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NCMHCE Review #9: Stages and Theories of Treatment

CEUs are available at

Dr. Dawn-Elise Snipes
Executive Director,
Podcast Host: NCMHCE Exam Review and Counselor Toolbox
~ Review the stages of treatment
~ Review theoretical approaches for individual counseling including
~ Behaviorism
~ Humanistic
~ Developmental

~ Immediate Concerns
~ Evaluate risk factors
~ Establish rapport
~ Enhance motivation and hope
~ Address administrative and policy issues
~ Make a preliminary diagnosis or narrow to a couple
~ Assessment and Goal Setting
~ Ask questions about
~ The perception of the problem
~ Duration
~ Mitigating and Exacerbating factors
~ Hoped for resolution
~ Impact on PSF in multiple dimensions
~ Physical symptoms
~ Make observations
~ Use collateral sources

~ Treatment plan development (specific as possible—SMART)
~ Prioritize goals
~ Identify needs and services to meet those goals
~ Work with client to select interventions
~ Make appropriate referrals
~ Provide psychoeducation
~ Middle stages
~ Consider a systems approach and involving family or at least addressing contributions of family to the problem and/or solution
~ Teach mindfulness, feelings identification, distress tolerance and coping skills to reduce core symptoms
~ Improve social support
~ Enhance self esteem and efficacy
~ Regularly monitor motivation, resistance and unanticipated barriers to change

~ Late Stage
~ Solidifying gains
~ Generalize skills to other areas
~ Mindfulness and coping skills can be used not only for being aware of and addressing depression, but also anxiety, anger
~ Social support is helpful in recovering from depression, but can also be helpful for behavior change or coping with stress or grief.
~ Termination Stage
~ Consolidate gains by reviewing progress and enhancing efficacy.
~ Ensure a support system is in place
~ Develop a relapse prevention plan
~ Identify and address issues related to termination
~ Cognitive theories are active, directive and time limited
~ May include
~ REBT (Identify unhelpful thoughts, unhelpful emotions, UPR, anger management)
~ CBT (Identify unhelpful cognitions, and behaviors and choose more helpful ones and alter the cognitive triad—Self-World-Future)
~ DBT (Distress tolerance, emotion regulation, interpersonal, problem solving)
~ ACT (Radical acceptance, mindfulness, commitment to purposeful action, Unhooking/Defusion)
~ CPT (Challenging questions)

~ Goals are to
~ Increase self monitoring and awareness
~ Identify unhelpful cognitions
~ Clarify and challenge underlying beliefs
~ Replace unhelpful triggers and behaviors with helpful ones
~ Increase adaptive problem solving
~ Counterindications: Psychotic disorders, dementia, FASD
Behavioral Approaches
~ Emphasis on changing or replacing current behaviors by altering the antecedents and/or consequences through
~ Positive and negative reinforcement of alternate behaviors and punishment and lack of reinforcement of target behaviors
~ Social/observational learning
~ Focuses on observable, measurable behaviors not thoughts or emotions
~ Always gather baseline data and conduct a functional analysis
~ Interventions are conducted in the person’s natural setting and involve SOs

Behavioral Approaches
~ Techniques in behavioral approaches
~ Systematic desensitization
~ Flooding
~ Assertiveness training
~ Aversion therapy
~ Extinction
~ Token Economy

Humanistic Models
~ Seeks to understand people’s subjective experience
~ UPR for people’s uniqueness, wholeness
~ Belief in people’s natural tendency to move toward self actualization
~ View problems as stemming from incongruence between the self and perceived conditions of worth
~ Overall goal is to achieve congruence between the self and experience and an enhanced ability to cope with future problems
~ Rogerian therapy views assessment and diagnosis as detrimental
~ Goals
~ Increase self-awareness
~ Increase sense of responsibility for actions and destiny
~ Help clients gain intrinsic rewards instead of needing extrinsic ones
~ Techniques
~ Encourage awareness of the present moment
~ Using “I” language
~ Adding the phrase “and I take responsibility for it” to statements
~ Empty chair
~ Reversal
~ Rehearsal

