma in childhood and defend against them.

Disagree with psychosexual stages, life-long deficits, different view of transference.

Tries to extinguish transference by being transparent; instead do a chain analysis and validate the transference.

Agrees with pleasure principle, people with painful behavior may persist because alternative is worse.

Agrees with unconscious compromise.
DBT vs. CBT
DBT is similar to traditional CBT in that they both look at the impact of thoughts, feelings and behaviors.

However, DBT is looking not just at changing behavior, but in balancing acceptance with change.

Additionally, DBT focuses more on emotions and behaviors rather than thoughts and behaviors.

Both use chain analysis and behavior modification.
Wise Mind
(DBT)
the intersection of the rational mind and the emotional mind
Radical Acceptance
(DBT)
To not being overly judgmental of a situation or overly critical of oneself. Acknowledge present situation without judging the events or criticizing oneself. Present situation exists because of a long chain of events that begun far in the past. Does not mean one condones or agrees with bad behavior in others.
Types of Mindfulness Skills
WHAT: observe, describe, participate

HOW: non-judgmentally, one-mindfully, effectively
Mindfulness
(DBT)
Mindfulness will help you experience more fully the present moment while focusing less on painful experiences from the past or frightening possibilities in the future.

Mindfulness will also give you tools to overcome habitual, negative judgments about yourself and others.
Types of Distress Tolerance Skills
(DBT)
• Crisis Survival Strategies: tolerating short-term pain and getting through problems without making them worse

• Guidelines for Accepting Reality: skills for when we can’t solve things in short or long term
Distress Tolerance
(DBT)
Distress tolerance will help you cope better with painful events by building up your new resiliency and giving you new ways to soften the effects of upsetting circumstances.
Emotion Regulation
(DBT)
Emotion regulation skills help you to recognize more clearly what you feel and then to observe each emotion without getting overwhelmed by it.

The goal is to modulate your feelings without behaving in reactive, destructive ways.
Interpersonal Effectiveness
(DBT)
Interpersonal effectiveness gives you new tools to express your beliefs and needs, set limits, and negotiate solutions to problems—all while protecting your relationships and treating others with respect.
Emotions
(DBT)
Electrical and chemical signals in your body that alert you to what is happening.

These signals often begin with your senses of sight, touch, hearing, smell, and taste.

Emotions help you to survive (fight or flight), remember people and situations, cope with situations in your daily life, communicate with others, avoid pain, seek pleasure.
Limbic System
(DBT)
specializes in observing and processing emotions so that you can respond to emotional situations. It can also tell your body what to do in response to an emotional situation.
In DBT, a Therapist Stance incorporating the use of humor to connect in the face of suicidality.

Analogous to wise, imperfect Zen Master, Bodhisattva.
Irreverence
Theory positing emotions as part of a unique sensory system
Dialectical Behavior Therapy
Intervention Strategies
for Culturally Alert Counseling
• Challenge Internalized Oppression
---emphasize cultural strengths
---liberation counseling

• Adapting Conventional Methods to Specific Cultures

• Narrative Approaches to Therapy
---shifting from problem-saturated story to alternative
• Developer of Narrative Theory
• Influenced by Systems Theory, Cultural Anthropology, Post-structuralism
• Opened Dulwhich Center in 1983
Michael White
Steve de Shazer
& Insoo Kim Berg
• Solution Focused Therapy
• Similar to Narrative, but apolitical, brief, pragmatic
• Collaborator, friend, colleague of Michael White
• Interesting work on eating DO's
Epston
Jill Freedman
& Gene Combs
Evanston Family Therapy Center in Illinois
Other Narrative Therapy Tools
• Documents
• Therapeutic Letters
• Rituals
• Celebrations
• Definitional Ceremonies
• Outsider-witness groups (reflecting teams)
SMART Objectives
(acronym)
Simple/Straightforward
Measurable
Attainable
Realistic
Time-framed
Three Criteria to establish
Medical Necessity
• Qualifying Diagnosis
• Related Functional Impairments
• Mental Health Services needed to reduce/eliminate impairments
Functional Impairment
(types)
• Occupational
• Social
• Disruption of primary relationship
Impairments in functioning
(definition)
ways in which symptoms of diagnosis interfere with individual's ability to do what they want
Intervention Criteria
Must address the impairment by:
• significantly reducing it
• preventing things from getting worse
True or False

Evidence of Client Benefit
is crucial for billing
TRUE

interventions must address the impairment to qualify for reimbursement
Characteristics of recovery-promoting relationships
• Purposeful
• Reciprocal
• Friendly
• Trusting
• Empowering
• Hope-inspiring
Stages of Change
(Prochaska & DiClemente)
Precontemplation
Contemplation
Preparation
Action
Maintenance
Termination
(Relapse)
Motivational Interviewing
General Principles in Practice
Express Empathy
Develop Discrepancy
Roll with Resistance
Support Self-Efficacy
Types of Reflective Responses
Motivational Interviewing
Simple Reflection
Amplified Reflection
Double-sided Reflection
Signs of Readiness for Change
Motivational Interviewing
Decreased Resistance
Decreased discussion of problem
Resolve
Change Talk
Questions about change
Envisioning
Experimenting
The phenomenon of 'desensitization' of brain cells to the effects of a drug is also known as:
Tolerance
The bulk of the MDA/MDS system is in the ______ region of the brain.
Limbic System
Vulnerability to relapse of individuals in recovery from late chemical dependency can be explained in part by:
• synaptic plasticity
• neurological power of triggers
• psychological power of triggers
True or False

Functional Analysis addresses deep-seated traits & personality types that contribute to use
FALSE

Functional Analysis:
• Focuses on current contextual costs & rewards of continued substance use

• Is clinically useful in that it suggests areas for intervention that may increase motivation to change
According to Miller & Rollnick's model of Motivational Interviewing, 'Eliciting Self-Efficacy' refers to:
Attempting to engage the client in optimistic, problem-solving statements about the potential for change
True or False

According to principles of integrated treatment, for clients who suffer from both substance abuse and mental health problems, it is important to identify and treat the mental health disorder first, as substance abuse issues are otherwise unlikely to improve
FALSE

Treatment for both disorders should be provided concurrently in a time-unlimited frame that offers multiple modalities and types of interventions by a team of professionals who share the same philosophical assumptions about behavior change.
Stage of Change:

in which clients often enter treatment under pressure of others, expressing surprise & resentment
Pre-Contemplation
Stage of Change:

involving ambivalence, swings between concern and justifying 'unconcern'
Contemplation
Stage of Change:

involving brief experience of serious concern, window of opportunity for movement into action
Determination/Preparation
Stage of Change:

involving anxiety, possible withdrawal symptoms (physical and emotional)
Action
Stage of Change:

involving feelings of accomplishment, relative stability, increased confidence, and possible feelings of loss
Maintenance
Stage of Change:

return from Maintenance to any of the previous four stages
Relapse
Most widely accepted model of Substance Abuse Etiology
Transactional (i.e., Integrated Treatment Model)
Traditional Models of SA Treatment
Sequential --> one d/o as primary
Parallel --> tx for both, but in diff. pgms
Principles of
Integrated Treatment
• Concurrence
• Comprehensiveness
• Long-term Perspective
• Assertiveness of Tx
• Harm Reduction Approach
• Motivational Approach
Predictors of
Behavioral Change
• Internal Perception of Need
• Sense of Self-Efficacy
• Stated Intention to Change
True or False

