AN EXCERPT FROM THE BTA LICENSE EXAM REVIEW WORKBOOK CHAPTER ON THERAPEUTIC INTERVENTIONS

The BTA License Exam Home Study Course provides you with clearly presented, well organized summaries of key clinical issues which have been repeatedly addressed on license examinations. Here’s a sample...one of many psychotherapy theoretical orientations, summarized with clear definitions and explanations of key concepts that have repeatedly appeared in license examinations.

SOLUTION FOCUSED THERAPY
(Based on an eclectic mix of theories, notably Cognitive Behavioral Theory)

Solution focused interviewing is a recent way of expressing a variety of classical social work intervention principles. Although some refer to this perspective as "solution focused therapy" it is an overstatement to consider these concepts as a fully articulated therapy model. However, these interviewing techniques may be well suited to effective, time limited interventions by social workers drawing on any one of many theoretical orientations.

WELL FORMED GOALS. Solution focused interviewing emphasizes the importance of "well formed goals" in therapy. This refers to goals that...
• are important to the client
• are small and, therefore readily reachable
• are concrete, specific and behaviorally defined
• have presence, not absence (e.g., "feel relaxed" rather than "reduce anxiety")
• focus on beginnings (next steps), not ultimate endings (for example "set limits on Johnny's television time" rather than "become an effective parent")
• are realistic in view of the client's life circumstances
• are perceived by the client as involving "hard work" so that a sense of accomplishment is felt when achieved

EXCEPTIONS. Solution focused interviewing also addresses "exceptions". Exceptions refers to identifying the times in the client's life when the problem might have occurred but didn't. For example, if a client complains of "high anxiety in the presence of other people" the interviewer would ask the client to describe the times when he was able to feel relaxed or less anxious than usual while in the presence of others. This approach draws attention to the client's strengths, provides a clear and concrete vision of the goal, and instills hope by demonstrating that the client's goal is possible.

INTERVIEWING FOR CLIENT STRENGTHS. In part, the focus on client strengths is accomplished by the two fundamental principles of focusing on well-formed goals and exceptions. Other Solution Focused interviewing techniques include the following.

The Miracle Question. This question is used to refocus the client's attention away from the problem and onto solutions.

Suppose while you are sleeping tonight a miracle happens. The miracle is that the problem that brought you to see me is somehow solved. Only you don't know that it has been solved because you are asleep. What will you notice different tomorrow morning that will indicate to you that this miracle has happened?

The client's answer to this question is the beginning of formulating a positive goal image. The client will begin to focus on the presence of positives rather than the absence of negatives.

Exception Finding Questions. The client's response to the miracle question can lead to exception finding questions. For example, "You've just described to me how your day would be different after the miracle. Can you tell me about times in the past when the same thing happened?" In the course of discussing this issue, attempt to clarify what the client may have contributed to making the exceptions happen.

Scaling Questions. These questions call on clients to rate some aspect of their behavior or experience on a scale from 0 to 10, with 10 at the most positive end of the scale. If the client answers with any number greater than 0 (for example, "My anxiety is at a 3") the interviewer can ask the client what he has done to raise his score from the time when it was lower.

Coping Questions. These questions ask how the client to describe how she is able to cope with the problematic circumstances and experiences that she usually begins talking about when she first comes seeking help. This helps the client uncover coping strengths.

"What's Better?" Questions. As sessions progress, simply ask the client "What's happening in your life that's better?" This is another way of identifying strengths by focusing on exceptions to the problem.

This approach to interviewing has been associated, by its proponents, with the following values.
• empowerment (helping clients discover the considerable power within themselves)
• membership (fostering links to contexts where client strengths can flourish)
• regeneration and healing from within (by focusing on the client's own goals and inherent strengths)
• synergy (referring to the therapeutic alliance that develops between the therapist and client)
• "between worker and client" (referring to the synergistic change that occurs when the client contributes content to the interaction and the therapist contributes an understanding of the change process)
• "between client and client's context"
• dialogue and collaboration (respecting the client's otherness, that is, individuality, autonomy and self-determination)
• suspension of disbelief (in support of instillation of hope and respecting its value as self- fulfilling prophecy)

AN EXCERPT FROM THE BTA LICENSE EXAM REVIEW WORKBOOK CHAPTER ON THERAPEUTIC INTERVENTIONS

The BTA License Exam Home Study Course provides you with clearly presented, well organized summaries of key clinical issues which have been repeatedly addressed on license examinations. Here’s a sample.

CLIENT CHARACTER TRAITS AND CORRESPONDING COUNTERTRANSFERENCES

CHARACTER TRAITS, like personality disorders, are persistent, pervasive, and inflexible personality patterns that deviate markedly from the expectations of the individual's culture. When they lead to clinically significant distress or impairment they may constitute Personality Disorders. Character traits are less inflexible and cause less impairment.

• Avoidant Personality
Social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation.

• Dependent Personality
Submissive and clinging behavior due to an excessive felt need to be taken care of.

• Obsessive Compulsive Personality
Preoccupation with orderliness, perfectionism, and control.

• Passive-Aggressive Personality
Preoccupation with negativity and passive resistence to authority, with a tendency to “back off” when confronted by authority.

• Masochistic Personality
A tendency to take gratification/pleasure through punishment and emotional abuse by others.

• Paranoid Personality
Distrust and suspiciousness of others' motives.

• Schizotypal Personality
Acute discomfort in close relationships, cognitive or perceptual distortions, and behavior eccentricities.

