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452 Cards in this Set
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Important tips |
* read carefully (read question and ALL answers before choosing answer) * don't skip questions (answer and mark instead) * be careful when changing answers |
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Crisis is... |
"a period of psychological disequilibrium, experienced as a result of a hazardous event or situation that constitutes a significant problem that cannot be remedied by using familiar coping strategies"
(time limited, ordinarily no more than 6-8 weeks) |
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Components of Crisis |
1) hazardous event - specific stressor (marriage, retirement, death of family member, etc) 2) vulnerable state - person's physical, emotional, cognitive and behavioral responses to the hazardous event, increase in tension 3) precipitating factor - final stressful event in a sees that moves a person from acute vulnerability to disequilibrium. 4) active crisis state - coping skills have broken down, tension is at a maximum. a) physical and psychological agitation, impaired problem-solving ability, anxiety, depression, stomach disorders, headaches; b) preoccupation with event, c) graduate return to a state of equilibrium 5) reintegration - restoration of equilibrium |
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Crisis Origins |
1. Situational Crises - triggered by a sudden, uncontrollable, usually unanticipated event (physical illness, unexpected death, job loss, rape, natural disaster) 2. Maturational (Developmental) Crises - embedded in developmental processes (struggle with transition from one life stage to another) |
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Reactions to a Crisis |
A. Phases - 3 overlapping phases 1) impact phase immediately after the event (few min-hrs) (shock, fear, confusion, overt signs of distress or may deny event has occurred); 2) recoil phase, individual begins to acknowledge the reality of his situation (intensification of emotional and physical symptoms); 3) post traumatic recovery - alternating periods of adjustment and relapse as the person becomes fully aware of the implications and attempts to reestablish a state of equilibrium. |
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Crisis Symptoms |
* combination of affective (shock , numbness, fear, anxiety, sadness), cognitive (flashbacks, intrusive thoughts), behavioral (difficulty with daily activities subst. abuse), and physical symptoms (appetite, sleep, muscles, pain) that may appear a few hours, days or even months after the precipitating event occurs. |
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Risk Factors |
* previous unresolved trauma or loss * previous psychiatric hx * substance abuse * concurrent life stressors * SES disadvantage * female gender |
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Anniversary Reaction |
physical, emotional, and behavioral symptoms that occurs around the anniversary of the even that precipitated the crisis. |
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Crisis and the Impact of Culture |
* culture may impact whether a specific event precipitates a crisis, how he reacts and recovers * also affects how people express their feelings and interpret their psychological feelings |
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Crisis Assessment |
* it is clearly linked to crisis resolution
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Crisis (Communication Skills) |
effective communication techniques: 1) silence 2) non verbal attending 3) restatement 4) paraphrasing 5) reflection of emotion 6) close-ended questions 7) open-ended questions |
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Assessment Domains |
1. Risk of Life (all pts. in crisis should be assessed for danger to self or others) - ask direct questions to clarify 2. Origins, Severity and Development of the crisis 3. Manifestations of the Crisis 4. Family, Community and Sociocultural factors |
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Types of Assessment Triage Assessment |
Triage Assessment - occurs immediately following a community disaster or other traumatic event; conducted by front-line crisis intervention workers. Obtain crucial demographic and information. Determine if intervention is necessary, and if so, the appropriate intervention. |
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Types of Assessment Crisis Assessment |
* goals are to provide a systematic method of organizing client information related to personal characteristics, parameters of the crisis episode, and the intensity and duration of the crisis and use data to develop effective tx plans. Distinguish between normal reactions and reactions that are excessive or reflect a pre-existing condition a. Rapid Assessment Instruments (RAIs) b. Semi-Structured Interviews |
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Rapid Assessment Instruments (RAIs) |
brief standardized self-report measures that are easy to administer and score can be included in the initial assessment and sued to monitor the progress of tx. (BAI, BDI, Impact of Events Scale and the Lewis-Roberts Crisis State Ass. Scale) |
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Semi-Structured Interviews |
have been developed for the purpose of crisis assessment. ex: Myer's triage assessment model: reactions are recorded on a triage assessment form and identified as being the most severe are the initial target of intervention. |
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Biopsychosocial Assessment |
* used to obtain information on the individual's biological, psychological, and sociocultural experiences/functioning |
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Crisis Intervention Goals |
* depends upon the nature of the crisis and the pt. reaction but in general includes 1) relieve the client's current symptoms 2) help the client identify and gain some understanding of the factors that led to the crisis state 3) use remedial measures and available resources to restore the client to his pre-crisis level of functioning 4) help the client develop adaptive coping strategies 5) help the client connect current stresses with past life experience |
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Crisis Intervention Focus |
* not focus on diagnosis but on crisis assessment * tx focus - immediate traumatized aspects of the person * Tx plan - problem-specific plan to alleviate crisis symptoms * tx strategies - time-limited techniques for immediate resolution of the crisis * evaluation of results - behavioral evaluation of person's return to pre-srisis state of equilibrium |
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Principles of Crisis Intervention |
Based on 7 core principles: 1. proximity - normal surroundings if possible 2. immediacy - as soon as feasible 3. expectancy - instill hope early 4. brevity - 1-5 contacts 5. simplicity - simple intervention 6. innovation - modification of routine to fit pt. 7. practicality - must be able to be carried out |
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Crisis Intervention Tasks |
4 primary tasks: 1. physical survival - homicide/suicide/phy safety 2. expression of feelings - 3. cognitive mastery - address irrational beliefs 4. behavioral and interpersonal adjustment - adapting to changes in relationships, goals, etc. |
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Evaluating a Crisis Intervention... |
* has the pt regained equilibrium in all of the basics areas of functioning? * has the pt regained coping capabilities? * has the pt. integrated the crisis event into his life as a while so that it no longer requires intense attention? * were previously unresolved personality issues triggered by the crisis, and if so, have they been successfully worked through? |
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Crisis Intervention Models Burgess and Roberts 7 level stress-crisis continuum |
1. Somatic Distress - precipitated by biomedical disease, depression, anxiety, etc. 2. Transitional Crisis - stressful events (preg,job) 3. Traumatic Stress Cr - natural disaster, rape 4. Family Crisis - child abuse, DV, homelessness 5. Serious Mental Illness - dementia, psychosis 6. Psychiatric Emerg - suicide attempt, overdose 7. Catastrophic Crisis - combines 2 or + levels |
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Seven-Stage Crisis Intervention Model
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1. Crisis Assess. (lethality, needs, risk, protective) 2. Establish Report 3. Identify Major Problems - event/reactions 4. Explore Feelings and Emotions 5. Generate and Explore Alternatives 6. Develop and Implement and Action Plan 7. Follow up - assess functioning, satisfaction |
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Crisis Intervention Methods Crisis Intervention Approaches (Gilliland and James) 3 approaches to action/involvement (depending on the pt's level of mobility/immobility/change) |
1. A non directive approach - pt is able to initiate and perform the actions steps to resolve crisis; crisis is less severe; facilitate pt's ability 2. Collaborative Approach - pt can work collaboratively; therapist is catalyst, facilitator 3. Directive Approach - pt is too immobile to cope effectively. Crisis worker assumes temporary responsibility and control |
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Intervention Alternatives
Psychological First Aid (PFA) |
* MH services provided to an individual immediately after a disaster/trauma. Involves 6 steps: 1. immediate intervention 2. establish report 3. assessment 4. take action 5. utilize referral sources 6. provide aftercare |
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Group Interventions |
* group cognitive processing therapy * cognitive-behavioral group therapy * bereavement support groups * critical incident stress management (disaster, etc. Multimodal, includes group defusing/debriefing) |
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Individual Interventions |
* behavior therapy * CBT * solution focused therapy * trauma focused CBT (TF-CBT) |
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Family Interventions Harris's Systemic Model, based on a problem-solving approach, involves 5 steps: |
1. making psychological (therapeutic) contact 2. exploring the dimensions of the family problem, immediate concerts, streng, weakness 3. exploring possible solutions 4. assisting the family in taking concrete action 5. providing follow up by continuing to see family, make referrals, etc. |
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Suicide Assessment |
A. Assessment Goals - determine client's imminent and future risk for suicide, obtain info needed to develop a tx plan, and monitor effectiveness. B. timing of assessment - ongoing process C. assessment methods - clinical interview, mental status exam, family members, physician, psychological tests, etc. |
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Suicide Risk Factors (3 of 6) |
1. suicidal thoughts/behaviors - threats, giving away possessions, will. Plan, access to firearms hx of attempts or self-mutilation 2. psychiatric diagnosis - MDD, bipolar disorder, anorexia, schizophrenia, alcohol or other substance, Borderline, antisocial PD 3. Psychiatric Symptoms - hopelessness, dysphoria, severe or chronic anxiety, panic attacks, impulsive tendencies, command hallucinations, chronic sleep disturbances. |
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Suicide Risk Factors (last 3 of 6) |
4. Physical Illness - neurological disorders, HIV/AIDS, cancer (especially of the head and neck) 5. Psychosocial Factors - recent stressful life events, lack of social support, hx of DV, hx of childhood trauma, family hx of suicide or MH 6. Demographic characteristics - older age, male gender, while race, divorced, widowed, or single (esp. men), LGBT, employment (nurse, physician, dentist, health related occupations) |
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Risk Factor for Adolescents |
* aggression and hostility (esp. combine with depression) * impulsivity * Recent interpersonal conflict or loss * substance abuse * hx of physical and/or sexual abuse |
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Risk Factors for Older Adults |
* physical illness * depression or bipolar disorder * multiple losses associated with aging * access to firearms or other lethal means |
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Treatment Planning |
Involves setting goals and tasks of treatment that take into consideration the uique patient, the nature of the patient's problems and concerns,the likely prognosis and expected benefits of tx, and available resources. |
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Approaches to tx planning usually include: |
1) developing a case formulation 2) identifying treatment goals and objectives 3) selecting appropriate intervention strategies 4) identifying methods for monitoring tx progress |
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treatment implementation |
1) pts for less complicated problems may be conceptualized as a single phase 2) for pts with more complex and severe problems, it can be views as a eries of phases |
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Developing a Case Formulation
(a set of hypotheses about the causes, precipitants, and maintaining influences of a person's psyhcological, interpersonal, and behaviroal problems) |
1. Content of the Case Formulation - affected by clinician's theoretical orientation and other factors. contains identifying information, problem list, diagnosis, precipitating and predisposing factors, hypothesis, strengths, tx expectations.
2. Integrating Diversity into the Case Formulation (cultural distress, stressor and cultural features of vulnerability and resilience, cultural features of clin/clinician relation, etc).
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Identifying Tx goals and objectives |
* represent the desired outcomes of psychotherapy * goals are broad, comprehensive and long term * reducing core symptoms and achieving a satisfactory level of functioning are often goals * objectives are specific, short term and measurable |
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Selecting Intervention Strategies |
* based on:
1. client characteristics - indiv/couple/family, psych hx, medical hx, expectations, environment, social support, diversity, etc
2. tx factors - clinician's theoretical orientation, experience. tx mode and format, level of care, etc |
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Psychoanalytic (Freudian) Psychotherapy |
* view of maladaptive behavior: stems from unconscious, unresolved childhood confict
* goal of therapy: reduce or eliminate pathological symptoms by bringing the unconscious into conscious awareness, integrating repressed into personality
* therapy techniques/strategies: analysis, free associations, dreams, resistance, transference |
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Person-Centered Therapy |
Maladaptive behavior - the "self" becomes disorganized as a result of incongruence between self and experience
Goal of therapy: help client achieve congruence between self and experience, self-actualizing
Techniques: unconditional positive regard, empathic understanding, attending, using restatement, reflection, nonevaluative attitude |
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GestaltTherapy |
* neurotic behavior is viewed as "growth disorder" that involves abandonment of the self for the self-image and a resulting lack of integration
* help the client achieve integration of the various aspects of the self in order to become an integrated, unified "whole"
* awareness, use a variety of techniques to increase the client's awareness of his thoughts, feelings, actions in the here and now, games of dialogue, dram work |
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Interpersonal Psychotherapy |
* depression and other symptoms are related to problems in social roles and interpersonal relationships that are traceable to a lack of strong attachments in early life
* reduce pt's sx by improving his interpersonal functioning in one or more domains (grief, interpersonal conflict, role transition, interpersonal deficits)
* combines a variety of cognitive and behavior techniques including encouragement of affect, communication analysis, modeling and role playing |
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Solution Focused Therapy |
* understanding the etiology or attributes of problem behavior is irrelevant; focus on solutions to problems
* assist the client in recognizing and suing his strengths and resources to achieve specific goals
* incorporates a variety of techniques designed to help clients identify solutions to problems including asking miracle, exceptions, and scaling questions. |
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Behavior Therapy |
* the result of classical conditioning, operant conditioning and/or social learning
* help the client achieve desired and realistic changes in observable behaviors
* incorporates a variety of behavioral interventions (exposure, counterconditioning, reinforcement, modeling, skills training, self-control training) |
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Cognitive Therapy |
* due to dysfunctional cognitive schemas that develop early in life and are subsequently activated by internal or external stressors
* help the client identify, reality-test, and correct dysfunctional schemas, negative automatic thoughts and cognitive distortions
* incorporates a variety of cognitive and behavioral techniques (socratic dialogue, graded homework assignment, activity scheduling, relaxation, behavioral rehearsal, cognitive rehea.) |
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Structural Family Therapy |
* family dysfunction is the result of an inflexible family structure that prohibits the family from adapting to maturational and situational stressors in a healthy way
* alleviate sx and change relationships between family members by restructuring the family (realigning subsystem and altering overly right or permeable boundaries)
* focus on behavior change that will lead to modification of the family structure and include joining (mimesis and tracking), enactment, and reframing. |
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Strategic Family Therapy |
* symptoms are strategies for controlling interpersonal relationships
* alleviate the family's presenting problem(s) by using strategies designed to alter communication patterns and other interpersonal behaviors.
* entails the use of a variety of strategies including directives and paradoxical techniques (ordeals, positioning, reframing, prescribing the sx) |
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Bowenian Family Systems Therapy |
* result of a multigenerational transmission process in which progressively lower levels of differentiation are transmitted from one generation to the next
* reduce the client's anxiety and increase his self-differentiation
* utilizes techniques designed to help family members achieve greater intellectual and emotional differentiation (therapeutic triangle, questioning, having the client take an "I" stand, having the client re-establish contact with his family of origin. |
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Empirically Support Treatments and Evidence-Based Practice * a shift in the field in rent years has been toward an emphasis on evidence-based practice rather than EST Evidence based - the integration of the best available research w/clinical expertise in the context of patient characteristics, culture and preferences. |
* specific psychological tx that have been shown to be efficacions in controlled clinical trials
* well established/efficacious (supported by at least 2 rigorous randomized control trials or a series of rigorous single-care experiments) |
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Empirically Supported Treatments (from chart) Anxiety Disorders |
CBT for panic disorder, GAD and social phobia
Exposure for agoraphobia, specific ph and PTSD
Exposure with response prevention for OCD |
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Empirically Supported Treatments (from chart) Depression |
CBT
Interpersonal Psychotherapy (ITP) |
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Empirically Supported Treatments (from chart) Eating Disorders |
CBT for bulimia and binge eating |
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Empirically Supported Treatments (from chart) Dementia |
Environment behavioral interventions for behavioral problems |
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Schizophrenia |
Social learning programs
Social skills training
Behavioral family therapy
Supportive long term family therapy |
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Substance Abuse and Dependence |
Community reinforcement
Motivational interviewing for alcohol abuse/dep |
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Personality Disorders |
Dialectical Behavior therapy for BPD |
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Health Problems |
Behavioral Therapy for headache
CBT for chronic pain
Multicomponent CBT with relapse prevention for smoking cessation |
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Marital Discord |
Behavioral marital therapy |
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ADHD |
Behavioral parent training
Behavioral modification in the classroom Neurofeedback Psychopharm |
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Conduct Disorder/ Oppositional Defiant |
Parent training programs
Cognitive problem-solving skills training
Multisystemic therapy |
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Enuresis |
Behavior modification |
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Phobias (children) |
participant modeling
Reinforced practice |
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Level of Care and Mode of Treatment |
* appropriate level of care: inpatient, partial hospitalization/day treatment, intensive outpatient or outpatient
* consider severity of sx and risk to self/others
* identify most appropriate mode of tx (therapy, pharmacological, medical, education, support group, multimodal, etc).
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Format of Treatment |
Consider whether tx should be delivered * individual therapy * group therapy * marital/family
Consider: a. nature of pt's problems and sx, b) the way problems are manifested (multiple contexts, family only, etc); c. the clinician's theoretical orientation; d. goals and objectives of tx; e. pt's preferences; f) efficacy and effectiveness of tx for the sx/disorder |
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Treatment Monitoring |
* tx plan should identify the methods that will be used to monitor tx progress (self-reports,therapist observations, structured symptoms checklists) that are administered at the onset of therapy to obtain baseline data, regularly during the course of tx and at the end. |
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Treatment Termination |
* tx plan should also include criteria that will be sued to determine when tx termination is appropriate * states in concerts, measurable terms (e.g. 3 weeks w/o delusions/hallucinations; BDI of 13 or less for 4 weeks) |
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Generic Treatment Plan Example Early Stage |
Early Stage (Immediate Concerns)
* evaluate risk factors, create therapeutic framework, establish rapport, address clinical and legal/ethical issues, preliminary assessment, provisional diagnosis)
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Early Stage: Assessment, Goal-Setting and Initial Intervention |
* conduct a through assessment (demographics, expectations for therapy, coexisting mental disorders, etc) * make appropriate referrals * educate pt about problem and tx options * integrate the assessment info to confirm diagnosis and conceptualize case * construct the tx plan (goals, objectives, strategies, modalities, interventions) * being to address the pt's sx/problems. When appropriate refer to psychiatrist or other svs. |
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Generic Treatment Plan - Middle Stage |
* reduce core sx using strategies that eager affect, cognitions, and/or behaviors * identify and strengthen the pt's ability to cope, provide referrals if necessary * decrease pt's isolation * increase pt's self-esteem and sense of personal efficacy. Provide positive feedback * address family and environmental factors contributing to the pt's problem * when appropriate, interpret the pt's defenses and transference and resistance * periodically evaluate the pt's progress and make necessary adjustments * as appropriate, have regular consultations with members of multimodal tx team
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Late Stage |
* once goals have been met, help pt understand the development roots of his problem * prepare the pt to cope successfully with future problems; focus on relapse prevention * connect the pt to appropriate resources * continue to encourage the pt to assume responsibility for own behavior |
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Termination Stage |
* Review pt's progress, emphasize change maintenance * express confidence in the pt's ability to cope independently * according to pt's wishes, schedule additional sessions several weeks after termination to assess any loose ends * ensure that support system is in place * identify and address pt's feelings about termination (abandonment, etc) |
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Treatment Implementation |
* monitor the effectiveness of tx * what and when to assess (address variables such as therapeutic relationship; pt's motivation, etc) - during the 1st few sessions, the pt's feelings of hep fullness increase, in the next phase, there is a reduction in sx, final phase, pt. establish new ways of dealing with issues * Remoralization, Remediation, Rehabilitation |
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Treatment for Mental Disorders Autism Spectrum Disorder |
a. assessment - evaluation and monitoring, requires multidisciplinary approach (psych, neurologist, speech path, pediatrician, school)
b. instruments - Parent Interview for Autism, Autism Diagnostic Interview-R, Childhood Autism Rating Scare, Autism Diagnostic Observation Schedule, etc. |
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Autism Treatment I |
1. Educational and Vocational Interventions - TEACCH (Treatment and Education f Autistic and Related Communication Handicapped Children) structured teaching approach that targets communication, social, and coping skills 2. Behavioral Interventions - used to reduce undesirable behaviors and improve social, communication and daily living skills (shaping, discriminating) - ABA, Pivotal Response Training (PRT) is an application of ABA |
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Autism Treatment II |
3. Psychotherapy - insight oriented are not viable. Structured, directive may be useful for older and higher functioning 4. Parent/Family Interventions - Include parent training, support groups, advocacy groups 5. Pharmacotherapy - generally not effective, only for comorbid depression, anxiety, etc. |
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Attention-Deficit Hyperactive Disorder |
1. Assessment : ADHD Rating Scale, Conners, Child Behavior Checklist, etc. 2. Pharmacotherapy - methylphenidate and other stimulants, beneficial for up to 85% children; side effects. Drug holidays 3. Behavioral Int: classroom behavior management, time out, response cost, self-instruction, self-evaluation, self-reinforcement, self-control techniques 4. Neurofeedback - EEG biofeedback 5. Parent Education Training - rules consistency, structured environment, predictable routines. Realistic expectations, support groups. |
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Specific Learning Disorder |
A. Assessment - intelligence and academic achievement tests, neuropsychological, psychoeducational, socio-emotional assessm. B. Treatment - multidisciplinary approach (psycho, speech, occupat. therapist, etc. 1. Instructional Interventions - EIP, education plans, teach skills to compensate for problems 2. Behavioral Interventions - behavior modification programs at home and school 3. Family Interventions - parents' expectations, responses. help parent's structure routines |
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Tourette's Disorder |
Assessment - clinical interview and clinician,self and parent scales to confirm diagnosis. Clarify the nature and severity. Involves evaluating the effects of the disorder on academic/vocational and social functioning and comorbid situations Treatment - antipsychotic or antihypertensive drugs. Stimulants may increase tics so pt may take an antidepressant as well if ADHD is present. Behavioral -Self-monitoring, relaxation training, habit reversal training, social supports, comprehensive behavioral interventions for tics |
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Schizophrenia part 1 |
Assessment - collecting information on specific symptoms, on social, occupational/vocational, self-care and other areas of functioning. Structured clinical interviews such as brief psychiatric rating scale, positive and negative syndrome scale, social adjustment scale, quality of life scale. Complete hx, mental status exam, screening for suicide, danger, aggression, living circumstances, medical info, hospitalizations, support system. |
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Schizophrenia part 2 |
Treatment - depends on the clinical phase of the disorders. During acute phase, primary goal of tx is to reduce the severity of psychosis and associated sx, develop therapeutic alliance and help individual return to best level of functioning. During stabilization phase, goals are to facilitate continued reductions in sx, enhance community adaptation. During stable phase, goals are to sustain symptoms remission, minimize risk and consequences of relapse, improve the individual's level of functioning.