Grieving the 'loss' of an addiction can be essential to recovery
TRUE

The same brain pathways involved in addiction are also implicated in the reinforcing qualities of close relationships; thus, to lose a drug is to lose a friend, a lover.
Whereas addiction changes reward pathways in the striatal dopamine circuit of the brain, treatment involves ____ ?
Retraining the prefrontal cortex to self-regulate emotion and behavior via the amigdala
Basic Principles
of Motivational Interviewing
• Express Accurate Empathy
• Develop Discrepancy
• Avoid Argumentation
• Roll with Resistance
• Support Self-Efficacy
According to Miller and Rollnick's model of Motivational Interviewing, eliciting Self-Efficacy refers to:
Attempting to engage the client in optimistic, problem-solving statements about the potential for change
Appropriate MI interventions for:
Pre-contemplation Stage
• ask open-ended questions
• listen reflectively
• affirm
• summarize
• elicit change talk
Appropriate MI interventions for:
Contemplation Stage
• elaborating change talk
• reflecting change talk
• summarizing change talk
• affirming change talk
• clarifying ambivalence
• clarifying values
Appropriate MI interventions for:
Determination/Preparation Stage
Reflective Responses
• simple reflection
• amplified reflection
• double-sided reflection

Other Responses
• shifting focus
• reframing
• agreeing with a twist
• emphasizing personal choice
• coming alongside
Appropriate MI interventions for:
Action Stage
Initiating
• recapitulation
• key questions
• giving information/advice

Negotiating a Change Plan
• setting goals
• considering change options
• arriving at the plan
• eliciting commitment
• slurred speech
• lack of coordination
• unsteady gait
• nystagmus (involuntary eye mov't)
• impairment of attention or memory
• stupor or coma
Signs of
Alcohol Intoxication
• tachycardia dilation
• papillary dilation
• +/- blood pressure
• perspiration or chills
• nausea or vomiting
• evidence of weight loss
• psychomotor agitation or retardation
• muscular weakness,
• respiratory depression, chest pain
• cardiac arrhythmias
• confusion, seizures, dyskinesias
• dystonias or coma
Signs of
Amphetamine Intoxication
• restlessness
• nervousness
• excitement
• insomnia
• flushed face
• diuresis (+urination)
• gastrointestinal disturbance
• muscle twitching
• rambling flow of thought and speech
• tachycardia or cardiac arrhythmia
• periods of inexhaustibility
• psychomotor agitation
Signs of
Caffeine Intoxication
• conjunctival injection (red eye)
• increased appetite
• dry mouth
• tachycardia (+heart rate)
Signs of
Cannabis Intoxication
• tachycardia or bradycardia
• papillary dilatation
• +/- blood pressure
• perspiration or chills
• nausea or vomiting
• evidence of weight loss
• psychomotor agitation/retardation
• muscular weakness
• respiratory depression, chest pain
• cardiac arrhythmias
• confusion, seizures,
• dyskinesias, or coma
Signs of
Cocaine Intoxication
• automatic hyperactivity
• increased hand tremor
• insomnia
• nausea or vomiting
• transient AH/VH/TH or illusions
• psychomotor agitation
• anxiety
• grand mal seizures
Signs of
Alcohol Withdrawal
• dysphoric mood
• fatigue
• vivid, unpleasant dreams
• insomnia or hypersomia
• increased appetite
• psychomotor retardation/agitation
Signs of Amphetamine
AND/OR Cocaine Withdrawal
Signs of Cannabis Withdrawal
There is not Canabis Withdrawal in the DSM
Signs of Caffeine Withdrawal
There is not Caffeine Withdrawal in the DSM
DSM Criteria
for Substance Abuse
• within a 12-month period
• manifested by one or more Sx

Recurrent or Continued Use
• resulting in failure to fulfill obligations
• in physically hazardous situations
• substance-related legal problems
• despite having related social or interpersonal problems
DSM Criteria
for Substance Dependence
• at the same time in the same 12-month period
• manifested by three or more Sx:

• Tolerance
• Withdrawal
• Persistent desire or failure to control use
• time and energy to obtain, use, recover from substance
• social/occupational/recreational activities given up in favor of use
• continued use is ego-dystonic
Psychodynamic and
Interpersonal Groups
--Assumptions--
• Change occurs in the “Here-&-Now”
• Interpersonal Learning occurs at several levels
• Corrective emotional experience more important than insight
Psychodynamic and
Interpersonal Groups
--Intervention Strategies--
• create appropriate group culture allowing study of interpersonal Bx
• Feedback given with immediacy, focus on sender message, affective language
Self-Help Groups
--Assumptions--
• Voluntary collection of ppl gathering to share concerns, support/cope
• Generally w/o formal leadership
• Equality among peers
• Self-disclosure & listening elicit peer support and reduce social isolation
• ex., Alcoholics Anonymous
Self-Help Groups
--Intervention Strategies--
Facilitate cognitive restructuring by encouraging self-disclosure and peer support
Type of Group Emphasizing

• Relatively brief time-frame
• Focused on specific population/goals
• Imparting information
• High structure
Psychoeducational Groups
Psychoeducational Groups
--Intervention Strategies--
• sharing information
• low to moderate levels of process
• some emotional content
Brief Groups
--Assumptions--
• More structured
• More active leadership
• Often focused on specif. pop. or theme
• Settings include: Outpatient/Inpatient, Partial Hospitalization, Managed Care
Brief Groups
--Intervention Strategies--
• Maintain clear/specific focus
• High level of therapist activity
• Awareness of sessions remaining
• Encourage clients' work outside of therapy through 'homework'
Support Groups
--Assumptions--
• Emphasis on conscious material
• Support of existing healthy defenses
• Identifies available int/ext resources
• Facilitate ego functioning, capacity for growth, coping, mastery
Support Groups
--Intervention Strategies--
• Cognitive & Didactic elements
• Modeling
• Advice Giving
• Suggestions
• Bx Prescriptions
• Teaching
• Homework Assignments
Group as a Whole
(Bion, Foulkes, Lewin)
TENSIONS BETWEEN
• Individual vs. Collective needs
• Authoritarian vs. Democratic patterns
Functions of a Focus on
the 'Here & Now'
• Experiential: allowing 'in vivo'
affective involvement
• Illumination: forming new cognitive framework of present experiences
focus on 'process' or feelings about disclosure
Horizontal Disclosure
disclosures focused on content
Vertical Disclosure
The unstructured flow of affect, behaviors, and cognitions that are manifested both verbally and nonverbally.
Process
Bridging (Ormont)
Interventions aimed at strengthening emotional bonds and generative communication between group members
Types of Bridging
• Simple Similarity Bridge
• Consulting Bridge
• Reactive Bridge
Contracting (Ormont)
• Setting ground-rules for group
• 'Groupalogue' vs. mono/dialogue
• Managing Aggression
• Communication of Emotions
Immediacy (Ormont)
Group as 'treatment of immediate experience' (i.e., Here & Now)
Induction of Group Resistance
(Ormont)
utilizing countertransference to shed light on group processes
Interventions for
Resistances to Intimacy
(Ormont)
• Identify Defenses
• Dispel Irrational Fears
• Develop Mature Intimacy Patterns
collection of two or more individuals, meeting in face-to-face interactions interdependently, with an awareness that each belongs to the collective, and for the purpose of achieving mutually agreed upon goals
GROUP
Characteristics of a Group
• Comprised of parts
• Relationship between parts
• An organizing principle
Optimal Size: Psychodynamic or Interpersonal Groups
6-8 members
Optimal Size: Psychoeducational Groups
10-30 members
Optimal Size: Support Groups
8-12 members
Term describing the blend of client characteristics most conducive to the creation of an effective therapy group
Composition
TRUE or FALSE
A generally homogenous level of ego functioning or development will be most conducive to an effective therapy group
TRUE
TRUE or FALSE
Heterogeneity on the hostile/affiliative spectrum in terms of group members' interpersonal difficulties and/or character styles will be most conducive to an effective therapy group
TRUE
The idea that everyone in a group should have someone they identify with on some conscious aspect of their own self-concept on controlling/submissive spectrum
'Noah's Ark' Principle
Group Norms
(definition)
• Explicitly stated descriptions of what actually happens in a given group

