Certified School Psychologist Exam Review

013 MSE- Attention, Concentration and Memory

2010-12-23T08:58:00.000-08:00

MSE- Attention, Concentration and Memory

The initial interview with a client is critical, not only for information gathering but for rapport building. A skillfully done interview should help the professional: diagnose, estimate severity of problems, decide on a course of action, gain a dynamic understanding of the client, and engage the client in psychotherapy. Supportive, attentive, and nonjudgmental attitude can help pave the way toward a productive interview. As previously indicated, the MSE is a critical component of the initial diagnostic interview. The MSE serves not only to gauge a persons current level of functioning but also aids in diagnosis and can serve as a baseline for future reference. We will look at other areas of the initial interview in later segments. For now, let us finish with the MSE.

When focusing on attention, two general areas are under consideration. The first is the individual’s ability to “attend”, or the ability to pay attention for short periods of time without being distracted. The second is the ability to attend for long periods (concentrate). The ability to concentrate is primary in testing higher levels of functioning.

Attention can be tested in several ways. One is to simply observe the interviewee’s ability to stay focused and attend to the interview. A more structured assessment of attention may be gleaned with digit span or a nonnumeric test. Digit span is simply listing a series of numbers (write them down as you say them), starting with three numbers. They should be spoken in a monotone voice, with one spoken every second in cadence. On the last number in the series, your voice should drop, indicating the end of the series. Start with three numbers (e.g. 3-7-1). Do two sets of three numbers. If at least one of the two series is repeated back, go to four numbers- until the client fails both trials. Then do the same in reverse. The average is five numbers remembered. The nonnumeric test consists of reading a list of random letters and asking the client to tap his finger when certain letters are stated. In this test, it is best to have a prepared list of letters.

Concentration can be assessed using serial number counting (subtracting 7, 5 or 3 from 100 consecutively). This may be hard for some people with lower educational levels, so days of the week or months said backward may be substituted. Simple multiplication problems may be useful but have the same limitations on premorbid intellectual functioning and general education level, as do the serial counting tests. Asking a person to draw a picture or do some math problems on paper will also give information as to their concentration ability.

There are several different types of memory and ways of referring to them. In Psychology, the terms short term and long term memory are used. The medical tradition refers to immediate, recent and remote. Some also break this up to recent past and remote past. (See the MSE content sheet for one example). Unless you want to do a very comprehensive memory assessment (in that case use a memory assessment instrument), the immediate, recent and remote memory should be assessed. Immediate memory assessments are the digit span (described above), asking the client to remember three objects (dog, house, ball) to be recalled after a 5 minute delay. A counting test where one asks the client to count to a number (e.g. 27) stop for 1 minute, continue counting where they leave off, stop at a specific number for 1 minute (do this three times), is also useful. Recent memory is events of the last 24 hours and remote is assessed with early memories or dates of employment, etc.

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012 MSE- Orientation-intellectual ability

2010-12-16T07:47:00.000-08:00

MSE-Orientation-intellectual ability

Orientation is central to the mental status exam. A person’s awareness of their surroundings, their location temporally, and their own identity is primary to general functioning. Of course, everyone occasionally loses track of the date, but when an individual that you are interviewing believes it is 1983- or that it is summer, when the coat rack in the corner is full, this is a significant finding that must be explored further. Assessment of orientation always includes person, place and time (Oriented x 3). Questions of person generally include the identity of the patient and who you are (Dr or counselor, etc.). Orientation to place may include the city, state, or town- where he lives and where he is now. For some patients, it may be appropriate to ask “what planet is this”. If they say Jupiter, then you may have an alien (or a psychotic individual) on your hands. Time orientation include day of the week, date, month, year, etc. (The interviewer may also ask about the current situation, why a person is in your office, etc. This would be oriented x 4.) As a rule, confusion about person is more significant than is confusion about time, place, or situation. If the patient says he is the boogieman and you are Jethro Tull, the patient is exhibiting significant problems (since Jethro Tull was not an individual, but the name of a group). Problems in orientation are often the result of organicity. However, some very depressed individuals may lose tack of time, by several days or even weeks. Further, there is a difference between confusion and delusion about person, place and time. Both schizophrenic and dementia patients may exhibit either delusions or confusion in their orientation.

It is often important to quickly evaluate a person’s intelligence. This can be difficult (as well as unimportant) if other more acute issues are primary (prominent suicide ideation with a plan, acute psychosis, or the person is very distressed and tearful). However, in a routine MSE, intelligence is an important aspect of treatment planning.

Quick and easy intellectual capacity can be obtained through asking the person to perform some simple calculations in their head (serial 7s, multiplication word problems). It is also important to know if an individual is able to reason abstractly. Proverbs are one of the simplest and best ways of getting information about concrete versus abstract reasoning ability. The responses may be literal, concrete, personalized, or bizarre. An example of proverbs that may be used is: “still waters run deep”; “a rolling stone gathers no moss”.

Orientation and Intellectual functioning is extremely important in the hospital setting. Delirious patients will often be quite disoriented. The MSE can be used for baseline functioning and tracking of the symptom pattern. In delirium, there is often a fluctuation of consciousness throughout the day. In this case, the MSE can quite useful. Further, it can be used to narrow down medications that might be negatively or positively affecting a patient’s mental status.

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011 Content of Mental Status Exam

2010-12-08T08:13:00.001-08:00

Content of Mental Status Exam

1. General Presentation.

A. Appearance-apparent age, grooming, state of health, hygiene/cleanliness, physical characteristic {build/weight, physical abnormalities, deformities, etc.), state of health, distress, pain, appropriateness of attire. pride, dignity, Note unilateral neglect of dress, description of appearance should be enough detail for identification. take into consideration the individual’s age, race, sex, educational background, cultural background, socioeconomic status, etc.

B. Motor Activity-posture {slouched, erect), gait {staggering, shuffling, rigid), coordination, speed-activity level, gestures, tremors, tics/grimacing, relaxed, restless, pacing, threatening, hyperactive or under active, disorganized, purposeful, stereotyped movements, repetitive.

C. Interpersonal-rapport with the interviewer. Engaged, interested, cooperative, opposition/resistant, submissive, defensive, fearful, note how they greet examiner.

D. Facial Expression-relaxed, tense, happy, sad, alert, day-dreamy, angry, smiling, distrustful/suspicious, tearful.

E. Behavior-distant, indifferent, evasive, negative, irritable, labile, depressive, anxious, sullen, angry, assaultive, exhibitionistic, seductive, frightened, alert, agitated, lethargic, somnolent.

2. State of Consciousness-alert, hyperalert, lethargic -reasons for lethargy often organic.

3. Speech.

A. Form-conversational, distractible, rambling, circumstantial, tangential.

B. Quantity-mute, overtalkative, can’t be interupted.

C. Rate-rapid, accelerated, pressured, slow, blocked.

D. Quality-dramatic, histrionic, sarcastic, humorous.

F. Expressive Language-normal, circumstantial, anomia, paraphasia, clanging, echolalia, incoherent, blocking, neologisms, perseveration, flight of ideas, mutism.

