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011 -NCMHCE Review Treatment Planning Part 1

Treatment Planning
Dr. Dawn-Elise Snipes PhD, LPC-MHSP, LMHC
Executive Director,
Podcast Host: Counselor Toolbox and NCMHCE Exam Review
~ Review goals and interventions to address anxiety, anger, grief, blended families and child issues.
Anger and Aggression
~ Rule out danger to others and substance abuse.
~ Goals
~ Increased awareness of angry feelings, triggers and responses
~ Decreased frequency and intensity of angry feelings
~ Increased awareness of alternatives to aggressive responses
~ Increased ability to use assertiveness skills to address triggers for anger and aggression
Anger Interventions
~ Daily journaling or logging to identify and track frequency, intensity and duration of angry feelings
~ Reflect upon and address anger triggers and aggressive behaviors
~ Use backward chaining to identify antecedents to anger and aggressive behavior
~ Construct a genogram to identify multigenerational triggers for and methods of dealing with anger
~ List prior experiences which have caused hurt and process those experiences to move toward forgiveness and release anger
~ Identify current triggers and targets for anger and address those.
~ Learn at least 5 alternatives to verbally or physically aggressive behavior.
~ Rehearse anger management skills
~ Refer for or teach effective communication skills
~ Bibliotherapy
~ Rule out PTSD
~ Goals
~ Increased awareness of anxious feelings and responses
~ Increased awareness of triggers for anxiety
~ Decreased frequency and intensity of anxious feelings
~ Enhanced distress tolerance skills
~ Increased awareness of ways to cope with anxious behavior
~ Improved problem-solving skills
~ Enhanced self-efficacy

Anxiety Interventions
~ Learn mindfulness to identify anxiety when it begins
~ Daily journaling or logging to identify and track frequency, intensity and duration of anxious feelings
~ Reflect upon and address triggers
~ Use backward chaining to identify antecedents to anxious behavior
~ Use cognitive interventions to address prior traumatic or fear-related experiences
~ Learn at least 5 coping skills to deal with anxiety
~ Learn at least 5 distress tolerance skills
~ Bibliotherapy
Blended Families
~ Assess the expectations of each family member
~ Contact schools for information about children
~ Goals
~ Develop a new family identity
~ Help each person develop a new identity
~ Redefine roles within the family
~ Identify and resolve losses
~ Develop tolerance and flexibility
~ Create a parent coalition
~ Develop effective conflict resolution skills

Blended families
~ Interventions
~ Normalize
~ Identify and process losses
~ Empower each person to create a new meaningful identity
~ Encourage verbal expression of all emotions including guilt, resentment, and feelings of failure or abandonment
~ Explore parental misperceptions about blending families and the children
~ Educate parents about varying developmental needs
~ Strengthen the identification of the new family unit
~ Identify and address conflicts within the blended family and with extended family members and ex-spouses
~ Ensure all members have personal space and can create a sense of “home.”
Child Clients
~ Complete a comprehensive developmental history and refer for psychological testing as needed (i.e. for suspected neurological issues)
~ Interview parents and child. Use behavior rating scales
~ Get ancillary information from school and pediatrician
~ Set clear goals with the parents
~ Goals
~ Decrease maladaptive behaviors
~ Improved interpersonal skills
~ Increased ability to identify and appropriately express feelings
~ Increased use of distress tolerance and coping skills
~ Improved problem solving skills
Child Clients
~ Interventions
~ Parent education of skills to model and behavior modification tools
~ Therapeutic play to assist with emotional processing
~ Family meetings and relabeling child’s behavior

Adult Clients with Child Abuse Issues
~ Assess for PTSD, depression, suicidality, substance abuse, dissociation
~ Goals
~ Increased awareness of the impact of the abuse emotionally, cognitively, physically and interpersonally
~ Process the trauma and integrate it
~ Increase awareness of trauma related reactions
~ Enhance the use of effective distress tolerance and coping skills