OR

• Implicit notions of what other members think/feel about group expectations
Groups likely do display:
• Increased search for leadership
• More subgrouping
• Wider gap b/t talkers & quiet ppl
Groups larger than Optimum Size
Behavioral patterns resulting from interactions b/t individual group members' personalities and group processes, both within and in the service (or disservice) of the group
Group Roles
Basic Tasks of Group Therapist
• Providing a Group Contract
• Culture Building
• Be Unifying Force for Members
Components of Culture Building
• Establish Norms/Values/Goals
• Activate Here & Now
• Focus on Process vs. Content
• Translate complaints into Sx
• Educate/Coach/Model
• Tend to Process via Commentary
Three Levels of Process Commentary
in Group Culture Building
• Individual (Intrapsychic)
• Between Members (Interpersonal)
• Group-as-a-Whole (Systemic)
Examples of INTRAPSYCHIC Process Manifestations in Group
• body language
• voice intonations
• interaction patterns
• common defenses
Examples of INTERPERSONAL Process Manifestations in Group
• patterns of communication
• repetitive areas of conflict
• levels of intimacy in interaction
Examples of SYSTEMIC
Process Manifestations in Group
• energy level
• enthusiasm of the group
• amount of cohesiveness
• avoidance of important group issues
Components of Therapist
as Unifying Force
for Group Members
• Caring
• Emotional Stimulation
• Meaning-Attribution
• Therapist use of Self
Meaning-Attribution
intervention facilitating clients' ability to assign meaning to experiences
degree to which the group represents a sense of warmth, acceptance, support, and belongingness to members

both for each other individually and for a shared commitment to the group and its primary task
Cohesion
often seen as Group Therapy equivalent of the 'therapeutic alliance'
Group Cohesion
One might describe a group with this characteristic as feeling like 'a safe harbor'
Cohesive Group
Members who fear intimacy often fear this in Group Therapy
Cohesion
Types of Group Climate
• Engagement: positive work atmosphere
• Conflict: tension and anger in group
• Avoidance: behavior indicating avoidance of personal responsibility
Term used to describe patterns of relationships between and among group participants
Group Dynamics
Levels of Group Dynamics
• Individual (intrapsychic)
• Interpersonal (dyadic)
• Sub-group
• Group-as-a-Whole
• Administrative
• Institutional
• Socio-cultural
• Socio-political
Examples of Group
Dynamic Mechanisms
• Basic Assumption Dynamics (Bion)
• Resistance (Ormont)
• Acting Out
• Defense Mechanisms
• Scapegoating
• Transference / Countertransference
• Affect Contagion
• Role Lock (valence)
• Spokespersons
• Therapeutic Impasses
• Hall of mirrors (mirroring)
Clinically effective interventions by therapist or group members involving boundary thresholds
Boundary Crossing
Interactions beyond that which is clinically indicated, causing discomfort and/or harm involving boundary thresholds
Boundary Violation
Types of Boundaries
• External Group Boundary
• Leadership Boundary
• Therapist Boundary
• Personal Boundary of Indiv. Member
• Interpersonal Boundary
• Internal Boundaries
• Subgroup Boundary
Boundary Type involving:
recognition of group as unique social system
External Group Boundary
Boundary Type that may extend to larger org. or admin. structure
Leadership Boundary
Boundary Type involving:
separation between group members/therapist
Therapist Boundary
Boundary Type involving:

sense of difference between internal state and how others in group might experience them.

Self-disclosures cross this boundary, as does feedback from other members.
Personal Boundary
of Individual Member
Boundaries between group members, (i.e., behavioral norms)
Interpersonal Boundary
Boundary type involving:

hypothetical boundaries within the individual (i.e., Johari Window)

Known vs. Unknown
by Self vs. Other
Internal Boundaries
close sense of identification formed between particular group members

can support and/or interfere with group work.

Often extends beyond External Group Boundary as well.
Subgroup Boundary
Concepts from Systems Theory
• System
• Boundary
• Open Systems
• Closed Systems
• Permeable/Dynamic Systems
• Autonomy
• Hierarchy
• Isomorphy
• Homeostasis
• Specialization
Components of Bion's
Basic Assumptions Theory
• Group Operations
• Basic Assumptions
2 Levels of Group Operation
Conscious Level
Unconscious Level
Conscious Level
of Group Operation
(Bion)
• a.k.a. 'Work Group'
• Bx directed at accomplishing task
Unconscious Level
of Group Operation
(Bion)
• a.k.a. 'Basic Assumption Group'
• Bx aimed at fulfilling emo. needs, avoiding dreaded relationships in group
Define 'Basic Assumptions'
(Bion)
unconscious defensive assumptions re: why group is meeting
Identify the 3 Basic Assumptions
(Bion)
• Dependency
• Fight or Flight
• Pairing
Describe 'DEPENDENCY' as it relates
to Bion's Basic Assumptions
• group members try attaching to leader as omniscient healer figure
• connected w/ unconscious agenda to assuage primitive fears of abandonment, badness, & helplessness
Describe 'FIGHT or FLIGHT' as it relates
to Bion's Basic Assumptions
• group meets to fight/flee from enemy
• looks to leader to identify enemy and lead group into battle
• group preservation is valued over intellectualism and introspection
Describe 'PAIRING' as it relates
to Bion's Basic Assumptions
• group awaits sexual pairing of individual members
• to produce a 'messiah' child/idea/creation that will result in ultimate redemption
• group may become focused on a 'couple' and joke about their sexuality
Stages of Group Development
**Tuckman Model**
• Forming
• Norming
• Storming
• Performing
Stages of Group Development
**Mackenzie Model**
• Engagement
• Differentiation
• Individuation
• Intimacy
• Mutuality
• Termination
Phases of Group Development
**Rutan & Stone Model**
• Formative Phase
• Reactive Phase
• Mature Phase
• Termination Phase
Levels of Group Development
**Rutan & Alonso Model**
• Oral: trust, greed, safety
• Anal: competitive, paranoid
• Oedipal: intimacy, sexuality, jealousy
Stages of Group Development
**Common 5 Stage Model**
• Forming: dependency, anxiety
• Storming: power, conflict
• Norming: trust, safety, intimacy
• Performing: differentiation
• Adjourning: appreciation, loss
Stages of Group Development
**Ariadne P. Beck Model**
• Making a Contract
.....(task leader)
• Establishing Group Identity
.....(scapegoat leader)
• Exploring group identity & direction
• Establishing intimacy
.....(emotional leader)
• Exploring mutuality
• Achieving autonomy
• Achieving interdependence
.....(defiant leader)
• Independence
• Termination
Group Roles
(Ariadne P. Beck)
• Task Leader
• Emotional Leader
• Scapegoat Leader
• Defiant Leader
Task Leader
(Beck)
• usually the facilitator
• concerned with understanding & organizing experience of the group
• providing focus and clarifying issues
.........Emerges in Stage 1
Emotional Leader
(Beck)
• sociable role
• complements task leader
• often well-liked
• most change-ready
........Emerges in Stage 4
Scapegoat Leader
(Beck)
• divergent role
• impulsive
• emphasizes differences
........Emerges in Stage 2
Defiant Leader
(Beck)
• goes up against power of the group
• challenges sense of cohesiveness
• feels vulnerable being in group
• half in/half out of group
........Emerges in Stage 5
Leader tasks
--PRE-GROUP Phase--
of Group Development
• assessment of client benefits,
• matching with group
• active role
• naming anxiety
• help members to feel connected
• guiding communication
Leader tasks
--INITIAL Phase--
of Group Development
• Orientation, building group culture
• Clarify boundaries
• Set clear frame/expectations
• Engaging members in dynamics
• Sharing/Clarifying Goals
Leader tasks
--SURVIVING CONFLICT Phase--
of Group Development
• Focus on inter-member interactions
• Noting sub-groups
• Facilitating negative transferences
• Containing hostility
• Watch for erosion of norms
Leader tasks
--WORKING Phase--
of Group Development
• Focus on inter/intrapersonal
• Manage group discomfort with increased intimacy
Leader tasks
--TERMINATING Phase--
of Group Development
• assist in acknowledging loss, reality of the approaching end
• reviewing accomplishments & disappointments in group
Therapeutic Factors
(Yalom)
• Instillation of Hope
• Universality
• Imparting of Information
• Altruism
• Corrective Recapitulation of Primary Family Group
• Development of Socializing Techniques
• Imitative Behavior
• Interpersonal Learning
• Group as Social Microcosm
• Group Cohesiveness
• Catharsis
• Existential Factors
Therapeutic Factor:
• therapeutic effect of faith in Tx model
• begins Pre-Group with positive expectations, possibility for healing
Instillation of Hope
(Yalom)
Therapeutic Factor:
• Sense that 'I am not alone' or
• 'We are all in the same boat'
Universality
(Yalom)
Therapeutic Factor:
• process of learning that others have thoughts/feelings similar to one's own
• challenge to internalized sense of uniqueness re: social isolation
• Assumption that 'There is no human deed or thought that lies fully outside the experience of other people.'
Universality (Yalom)
Therapeutic Factor:
• Didactic Instruction
• Direct Advice
Imparting of Information (Yalom)
Mode of Imparting Information (Yalom)
• Psychoed. concepts
• alter sabotaging thought patterns
• structure group
• initial binding force in group
• assuages some natural anxiety
Didactic Instruction (Yalom)
Mode of Imparting Information (Yalom)
• most often between members
• high frequency as predictor of group development
• poss. resistance to intimate engagement
• rarely benefits client aside from conveying mutual interest, caring
Direct Advice (Yalom)
TRUE or FALSE
Regarding Advice in Group Therapy
offering Direct Suggestion is MORE effective than a Series of Alternatives
FALSE

