Final Exam

Question 1

ethics goals

Answer 1

ensure client welfare,

protect clients,

avoid governmental interference in profession,

guide ethical practice,

avoid malpractice lawsuits,

develop public confidence in the profession

Question 2

ethics principles

Answer 2

Client Relationships

Client Welfare

Competence

Confidentiality

Interprofessional Relationships

Legal & Moral Standards

Non-Discrimination

Public Statements

Publication Credit

• Remuneration*
• Responsibility*
• Societal* Obligations

Question 3

4 deadly sins

Answer 3

Greed, Lust, Pride, Ignorance (i.e. lack of knowledge and application of ethical code)

Question 4

Ethics Hierarchy

Answer 4

Protect human life

Fostering independence & freedom

Fostering equality

Promoting a better quality of life

Protecting the right to privacy

Truthfulness

Abiding by rules & regulations

Question 5

Ethical standards supersede…

Answer 5

all other considerations

Question 6

informed consent coveys…

Answer 6

the “rules of counseling” to client

Question 7

describe informed consent

Answer 7

client has been informed, understands, and/or agreed to:

clearly laid out TX PLAN,

RoE in session,

boundaries of & right to confidentiality

Question 8

informed consent & expectations

Answer 8

lets client know exactly what to expect re: treatment outcomes

Question 9

informed consent and full disclosure

Answer 9

Full disclosure of all information, e.g. statement of your credentials, estimated length of treatment, what treatment(s) you offer, cost-benefits of treatment, fees/copays/insur, statement of confidentiality

Question 10

mental health & addictions counseling essential differences

Answer 10

Psychodynamic – views substance use disorders as a symptom of an underlying psychological problem and not as a primary disorder.

Behaviorally oriented – may view SUD as learned behaviors and therefore reject the Disease model.

Mental health – travels root causes of various disorders

Passive, interpretative, rehabilitative, supportive, laid back, quiet, analytic

Addiction counseling- may not explore the root causes of problem. Just getting off the substance is the important part in the early stages.

Active, directive, habilitative, confrontative, outgoing, supportive, pragmatic, collaborative

In addiction counseling it is more important to engage the client and establish and instill hope. Also the counselor must contain the crisis. Detox? Other?

Question 11

Biopsychosocial Assessment areas & example Q’s

Answer 11

• Substance Use Profile- type of substance, route of administration, frequency or patterns of use, settings or circumstances, loss of control, patterns of self-medication, tolerance and withdraw, positive effects, negative consequences
• Developmental history – trauma, parents that used, medical problems, school problems, peer dynamics, sexual identity, relationship history, coping skills, psychiatric use, early use
• Other Addictive/Compulsive Behaviors – coexisting problems or “substitute addictions,” antecedent to other addictive behaviors, what is the expectancy (relief, high), risks behaviors pose to clients recovery, readiness to change other addictive behaviors
• Prior treatment/12 Step Experience – when, where, what type, their response, complete/AMA, compliant?, feelings toward 12 Step, level of involvement, sponsor?, literature?, God?
• Family History of Substance Use - Tell me about you family growing up ->did anyone in your family have medical issues -> anyone use alcohol or drugs, what was acceptable drinking in your family, anyone go to AA or treatment
• Role of Family in Current Use – enabling, using, financial support, recovery support, shield negative consequences, should you meet with family or partners?
• Legal, Medical, Social, Educational, Occupational History - gather information about non-substance related functioning, any other problems, capable of managing finances, coping with everyday stress Other legal, medical, educational, social, psychological adjustment, occupational history

Question 12

Decisional Balance technique

Answer 12

see image

4 sq pro/con/continue/abstain:reasons

Question 13

Decisional Balance technique clients’ stage

Answer 13

Contemplative Stage – may have admitted to a substance use disorder and are toying with the idea of help. Helps client to weigh the pros and cons of continued use and abstaining from use

Question 14

what does the metaphor “M. I. is more like ballroom dancing than wrestling” mean

Answer 14

• Wrestling is conflictual and
• ballroom dancing you are on the same team and moving towards the same goal.
• In therapy you are moving towards the same goal together.
• It’s working together, not forcing someone into submission.
• Thoughts and motivations and goals need to be in unison and working towards that same goal.

Question 15

what does O-A-R-S stand for

Answer 15

Open-ended,

affirmations,

reflective listening,

summarizing

Question 16

various subtypes of reflective listening

Answer 16

Simple- close to what the client said

Client- I’m not sure I need counseling, Counselor- You’re not sure

Complex or Amplified- beyond what they said, add depth or meaning

Counselor- You’re frustrated when others make decisions for you

Understatement- Below what the client is conveying (checks client desire)

Continuing the Paragraph- adds to what client said

Counselor- You’re annoyed that your parents brought you here and insist you need counseling

Statements:

Double-sided Reflection- highlights ambivalence in client’s words

Counselor- “On the one hand you feel frustrated AND on the other hand you’re curious.