G. Receptive Language-normal, comprehends, abnormal.

H. Dysprodia-Flat monotone speech-no emotional expression.

4. Mood and Affect.

A. Mood-a symptom as reported by the individual describing how they feel emotionally, such as: normal, euphoric, elevated, depressed, irritable, anxious, angry.

B. Affect-observed reaction or expressions. Range of affect includes: broad, restricted, blunted, flat, inappropriate, labile, mood congruent, mood incongruent.

5. Orientation and Intellectual Ability.

A. Orientation-time, person, place, and self. The individual should be asked questions such as the day of the week, month, the date, where he lives, where he is now, if he knows who he is.

B. Intellectual Ability-above average, average, below average.

        a. General information-the last four presidents, governor, the capitol, what direction does the sun rise, etc.

        b. Calculation-serially subtracting 7 from 100 (at least six times). Simple multiplication word problems such as, “if a pencil costs 5 cents, how many pencils can you buy with 45 cents?”.

        c. Abstract Reasoning-proverbs. This is the ability to make valid generalizations. Responses may be literal, concrete, personalized, or bizarre. Example, “Still waters run deep”, “ A rolling stone gather no moss”.

        d. Opposites-slow/fast, big/small, hard/soft.

6. Attention & Concentration-.

A Concentration-Days of the week backward-serial sevens-serial threes, serial fives.

B. Attention-Non-numeric test-read series of random letters-have patient tap finger or say yes every time hear chosen letter. Numeric-string of digits forward and backward-starting with three digits. Stop when patient misses two of each. Average is 7 digits.

7. Memory-immediate (10 to 30 sec) short term (up to 1hour) recent (2 hours to 4 days) recent past (past few months) remote past (6 months to lifetime).

8. Thought Processes/Content-deals with organization and composition of thought. Examples include: normal, blocking, loose associations, confabulation, flight of ideas, ideas of reference, illogical thinking, grandiosity, magical thinking, obsessions, perseveration, delusions, depersonalization, suicidal ideation, homicidal ideation.

9. Hallucination-none, auditory, visual,olfactory, gustatory.

10. Insight-good, fair, poor. Understanding, thought,feeling, behavior.

11. Impulse Control-good, fair, poor. The ability/tendency to resist or act on impulses.

*This is not exhaustive-mental status questions could go on interminably.

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010 MSE- Consciousness, Speech, Mood and Affect

2010-12-06T09:04:00.001-08:00

MSE- Consciousness, Speech, Mood and Affect

The mental status exam can cover a myriad of areas and each mental health professional will need to decide what is important. Professionals from different disciplines are likely to be interested in areas relative to their specialty and area of expertise. For example, a neuropsychologist will be interested in neurological processes as they relate to behavior. Hence, the MSE conducted by a neuropsychologist might be detailed in assessment of attention, concentration, language, memory, etc. A psychiatrist on the other hand, may focus more on issues related to thought processes, mood and anxiety level. Of course, this is not clearly defined, as many areas of mental health treatment are cross-disciplined. The point is, one “good” MSE does not necessarily look like another. It can be adapted to one’s theoretical orientation as well as the specific information that is required at the particular time. As a rule, the interviewer must adapt to the situation based on information and observation. He must think on his feet, so to speak. Below is a brief case example.

A 25-year-old Hispanic female is brought into your office by her mother. The mother reports that her daughter is depressed. You speak to the girl alone and find that she is indeed depressed. In the course of the interview, you note that she uses an occasional word that you have never heard before. Since she is a Spanish-speaker, and you do not speak Spanish, you assume she is substituting occasional Spanish for English words. However, these words do not “sound” like Spanish, so (in passing) you ask about them. After discovering that these are made up words, you decide to pursue more detailed inquiry into language, thought processes and thought content.

Along the way, you must follow the clues brought up in the interview. In the above case, the client may have been exhibiting neologisms (made up words- often related to thought disorder and psychosis) or she could have been creating her own private language (for a variety of non-pathological reasons), or she might simply have some articulation problems related to organic brain damage. The interviewer should be “curious” about everything that comes up in the interview.

Some areas of inquiry are easily identified. If the interviewee is clearly drowsy, somnolent, or stuporous, this becomes primary to other areas of inquiry. However, if a person is alert and responsive, it is not necessary to conduct a Glasgow Coma Scale.

Mood and Affect are areas commonly evaluated in almost all mental status examinations. Mood is a “sustained” emotional state, such as: depressed, euphoric, elevated, anxious, angry, and irritable. Affect is more the observable emotional state at the time of the interview. These include descriptors such as: flat, blunted, restricted, and inappropriate.

In inquiry about mood, affective clues are important. Facial expression, quality of voice (timber pitch, intensity) eye contact and muscular tension (among others) all give clues as to mood. Of course, self-report is one of the best ways to evaluated mood. One interesting and useful bit of information for clarifying the difference between anxiety and depression is to use Brenner’s Definitions. A pervasive feeling that something bad “has happened” is indicative of depression. If one has a pervasive feeling that something bad is “going to happen,” this indicates anxiety.

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009 Schizophrenia and Mental Status Exam

2010-11-30T07:55:00.000-08:00

Schizophrenia and the Mental Status Exam

The mental status exam can serve as the basis for diagnosis and provide a foundation for the dynamic understanding of the client’s current level of psychological and emotional functioning.

By definition, the mental status gleans information on the immediate and current level of an individuals functioning at the time of the interview. It should be conducted with sensitivity and respect for the individual. Much of the information can be gained though natural observation and sensitive inquiry into the individual’s difficulties. Some of information must be directly requested and ideally, will naturally flow with the interview.

In the last several installments, we have been focusing on schizophrenia. Now we turn to integrating the mental status exam (MSE) with the assessment of schizophrenia. This discussion will cover the following areas of the MSE: Appearance-Behavior and Attitude, Characteristics of Speech, Mood and Affects, Orientation and Intellectual Ability, Memory, Thought Processes/Content, Hallucinations, Insight, Impulse Control.

To illustrate the important areas of the MSE, we will look at some clinical vignettes and apply the MSE to the examples.

You see a woman in the intake department of a psych hospital. She wears wrinkled clothing and has one missing stocking. Her hair is unkempt. She has trouble sitting still, almost violently shakes her leg and holds her hands up as if making a box in the air. She seems fearful and accuses you of having a gun when you open a desk drawer to get a pencil.

Much important information can be gained from simple observation. The following are suggestions for areas to consider in conducting the MSE. However, the descriptions in this article are not exhaustive and the areas described are more involved and detailed. Many publications and texts give very good descriptions of the MSE and different professionals need to decide what works best for them.

1) Appearance: Acutely psychotic individuals generally do not pay much attention to attire, grooming or hygiene. They may be disheveled and odiferous (unless family has taken the responsibility). This woman is generally unkempt and oddly dressed. Unless there is a good reason for the missing stocking, this could indicate significant confusion.