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Schizophrenia part 3 |
Hospitalization - may be indicated when pt is at risk for suicide or aggressive behavior; decompensating, noncompliant, resistant or has not improved with outpatient care; if medication regimen is being changed or reestablished or if individual is exhibiting signs of acute psychosis or has a coexisting substance related disorders. |
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Schizophrenia part 4
Typical (First Generation) Antipsychotics |
a. First Generation/Traditional ANtipsychotics - alleviate hallucinations, delusions, agitations, and other positive sx. Less effective for negative sx. Side effects include anticholinergic effects (dry mouth, blurred vision, tachycardia, urinary retention, constipations, delayed ejaculation) and extrapyramidal effects (parkinsonims, akathisisa, dystonia, tar dive dyskinesia) and neuroleptic malignant syndrome (rapid once of motor, mental and autonomic symptoms including motor rigidity, tachychardia, hyperthermia). |
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Schizophrenia part 4
Atypical (Second Generation) Antipsychotics |
Alleviate both positive and negative sx and are often effective when traditional drugs have failed. Side effects include anticholinergic effects, lowered secure threshold and sedation. Tardive dyskesia is uncommon, but may cause agranulocytosis and other blood dyscrasias and require blood monitoring. Also can cause NMS. |
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Schizophrenia Part 5
Psychosocial Interventions |
a. CBT - to address comorbid depression, anxiety, etc. Test beliefs, teach coping skills, problem solving Medication compliance b. Skills training - social skills, instruction, modeling, rehearsal, corrective feedback, contingence c. Family Interventions - crisis management, psycho ed, support groups, targets high expressed emotion that elevate relapse risk d. Assertive Community Tx. - multidisciplinary team approach e. Supported Employment |
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Bipolar 1 Disorder - part 1 |
Assessment - structured diagnostic interview, rating scales, other measures, mental status exam, safety evaluation, identify tx setting. Instruments schedule for affective disorders and schizophrenia, the young mania rating scale, the clinician-administered rating scale for mania, clinical global impressions bipolar scale. |
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Bipolar Disorder - part 2 |
Treatment - a mood stabilizer is usually first-line tx, combined with psychosocial intervention. 1. Pharmacotherapy - lithium effective in 60-90% of classic cases. Antiseizure medication. 2. Psychotherapy a. CBT - focus on identifying and altering negative thoughts. educating pt about disorder; monitoring sx; medication adherence; strategies for coping with mood, behaviors, cognitions; strategies for coping with stressors. |
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Bipolar Disorder 1 - part 3 |
Family Focused Treatment - integrates the pt's family into tx and focuses on teaching family members about BD. Psychoed, communication enhancement and problem solving.
Interpersonal and Social Rhythm Therapy (IPSRT) is a medication of ITP and incorporates strategies for improving interpersonal relationships and stability daily routines. Circadian rhythms dysregulation as trigger. |
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Major Depressive Disorder - part 1 |
Assessment - BDI, Inventory fo Depressive symptoms, Zung Self-Rating Depression Scale, and Hamilton Depression Rating Scale. Evaluation of level of functioning, risk for suicide and quality of life, comorbid conditions, stressor |
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Major Depressive Disorder - part 2
Treatment (depends on the stage: acute, continuation, maintenance), severity of sx, comorbid disorders, pt preference) |
a. Selective Serotonin Reuptake Inhibitors (SSRIs) - 1st line drug tx for moderate to severe depression, fewer side effects, lower risk overdos b. Tricyclics (TCAs) - most effective for classic depression that involve vegetative bodily symptoms. Can produce cardiovascular sx c. Monoamine Oxidase Inhibitors (MAOIs) - if pt doesn't respond to TCA/SSRI. pt with atypical sx. Hypertensive crisis may occur (no cheese, wine, beer, avocados, bananas) d. Other antidepressants - Effexor, Pristiq, Cymbalta SNRI's, increase both norepinephrine and serotonine. |
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Major Depressive Disorder = part 3
Psychotherapy (CBT or IPT most effective for mild depression; therapy plus antidepressant the best for moderate to severe, chronic and psychotic depression) |
a. CBT - help pt identify and alter distorted cognitions that underlie sx. Activity scheduling, behavior rehearsal, social skills training, relaxation, question the evident, decatastrophizing, mental imagery, corn rehear) b. IPT - manual based therapy base on the assumption that depression is due to problems in social roles and interp. relationships. Focus on sx reduction, improve interpersonal functioning
Phototherapy - involves exposure to artificial bright light, for MDD w/ seasonal pattern and reg
Electroconvulsive therapy (ECT) - rarely used but can be effective for severe endogenous depressions. |
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Separation Anxiety Disorder |
Assessment - self-report inventories, rating scales and structured interviews (state-trait anxiety inventory, self-report for childhood anxiety related disorder, revised children's manifest anxiety scale.
Treatment - incorporates behaviorla interventions, including in vivo exposure, systematic desensitization, contingency management, and modeling. Cogn therapy for more mature children and adolescents. Parent support and guidance. Immediate return school |
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Specific Phobia part 1 |
Assessment - clinical interview and self-report measures. Behavioral observation.
Treatment - Exposure with Response Prevention - exposing the individual to the feared object or situation while preventing him from engaging in cognitive or behavioral avoidance. In vivo exposure is usually preferred but virtual reality is as effective for flying and height. |
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Specific Phobia part 2 |
Treatment - combining exposures with other interventions is beneficial for certain phobias. Ex: applied tension combines exposure and muscle tension for pts. with blood-injection-injury phobias.
Cognitive Interventions - generally less effective than ERP but may be useful for certain kinds of fears, for example, just as effective as ERP for claustrophobia, children's fear of dark. |
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Social Anxiety Disorder |
Assessment - clinical interview, self-report measures (social phobia and anxiety inventory, social avoidance and distress scale).
Treatment 1. CBT - psychoeducation, cognitive restructuring, ERP, social skills training, applied relaxation. 2. Pharmacotherapy - antidepressants (SSRI sertraline + fluvoxamine and MAOI phenelzine) |
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Panic Disorder - part 1 |
Assessment - Anxiety Disorders inventory schedule, panic disorder severity scale and panci and agoraphobia scale. Evaluate individual's suicide risk and degree of functional impairment and co-existing conditions. Identify triggers.
Treatment - CBT - panic focused CBT (self-monitoring, cognitive restructuring, breathing retraining, applied relaxation, in vivo exposure, relapse prevention). Exposure to internal and internal cues that trigger panic attacks, (interoceptive exposure) |
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Panic Disorder - part 2 |
Treatment Panic Control Treatment (PCT) - brief cognitive behavioral intervention that incorporates 4 components a) psychoeducation, b) cognitive restructuring, c) breathing retraining, d) interoceptive conditioning.
Pharmacotherapy - TCAs, SSRIs, SNRIs and benzos. Risk for relapse is high when drugs are used alone. Drugs + CBT may not be more effective than CBT alone. |
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Generalized Anxiety Disorder - part 1 |
Assessment - clinical interview, self-report, evaluation of substance use, comorbid disorders, recent or chronic stressors, daily functioning. Hamilton Anxiety Rating Scale, BAI, GAD Severity Scale.
Treatment - CBT - incorporates several techniques to help the individual tolerate uncertainty, identify and replace maladaptive cognitions, and reduce anxiety: psychoeducation, self-monitoring, relaxation training, worry exposure, and cognitive restricting. Catastrophic thinking is primary target (decatastrophizing) |
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GAD - part 2 |
Treatment Applied Relaxation - teaching individual to control his anxiety in stressful situations. Pt learns several version of progressive muscle relaxation (release-only relaxation, cue-controlled relaxation and rapid relaxation).
Pharmacotherapy - benzos, buspiron and antidepressants venlafazine and imipramine. |
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Obsessive Compulsive Disorder - part 1 |
Assessment - Yale-Brown Obsessive Compulsive Scale, Compulsive Activity Checklist, Quality of Life Enjoyment and Satisfactions Questionnaire. quantify the severe of sx, determine daily functioning, quality of life, assess for suicide risk, self-injurious behavior and harm to others. MSE
Treatment - ERP for OCD, combines prolonged exposure to objects or situations that trigger obsessions with procedures that block the pt's ability to perform compulsive behaviors. Combined with social skills training or cognitive restructuring for better results. |
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OCD - part 2 |
Treatment
CBT
Pharmacotherapy - the tricyclic clomipramine or an SSRI is sometimes used in combination with exposure. High relapse for drug only. |
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Posttraumatic Stress Disorder (PTSD) |
Assessment - clinical interview, PTSD checklist, or other. Obtain additional info on the range and severity of sx and pt's functioning. Assess danger to self and others, coping skills and support systems. MSE.
Treatment- CBT for PTSD. Incorporates several strategies including psychoeducation, cognitive restructuring, breathing retraining, relaxation training, some form of expose to there traumatic event (in vivo, in imagination, virtual reality) and stress inoculation training.
Pharmacotherapy - SSRI sometimes useful as an adjusting tx to recede sx, especially for non combat related PTSD. |
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Somatic Symtom Disorder and Body Dysmorphic Disorder - part 1 |
Assessment - clinical interview and screening instruments. When screening is positive, screening may include a sx questionnaire to obtain additional inf on the type, number, and severity of the physical complaints, a measure of illness behavior and an evaluation of precipitating and current stressors / reinforcers |
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Somatic Symptom Disorder Treatment |
Treatment of Somatic Sx Dis. - no specific intervention has been consistently effective. An eclectic approach that emphasizes establishing a strong therapeutic alliance, educating the pt, providing constant reassurance. Having one single physician act as primary caregiver (gatekeeper). SSRI can reduce sx preoccupation, coexisting depression and anxiety. |
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BDD Treatment |
CBT for BBD and involves helping the pt identify, evaluate, and modify maladaptive ways of thinking about his body and altering problem behaviors such as mirror checking and avoidance of social interactions. Tx integrates cognitive restructuring, ERP, behavioral experiments, mirror (perceptual) retraining, and relapse preventions. for some, an antidepressant helps (clomipramine, fluoxetine, fluvoaxamine) |
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Anorexia and Bulimia Nervosa assessment |
Assessment - structured interviews, self-report inventories, informant rating scales, and other instruments. Eating Disoders Examinations, Eating DIosder Inventiory 3 and Questionnaire for Eating Disorders Diagnosis. Evaluation of danger to self, nutrition, body image, personality and comorbid sx and family factors. |
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Anorexia Treatment - part 1 |
* inpatient or outpatient, requires interdisciplinary approach Inpatient tx - initial priority is getting the indiviidual to gain weight in order to prevent/reduce medical complications. May require hospitalization or residentail tx. Individual, family, group therapy pus nutritional counseling and use of contingency management which links privileges w/ desired behaviors. |
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Anorexia Treatment - part 2 |
CBT- especialy useful for pt's who have already started gaining weight and emphasizes modifying the pt's erroneous belifes about weight and food. The CBT approach of Garner emphasizes modifying the pt's dysfunctional befiegs about weight and food, including the value of being thin. and the consequences of eating a) establishing a positive therapeutic alliance and pt motivation 2) normalizing the pt's eating pappterns and body weight, 3) identifying, evaluating and modifying the pt's beliefs about weight and food, 4) preparet the pt for termination and identifying ways of preventing relapse. |
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Anorexia Tx - part 3 |
Family Therapy - is normally sued in conjucntion with other tx and helps ensure the wights gains are maintained. Streuctural family therapy focuses on the boundaries, alliances, and interactions beween members that are maitinaing dysfunctional interactions.
Pharmacotherapy - medication has not been found useful as a routine tx, but an SSRI may be useful for reducing relapse and tx depression or OCD sx. |
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Bulimia Nervosa Treatment - part 1 |
Typically outpatient unless sx are severe or include medical complications
CBT - 1st goal, help pt gain control over his dysfunctional eating habits and develp helthy attitudes toward food, eating and body weight and shape. |
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Clinical Interview |
a. the intake interview b. psychosocial history c. diagnostic interview d. crisis interview |
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Mental Status Exam (MSE) |
* provides info about pt. current level of functioning * appearance, activity and behavior, attitude toward clinician, mood and affect, speech and language, thought content, thought process, insight and judgment, and sensorium/cognition. Mini Mental State Exam (MMSE) is a shortened version ( 11 questions that assess 6 aspects of cognitive functioning: orientation, registration 'immediate verbal recall', attention, and calculation, delayed recall, language, and visual construction. |
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Behavioral Assessment |
* purpose of obtaining date to assist in diagnosing, determining appropriate interventions for problematic behaviors, and assessing the progress and outcomes of interventions. * functional behavioral assessment - identify target behaviors, antecedents, consequences. |
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Psychological Tests Objective Personality Tests MMPI-2 |
* 567 T/F items, assesses social and personal maladjustment, assists in the diagnosis of mental disorders * 10 clinical scales, 8 validity scales * for ages 18 and older, at least 5th grade educ. * MMPI-A for 14-18 yo * T-score of 65 or higher, clinically significant * if valid, focus on 2 or 3 most elevated scales |
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MMPI-2 known scales |
* 4-9/9-4 - acting out behaviors and is characteristic of people with marital problems, alcohol and drug abuse, delinquency and sex offenses. * 6 -7 - 8 (low 7) - psychotic valley - associated with delusions, disordered thought, schizophr. * conversion V ? |
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Projective Personality Tests
Rorschach Inkblot Test |
* 10 inkblot cards (5 achromatic, 5 with color) * bilateral symmetrical inkblot * individuals 2 and older * scoring involves a) location, b) determinants, c) form quality, d) content, e) frequency |
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Projective Personality Tests
Thematic Apperception Test (TAT) |
* most used version consists of 19 cards containing vague black and white pics that include one or more human figures and one blank card. * examinee is asked to make up a story about each pic that influxes info about what is happening in the pic, what led to the situation, how the people fee, and how the story ends. * has little utility in assigning diagnosis; may be useful for gross diagnostic distinctions. |
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Wechsler Adult Intelligence Scale (WAIS-IV) |
* based on Wechsler's view of intelligence as a global ability * provides full scale IQ, 4 indexes (working memory, processing speed, perceptual reasoning and verbal comprehension) and scores on 10 core and 5 supplemental subtests * 16 years - 90 y 11 months |
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1) Wechsler Scale for Children (WISC-IV)
2) Wechsler Preschool and Primary Scale of Intelligence (WPPSI-IV) |
1) 6 years - 16 years, 11 months 2) 2 years, 6 months - 7 years 7 months
All Wechsler = * raw scores converted to standard scores * FSIQ and index standard have mean of 100 and st dev of 15 * subtests, mean of 10 and sd of 3 |
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Stanford Binet Intelligence Scale - 5th edition
* designed as measure of general cognitive ability and to assist in psychoeducational evaluation, diagnosis of developmental disabilities and exceptionalities, forensic, career, neuropsych, early childhood. |
* incorporates 5 cognitive factors (fluid reasoning, knowledge, quantitative reasoning, visual-spatioal processing, and working memory
* ages 2 to 85+ * SB5 subtest scores mean of 10, sd 3 * combined to obtain composite scores M=100, SD 15. 5 factor index scores, 2 domain scores, abbreviated battery and full scale IQ. |
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Culture-Fair Tests - reduced cultural content, make use of nonverbal format. Caution, there is evidence that they are still culturally loaded.
Leiter International Performance Scale Third Edition (Leiter-3)
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for ages 3-75+ ; can be administered w/o verbal instructions; useful for individual w/ language problems or hearing impairment. Match a set of response cards to corresponding illustrations on an easel. Emphasize fluid intelligence and evaluate 4 domains of cognitive functioning - visualization, reasoning, memory and attention. |
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Culture-Fair Tests
Raven's Progressive Matrices |
* nonverbal measure of general intelligence (g) * relatively independent of the effects of education and cultural learning * requires examinee to solve problems involving abstract figures and designs * most used is the Standard Progressive Matrices (SPM) - for 6 yo or older * instructions can be pantomimed, can be used with hearing impaired and non Engl.speakers, individuals with aphasia or physical disability. |
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Neuropsychological Tests - used to screen for brain dysfunction and diagnose neurological disorders.