Use AND (adds to statement), not BUT (negates prior statement)

Use of Metaphor- provides alternative understanding

Counselor- So it’s like a game you feel forced to play that no one told you the rules or the point of.

Question 17

what are “affirmations” and give examples

Answer 17

Focus on – specific behaviors not attitude, descriptions not evaluations, no “I” words, attend to non-problem areas not problem areas, should nurture a competent not a deficit

• Bolster a “can do” attitude
• Empower clients
• Increase self-efficacy
• Re-orient the client back to the inner resources that have at their disposal
• Statements of appreciation of a client’s efforts
• Client should neither feel judged or patronized (Affirmations are not compliments)

Question 18

what is meant by collecting, linking and transitional summaries and provide examples

Answer 18

Collecting: purpose is to gather information together and present if back to the client, also should be designed to keep conversation moving forward

Linking: seeks to contrast ideas heard in the present moment with previously shared information or information shared by outside or collateral sources (use “AND”)

Transitional: used to change direction of the session. Summarize part 1 of tx but you’re now moving to part II

Question 19

what is D-A-R-N and how does it relate to “change talk”

Answer 19

Desire to change, Ability to change, Reason to change, Need for change

Desire- stops short of commitment (“I wish things were different,” “I just want to feel better,” “This isn’t who I want to be.”)

Ability- about self-efficacy or ability reflecting clients perception that change is possible (“I know what I have to do, I just have to do it,” “I can change, if I set my mind to it.”)

Reason – clients articulate ways their life would be better if they changed (“my husband will get off my back if I stop drinking,” “I’ll have more energy to worry about my blood sugar.”)

Need – statements that things are not working in the client’s life, recognize need to change (“I need to get a handle on things,” “I can’t keep using cocaine, I’ve spent all my money”)

Question 20

what is meant by Elaborative- Evocative- and Key questions and give examples

Answer 20

• Evocative questions: asks the client directly for change talk (e.g. “in what ways does this concern you?” Or “How would you like things to be different?”)
• Elaborative questions: ask clients for examples of situations that illustrate change talk (e.g. “tell me about a recent time when you spent too much on gambling?” “What does it look like when you’ve had more to drink than you intended to?”
• Key questions: special type of inquiry in which counselor asks, “What’s your next step?” Or “what if anything will you do now?” (Similar to solution-focused questions
• Extremes – “what’s the worst-case scenario if things don’t change?”
• Looking back – Getting clients to recall how things were before the problem began
  
  • “What did you envision for your life when you were young?”
• Looking forward – asking the client to look at what things might look like in the future if change occurs and if it doesn’t.
• Exploring goals – how does the client’s target behavior fit with their overall goals Values?

Question 21

advantages and limitations of group counseling

Answer 21

Advantages – encourage and support, healing powers, instill optimism and hope, positive peer pressure, desensitize reluctant to self-disclose, healthy group emphasizes self-disclosure, participation, honesty, attendance, and behavior change, can treat more clients at reduced fees

Limitations – reluctance to self-disclose, no guaranteed confidentiality, may not be able to address needs of all individuals, content and pace is determined by group as a whole, group may not be suitable for all clients

• Groups can encourage/support difficult change
• Healing power of group is important given shame, guilt
• Groups instill optimism/hope
• Can be source of positive peer pressure
• Forthright discussion of important personal issues can desensitize new group members
• Healthy group emphasizes self-disclosure, regular participation, attendance, behavior change
• Counselors can treat more clients
• Clients may be reluctant to self-disclose
• Confidentiality cannot be guaranteed
• May not be able to address the needs of all individuals

Question 22

role of a group facilitator is in addictions groups

Answer 22

1. establish and enforce rules
2. screen, prep, & orient members
3. keep discussion focused on impt issues
4. emphasize, promote, & maintain cohesiveness
5. create & maintain caring, nonjudgmental, support atmosphere
6. manage problem members and problematic group behaviors
7. provide psychoeducation when appropriate
8. model appropriate confrontation and expression of concern

Question 23

when is an abstinence approach necessary vs. when a harm reduction approach might be considered Tx goal

Answer 23

• Abstinence is the preferred treatment goal especially when the client experiences a loss of control and when there is a risk of serious harm (liver disease, arrest) if personal continues use
• Harm reduction- only if health allows
• Meet the client where they are at

Question 24

William Miller’s basic M.I. principles

Answer 24

R – Resist the righting reflex - Don’t actively attempt to fix things in your client’s lives.