• Schizoid Personality
Detachment from social relationships and restricted range of affect.

• Histrionic Personality
Excessive emotionality and attention seeking.

• Narcissistic Personality
Grandiosity, need for admiration, and lack of empathy.

• Borderline Personality
Instability in interpersonal relationships, self-image, and affect, and marked impulsivity.

• Antisocial Personality
Disregard for, and violation of the rights of others.

Therapists should be conscious of the following common countertransference tendencies experienced by therapists when working with clients of each character type.

AVOIDANT
• Pushing the client too fast
• Overprotectiveness

DEPENDENT
• Guilt
• Overprotectiveness
• Rejection

OBSESSIVE COMPULSIVE
• Boredom
• Power struggles or collusion
• Becoming compulsive

PASSIVE AGGRESSIVE
• Power struggles
• Authoritarianism
• Unassertiveness

MASOCHISTIC • Sadism or masochism
• Guilt

PARANOID
• Anger
• Withholding negative statements

SCHIZOTYPAL
• Underestimating importance of treatment to client

SCHIZOID
• Rejection
• Indifference

HISTRIONIC
• Seduction
• Indifference
• Tendency to explore out of personal curiosity

NARCISSISTIC
• Seeking client's admiration
• Anger and retaliation
• Grandiosity
• Embarrassment

BORDERLINE
• Rescuing
• Rejecting
• Rage
• Guilt

ANTISOCIAL
• Gullibility
• Excessive suspiciousness

AN EXCERPT FROM THE BTA LICENSE EXAM REVIEW WORKBOOK CHAPTER ON TREATMENT INTERVENTIONS

The BTA License Exam Review Workbook contains clearly presented and easy to follow descriptions of the phases of therapy. Over recent years our customers and workshop participants have consistently emphasized how valuable this information was in achieving their success with their license examinations.

Here is a sample. Note how the phases of therapy are described. Then this is followed by a case example. In the BTA License Exam Review Workbook this example is followed by sample progress notes that illustrate how these principles are followed into the middle phase of therapy, and this is followed by a complete section showing how the phases of therapy vary by theoretical orientation.

X. SENSE OF DIRECTION IN CLINICAL PRACTICE

Effective therapeutic interventions are characterized by a sense of direction. Certain things must occur before others occur, before others then become possible.

A clinical sense of direction should be evident throughout one's case documentation. Review the following Case Example, set in a community mental health outpatient clinic. Look for the sense of direction between....

Beginning Phase
- presenting problem(s) which lead to...
- assessment findings which lead to...
- case formulation which leads to...

Middle Phase
- a negotiated treatment plan which contains...
- selected goals which lead to...
- selected treatment objectives which lead to...
- a course of intervention and client progress toward treatment plan goals/objectives which leads to...

Ending Phase
- termination and preparation for follow-up if the case is ready for termination

CASE EXAMPLE

IDENTIFYING INFORMATION

Bob K is a 34 year old single African American man who initially sought treatment at the Riverdale Outpatient Clinic on February 5, 2002.

PRESENTING PROBLEM/REFERRAL REASON

At his initial session Mr. K complained that "I'm afraid I'm going crazy." He also complained that "I'm afraid I'll do something to myself," explaining that he has suicidal ideation and is afraid he will act on it.

MENTAL STATUS EXAM AND OTHER SYMPTOMATOLOGY

At the time of his intake assessment Mr. K's clothing was clean but somewhat disorderly with shirt half tucked into trousers. His hair was uncombed and he was unshaven. He listened to the interviewer's questions but asked me to repeat myself several times, perhaps indicating disturbed concentration. He appeared to reveal information freely, but answers regarding substance use and family members appeared vague and evasive. Posture was slumped but rigid. Speech and body movements were slow. Mood was sad but occasionally reactive to content. Anxiety indicated by dry mouth, sweaty palms, apprehensive anticipation, and client report. Denies present hallucinations or illusions, but reports "seeing things out of the corner of my eye that weren't really there" in the past. Client was oriented x3 with no indication of memory impairment or stream of thought disturbance. Thought content focused on fear of losing control, related to fear of "going crazy" and fear of suicide.

By history, client reports brief episodes of intense anxiety and autonomic hyperactivity with no apparent precipitant, since December, 1997. He reports recurrence "every few weeks." He reports no evidence of triggered panic attacks or phobias. He also reports anhedonia, initial insomnia, early morning wakening, appetite loss and suicidal ideation for the past 2 months with no apparent trigger. Client reports "my health ain't so good with this asthma and my backaches," adding that he has seen his physician, Dr. Kaplan, four months ago who reported no physical basis for the intense anxiety. Attendance at work has been erratic since 2 months ago. Client reports that "I rarely talk to anybody these days," referring to family and friends. Long term mood reported as "sad" with indications of low self-esteem ("I ain't much."), a tendency toward self-blame and pervasive sadness "since I was a kid." Client denies indications of manic or hypomanic episodes. Client denies substance use, but responses are vague and curt relative to his responses to other issues.

DIAGNOSIS

Axis I: Major Depressive Disorder, single episode, melancholic features (moderate)
Dysthymic Disorder
Panic Disorder without Agoraphobia
R/O Substance Related Disorders
Axis II: No Diagnosis
Axis III: Client reports asthma and backaches but that physical cause for panic attacks
have been ruled out by physician. Axis IV: Threat of job loss arising subsequent to onset of depressive episode
Axis V: GAF 60

CLINICAL RISKS

Suicide risk indicated by thoughts in which client imagines himself taking his life while driving or while using heavy machinery at work. Client is distressed by these thoughts, states that he does not want to die, and has no history of suicide attempts or intentional self-injurious behavior. States he has not mentioned these thoughts to others for fear of being labeled as "crazy." Client says he feels relieved to have shared these thoughts with therapist, and is hopeful that "now I can get a grip on this thing."