Offering a series of alternative suggestions is most effective
Therapeutic Factor:
• intrinsic benefit to act of giving
• challenging deep sense of 'nothing to contribute'
• finding can be important to others rather than a burden
• encourages role versatility
Altruism (Yalom)
Therapeutic Factor:
• transference reactions rooted in early relationships
• Group as venue for early conflicts to be resolved
• Explore/Challenge Fixed Roles
Corrective recapitulation
of the primary family group
(Yalom)
Therapeutic Factor:
• deliberate alterations of social behavior
• permits clients to understand discrepancy b/t intent vs. impact
• accomplished through open, accurate feedback re: maladaptive social Bx
Development of Socializing Techniques (Yalom)
Therapeutic Factor:
• clients may follow Bx of other members and/or therapist
• learning through observation of others tackling problems
• Vicarious/Spectator Therapy
Imitative Behavior (Yalom)
process by which group members benefit by observing therapy of another member with a similar problem constellation
Vicarious or Spectator Therapy
(Yalom)
Therapeutic Factor:
• Importance of Interpers. Relationships
• Corrective Emotional Experience
Interpersonal Learning (Yalom)
• re: fundamental power of human need for intense, persistent relationships
• Parataxic/Interpersonal Distortions
• Consensual Validation
Importance of Interpersonal
Relationships (Yalom)
Parataxic/Interpersonal
Distortions (Yalom)
• individuals' proclivity to distort their perceptions of others, on the basis of a personification existing mainly in fantasy