Halstead-Reitan Neuropsychological Battery |
* found to accurately differentiate "normals" from individuals with brain damage
* clinician selects the types and number of tests to use. Administration ordinarily includes a standard set of subtests designed to assess sensorimotor, perceptual, and language functioning. Original battery is for adults. A downward extension is available for ages 5-14 |
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Luria-Nebraska Neuropsychological Battery |
* 11 subtests that each assess a different skill that is likely to be affected by brain damage * each item receives a score of 0 (normal performance), 1 (borderline performance), or 2 (clearly abnormal performance). * provides scores on 14 scales * a high score on 3 or more a scales suggests neuropsych impairment * 2 forms: adults and adolescents, 1 for children |
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Bender Visual-Motor Gestalt Test - Second Edition |
* brief measure of visual-motor integration * ages 3 and older * 16 stimulus cards containing geometric figures and requires the examinee to first copy then figures and then draw them from memory * valid screening device for neuropsych impairment and useful for tacking developmental changes in visual-motor skills |
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Measures of Specific Symptoms, Behaviors and Abilities
Beck Depression Inventory-II (BDI-II) |
* 21 item self-report measure of depression * for indiv. 13 and older with at least 8th grade reading level * items asses the severity of the complains related to depression * item scores range from 0-3 * 0-13 mininum depression, 14-19 mild depression, 20-28 moderate dep, 29-63 severe |
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Vineland Adaptive Behavioral Scales, Second Edition |
* survey interview form and parent/caregiver and teach rating forms and is used to evaluate the personal and social skills of individuals from birth to age 90 * useful for assisting in diagnosis of disorders including intellectual disability, autism, ADHD, Major neurocognitive disorder, brain injury * provides adaptive behavior composite score, 4 domain scores (communication, daily living, socialization, motor skills) and optional maladaptive behavior index. |
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Activities of Daily Living (ADL's) |
* routine activities and tasks of everyday life * personal self-care and independent living * an assessment of ADL's is an essential component of the evaluation of a person's legal competence; useful for identifying interventions for indiv. with Major Neurocogn. Disorder etc. * Measures of ADL include the Nottingham Extended Activities of Daily Living Scale and the Laughton Instrumental ADL Scale. |
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DMS 5 |
* non axial * al mental and mental diagnoses are listed tighter with the primary diagnosis listed first. * psychosocial and contextual factors (using ICD-10 codes) and level of disability (using World Health Organization Disability Assessment Scheduled etc.) are then listed separately. |
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DSM 5 |
* uncertainty about diagnosis is coded: - other specified disorder (clinician wants to indicate the reasons why the pt's sx do not meet the criteria for a specific disorder). Ex: other specified depressive disorder, recurrent brief depression - unspecified disorder (when the clinician does not want to indicate the reason why the pt's sx do to meet criteria for a specific diagnosis). |
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Neurodevelopmental Disorders
* Intellectual Disability (mild, moderate severe and profound)
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3 diagnostic criteria must be met:
* deficits in intellectual functions that are confirmed by a clinical assessment and individualized, standardized intelligence testing * deficits in adaptive functioning that result in a failure to meet community standards of personal independence and social responsibility, and impair functioning across multiple environments in 1 or more ADL * once of intellectual and adaptive functioning during the developmental period |
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Neurodevelopmental Disorders
* Autism Spectrum Disorder
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* persistent deficits in social communications dn interactions across multiple contexts manifested by deficits in social emotional reciprocity, nonverbal communication and the development, maintenance and understanding of relationships. * restricted, repetitive patterns of behavior, interests or activities (stereotyped, repetitive, sameness, inflexible adherence to routines, ritualized patterns, restricted, fixated, abnormal) Hyper or hyperactivity to sensory input * sx during the early developmental period * impairment in social, occupational, etc areas |
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Neurodevelopmental Disorders
* Autism Spectrum Disorder part 2 |
Associated features:
* many individuals also have intellectual impairments and/or language abnormalities (echolalia, pronoun reversal, unusual prosody) * may have motor deficits and engage in self-injurious behaviors * best prognosis is associated with ability to communicate by age 5 or 6, IQ over 70 and later onset of symptoms |
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Neurodevelopmental Disorders
* Attention-Deficit/Hyperactivity Disorder |
* characterized by a pattern of inattention and/or hyperactivity-impulsivity that has persisted for at least 6 months, onset prior to 12 yo, is present in at least 2 settings and integers with social, academic, occupational functioning. * diagnosis requires at least 6 sx of inattention and/or 6 characteristic sx of hyperactivity-impulsivity (or for 17 and older, at least 5 sx of inattention and 5 of hype-impuls) |
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Neurodevelopmental Disorders
* Attention-Deficit/Hyperactivity Disorder part 2 |
Inattention - fails to give close attention to details, difficulty sustaining attention, doesn't listen when directly spoken to, fails to finish schoolwork or chores, easily distracted by extraneous stimuli, forgetful
Hyperactivity-Impulsivity - frequently fidgets or squirms in seat, leaves seat at inappropriate times, runs or climbs in innapropriate situations, talks excessively, difficulty waiting turn, interrupts or intrudes on other. |
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Neurodevelopmental Disorders
* Attention-Deficit/Hyperactivity Disorder
Part 3 |
3 specifiers are provided: * predominantly inattentive presentation * predominately hyperactive/impulsive presen. * combined presentation
- typically test lower on IQ and have academic difficulties - problems with social adjustment |
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Neurodevelopmental Disorders
Tic Disorders - Tourette's Disorder |
* Tourette's is one of 3 Tic Disorders in DSM5 (others are persistent motor or vocal tic disorder and provision tic disorder) * characterized by the presence of at least 1 vocal tic and multiple motor tics that may appear simultaneously or at different times * it may wax and wane in frequency but have persisted for more than 1 yr, and began prior to age 18 |
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Schizophrenia Spectrum and Other Psychotic Disorders
Delusional Disorder |
* essential feature is the presence of 1 or more delusions that last at least one month. * overall psychosocial functioning is not markedly impaired, and any impairment is directly related to the delusions * subtypes: erotomanic, grandiose, jealous, persecutory, somatic, mixed, and unspecified. |
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Schizophrenia Spectrum and Other Psychotic Disorders
Schizophrenia |
* requires a present of at least 2 active phase sx (delusions, hallucinations, disorganized speech, grossly disorganized behavior, negative sx) for least least 1 month with at least 1 sx being delusions, hallucinations or disorganized speech. There must be continuous signs of the disorder for at least 6 months and sx must cause significant impairment in functioning. |
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Schizophrenia Spectrum and Other Psychotic Disorders
Schizophrenia Part 2 |
* prevalence is slightly lower for females * onse late teens and early 30's, with the peak age of onset being in the early to mid-20s for males, and late 20's for females * usually chronic, with complete remission being rare * good prognosis associated with good premorbid adjustment, acute and late onset, female gender, presence of a precipitating event, beige duration of active phase, insight, family hx of mood dis. and no family hx of schiz. |
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Schizophrenia Spectrum and Other Psychotic Disorders
Schizophreniform Disorder |
* identical to those for schizophrenia except that the disturbance is present for at least one month but less than 6 months * impaired social or occupational functioning may occur but it is not required. |
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Schizophrenia Spectrum and Other Psychotic Disorders
Brief Psychotic Disorder |
* presence of 1 or more of 4 characteristic symptoms (delusions, hallucinations, disorganized speech, grossly disorganized or catatonic behavior) with at least one symptom being delusions, hallucinations, or disorganized speech. Sx are present for at least 1 day but less than one month with an eventual return to premorbid functioning. The onset often follows exposure to an overwhelming stressor. |
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Schizophrenia Spectrum and Other Psychotic Disorders
Schizoaffective Disorder |
* uninterrupted period of illness during which, at some time, there are concurrent symptoms of schizophrenia and sx of a major depressive or manic episode with a period of at least 2 weeks without prominent mood sx. |
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Bipolar and Related Disorders
Bipolar 1 Disorder |
* requires at least 1 manic episode * manic epis. is a distinct period of abnormally and persitently elevated, expansive, or irritable mood and abnormally and persistently increased goal-directed activity or energy" * episode must last for at least 1 week, be present most of the day nearly every day, and include at least 3 characteristic sx: inflated self-esteem or grandiosity, decreased need for sleep, excessive talkativeness, flight of ideas * requires marked impairment in functioning and hospitalization or include psychotic feat. * MAY include 1 or more hypomanic or major depressive episode |
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Bipolar and Related Disorders
Bipolar 2 Disorder |
* requires at least 1 hypomanic episode and one major depressive episode * hypomanic episode last for at least 4 consecutive days. * must involved at least 3 characteristics, such as in manic episodes, but are not severe enough to cause marked impairment in social or occupational functioning or hospitalization * a major depressive episode lasts for at least 2 weeks and involves 5 or more characteristics sx, at least one of which must be a depressed mood or a loss of interest or pleasure |
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Bipolar and Related Disorders
Cyclothymic Disorder |
* numerous periods with hypomanic sx that do not meet criteria for hypomanic episode and numerous periods with depressive sx that do not meet criteria for a MDE. * causes significant distress or impaired functioning * sx last for al least 2 years in adults or not year in children and adolesc. * are present for at least half the time with the individual not being sx-free for more than 2 months at a time. |
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Depressive Disorders
Major Depressive Disorder |
* at least 5 sx of a MDE nearly every day for at least 2 weeks, which at least one sx being depressed mood or a loss of interest or pleasure. * depressed mood, diminished interest or pleasure, appetite, sleep, psychomotor agitation/retardation, fatigue/low energy, feelings of worthlessness, diminished concentration, recurrent thoughts of data, suicidal ideation, or attempt |
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Depressive Disorders
Persistent Depressive Disorder |
* characterized by a depressed mood on most days for at least 2 years in adults or at least one year in children and adolescents * indicated by the presence of at least 2 of the following sx: poor appetite or overeating, insomnia or hypersomnia, low every or fatigue, low self-esteem, poor concentration, feelings of hopelessness. * during the 2 or 1 yr period, pt has not been sx-free for more than 2 months; causes distress |
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Anxiety Disorders
Separation Anxiety Disorder |
* developmental inappropriate and excessive fear or anxiety related to separation from home or attachment figures * 3 characteristic sx: recurrent excessive distress when anticipating or experiencing separation, persistent excessive ferar of being alone; repeated complaints of physical sx when separation occurs or is anticipated. * must last for at least 4 weeks in children/adole * at least 6 months in adults * usually accompanied by stomachache, nausea, headache, etc. |
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Anxiety Disorders
Specific Phobia (animal, natural, environment, blood-injection, situational and other) |
* intense fear of or anxiety about a specific object or situation * individual either avoiding or enduring it with marked distress * fear /anxiety is not proportional to the actual danger posed * is persistent (typically more than 6 months) * causes distress or impairment |
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Anxiety Disorders
Social Anxiety Disorder |
* intense fear of or anxiety about 1 or more social situations in which the individual may be exposed to scrutiny by others * pt fears he will exhibit sx that will be negatively evaluated * he avoids or endure situations w/intense fear
* fear /anxiety is not proportional to the actual danger posed * is persistent (typically more than 6 months) * causes distress or impairment |
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Anxiety Disorders
Panic Disorder |
* recurrent unexpected panic attacks with at least one attack being followed by at least one month of persistent concern about having additional attacks or about their consequences and/or significant maladaptive change in behavior related to the attack * abrupt surge of intense fear or intense discomfort that reaches a peak within minutes * minimum of 4: accelerated hear rate, sweating, trembling, feelings of choking, chest pain, paresthesias, derealization or depersonalization, fear of losing control. * rule out medical problems |
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Anxiety Disorders
Agoraphobia |
* requires the presence of marked fear or anxiety about at least 2 of the following: using public transportation, being in open spaces, being in enclosed spaces, standing in line or being part of a crowd, and being outside the home alone. * pt avoids situations, concern it may be difficult to escape or help will be unavailable * avoid/endurance with distress / persistent (at least 6 months) / fear is disproportionate |
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Anxiety Disorders
Generalized Anxiety Disorder |
* excessive anxiety and worry about multiple events or activities that are relatively constant for at least 6 months * person finds difficult to control and causes significant distress/ impaired functioning * at least 3 sx (one for children): restlessness or feeling keyed up or on edge, being easily fatigued, difficulty concentrating, irritability, muscle tension, sleep disturbance. |
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Obsessive Compulsive and Related Disorders
Obsessive Compulsive Disorder |
* recurrent obsessions and /or compulsions that are time consuming or cause clinically significant distress or impaired functioning: - obsessions - persistent thoughts, implosives or images that the person experiences as intrusive and unwanted and attempts to ignore or suppress. Cause marked anxiety/distress. - compulsions - repetitious and deliberate behaviors or mental acts that the persons feels driven to perform either in response to an obsession or according to rigid rules. The goal of the behavior is to reduce distress or prevent a dreaded situation. They are either excessive or not connected in a logical way to this goal. |
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Obsessive Compulsive and Related Disorders
Body Dysmorphic Disorder |
* preoccupation with a defect or flaw in appearance (spots on the skins, excessive facial hair) that appears minor or is unobservable to others. * the person has, at some time during the course of the disorder, performed repetitive behaviors or mental acts because of the defect * causes distress or impairment * often seek plastic surgery and other medical tx |
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Trauma and Stressor Related Disorders
Posttraumatic Stress Disorder (double check this on DSM) |
* requires exposure to actual or threatened death, serious injury or sexual violence with the presence of a specified minimum number of sx in the following categories: - intrusion sx (recurrent, involuntary memories) - persistent avoidance - negative changes in cognition or mood - marked change in arousal and reactivity * duration of more than 1 month * delayed expression if criteria is met at least 6 months after the event |
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Trauma and Stressor Related Disorders
Acute Stress Disorder (double check this on DSM) |
* exposure to actual or threatened death, severe injury or sexual violation in at least one of 4 ways: - direct experience - witnessing the event in person as it happened to others - learning that the event occurred to a close family member or friend - repeated or extremem exposure to aversive details of the event * at least 9 sx from any of the 5 categories (intrusion, negative mood, dissociative sx, avoidance, arousal) * 3 days to a month, cause distress |
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Trauma and Stressor Related Disorders
Adjustment Disorders |
* involve the development of emotional or behavioral sx in response to 1 or more identifiable psychosocial stressors within 3 months of the once of the stressor. * sx must be clinically significant as evidenced by the presence of marked distress that is not proportional to the severity of the stressor * must remit within 6 months after termination of the stressor or its consequences. * NOT DIAGNOSED WHEN SX REPRESENT NORMAL BEREAVEMENT. |
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Somatic Symptom and Related Disorders
Somatic Symptom Disorder |
* presence of 1 or more somatic sx that cause distress or a significant disruption in daily life accompanied by excessive thoughts, feelings, or behaviors related to the sx as manifested by at least 1 of the following: - persistent and disproportionate thoughts about the seriousness of the sx - persistent high level of anxiety about health - excessive time and energy devoted to it * persistent (usually more than 6 months) although any one sx may not be continuously present * predominant pain specifier is applied when pain is the primary sx. |
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Somatic Symptom and Related Disorders
Illness Anxiety Disorder |
* preoccupation with having a serious illness, an absence of somatic sx or the presence of mild somatic sx, a high level of anxiety about one's health, and performance of excessive health-related behaviors or maladaptive avoidance of doctors, hospitals, * preoccupation present for at least 6 months, although the specific illness that is of concern may change over time |
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Somatic Symptom and Related Disorders
Conversion Disorder |
* requires the presence of sx that involve disturbance sin voluntary motor or sensory functioning and suggest a serious neurological or other medical condition (paralysis, seizures, blindness, loss of pain sensation) with evidence of an incompatibility between the sx and recognized neurological or medical conditions * specifiers are provided for sx type: with weakness or paralysis, with abnormal movement, with anesthesia or sensory loss, course (acute or persistent) and presence or absence of a psychological stressor |
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Somatic Symptom and Related Disorders
Factitious Disorder |
* 2 types: Factitious Disorder - Factitious Disorder Imposed on Self - falsify physical or psychological sx that are associated with their deceptions; present themselves as being ill or impaired, engage in the deceptive behavior even in the absence of an bosious external reward. - Factitious Disorders Imposed on Another - falsify physical or psychological sx in another person, present that person to others as being ill or impaired, and engage in the deceptive behavior even in the absence of external reward. * can involve feigning, exaggeration, simulation or induction (self injury, ingestion) * different than malingering, which is for the purpose of obtaining external reward. |
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Feeding and Eating Disorders
Anorexia Nervosa |
a) a restriction of energy intake that leads to a significantly low body weight for the person's age, gender, developmental trajectory, and physical health b) an intense fear of gaining weight or becoming fat or behavior that interferes with weight gain c) a disturbance in the way a person experiences his body weight or shape or a persistent lack of recognition of the seriousness os his low weight * specifiers (restricting or binge-eating/purging) * Course (in partial or full remission) * severity (mild, moderate, severe or extreme) based on current BMI. 90% are female |
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Feeding and Eating Disorders
Bulimia Nervosa |
a) recurrent episodes of binge eating that are accompanied by a sense of a lack of control b) inappropriate compensatory behvaior to prevent weight gain (self induced vomiting, misuse of laxatives of diuretics, fasting, excessive exercise) c) self-evaluation that is unduly influenced by body shape and weight * for diagnosis, binge eating and compesanrtory behavior must occur, on average, at least once a week for 3 months. * specifiers (partial, full remission), severity (mild, moder, seve, extr) based on average number of episodes of compensatory beh/week * over 90% are female |
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Disruptive, Impulse-Control and Conduct Disorders
Oppositional Defiant Disorder |
* essential feature is a recurrent pattern of angry/irritable mood, argumentative/defiant behavior, or vindictiveness as evidenced by at least 4 characteristic sx that are exhibited during interactions with at least 1 person who is not a sibling (often loses, tempers, often argues with authority, refuses to comply with requests, blames others for mistakes). * Sx have persisted for at least 6 months * causes distress for person or others |
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Disruptive, Impulse-Control and Conduct Disorders
Conduct Disorder |
* requires a persistent pattern of behavior that violates the basic rights of others and /or age appropriate social normals or rules as evidenced by the presence of at least 3 characteristics sx during the past 12 months and at least 1 sx i the past 6 mo. sx divided 4 categ: 1) aggression to people and animals 2) destruction of property 3) deceitfulness or theft 4) serious violation of rules * cannot be assigned to individu. over 18 (APD) |
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Substance Related and Addictive Disorders
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* includes substance use and substance induced disorders for 10 classes of substances and one non-substance disorder (gambling) * alcohol, caffeine, cannabis, phencyclidine, and other hallucinogens, inhalants, opioids, sedatives, hypnotics, or anxiolytics, stimulants, tobacco and other/unknown. |
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Substance Use Disorders |
* characterized by a cluster of cognitive, behavioral, and physiological sx indicating that the individual continues using the substance despite significant substance-related problems as manifested by at least 2 characteristic sx during a 12-month period. |
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Substance Use Disorder characteristic Symptoms 4 groups:
(groups 1 and 2) |
1) impaired control - substance used in larger amounts or for longer period than intended; persistent desire or unsuccessful efforts to cut down; great deal of time spent; craving. 2) Social Impairment - results in failure to fulfill major role obligations at home, school, work. Use despite persistent social problems, activities given up or reduced due to substance |
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Substance Use Disorder characteristic Symptoms 4 groups
(groups 3 and 4) |
3) Risky Use - recurrent substance use in situations in which it is physically dangerous to do so; continued use despite knowing that doing so creates or worsens a physical or psychological problem 4) Pharmacological criteria - tolerance (need for increased amounts of the substance to achieve the desired effect or markedly diminished effect with continued use); withdrawal |
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Substance Use Disorder |
* a diagnosis of substance use disorder can be applied to all classes of drugs except caffeine * specifiers are provided to indicate if the individual is in remission (early remission or sustained remission), or in a controlled environment and for severity (mild, moderate, or severe) based on number of sx. |
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Substance-Induced Disorders |
* include substance intoxication, withdrawal, and substance/medication-induced mental disorders * potentially severe, usually temporary, but sometimes persisting central nervous system syndromes that develop in the context of the effects of substances of abuse, medications, or toxins". * include Substance/medication induced psychotic disorder, SM induced depressive disorders, SM induced neurocognitive disorders |
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Substance-Induced Disorders part 2 |
* all share following features: a) involves a clinically significant symptomatic presentation of a mental disorders b) there is evidence form a hx, physical exam or lab results that developed during or within one month of substance intoxication or withdrawal, or taking a medication c) cannot be better explained by another mental or medical condition d) does not occur only during course of delirium e) sx cause clinically significant distress |
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Neurocognitive Disorders (represent 6 domains: complex attention, executive function, learning and memory, language, perceptual-motor, and social cognition)
Delirium |
Delirium requires: a) a disturbance in attention and awareness that develops over a short period of time (ordinarily hrs to a few days), represents a change from baseline functioning, and tends to fluctuate in severity over the course of a day (often worsening in the evening and at night) b) at least 1 additional disturbance in cognition (memory, disorientation, language, visuospatial ability, perceptual distortions). * must not be due to another NCD
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Neurocognitive Disorders (major and mild neurocognitive disorder distinguished based on severity of symptoms) both identify CD based on etiology: Alzheimer's, frontrotemporal lobar degeneration, Lewy body disease, vascular disease, TBI, subst/medic use, HIV infection, prion disease, Parkison's, Huntington, another medical, multiple etiologies, unspecified.