2) Excessive motor activity and odd mannerisms that are repeated over and over may indicate agitation or extreme disorganization (think about Disorganized Subtype). Alternatively, the individual may be rigid in posture (catatonic rigidity) or exhibit waxy flexibility (limbs can be moved into any position and will remain for extended periods of time). The latter is suggestive of Catatonic Subtype. One should also look for unusual motoric activity (parkinsonian tremors, etc)

3) Interpersonal behavior: This woman exhibits fear and paranoia. Since it may not be so apparent in all cases, asking if the individual is ever “frightened or worried that someone will hurt her” or “concerned that people are sometimes watching her” is a good way to determine level of paranoid ideation. Observing her way of engaging you and your countertransference reaction can lead to better understanding of general interpersonal relationships as well as mood, level of dangerousness, motivation, etc. Other important observations include:

4) Facial Expression: Facial expression may give important clues as to emotional expression or lack thereof, mood affect, level of fear, etc.

5) General behavior: In this case, the woman before you is quite agitated (violent shaking of her leg). This appears to be indicative of agitation. However, gait problems, ticks, or lethargy and somnolence should be noted.

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008 Schizophrenia- Emotions and Behavior

2010-11-29T08:09:00.001-08:00

Schizophrenia- Emotions and Behavior

The term schizophrenia has been misused (in lay terms) for years. This misuse is the result of the dramatic license taken in movies and in the media as well as general ignorance on the part of the average lay person. The word schizophrenia literally means- split mind. Eugene Bleuler coined this term in 1911 as a replacement for Dementia Praecox (which means premature dementia). In common usage, schizophrenia became “split personality” and was used to mean “of two minds” or “ two personalities.” This usage has been used to describe everything from Dissociative Personality Disorder to simply feeling extreme ambivalence. In fact, Bleuler coined the term to describe the cleavage between cognitive and emotional functions in the mind (previously described as the primary autonomous ego function). He was really describing the “fragmentation” of the ego functions that causes one to lose touch with reality. More recently, common usage of the term schizophrenia bring with it concerns of very dangerous or murderous behavior. In fact, most people diagnosed with schizophrenia are much more dangerous to themselves, due to the lack of self-care and poor judgment, than they are dangerous to others.

Schizophrenic individuals (especially during acute psychosis) may display a variety of emotions in a short period. This “affective lability” may be quite intense and may appear inappropriate for the situation or subject of discussion (the thoughts or speech of the individual). Labile emotions are more characteristic of acute psychosis, whereas blunted or flat affect is more likely seen in the residual or chronic phases of the illness. However, this is not a hard and fast rule.

Disturbance of behavior was mentioned previously. Behavioral anomalies such as generally bizarre or strange behavior, grimacing and posturing, ritual behavior (sometime similar to OCD symptoms), excessive “stony” stillness, as well as some aggressiveness and inappropriate sexual behavior.

If the onset of acute symptoms is shorter (less than 4 weeks after noticeable behavior change) and there is good premorbid functioning, this indicates the use of the DSM-IV specifier “With Good Prognostic Features.” Other considerations for the “Good Prognostic Features” specifier is a lack of blunted affect and the presence of confusion at the height of the episode. On the other hand, the “Without Good Prognostic Features” specifier is used if less than two of these are indicators are present. (Research has also shown that a later than average age of onset of the illness is indicative of better prognosis while earlier onset is a poor prognostic indicator. However, do not confuse this with the use of the DSM specifier, which does not include “age of onset”).

In the next installment, we will try to pull together the assortment of issues covered thus far in the diagnosis of schizophrenia. A closer look at the differential diagnosis of schizophrenia will give some important clues as to conducting a good mental status exam. The mental status examination is important for assessing the current functioning (in the office) of the individual being assessed. Combining the mental status exam with a good history is the core of a diagnostic assessment. However, I feel that the best assessment occurs over time when you are able to experience an individuals patterns of relating- both to themselves and to others (including the therapist).

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007 Schizophrenia- Delusions and Hallucinations

2010-11-24T10:01:00.000-08:00

Schizophrenia- Delusions and Hallucinations

While schizophrenia is considered a chronic illness, the course of the illness appears to follow several stages (often classified according to the particular point of view or theoretical orientation of the clinician). Of course, the DSM-IV is considered non-theoretical as to diagnosis and etiology. The DSM-IV is empirically based and is organized into diagnostic categories according to symptoms. In classifying schizophrenia, the DSM speaks of active-phase and residual to refer to acute psychosis versus more chronic and long standing symptoms. It uses Residual as a Subtype classification. This means that most people diagnosed with Schizophrenia will move between Subtypes as their illness progresses. Others refer to acute, sub- acute and chronic phase patterns of symptoms. Whatever the theoretical considerations, for the purpose of communication and third party reimbursement, the DSM the most widely utilized tool for mental disorders. With that said, let’s look further at the acute symptom as they may manifest in the clinical situation.

We discussed disturbance of thought form last time. Now we move to Disturbance of thought content (delusions) and Disturbance of Perceptions (Hallucinations). In the organization of the DSM-IV, these symptoms give further clues as to diagnosing schizophrenia and choosing a Subtype classification.

Delusions are fixed false beliefs that are usually incredible and beyond belief. The may be bizarre or “nonbizarre” (nonbizzare delusions are a characteristic of Delusional Disorder-which will be touched on in later articles). Usually, the more acute the illness at the time of the assessment, the more disorganized and bizarre are the delusions. The following are some of the types of delusions that might be seen:

1. Bizarre and confused delusions with no systematic content

2. Persecutory delusions that are also relatively without systematic form

3. Delusions of Grandeur- “I am the second coming of Christ; I am the president”

4. Delusions of Influence- “I have powers of mind control and can make you stand on your head if I want”

5. Ideas of Reference- Casual events of others are seen as being directed toward the individual

6. Thought insertion- “The FBI is transmitting thoughts into my mind”

7. Thought Broadcasting- “The Government has been listening to my thoughts for years. (So, the individual covers her head and entire apartment with aluminum foil to block the transmission).

Most Delusions have a paranoid flavor. Hence, preoccupation with delusions is considered a characteristic of the Paranoid Subtype in the DSM-IV. The other criteria for Paranoid Type include prominent hallucinations as well as a lack of “prominent” disorganized speech, catatonic or disorganized behavior, or flat or inappropriate affect (which are criteria for other subtypes).

Perceptual disturbances (hallucinations) can be Auditory, Visual, Olfactory, and Tactile. Auditory hallucination may be just running commentary, negative or threatening statements, or directives for action (command hallucinations- often to hurt or kill oneself or others. Illusions (misperceptions of real objects) are also possible as are derealization (the world seems unreal) and depersonalizations (feels like observing self from outside). Note the latter is different from dissociation. (See Glossary, pg. 766 DSM-IV)

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006 Schizophrenia, Symptom Characteristics and Diagnosis

2010-11-22T08:08:00.001-08:00

Schizophrenia, Symptom Characteristics and Diagnosis

Individuals with schizophrenia display odd, unusual and idiosyncratic behavior that results from defects in ego functioning. One aspect of this deficit is loosening of ego boundaries. What I mean by fluid or loose ego boundaries is that there seems to be difficulties distinguishing internal fantasy and thoughts from external reality. Moreover, one’s internal world is not integrated. There appears to be internal chaos, confusion, and sometimes, overwhelming anxiety. This is the result of impairment in the primary autonomous ego functions. This constitutes basic contact with reality and integration of thought feelings, and perceptions.

