Test 2 (new content only) Flashcards
The client, not the therapist, is the expert
Dialogue is used to elicit perspective, resources, and unique client experiences
Questions empower clients to speak and to express their diverse positions
The therapist supplies optimism and the process
Goal of therapy – help client find new meaning
Social Constructionism
Therapy grounded on a positive orientation—people are healthy and competent
Past is downplayed, while present and future are highlighted
Therapy is concerned with looking for what is working and going well
Therapists assist clients in finding exceptions to their problems
Solution-Focused Therapy
Questions can get clients to notice when things were better
Useful questions assist people in paying attention to what they are doing and can open up possibilities for them to do something different
Effective questions focus attention on solutions
Solution-Focused Questions
Types of Relationships
Customer-type relationship
Complainant relationship
Visitors
Client and therapist jointly identify a problem and a solution to work toward
Customer-type relationship
A client describes a problem, but is not able or willing to take an active role in constructing a solution
Complainant relationship
Clients come to therapy because someone else thinks they have a problem
Visitors
Pre-therapy change
Formula first session task
Exception questions
Miracle question
Types of Questions
Therapists ask, “On a scale of zero to 10, where are you with respect to __________?”
Scaling questions
Therapists take a short break during each session to write a summary for clients
Therapist feedback to clients
begins at the first session
Termination
We live our lives by the stories we tell about ourselves (internalized and externalized stories) and that others tell about us.
Our stories shape our reality.
The stories we live by grow out of conversations in a social and cultural context.
Change occurs by exploring how language is used to create and maintain problems.
Narrative Therapy
Collaborate with the client in identifying (naming) the problem
Separate the person from his or her problem
Investigate how the problem has been disrupting or dominating the person
Search for exceptions to the problem
Ask clients to speculate about what kind of future they could expect from the competent person that is emerging
Create an audience to support the new story
Narrative Therapy - Process
involves turning the tables by asking what clients think of the judgments they have been assigned
Deconstruction
Problem-saturated stories are deconstructed before new stories are co-created
Unique possibility questions enable clients to focus on their future
An appreciative audience helps new stories to take root
Creating alternative stories
Narrative therapist pioneered the use of therapeutic letter writing
Can be as effective as up to 5 sessions
Use of direct quotes from client
Carry the session content into the client’s life outside of session
Letter writing
Social constructionism is congruent with the philosophy of multiculturalism
Clients are encouraged to explore how their realities are being constructed out of cultural discourse and the consequences that follow from such constructions
Narrative therapy is grounded in a sociocultural context
Clients can make significant progress in building more satisfying lives in a short time
The postmodern approaches remind us that people cannot be reduced to a specific problem
Practitioners adopt a nonpathologizing stance
Strengths of narrative therapy
Adopting a “not knowing” stance may lead clients from some cultures to lose confidence in the therapist
Therapists must be skilled in implementing brief interventions
Therapists may employ techniques in a mechanistic fashion
Reliance on techniques may detract from building a therapeutic relationship
More empirical research is needed
Limitations of narrative therapy
Anything that overwhelms a persons capacity to cope
Time limited
Crisis
Is the employment of a variety of direct and action-orientated approaches to help individuals find resources within themselves and/or deal externally with crisis
Crisis counselling
The restoration of psychological balance
The aim is coping with the immediate difficulty
A more direct approach on the part of the counsellor, psychiatric nurse is often appropriate because the person’s inner resources have gotten stuck or are paralyzed
Objectives of Crisis Intervention
Steps of crisis intervention
- Listen
- Assessment
- Develop an action plan
- Termination
To help the person cope effectively with the crisis situation and return to his usual level of functioning
To decrease the anxiety
To teach crisis-management techniques
Crisis intervention goals
Establish rapport and trust
Identify precipitating problems
Help the person deal with, identify, and diffuse feelings
Ask direct questions
Explore underlying feelings
Step 1 of Crisis Counselling - Listen
Determine the severity of the crisis
Thoughts of suicide, homicide or both?
Find out to what extent the crisis has disrupted the person’s regular life pattern
Find out if the level of tension has distorted their perception
How are they coping at present?
What coping methods were used in the past?
Resources? Supports?