• different origins than concept of transference, but operationally very similar
Consensual Validation (Yalom)
comparison of one's interpersonal evaluations with those of others
primary means of altering parataxic distortions
Consensual Validation (Yalom)
• telltale sign of a Here & Now Corrective Emotional Experience
• 'turning point' for group member, single most therapeutic event for indiv.
• usually involves another group member, not the therapist
Critical Incident (Yalom)
Common Types
of Critical Incidents
(Yalom)
• Conflict
• Strong Positive Affect
• Self-Disclosure
Critical Incident involving:
• often sudden expression of strong emotion toward another member
• communication is maintained and client experiences 'enhanced ability to explore more deeply his or her interpersonal relationships'
Conflict
Critical Incident involving:
• failure to confirm fear of catastrophe, derision, rejection, engulfment
• client discovered previously unknown part of the self
Strong Positive Affect
Critical Incident involving:
• plunging into greater involvement with group
Self-Disclosure
Components of a Corrective
Emotional Experience (Yalom)
• risk strong expression of emotion
• sufficient safety in group
• open to Consensual Validation
• Recognizing maladaptive Bx
• Ultimate facilitation of ability to communicate deeply, honestly
Positive Attending Skills
i. Eye contact
ii. Body language
iii. Vocal qualities
iv. Verbal tracking
Negative Attending Behaviors
• excessive head nods,
• overusing “uh huh,”
• too much/infrequent eye contact
• repeating the client’s last word
• excessive mirroring of body language
• turning 45 degrees away from client
• leaning back from the waist up,
• crossing legs away from client,
• folding arms across chest
Content
consists of the explicit words spoken
Process
• what is communicated beyond the explicit words spoken
• conveyed paraverbally/behaviorally
• explores the how/why of the utterance
Paraverbal Communication
• nuance
• inflection
• pitch
• tone
Open Questions
• cannot be answered w/simple yes/no
• designed to facilitate conversation
• start with 'How' and 'What'
• 'Why' can elicit defensive explanations
Closed Questions
• can be answered with simple yes, no, or very specific info
• generally restrict client verbalization
• typically begin with Who, Where, When
Suicide Assessment
--Risk Factors--
• Depression
• Age
• Sex
• Race/Ethnicity
• Religion
• Marital Status
• Employment Status
• Socioeconomic Status
• Physical Health
• Social & Personal Factors
• Substance Abuse
• Mental Disorders, Psych. Tx
• Sexual Orientation
• Trauma/Abuse History
Age Range at which Suicide
becomes most prevalent
70+ years
Age Range at which significant
increase in Suicide Rate occurs
20-24 years
TRUE or FALSE
Approximately 3x more women attempt suicide than men
TRUE
TRUE or FALSE
Men complete suicide 4x more frequently than women
True
Most common means of suicide attempts among men
About 73% of men choose firearms compared to 31% of women
TRUE or FALSE
higher degree of religious affiliation is associated with higher risk of suicide
FALSE
Mental Disorders
w/highest suicide risk
• depression
• Bipolar DO
• Schizophrenia
Components of Suicide Assessment
• Assessment of depression
• Presence of suicidal thoughts
• Exploration of suicidal plans
• Assessment of client self-control
• Determine presence of intent
Suicide Assessment:
Crisis Intervention Strategies
• empathic listening
• establish rapport
• identify alternatives
• separate psychic pain from the Self
• establish Bx contracts
• Become directive and responsible
Suicide Assessment
**Levels of De-escalation**
• Anecdotal evidence re: safety
• Contracting/Planning (schedule follow-up visit, contact supports)
• Voluntary Hospitalization
• Call law enforcement re: 5150
Five Arenas of Suffering
• Internal
• Interpersonal
• Work/School
• Play
• Spirit
Crisis Intervention: Suicide
--Things to Document--
• Risk Assessment
• Record of Decision-Making Process
• Changes in Treatment
• Optimal zone between hyperarousal and hypoarousal
• shrinks in response to trauma
Window of Tolerance
Focus in BEGINNING Stage of Tx
• Initial Intake
• Informed Consent
• Mental Status Exam
• Presenting Problem
• Psychosocial Info
• Diagnosis & Differentials
• Form Clinical Picture
Focus in MIDDLE Stage of Tx
• Collaborative Tx Plan
• Chosen Tx Modality
• Therapeutic work
Focus in END stage of Tx
• Assess for goal completion
• Prepare for termination
Four Effects of Empathy
• Enhance Rapport
• Increase safety in Tx relationship
• Enhance working alliance
• Related to positive Tx outcomes
Components of
Mental Status Exam
• Appearance
• Manner/Approach
• Psychomotor Activity/Bx
• Mood/Affect
• Level of Orientation
• Speech
• Thought Process
• Thought Content
• Perceptions (AH, VH, SH?)
• Cognition (memory, intelligence)
• Level of Insight
• Judgment
In MSE, the degree of organization, logic, clarity, differentiation, and control demonstrated in one's thinking.
Thought Process
In MSE, apparent level of reality testing, relevance, appropriateness of one's thoughts.
Thought Content
Mental Status Exam
--Levels of Orientation--
• Person
• Place
• Time
• Situation
Components of Clinical Assessment Report
• Identifying Data
• Presenting Problems
• Mental Status Exam
• Psychosocial Hx
• Diagnosis
• Clinical Impressions
• Collaborative Tx Goals
the prevailing emotional tone observed by an interviewer
AFFECT
the prevailing emotional tone
reported by a client
MOOD
SOAP Notes Acronym
• Subjective
• Objective
• Assessment
• Plan
4 Forces in Psychotherapy
• Biological
• Psychological
• Social
• Spiritual
Protective Factors for Suicide
• Children in the home
• Sense of responsibility to family
• Pregnancy
• Religiosity
• Life Satisfaction
• Reality Testing Ability
• Positive Coping Skills
• Positive Problem-Solving Skills
• Positive Social Support
• Positive Therapeutic Relationship
Psychodynamic/Psychoanalytic (Freud)
--Philosophy--
• people motivated by primitive drives, psychic energy, early experience
• Bx determined by irrational forces
• pathology rooted in repressed early childhood conflicts
Psychodynamic/Psychoanalytic (Freud)
--Goals--
• Bring unconscious to consciousness
• reconstruct basic personality
• re-live earlier experiences; work through repressed conflicts
• Achieve intellectual and emotional awareness
• assimilation of new material by the ego
term describing the concept that all aspects of a person's psychological makeup arise from specific causes or forces, as previous experiences or instinctual drives, which may be conscious or unconscious.
Psychic Determinism
(Freud)
Tri-partite structure of personality (Freud)
• Id (what I wanna do)
• Superego (what I oughta do)
• Ego (what I decide to do)
Repression (Freud)
serves to remove painful thoughts, memories, or feelings from conscious awareness by excluding painful experiences or unacceptable impulses.
Reaction formation (Freud)
A way of avoiding an unacceptable impulse is to act in the opposite extreme. By acting in a way that is opposite to disturbing desires, individuals do not have to deal with the resulting anxiety.
Projection (Freud)
Attributing one’s own unacceptable feelings or thoughts to others is the basis of projection.
Displacement (Freud)
When anxious, individuals can express their feelings not to an object or person who may be dangerous but to those who may be safe. ('Kick the dog')
Sublimation (Freud)
Somewhat similar to displacement, sublimation is the modification of a drive (usually sexual or aggressive) into acceptable social behavior.
Rationalization (Freud)
To explain away a poor performance, a failure, or a loss, people may make excuses to lessen their anxiety and soften the disappointment.
Regression (Freud)
To revert to a previous stage of development is to regress. Faced with stress, individuals may use previously appropriate but now immature behaviors.
Identification (Freud)
By taking on the characteristics of others, people can reduce their anxiety as well as other negative feelings.
Intellectualization (Freud)
emotional issues are not dealt with directly but rather are handled indirectly through abstract thought.
• therapeutic listening/responding
• dream interpretation
• free association
• analysis of resistance
• insight/assimilation of new material
• therapeutic alliance
Clinical Applications of Psychoanalytic/Psychodynamic Theory
Psychoanalytic Neo-Freudians
Alfred Adler, Carl Jung, Eric Erikson, Melanie Klein, Anna Freud, Wilfred Bion
Theory Stating: Humans motivated by social interest, striving toward collective goals & dealing with life tasks.
Adlerian Psychotherapy
--Philosophy--
Adlerian Psychotherapy
--Goals--
• Challenge client's basic premises & life goals
• Offer encouragement
• Develop a sense of belonging
Theory Emphasizing:
• Unity of personality
• Finding meaningful goals
• Struggle between superiority/inferiority
• Understanding the family constellation
• Importance of birth order
Adlerian Psychotherapy
--Key Concepts--
Adlerian Psychotherapy
--Clinical Application--
• Provide encouragement
• Acknowledge the client’s experience
• Client change cognitive perspective, Bx
• Gather life-history data
• Questionnaires/Homework
• Acting as if
• The Question: 'What would be different if you were well?”
theory that human being is by nature religious, psychology of this can be explored
Jungian Therapy
--Philosophy--
Jungian Therapy
--Goals--
• individuation via integration of conscious and unconscious
• one must individuate to become whole
Archetypes (Jung)
images of universal experiences contained in the collective unconscious

represent the possibility of types of perceptions; they take a person’s reactions and put them into a pattern.

pathways from the collective unconscious to the conscious, which may lead to an action
Persona (Jung)
means “mask” in Latin, is the way individuals present themselves in public; the roles they play
Anima/animus (Jung)
qualities of the other sex, such as feelings, attitudes, and values. For men, the anima represents the feminine part of the male psyche, such as feelings and emotionality; animus is the masculine part of the female psyche, representing characteristics such as logic and rationality.
Shadow (Jung)
potentially the most dangerous and powerful of the archetypes, representing the part of our personalities that is most different from our conscious awareness of ourselves.
Self (Jung)
energy that provides organization and integration of the personality.
Synchronicity (Jung)
coincidences that have no causal connection; e.g. dreaming of seeing two snakes and then seeing snakes the next day.
Interventions for this theory include:
• Examining Archetypal material in dreams
• Active Imagination
• Creative Techniques
• Projective Techniques
• Measures of Personality (Myers-Briggs)
Jungian Therapy
--Clinical Applications--
Erik Erikson: 8 Psychosocial Developmental Stages
Infancy
Early Childhood
Preschool Age
School Age
Adolescence
Young Adulthood
Middle Age
Later Life
Infancy (Erikson)
Trust vs. Mistrust
Early Childhood (Erikson)
Autonomy vs. shame/doubt
Preschool Age (Erikson)
Initiative vs. Guilt
School Age (Erikson)
Industry vs. Inferiority
Adolescence (Erikson)
Identity vs. Role Confusion
Young Adulthood (Erikson)
Intimacy vs. Isolation
Middle Age (Erikson)
Generativity vs. Stagnation
Later Life (Erikson)
Integrity vs. Despair
Id (Freud)
• inherited, primal, infantile, survival instincts
• home of pleasure principle, libido, cathexis, primary process
• impulsive, self-indulgent, destructive
Cathect / Cathexis (Freud)
investment of energy; the id cathects in objects that will satisfy its needs
Primary Process (Freud)
action of id that satisfies a need, reducing drive tension by producing mental image of a need-satisfying object
Ego (Freud)
• delaying id gratification in support of Reality Principle, maintaining external environment
• planning, logical thinking, for satisfying needs later on
• anticathexis
Anticathexis (Freud)
• control/restraint over id,
• imposing limits on investment of energy in need-satisfying object
Superego (Freud)
• learned/perceived social standards, values, ego ideals, seeking approval
• irrational, idealistic, strict, unrealistic, high standards
Types of Superego Anxiety (Freud)
• realistic
• neurotic
• moral
Realistic Anxiety (Freud)
fear of external consequences
(Freud)
Neurotic Anxiety (Freud)
fear of reprimand, loss of control
(Freud)
Moral Anxiety (Freud)
fear of superego failure, rule violation, badness
Psychosexual Stages of Development (Freud)
• Oral: 0-18 months
• Anal: 18 mo. – 3 years
• Phallic: 3 yr. – 6 yr.
• Latency: 6 yr. – 12 yr.
• Genital: 12 yr. – ∞
Oral Stage (Freud)
• 0-18 months
• eating, gaining knowledge
• fixation on breast/parent/etc
Anal Stage (Freud)
• 18 mo. – 3 years
• body self-esteem
• retentive vs. expulsive
• control over self & others
Phallic Stage (Freud)
• 3 yr. – 6 yr.
• penis envy, castration anxiety
• Oedipus Complex sublimated into future sexual relations
Latency Stage (Freud)
• 6 yr. – 12 yr.
• post-oedipal
• sex instinct appears dormant
• libido festering unconsciously
Genital Stage (Freud)
• 12 yr. – ∞
• focus of sex drive is on others as sex objects
Erikson