In the acute phase of schizophrenia, there are five areas of disturbance (symptoms) that should be assessed. These include a disturbance of:

1. Thought form

2. Thought content

3. Perception

4. Emotion

5. Behavior

Most of these symptoms will be readily apparent in an interview.

Disturbance of Thought Form: This may be a “formal thought disorder”. Thinking is illogical and often incomprehensible. Characteristics of a formal thought disorder include (among others):

1. Loose Associations: Disconnection of ideas- jumping from topic to topic, often midsentence.

2. Overinclusivness: use of irrelevant information that interrupts logical thought.

3. Neologisms: Creation of new words- may have meaning to client.

4. Blocking: Speech simply stops midsentence- speech may start again in a few minutes, often in another place. May be the interference of hallucinations.

5. Clanging: Choice of words based on sounds- often rhymes a primary word in one sentence with a word in a previous sentence.

6. Echolalia: repeating words without concern for meaning.

7. Concreteness: Lack of ability to think in abstract terms.

8. Alogia: Also called poverty of speech. Speaks little, without intentional resistance.

Individuals with a formal thought disorder, (which is pathognomonic of schizophrenia) appear to be caught up in an idiosyncratic world and have a relatively “unique” way of communicating.

Other psychotic disorders may exhibit formal thought disorder. Schizophreniform Disorder is virtually identical in the initial clinical presentation to schizophrenia except (according to the DSM-IV)

1) there is a shorter duration

2) the diagnosis does not require impaired occupational or social functioning (however, it is hard to imagine how psychosis would not impair functioning).

In addition, symptoms are usually more turbulent, and functioning after the acute episode is usually better.

An individual who presents with Brief Psychotic Disorder may also have formal thought disorder, but duration can be as short as one day and no longer than one month.

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005 Schizophrenia- DSM-IV Diagnosis

2010-11-18T08:32:00.001-08:00

Schizophrenia

The diagnosis of Schizophrenia according to the DSM-IV the individual must:

Have at least 6 months of significant impairment in occupational, interpersonal, and self-supportive functioning. The individual must have experienced a period of actively psychotic symptoms without the presence of a major mood disorder, autism, or organic condition.

The course or the illness is classified as continuous or episodic, with or without intereposidic residual symptoms, or single episode in partial or full remission. There are also five subtypes, which describe the most frequently observed behavioral manifestations observed during the illness. While schizophrenia is a well-defined and stable diagnosis, the subtypes are relatively inadequate and ill defined. Often, individuals tend to overlap in symptoms pattern and the diagnosis can shift from one time to another. Further, as time passes, the symptoms of the illness tend to converge toward general social withdrawal, idiosyncratic thinking, and flattened affect. The course of the illness also tends to be more stable with less acute episodes or symptoms.

Neuroleptic medications are used to treat the symptoms of schizophrenia. The newer antipsychotic drugs tend to have fewer side effects and better efficacy. However, medication tends to treat only the positive symptoms and appears to have little impact on negative symptoms. (Just to clarify, positive symptoms are just that, symptoms that are active- delusions, hallucinations and bizarre behavior. Negative symptoms are the “lack” of behavior- withdrawal, flat affect, and thought blocking.)

Let’s look at a case to help get a sense of diagnosis:

Billy Jean has been acting strangely for several months now. She reports that her neighbors are trying to poison her. They are trying to give her poisoned food and have attempted to pump poisoned gas into her apartment through the air conditioning vents. She states that her mother is in collusion with the “group” that is after her- as are the neighbors. Billy Jean appears very nervous and has pressured speech. She appears confused and frightened.

This is not even a close call. The likely diagnosis is delusional disorder for the following reasons: First, the delusions are non-bizarre. In schizophrenia, the delusions are usually bizarre (e.g. aliens are projecting thoughts into my mind). The duration is too short for schizophrenia (but are sufficient for Brief Psychotic or Schizophreniform Disorder). While there may be an absence of hallucinations in Schizophrenia, this is relatively rare. (Auditory hallucinations in the form of voices are most common, visual are the next common and olfactory and kinesthetic are rare. Olfactory hallucinations are suggestive of organicity). A patient might have a residual or prodromal presentation that could look similar to the above case. However, the residual phase must (by definition) be preceded by an acute phase. In this case, the course and duration do not fit. The Prodromal phase (Prodromal: the period between the first appearance of symptoms and the acute state) is usually characterized by odd behavior and thinking, not clearly define delusions.

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004 Psychotic Disorders

2010-11-16T08:31:00.001-08:00

Psychotic Disorders

Psychosis is a term that describes severe mental disturbance not a specific disorder. Many disorders have symptoms of psychosis including: Schizophrenia, Schizophreniform Disorder, Brief Psychotic Disorder, Schizoaffective Disorder, Shared Psychotic Disorder, Delusional Disorder, Psychotic Disorder Due to a General Medical Condition, Substance Induced Psychotic Disorder, and Psychotic Disorder NOS. These disorders are clinical syndromes not discrete diseases.

Most Psychotic disorders do not have clear etiology. Of course, the disorders related to medical conditions and substance withdrawal are more easily traced to a precipitating factor and are therefore more likely to be easily diagnosed.

Evaluation of persons suspected of having a psychotic disorder requires a good history and a physical examination by a physician. Generally, non-organic disorders present with disturbances in thought and emotion, while organic disorders tend to present with mental clouding, confusion, and disorientation because of some degree of delirium. This is not a hard and fast rule, and in practice, there are many exceptions. The following are some characteristics that suggest the presence of an organic disorder:

1. No personal or family history of mental illness. Someone who presents with schizophrenia like psychotic symptoms will undoubtedly have some family or personal history of psychiatric treatment. This is particularly true if the subject is well into adulthood. First time psychotic breaks usually occur in early adulthood (early 20’s of men, late twenties for women). The lack of history makes it more likely that there is some organic factor operating.

2. There is a history of serious medical illness with periodic relapses. This suggests organic etiology, especially if the subject is an elderly person.

3. There is very rapid onset. If the onset is in a few hours of days, this is a strong indicator of organic etiology. With symptoms that are not organically based, family members usually report some period of time that the client is acting “strange”.

4. The client presents with significant memory loss, confusion, disorientation, and clouding of consciousness (that may fluctuate rapidly- within hours).

Major Depression and Bipolar Disorder may have psychotic symptoms that are secondary to affective symptoms. Affective disturbance always precedes psychosis in these cases. Individuals with severe personality disorders may have brief periods of psychosis, especially at times of severe stress. Psychotic symptoms usually resolve when the environmental stressors are stabilized, either through direct psychosocial intervention or by removing the individual from the environment and placing them into a stable and safe environment such as a hospital setting. Both Pervasive Developmental Disorder NOS and Autistic Disorder may have psychotic symptoms. Again, these symptoms appear to be secondary to the developmental impairment.