Major Neurocognitive Disorder
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* subsumes the DSM-IV-TR diagnosis of Dementia and is diagnosed when there is evidence of significant decline from a previous level of functioning in one or more cognitive domains that interferes with the individual's independence in everyday activities and does not occur only in the context of Delirium. |
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Neurocognitive Disorders
Mild Neurocognitive Disorder |
* subsumes the DSM-IV-TR diagnosis of Cognitive Disorder NOS and is the appropriate diagnosis when there is evidence of a modest decline from a previous level of functioning in 1 or more cognitive domains that does not interfere w/ the pt's independence in everyday activities (but may require greater effort or compensatory strategies) and does not occur in the context of delirium. |
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NCD due to Alzheimer's Disease |
* it is diagnosed when the criteria for Major of Mild ND is met, there is an insidious onset of sx and a gradual progression of impairment in 1 or more cognitive domains (or at least 2 domains for Major) and the criteria for probable or possible Alzheirmer's disease are met: |
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NCD due to Alzheimer's (probable vs. possible Alzheimer's)
part 2 |
For Major: probable Alzheimer is diagnosed if there is evidence of causative genetic mutation, clear evidence of a decline in memory and at least 1 other cognitive domain, a steadily progressive and gradual decline in cognition without extended platers, and no evidence of mixed etiology. Otherwise, possible Alzheimer is diagnosed |
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NCD due to Alzheimer's (probable vs. possible Alzheimer's) |
For Mild, probable Aizheimer's is diagnosed when there is evidence of a causative genetic mutation, while possible Alzheimer's is diagnosed when there is no evidence of a causative genetic mutation, clear evidence of a decline in memory and learning, a steadily progressive and gradual decline in cognition w/o extended plateaus, and no mixed etiology |
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NCD due to Alzheimer's (stages)
* characterized by a gradual onset of sx and a slow progressive decline in cognitive functioning: |
- Stage 1 (1-3 years) anterograde amnesia, especially for declarative memory, deficits in visuospatial skills (wandering), indifference, irritability, sadness and anomia - Stage 2 (2-10 years) - increasing retrograde amnesia, flat or labile mood, restlessness and agitation, delusions, fluent aphasia, acalculia, ideomotor apraxia (translate idea int movement) - Stage 3 (8 to 12 yrs) - severely deteriorated intellectual functioning, apathy, limb rigidity, urinary and fecal incontinence. |
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Vascular Neurocognitive Disorder |
* diagnosed when the criteria for Major or Mild ND are met, the clinical features are consistent with a vascular etiology, and there is evidence of cerebrovascular disease from the individual's hx, a physical examination and neuroimaging. * often has a stepwise, fluctuating course with a patchy patterns of sx that is determined by the location of the brain damage, and the timing and extend of recovery depends on the cause. Risk factors include hypertension, diabetes, cigarettes, obesity, high cholesterol, atrial. |
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Personality Disorders |
Cluster A - odd or eccentric -Paranoid, Schizoid, and Schizotypal
Cluster B - dramatic, emotional, erratic - Antisocial, Borderline, Histrionic, Narcissistic
Cluster C - anxiety, fearfulness - Avoidant, Dependent, Obsessive-Compulsive |
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Paranoid Personality Disorder |
*pervasive pattern of distrust and suspiciouness * interprets motives of others as malevolent * have at least 4 of the following: - suspects others are exploiting, harming, deceiving -preoccupied w/ trustwoththiness of others - reluctant to confide in others - reads demeaning content into benign remarks - persistently bears grudges - perceives attacks on his character, reacts anger - persistently suspicious about the fidelity of partner |
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Schizoid Personality Disorder |
* pervasive patterns of detachment from interpersonal relationship, restricted range of emotion in social settings * at least 4 of following: - doesn't desire or enjoy close relationships - almost always chooses solitary activites - has little interest in sexual relationships - takes pleasure in few activities - lacks close friends other than 1st degr relatives -seems indifferent to praise and criticism - exhibits coldness and dettachment |
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Schizotypal Personality Disorder |
* pervasice social and interpersonal deficits involving acute discomfort with and reduced capacity for close relationships and eccentricities in cognition, perception and behavior * at least 5: - exhibits ideas of reference - has odd beliefs or magical thinking and speech - suspicious, paranoid ideation - inappropriate or constricted affect - peculiarities in behavior and appearance. - lacks close friends - has excessive social anxiety * may express desire close contact but have few friends and prefer being alone. |
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Antisocial Personality Disorder
(person must be at least 18 and have a hx of Conduct Diosrder before age of 15) * common associated sx include an inflated sense of self, lack of empathy for others, and superficial charm. Chronic, but sx become less severe and pervasive by 4th decade of life |
* pattern of disregard for and violation of the rights of others that has occurred since age 15 * at least 3 characteristics: - failure to conform to social norms/lawful beh - deceitfulness - impulsivity - irritability and agressiveness - reckless disregard for the safety of self +others - consistent irresponsibility - lack of remorse |
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Borderline Personality Disorder
* pervasive patterns of instability in interpersonal relationships, self-image, and affect, marked by impulsivity that began in early childhood and is apparent in multiple contexts |
* at least 4 characteristics" - frantic efforts to avoid abandonment - patterns of unstable, intense interpersonal relationships (idealization/devaluation) - an identity disturbance; unstable self-image - impulsivity in at least 2 areas (self-damaging) - recurrent suicide threats or gestures - affective instability - transient stress-related paranoid ideation or severe dissociative sx. * most common ages 19-34, chronic |
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Histrionic Personality Disorder
* pervasive pattern of emotionality and attention seeking. |
At least 5 characteristics: - discomfort when not the center of attention - inappropriate sexually seductive or provocative - rapidly shifting and shallow emotions - consistent use of phys appearance 4 attention - excessively impressionistic speech lacks detail - exaggerated expression of emotion - easily influenced by others - considers relationships + intimate that they are |
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Narcissistic Personality Disorder
pervasice pattern of grandiosity, need for admiration, lack of empathy |
at least 5: - grandiose sense of self-importance - preoccupied w/ fantasies of unlimited success power, beauty, love - believes he is unique and can be understood only by other high status people - requires excessive admiration - has a sense of entitlement - is interpersonally exploitative - lacks empathy - is often envious or others or believes others are envious of him - exhibits arrogant behaviors and attitudes
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Avoidant Personality Disorder
pervasive pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation |
at least 4: - avoids work activities involving interpersonal contact due to fear of criticism, rejection, disap. - is unwilling to get involved with people unless certain of being liked - exhibits restraing in intimate relationships - preoccupied with being criticized, rejected - inhibited idue to feelings of inedequacy - views self as social inept, inferior, or unappealing to others - is usually reluctant to engage in new activities because they may be embarrassing |
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Dependent Personality Disorder
pervasive and excessive need to be taken care of, which leads to submissive, clinging behavior and fear of separation |
at least 5: - difficulty making decision w/o advice/reassura - need others to assume responsibility for most aspects of his life - fears disagreeing w/ others because it might lead to a loss of support from others - feels helpless or uncomfortable when alone - urgently seeks another relationship when another ends - it unrealistically preoccupy with fears of being left to care for himself |
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Obsessive-Compulsive Personality Disorder
persistent preoccupation with orderliness, perfectionism, and menial and interpersonal control that severely limits his flexibitility, openness and efficiency. |
at least 4: - preoccupied with details, rules, major pt is lost -perfectionism that interferes w task completion - excessively devoted to work and productivity to the exclusion of leisure activities/friendships - is overconscientious and inflexible about morality, ethics, values - unable to discard worn-out/worthless objects - reluctant to delegate work unless others are willing do to it his way - adopts a miserly spending style towards self and others - exhibits rigidity and stubbornness does not involved true obsessions +compulsion |
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Treatment Implementation |
* once tx plan has been constructed, tx implementation begins:
Monitoring the Effectiveness of Tx: assessing the effects of tx at regular intervals provides data needed to validate the initial case conceptualization, inform the clinician, client and relevant 3rd parties about client's progress, help determine if tx plan should be modified, help determine when to terminate therapy. |
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Monitoring the Effectiveness of Tx |
1. What to Asses - each pause of tx should include methods of assessment that are relevant to the tx objectives for that phase
2. The Use of Assessment Data: there are several ways to interpret assessment results, ex: a) compare the pt status to the outcomes identified in tx objectives b) compare client with normative datea c) use statistical techniques d) compare clients course of recovery to an expected course of recovery |
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Making Referrals |
* when the client's problems exceed the therapist's expertise * a dual relationship or conflict of interest * there are significant problems in the therapeutic alliance * unable to resolve the client's resistance * relocation * client requests second opinion * client needs adjunctive services * termination (when referral is recommended) |
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Preparing for Termination |
* the tx plan should specify criteria for determining a client's readiness for termination and strategies that will be used during the final phase of therapy to help ensure that the client maintains the changes he has made |
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Legal and Ethical Standards
Health Insurance Portability and Accountability Act (HIPAA)
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* psychologists should follow whichever law (either a HIPAA regulation or California law) that is stricter - that is PROVIDES GREATER PRIVACY PROTECTION TO CLIENTS and PROVIDES CLIENT WITH GREATER ACCESS AND CONTROL. |
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HIPAA's Privacy Rules
Requires providers: |
1) inform clients of their privacy policies 2) grand client access to their health information 3) obtain client authorization before sharing information for non routine purposes 4) secure client records 5) inform business associates of privacy practice 6) train employees on privacy procedures |
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Access to Health Information |
* HIPAA regulations for denying access to records PREEMPTS California (HIPAA is more strict, meaning, it makes it harder for provider to deny, more accessible for patients)
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HIPAA - distinguishes between circumstances in which the client does and does not have the right to request a review of the denial of record review |
* client does not have the right to request a review of a denial when the information is exempt from the right to access (the request is for PHI that was complied for use in a criminal, civil, or administrative hearing) or the PHI was obtained from someone other than the health care providers under a promise of confidentiality. |
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Psychotherapy notes |
* HIPAA permits (does not require) psychologist to maintain 2 sets of records
* under HIPAA, clients do not have the right to review psychotherapy notes
* California law, preempts HIPAA, upon request, psychologists provide the client with a copy or summary of notes. They may decline if there is a lawful reason for doing so. |
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Amendment of Health Information |
* HIPAA, clients have the right to request an amendment if they believe it is incorrect * provider may deny if : a) the info was not created by the provider, unless the person who created is not available to make the amendment b) the information is not part of the designated set or is not available for inspection c) the providers believes the information is accurate and complete |
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Consent and Authorization to Disclose Health Information |
* august 2002, eliminated the need for a health care provider to obtain consent from a patient prior to using or disclosing PHI for the purpose of tx, payment or health care operation (TPO). * however, to best protect the rights of clients, psychologist should usually obtain a written or verbal consent from clients prior to using or disclosing PHI to 3rd parties, unless there is a valid reasons for not doing so. |
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HIPAA privacy rule |
* written authorization from the client is ordinarily required prior to disclosing individually identifiable PHI for resins other than TPO and prior to releasing psychotherapy notes to a 3rd party. The authorization must include a description of the information to be disclosed and limitations on the type of inf that will be disclosed, name and function of person, expiration date, right to receive cody and revoke. |
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It is not necessary to obtain an authorization when: |
* releasing de-identified information or when PHI or psychotherapy notes must be disclosed to avert a serious thereat to the health or safety of the client or another person |
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Competence
Scope of Competence |
Illegal * shall not function outside his particular field or files of competence (...) established by his education, training and experience. * the board may refuse to issue any registration or license, or may issue license with conditions or may suspend or revoke it for unprofessional conduct, such as practicing outside of of field of competence. |
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Scope of competence |
Unethical: * psychologists provide services only within the boundaries of their competence, based on their education, training, supervised experience, consolation, stud or professional experience. * may provide such services to ensure that services are not denied; the svs are discontinued as soon as the emergency has ended or appropriate svs are available. |
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Personal Problems |
* psychologists are legally and ethically obligated to take appropriate actions whenever personal problems or other factors might interfere with their ability to provide effective services. |
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Confidentiality and Privilege
Confidentiality |
* refers to the obligation of psychologists to protect clients from unauthorized disclosure of information revealed in the context of a professional relationship. |
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Confidentiality disclosures: |
1) psychologists MAY disclose conf. info w/ the consent of the client or another legally authorized person unless prohibited by law 2) psychologists MAY disclose con.info w/o the client's consent only as mandated by law, or where PERMITTED by law for a valid purpose purpose such as: a) provide needed professional svs b) obtain appropriate professional consultations c) protect the client or others from harm d) obtain payment f/ client (limited disclosure) |
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REQUIRED Legal confidentiality breaches:
* psychologist is legally required to break client confidentiality in the following situations: |
1) client communicates serious threat of physical violence against a reasonably identifiable victim(s). 2) psychol. has a reasonable cause to believe a client is a danger to self and disclosure is necessary to avert it 3) within professional role, learns/suspects minor, elderly, dependent adult abuse 4) court orders to release records or testify 5) Patriot Act - prove certain info to FBI and not tell client or anyone |
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Privilege
* legal term that refers to a person;s right not to have confidential information revealed in a legal proceeding |
* HOLDER OF THE PRIVILEGE a) the client b) guardian, conservator c) personal representative if patient is dead * only holder can waive privilege (or court has determined that exception to privilege applies)
Who can claim, assert, invoke privilege? * client (or representative) and therapist (?) |
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Privilege and parents/guardians part 1 |
* EC Sections 1013 specifies "guardians" and "conservators" as holding the privilege, not "parents". Also, several court decisions have confirmed that minors hold the privilege in California, even though they typically rely on adults to claim or waive the privilege on their behalf. |
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Privilege holding and claiming |
* although client (or guardian/representative) is the HOLDER of the privilege, a therapist can CLAIM the privilege on behalf of the client when asked to disclose confidential information in a legal proceeding. * the 1st time therapist is asked to disclose confid. info. while providing testimony, he should state that he is claiming the privilege on client's behalf. Therapist then release the info only if ordered to do so by the court or the client (represent). |
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Exceptions to Psychotherapist-Patient Privilege
Privilege does not apply in legally defined circumstances, including the following: |
1) client authorizes a release of information
2) psychologist is legally mandated to breach confidentiality (child abuse, etc)
3) the client has disclosed a significant part of the information to a third person
4) the situation represents a legally defined expect ions of privilege* |
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Legally defined exception to privilege:
4 of 9 |
1) patient-litigant exception (1016) patient emotional condition has been raised as an issue by the patient or the patient's representative. 2) therapist has been APPOINTED by the court to examine a defendant, to help determine defendant's competence to stand trial (sanity) 3) APPOINTED by the Board of Prison Terms to evaluate inmate to determine need for MH tx 4) crime or tort - therapist was sought to enable or aid anyone to commit or plan a crime or escape detection or apprehension
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Legally defined exception to privilege:
5-7 of 9 |
5) when therapist or patient alleges a breach of duty arising out of therapeutic relationship. 6) in a proceeding initiated at the request of the defendant in a criminal action to determine sanity (unless requested by defense attorney) 7) (1024) - MAY contact whomever is necessary, if has a reasonable cause to believe that the patine is in such a mental or emotional condition as to be dangerous to himself, others, or to the property of others and that disclosure of the communication is necessary to prevent the threatened danger. |
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Legally defined exception to privilege:
8 and 9 |
8) there is no privilege in a proceeding brought by or on behalf of an individual to establish his/her competence. 9) there is no privilege when the patient is under the age of 16 and the psychotherapist has reason to believe that the patent has been the victim of a crime and that disclosure of conf. info is in the best interest of patient. |
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Client Notices |
1) Notice to Consumers - place NOTICE TO CONSUMERS in a conspicuous place in their office. Information in how to contact the board for questions and complaints. 2) Notice of Privacy Practices - HiPAA requires psychologists to give a Notice of PP to clients at the beginning of or prior to the first therapy session, to provide a copy of the NPP to clients when requested, and post the NPP is a prominent place in their office. (written?) |
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Informed Consent (Capacity, Comprehension, Voluntariness) |
A. in research, assessment, therapy, counseling, or consulting in person or via electronic transmission or other forms, psychologists obtain the informed consent of the individuals using language that is reasonably understandable to that person except when conducting such activities without consent is mandated by law or government regulation or as otherwise provided in this Ethics Code. |
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Informed Consent |
B. for persons who are legally incapable of giving informed consent, psychologist nevertheless provide an appropriate explanation, seek the individual's assent, consider such persons' preferences and best interested, and obtain appropriate permission from a legally authorized person, if such substitute consent is permitted or required by law. when consent by a legally authorized person is not permitted or required by law, psychologist take reasonable steps to protect the individual's rights and welfare. |
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Informed Consent |
C. when psychological services are court ordered or otherwise mandated, psychologist inform the individual of the nature of the anticipated services, including whether the services are court ordered or mandated and any limits of confidentiality, before proceeding. D. psychologist appropriately document written or oral consent, permission, and assent. |
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Informed Consent
Telehealth |
* a psychologists obligations related to obtaining an "informed consent" are determined primarily by ethical requirments * an exception is Section 2290.5, which requies health care providers to obtain VERBAL consent from clients prior to providing tele health services and to document the consent in the client record. * to provide therapy over the internet to residents of California, the provider must be licensed in California. |
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Client Records
Confidentiality of Records |
a) psych. must maintain confidentiality in creating, strong, accessing, transferring, and disposing of records under their control, whether those are written, automated, or in any other medium b) if info is entered into databases or systems of records avail be to persons shoe access had not been consented to by the recipient, psychologists use coding or other techniques c) psych. make plans in advance to facilitate the transfer and protect confidentiality in the event of psych. withdrawal from positions or practice. |
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Duration of Record Retention |
Section 2919 - 7 years from the patient's discharge date
minor - 7 years from the date the patient reaches 18 yo |
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Electronic Recordkeeping |
a) providers keeping electronic recordkeeping services shall comply with teha dditional requirements of this sections. DO NOT APPLY TO PAITNE RECORD IF HARD COPY VERSIONS OF THE RECORDS ARE RETAINED. b) shall ensure the safety and integrity . set forth in subdivision a) employ an offside backup storage system, an image mechanism that is able to copy signature documents and a mechanism to ensure that oct a record is input, it is unalterable. c) hard copies may be destroyed once the record has been electronically stored. |
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Client Access to Records |
* there are circumstances in which HIPAA requirements preempt Ca law. * PSYCHOLOGISTS MAY DENY A CLIENT ACCESS TO HIS RECORD IF THEY HAVE DETERMINED THAT ACCESS IS REASONABLY LIKLEY TO ENDANGER THE LIFE OR PHYSICAL SAFETY OF THE CLIENT OR ANOTHER PERSON" (HIPPA) preempts Ca that allows access denis if "substantial risk of significant adverse or detrimental consequences". * HIPPA PREEMPTS BECAUSE CA GIVES CLIENTS LESS CONTROL over their records. |
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Client Access to Psychotherapy Notes |
Ca Section 123115 preempts HIPAA, because HIPAA allows for an absolute non-reviewable denial of access but Ca law does not. * CA LAW - UPON REQUEST FORM A CLIENT, PSYCHOLOGIST MAY GIVE THE CLIENT ACCESS TO THE COMPLETE PSYCHOTHERAPY NOTES OR A SUMMARY OF THEM OR MAY DECLINE TO PROVIDE PSYCHOTHERAPY NOTS IF THERE IS A LEGAL REASON FOR DOING SO. |
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An adult client, a minor client authorized by law to consent to tx, and a client representative are entitled to have access to client's record but... |
Ca law: * must present provider with a written request * pay reasonable clerical costs
HIPAA - also for hipaa regulations as long as the provider has informed the client that he only accepts a written request. |
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H&SC Section 123110 (j)... |
prohibits health care provides from withholding patient records or summaries of patient records because of an unpaid bill for health care services. (not consistent w/ ethics code, which says may not withhold for an emergency). Law supersedes ethics code in this case) - DO NOT WITHHOLD for LACK OF PAYMENT. |
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Time Frame for Responding to Request for Access of Records (H&SC) |
* must permit client to inspect records during business hours within 5 working days * must ensure a copy is transmitted to the client or representative within 15 days of receipt of written request * make summary available within 10 work. days * for extraordinary length or because patient was discharged from a licensed health facility whiten the last 10 days, summary will be competed in no more than 30 days after request |
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Multiple Relationships
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* psych. refrain from entering into a multiple relationship if it could reasonably be expect to impair the psychologist's objectivity, competence, or effectiveness, (...) or otherwise risks exploitation or harm to the person (...)