psychosocial stage involving: safe attachment, dependency, survival needs, drives
Trust vs. Mistrust
--Infancy--
(Erikson)
Autonomy vs. Shame/Doubt
--Early Childhood--
(Erikson)
psychosocial stage involving: bladder/bowel control, self/body awareness, independence
psychosocial stage involving: acquisition of basic skills, cognitive & sociosexual roles
(Erikson)
Industry vs. Inferiority
--School Age--
(Erikson)
psychosocial stage involving: resolution of oedipus crisis, investment of energy in competence/confidence
(Erikson)
Initiative vs. Guilt
--Preschool--
(Erikson)
psychosocial stage involving: self-esteem, goal setting, interpersonal confidence
(Erikson)
Identity vs. Role Confusion
--Adolescence--
(Erikson)
psychosocial stage involving: cooperative social/work relationships, vulnerability & closeness with others
(Erikson)
Intimacy vs. Isolation
--Young Adulthood--
(Erikson)
Generativity vs. Stagnation
--Middle Age--
(Erikson)
psychosocial stage involving: movement beyond intimacy, toward productivity, worldliness, accomplishment
Integrity vs. Despair
--Later Life--
(Erikson)
psychosocial stage involving: gerotranscendence, shift from materialistic & rational vision to peace of mind & spirituality
• neo-freudian theory focusing on unconscious childhood views of internalized love objects
Object Relations
mother who adequately allows infant to move from omnipotence to awareness of others
Good-Enough Mother (Winnicott)
True Self (Winnicott)
• spontaneous
• realness
• distinct/individuated self/other
False Self (Winnicott)
• compliant
• slave to expectation
• develop true self, extinguish false self
• help client understand “false self”
• help client to feel they are center of attention in therapy
• controlled regression in Tx to repair defective early childhood parenting
Object Relations Therapy (Winnicott)
Splitting (Kernberg)
• normal defensive process of keeping incompatible feelings separate from each other
• more apparent in Borderline features
Controlled Regression
(Object Relations)
• process in which patient returns to stage of early dependence. Therapist must sense what 'being the client' is like and be the subjective object of client's love or hate.
• Therapist must deal with irrationality and strong feelings of patient without getting angry or upset at patient.
Self-Psychology (Kohut)
• emphasis on narcissism, not as pathological condition, but as motivating organizer of development in which love for self precedes love for others.
Developer of Self-Psychology
Heinz Kohut
Developed Object Relations framework for working with Borderline presentations
Otto Kernberg
Names associated with classic Object Relations theory
Winnicott, Kernberg, Mahler, Klein
Narcissism
(Kohut)
motivating organizer of development in which love for self precedes love for others.
narcissistic, all loving, all lovable, self-concept in Self-Psychology
Grandiose Self
(Kohut)
• core/center of individual
• initiative, motivation
• provides central purpose to personality
• responsible for patterns of skills/goals
• comprised of: object, subject, self-object
Self
(Kohut)
in Self-Psychology: internalized image of idealized parent
Object
(Kohut)
Self-object
(Kohut)
in Self-Psychology:
• patterns of unconsc. thoughts, images, ideas of other
• internalized representation of oneself
Subject
(Kohut)
in Self-Psychology: internalized Grandiose Self of the child
in Self-Psychology:
• develops through series of small empathic failures
• negotiating 'bipolar self' via reality-testing
Sense of Self
(Kohut)
Bipolar Self
(Kohut)
in Self-Psychology:
• choice between parent expectations (idealized object) and internal desire (grandiose self)
• negotiation of this facilitates strengthening Sense of Self
Narcissistic Outbursts
(Kohut)
in Self-Psychology:
• due to removal of mirroring selfobject, Grandiose self incorporates idealized object (Parent) to perform function of mirroring (in service of narcissism)
theory that disorders occur b/c
• lack of stable narcissistic images
• lack of stable idealized object (parent)
• damaged narcissism (lost self-esteem)
Self-Psychology
Theory of Pathology
(Kohut)
In Self-Psycholgoy: When the parent reflects or mirrors the child’s view of him/herself.
Mirroring
(Kohut)
Twinship Transference
(Kohut)
in Self-Psychology: analysand's need to rely on the analyst as a narcissistic function possessing characteristics like herself.
Founders of Existential Thought
Kierkegaard, Nietzsche, Heidegger, Jean Paul Sartre, Martin Buber
Founders of Existential Psychology
Viktor Frankl, Rollo May, James Bugental, Irv Yalom
Types of Dream Content (Freud)
• Manifest Content: as experienced by dreamer
• Latent Content: symbolic/unconscious motives within dream
Types of Assessment in Psychoanalytic/Psychodynamic
• Rorschach
• Blacky Test
• Working Alliance Inventory
Negative Transference in Psychoanalytic/Psychodynamic
• Transference Psychosis: intense and primitive feelings in delusional periods of deep regression
• Projective Identification
Style of Life (Adler)
methods of adaptation to obstacles, creating solutions, achieving goals
Stages of 'Social Interest' development (Adler)
• Aptitude: for cooperation/social living
• Ability:for expressing aptitude
• Secondary Dynamic Characteristics: attitudes & interests as means for expressing Social Interest
Factors threatening development of self-confidence & social interest (Adler)
• pampering
• physical disabilities
• neglect
Inferiority Complex (Adler)
presentation of one to oneself & others that one is not strong enough to usefully solve problems
Superiority Complex (Adler)
means of inflating one's self-importance in order to overcome feelings of inferiority
Reorientation Techniques (Adler)
• Immediacy
• Encouragement
• Acting As If
• Catching Oneself
• 'The Question'
• Spitting in the Client's Soup
• Avoiding the Tarbaby
• Push-Button Technique
• Paradoxical Intention
• Task Setting & Commitment
• Homework
Spitting in the Client's Soup (Adler)
therapist making comments that cause unwanted behaviors to seem unattractive to client
Avoiding the Tarbaby (Adler)
exercising care around confirming client's negative self-perceptions
Push-button technique (Adler)
imagine positive memory to overshadow hurt/anger/failure/etc
Paradoxical Intention (Adler)
prescribing intensification of symptoms to expose problem behaviors to client with hope that bx will be changed
Recognition Reflex
'unconscious, uncontrollable grin signaling a sudden, not quite conscious awareness that an interpretation is correct'
Stages of Change
Brief Therapy
• BEHAVIORAL description of prob
• UNDERLYING rules of interaction
• REORIENTATION to possibility that rules can change
• PRESCRIBING new behavioral rituals
study of objects as they are experienced in the consciousness of individuals
Phenomenology (Husserl)
study of objects as they are experienced in the consciousness of individuals
Phenomenology (Husserl)
Heidegger's word for 'personhood existing in reality'
Dasein (Heidegger)
Daseinanalysis (Boss)
degree to which ppl relate with openness & clarity in context of time (mood dependent)
• Umwelt
• Mitwelt
• Eigenwelt
• Überwelt
Levels of 'Dasein'
(Heidegger)
Level of Dasein:
• biological world
• drives
• beyond control
• 'thrown world'
Umwelt (Heidegger)
Level of Dasein:
• human relationships
• mutual awareness of 'other'
Mitwelt (Heidegger)
Level of Dasein:
• relationship with self
• self-awareness viewing world
Eigenwelt (Heidegger)
Level of Dasein:
• relationship with spiritual
• ideal world
• belief system
• values
Überwelt (Heidegger)
Types of Anxiety
(Existential Therapy)
• Normal: situation appropriate, not repressed
• Existential: regret, guilt for self-betrayal
• Neurotic: out of proportion, destructive, evasive
Dasein
personhood in reality
umwelt
bio. world, drives/instincts
mitwelt
human relationships
'middle world'
eigenwelt
relationship with self
'own world'
überwelt
ideal world
relationship with spiritual
Anxiety for Existentialists
Normal
Existential
Neurotic
Existentialist Concepts
Living/Dying
Freedom
Responsibility
Will/Choice
Isolation
Loving
Meaning/Meaninglessness
Types of Isolation
(Existentialist)
Interpersonal
Intrapersonal
Existential
Interpersonal Isolation
geographical, psychological, social distance from others
Intrapersonal Isolation
separated parts of self using defense mechanisms to hide own wishes
Existential Isolation
idea that we are all uniquely separate in our experience of the world
Stages in Development of Existential Awareness (May)
• Innocence/Openness of Infant
• 2-3 yrs: Reaction to external world
• Consciousness of self as indiv.
• Transcendant Consciousness: more objective view of self & experience
Objective/Projective Assessments in Existential Therapy
rorschach
TAT
PIL
Experiencing Scale
Templer's Death Anxiety Scale
Silver Lining Questionnaire
Therapeutic Love
(Existential Psych)
loving friendship, nonreciprocal, intimacy, openness, trust, sharing, caring, authentic
Iatrogenic Effects
negative effects caused by treatment
Existential Therapy
--Goals--
develop authenticity re: central genuineness & awareness of being
Existential Therapy
--Clinical Application--
• listen for themes of isolation, meaninglessness, responsibility, morality
• assess for ability to face life honestly
• projective/objective instruments
• help client to clarify values
Person/Client Centered (Rogers)
--Philosophy--
human being is positive at the core, able to self-actualize, care for self, etc
Person/Client Centered (Rogers)
--Goals--
• become self-directed, self-actualized
• increase positive self-regard