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003 Mental Retardation

2010-11-11T07:51:00.000-08:00

Mental Retardation

Approximately 2,000,000 individuals in the United States are mentally retarded. The diagnosis as described by the DSM-IV requires an IQ of 70 or below as measured by standardized IQ testing, impairment in general functioning (adaptive functioning) in two areas, and onset before the age of 18. If onset is after age 18, this is considered Dementia.

About 80-85% of these individuals are mildly retarded, (IQ of 50-70- considered educable); about 10% are moderately retarded (IQ of 35-50- considered trainable); 3-4% are severely retarded (IQ scores of 20-35), and 1% of individuals are profoundly retarded (IQ below 20). Individuals with severe and profound retardation will undoubtedly need supportive or institutional care for life. Mentally Deficient and Intellectually Deficient are terms sometimes used in reports and documents as a substitute for Mental Retardation. These terms are interchangeable but are often chosen due to personal preference or bias.

There is an identifiable cause for retardation in about 50% of the cases. Factors are often biological, which are more likely to create moderate to profound retardation. Environmental factors, including perinatal problems, infant illness, neglect, and malnutrition all are factors that can lead to retardation in intellectual development. Moderate to profound Mental Retardation is distributed evenly across all social classes. Mild Mental Retardation appears more commonly in lower classes. One interesting point- infant developmental measures are not a good predictor of future retardation. However, they are a good predictor of exceptional intellectual development in the future. The WISC-III is not a good measure of more severe retardation because it has an inadequate floor. Tests such as the Stanford-Binet or Woodcock Johnson-Cognitive Battery are better measures on the lower end of the scale.

The following are examples of cases:

Bobby is 6 years old. His parents report that he started school this year and cannot keep up with the other kids. He is unable to identify letters, cannot yet write his own name. Interviewing him, you find that he is very difficult to understand and often uses words that make no sense. His parents are of average education level and speak well. Apparently, Bobby also has trouble tying his shoes and has trouble bathing on his own. His IQ is 68 as measured on the WISC -III in both Verbal and Performance areas (Full Scale of 67).

This child may very likely be diagnosed with Mild Mental Retardation. He meets criteria with the IQ score below 70. Further, he has communication problems and has problems in self-care skills. Of course, it is important to get a good history of childhood illnesses and injuries. This can help to clarify the diagnosis.

Tommy is 12 years old. His mother says he can’t read and even has trouble writing his own name. He is difficult to understand when you speak with him. His Full Scale IQ in the WISC-III is 69, with a verbal of 62 and a Performance IQ score of 75. His mother reports that he has some trouble with self-care skills. His mother is of a low SES; she has a 5th grade education.

This is a difficult case to make a differential diagnosis. However, several factors lend themselves to not diagnosing Mental Retardation. First, The IQ scores show a significant split (12 points on the WISC-III is considered significant). His performance IQ score is in the Borderline Range. Furthermore, his mother is of a low education level (carefully look into early stimulation, e.g. reading, talking, etc.). This child probably has some language problems or learning disabilities that affect his intellectual development and school performance.

http://schoolpsychologyexam.com

002 ADHD

2010-11-09T08:37:00.001-08:00

Attention-Deficit Hyperactivity Disorder (ADHD) as described by The DSM-IV includes either symptoms of inattention or hyperactivity-impulsivity with at least six symptoms in either area. Symptoms of inattention include: problems listening, following through on instructions, organizing work or activities, forgetfulness, reluctance or distaste of tasks that require sustained attention, and losing things that are required for tasks or activities. Symptoms of hyperactivity include: general inability to sit still, fidgeting, problems playing quietly, driven behavior, and excessive talking. Impulsivity includes problems with blurting out answers, problems waiting for turn and interrupting or intruding on others. Young children may be naturally more prone to hyperactive and impulsive behavior- so the criteria should have an onset prior to age 7 and should continue beyond that age and should create impairment in two or more areas at a clinically significant level.

ADHD is often difficult to distinguish from anxiety or oppositional behavior for a couple of reasons. First, children with ADHD often have co-morbid symptoms of anxiety and oppositional behavior. Second, anxiety and oppositional behavior often “look like” ADHD and can become confusing when presented by a parent or teacher who has already made up their mind the child has ADHD.

The following are two brief vignettes that one may see in clinical practice.

Little Johnny’s mother describes him as “very hyper”. She says that Johnny “is always moving, never sits on the couch but climbs all over it, and won’t stop talking”. Furthermore, his teacher says that he can’t stay in his seat for more than a few minutes, always butts in line when going to the lunchroom and he yells at the other children to hurry when playing a game. He often tries to play out of turn. Johnny is currently 12, and he has been having increasing problems for the past several years.

In this example, it is likely that Johnny has ADHD- Primarily Hyperactive-Impulsive Type. Three symptoms of hyperactivity and three of impulsiveness are described.

Billy is 10. His mother also describes him as “very hyper”. He does not like to go to bed at night and often puts up a fight. He does not play well with other children. He is impatient and often yells and fights with them. Billy does not listen when told to do his chores, and he can’t seem to follow instructions given by the teacher. He is failing in school. He has been having these problems for some time.

In this example, Billy may have ADHD, inattentive type. However, the diagnostic criteria are not met. He may be oppositional based on his refusal to go to bed and fighting, and he may be refusing to follow instructions rather than having trouble attending to them. If he is fearful of going to bed, he may suffer from anxiety, night terrors or he may simply be afraid of the dark. Often, anxious children may have trouble sitting still. School failure may be due to a specific Learning Disorder or reading problem and the course of the disorder is not clear from the description. This description might meet the diagnostic criteria for ADHD, Not Otherwise Specified, but the symptoms of inattention and hyperactivity-Impulsivity must be differentiated from anxiety, oppositional behavior and learning disorders. It is possible that these other symptoms are co-morbid with ADHD. An important question clinically may be: are oppositional and anxiety symptoms primary or secondary to ADHD.

http://schoolpsychologyexam.com

001 Cognitive Behavioral Therapy

2010-11-04T13:05:00.000-07:00

COGNITIVE BEHAVIORAL THERAPY

Key Figures: Albert Ellis, Aaron Beck

Theory: Maladaptive behavior is associated with patterns of thinking and response which do not result in mentally healthy outcomes.

Treatment: The goal of Cognitive Behavioral Therapy is to change or substitute these patterns with more realistic and useful thoughts and responses.

Relevance: It is used to treat depression, anxiety disorders, phobias, and other forms of mental disorders. Medication is often used in conjunction with this approach to treat mood disorders and more severe forms of mental disorders. Schools of psychotherapy associated with this discipline are Rational Emotive Therapy, Rational Behavior Therapy, Rational Living Therapy, Cognitive Therapy, and Dialectic Behavior Therapy.

BECK (Cognitive Therapy)

Identification of automatic thoughts similar to preconscious. Depressed individuals this internal dialog is negatively oriented resulting in low self-esteem and negative self-concept. Cognitive Therapy and Beck Depression Inventory utilize Clients Thought Patterns (Cognitive Schema).