Client denies desire or intent to assault or otherwise hurt others. Client denies history of assaultive behavior. Current suicide and assault risk are low.

TREATMENT HISTORY

No prior treatment by mental health specialists. Client reports he has received prescriptions for "anxiety medicine" from primary care physicians. He says that Dr. Kaplan, who is currently treating him for asthma, refused to provide antianxiety meds but did offer "depression meds." Client says he refused the prescription because he heard that depression meds interfere with sexual performance. He now says "I should have taken them because now I couldn't care less about sex."

CASE FORMULATION

Mr. K lives alone in a single apartment downtown. He works in a warehouse…sees the work as "boring" but says "there's some good people working there." Client values friendships. He has withdrawn from his co-workers since onset of depressive episode, and has missed work "one or two days a week…I call in sick ‘cause I just can't get out of bed."

Client was previously active in a local Baptist church but has not participated since his current depressive episode. He reports supportive relationships with the minister and several church members in the past. Client draws strength from religious values. He maintains telephone contact with a brother in Los Angeles who "has sent money in times of crisis" but is not seen as a confidant regarding other personal matters. Client speaks of "my girlfriend Angela" whom he has felt close to for the past two years. He says they "get along well but she is no help with these problems….she doesn't really know what's going on."

PLAN

Goals
1. Contain suicide risk.
2. Minimize depression symptoms.
3 Minimize anxiety symptoms.
4 Improve and stabilize social functioning and social participation.

Objectives
1. Reveal suicidal concerns to at least two supportive others by (date)
2. Contract for safety by (date)
3. Reveal and examine at least 10 effects of substance use, if any, by (date)
4. Regular attendance at panic disorder psychoeducational group for 3+ consecutive months by...
5. Maintain compliance with med regimen, if prescribed, for at least two months by (date)
6. Stabilize sleep at 7 hours+/night for two full weeks by (date)
7. Regular attendance at work for at least three consecutive months by (date)

Services To Be Provided:
1. Individual weekly psychotherapy visits
2. Refer to MD for med evaluation
3. Refer to Panic Disorder group at Anxiety Associates

EXAMPLE OF SUBSEQUENT PROGRESS NOTE (One Example Provided Here)

February 7, 2010
Client welcomes discussion of a safety plan to contain suicide risk. Understands and commits to no suicide contract: will call therapist if changes in intention, planning, or desire to die. Client given phone number for Suicide Hotline…service explained and role play practice call made in session. I recommended that client reveal suicide concerns to PCP, psychiatrist, girlfriend, or other potentially supportive person. He refuses to do so and says he doesn't think he needs to right now. "I'm not even sure I still feel suicidal. Let's wait and see." I presented referral to panic disorder group and discussed referral with client. He says he is skeptical, but intends to apply for service. Saw Dr. Kaplan who prescribed Zoloft and Trazadone. Client signed consent to communicate with Dr. Kaplan and psychiatrist, Dr. Wright.

For a sense of direction, note the relationship between the interventions of the Progress Note and the Treatment Plan Objectives, and how those relate to Assessment findings.

AN EXCERPT FROM THE BTA LICENSE EXAM REVIEW WORKBOOK CHAPTER ON CLINICAL RISK ASSESSMENT

The BTA License Exam Review Workbook contains clearly presented and easy to follow frameworks for Biopsychosocial Assessments including...
• Developmental Assessment
• Personality Assessment
• Assessment of Families and Groups
• Assessment of Role Functioning
• Clinical Risk Assessment (Suicide, Assault, Child Sexual Assault, Recidivism Risk)

Here is a sample, followed by principles for managing suicide risk in clinical practice..

XIV. CLINICAL RISK ASSESSMENT

SUICIDE RISK ASSESSMENT

Demographics: Highest risk is associated with...
• males
• over age 40
• divorced/separated/widowed
• living alone
• unemployed/retired.

Motivation:
• Wishes to influence someone's behavior (lowest risk).
• Wishes to escape an intolerable situation, intrapsychic or external, by death (highest risk).

Mental Disorder Diagnosis:
• Risk is associated with depression, thought disorder, hallucinations or delusions regarding death or suicide.

Resources: Are significant others available?

Past Suicide Behavior:
• If so, how lethal was it?
• What is the client's concept of the prior attempt's lethality?
• How does the client feel about the outcome of prior attempts?

Suicidal Ideation: If present, does the client....
a. Intend to act on it?
b. Want to live or want to die?
c. Have reasons for living?
d. Feel negative/frightened about suicidal thoughts or welcome them?
e. Have only abstract/general thoughts or have specific thoughts regarding the suicide plan, circumstances surrounding death, the funeral, etc.?
f. Attempt to keep the suicidal thoughts under control?
g. Think about it fleetingly or as a persistent preoccupation?
h. Perceive available sources of help/support or believe there's nowhere to turn?
I. Seek help or avoid interference with suicidal plans?
j. Prepare for death? Feel prepared for death?
k. Plan out or write a suicide note?
l. Think about a specific method of suicide?
m. Have available the means by which to carry out the planned method?