Adult Survivors
~ Interventions
~ Explore family of origin
~ Identify and express feelings and thoughts associated with the abuse
~ Help the client let go of self blame and address unhelpful cognitions
~ Refer for EMDR or hypnosis if appropriate
~ Teach grounding, reorienting and distress tolerance techniques to address dissociation
~ Consider internal family systems theory approaches to help the client integrate fragmented parts of self
~ Enhance the client’s support network
~ Refer for medication for mood symptoms as appropriate
~ Bibliotherapy
~ Rule out depression
~ Assess for substance use and suicidal ideation
~ Goals
~ Increase awareness of the impact of grief on the person
~ Develop vocabulary to describe feelings of grief and loss
~ Develop a short-term action plan for dealing with grief and loss
~ Identify grief and loss issues
~ Identify steps toward moving toward acceptance and integration
~ Interventions
~ Develop support system—Refer to support groups as appropriate
~ Identify current and historical losses and process related feelings and cognitions including guilt, anger, depression
~ Challenge cognitive distortions or maladaptive thinking patterns
~ Refer to physician as appropriate for depressive symptoms
~ Empower clients to integrate the loss(es) into their identities with narrative therapy
~ Make referrals to wrap-around services as needed
~ There are a myriad of issues, not just DSM V diagnoses that NBCC wants to make sure the counselor can address
~ Review the preliminary content outline for an idea of the types of issues you may be asked to deal with
~ In preparing for the exam, consider making your own scenarios that involve not only a diagnosis, but also administrative and ethical issues.
~ HIPAA permits health care providers to:
~ Communicate with a patient’s family members, friends, or others involved in the patient’s care
~ Communicate with family members when the patient is an adult
~ Communicate with the parent of a patient who is a minor
~ Consider the patient’s capacity to agree or object to the sharing of their information
~ Involve a patient’s family members, friends, or others in dealing with patient failures to adhere to medication or other therapy as long as the patient does not object or, if the patient cannot consent, as long as it is in the patient’s best interest. In making this determination about the patient’s best interests, the provider should take into account the patient’s prior expressed preferences regarding disclosures of their information, if any, as well as the circumstances of the current situation
~ Listen to family members about their loved ones receiving mental health treatment
~ Communicate with family members, law enforcement, or others when the patient presents a serious and imminent threat of harm to self or others
~ Communicate to law enforcement about the release of a patient brought in for an emergency psychiatric hold.
~ A health care provider is permitted to share patient information with a patient’s personal representative under the Privacy Rule but NOT psychotherapy notes
~ HIPAA defers to state law to determine the age of majority and the rights of parents to act for a child in making health care decisions, and thus, the ability of the parent to act as the personal representative of the child for HIPAA purposes
~ Exceptions…A parent is not treated as a minor child’s personal representative when:
~ State or other law does not require the consent of a parent or other person before a minor can obtain a particular health care service, the minor consents to the health care service, and the minor child has not requested the parent be treated as a personal representative
~ Someone other than the parent is authorized by law to consent to the provision of a particular health service to a minor and provides such consent
~ A parent agrees to a confidential relationship between the minor and a health care provider with respect to the health care service
~ The Privacy Rule permits a HIPAA covered entity, such as a hospital, to disclose certain protected health information, including the date and time of admission and discharge, in response to a law enforcement official’s request, for the purpose of locating or identifying a suspect, fugitive, material witness, or missing person.
~ If a health care power of attorney is currently in effect, the named person would be the patient’s personal representative
~ HIPAA generally does not require authorizations for disclosures of PHI between health care providers for treatment, case management, and care coordination, EXCEPT for psychotherapy notes.
~ Other Reasons for Breeching Confidentiality
~ Abuse (state laws vary)
~ Mandated reporter who is otherwise required to report does not have to report if he or she:
~ Does not learn of the suspected abuse or neglect until after the alleged victim of the suspected abuse or neglect is eighteen years of age or older; and
~ Does not have reasonable cause to know or suspect that the perpetrator of the suspected abuse or neglect:
~ has subjected any other child currently under eighteen years of age to abuse or neglect or to circumstances or conditions that would likely result in abuse or neglect; or
~ is currently in a position of trust with regard to any child currently under eighteen years of age.”

~ Other Reasons for Breeching Confidentiality
~ Court orders
~ If the therapist is being sued by the client
~ Scenario: An adult client’s father is paying for her treatment and wants to be notified by the therapist of her progress and discharge. The client becomes suicidal and is admitted to the crisis stabilization unit after disclosing a history of abuse by the father.
~ Scenario: A client is referred for involuntary treatment by his department after his Sargent noticed erratic behavior. Can you communicate with the Sargent about progress and discharge without a signed release of information?