Beck's Cognitive Therapy is most effective for treating phobias and depression. The client's difficulties are a result of a distorted construction of reality in three levels:

1. View of Self
2. View of Experiences
3. View of the Future

Beck believes that when a client changes his or her thinking, biochemical changes occur in the brain which results in the client feeling better and less depressed.

http://schoolpsychologyexam.com

51-Banduras_Social_Learning_Theory

2009-11-23T06:14:00.000-08:00

Bandura's Social Learning Theory
Albert Bandura, born in Canada in 1925, is a psychologist in the behavioral movement who has been referred to as a founder of the cognitivist movement because of his movement from strict behavioral psychologist to seeing personality as being formed by environment, behavior and the individual?s psychological processes.
Bandura developed the idea of reciprocal determinism. He believed the pure behaviorist model of environment (variables that can be observed, measured and manipulated) cause behavior was too simplistic. He suggested behavior also causes elements in the environment, making the relationship of environment and behavior reciprocal, with elements of each interacting with one another. He called this phenomena reciprocal determinism. He later took this a step further, adding a cognitive element, one of imagery, moving him from the behaviorist movement into the foundation of the cognitive movement.
Bandura is best known for his study known as the Bobo Doll Studies. He made a film of a young woman, one of his students, attacking a Bobo doll (an inflatable clown that returns to an upright position when knocked down). In the film, she attacked it both verbally and physically. He showed the film to kindergartners. The children liked the film and were later let into a room to play. In the room was a Bobo doll. Observers noted the children mimicking what they had seen on the film, indicating observational learning. No requirements for rewards, punishments or approximations to learning the new behavior were needed for the behavior.
Bandura established steps involved in the modeling process for learning. Attention is required. If attention is limited, such as by illness, emotional state, physical state, or environmental limits, the ability to attend to what is modeled is limited and learning is hampered. If attention is enhanced, such as with drama, prestige, delivery (by credible or entertaining source) or like the subject, more attention is paid.
Retention is required for effective modeling. The individual must be able to remember what was seen or to what was attended. Imagery and verbal descriptions assist in bringing forth what is needed to duplicate it in behavior.
Reproduction is part of effective modeling. Prior to duplicating the behavior, the thoughts are not more than daydreaming. The images and language must be translated into action, which requires the individual to reproduce the behavior. If an individual watches the quarterback on a football, but is not able to throw a football, he has not engaged in reproduction. On the other hand, if he has thrown a football and has the basic skill set, he may improve his performance through imitation of what he observes in those who are more proficient that he is. Beyond observation of another performing a desired skill, one can imagine his or herself performing the desired skill in the mind?s eye before performing the skill and improve performance by the internal observation and practice of the performance in the arena of imagery or imagination.
Motivation is another element of modeling because without the will or desire to do the behavior, the individual will not do it. He may do it because of past reinforcement, promised reinforcement or vicarious reinforcement. Bandura holds that negative motivations are also reasons one may elect to do or not do a modeled behavior, such as past punishment, promised punishment or vicarious punishment.
Stepping out of a pure behavioral perspective, Bandura believed in self-regulation as the other element in human personality. He suggested three elements in this process. First, self-observation in which one looks at the self and behavior and monitors each. Second, judgment in which one compares the self with some standard, traditional, performance or another. Third, self-response in which if one does well with the set or desired standard, one is rewarded, or if done poorly, one is punished in some way. Rewards or punishments may be tangible (favorite meal) or covert (emotions of achievement, self-worth, shame). Out of this result, he believed those who struggle with poor self-esteem or self-concept elicit this from elements of self-regulation: self-observation (have an accurate reflection of self), standards (set reasonable ones) and self-response (use of self-reward and celebration of success without dwelling on failure).

Attachment Theory

2009-11-09T06:43:00.001-08:00

Attachment theory explores the relationships between humans using psychological, ethological and evolutional theory. John Bowlby, a British psychoanalyst and psychiatrist who lived from 1907 to 1990, created the original theory. The central tenet is the belief an infant needs to develop a relationship with one or more primary caregivers for normal emotional and social development to occur.

Bowlby believed in four basic, distinguishable characteristics in attachment. First is Proximity Maintenance. This is the desire to be close to the people to which we are attached. Second is Safe Haven. This is safety or comfort seeking with the attachment figure when feeling threatened or fearful. Third is Secure Base. Secure Base implies the attachment figure is a place the child can use and return to when exploring the surrounding environment, comforted that there is a place of security that acts as a touchstone, if needed, in which to return. Fourth is Separation Distress. This is the occurrence of anxiety when the attachment figure is not present.

Bowlby associated infant behavior with seeking proximity to an attachment figure (trusted caregiver) in situations of stress. The trusted caregivers establish Proximity Maintenance. Infants then become attached to caregivers who respond to them and are constant in their lives, especially from ages six months to two years, because they create a Safe Haven. As children approach the age of two, the child uses the attachment figures (caregivers familiar to them) as a Secure Base. The infant who is attached has an adaptive response of Separation Distress or Separation Anxiety when the attachment figure departs. This mechanism is an apparent survival mechanism for the child.

Initial criticism of Bowlby’s research came from the psychoanalytic community because of the departure from the predominant theory of the time. Later criticism came out of other disciplines after extensive empirical research surrounding the development of infant/child close relationships. However, the basis concepts associated with the theory have remained and serve as the foundation of theory, as well as the formulation of policy and practice in the arenas of social policy as it relates to children and childcare to enhance the attachments in early childhood.

Mary Salter Ainsworth, an American Developmental Psychologist who lived from 1913 to 1999, focused her work on emotional attachment. Through her research, she developed attachment patterns observed in infants: secure attachment, anxious/avoidant attachment and anxious/resistant attachment. She observed infants who experienced distress when their mother departed and sought comfort upon her return, referring to this as Secure Attachment. Ainsworth observed a lack of distress upon a mother’s departure from her infant and avoidance at her return, called Anxious/Avoidant Attachment. Ainsworth’s third category of observations involved a pattern of proximity to the mother in the initial minutes alone, followed by high levels of distress at mother’s departure, seeking comfort upon her return, followed by rejection at the closeness. She referred to this third category as Anxious/Resistant Attachment.

A fourth category was later theorized, called Disorganized Attachment, theorized by Mary Main and Judith Solomon. Disorganized Attachment resembles the Anxious/Avoidant infants/children, but had significant ambivalence upon reunion with the caretaker, both approaching and avoiding. Bowlby described this as pulling away with anger while seeking to be close.

Dependent and Independent variables

2009-10-22T18:16:00.000-07:00

You want to study the effects of caffeine on test scores. You assign subjects in one condition to drink three cups of coffee before the test. Subjects in the second condition drank three cups of water. In this experiment, what is the independent variable and what is the dependent variable, respectively?

Amount of caffeine consumed, Test scores

Test scores, Amount of caffeine consumed

Number of subjects in each condition, Test scores

Test scores, Number of subjects in each condition

The independent variable is the variable that you as a researcher are manipulating. In this example, you are manipulating the amount of caffeine consumed. The dependent variable is the variable that you are measuring (test scores).