MULTIPLE RELATIONSHIPS THAT WOULD NOT REASONABLY BE EXPECTED TO CAUSE IMPAIRMENT OR RISK EXPLOITATION ARE NOT UNETHICAL. |
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Multiple Relationships |
* when psych. are required by law, institutional policy, or extraordinary circumstances to serve in more than one role in judicial or administrative proceedings, at the oust they clarify role expectations and the extend of confidentiality and thereafter as changes occur. |
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Multiple Relationships In the Forensic Settings |
* when psych. are required by law, institutional policy, or extraordinary circumstance to serve in more than one role in a forensic setting, they must clarify role expectations and issues related to confidentiality. Only accept dual role when unavoidable. * when requested or ordered to provide either concurrent or sequential forensic and therapeutic svs, practitioners are encouraged to disclose the potential risk and make reasonable efforts to refer the request to another provider. When refer. not possible, psych. must consider the risks and benefits for all parties and must seek to minimize the potential negative effects of this circumstance. |
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Fees for Services |
* as early as feasible in a professional or scientific relationship, psych. and recipients reach an agreement specifying compensation and billing * psych.'s fee practices are consistent w/ law * psych. do not misrepresent their fees * if limitations of finance can be anticipated, this is discussed w/ the recipient as early as feasible * if the recipient does not pay and psych. intend to use collection angencies or legal measures to collect fees, psych. 1st inform the person that such measures will be taken and provide that person an opportunity to make prompt payment |
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Fees for Services (collection) |
* when psych. has unpaid fees, he should 1st discuss the matter with the client to attempt to reach an agreement. If mutually acceptable agreement cannot be reached, a psychologist MAY use a collections agency but only after notifying the client of the intention and giving the client an opportunity to pay fees WITHIN A SPECIFIED PERIOD OF TIME. * the psych. should also notify clients of their policy regarding the use of collection agencies as part of the informed consent process at the beginning of treatment * gives collections agency only essential info (name, address, amount owed) |
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Fees for Services (non payment) |
* psychologist are NOT obligated to continue treating a client who does not pay for services in the manner that was agreed upon but MAY terminate treatment in an appropriate manner |
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Pro Bono Services |
* aspirational principle rather than mandatory * recommended by not required * free sessions should never be used as an enticement to draw new clients into a psychologist's practice |
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Barter |
psychologists MAY barter only if it is not clinically contraindicated, and the resulting arrangement is not exploitative. * when considering bartering consider: psych theoretical orientation, client's diagnosis and dependency needs, expected duration of tx, the the nature of bartering arrangement. (housekeeping, childcare is clearly contraindicated) |
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Referral Fees |
* when psychologists pay, receive payment from, or divide fees with another professional, other than in a employer-employee relationship, the payment to each is based on the services provided (clinical, consultative, administrative, other) and is not based on the referral itself.
* PAYING REFERRAL FEES IT NOT PROHIBITED but, they must be based on the actual costs ad services provided and not simply on the referral itself.
* in addition, paying, offering to pay, accepting or soliciting any consideration, compensation, or remuneration whether monetary or otherwise for referral is unprofessional conduct (sec 2960) |
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Insurance-Related Matters |
Insurance fraud - both illegal and unethical
* psych take reasonable steps to ensure accurate reporting of the nature of svs. provided or research conducted, the few, charges or payments, and where applicable, identity of the provider, the findings, and the diagnosis.
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Insurance Fraud: |
1) routinely waiving copayments w/o notifying insurance company
2) billing for missed appts without the insurance company knowing that you are doing so
3) assigning an incorrect diagnosis on an insurance form |
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Interruption of Services |
* psych make reasonable efforts to plan for facilitating svs in the event that psychological svs are interrupted by factors such as the psych. illness, death, unavailability, relocation, or retirement or by the client's relocation or financial limitations |
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Termination of Therapy |
a) psych terminate therapy when it becomes reasonability clear that patient no longer needs the svs, is not likely to benefit, or is being harmed by continued svs b) pscyhologist MAY terminate therapy when threatened or otherwise endangered by pt or another person w/ whom pt has relationship c) except where precluded by the actions of pts. or 3rd party payers, prior to termination, psych provide pre termination counseling and suggest alternative svs provider as appropriate |
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Relationships with Colleagues and Other Professionals |
* psych cooperate with other professionals in order to serve their its effectively/appropriately * obtain consultation - when consulting, psych do not disclose confidential info that reasonably could lead to the identification of a pt, research participant, or other person or organization with whim they have a confidential relationship unless they have obtained prior consent or disclosure cannot be avoided. * they disclose info only to the extent necessary for consultation |
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Services from Another Mental Health Professional |
* if a pt or prospective pt is receiving services from another mental health professional, the psych must carefully consider the tx issues and the potential pt's welfare. In addition, the psych should discuss these issues with the client, consult with the other professional when appropriate, and proceed with caution and sensitivity to the therapeutic issues. |
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Advertising |
* section 1397 permits licensed psych to advertise professional svs. * must include license # in advertisement * section 651 so long as such advertising does not promote the excessive or unnecessary use of such svs. * section 17508 (...) unlawful (...) to make any false or misleading advertising claim, including claims that 1) purport to be based on factual, objective, or clinical evidence, 2) compare the product's effectiveness or safety to that of other brands or products, or that 3) purport to be based on any fact. |
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Advertising |
* psych do not make false, deceptive, or fraudulent statements concerning their training, or competence, their academic degrees, their credentials, their institutional or association affiliations, their services, the scientific or clinical basis for, or results or degree of success of, their services their fees, their publications or research findings. |
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Advertising |
a) psych who engage others to create or place public statements that promote their professional practice, products, or activities retain professional responsibility for such statements b) psych do not compensate employees of press, radio or tv, in return for publicity c) paid advertisement must be identified as such |
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Testimonials |
* psychologists do not solicit testimonials from current therapy pts or other persons who because of their particular circumstances are vulnerable to undue influence. |
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Solicitation of Business |
* psych do not engage, directly or through agents, in uninvited in-person solicitation of business from actual or potential therapy pts or other person who because of their particular circumstances are vulnerable to undue influence. However this prohibition does not preclude 1) attempting to implement appropriate collateral contact for the purpose of benefiting an already engaged therapy pt, 2) providing disaster or community outreach svs |
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Treatment of Minors
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minors (persons under 18 yo) cannot consent to their own treatment except in legally defined situations... |
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Emancipated Minors (Section 7050 e) |
* shall be considered an adult for the purpose of consent to medical, dental, or psychiatric care, w/o parental consent, knowledge or liability. Considered emancipated when he/she meets ANY of the following conditions: a) has entered into a valid marriage (dissolved or not) b) minor is on active duty w/ US armed forces c) received a declaration of emancipation f/court |
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Court may emancipate a minor when it finds that emancipation would not be contrary to the minor's best interests and when all of the following conditions are met: |
1) minor is at least 14 2) is living separate and apart from his parents or guardian w/ the consent or acquiescence of the parents/guardian 3) is managing his own financial affairs 4) doe not obtain his or her income from criminal activity |
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Emancipated minors and child abuse reporting |
* Emancipation does not change the driving, drinking or voting age.
* statutory rape laws apply to emancipated minors except when the minor is legally married and the sexual activity was with his/her spouse |
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Consent to Treatment by Unemancipated Minors
Mental Health Services section 124260 |
1) MENTAL HEALTH SVS - at least 12 yo and "mature enough to participate intelligently", determined by a professional person a) shall include the involvement of parent or guardian, unless the professional person determines that it would be inappropriate b) parent/guardian not liable for payment, unless they participate in the MH treatment. c) does NOT apply to minors who are receiving benefits under the Medi-Cal program and it does NOT permit minors to consent to inpatient MH tx or to receive psychotropic drugs, convulsive therapy or psychosurgery w/o consent or parent or legal guardian. (?clarify?) |
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Consent to Treatment by Unemancipated Minors
Mental Health Services (section 6924) |
* minor who is at least 12 yo can consent to outpatient MH svs by a profession person, a runaway house or crisi resolution center, or a government agency or agency contracting with a government agency or receiving community united funds (Medi-Cal) . * must be able to participate intelligently but also the minor "would present serious physical or mental harm to self or other without the svs or... is the alleged victim of incest or child abuse". This sections requires that the tx involve the minor's parents or guardian. (??) |
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Consent to Treatment by Unemancipated Minors
Substance Abuse Treatment |
* minor who is 12 or older may consent to medical care and counseling relating to the diagnosis and tx of a drug aor alcohol related problems. Does not authorize minors to receive replacement narcotic tx without the consent of parent/guardian. |
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Disclosure of Records of Minors to Parents/Legal Guardians |
* minors have the right to inspect or obtain a copy their own records when they pertain to health care for which the minor has consented or could have consented as permitted by law. In these situations, a health care provider should not ordinarily share records of confidential info w/ the minor's parents or guardian w/o the minor's authorization. |
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Disclosure of Records of Minors to Parents/Legal Guardians |
1) when records DO NOT pertain to health care for which the minor has legally consented or could have consented, the parents or guardian ordinarily have the right to have access to the minor's records. An exception: provider MAY refuse to provide access to parents when he determines that "access would have a detrimental effect on the provider's professional relationship with the minor, or the minor's physical safety or psychological well-being" * in this case, provider must include a written descriptions of the reasons for denial and permit access by another professional designed by request of patient. Consistent with HIPAA |
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Section 123115 a |
Applies to the denial of access to the parents of minor clients who are not legally permitted to consent to their own treatment, while other regulations apply to the denial of access to clients themselves, which induce adult clients and minor clines who are legally allowed to consent to treatment (?) |
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Access by parents (divorced) |
* notwithstanding any other provision of law, access to records and information pertaining to a minor child, including but not limited to, medical, dental, and school records, shall not be denied to a parent because such a parent is not the child's custodial parent (physical custody). |
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Tarasoff v. Board of Regents of the University of California (1974) |
* initially established a psychotherapist's duty to warn but now duty to protect the intended victim by warning him or her, notifying police and taking other reasonably necessary steps.
Section 43.92 - immunity statute designed to protect psychotherapists from monetary liability when a pt communicates a "serious threat of physical violence against a reasonably identifiable victim(s)" and the therapist dischargers the dirty to protect . |
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Determining Duty to Protect |
1. psych must determine that there is a REASONABLY IDENTIFIABLE VICTIM, and SERIOUS THERAT OF PHYSICAL VIOLENCE (grave bodily injury).
2. In 2004, Ewign v Goldstein, included communication from patient's "family members". This decision DOES NOT GO BEYOND IMMEDIATE FAMILY MEMBERS. |
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EC Section 1024 |
* there is no psychotherapist-patient privilege if "the psychotherapist has reasonable cause to believe that the patent is in such mental or emotional condition as to be dangerous to himself or to the person or property of another and that disclosure of the communication is necessary to prevent the threatened danger. * the disclosure is made to a person or persons reasonably able to prevent or less the threat, including the target of the threat. |
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Duty to Protect DOES NOT APPLY if |
1) someone other than the pt is the dangerous party
2) someone other than a family members reports the pt has threatened to harm someone
3) there is no reasonably identifiable victim |
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Involuntary Commitment and Conservatorship
Involuntary Commitment |
* regulations related to involuntary commitment are provided in the Lanterman-Petris-Short Act |
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WIC Section 5150 (72 hour hold) |
* 72-hour hold * when any person, as a result of a MENTAL DISORDER, is a danger to others, or to himself, or gravely disabled, a peace officer, a member of the attending staff of an evaluation facility designated by the county, designated members of a mobile crisis team, or other professional person designated by a county (...) place him in a facility approved by the state dept of MH, for 72-hr tx and evaluation. |
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Gravely Disabled |
section 5008 h 1 - a condition in which a person, as a result of a MENTAL DISORDER, is unable to provide for his or her basic personal needs for food, clothing or shelter.
mental disorder - the law does not define mental disorder for the purpose of involuntary hospitalization under 5150. However, Ca courts have usually interpreted it to include any significant mental disorder in the current DSM |
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WIC Section 5152 (?)
(at the end of the 72 hr period, the facility must release the individual, refer him to voluntary tx, certify him for additional involuntary tx, or begin the process of appointing a conservator) |
* requires that each person admitted to a facility for 72-hr tx and evaluation under the provisions of this article shall reeve an evaluation as soon after he is admitted as possible and shall receive whatever tx and care his condition requires for the full period that he is held. The person shall be release before 72 hr have elapsed only if psychiatrist that person no longer requires evaluation or tx. If other professional and psychiatrist disagree w/ release, matter shall be referred to medical director of the facility |
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WIC Section 5250 - initial 14-day hold |
* permits a person who has been detained for 72hr to be certified for up to 14 additional days for MH or chronic alcoholism: a) as the result of the MH of chronic alcoh. the person is a danger to self or others or is gravely disabled b) the person has been advised that tx is required but has not voluntarily consented to it |
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Sections 5251 and 5253 |
* require that a notice of certification be signed by 2 people (the professional person or his designee in charge of the facility or agency or psychologist who participated in the evaluation) and that a copy of the notice be personally delivered to the person certified, the person's attorney or other attorney or advocate designated in the certificate |
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Sections 5251 and 5253
(at the end of the 14 day period, the facility must release the individual, refer him to voluntary tx, certify him for additional involuntary tx, or begin the process of appointing a conservator) |
* in addition, the individual delivering the certification nice must inform the person that he is entitled to a certification review hearing to determine if there is sufficient reason to detain him (section 5254) or to a judicial review by writ of habeas corpus to ask for release from the certification. Section 5256 requires that unless the person has requested a judicial review, the certification review hearing must be held within 4 days of the date on which her person is certified unless the person or his attorney or advocate requests a postponement. |
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Postcertification Holds |
* the type of post certification hold that may follow the initial 14 day hold depends on whether the person is suicidal, gravely disabled, or poses a serious danger to others. |
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WIC Sectin 5260 - Suicidal Behavior |
* may be confined for further intensive tx for an additional period not to exceed 14 days
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WIC Section 5270.15 - Gravely Disabled |
* person may be certified for an additional period of not more than 30 days of intensive tx under both of the following conditions: a) person remains gravely disabled as a result form a mental disorder or chronic alcoholism b) person remains unwilling or unable to accept tx voluntarily |
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WIC Section 5300 - Serious Danger to Others |
* a person may be confined for further treatment pursuant to the provisions of this article for an additional period, not to exceed 180 days. |
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Conservatorship |
* a conservator may be appointed by the court for any person who is gravely disabled as the result of a mental disorder or impairment by chronic alcoholism. Conservatorship may be temporary (30 days) or long term (for renewable one-year periods) |
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Involuntary Commitment of a Minor WIC Section 5585.50 |
* minor, as a result of a mental disorder is a danger to others, self or gravely disabled and an authorization for voluntary tx is not available (...) take the minor into custody and place him in a facility designated by the county and approved by the State Dept of MH for 72-hour tx and evaluation of minors. The facility shall make every effort to notify the minor's parent/guardian as soon as possible after minor is detained. |
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Child Abuse Reporting
Reporting Requirements |
* as legally mandated reporters, psychologist must report known or suspected cases of abuse and neglect of children and adolescents under the age of 18, including minors who are emancipated. In addition, a report must be made whether the perpetrator is an adult or a child. |
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Mandated Reporting of Child Abuse |
* mandated reported shall make a report to an agency whenever the mandated reporter, in his professional capacity or within the scope of his employment, has knowledge of or observes a child whom the mandated reporter knows or reasonably suspects has been the victim of child abuse or neglect. * Shall make than initial report immediately or asap by telephone and prepare and send (fax, electronically) a written follow up reported within 36 hrs of receiving info. |
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Reporting suspected child abuse or neglect |
* shall be made to any police department or sheriff's dept, not including a school district police or security dept, county probation dept, if designated by the county to receive mandated reports, or the county welfare dept. * Note that the county welfare dept is also referred to as the county welfare service (CWS) agency and child protective services (CPS) |
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When 2 or more persons who are required to report jointly have knowledge of a known or suspected of child abuse or neglect... |
* they can make an agreement, and the telephone report may be made by a member of the team selected by mutual agreement and a single report may be made and signed by the selected member. * any member who has knowledge that the designated member has failed to do so, shall therefore make the report. |
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Acts that Must the Reported |
1) Physical Injury or death - that is inflicted by other than accidental means on the child by another person. 2) Sexual abuse - which includes sexual assault and sexual exploitation. |
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Sexual Assault and sexual exploitation |
Sexual Assault - includes rape, statutory rape, rape in concert, incest, sodomy, lewd and lascivious acts, oral copulations, sexual penetration, ad child molestation.