Other Related Issues:
a. Ask the client what he/she believes will result from his/her death and what effect it is expected to have on significant others.
b. In using past suicidal behavior remember that people motivated to die will generally increase the seriousness of their suicidal behavior. People motivated to influence another's behavior generally increase the seriousness of their suicidal behavior if there has been no response to their past behavior.

MANAGING SUICIDE RISK

1. Decide whether or not you can handle it.
• Do you have either the experience and knowledge base or is adequate supervision or consultation available to you?
• Are you linked to supportive resources such as medical consultation, suicide prevention center staff, or personally supportive colleagues?
• Can you be available to the client at almost all times?
• Are you already treating one or more suicidal clients?
• Are you working through your own deep depression, suicidal thinking, loss of a loved one or other suicidal client?
• Are you sufficiently aware of your own anxiety about suicide and the responsibilities associated with treating a suicidal client?

2. Openly discuss suicide.
• The client needs to develop a cognitive grasp of his or her situation and suicidality.
• The client needs to know that you are not too fearful about the subject to be helpful.

3. Make contracts.
• Do not rely on a contract alone. However a contract is useful for clarifying a course of action for the client at times of heightened risk.
• If outpatient therapy is considered the client should be able to agree to not attempt suicide while in therapy and for a specified time period. The client should further agree to use therapy toward the purpose of making this no suicide commitment a permanent one.
• Agree on exactly what the client should do when feeling suicidal.
• The client should agree to call you prior to carrying out his or her suicide plan.
• The client should surrender weapons, poisons, and/or "pill connections." It may be wise to enlist the aid of a family member in this effort.
• Later contracts can be developed regarding the client's frequency of social contacts, physical activity level, diet, grooming, and other issues as relevant.

4. Formulate a clear and specific initial treatment plan.
• Agree on a frequency and duration of contact.
• How long will sessions be?
• What will you talk about?
• What will be your objectives?
• Who else will be involved in the treatment process?
• Be sure the client and family members understand the plan.

5. Be accessible.
• Let the client know when and where to reach you by phone. Be sure your agency staff know where to reach you and know to provide professional back up if you cannot be reached.
• Be prepared to increase the frequency of visits or to set ad hoc appointments.
• Let the client know whom to call when you are not accessible.

6. Discuss responsibility.
• Let the client know you don't want him to kill himself. However, if the client attempts to manipulate you through suicide threats let him know that you will not accept responsibility for his death.

7. Acknowledge suicide as one alternative.
• ...and note that death is the most unknown and final alternative.
• Encourage the client to postpone thinking about suicide until other options have been identified and considered.

8. Provide hope.
• Give reassurance but only if you can also let the client know you understand the full depth of his or her suffering.
• Discuss the natural tendency of depression toward remission.
• Discuss prior problems or times of despair in the client's life and focus on how the situation resolved.

9. Discuss relevant perceptions and feelings.
• Note the client's ambivalence. Reinforce the desire to live. In helping the client express and examine such feelings as shame, anger, hostility also recognize the client's positive self-evaluations and affection and concern for others.
• Focus on that which has given life meaning, including significant others, work, hobbies, pets, music and other places or interests that have given the client pleasure.

10. Involve significant others.
• They can support the client and help monitor risk indicators.
• The family dynamics may be supporting depression and self-destructiveness on the part of the client and may be accessible to change.
• Family members may need information and support.

11. Develop social skills.
• Suicide is generally associated with frustrated desires for gratification from others. Assertion skills are a more effective way of resolving this problem.

12. Encourage structure in the client's life.
• Encourage the client to go to work and attend structured activities.
• Develop "homework" assignments to build structure and activity into the client's day.
• Structure in therapy is also helpful in motivating and engaging the client. This is especially important for the suicidal client who is often confused and concrete.

AN EXCERPT FROM THE BTA LICENSE EXAM REVIEW WORKBOOK CHAPTER ON TREATMENT PLANNING BY DIAGNOSIS

The BTA License Exam Review Workbook contains clearly presented and easy to follow definitions and descriptions of key therapeutic models and techniques.

Here is a sample from our popular section on Treatment Planning by Diagnosis. This section of the Workbook provides valuable information for addressing license exam questions in the Therapeutic Interventions and Treatment Planning Content Areas.

III. TREATMENT PLANNING BY DIAGNOSIS

Little empirical evidence exists to link most DSM diagnoses to a clear "treatment of choice." However, the available research evidence and the prevailing "practice wisdom" do associate diagnoses with important practice considerations.

Never plan treatment by diagnosis alone. Remember that social work treatment plans need to be individualized to the unique person-in-situation gestalt, not only to the client's diagnostic category. The treatment plan should be influenced by all of the following factors in addition to diagnosis:

• Nature of the Problem
A person with bulimia who is abusing her child will be treated differently than a person with bulimia who has recently separated from her husband.
• Treatment Goals
A person with dysthymic disorder who seeks therapy to become a more effective parent of his adolescent son will be treated differently than a person with dysthymic disorder who seeks therapy to feel less depressed.
• Client's Treatment Preferences
A person with generalized anxiety disorder who seeks the benefit of interpersonal feedback and support will be treated differently than a person with the same diagnosis who is only willing to accept the privacy of individual sessions.
• Personality Factors
A person with a social phobia might do well in an intensive, interactive therapy group, but not if the individual relies on denial or other self-deceptive defenses, persistently projects, or persistently acts out.
• Social Environment
A woman with bipolar disorder who is in a loving, mutually supportive relationship will be treated differently than a woman with the same diagnosis who is being battered and humiliated by her husband.