• empower client to make choices increasing their own capacities
Person/Client Centered (Rogers)
--Key Terms--
• Empathic Understanding
• Congruence
• Unconditional Positive Regard
Organismic Sensing (Rogers)
trusting one's own reactions to the environment
Positive Regard (Rogers)
• need increases with age
• experience affects self-regard
Conditions of Worth (Rogers)
• process of evaluating one's own experience based on beliefs/values of others
• may limit development of individual
Conditional Regard leads to...
(Rogers)
leads to misdirected, disorganized love-seeking Bx, inauthentic self, anxiety due to difficulty conforming to perceived (distorted) expectations
Congruence (Rogers)
• agreement between individual's experience and view of self
• matching of inner experience with external Bx expression
Person/Client Centered (Rogers)
--Clinical Applications--
• Active listening
• reflection of feeling
• clarification
• relationship b/t therapist & client
• focus on present moment
• focus on what is right with client
Necessary & Sufficient Conditions for Change (Rogers)
• Psychological Contact: engaging, connecting, impacting
• Incongruence: b/t self-perception & experience, brought into awareness
• Congruence/Genuineness: w/o facade from therapist
• Unconditional Positive Regard (UPR)
• Empathy
• Perception (by patient) of UPR
Aspects of Client Experience
(Rogers)
• Experiencing Responsibility
• Experiencing the Therapist
• Experiencing Process of Exploration
• Experiencing the Self
• Experiencing Change
Types of Perceived Empathy
(Rogers)
• Cognitive: experience/motivation understood
• Affective: therapist involved in client's feeling-state
• Sharing: therapist shares relevant opinions
• Nurturing: therapist attentive, providing security & support
Gestalt Therapy (Perls)
--Philosophy--
It is more important to experience the problem than to explain it.
Gestalt Therapy (Perls)
--Goals--
• Assist clients in gaining awareness
• Help clients expand capacity to make choices
• Integration is objective, not analysis
Gestalt Therapy (Perls)
--Key Concepts--
• Energy, blocks to energy
• Figure and ground
• Contact
• Disturbances of Contact
• Unfinished business
• Awareness
Gestalt Therapy (Perls)
--Techniques--
• fully functioning I-thou relationship
• creative experiments/exercises
(i.e., empty chair, enactments)
Thorndike's Law of Effect
consequences that follow behavior will facilitate learning process; behavior is altered by systematically changing consequences
Aspects of Observational Learning and Personality Formation (Bandura)
• Attentional Processes
• Retention Processes
• Motor Reproduction Processes
• Motivational Processes
Individual perception of ability to deal with a variety of situations
Self-Efficacy (Bandura)
Sources of Self-Efficacy (Bandura)
• Performance Accomplishments
• Vicarious Experiences
• Verbal Permission
Goals of Behavior Therapy
• Early in treatment: change specific target behaviors
• 'Functional Analysis' to set further goals
Assessment in Behavior Therapy
• Interviews: specific Bx info (i.e., antecedents/consequences/etc)
• Reports & Ratings: self-report inventories, ratings by others
• Behavioral Observations
• Physiological Measurements
Naturalistic Observations
(Behavior Tx)
observer is seen by subject
Simulated Observations
(Behavior Tx)
observer is NOT seen by subject
(i.e., one-way mirror, microphone, etc)
Physiological Measurements used in Behavioral Assessments
• blood pressure
• heart rate
• respiration
• skin conductivity
Systematic Desensitization
(Behavior Tx)
'relaxation paired with thoughts of events that had previously evoked anxiety'
Goals of Systematic Desensitization
• Learn & reinforce relaxation techniques
• Identify 'Anxiety Hierarchies'
• Desensitization
Desensitization
(Behavior Tx)
• learned ability to confront anxiety with relaxation
• self-reinforcing through Performance Accomplishment
• can be generalized
Imaginal Flooding Therapy
--Techniques--
(Behavior Tx)
• In Vivo
• Virtual Reality
• Modeling Techniques
• Self-Instruction
• Stress Inoculation Training
Modeling Techniques
(Imaginal Flooding Tx)
• Live Modeling
• Symbolic Modeling
• Role Play
• Participant Modeling
• Covert Modeling
Cognitive Behavioral Tx
--Philosophy--
• Psych. distress is combo of bio/env/social factors
• These factors interact, leading to cognitive distortions
• Distortions cause maladaptive beliefs and behaviors
Cognitive Behavioral Tx
--Goals--
• Determined by client
• modify and change cognition by removing distortions
• improve regulation of affect
• alter behavioral patterns
Piaget's Stages of Cognitive Development
• Sensorimotor (birth - 2)
• Preoperations (2-7)
• Concrete Operations (7-11)
• Formal Operations (11+)
spontaneous cognitions that can be organized to describe & articulate an individual's cognitive schemas
Automatic Thoughts (CBT)
Cognitive Model of Schema Development
• Early childhood experience shapes beliefs re: self/world
• Beliefs organized into cognitive schemas, solidified by Critical Incidents
• Schemas become manifest in Automatic Thoughts, and emotional, behavioral, physio responses
Early Maladaptive Schemas
(CBT)
Resistant to change, activated by change & negative emotions
Disconnection/Rejection
(CBT)
Early Maladaptive Schema:
a belief that the need for security, caring, love, empathy, is NOT predictably met
Impaired Autonomy/Performance
(CBT)
Early Maladaptive Schema:
belief that one cannot function independently
Impaired Limits
(CBT)
Early Maladaptive Schema:
belief that one has difficulty respecting rights of other, is less cooperative
Overvigilance & Inhibition
(CBT)
Early Maladaptive Schema:
belief that one must suppress emotion to meet high expectations
Qualities of Schemas in CBT
• Adaptive vs. Maladaptive
• Active vs. Inactive/Periodic
• Compelling/Learned vs. Noncompelling
• Easily changeable vs. unchangeable
Types of Schemas in CBT
• Cognitive-conceptual
• Affective
• Physiological
• Behavioral
• Motivational
Cognitive-conceptual Schemas
(CBT)
• means of storing, interpreting, & making meaning
• 'core beliefs'
Affective Schemas
(CBT)
qualitative evaluation of positive vs. negative feelings
Physiological Schemas
(CBT)
perception of physiological functions
Behavioral Schemas
(CBT)
actions taken in response to particular stimuli
Motivational Schemas
(CBT)
necessary conditions to initiate an action
Cognitive Distortions
(CBT)
• All or Nothing thinking
• Selective Abstraction
• Mind Reading
• Negative Prediction
• Catastrophizing
• Overgeneralization
• Labeling/Mislabeling
• Magnification/Minimization
• Personalization
Methods of Altering Schemas
(CBT)
• Reinterpretation
• Modification
• Restructuring
Assessment in CBT
• Intake Interview
• Self-Monitoring (client record)
• Thought Sampling
• Scales and Questionnaires
assessment technique in which clients record (write) thoughts at random intervals as prompted by audible tone
Thought Sampling
(CBT)
Cognitive Behavioral Tx
--Therapeutic Relationship--
'joint scientific exploration in which both therapist and client test new assumptions'
Cognitive Behavioral Tx
--Techniques--
• Understanding Idiosyncratic Meaning of Client Word Choice
• Challenging Absolutes
• Reattribution
• Labeling Cognitive Distortions
• Decatastrophizing
• Challenge All-or-Nothing Think.
• Listing Advantages & Disadvantages of beliefs
• Cognitive Rehearsal
Reattribution (CBT)
helping client to fairly distribute responsibility for an event
Developer of REBT
Albert Ellis
REBT Acronym
Rational Emotive Behavior Therapy
ABC Theory of Personality (Ellis)
• Ppl exposed to ACTIVATING EVENTS
• develop unconscious BELIEF SYSTEM
• experience emo/bx CONSEQUENCES
Theory of personality in which emotional/behavioral Consequences result from pairing of rational/irrational Beliefs with pleasant/unpleasant Activating Events
ABC Theory of Personality (Ellis)
Musterbation (Ellis)
cyclical development of irrational beliefs that lead to emotional disturbance
Types of 'Musts' (Ellis)
• demands of self
• demands of others
• demands of the world
Types of Anxiety in REBT/ABC
(Ellis)
• Discomfort Anxiety
• Ego Anxiety
Discomfort Anxiety (Ellis)
threat to one's comfort level, need to meet a desire/expectation
Ego Anxiety (Ellis)
• threat to sense of self-worth
• must perform well
• belief in catastrophic results of failed wish fulfillment
REBT -- Goals
(Ellis)
• minimize emotional disturbance
• change self-defeating Bx
• increase self-actualization
• improve happiness
REBT -- Assessment Techniques
(Ellis)
• BDI
• REBT Self-Help Form
• ABC-focused interviewing
REBT -- Clinical Approach
(Ellis)
• build rapport, focus on ABC
• mentor-protege relationship
• ABCDE Approach
ABCDE Approach
(Ellis)
• Specify Activating Event
• Differentiate Rational/Irrational Beliefs
• Identify Consequences
• Disputing
• Effect (tx outcome)
Levels of Disputing in REBT
(ABCDE Approach)
• Detecting Irrational Beliefs
• Discriminating rational/irrational
• Debating Irrational Beliefs
REBT -- Therapist Strategies
• lecture
• socratic dialogue
• humor, metaphor, creativity
• self-disclosure of therapist Irrational Beliefs
Developer of DBT
Marsha Linehan
DBT Acronym
Dialectical Behavioral Therapy
DBT -- Theoretical Roots
• Bx-change
• psychodynamic relationship
• Zen-acceptance & validation
• dialectical philosophy
• bio-social theory
DBT -- Goals
• decrease life-threatening Bx
• decrease therapy interfering Bx
• Decrease quality-of-life interfering Bx
• Increase mindfulness Bx skills
Four Modules of DBT
• Mindfulness
• Distress Tolerance
• Emotional Regulation
• Interpersonal Effectiveness
Mindfulness Skills (DBT)
WHAT
• Observe
• Describe
• Participate