U – Understand your client’s motivation – help them to recognize the motivation within them.

L – Listen to your client – we create an atmosphere where they can safely explore conflicts.

E – Empower your client – we support our client’s belief that they are capable – engagement w/client is necessary for your client to find their inner strength and determination.

Question 25

what does Washton suggest for how to utilize the “self-medication hypothesis” in treatment?

Answer 25

People who become dependent on substances do so as a result of ego impairments resulting in problems with affect regulation, self-esteem, self-care, and interpersonal relationships Ex- opiate users seek to control anger, rage and loneliness Cocaine users seek to manage depression, boredom, feeling empty Find the desired effect and use it as a clue for what to work on providing alternatives t dependence and drug use to produce that effect

Question 26

therapeutic traps and how Washton recommends counselors manage to avoid those traps

Answer 26

**Savior** Trap – being over-involved in convincing your client they have a problem. Allow client to talk about pos/neg of use **Abstinence** makes it **worse** – bring factual information in chunks and assist client in seeing possible long-term benefits of recovery **I Can’t be an addict** because – _Rationalization and minimalization_. Explore reasoning behind their conclusion, avoid labeling as addict or alcoholic and look at behaviors or consequences

Question 27

make the case for abstinence using both Washton’s approach and a M.I.

Answer 27

MI says we start where the client is and work toward mutual agreement on goals Risk factors: Future danger to themselves or others if they continue using, if they are drinking and driving, are on probation and using as a harm reduction **Abstinence is:** * Clearly the safest choice * Provides opportunity to see things from a different perspective * Gives you better access to your emotions * Gives you a chance to break old habits, build self-confidence, experience change * Helps you to identify internal and external triggers associated with substance use * Can help reduce conflicts with family * Can provide you with indication of how difficult or easy it would be to stop using * Exposes voids and unmet needs in your life * Can enhance or restore effectiveness of prescribed medications for other problems, e.g. depression.

Question 28

express concerns using Washton’s approach

Answer 28

Express interest, concern, and curiosity. “Simple expressions of interest and caring by the therapist can go a long way toward creating a trusting atmosphere that encourages truthful self –revelation” – quote from his book

Question 29

How can you best help your client manage cravings?

Answer 29

Cravings do not have to result in use Stronger in first days of stopping but diminish in frequency and intensity Think it through – play tape until the end, past the initial high/buzz Leave situation and do something else – move a muscle change a thought Thought stopping techniques- rubber band, music, drive, exercise Reach out for help Detach craving – be an outside observer Delay decision – won’t pick up for the next hour

Question 30

examples of substitute addictions and be able to provide an example of how you would address this in counseling

Answer 30

Other drugs trigger desire to return to DOC, can “give permission” for DOC, other drugs thwarts use of coping strategies, other drugs impair judgement and decision making, other drugs prevent relationship forming

Question 31

match your counseling strategies with the client’s stage of change

Answer 31

_Precont-_ don’t argue with client or pressure, build rapport, establish open dialogue, work with and not against EX- explore referral, examine discrepancies between perceptions, “Columbo approach” suggest experimental abstinence or temp reduction _Cont-_ increase awareness, heighten ambivalence, don’t only focus on neg consequences, acknowledge “two minds” of using and stopping EX- past abstinence, abstinence experiment, what would you be willing to do, whats the next step? _Prep/Action-_ present a menu of options, explore best treatments EX- identify those who support change, what has worked in past, how to avoid pitfalls and failures _Maintenance-_ relapse prevention, support self-efficacy, relapse triggers EX- review triggers, clues to pending relapse (mood, attitude, stop meetings)

Question 32

difference between “escape” and “action” gamblers

Answer 32

_Escape Gamblers-_ usually *depressed, lives mundane lives, often isolated* (divorced, single), some have other addictions (substances or food), may be in abusive or neglectful relationships. _Action Gamblers-_ these are *high sensation seekers, need to be “in the game” in order to feel alive, obsessed with gambling, have very restricted lives otherwise, no interests, not much social contact* (other than those whom they can exploit), may have manic tendencies.

Question 33

how to assess sociopathy in those with Gambling Disorders and why it's important

Answer 33

The greater the level, the poorer the prognosis Stolen from family or friends? Lied about debts or to scam more money? Stolen from employers or strangers (scamming, conning, and embezzlement)? Experience remorse or justify?

Question 34

which mental health disorders are of most concern in treating COD?