I. DISORDERS USUALLY FIRST DIAGNOSED IN INFANCY, CHILDHOOD OR ADOLESCENCE

MENTAL RETARDATION

• Early intervention programs.
Programs such as Head Start can help improve intellectual functioning.
• Structured training and vocational services.
• Group living.
Consider a group living situation if the individual is so severely impaired that sufficient care and support cannot be provided in a family home.
• Socialization opportunities.
Provide opportunities for social interaction.
• Independent living skills training.
• Family guidance and support.
Help the family adjust to the stress of caring for a mentally retarded member. Help family members learn to provide care and support for their loved one.

ATTENTION DEFICIT - HYPERACTIVITY DISORDER

• Medications.
Help the client access medications if a medication evaluation calls for this approach. About 70% of ADHD children respond positively to stimulants, such as Ritalin. Medication does not appear to affect antisocial behavior, poor peer relationships and learning difficulties that often arise as associated features of ADHD. Therefore, the following additional psychosocial interventions should be considered.
• Self-instruction (a Cognitive Behavioral technique)
In self-instructional procedures clients learn to make a set of statements such as "I have to go slowly and carefully. Remember, go slowly."
• Modeling and role playing.
• Classroom contingency management programs (structured reinforcements)
• Parent training programs.
• Supportive counseling.
Help the client overcome the emotional and social consequences of their disorder.

The American Academy of Pediatrics Treatment Recommendations for the Treatment of ADHD

In 2008 the American Academy of Pediatrics issued updated and evidence based Treatment Recommendations for the treatment of ADHD in school aged children. These recommendations recognize ADHD as a chronic condition and call for a child-specific, individualized treatment program with a goal of...
* maximizing function to improve relationships and performance at school
* decreasing disruptive behaviors
* promoting safety
* increasing independence
* improving self esteem.

Other recommendations include...
* use of stimulant medications and/or behavior therapy
* regular and systematic follow-up to monitor goals and possible side effects.

The recommendations include a policy statement regarding what to do with children who don't respond to standard treatments. Often, when a child doesn't respond to a medication, the treatment is stopped and the child is left to continue to do poorly at school, have behavior problems and poor relationships with others. Instead, the AAP recommends that when the selected management for a child with ADHD has not met target outcomes, clinicians should evaluate...
* the accuracy of the original diagnosis
* use of all appropriate treatments
* adherence to the treatment plan
* presence of coexisting conditions which may be complicating the ADHD treatment

Children who continue to have problems with core symptoms (such as inattention, hyperactivity, and impulsivity) after a course of behavioral therapy should be considered for stimulant medication, as well as an augmented behavioral treatment strategy.

The AAP policy statement reviews medications used in the treatment of ADHD, including stimulants, which are "first line treatments," and antidepressants, which are "second line treatments". Antidepressants might be considered if two or three stimulant medications are not effective for a specific child.

(ALL OTHER "CHILDHOOD DISORDERS" ARE ADDRESSED IN THE WORKBOOK.)

II. COGNITIVE DISORDERS

• Supportive psychotherapy.
Help the client deal with emotional aspects of the disorder.
• Self-instruction.
This approach can help to improve attention and concentration. Typically, the client might learn a set of self-instruction statements such as "In order to fully concentrate I must look at the person speaking to me." "I must focus on what is being said, not on other thoughts that want to intrude." Teach the client these statements. Then the client repeats them until they become second nature.
• Anger management techniques.
Cognitive Behavioral techniques are effectively used to manage the anger that often accompanies cognitive disorders. Typically a person learns to manage angry thoughts through "thought stopping," and by learning a set of self-verbalizations or self-instructions that are incompatible with the expression of anger. Then, in application training, the person learns to apply these skills in a sequential hierarchy of anger evoking situations.
• Counseling for collaterals: Help family and friends assist the client.
1. The living environment must be modified for safety. For example, use of rails to guide and support the person, remote control devices for television and radio, guard rails for the bathtub and anything that will enhance a sense of security when moving about.
2. The person should be encouraged and assisted to maintain social contact. However, visits should generally be kept short and limited to individuals or small groups of people so that the client doesn't feel overwhelmed.
3. Diversions, such as going out for a walk, especially in calm, peaceful surroundings, are helpful.
4. Assignment of tasks that support a person's sense of self-worth and a sense of contributing to the immediate environment and community.
5. Keep in mind that caregivers are likely to need support themselves.
• Physical rehabilitation.
These services may be needed if the brain damage also involves loss of motor skills. The client may need help to access resources.
• Medications.
Help the client access medications if a medication evaluation calls for this approach. Antidepressants are sometimes used with cognitively impaired people to deal with the emotional problems associated with their disorder.
• Surgery.
Surgical treatment is needed when the disorder is due to cerebral tumors or ruptured blood vessels. The client may need help to access resources.