Developmental Models
~ When working with children, many times the family is integral to the treatment process
~ General questions for the assessment
~ Has there been any disruption to the homeostatic balance of the family
~ Are members permitted age-appropriate autonomy
~ Which life-cycle transitions have been experienced and how have they been managed? How does this influence current patterns and future transitions?
Developmental Models
~ Erikson
~ Trust/mistrust
~ Autonomy/shame
~ Initiative/Guilt
~ Industry/Inferiority
~ Identity/Confusion
~ Intimacy/Isolation
~ Generativity/Stagnation
~ Integrity/Despair
~ Vygotsky
~ Use scaffolding to encourage cognitive development from the zone of proximal development
Family Therapy
~ Goals
~ Defocusing the IP
~ Improving communication in the family unit
~ Increasing awareness of the one’s personal experience and intrapsychic conflicts that influence behavior and interactions
~ Reducing emotional reactivity among individuals and enhance congruent affective interactions
~ Restoring homeostasis
~ Addressing inflexible roles
~ Strengthening the family system
~ Strengthening the executive subsystem
~ Increasing separation/individuation of members
~ Identifying ongoing, repetitive interactions between people (learned responses)
~ Increasing recognition of circular patterns of behavior
~ Restoration of trust, responsibility
Family Therapy
~ Beliefs
~ Wholeness and transactionalism
~ The whole is equal to more than the sum of its parts
~ Study of the causes of problems is not important because the same problem may have multiple causes. The process is important.
~ Not why did John become depressed but how is John’s depression impacting family members and their behaviors
~ All behavior is communication
General Interventions
~ Empathy
~ Reassurance
~ Normalization
~ Reframing
~ Reflection
~ Interpretation
~ Verbalization/ventilation
~ Simulations/role-plays
~ Letter writing
~ Psychoeducation
~ Bibliotherapy
~ Strengths focus
~ Behavior modification
~ Motivation enhancement
~ Social learning and support
~ Modeling
~ Respite support
~ Resource enhancement
~ In the initial meeting, establish rapport and identify emergent issues
~ During the assessment and treatment planning, use collateral information as well as client self report and testing
~ Develop treatment plans in conjunction with the client
~ Be familiar with basic concepts of the different theoretical approaches in case you are asked to address a problem from a particular perspective.
Test Taking
~ Judy and Sam. Judy brings her 9 year old son to counseling based upon a recommendation by the school counselor. Sam has been cutting class and was caught fighting at school. Recently Sam has begun lying to Judy. Sam’s parents recently got divorced and Sam did not want to return to Judy’s after a weekend visit. Judy wants you to testify in court that joint custody is too difficult for Sam and she needs to have sole custody.
~ What would be a preliminary diagnosis
~ Adjustment disorder, rule out ODD, CD
~ What steps should the counselor take?
~ Observe the interactions between Judy and Sam
~ Ask Judy about the onset of these behaviors
~ Ask Sam to draw pictures of Mom and Dad’s houses
~ Observe Sam alone as he plays with family dolls
~ Ask Sam why he doesn’t want to live with Judy
~ Check with CPS regarding any reports**
~ Order a drug test for Sam**
~ Get permission to talk to Sam’s dad
~ Interview Judy alone to get more information about the divorce
~ Get permission to talk to Sam’s teachers and school counselor
~ What theoretical orientation(s) would you use?
~ Family Systems*
~ Behavioral*
~ Gestalt
~ Narrative
~ Solution Focused*

Treatment Plan Interventions
~ Refer Sam to peer-group counseling*
~ Refer Judy to a parenting support group*
~ Use behavior modification and reinforce alternate behaviors to reduce cutting class
~ Have Sam and Judy plan fun activities together
~ Teach Judy about the developmental needs of 9-year olds
~ Explore Judy’s parenting style and beliefs about parenting
~ Role play situations to help Sam learn to better manage conflict
~ Encourage Judy to ask Sam about his day at school and help with homework