Answer 34

COD clients that are at higher risk for suicide are mood disorders and schizophrenia

Question 35

which mental health disorders most often correlate with SUD?

Answer 35

COD clients that are at higher risk for suicide are mood disorders and schizophrenia

Question 36

what does reciprocal relapse mean as it pertains to COD

Answer 36

Common relapse to one problem results in relapse to other (ex a client with mood disorder stops taking meds and eventually begins drinking again)

Question 37

how would you go about making a suicide assessment using the SAD PERSONS acronym?

Answer 37

S-sex, A-age, D-depression, P-previous attempts, E-ETOH abuse, R-rational thinking loss, S-social support, O-organized plan, N-no spouse, S- sickness (physical)

Question 38

what is meant by “trauma-informed care”?

Answer 38

an overview of trauma informed care treatment models (e.g., trauma focused cognitive behavioral therapy, trauma systems therapy, cognitive behavioral Intervention for trauma in schools, and Life Improvement for Teens (LIFT) interactive intervention for adolescents exposed to trauma), and concepts, such as trauma informed care and related approaches, that can be implemented in schools and in classrooms to create a trauma informed culture. _Realizes_ the widespread impact of trauma and understands potential paths for recovery. _Recognizes_ the signs and symptoms of trauma in clients, families, staff, and others involved with the system. _Responds b_y fully integrating knowledge about trauma into policies, procedures, and practice. Seeks to actively _resist re-traumatization_

Question 39

how can medications be safely used in the treatment of COD?

Answer 39

_Timing of prescription of med impt._ Benzos are very effective but…addictive Buspar, SSRIs (Wellbutrin). Alternatives like Kava Kava, melatonin, valerian root Also exercise, yoga, relaxation, REI, EMDR, Brainspotting New antidepressants have fewer side effects and take less time to reach active potential.

Question 40

how medications might be useful in the treatment of SUD in terms of addressing withdrawal, cravings and relapse prevention

Answer 40

_Alcohol-_ inpatient setting unless no other options or history of seizures, Librium and Ativan. Acamprostate (Campral)- reduces alcohol cravings. Topirimate (Topamax)- reduces alcohol craving and drinking is less reinforced. Disulfram (Antabuse) - alcohol antagonist, prevents individual from breaking down toxic elements of alcohol thereby poisoning themselves _Benzos-_ difficult and long _Opioids-_ outpatient, methadone, buprenorphine, Darvon or Vivitrol- prevents opiate relapse _Craving blockers-_ Naltrexone (doesn’t completely block alcohol but makes it less pleasurable), Trexan, or ReVia are opiate antagonist that blocks the user from experiencing the high Smokers: Chantix & Zyban- used for smokers

Question 41

precipitants or triggers of relapse

Answer 41

Positive or negative affect states Environmental cues or triggers associated with use Inadequate coping or problem solving skills Sexual triggers Unrealistic expectations or “mind traps” or cognitive distortions (irrational beliefs) Lingering PAW Conscious or unconscious motivations to use (e.g. to decrease shame, guilt or deal with trauma) Negative social interactions (fear of abandonment, rejection)

Question 42

what is meant by the “relapse chain”?

Answer 42

Build up of stress, tension often as a result of negative events Stress activates negative thoughts, moods, feelings of being overwhelmed Client either overreacts or numbs, this results in a failure to take positive action Client begins to withdraw from their recovery support network This results in a re-surfacing of denial, increased skepticism or cynical attitudes Feeling of futility about one’s ability to manage life, coupled with belief that relapse is inevitable Signs of impaired judgment or impulsiveness As a person’s life becomes more unmanageable feelings of frustration, despair and self-pity set in, obsessive thoughts of using are triggered Client experiences irresistible cravings, urges to pick up Chain is complete