Step 2 of Crisis Counselling - Assessment
Selectively choose and use appropriate approaches to action planning
Use three basic approaches:
- Start by being non-directive
- Be collaborative by working together on a joint plan
- Be directive if the person does not or will not make a plan
Step 3 of Crisis Counselling - Develop an action plan
Review completed action plan
Do anticipatory planning for building new ties with resources
Plan and provide follow-up provisions
Step 4 of Crisis Counselling - Termination
Immediate accessibility
Lack of stigma associated with this modality
Clients’ may be resistant to using treatment
Non-threatening
Often easier to quickly establish closeness on the telephone without the distractions of physical cues – done through the voice
Sense of anonymity
Exclusive focus is the communication
Mobile crisis services
- Identify risk factors
- Assessment mood symptoms (depression)
- Explore suicidal ideation
- Explore suicide plan
- Determine intent
- Assess clients level of self control
- Develop a plan to keep the client safe
Suicide assessment interview
Psychache
Perturbation
Adamance
Assessing Risk and Lethality
sense of tension or agitation, anxiety, restlessness, psychomotor arousal
Perturbation
subjective mental pain, including sadness, anger, hurt, humiliation, sense of loss, dread, etc.
Psychache
steely resolve not to bow to circumstances of current adversity or accept any humiliation that may be necessary in order to deal with problems – unyielding or inflexible
Adamance
- Helplessness (feelings of weakness and powerless to deal with the problems, which might include client’s illness)
- Hopelessness (feeling there will be no effective rescue from the outside)
- Lethality (the person has been considering violent, aggressive or potentially lethal ways of ending their problems)
- Impulsivity
- Resignation and acceptance of suicide equation
- Ideation (e.g. command hallucinations, depression)
- Alcohol or narcotic abuse problem
- Primary psychiatric disorder playing major role
- Lethality of plan
High Risk Scale
Stoicism
Adaptability and coping capacity
Alternative solution- seeking
Spirituality
Supports
Protective factors
results from an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or life threatening and that has lasting adverse effects on the individual’s functioning and mental, physical, social, emotional, or spiritual well-being
Trauma
It was unexpected.
The person was unprepared.
There was nothing the person could do to stop it from happening.
Common elements of individual trauma
Changes to the brain
Compromised immune systems
Increased physical and mental stress
Decreased trust
Attachment difficulties and conflictual relationships
Hyperarousal and hypervigilance
Rigid or chaotic behaviour
Impacts of trauma
Are sensitive to the ways that persons current difficulties may be related to past trauma’s
Validate and normalize the client’s experiences
Help clients manage distress for more effective daily functioning
Develop a therapeutic relationship
Empathetic
Empower clients
Develop client appropriate boundaries
Engage in self-care and reflection
Trauma informed clinicians
Often unhelpful to:
Avoid discussing trauma
Ask for too much detail
Minimize the aspect that trauma has had on the persons life
Do not:
Conduct trauma therapy if not trained to do so
Trauma informed clinicians
- Safety
- Trustworthiness and Transparency
- Peer Support
- Collaboration and Mutuality
- Empowerment, Voice and Choice
- Cultural, Historical, and Gender Issues
Key principles of trauma informed approach
Build relationships based on respect, trust and safety.
Use a strengths-based perspective.
Frame the client’s coping behaviours as ways to survive, and explore alternative ways to cope as part of the recovery process.
Respond to disclosure with belief and validation that will inform practical issues related to care.
Help the client regulate difficult emotions.
Acknowledge that what happened to the client was bad, but that the client is not a bad person.
Recognize that the client had no control over what happened to them.
Provide an appropriate and knowledgeable response to the client that addresses any concerns they may have about the services offered to them, and then use this knowledge to guide service delivery.
Watch for and try to reduce triggers and trauma reactions.
Trauma informed practice standards
the emotional residue of exposure that counselors have from working with people as they are hearing their trauma stories and become witnesses to the pain, fear, and terror that trauma survivors have endured.
Vicarious trauma
Provides a new paradigm that views trauma as an injury.
The shift from “what is wrong with you?” to “What has happened to you?”
Understands freeze, flight and fight as survival responses.
Recognizes that trauma is pervasive.