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2009-08-24T07:19:00.000-07:00

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Individually based theory and therapy models 15

2007-07-23T12:50:00.000-07:00

Gestalt Therapy 04

Techniques

■ The experiment in Gestalt therapy
        o To assist clients self awareness of what they are doing and how they are doing it
        o Expanding awareness of client
        o Opportunity to “Try on” new behavior
        o Experiments bring struggles to life, inviting client to enact them in the present
        o Major emphasis on preparing clients for experiments though trusting relationship

■ Confrontation
        o Imposing stance
                ● Therapist meets own agenda for the client
                ● Acts as expert, power and control in therapist
        o Competing stance
                ● Therapist promotes rugged individualism with lots of negotiation compromise and                 confidence
        o Confirming stance
                ● Acknowledging the whole being of client
                ● Client’s needs and experience center of relationship
                ● Ideal type of confrontation
                ● Invites client to look at incongruities in verbal and nonverbal language, in words
                versus action.

■ Internal Dialogue
        o Identifies the struggle for control in a person, fragmented between controller and controlled, through Introjection of aspects of others
        o Between top dog and underdog
        o Between critical parent should and oughts and passive recipient without responsibility and with excuses
        o Empty chair
                ● Shift client into two chairs for dialogue role lay.
                ● Experiences conflict

■ Reversal technique
        o Role play the opposite of symptoms and behaviors client suffers
        o Client tries the very thing fraught with anxiety, therefore submerged and denied
        o Help clients to accept personal attributes that they have tried to deny

■ Rehearsal exercise
        o Behavioral rehearsal: role play a planned for new behavior with a person or people in client’s environment.
        o Reduce stage fright, anxiety or fear
        o Encourages spontaneity and willingness to experiment with new behaviors

■ Exaggeration Technique
        o Exaggerate movement or gesture repeatedly to intensify feelings attached by behavior to make inner meaning clear
        o Trembling hands or feet, slouched posture, bent shoulders, clenched fists, tight frowning etc.

■ Staying with Feelings
        o Keep client from escaping fearful stimuli and avoiding unpleasant feelings
        o Encourage to go deeper into feeling or behavior they wish to avoid
        o Facing, confronting, and experiencing feeling makes them able to unblock and make way for new levels of growth
                ● Takes courage and pain.

Individually based theory and therapy models 14

2007-07-23T12:42:00.000-07:00

Gestalt Therapy 03

Five Major Channels of Resistance

■ Introjection
        o Tendency to uncritically accept other’s beliefs and standards without assimilating them to make them congruent with who one is
        o Passively incorporate what the environment provides, spending little time on becoming clear about what we need or want.

■ Projection
        o Disown aspects of self by assigning them o the environment
        o Trouble distinguishing between inside and outside world
        o Disown attributes of self that are inconsistent with self image and put onto other people
        o Avoid taking responsibly of feelings and person one really is
        o Keeps self powerless to initiate change

■ Deflection
        o Process of distraction
        o Keeps difficult to sustain sense of contact with reality
        o Overuse of humor, abstract generalization, and questions rather than statements, resulting in emotional depletion
        o Diminished emotional experience by seeking through and for others

■ Retroflection
        o Do things to self rather than others

■ Confluence
        o Blurring differentiation between self and environment
        o Fitting in, absence of conflict, belief all people feel and think the same way
        o High need for acceptance and approval
        o Stay safe, never express own feelings
        o Therapist uses W’s questions to get client to open up

Other Forms of Resistance

■ Control of environment
        o Resistance to contact
        o Boundary disturbance

■ Blocks to energy manifested by
        o Tension in part of body
        o By posture
        o Keeping body tight and closed
        o Not breathing deeply
        o Looking away from people when speaking
        o Numbing feelings
        o Speaking with restricted voice

Individually based theory and therapy models 13

2007-07-23T12:39:00.000-07:00

Gestalt Therapy 02

Major Principles

■ Holism
        o Interested in the whole person
        o Emphasis on integration of thoughts feelings, behaviors, body and dreams

■ Field Theory
        o Organism must be seen in its environment or its context as part of a constantly changing field
                ● Relational
                ● In flux
                ● Interrelated
                ● In progress

■ Figure Formation Process
        o How client organizes environment from moment to moment
        o Background
                ● The undifferentiated field or ground
        o Figure
                ● The emerging focus of attention

■ Organismic Self Regulation
        o Restore equilibrium or contribute to growth and change

Therapy Process

■ The Now
        o Power in the present
        o Nothing exists except the now
        o The past is gone and the future has not yet arrived
        o For many people the power of the present is lost
                ● They may focus on their past mistakes or engage in endless resolutions and plans                 for the future.

■ Unfinished Business
        o Feelings about the past are unexpressed
        o These feelings are associated with distinct memories and fantasies
        o Feelings not fully experienced in the background and interfere with effective contact
        o Preoccupation, compulsive behavior, wariness oppressive energy and self defeating behavior.

■ Layers of Neurosis
        o Perls likens the unfolding of adult personality to the peeling of an onion.
        o Phony layer- stereotypical and inauthentic
        o Phobic layer- fears keep clients from seeing themselves
        o Impasse layer- giving up power
        o Implosive layer- fully experiencing deadness
        o Explosive layer- letting go of phony roles

Individually based theory and therapy models 12

2007-07-23T12:36:00.000-07:00

Gestalt Therapy 01

Foundations

■ Existential and Phenomenological
        o Grounded in the client’s “here and now”

■ Initial goal is for clients to gain awareness of what they are experiencing and doing now

■ Promotes direct experiencing rather than the abstractness of talking about situations

■ Rather than talk about childhood trauma, the client is encouraged to become the hurt child

■ Holistic approach to personality vs. mechanistic approach of Freud.

■ Value of examining present situations vs. repressed intra-psychic conflicts from early
childhood

■ Focus on process versus content

■ On presently experienced vs what is revealed by client from memory

■ Self understanding comes from individual’s behavior in the present versus why they behave as they do

■ Therapist goal: create experiments for client to assist their self awareness of what they are doing and how they are doing it.

Therapy Process

■ Promote awareness in client through
        o Insight
        o Self acceptance
        o Knowledge of the environment
        o Responsibility for choices
        o Paradoxical theory of change
        o Ability to make contact with others
        o Clients expected to do their own seeing, feeling, sensing and interpreting vs passively allowing therapist to give insight and answers

■ Concepts of human nature
        o Clients are manipulative
        o Avoid self reliance
        o Avoid taking on personal responsibility
        o Clients have to stand on own two feet to deal with life problems themselves
        o Move clients from environmental supports to self-support
        o Help clients reintegrate disowned parts of personality

Individually based theory and therapy models 11

2007-07-23T12:33:00.000-07:00

Experiential Therapy 03

Aim of Existential Therapy

■ Rejects deterministic outlook on mankind

■ People are free and responsible for their choices and actions

■ People are the authors of their lives

■ Existential therapy encourages clients to:
        o Reflect on life
        o Recognize range of alternatives
        o Decide among them

■ Goal
        o Help clients recognize ways they passively accepted circumstances and surrendered control
        o Help clients to start to consciously shape their own lives by exploring options for creating a meaningful existence.