Sexual exploitation - includes preparing, selling or distributing pornographic materials involving a minor, employing a minor to perform in pornography, and employing or coercing a child to engage in prostitution. |
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Mandatory Child Abuse Report |
* note that mandated reporters must report sexual intercourse or other sexual activity with a minor under 18 yo when they have a reasonable suspicion that the activity was not consensual, even when the minor claims it was consensual and regardless of the partner's age.
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Lewd and lascivious acts involving a minor MUST ALWAYS BE REPORTED regardless of consent when: |
a) minor is under 14 yo and the partner is 14+ b) minor is 14 yo and the partner is 24+ c) minor is 15 yo and the partner is 25+ |
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Willful harm or injury |
* refers to a situation in which any person willfully causes or permits any child to suffer, or inflicts thereon, unjustifiable physical pain or mental suffering, or having the care or custardy of any child, willfully causes or permits the person or health of the child to be place in a situation in which his or her person or health is endangered. |
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Unlawful corporal punishment or injyrt |
* person willfully inflicts upon any child any cruel or inhuman cop oral punishment or injury result in a traumatic condition.
* it does not include force necessary for a person employed by or engaged in a public school to quell a disturbance threatening physical injury or property damage, self-defense, or to obtain possession of weapon or other dangerous object |
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Neglect |
* negligent tx or the maltreatment of a child by a person responsible for the child's welfare (...) indicating harm or threatened harm to the child's health or welfare. * includes both acts and omission * severe and general neglect |
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Acts that MAY be reported |
* psychologists ARE NOT REQUIRED to report "serious emotional damage" but MAY do so.
* "... evidenced by states of being or behavior, including but not limited to, severe anxiety depression, withdrawal, or untoward aggressive behavior toward self or others..." |
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Immunity form Liability for Making a Required Report |
* mandated reports have immunity from criminal and civil liability for making a report and it applies EVEN WHEN the knowledge or reasonable suspicion of abuse was acquired outside the reporter's profession capacity or scope of employment.
* any other persons has immunity unless the report is false and person either knew it was false or made it with "reckless disregard of the truth or falsity of the report" |
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Liability for Failing to Make a Required Report of Child Abuse |
* criminal penalties MAY be imposed on a mandated reported who fails to make a required report * that failure MAY also lead to civil liability as well as disciplinary action by the licensing board
* misdemeanor, up to 6 mo jail, $1000 (or both) * if there is death or great bodily injury: no more than 1 year jail, $5000 fine or both |
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Adult who were abused As Children |
* unless the victim is still under 18 a mandated reported is not required
* psych should be alert to the possibility that an adult client's abuse may be currently victimizing other children, and is there is reasonable suspicion, must file a report
* if doubts or insufficient info, call CPS anonymously to ask for guidance |
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Elder and Dependent Adult Abuse Reporting |
* an elder is any person residing in California who is 65 yo of age or older * dependent adult is any person between the ages of 18 and 64 who resides who resides in Ca and "has physical or mental limitations that restrict his or her ability to carry out normal activities or to protect his or her rights, including, but not limited to, persons who have physical or developmental disabilities, or whose physical or mental abilities have diminished because of age... or who is admitted as an inpatient to a a 24 hr health facility. |
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Reporting elder and dependent adult abuse
* any mandated reporter who, in his professional capacity or scope of employment, has observed, has knowledge or has been told by an elder or dependent adult that he/she: |
"has experienced behavior, including an act or omission, constituting physical abuse... abandonment abduction, isolation, financial abuse, or neglect, or reasonably suspects that abuse, shall reported the know or suspected instance of abuse by telephone or through a confidential internet reporting tool immediately or asap. A written report shall be sent, or an internet report within 2 working days. |
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The agency authorized to receive a sport of elder/dep adult abuse depends on where the abuse occurred and the type of abuse
Long-term care facility (except state mental health hospital or state developmental center) |
w/ serious bodily injury - telephone report to local law enforcement agency immediately (and no later than within 2 hours) and written report to local ombudsman, corresponding licensing agency and local law enforcement agency within 2 hrs. w/o serious bodily injury -telephone report to local law enforcement agency within 24 hrs and written report to local ombudsman, corresponding licensing agency and local law enforcement agency within 24 hrs. |
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Long-term care facility (except state mental health hospital or state developmental center) |
physical abuse without serious bodily injury that is believed to be came by a resident with a diagnosis of dementia - telephone report to local ombudsman or law enforcement agency immediately or asap and written report to local ombudsman, coring licensing agency, and law enforcement agency within 24 hrs. abuse other than physical abuse - telephone report and written report to local ombudsman or local law enforcement agency. |
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State Mental Health Hospital or State Developmental Center |
abuse of neglect involving death, sexual assault, ass.deadly weapon by nonresident, injury to the genitals and broken bone when cause unknown - telephone report to designated investigator soy the state department of state hospitals or to state dept. of developmental svs. AND to local law enforcement agency immediately (no >2hrs) all other types of abuse or neglect - telephone report to designated investigator soy the state department of state hospitals or to state dept. of developmental svs. OR to local law enforcement agency immediately (no >2hrs) |
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Any other Location |
all types of abuse - telephone report to adult protective services agency or local law enforcement agency immediately and written reports to adult protective service or local enforcement within 2 working days. |
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A mandated reporter it NOT required to file a report when the reporter has been told by an elder or dep. adult that he has experienced an acti that constitutes reportable abuse BUT ALL of the following conditions apply: |
* mand. reporter doesn't have any independent corroborating evidence abuse occurred * the adult has received a diagnosis of dementia or a mental illness or is the subject of a court-ordered conservatorship due to demen/m.illnes * based on his clinical judgment, reporter reasonably believes that abuse has not occurred. |
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Spousal/Partner abuse |
* psychologist are mandate to report only when the parter being abuse is an elder or dependent adult or is under the age of 18. |
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Types of Elder/Dependent Adult Abuse
Must be reported: |
a) physical abuse (includes physical constraint, prolonged or conintual deprivation of food or water, sexual assault including spousal rape, and lewd and lascivious acts), use of chemical restraint or psychotropic med. punishment b) Abandonment - desertion, willful forsaking c) Abduction - removing an eder or depend adult from California or restraining him from returning to Ca when the elder or d.a. does not have the capacity to consent to the removal or restraint (or conservator has not consented) |
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Must be reported: |
d) Isolation - includes deliberately preventing person from receiving his mail/phone calls; telling a caller/visitor person is not present or does not want to walk; false imprisonment, physical restraint to prevent person f/ meeting with visitors. Except if performed in accord w/ the instructions of a licensed physician or in response to a threat of danger e) financial abuse - a person or entity takes,secretes, appropriates, ore retains real or personal property to a wrongful use with w/ intent to defraud (or assists in doing so) |
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Must be reported: |
f) neglect - fail to care, assist person in personal hygiene, provide food, clothing, shelter, or necessary physical or MH care, or to protect the adult from exalt or safety hazards or from malnutrition or dehydration. Also includes self-neglect that is the result of impaired cognitive functioning, mental limitation, substance abuse , or chronic health problems. |
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Elder or Dependent Adult emotional abuse (and 'other' types) |
* mandated reported MAY make a report if he has knowledge or suspect "that types of abuse for which reports are not mandated have been inflicted, or that his or her emotional feel-being is endangered" |
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Immunity from liability for making a required report: |
* mandated reporters are not civilly or criminally liable fro making a report that is authorized by law, and any other person who makes a report is not civilly or criminally liable unless it can be proven that he know the report was false. |
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Liability for Failing to Make a Required Report |
* misdemeanor, no more than 6 mo jail, no more than $1000 (or both) * if there is death or great bodily injury: no more than 1 year jail, not more than $5000 fine or both |
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Sexual Misconduct |
* psychotherapists may be held criminally and civilly liable for engaging in sexual relations w/ their clients, and sexual misconduct w/ clients may also lead to disciplinary action by the board * in no instance shall consent of the patient be a defense * action exists if contact occurred: a) during the period pt was receiving svs, b) within 2 yrs following termination of therapy, or c) by means of therapeutic deception |
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Sexual Misconduct Disciplinary Action by BOP |
* shall contain an order of revocation (which) shall not be stayed by the administrative law judge. |
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Ethical Standards Pertaining to Sexual Relations |
1) 10.05 prohibits psych from engaging in sexual intimacies w/ current therapy clietns 2) 10.08 psych do not engage in sexual intimacies w/ former pts. for at least 2 yrs after termination; do not engage in sexual intimacies w/ former pts even after a 2yr interval except in the most unusual circumstances (bear the burden of demonstrating there was no exploitation: amount of time that has passed, nature, duration, intensity of therapy, circumstance for termination, pt personal hx, pt current MH status, likelihood of adverse impact, any suggestion by the therapist during the course of therapy inviting sex/rom relationship |
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Sexual intimacies with relatives or significant others of current therapy clients |
* prohibits psych from engaging in sexual intimacies with individuals they know to be close relatives, guardians, or significant others of current patients. It also states that psychologists do not terminate therapy to circumvent this standard. |
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Sexual relationships |
* prohibits psychologists from providing therapy to former sexual partners
* psychologists do not engage in sexual relationships with students or supervises who are in their department, agency, or training center or over whom they have or are likely to have evaluative authority. |
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Sexual Intimacies Between Colleagues and Clients
* when a psychologist learns that a colleague has had sexual relations with a therapy client, the psychologist is ethically and legally obligated to take steps: |
1. if client reports having sex w/ another therapist: a) give client the brochure Professional Therapy Never Includes Sex and discuss the contents. b) file child abuse report if client is a minor;
2. when a colleague discloses that he/she had or is having sexual relationship w/ a client, the psych. should carefully with the ethical and legal implications of taking action. Don't file complain with BOP if violates the client's confidentiality (takes precedence over responsibility to report) |
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Forensic Issues
Definition of Forensic Psychology |
* refers to professional practice by any psychologist working within any sub-disclipline of psychology when applying the scientific, technical, or specialized knowledge of psych to the law to assist in addressing lead, contractual, administrative matters. * professional practice is not necessarily forensic simply because it occurs in a forensic settings. |
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Expert vs Fact Witness
Psychologists may be asked to testify in court as an expert of fact witness |
Expert witness - person who has special training, knowledge, skill,for experience in an area relevant to resolution of the legal dispute and who is allowed to offer an opinion as testimony in court
Fact witness - person testifies to what he has seen, heard, observed regarding a circumstance, event, or occurrence as it actually took place. Generally not allowed an opinion. A fact witness may provide information abut a client in a legal processing only w/ the consent of the client or a court order. |
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Privilege and Confidentiality
Testimonial privilege may be waived by the client ask does not apply in certain legally defined situations: |
* there is no threapist-patient privilege in a proceeding in which a patient's emotional condition has been raised as an issue by the patient or the patient's representative. * not privilege when a psychotherapist has been appointed by the court to evaluate a patient to help the court determined if the defendant is competent to stand trail or ascertain the defendant's state of mind (sanity_ at the time of the crime.
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Forensic Setting Confidentiality |
* when psychological svs are court ordered or otherwise mandated, psych. inform the individual of the nature of the anticipated svs, including whether the services are court-ordered or mandated and any limits of confidentiality, before proceeding. For exam, psych are ordinarily asked to inform the court whether or not a client has attended court-ordered therapy session and to provide the court w/ progress reports. In most circumstances, the client must have signed a release before the psychologist may do so. |
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Informed Consent (Forensic Settings)
psych strive to inform service recipients about the nature and parameters of the services to be provided and to do so "as soon as is feasible": |
* unless court ordered, psych obtain the informed consent of the examinee before proceeding w/ a forensic examination. * if examinee is unwilling to proceed after being informed of the nature and purpose, the psych. may consider postponing the examinations, advising the examinee to contact his attorney, and notifying the retaining party about the examinee's unwillingness to proceed. |
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When a person is ordered or mandated to participate in an examination or treatment.... |
a psychologist can conduct the examination over the objection, and without the consent of the examinee. If the examinee declines t proceeds after being notified of the nature of and purpose, the psych. may consider postponing the examinations, advising the examinee to contact his attorney, and notifying the retaining party about the examinee's unwillingness to proceed. |
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When the person is lacking the capacity to give informed consent... |
* psych. provides an appropriate explanation, seeks the examinee's assent, and obtains appropriate permission from a legally authorized person, as permitted or required by law. |
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The Insanity Defense |
* in any criminal proceeding, (...) he or she was incapable of knowing or understanding the nature and quality of his act of distinguishing right from wrong at the time of the commission of the offense. * this defense shall not be found (...) solely on the basis of a personality or adjustment disorder, a seizure disorder or an addition, or substance intoxication. |
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Subpoenas |
Subpoena - court ordered document requiring a person to appear to give testimony at a deposition or in court. The individuals who may issue a subpoena depend on the type of case (civil or criminal) but include a judge, a court clerk and the attorney for the plaintiff or defendant. Subpoena duces tecum - requires a person to personally bring to the court processing a specified document or property in his possession or under his control. |
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Responding to Subpoenas |
1. a) determine if it is a valid demand, b) if valid, formal response wil be required but 1st, contact the client to discuss the implications of providing the info. If client consents and there are no reasons for withholding info, psychologist should provide the requested information. If client does not consent, psych or his attorney can attempt to negotiate w/the party who issued the subpoena. File a motion to quash the subpoena or a motion for a protective order |
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Responding to Subpoenas |
* when a request for confidential information arises fro the 1st time during court testimony or at a deposition, psych should claim privilege on the client's behalf and refuse to provide information until ordered by the court to do so. * when court issues an order to provide testimony or produce documents and attempts have been unsuccessful, psych must comply. Psych should release to court only info that is relevant to the case and present the subpoenaed records to the court in a sealed envelop marked confidential. It is illegal to destroy or tamper with records for the purpose of avoiding disclosure. |
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Malpractice
for a client or other person to bring a claim of malpractice against a psych., 4 conditions must be met: |
1) psych must have had a professional relationship with the person, legal duty of care 2) there must be a demonstrable standard of care that the psychologist has breached 3) there person suffered harm of injury 4) the psych breach of duty within the context of the standard of care was the proximate cause of the person's harm or injury |
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Licensure Requirements for psychologists
candidates for psychology licensure: |
1) doctorate degree in psychology (ed. psyc, etc) 2) from accredited university, college, prof. scho 3) completed at least 2 years of supervised professional experience 4) passed the required examinations 5) completed coursework - human sexuality - child abuse asses. and reporting - chemical dependency - spousal or partner abuse - aging and long term care |
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Individuals licensed in another state... |
* may offer psychological services in this state for a period not to exceed 30 days in any calendar year. |
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Individuals licensed in another state who want to become licensed in California.... |
* must pass the board's supplemental licensing examination * at the time of the application be licensed for at least 5 years by a psychology licensing authority in another state or Canadian province (if substantially equivalent) * person may perform activities and svs without a valid license for a period not to exceed 180 calendar days from the time of submitting his application or from the commencement of residency in this state, whichever is 1st.