Being trauma informed
Feeling stuck in some part of body
Feeling cold/frozen, numb, pale skin
Sense of stiffness, heaviness
Holding breath/restricted breathing
Sense of dread, heart pounding
Decreased heart rate (can sometimes increase)
Orientation to threat
Fight, flight freeze
Are protective measures that help to ensure the psychological safety of the clinician while maintaining boundaries in the therapeutic relationship
Self care and reflection
Realizes
Recognizes
Responds
Resists re-traumatization
4 R’s of trauma informed approach
Empathy and Compassion
Able to talk openly
Self-awareness
Self-care and wellness
Flexible
Comfortable with the unknown
Willingness to learn from clients
Willingness to connect emotionally with the client’s experience of trauma
Willingness to step into the world of the client
Able to regulate own emotions
Trauma informed clinician characteristics
Pre-therapy change
Formula first session task
Exception questions
Miracle question
Scaling questions
Therapist feedback to clients
Terminating
Solution focused therapy techniques
Step 1: Client narrates her/his preferred story of a significant life event or experience, with guidance from the therapist, and with the outsider witness as the audience.
Step 2: The outsider witness is asked to respond to what was just said.
The therapist asks questions of the outsider witness to elicit their response in each of these four areas: expression, images, resonance, and transport.
Step 3: Client re-tells the story once more, this time with special emphasis on the expressions, images, resonance, and transport that the outsider witness brought to light.
Step 4: The therapist, client, and outsider witness reflect on the original story, the outsider witness response, and the re-telling of the story, discussing the therapeutic processes that took place.
Narrative: Alternate Story - Outsider Witnessing
Understanding what it means to be human
Sets to understand the balance of the limits and opportunities of human life
Our existence is never fixed
Philosophical approach
Existential therapy
The capacity for self-awareness
Freedom and responsibility
Striving for identity and relationships
Searching for meaning
Anxiety as a living condition
Awareness of death and nonbeing
Existential therapy - dimensions of human beings
Multicultural perspectives
Can be adapted to brief therapy
Emphasis on the quality of relationships
Emphasis on freedom and responsibility
Existential therapy strengths
Help to increase clients levels of awareness of self and the nature of their problems
Aimed at understanding the client’s experience
Development of the therapeutic relationship
Existential - therapist role
Does not take into account social factors or environmental circumstances
Highly philosophical
Not an overly structured approach
Not effective in trauma or crisis
Existential limitations
An existential and holistic approach
Goal is to expand clients awareness regarding how they function in life
Clients are experts and direct therapy
Focuses on clients perceptions of reality and what is taking place in the present
Affirms the capacity for growth and change
Values self-discovery and self-acceptance
Therapeutic relationship is collaborative
Gestalt therapy
Active partnership
Pay attention to clients verbal and non-verbal language
Listens to clients use of metaphors and explores the metaphor
Uncovers client’s stories
Gestalt therapy - therapist
- The empty chair
- Future projection
- Exaggeration exercise
- Staying with a feeling
Gestalt - interventions
Appropriate to use for diverse range of clients
Effective at treating a variety of psychological disorders, personality disturbances, psychosomatic problems and substance abuse
Holistic
Gestalt strengths
Little attention is paid to cognitive processes
Requires in-depth training and strong clinical background is required to strongly master technique
Gestalt limiations
No single individual can be identified as the founder of this approach, reflecting a central theme of feminist collaboration
The beginnings of feminism (the first wave) can be traced to the late 1800s
The women’s movement of the 1960s (the second wave) laid the foundation for the development of feminist therapy
Feminist theory and movements are continually evolving
Feminist therapy history
Racial inequality was a factor that was largely ignored by first-wavefeminism (and even used regarding the suffrage movement), which was primarily concerned with gaining political equality between men and women. Though at the same time, there were abolitionist feminists (both women of colour and white women). Vote, education, employment, right to own property
What became known as “First Wave feminism”
usually referring to feminism of the 60’s -1980’s – not just political equality (fought by first wave), but social equality – pay gap, birth control, reproductive freedom. Women of colour lead the movement of no more forced sterilization, but this was not fully embraced by mainstream feminism
Second wave feminism
More about intersectionality – equality and oppression relating to “racism, able-bodieism, ageism, speciesism, classism, thinism, sexism, anti-semitism and heterosexismracism, “ Riot Grrrl Manifesto 1991
Third wave 1991- ??
feminism that is queer, sex-positive, trans-inclusive, body-positive, and digitally driven.