Question 43

Relapse Prevention planning strategies and steps that Washton discusses

Answer 43

* buildup of stress, stress activated negative thoughts, client over reacts of numbs, withdraw from recovery support, resurfacing denial and skepticism, belief relapse is inevitable, impaired judgement and impulsiveness, more unmanageable frustration and despair trigger, irresistible cravings and urge to use. * Educate clients about relapse (relapse chain and relapse prevention) * Identify relapse precipitants (triggers) and warning signs including high risk situations, behavioral warning signs (conflict with others), affective warning signs (dysphoria, anhedonia), cognitive warning signs (euphoric recall, discontinue recovery support contact), physiological warning signs (PAWS, cravings, urges, physical illness, chronic pain)n * Dealing with substance specific relapse factors: * Alcohol: since there is social acceptance & availability better to focus on refusal skills and ways to deal with abundant opportunities to drink * Stimulants: better to deal with conditioned stimuli or cues (using cue extinction training) * Opioids: assist client in dealing with protracted withdrawal (anxiety, depression, craving). Ways to deal with physical pain, insomnia * Dealing with A.V.E. (Abstinence violation effect) * “I’ve had a drink or drug and have therefore messed up my recovery so why not just return to regular use” * Take the slip seriously, regret it happened but don't become demoralized * Discuss the slip openly and honestly with others esp. sponsor * Examine circumstances leading up to slip, what can be learned? * Re-establish recovery routines, support, positive activities * re-double your commitment to working on your recovery and maintaining abstinence * Heightened awareness of S.I.S. “seemingly irrelevant decisions” * Clients heading for relapse often make a series of self-defeating choices (accidentally exposing themselves to a high risk situations) which may sabotage their recovery * Counselors role is to heighten awareness of such SID type of decisions or instances where client is not exercising good judgment or conscious decision making, mindful decision making * Dealing with fantasies of returning to “controlled use “ * Common in early recovery * Signals a return to ambivalence about recovery * May signal an overconfidence in one’s recovery or a complete attitude shift where client begins to feel “different” or unique from others in recovery * Dealing with resistance to abstaining from secondary drugs of abuse and process addictions * Many relapses occur as the result of client’s indulging in secondary drugs or process addictions which they perceive as less “dangerous” however it often “gives permission” to use drug of choice or lowers refusal skills

Question 44

Powell's models of clinical supervision

Answer 44

* Administrative- responsible for carrying out mission of the agency * Makes sure policies and procedures are maintained * Deals with counselors and administrative staff * Schedules, raises, promotions, time off, personal issues * Coordinates with clinical supervisor for professional development plans * Clinical- supervises cases for best quality of care standards * Makes sure clients are being treated ethically * Helps counselors explore roadblocks * Client resistance, transference, case management

Question 45

"servant leadership"

Answer 45

**“**Bottom up management” - all in the agency are considered equal regarding input of decision making process Leader (supervisor) serves support staff, leader is not above others Leader “bears pain, not inflict it”

Question 46

"developmental models” of supervision and provide examples

Answer 46

Hogan (1964)- Counselor depends on supervisor, autonomy-dependence conflicts w/ supervisor, higher level of counselor self-confidence and autonomy in thought & action, counselor acts as master clinician with high personal autonomy, insight, security, motivation, and awareness of personal development needs Bradley (1989)- 1. Counselor learns entry level skills and basic foundation, 2. Counselor progresses to fully functioning with more competency but limited skills, 3. Counselor acquires skills lacking in 2, 4. Counselor acquires more advanced skills and assumes supervisor responsibility Blended Model-1. People can bring out change in life with assistance of a guide, 2. People don’t always know what’s best for them, 3. Key to growth is to blend insight and behavioral change in right amount at right time, 4. Change is constant and inevitable, 5. Guide concentrates on what is changeable, 6. No need to know great deal about cause of function of problem to solve it, 7. Many correct ways to view the world

Question 47

types of questions that are important for clinical supervisors to ask or address

Answer 47

Expectations of supervision Procedures to be used to determine the counselor’s reasoning, case conceptualization, and decision-making skills Questions of transference and countertransference Fears of failure or success

Question 48

what makes for an effective clinical supervisor and a good supervisee

Answer 48

Supervisor has two essential qualities: clinical skills and experience, passion for counseling 4 A’s- Available (open, receptive, trusting, non-threatening) Accessible (easy to approach and speak freely with) Able (has areal knowledge and skills to transmit) Affable (pleasant, friendly, reassuring)

Question 49

When and how can significant others be involved in the addictions counseling process?

Answer 49

_When-_ couples (one or both addicted), parents (teen or adult child is addicted), grandparents (they are guardian), siblings, other family members _Why-_ have information, tried other things before, can encourage or sabotage treatment, have been impacted or are also addicts, role patterns (enabler, martyr, hero, scapegoat)

Question 50

when it would be advisable to involve family members in the counseling process and when family involvement (with the significant other) is contraindicated?

Answer 50

_NOT INVOLVED-_ past history of infidelity, too much anger or hurt, no trust in others recovery, family stays hypervigilant about others behavior and moods, family member is actively using drugs _INVOLVE-_ supportive, basic understanding of addiction, don’t blame selves and see addiction as a brain disease, don’t have unreasonable anger, willing to let go of enabling

Question 51

what alternatives to offer family members when counseling with their significant other may be inappropriate

Answer 51

ALANON, Naranon, own counseling