IV. SUBSTANCE RELATED DISORDERS

• Help the client access detoxification resources, if needed.
• Self help group referral. Remember that skillful counseling is needed to prepare the client to accept the referral and support follow-through.
• Help the client access medications if prescribed by a physician.
Antabuse, the generic Disulfiram, may be used to produce an aversion to alcohol because it causes a person to experience nausea, vomiting, and severe discomfort if they drink. Most alcoholics will not consume alcohol after ingesting Antabuse, however Antabuse is effective for only one or two days and must continue to be taken regularly. Methadone is a synthetic narcotic that reduces the craving for heroin without producing euphoria. Methadone is addictive. Naltrexone is used to reduce the craving for either alcohol or heroin. Even while taking Antabuse, Naltrexone or Methadone, counseling is usually needed to maintain compliance and help the individual develop better coping skills and alternative life style patterns.
• Family therapy.
In work with family members they are helped to overcome codependent patterns and to focus on dealing with the chemically dependent person's negative behaviors rather than trying to manage their substance use. Family therapy should be used whenever possible with adolescent drug abusers.
• Aversion therapy.
In this approach the sight, smell and taste of a drug is paired with noxious stimuli such as electric shocks or strong odors. In some cases the client is given emetics (agents that induce vomiting) when they get the urge to use a substance, or after using, smelling or tasting their substance. In covert sensitization imagery is used as a part of aversion conditioning. The individual is trained to imagine nausea and vomiting in the presence of their drug of choice.
• Counseling or psychotherapy.
When aversion therapy or other behavioral techniques are used, generalization of symptoms beyond the treatment situation, and long term maintenance of symptom improvement, has been equivocal. Therefore, ongoing counseling or psychotherapy will likely be needed to enhance social functioning, develop resistance to stress, and reduce anxiety.
• Stress management counseling.
This can help chemically dependent people find alternative ways of dealing with emotional problems that, in the past, were dealt with by drug use.
• Cognitive restructuring techniques.
Cognitive restructuring may be used to help addicts change their thoughts about the pleasant effects of drug use. For example, the addict may be taught to substitute negative thoughts (I feel an urge to snort coke, but I know that I will feel depressed and guilty later, that I need my money for better things, and that I will make a fool of myself while using) for previous positive thoughts about the drug use.
• Urine toxicity screenings.
These are commonly and effectively used, especially in follow up treatment of those who have been in residential treatment programs. They not only monitor compliance but they provide the client with an added incentive not to use, since the person knows they are likely to be detected.
• Treatment programs.
Residential treatment may be especially useful for someone whose living situation is chaotic and unstable and who may need the program's high degree of structure. These programs commonly have a duration of 30 to 60 days (some much longer). Outpatient and aftercare programs commonly continue for about two years. Ongoing support from self help groups is usually recommended even beyond that point.

Chemical dependency treatment programs tend to be effective with those who complete the programs. However, high attrition rates are common. In order to reduce attrition rates programs should be conveniently located and relatively small. Programs with higher staff to client ratios have lower attrition rates than other programs, and programs where treatment is designed to be more "user friendly" and personalized tend to have lower attrition rates.

V. SCHIZOPHRENIA AND OTHER PSYCHOTIC DISORDERS

SCHIZOPHRENIA

• Medications.
Help the client access medications if a medication evaluation calls for this approach. Also help the client maintain compliance with their medication regimen once it is prescribed. Your contacts with the client can also help in monitoring for side effects such as tardive dyskinesia. There is some danger of overmedication. When dosages are lowered relapse of acute episodes increases to some extent, however, lower dose patients show greater social competence and social adjustment. The need for higher or lower dosage levels may depend on whether or not the client has supportive family available. The better the support, the lower the dosage needed.
• Supportive counseling.
Note that psychotropic medications may be effective with the psychotic symptoms of schizophrenia (delusions, hallucinations and thought disorder) but not with the residual symptoms such as poor hygiene, social withdrawal, and bizarre behavior.
• Psychosocial rehabilitation.
This approach, usually involving a group oriented program setting such as day treatment, focuses on improving self-care behavior, conversational skills, or occupational skills development and vocational training.
• Reinforcement and modeling techniques.
Undesirable behavior such as "crazy talk" or social withdrawal can be decreased using these techniques.
• Social skills training.
For example, role play can be used to teach communication skills. One specific approach to social skills training is known as integrated psychological therapy. This Cognitive Behavioral approach involves cognitive differentiation in which the client is taught to discriminate stimuli. Clients learn to accurately recognize and respond to social cues. Verbal communication is improved as clients learn to understand and evaluate verbal statements and how to converse with others. Other social skills, such as self-assertion or job interviewing skills, may also be addressed.
• Family interventions.
Family interventions now focus on the issue of expressed emotions. It has been found that families that are too closely involved in the day to day activity of their schizophrenic member and who have high degrees of expressed emotion are those where the acute episode relapse rate is highest.
• Hospitalization.
This intervention is needed if the client is posing an imminent risk of danger to self or others, or is gravely disabled.

(ALL OTHER PSYCHOTIC DISORDERS ARE ADDRESSED IN THE WORKBOOK)

VI. MOOD DISORDERS

MAJOR DEPRESSION AND DYSTHYMIC DISORDERS

• Medications.
Help the client access and manage medications if a medication evaluation calls for this approach. Medication treatment is generally focused on controlling the level of neurotransmitters at brain synapses. Tricyclic antidepressants have been effective. MAO inhibitors are also effective. MAO inhibitors are generally only used with people who have not responded well to Tricyclics because of the many side effects and cautions involved in using this drug. People on MAO inhibitors should not eat cheese, pickled products, or chocolate, or drink beer and wine. These foods contain a chemical known as tyramine. See the section of this workbook on psychotropic medications for further information.

Prozac (fluoxatane) and other SSRI's are also used to treat depression, and seem to be as effective as Tricyclics, but with fewer unpleasant side effects. The effectiveness of antidepressants tends to be highly rated by clinicians but patients themselves give less favorable ratings. Patients treated with placebos give similar ratings to those of patients treated with antidepressants.