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Supervised Professional Experience (SPE) |
* 2 years of qualifying SPE must be completed prior to licensure, 1 year being defined as 1500 hrs. At least 1 yr must be postdoc, each yr must be competed within a 30 consecutive month period. * if both years fare completed posdoc, they must be competed within a 60 month period. |
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Predoctoral SPE may be accrued: |
1) in a formal placement (APA, APPIC or CAPIC) 2) as an employees of an exempt setting 3) as a psychological assistant with registration with the board 4) pursuant to a Dept of MH waiver |
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Postdoctoral SPE bay be accrued: |
1) inf a formal postdoc training program (APA or APPIC) 2) as a registered psych. w/ registration w/ BOP 3) as an employee an an exempt setting 4) as a psychological assistant w/ registration w/ the board 5) pursuant to a dept of menta health waiver |
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Requirements for SPE:
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a. supervison for at least 10% of total weekly work time, at least 1 hr face to face w/ primary supervisor. no more than 44 hr/week work b. primary superv. must be employed by the same work setting, available 100%, any technol. c. primary superv. must have plan protect pt. d. SPE cannot be accrued if supervisee is working under another license e. SPE shall not be obtained from supervisors who have received payment for supervision f. trainees must have no proprietary interest in the business of the primary or delegated superv or serve in any capacity of influence over them g. parties must sign SEP agreement prior to start * supervisees must keep weekly hour log |
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Primary Supervisors |
* all primary supervisors shall be licensed psychologist, except that board certified psychiatrists may be primary supervisors of their own registered psychological assts. (max 750 hrs out of required 3000) * must posses a valid license, free from disciplinary action * must ensure training, ed., exp. in areas supervi
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Primary Supervisors part 2 |
* complete a minim 6hr coursework/every2yrs * primary supervisors are responsible for ensuring that the trainee complies w/ the provisions of the law and APA * responsible monitoring welfare of trainee's pts * monitoring the performance and prof devel
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Primary Supervisors part 3 |
* ensure each client is informed prior to receiving svs from trainee that trainee is unlicensed being supervised, supervisor has full access to records, any fees pay for the trainee's sv must be paid directly to supervisor/employer * do not have family, intimate, business, or other relationship w/ trainee that compromise their effectiveness or violate ethics code * cannot supervise a trainee that has been therapy with supervisor * must not exploit trainees or egange in sex. rel * requires trainees to review pamphlet PTNIS * monitor supervision perform of delegated sup |
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Mandatory Continuing Education (CE)
Initial Renewal: |
* 1st time after the initial issuance is only required to accrue CE for the number of months that the license was in effect, including the month the license was issues, at the rate of 1.5 its of approved CE per month. * no more than 75% can be done via independent learning per renewal period
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Subsequent Renewals |
* 36 hours of approved CE in the preceding 2 years * except for qualified individuals with disabilities who apply, all others, should do no more than 75% (27 hrs) of CE via independent learning each renewal cycle |
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Subsequent Renewal courses |
* person renewing or reactivating must compete a course in law and ethics as it applies to psychology. There is not specific hr requirement * those licensees who began graduate training prior to jan 1, 2004, take CE in spousal or partner abuse. Must be at least 1 hr; t is a 1 time requir * those who began grad training prior. Also aging, long term care. At least 3 hrs, 1 time requi |
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Ethical Violations and Complaints |
* psych. are required to cooperate with the ethics committee. * failure to cooperate is is elf an ethics violation * making a request for deferment of adjudication of an ethics complaint pending the outcome of litigation does not alone constitute noncooperation |
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Handling Ethics violations
* ethic violations by members of the APA can be handled by the ethics committee or other entities such as the state licensing board or the courts. Violations by nonmembers are not within the jurisdiction of APA and must be handled by other entities. |
* upon investigation, the commmitte will dismiss the case or recommend one of the following actions: a) reprimand (there has been a violation but was not a likely to cause harm to another or substantial harm to the profession), b) censure is the appropriate sanction if there has been violation and it was likely to cause harm to another peson but not likely to cause substantial had to another person/profession; c) expulsion - there was violation, it was likely to cause harm to another person or the profession, d) a stipulated resignation may be offered. |
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Ethical Violations by Colleagues |
* encourages psych. to handle ethical violations informally by discussing the matter w/ the offender when an informal resolution appears appropriate. * psych make a formal report to the ethics committee, BOP, or other when the problem involves "substantial harm" and is not appropriate for an informal resolution, or hasn't been resolved by an informal attempt * both standards require confidentiality consideration BEFORE taking any action, which always takes precedence over the need to educate or penalize an offending psychologist. |
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Delegated Supervisors |
* primary superv. may delegate supervision to other qualified psychologists or other mental health professionals (MFT, licensed educational psych, LCSW, board certified psychiatrists) * prim sup remains responsible for min 1 hr per week of face-face |
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Delegated Supervisorpart 2 |
* a regist. psych asst (...) may received delegated supervsion pursuant to to section 1387 c from a qualified psychologst or a board certified psychiatrist other than the supervisor to whom he is registered if the delegated supervsor is also employed within the same organization. (?) |
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Requirement 1) primar superv must be lic psych 2) primar super - 6hrs cour/2yr 3) prima super employed same agency, avail 100% time 4) prima su min 1hr face-face week 5) superv. @least 10% of total hrs 6) # of trainees per prim. superv. |
Psy inter Psy Asst Reg Psy 1) yes no (psychi) yes 2) yes yes (no4psychi) yes 3) yes yes yes 4) yes yes yes 5) yes yes yes 6) no limit 3 psycho no lim. 1 psychi |
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Board of Psychology ActionsIf BOP determines that a consumer complain is valid, may take one of severa actions: |
1. Nondisciplinary actions - usually confidential. Minor violations (fail to commun clear tx plan, billing misunderstanding). * Letter of warning and educational review. * Citations and fines are nondisciplinary but public. |
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Board Actions |
2. for more serious violations, disciplinary action (always public) * letter of reprimand, probation, ans suspension, surrender or revocation of license. |
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Unprofessional Conduct |
* the BOP may order the denial of an application for licensure, issue a license w/ terms and conditions, or suspend or revoke the reigstarion or license of any registrant or licensee wgi gas beeb guilty of unprofessional conduct. |
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Treatments for Mental Disorders
Autism |
1. Educational and Vocational Interventions (TEACCH - tx and education of autistic and related communication handicapped children) 2. Behavioral Interventions (ex: shaping) (ABA) 3. Psychotherapy 4. Parent/Family Interventions 5. Pharmacotherapy |
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Attention-Deficit/Hyperactivity Disorder |
1. Pharmacotherapy (methylphenidate) 2. Behavioral Interventions (classroom behavior. manag., self-instruction/reinforcement) 3. Neurofeedback 4. Parent Education/Training (providing child w/ consistent rules, structured environment, predictable routines) |
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Schizophrenia |
1. Hospitalization 2. Pharmacotherapy a. Traditional (1st generation) antipsychotics b. Atypical (2nd generation) antipsychotics 3. Psychosocial interventions a. Cognitive Behavioral Therapy b. Skills Training c. Family Interventions d. Assertive Community Treatment (community based multidisciplinary team approach designed to prevent relapse, tailored to the needs, available 24 hr a day, case management, housing, etc) e. Supported Employment |
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Bipolar I Disorder |
1. Pharmacotherapy 2. Psychotherapy a. CBT b. Family-focused Treatment (FFT) c. Interpersonal and Social Rhythm Therapy (IPSRT) |
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Major Depressive Disorder
part 1 |
1. Pharmacotherapy a. Selective Serotonin Reupotake Inhibitors (SSRIs) (fluoxetine, fluvoxamine, paroxetine, sert) b. Tricyclic (TCAs) - most effective for "classic" depression that involve vegetative (bodily) sx - they are cardiotoxic c. Monoamine Oxidase Inhibitors (MAOIs) - indiv do not respond to a or b or have atypical sx d. Other Antidepressants - venlafaxine (Effexor), desvenlafaxine (Pristiq), duloxetine (Cymbalta) - serotonin norepinephrine reuptake Inhibitors |
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Major Depressive Disorder
part 2 |
2. Psychotherapy a. CBT (includes activity scheduling, beh. rehearsal, social skills training, relaxation, questioning the evidence, decatastroph., mental imagery, cognitive rehearsal) b. Interpersonal Psychotherapy (IPT) ( dep is traceable to lack of strong attachments early in life. target 4 main areas: unresolved grief, interpersonal role disputes, role transitions, interpersonal deficits)
3. Phototherapy 4. Eletroconvulsive Therapy (ECT) |
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Panic Disorder |
1. CBT (includes self-monitoring, cognitive restructuring, breathing retraining, applied relaxation, in vivo exposure; interoceptive exposure) 2. Panic-Control Treatment (PCT) (4 components: a. info about panic disorder, b. cognitive restructuring helps cl. identify, challenge and replace maladaptive thoughts, c. breathing retraining exercises; d. interoceptive conditioning reduces fear of bodily sensat/anxie 3. Pharmacotherapy risk of relapse is high when drug tx is used alone; combining CBT w/ drugs may not be more effective than CBT alone |
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Generalized Anxiety Disorder |
1. CBT (help pt. tolerate uncertainty, identify, replace maladaptive cognitions, reduce anxiety, psyched., self-monitoring, relaxation training, worry exposure, cognitive restructuring) 2. Applied Relaxation 3. Pharmacotherapy |
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Obsessive Compulsive Disorder (OCD) |
1. Exposure with Response Prevention (ERP) 2. CBT 3. Pharmacotherapy |
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Posttraumatic Stress Disorder (PTSD) |
1. CBT 2. Pharmacotherapy |
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Somatic Symptoms Disorder |
* no specific intervention has been identified as consistently effective |
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Body Dysmorphic Disorder |
* CBT... |
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Anorexia Nervosa |
1. Inpatient treatment 2. CBT 3. Family Therapy 4. Pharmacotherapy |
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Bulimia Nervosa |
1. CBT 2. IPT 3. Nutritional Counseling 4. Pharmacotherapy |
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Sexual Dysfunctions |
1. Sex therapy a. Sensate Focus b. Start-Stop and Squeeze Techniques c. Kegel Exercises
2. Couples therapy 3. Pharmacotherapy |
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Conduct Disorder |
1. Family Interventions 2. Cognitive Problem Solcing Skills Training (CPSST) 3. Multisystemic Therapy 4. Pharmacotherapy 5. Out-of-home Placement |
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Substance Use Disorder |
1. Level of Care 2. Dual Diagnosis Treatment 3. Psychosocial Interventions a. CBT b. Behavioral interventions c. Motivational interviewing d. relapse Prevention e. self help groups f. Group therapy g. Family and COuple Therapy 4. Pharmacotherapy |
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Major and Mild Neurocognitive Disorder |
1. Psychosocial interventions 2. Environmental Manipulation 3. Pharmacotherapy 4. family/Caregiver Interventions |
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Antisocial Personality Disorder (APD) |
1. Milieu/residential Treatment 2. Cognitive behavioral interventions 3. Pharmacotherapy |
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Borderline Personality Disorder |
1. Dialetical Behavioral Therapy (DBT) 2. Tranference-Focused Psychotherapy 3. Mentalization-Based Therapy 4. IPT 5. Pharmacotherapy |
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Treatment for Specific Client PopulationsOlder Adults |
* they benefit from various forms of therapy including brief psychodynamic, behavior th., CBT, and IPT when tailored to their needs * may be necessary to address pt's negative attitudes towards the problem and ability to deal w/them, slow the pace and increase structure of therapy, include family members or other caregivers, address role of physical sx. * Reminiscent therapy and validation therapy are 2 of several interventions that have been developed specifically for older adults. |
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Culturally Diverse Clients:American Indian Clients: |
* common for family members, friends and other community members to participate in healing rituals and other forms of tx * Network therapy, conducted in the individual's home, incorporates family and community members into the tx process, and situates the individual's psychological problem within the context of his family, workplace, community and other social systems. |
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African American Clients |
* generally prefer structured time-limited, problem-solving therapies, interventions that foster empowerment by adopting an egalitarian approach, and family approaches that include the extended family system. * Boyd-franklin recommends a multisystems approach that combines elements of structural and behavioral family therapy and addresses multiple systems, intervenes at multiple levels, and empowers the family by directly incorporating their strengths into intervention. |
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Asian American Clients |
* often expect therapy to focus more on behaviors than on emotions * expect therapist to give concrete advice * view therapist as knowledgeable expert * CBT, solution-focused therapy and other brief structured, goal-oriented, problem-solving approaches that focus on alleviating specific sx * because ind. from collectivist Asian cultures prioritize respect and concert for the needs of others, it may be necessary to modify tx so they incorporate a collectivist perspective. |
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Hispanic/Latino American Clients |
* Culturally adapted behavioral and cognitive-behavioral therapis and other active, directive and solution-focused approaches are generally preferred * include members of the immediate and extended family (familismo) * Aponte's ecostructural family therapy is derived from structural family therapy, was developed specifically for low-income ethnic minorities and is consistent with hispanic/latino culture. Provides intensive family therapy and fosters relationships between the family and community agencies and services. |
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Lesbian, Gay,Bisexual (LGB) Clients
Part 1 |
1. Affirmative Psychotherapy - encourage LGB individuals to accept their sexual orientation and are based on the assumptions that a) homosexuality is a normal variation of human sexuality, b) homosexuality per se is not the cause of pathology and c) to be effective as practitioners of affirmative psychotherapy, clinicians must be aware of the impact of heterosexism on the lives of LGB individuals
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Lesbian, Gay,Bisexual (LGB) Clients
part 2 |
2. Sexual identity Therapy (SIT) developed by Throckmorton and Yarhouse, its goes is "the synthesis of a sexual identity that promotes personal well-being and integration with other aspects of personal identity (cultural, ethnic, relational, spiritual, etc). 3. Phase Specific Psychotherapy - Ritter and Terndrup recommend a phase-specific approach to psychotherapy that addresses the developmental needs of LGB individuals. For example, during phase 1 (sensitization), therapy focuses on empathizing w/ and destigmatizing the client's feelings of alienation and isolation, addressing depression and suicidal ideation, and addressing impulsivity, anger, and other behavioral problems. |
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Victims of Child Abuse
Part 1 |
1. Abuse-Focused Cognitive-Behavioral Therapy (AF-CCBT) - short term tx for children who have been physically abused and their families. It targets child and parent characteristics associated w/ abuse and the family context in which abuse occurs as well as the consequences of the abuse for the child. |
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Victims of Child Abuse
Part 2 |
2. Trauma-Focused Cogntivie Behavioral Therapy (TF-CBT) - short term tx for educing PTSD sx, depression, and behavioral problems in children who have been sexually abuse or have been exposed to other traumatic events. (includes psychoeducation, stress management, affective expression and regulation, gradual exposure through verbal, written, or symbolic recounting of the abuse [trauma narration], cognitive reprocessing and reframing, personal safety skills training, parent training in behavioral management skills, and join parent-child therapy sessions. |
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Victims of Intimate Partner Abuse
Part 1 |
1. Safety Planning - the next step is to conduct a risk assessment, which should take place in private, unless a friend or family member is requested. If safety concern is acute, clinical should discuss immediate options (someone to stay with, how to obtain emergency assist.). Help develop a safety plan and discuss referral sources. 2. Individual Therapy - includes approaches based on crisis intervention models, feminist theory, the stages of change model, and CBT. Survivor therapy combines CB strategies w/ trauma therapy and feminist therapy and emphasizes the woman's strengths.
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Victims of Intimate Partner Abuse
Part 2 |
3. Group Therapy - may be provided alone or in conjunction w/ individual therapy. Abuse-specific groups that include women only are generally recommended and may be led by abuse survivors or mental health professionals. 4. Couples therapy - is controversial, w/ some experts arguing that partners in an abusive relationship should usually be treated separately, especially in the initial stages of tx before the woman has had a change to being her own recovery. Couples therapy should generally be avoided until the following: a) no incidents of violence for at least 5 months; b) the abuser has accepted responsibility for his violent behaviors and c) both partners have been actively involved in tx groups. |
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Notice of Privacy Practices
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HIPAA’s privacy rules requires psychologists to provideclients with a written Notice of Privacy Practices on or before the onset oftreatment that indicates how health information may be used and disclosed andthat informs clients of their rights with regard to health information. The NPPmust also be posted in a prominent place in the psychologist’s office, and thepsychologist must make a “good faith effort” to obtain the client’s writtenacknowledgement of receipt of the notice.
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Business Associate
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BA is a person or organization other than a member of apsychologist’s staff who receives PHI in order to provide serves (lawyer,accountant, billing service, etc). Psychologists must have a HIPAA contract w/all Bas and if he learns BA is violating the contact, they must take reasonablesteps to correct the violation, terminate the contract or report the violationto DHHS.
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Impaired Psychologists (law)
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(law) Psych shall not knowingly undertake any activity inwhich temporary or more enduring personal problems in the psychologist’spersonality integration may result in inferior professional services or harm toa pt. If psychologist is already engaged in such activity when becoming aware ofsuch personal problems, he shall seek competent professional assistance todetermine whether services should be continued or terminated.
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Impaired Psychologist (ethics)
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(ethics) … take appropriate measures, such as obtainingprofessional consultation or assistance, and determine if he should limit,suspend or terminate their work related duties…
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Impaired Psychologist that Continue to Provide Services
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(law) Licensed psychologists who continue to provideservices when a physical or mental impairment is adversely affecting servicesmay have action taken such as revoking, suspending license, put on probation,etc.
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Privilege (guardians vs. parents)
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Minors are considered the holder of the privilege inCalifornia, eve though they may rely on adult to claim or waive the privilegeon their behalf. Children who are ward of the court: privilege is invoked bychild or counsel; if the child is 12, child may invoke the privilege, counselmay not waive it. If counsel invokes the privilege, child may waive it. Counselis the holder if child is too young or not mature to consent.
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Informed Consent in Assessment
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Psychologists obtain informed consent for assessments,evaluations, or diagnostic services… except when (1) testing is mandated by lawor governmental regulations, (2) informed consent is implied because testing isconducted as a routine education, institution or organizational activity or (3)one purpose of the testing is to evaluate decisional capacity.
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EAP
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*patient has rights to confidentiality
* it employer requested a fitness-for-duty evaluation,employee is usually asked to sign an authorization to release confidentialinformation prior to the evaluation. However, even when the employee refuses,the employer has a right to limited information: if the employee is able toperfume essential job function, functional limitation, and whetheraccommodations are needed. |
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Confidentiality in Multi-Client Situations
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* group therapists must stress the importance ofconfidentiality (even though group member are not legally obligated to maintainone another’s confidentiality).
* w/ regard to couple and family therapy,psychologist must clarify the probable uses of the services provided or theinformation obtained. For example, the problem of “secrets” may arise in coupleor family therapy. Therapist should clarify his policy w/ regard to this typeof information at outset of therapy. |
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Confidentiality and Clients who are minors:
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* unless a legal exception applies, parents have alegal right to be informed of information revealed by their minor child duringcourse of treatment.
* However, full disclosure is likely to undermined=the effectiveness of treatment. A good strategy is to obtain an agreementwith all parties at the beginning of therapy regarding what kinds ofinformation will be disclosed to parents (not a legal binding agreement). THEREARE LEGAL EXCEPTIONS. |
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Clients Records
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in general, the client owns the contents of therecords, while the psychologist or facility owns the physical documents.
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Maintenance and Retention of Records
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* (ethics) psychologists create, and to the extentthe records are under their control, maintain, disseminate, scores, retain anddispose of records (therapy, scientific) in order to 1) facilitate provision ofservices by them or other professionals, 2) allow for replication of research,3) meet institutional requirements, 4) ensure accuracy of billing, 5) ensurecompliance with law.
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Electronic Recordkeeping
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HIPAA and CA law:
* shall comply if hard copy version are notretained * any use of electronic recordkeeping to store patientrecords shall ensure the safety and integrity of those record at least to theextend to hard copy record * shall employ a offside backup storage system, animage mechanism that is able to copy signature documents, and a mechanism to ensurethat once a record is input, it is unalterable |
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Conflict of Interest Guidelines:
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* when psychologists are considering theacceptability of a multiple relationship, they evaluate each relationship interms of 3 factors:
1. Power differential (the more power psych hasover the other person, the less likely it is ethical). 2. Duration of the relationship (the longer, themore dubious) 3.Clarity of termination (what’s the likelihoodthat the individual will desire additional services in the future? The morelikely, the less acceptable). |
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When client is experiencing temporary financial crisis
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* a psych may temporarily waive or lower fees· schedule fewer appts
* suspend therapy for an agreed-upon period * IT IS UNACCEPTABLE TO ABANDON THE CLIENT andabruptly referring a client to a lower-cost provider may constitute abandonmentif the therapeutic relationship has been established and treatment is underway * In an emergency situation, a psych has anobligation to continue providing tx to a client, regardless of the client’sability to pay, until the crisis has been resolved. * Psych are not obligated to continue treating a clientwho does not pay for services in the manner that was agreed upon but may terminatedtreatment in an appropriate manner. |
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Initial Renewal
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A license who renews his license for the first time afterthe initial issuance of it is only required to accrue continuing education forthe number of months that the license was in effect, including the month thelicense was issued, at the rate of 1.5 hrs of CEU per month. 75% can be viaindependent learning.
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Subsequent Renewals
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Subsequent Renewals
The board shall issue renewal licenses only to thoseapplicants who have completed 36 hrs of approved continuing education in thepreceding 2 years. |
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Renewal of Inactive Licenses
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* if license has been place on inactive status =exempt from CE requirements
* To activate license on inactive status – must submitevidence of completion of 36 hrs of qualifying CE courses for the 2 year periodprior to establishing the license as active |
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Renewal of Delinquent Licenses
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* For the renewal of delinquent license within 3years of the date of expiration = applicant shall provide documentation ofcompletion of the required hours of CE
* Delinquent for 3 years = license isautomatically cancelled and the applicant must submit a complete licensingapplication, meet all current licensing requirements, and successfully pass thelicensing examination just as for the initial licensing application unless theboard grants a waives of examination |
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Psychological Assistants
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* completed master’s degreed in psychology or educationw/ the field of specialization in psychology or counseling psychology OR
* has been admitted to candidacy for a doctoraldegree in psychology |
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Registered Psychologists
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· may accrue supervised professional experience
· must have doctoral degree that qualifies forlicensure · completed 1500 hrs of SPE · be employed at a nonprofit community agency thatreceives a minimum of 25% of funding from a government source · be supervised by a licensed psychologist |
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Types of compensation for malpractice
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Types of damages awarded to plaintiffs in malpractice suitsare 3 types:
1. the award of of compensatory damages is based on the assumption that a plaintiffshould be restored to his or her pre harm condition. Includes payment for future of past work losses,medical care, and physical and mental pain and suffering. 2. Nominal damages are awarded when harm hastechnically occurred but cannot be translated into monetary terms. 3. Punitive damages are awarded to penalize thepsychologist and are usually awarded only when the psych has clearly acted in areckless, malicious or willful manner. |
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Reducing the Risk for a charge of malpractice
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· several guidelines for reducing risk for acharge of malpractice:
· most important, being familiar w/ all relevantlegal and ethical standard · maintaining detailed, well organized records |
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Confidentiality and Access to Records(Minors)
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· minors, like adults are legally and ethicallyentitled to a confidential relationship with their therapists. In most cases,the parent or legal guardian of an unemancipated minor has a legal right toaccess information shared by a minor during tx.
· A therapist must balance disclosures in order tokeep child’s trust. · It can be useful to explain that to parents · A psych MAY legally breach the confidentialityof minor clients when permitted or required to do so by law (ex: child abuse,court) |
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Disclosure of Records of Minors to Parents/Legal Guardians - part 1
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· minors have the right to inspect or obtain acopy their own records when they pertain to health care for which the minor hasconsented or could have consented as permitted by law. In these situation,provider should not ordinarily share records or other info with minor’s parentsor guardian without minor’s authorization.