Fourth wave maybe now?
Problems are viewed in a sociopolitical and cultural context
The psychological oppression that women and minorities have experienced is acknowledged
The client knows what is best for their life and is the expert
Emphasis is on educating clients about the therapy process
Traditional ways of assessing psychological health are challenged
Clients are encouraged to take social action related to many forms of oppression
Feminist perspectives key concepts
Political and critical consciousness are central concepts
Committed to social change
Voices and ways of knowing, and the voices of others who have been oppressed, are valued and honored
The counseling relationship is equal
Focuses on strengths and offers a reformulated definition of psychological distress
All types of oppression are recognized
Principles of feminist theory
The view that people experience oppression in varying configurations and in varying degrees of intensity. Cultural patterns of oppression are not only interrelated, but are bound together and influenced by the intersectional systems of society. Examples of this include race, gender, class, ability, and ethnicity.
Intersectionality
Become aware of their own gender-role socialization
Identify their internalized messages of oppression and replace them with more self-enhancing beliefs
Develop a sense of personal and social power
Recognize the power of relationships and connectedness
Evaluate the impact of social factors on their lives
Goals of feminist theory
Empowerment
Self-Disclosure
Gender-Role or Social Identity Analysis
Gender-Role Intervention
Power Analysis
Bibliotherapy
Assertiveness Training
Reframing and Relabeling
Social Action
Group Work
Feminist techniques
Most in common with the multicultural and social justice perspectives
Clinicians strive to create an egalitarian relationship and collaborate with clients in setting goals and choosing strategies
Has paved the way for gender and culturally sensitive practice
Has made significant theoretical and professional advances in counseling practice
Can incorporate principles and techniques into many therapy models
Feminist strengths
Advocating for change in the social structure can be problematic when working with women who do not share these beliefs
If therapists do not fully understand and respect the cultural values of clients from diverse groups, they run the risk of imposing their own values
Therapists do not take a value neutral stance
More empirical support is needed for this approach
Feminist limitations
Technical Integration
Theoretical Integration
Assimilative Integration
Approaches to integration
Emphasizes common elements across different theoretical systems:
Empathy
Support
Therapeutic relationship
Common factors are more important in accounting for therapeutic outcomes than the unique factors that differentiate one theory from another
Integration - common factors
Current theories can and should be expanded to incorporate a multicultural dimension
Practitioners need to tailor their theory and practice to fit the unique needs of the client
Practitioners should be aware of their own and their clients’ worldviews, and use culturally appropriate interventions
Integration of multicultural perspectives
Spiritual and religious matters are therapeutically relevant and ethically appropriate to discuss in counseling
Spiritually informed therapy is a form of multicultural therapy
Clients in crisis may find a source of comfort, support, and strength in drawing upon their spiritual resources
Integration of spiritual and religious perspectives
Distinguishing between spirituality and religion
Active listening
Conversing about spiritual issues
Seeing client as a person, not an illness
Careful spiritual assessment
Being present
Being aware of own spirituality
Engaging in various spiritual interventions
Facilitating spiritual growth
Referring to pastoral care
Psych nurses role - spirituality
FIT is an evidence-based practice that monitors client change and identifies modifications needed to enhance therapy
The Outcome Rating Scale (ORS) and Session Rating Scale (SRS) are used to measure client progress and to rate the quality of the therapeutic relationship
Feedback informed treatment
designed to evaluate and to improve the quality and effectiveness of counseling services
Feedback informed treatment (FIT)
refers to the range of activities that members of ourprofession are educated in and legally authorized to provide
Scope of practice
In regards to individual counselling competencies include:
- Apply therapeutic use of self to inform all areas of psychiatric nursing practice
- Establish, maintain and terminate a therapeutic relationship with the client
- Demonstrate knowledge of therapeutic modalities
- Use reflective practice and evidence to guide psychiatric nursing practice
- Integrate cultural awareness, safety and sensitivity into practice
- Uphold and promote the ethical values of the profession
Entry level competencies
Up until this August (2022), Registered Psychiatric Nurses are followed the Registered Psychiatric Nurses Act.
Now, the profession has moved under the _____________________
Regulated Health Professionals Act