• Electroconvulsive therapy.
Help client access resources for electroconvulsive therapy (ECT) if prescribed by a physician. ECT is primarily reserved for patients with severe unipolar depression who have not responded to medications. The response to treatment is relatively fast but side effects include headaches, confusion and memory loss.

• Cognitive Therapy.
This treatment approach, used in combination with behavioral therapy (see below), involves several steps.
1. Teach the client to identify automatically occurring negative and self critical thoughts.
2. Draw attention to the connection between negative thoughts and the resulting depression.
3. Examine each negative thought and decide whether or not it can be supported.
4. Replace distorted negative thoughts with realistic interpretation of personal experiences and life events.
5. The client is usually then asked to monitor his or her negative thoughts and list them on a chart. The chart is then brought to therapy sessions and the therapist uses this to demonstrate that the client's distress is caused by the unnecessarily negative thought. The client is helped to come up with his or her own rational alternatives to these thoughts and makes a conscious effort to adopt these alternatives. Ultimately the client learns to automatically substitute logical interpretations for self-denigrating thoughts.

• Behavioral Therapy.
Following Cognitive Therapy, the intervention strategy then commonly moves on to a second aspect, the Behavioral Therapy. The client is asked to keep a daily activity schedule in which they list life events from hour to hour, and rate how pleasant or unpleasant each event is. The primary purpose of this exercise is to increase the volume of a person's activities. Volume spontaneously increases among those who participate in this monitoring. Simply engaging in more activity increases the chance that the person will become involved with pleasant and reinforcing events. As the person becomes more active they may be engaged in social skills training which helps the client become more socially involved and helps make social involvement more rewarding.

(ALL OTHER MOOD DISORDERS ARE ADDRESSED IN THE WORKBOOK.)

VII. ANXIETY DISORDERS

When treating anxiety disorders, note that anxiety has three dimensions.... cognitive, behavioral and biological.
• Cognitive restructuring deals with the cognitive element.
• Graduated exposure deals with the behavioral aspect.
• Medications deal with the biological aspect.

PANIC DISORDER

• Medications.
Help the client access medications if called for following a medication evaluation. Both antidepressants and tranquilizers have been used. The antidepressants, especially Imipramine, appear to reduce extreme fears. Alprazolam and Verapamil are also used. In general medications have been useful in treating anxiety disorders but relapse rates after discontinuing medications are high. If the client discontinues the medications watch for rebound panic attacks that may be worse than those they originally experienced.

• Psychotherapy.
Cognitive Behavioral treatments are favored. One reviewer of Cognitive Behavioral treatments for panic disorder found that 80% or more of clients achieve panic free status, and this is maintained on follow up studies. One researcher found that behavioral approaches have higher success rates and lower relapse rates than medications.

Reflecting a typical Cognitive Behavioral approach, six steps for dealing with a panic disorder have been recommended by Bourne:
1. Provide cognitive explanations of the panic experience.
2. Help the client identify and change unrealistic thoughts.
3. Encourage the client to face the symptoms, that is, to allow themselves to have the symptoms rather than trying to control and suppress the symptoms, thereby letting the symptoms extinguish spontaneously.
4. Provide coping statements. For example, the client might learn to say "This feeling isn't pleasant but I can handle it."
5. Teach the client to identify the antecedents of the panic.
6. Help the client develop coping strategies such as use of a relaxation response and other stress management techniques.

GENERALIZED ANXIETY DISORDER

• Medications.
Help the client access medications if a medication evaluation calls for this approach. Benzodiazepines have been used but tolerance and dependance are a problem. In general medications may help reduce the anxiety but psychological intervention is also necessary to reduce avoidance responses.

• Psychotherapy using relaxation training and graduated exposure.
Cognitive and behavioral techniques are used as they are with panic disorder. The variety of cognitive and behavioral techniques plus relaxation training is generally recognized to be more effective than relaxation training alone. Treatment includes graduated exposure to anxiety arousing situations. Steps might include the following:
1. Identify and alter anxiety evoking thoughts.
2. Develop coping strategies.
3. Teach relaxation training.

The following is an example of how a relaxation training program might be implemented: Concentrate on one set of muscles at a time. For example, begin with your hands. First tense them and then relax them. As you release tension focus on the sensation of warmth and looseness in your hands. Then proceed to another muscle group, such as your lower arms. Then, after each muscle group has been addressed, tighten and relax your entire body. This process may go on for about 30 minutes. With practice the individual eventually learns to relax muscles without first having to tense them.

4. Gradually expose the client to anxiety provoking situations.

(ALL OTHER ANXIETY DISORDERS, AS WELL AS ALL OTHER CATEGORIES OF DSM DISORDERS, ARE ADDRESSED IN THE WORKBOOK.)

AN EXCERPT FROM THE BTA LICENSE EXAM REVIEW WORKBOOK CHAPTER ON CLINICAL INTERVENTION TECHNIQUES

The BTA License Exam Review Workbook contains clearly presented and easy to follow definitions and descriptions of key therapeutic models and techniques.

Here is a sample, describing core clinical techniques. The terminology you'll see here is commonly used in day to day clinical practice. For successful exam performance it helps to be able to clearly identify the meaning of this terminology.

I. CLINICAL INTERVENTION TECHNIQUES

The following list of social work intervention techniques was originally developed by Florence Hollis, seminal social work theorist. This framework has subsequently been used in research and for practice theory development. These techniques are used in all social work practice approaches and in virtually any and all approaches to psychotherapy.