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Disclosure of Records of Minors to Parents/Legal Guardians - part 2
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· When the record DO NOT pertain to health carethat minor has legally consented or could have consented, the parents/guardianof a minor ordinarily have the right to have access. HOWEVER, an exception tothis general rule, states that a provider may refuse to provide parents andguardian with access when provider determines that access to the patientrecords would have a detrimental effect on the provider’s professionalrelationship with the minor or the minor’s physical safety or psychologicalwell-being. In this case, provider must include a written description of thereasons for denial and permit inspection by another professional designated bypatient.
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Disclosure of the Records of Minors to Third Parties
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Except in legally defined situations, a patient’s writtenauthorization be obtained before disclosing confidential medical information.When an authorization is required for disclosure of the record of a minor, theauthorization must be signed by the minor when the record pertains to servicesthat the minor could lawfully have consented to.
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Involuntary Hold
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* psychologist (or any other person over the age of 18 yo) mayinitiate an involuntary hold but only certain individuals may institute aninvoluntary hold (police officers, member of the attending staff of anevaluation facility designated by the county, designated members of a mobilecrisis team, or other professional persons designated by the county)
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Involuntary Hold
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* each person admitted for 72-hour treatment and evaluation
* shall receive an evaluation as soon after he is admitted * shall receive treatment and care for the full period thathe is held * the person shall be released before 72 hrs have elapsedonly if the psychiatrist directly responsible for the person’s treatmentbelieves the person no longer requires evaluation or treatment. If there isdisagreement, matter is directed to the medical director of the facility. |
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Notifying clients about Child Abuse Report
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· psych are not legally required to tell involvedindividuals that they are filing a report· however, if therapist foresee a futuretherapeutic relationship , it is usually best to advise him or her of theintent to make a report, unless doing so is contraindicated.
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Child Abuse Information from Third Party
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When psychologists learn about child abuse from a 3rdparty, they must make a report if the information is revealed to them in theirprofessional capacity.
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section 124260
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Law and ethics page 33 – section 124260, does not apply tominors who are receiving benefits under the Medi-Cal program and it foes notpermit minors to consent to inpatient mental health tx, receive psychotropicdrugs, convulsive therapy or psychosurgery w/o consent of parent or guardian.
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section 6924
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Section 6924, program receiving Medi-Cal, other government funds. More restrictive, not only requires that the minor be able to participate intelligently and be at least 12 yo, but also “present serious physical or mental harm to self or others without the services or is the alleged victim of incest or child abuse”
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Criminal Liability for Sexual Misconduct
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· shall be punishable by imprisonment in a countyjail for a period of not more than 6 months, or a fine not exceeding $1000 orby both.
· Multiple acts in violation w/ a single victim,when the offender has no prior conviction for sexual exploitation, shall bepunishable by imprisonment in a country jail for a period of not more than 6months and a fine of $1000 or both· 2 or more victims, imprisonment in state prisonor a period of 16 months, 2 years or 3 years, and a fine not exceeding $10,000or no more than 1 yr in county jail, fine not excessing $1000. · 2 or more violations, with a single victim, thenoffender has prior conviction, state prison for 16 months, 2 or 3 yrs, and finenot exceeding $10,000 or no more than 1 yr in county jail, fine not excessing$1000. · 2 or more victims, w/ a prior conviction, 16months, 2 or 3 years in state prison and $10,000 |
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Enuresis Treatment
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1. Urine Alarm - also known as moisture alarm and the bell-and-pad and causes a bell to ring when the sleeping child beings to urinate.
2. Pharmacotherapy - imipramine |
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Sexual Dysfunctions Treatment
part 1 |
1. Sex Therapy - a variety of CBT interventions that target sx, associated anxiety, maladaptive attitudes and beliefs. When possible, the partners (rather than an individual are a treated by co-therapists):
a. Sensate Focus - sensory awareness training, cossets of a series of graded exercises, beginning w/ nongenital pleasuring and gradually processing to genital stimulations. b. Start-Stop and Squeeze Techniques - used to treat premature ejaculation by increasing the male control over ejaculatory reflex c. Kegel Exercises |
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Sexual Dysfunctions Treatment
Part 2 |
2. Couples therapy
3. Pharmacotherapy (sildenafil citrate, viagra. for erectile disorder; SSRI have also found to be effective for some) |
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Conduct Disorder Treatment
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1. Family Interventions - include parent management training (PMT) and functional family therapy (FFT). PMT is based on social learning theories and targets inconsistent discipline and negative coerce interactions. FFT emphasizes the functions that behaviors severe and begins w/ fa functional behavioral assessment.
2. Cognitive Problem-Solving Skills Training (CPSST) incorporates cogni and beha strategies to teach individual new skills for approaching situations that have previously elicited problematic behaviors. |
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Conduct Disorder Treatment
Part 2 |
3. Multisystemic Therapy - comprehensive tx that targets factors within the individual, family, school, peer group, and community that are maintaining conduct problems. Interventions include academic support, social skills training, parent management training, individual psychotherapy, family therapy, peer and school interventions and pharmacotherapy.
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Conduct Disorder Treatment
Part 3 |
4. Pharmacotherapy - although medication is generally not recommended for managing behavior, drugs may be used (usually for a limited time) when the behavior is escalating and/or pose a high risk for danger or for the tx of co-occurring disorders.
5. Out-of-Home-Placment - residential tx should be considered for an individual who exhibits marked noncompliance or persistent involvement w/ deviant peers or whose family has severe dysfunction; while hospitalization may be indicated for those who are at risk for suicidal or homicidal behavior or severely impaired |
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Substance Use Disorder
Part 1 |
* it is a multimodal and multidisciplinary tx and is conceptualized as a long-term process
- acute intervention - emergency tx, detoxification, and screening - rehabilitation - evaluation/assessment primary care (brief and intrusive interventions) and extended care and stabilization - maintenance - aftercare, relapse prevention, and when necessary domiciliary care. |
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Substance Use Disorder
Part 2 * readiness for change (prochaska and diclemente): |
a) pre contemplation stage - little insight and does not intend to change b) contemplation stage - aware of the need for change, intends to take action within the next 6 months but not committed to change c) preparation stage - plans to take action in the near future (usually in the next month) and has a realistic plan of action d) action stage - takes concrete steps to change, public commitment e) maintenance - maintained change for at least 6 months, taking steps to prevent relapse f) termination stage - person feels he can resist temptation, is confident |
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Substance Use Disorder
Part 3 |
Level of Care - when choosing the level of care the general rule is to provide treatment in the least restrictive setting that is likely to be both effective and safe. Types:
* outpatient tx, * intensive outpatient tx and partial hospitalization * residential/inpatient treatment and * medically managed intensive tx |
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Substance Use Disorder
Part 4 |
Dual Diagnosis Tx: 3 approaches for treating individuals w/ a dual diagnosis:
- the sequential approach ( treating the most acute disorder first, and the less acute next) - the parallel approach ( involves treating the 2 disorders simultaneously but by different providers) - integrated approach ( treating 2 different disorders simultaneously by the same provider) RESEARCH SUGGESTS THAT THE INTEGRATED APPROACH IS MOST EFFECTIVE |
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Substance Use Disorder
Part 5 |
Psychosocial Interventions
a. Cognitive Behavioral Interventions (strategies to reduce or replace thoughts and maladaptive behaviors; coping skills training, social and problem-solving skills training, stress management, and behavioral self-control training) b. Behavioral Interventions - goal is to alter environmental stimuli that trigger and maintain substance use. Behavioral contracting, stimulus control, cue exposure and relaxation and aversion therapy. The community reinforcement approach (CRA) incorporates the use of naturally occurring reinforcers w/ training in communication and social skills and substance refusal. |
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Substance Use Disorder
Part 6 |
c. Motivational Interviewing - focuses on enhancing intrinsic motivation to change by helping patients examine and resolve ambivalence about changing. 4 general principles:
- express empathy - develop discrepancies between current behavior and personal goals and values - roll with (rather than oppose) resistance - support self-efficacy |
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Substance Use Disorder
Part 7 |
*Relapse Prevention - focus on helping individuals recognitive the internal and external cues that increase the risk for substance use and teaching them alternative ways for responding to these cues.
*Self-Help Groups - participation in AA or other *Group Therapy - variety theoretical orientations *Family and Couple Therapy - often an adjunct tx; primary goal is to promote living environment that helps prevent relapse and reduce enabling *Pharmacotherapy - some treat acute intoxicate, overdose, etc. Disulfiram (antabuse) produces unpleasant physical sx, |
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Delirium
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Treatment has 2 primary targets:
* the underlying cause of the disorder * the reduction of agitated behaviors (combination of environmental manipulation and psychosocial interventions (calm friend, etc) * haloperidol or other antipsychotic may help reduce agitation, delusions, and hallucinations. Other than a benzo for alcohol withdrawal delirium, sedatives are contraindicated because of their side effects / also may mask symptoms |
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Major and Mild Neurocognitive Disorder
part 1 |
* the optimal treatment approach depends on its etiology and severity
* however, the primary foals include delaying the onset or progression of sx in order to provide a better quality of life and helping the individual and caregivers cope w/ current/future sx |
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Major and Mild Neurocognitive Disorder
part 2 |
1. Psychosocial Interventions - include behavioral-oreitned tx to reduce disruptive, agitated etc. behaviors and improve functional skills. Emotion oriented therapies (reminiscence, validation, supportive); cognitive training and rehabilitation; and stimulation-oriented interventions (exercise, music, art)
2. Environmental Manipulation - moderate to severe impairment. Used to enhance memory and increase safety. Structure daily routine, installing safety measures to prevent accidents, familiar and calming environment, familiar objects, adequate lighting, < noise + distractions. |
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Major and Mild Neurocognitive Disorders
Part 3 |
3. Pharmacotherapy - may include an antipsychotic to reduce agitation, an SSRI or other antidepressant to reduce associated depression, and a cholinesterase inhibitor (donepezil, rivastigmine, galantine) to slow the rate of cognitive impairment.
4. Family/Caregiver Interventions - these interventions have been linked to delayed out-of-home placement for the patient and better quality of life and emotional well-being for caregivers. Include psych educational programs, stress management, support groups, family therapy, and adult daycare for the patient and respite services. |
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Antisocial Personality Disorder Treatments
* one of the most difficult disorders to treat because pt are often in therapy only because they have been referred by the legal system, are resistant to tx, sx are ego syntonic, and more concerned about manipulating the therapist than cooperating with treatment. |
1. Milieu/Residential Treatment - token economy programs and therapeutic communities.
2. Cognitive-behavioral interventions - establishes and enforces clear rules and consequences for violating them. Also corn skills, life skills, etc. 3. Pharmacotherapy - medication may be useful for treating specific sx - mood stabilizer to reduce impulsivity or low-dose antipsychotic to alleviate cognitive-perceptual abnormalities. |
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Borderline Personality Disorder Treatment
treated both inpatient and outpatient |
1. Dialectical Behavior Therapy - combines 3 strategies: a) group skills training to help pts regulate their emotions and improve their social and coping skills, b) individual outpatient therapy to strengthen their motivation and newly acquired skills, c) telephone consultations to provide additional support and between-session coaching.
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Borderline Personality Disorder Tx Part 2 |
2. Mentalization-Based Therapy (MBT) - it is a form of psychodynamic therapy; it views BDP as resulting from early trauma which leads to disorganized attachment and interferes w/ the development of the social and cognitive abilities required for metallization (for the capacity to make sense of oneself and other thought mental processes). Focuses on increasing metallization capacities and involves helping pt identify and understand their emotions by "clarifying and naming them, understanding immediate precipitants, understanding the emotion in the context of past and current relationships, learning to express the emotion appropriated, and learning to understand the response others are most likely to have to their expression of emotion.
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Borderline Personality Disorder Tx
Part 3 |
4. IPT
5. Pharmacotherapy - some evidence that a combination of psychotherapy and symptom-focused pharmacotherapy enhances tx outcomes. Fluvoxamine to be useful for reducing rapid mood changes and olanzapine to be effective for alleviating depression and impulsive aggression. |
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Paraphilic Disorders
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1. CB interventions - aimed at altering maladaptive beliefs and justifications and eliminating undesirable sexually arousing or pleasurable responses to specific individuals, objects, or situations. Include sex education, cognitive restructuring, empathy training, and relapse prevention. Behavioral strategies include aversion therapy, covert sensitization, and orgamisc reconditioning. Often combined w/ family therapy, group therapy, social skills training, 12-step program, and relapse prevention2. the drug medroxyprogesterone acetate (depoprovera) reduces paraphiliac behaviors in many men. Antidepressants have been found useful for reducing fantasies.
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Treatment of American Indian clients
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* therapist reaffirm the values of their own culture
* may be distrustful of therapist * focus on building trust and credibility during initial session, demonstrating familiarity and respect for client's culture * adopt collaborative approach, problem solving, client centered * incorporate elders, medicine people, healers * likely spiritual and holistic orientation * Network Therapy - conducted in the individual's home, psych problem within the context of family, workplace, etc |
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Treatment of African American Clients
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* culture focuses on interconnectedness
* family is often an extended kindshop network, nuclear and extended, and people outside of it * for many, church is important * roles are flexible and non-hierarchial * men and women tend to be egalitarian * healthy cultural paranoia (distrust white thera.) * prefer structured, time limited problem solv. * interventions that foster empowerment, include extended family * multi systems approach that combines elements of structural and behavioral family therapy and addresses multiple system and levels, incorporate strengths, is recommended. |
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Treatment of Asian American Clients:
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* place greater emphasis on the group than indi
* hierarchical family structure, traditional tend * shame, humility and obligation are important * restraint of emotion is valued * modesty and self-deprecation not necessarily signs of health problems * tend to somaticize psychiatric symptoms * they should be passive and respectful i therapy and expect formalists * to establish credibility, auhtority and expertise early, clinicians can disclose info about their education background and experience, show familiarity w/ culture, and provide cleitn w/ an immediate and meaningful benef/solution 4 prob |
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Treatment of Hispanic/Latino American Clients
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* generally emphasize family
* family structure is patriarchal * relatively inflexible gender roles * often adopt concrete, tangible approach to life * may believe in luck, supernatural forces, acts of God or other external factors * physical and mental health are interdependent, may somaticize * empashizes on personalismo and familismo * Ecostructural family therapy developed for this group |
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Lesbian, Gay and Bisexual Clients
* critical not to assume that problems are necessarily related to the sexual orientation* goals and nature of tx depend on the client's presenting issue and that issue's relations to the client's sexual orientation |
1. Affirmative Psychotherapy - refers to individual, couple and group therapies that encourage LGB individual to accept their sexual orientation. a) homosexuality as a normal (healthy) variation of human sexuality b) homosexuality is not per se the cause of pathology c) to be effective, clinicians must be aware of the impact of heretosexism on the lives of LGB |
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Lesbian, Gay and Bisexual Clients
Sexual Identity Therapy (SIT) |
* developed as an alternative to Affirmative psychotherapy and sexual reorientation therapy for clients who are experiencing conflicts between their sexual identity and personal attitudes, beliefs and values.
* goal is "the synthesis of a sexual identity that promotes personal well-being and integration with other aspects of personal identity (cultural, ethnic, relational, spiritual, etc). * 4 phases: assessment, advanced informed consent, psychotherapy and sexual identity synthesis. |
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Phase Specific Pyschotherapy
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a. Phase 1 - Sensitization - empathize w/ and destigmatize client's feelings of alienation
b. Phase 2 - Identity Confusion - empathize and explore confusion about sexual identity and related fears. Help him identify and acknowledge same sex feelings. dispel myths, reframe being gay as positive, facilitate grieving process. c. Phase 3 - Identity Assumption/Tolerance - validate client's self-perception; facilitate decision making about self-disclosure, provide education of human sexuality, help client develop a new identity d. Phase 4 - Identity Acceptance/Commitment - refer a gay, lesbian if possible; support client's involvement in the community, continue discuss self-disclosures. e. Phase 5 - Identity Pride/Synthesis - validate the client's pride in being gay or lesbian; acknowledge heterosexist oppression. |
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Victims of Child Abuse Treatment
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* when interviewing, use open ended, nonjudgmental questions about parenting and discipline: do you ever fear for your child's safety?
* when there is a reason to believe the parent is the perpetrator of abuse "what do you do when your child misbehaves?" * assessment identify antecedents, consequences, etc. * identify parent strengths, and problem areas identify child strengths and problem areas, evaluate the relationship. |
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Child Abuse Treatment
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a. Abuse-Focuses Cognitive-Behavioral Therapy (AF-CBT) - tx for children who have been physically abuse and their families. It targets child and parent characteristics associated w/ the abuse and the family context in which abuse occurs (negative perceptions of the child, harsh punishment, anger and hostility) as well as consequences of the abuse for the child.
* consists of individual sessions w/ the child and parent and joint parent-child session. Teaching parent alternative discipline, inhaling family interactions, training for child in coping skills, anxiety and anger management As needed involvement of community and social system |
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Child Abuse Treatment
Parent-Child Interaction Therapy (PCIT) |
* provides a structured parent training program in which there therapist acts as a coach by giving prompts to parents (through a bug in the ear device) from an observation room while the parents interact w/ their child. Parents are taught specific strategies that are designed to improve the parent-child relationship and increase the child's compliance.
* 5 basic relationship-building skills (praise, reflection, imitation, description, and enthusiasm) |
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Child Abuse Treatment
Trauma-Focused Cognitive-Behavioral Therapy (TF-CBT) |
* short term tx for reducing PTSD sx, depression, and behavioral problems in children who have been sexually abused or have been exposed to other traumatic events
* consists of several core components that address the need soy the child and his family including psychoeducaiton and normalization of reactions, stress management, affective expression, and regulation, gradual exposure through verbal, written, or symbolic recounting of the abuse (trauma narration), cognitive reprocessing and reframing, personal safety kills training, parent training in behavioral management skills and join parent child therapy sessions. |
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Victims if Intimate Partner Abuse
Interview Guidelines |
a) conduct interview in private
b) being with open ended questions c) avoid leading questions d) convey interest and be nonjudgmental and supportive e) avoid giving advice or making interpretations f) avoid rushing the woman into disclosing g) clarify any unclear words or satements |
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Victims of Intimate Partner Abuse
Risk Assessment |
* includes evaluating the risk for further assault or homicide, suicide or self-harm
* if safety concerns are acute, the clinician should discuss immediate pitons (someone to stay with, emergency assistance, police if appropriate) * when safety concerns are ongoing, help client develop a safety plan and discuss referral resources |
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Victims of Intimate Partner Abuse
Treatment |
1. Individual Therapy - based on crisis intervention models, feminist theory, stages of change model, CBT, survivor therapy (combines cognitive-behaviorla strategies w/ trauma therapy and feminist therapy and emphasizes the woman's strengths).
2. Group Therapy - may be provide alone or in conjunction with individual therapy; mostly based on support model 3. Couple's Therapy - controversial, w/ some experts arguing that partners in an abusive relationship should usually be treated separately, especially in the initial stages of tx before the woman has had a chance to being her own recovery. Couples should generally be avoided until: a) there have been no incidents of violence, b) the abuser has accepted responsibility for his behavior, c) both partners have been involved in tx groups. |
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Instrumental and Expressive Abuse
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Instrumental Abuse - brutal, dangerous, and occurs w/ little provocation. Woman's safety is at risk, partners should be physically separated and provided w/ separate therapy.
Expressive abuse - related more to the couple's emotional life and occurs in a context of escalating conflict about specific issues. For this type of abuse it may be appropriate to have partners sign a no-violence contact and provide couple's therapy. |