HOW
• Non-judgmentally
• One-Mindfully
• Effectively
Distress Tolerance Skills (DBT)
• Distraction with ACCEPTS
• Self-Soothe
• IMPROVE the moment
• Pros & Cons
• Radical Acceptance
• Turning the Mind
• Willingness vs. Willfulness
Emotional Regulation Skills (DBT)
• Story of Emotion
• PLEASE MASTER
• Opposite Action
• Problem Solving
• Letting go of Emo. Suffering
Interpersonal Effectiveness Skills
(DBT)
• DEARMAN -- to get something
• GIVE -- giving something
• FAST -- keeping self respect
Distract with ACCEPTS
(DBT)
• Activities: do things you enjoy
• Contribute: to community
• Comparisons: to ppl 'worse off'
• Emotions (other): i.e., humor
• Push away: change activities
• Thoughts (other): change thoughts
• Sensations: engage body/senses
IMPROVE the Moment
(DBT)
• Imagery: imagine relaxing scenes
• Meaning: seek meaning in emotions
• Prayer: pray, meditate, etc
• Relaxation: muscles, breathing, body
• One thing in the moment: focus attention
• Vacation (brief): take a break
• Encouragement: be own cheerleader
Story of Emotion (DBT)
List used to understand present emotion:
• Prompting Event
• Interpretation of Event
• Body sensations
• Body language
• Action urge
• Action
• Emotion name, based on above
PLEASE MASTER
(DBT)
• PhysicaL illness: seek treatment
• Eating: healthy diet
• Avoid: non-prescribed meds/drugs
• Sleep: about 8 hours/day
• Exercise: for health and mood
• MASTERy: activities to build sense of competence/control
DEARMAN
(DBT)
• DESCRIBE situation
• EXPRESS feelings
• ASSERT clear expectations
• REINFORCE position w/positive results
• MINDFUL of focus on goals
• APPEAR confident no matter what
• NEGOTIATE comfortable compromise
GIVE
(DBT)
• GENTLE
• INTERESTED
• VALIDATE
• EASY manner
FAST
(DBT)
• FAIR to self/other
• APOLOGIES (few)
• STICK (to your values)
• TRUTHFUL
Recovery Model
-- Philosophy --
• DSM as work of fiction
• focus on collective
• problems in community, not indiv.
• Pathology as problems in living
• opposed to Medical Model
• strengths-based
• providing respect & hope
• no condition is 'chronic'
• integrated team vs. indiv. provider
• case mgmt vs. 50 min. hour
• community vs. clinic based
• consumer-driven
• person-centered, holistic
Empowerment
(Recovery Model)
self-direction + self-determination
Types of Goals
(Recovery Model)
Living Goals
Treatment Goals
Quality of Life Goals
Community treatment model focused on meeting each consumer where they are, helping them decide where they would like to be next
Recovery Model
Operant Conditioning
A type of learning in which behavior is increased or decreased by systematically changing its consequences.
The process of no longer presenting a reinforcement. It is used to decrease or eliminate certain behaviors.
Extinction
An evidence-based therapy designed for the treatment of suicidal clients and those with borderline disorder. Mindfulness values and meditation techniques have been incorporated into this treatment.
DBT (Linehan)