The descriptions are designed to provide you with clear, focused definitions of terminology and concepts that are commonly used in day to day practice. The effects of these procedures are also presented. Note that all procedures have potential negative effects when not properly used. This information will help you articulate your sense of intention and purpose in developing treatment plans and intervention strategies. Your awareness of the limitations of these procedures will help you convey your capacity to practice independently.

SUSTAINING PROCEDURES

A. PROCEDURES

Support. Demonstrating interest and respect for the client. Demonstrating a desire to help. Expressing realistic confidence in the client's abilities. Demonstrating understanding of the client's meaning. Raising questions and making confrontations in an accepting manner.

Reassurance. Informing the client of attainable solutions. Expressing realistic confidence in the client's abilities. Identifying the unrealistic nature of the client's anxiety and/or guilt when appropriate. Promoting universalization.

B. EFFECTS

Sustaining procedures reduce anxiety and guilt feelings, stimulate hope and confidence, and enhance self-esteem. A secondary effect is to "free up" energies for adaptive problem solving. They can also promote a positive transference which should be recognized by the therapist. The therapist should also be aware that sustaining procedures can promote dependency. They should not be used to reduce anxiety beyond the point where a client's motivation for change would be lost.

DIRECT INFLUENCE PROCEDURES

A. PROCEDURES

Advice and suggestion. This refers to the therapist's recommendations for client behavior or ways of thinking. These techniques are best used when the client is in a crisis and unable to formulate his or her own sense of direction and when there is no reasonable alternative. Advice should be concerned with means, not ends, for the client. The rational basis for a therapist's advice should be shared with the client.

Reward and punishment. This refers to providing desirable or aversive consequences for client behaviors. All therapists directly influence their clients' behavior through a variety of reinforcements, many of which are subtle. For example, these include attention, smiles, frowns, looking either interested or bored, giving advice when sought, withholding advice when sought.

B. EFFECTS

Depending on the manner offered, advice and suggestion can also "free up" a client's energies from confused decision making to directed problem solving actions. If the advice is inappropriate or not properly communicated it can reduce the client's self-confidence, set the foundation for manipulation by the client, and destroy the social worker's credibility with the client.

VENTILATION PROCEDURES

A. PROCEDURES

Encouraging verbalization. This refers to using exploratory questions, active listening, attention to affect, honest labeling of client's behavior, and explaining the value of verbalization.

Self-demonstration. Examples include role plays, psychodrama, structured fantasy, free association, play therapy, activity programs, audiotape and videotape feedback. These are procedures that enable a person to act out her inner life in a manner that can be observed and reflected upon.

B. EFFECTS

Ventilation can set the foundation for rational discussion and self-exploration.

Anxiety and guilt, which are expressed in ventilation, become accessible to support and reassurance. Self-demonstrations enable clients to participate in a situation where they can observe their feelings, attitudes, beliefs and behavior patterns. Ventilation procedures are generally not seen as productive ends in themselves. They lead to reflective thinking and discussion. Premature ventilation and over-ventilation are to be avoided as they could result in a regression inducing sense of premature exposure and shame.

REFLECTIVE DISCUSSION

A. CONTENT

Discussion of the situation. Uncovering and understanding facts about the client's economic situation, physical environment and significant others.

Discussion of personality. Determining the nature of the client's feelings, attitudes, beliefs and response tendencies. Evaluating these as adaptive or maladaptive.

Discussion of effects of client's actions. Determining how the client's behavior affects the client or significant others.

Discussion of social worker and agency. Determining the nature of the social worker and agency. These are important facets of the client's situation.

B. PROCEDURES

Explanation. Presenting the client with the meaning, motives, or causes of an issue or event. Similar to interpretation but involves less inference.

Suggestion. Asking the client to "try looking at it this way." Suggestion, in this sense, is used in the process of reframing or learning to attribute new meaning to a situation or experience.

Confrontation. Making the client aware of inconsistencies within his/her perceptions, or between perceptions and objective facts, or between his/her verbal and nonverbal communication.

Questions. Directing the client's attention to certain aspects of the person-situation configuration. They may be a subtle form of explanation, suggestion or confrontation since all questions make a statement as well as requesting a response.

Clarification. Developing a more accurate understanding of the facts regarding the client's thoughts, feelings, behaviors and situation.

Interpretation. Taking what is already known to the client and attributing new meaning to it. Generally this is done according to some theoretical and/or cultural framework. For example, a Jungian therapist might attribute meaning differently than a Freudian therapist. An Italian-American therapist from the Bronx might attribute meaning differently than an Asian-American therapist at U.C. San Diego. Interpretation is especially relevant to the following two sections on response pattern dynamics and development.

C. EFFECTS

Reflective discussion enables the client to gain a sense of control through a cognitive grasp of reality. This supports many ego functions including reality testing, judgment, sense of reality, stimulus barrier and others. It enables clients to perceive a range of choices in attacking their problems and to select from among these choices.

(ADDITIONAL CLINICAL TECHNIQUES, MODELS AND METHODS ARE REVIEWED THROUGHOUT THE BTA LICENSE EXAM REVIEW WORKBOOK CHAPTERS ON TREATMENT PLANNING AND THERAPEUTIC INTERVENTIONS.)

AN EXCERPT FROM THE BTA LICENSE EXAM REVIEW WORKBOOK CHAPTER ON ***

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