Tasks of the Therapist

■ Invite clients to recognize how they have allowed others to decide for them

■ Encourage clients to take steps toward autonomy

■ The Question
        o “Although you have lived in a certain pattern, now that you recognize the price of some of your ways, are you willing to consider creating a new pattern?”

■ Relationship between therapist and client
        o Therapy is a journey taken by BOTH therapist and client
                ● The person to person relationship is key
                ● The relationship demands that therapists be in contact with their own                 phenomenological world
        o The core of the therapeutic relationship
                ● Respect and faith in the client’s potential to cope.
                ● Sharing reactions with genuine concern and empathy

Individually based theory and therapy models 10

2007-07-20T08:20:00.000-07:00

Experiential Therapy 02

Basic Dimensions of the Human Condition

■ The capacity for self awareness:
        o The greater our awareness, the greater our possibilities for freedom
        o Awareness is realizing
                ● We are finite- time is limited
                ● We have potential, the choice to act or not to act
                ● Meaning is not automatic- we must seek it
                ● We are subject to loneliness, meaninglessness, emptiness, guilt and isolation

■ The tension between freedom and responsibility
        o People are free to choose among alternatives and have a large role in shaping personal destinies
        o Manner in which we live and what we become are result of our choices
        o People must accept responsibility for directing own lives

■ Creation of an identity and establishing meaningful relationships
        o Identity is the courage to be
        o We must trust ourselves to search within and find our own answers
        o Our great fear is that we will discover there is no core, no self
        o Aloneness
                ● We must tolerate being alone with self
                ● We must have a relationship with ourselves first
        o Struggling with identity
                ● We are trapped in doing mode to avoid experience of being
        o Relatedness
                ● At their best our relationships are based on our desire for fulfillment, not our                 deprivation

■ The search for meaning
        o Like pleasure, meaning but be pursued
                ● Finding mening in life is a byproduct of a commitment to creating, loving, and                 working
        o Life is not meaningful in itself, the individual must create and discover meaning
        o Goals deal with
                ● Discarding old values
                ● Coping with meaninglessness
                ● Creating new meaning

■ Accepting anxiety as a condition of living
        o Anxiety arises from striving to survive and maintain own being
        o Existential anxiety is normal- life cannot be lived, not can death be faced, without anxiety
                ● Anxiety can be a stimulus for growth as we become aware of and accept our                 freedom
                ● We can blunt our anxiety by creating the illusion that there is security to life
                ● If we have the courage to face ourselves and life we may be frightened, but we will                 be able to change
        o Neurotic anxiety creates guilt

■ The awareness of death and nonbeing
        o Awareness of death is a basic human condition which gives significant to our living
        o We must think about death if we are to think significantly about life
        o If we defend against death our lives can become meaningless
        o We learn to live in the “now”
        o One day at a time results in a zest for life and creativity

Individually based theory and therapy models 09

2007-07-20T08:17:00.000-07:00

Experiential Therapy 01

Theory Foundation

■ Modern person has means to live but often has no meaning to live for- this is the malady of our times, meaninglessness or existential vacuum

■ Purpose of therapy is to challenge people to find meaning and purpose through suffering,
work and love

■ It takes courage to BE
        o Our choices determine the kind of person we are
        o We are in constant struggle with
                ● Our want to grow toward maturity and independence
                ● Realizing expansion and growth is often a painful process
                ● Struggling between security and dependence and delights and pain of growth

■ Phenomenological approach
        o People’s perceptions or subjective realities are considered to be valid data for investigation
        o Phenomenological discrepancies
                ● Two people perceiving the same situation differently

■ Non-Deterministic approach
        o Existentialist argue that it is an oversimplification to view people as controlled by fixed physical laws
        o Encouragement of theories that consider individual initiative, creativity, and self fulfillment
        o Focus on active, positive aspects of human growth

■ I-Though dialogue vs. I-It Dialogue
        o I-though
                ● human confirms the other person as being of unique valued
                ● Direct mutual relationship
        o I-it
                ● Person uses others but does not value them for themselves
                ● Utilitarian
        o Self disclosing of therapist emotional response to client’s demonstration of valuing of client’s feelings and perspective.

Individually based theory and therapy models 08

2007-07-17T08:16:00.000-07:00

Person Centered Therapy 02

The Therapy Process

■ Six conditions necessary and sufficient for personality changes to occur:
        o Two persons are in physiological contact
        o The first, the client is experiencing incongruence
        o The second, the therapist, is congruent or integrated in the relationship
        o The therapist experiences unconditional positive regard or real caring for the client
        o The therapist experiences empathy for the client’s internal frame of reference and endeavors to communicate this to the client
        o The communication to the client is, to a minimal degree, achieved.

■ Three Requirements for Therapy

        o Genuineness
                ■ Accurate empathic understanding
                ■ Genuineness or realness in relations between therapist and client
                ■ Being oneself in the therapeutic relationship with the client

        o Unconditional positive regard
                ■ Acceptance and caring
                ■ NOT approval of all behavior

        o Congruence
                ■ Understanding of client’s frame of references
                ■ Ability to deeply grasp the client’s subjective world and communicate this to the client

Role of the Therapist

        o Focuses on the quality of the therapeutic relationship
        o Serves as a model of a human being struggling towards greater realness
        o Is genuine, integrated, and authentic, without a false front
        o Can openly express feelings and attitudes that are present in the relationship with the client

Individually based theory and therapy models 07

2007-07-17T08:11:00.000-07:00

Person Centered Therapy 01

Theoretical Foundations

■ Focus is on the person and not the presenting problem

■ Humanism
        o Philosophical movement that emphasizes worth of the individual and the centrality of human values
        o Attends to matters of ethics and personal worth
        o Gives credit to the human spirit
        o Emphasis on creative, spontaneous, and active nature of humans
        o Optimistic
        o Human capacity to overcome hardship and despair

■ Non-Deterministic
        o Beliefs that it is oversimplification to view people as controlled by fixed physical laws.
        o Encouragement of therapy that considers individual initiative, creativity, and self fulfillment

■ Self Actualization
        o Innate process by which a person tends to grow spiritually and realize potential

■ The Experiencing Person
        o Important issues must be defined by the client
        o Special concerns are discrepancies between what a person thinks of himself and the total range of things he experiences

Techniques

■ Listening
■ Accepting
■ Respecting
■ Understanding
■ Empathic Responding

Individually based theory and therapy models 06

2007-07-17T08:01:00.000-07:00

Adlerian Therapy 04

Adlerian Therapy Process

■ The role of the client
        o Explore private logic- concepts about self, others and life
        o Discover purposes of behavior or symptoms of basic mistakes associated with their coping.
        o Learn how to correct faulty assumptions and conclusions

■ The Client Therapist Relationship
        o Based on mutual trust, respect, confidence and alignment of goals.
        o Collaborative relationship
        o Develop a therapeutic contract (goals for therapy)
        o Emphasis of responsibility on client for his or her own behaviors

Techniques

■ Establish a therapeutic relationship
        o Therapists gets to know the client as a person
        o Collaborate on goals for therapy
        o Supportive therapist creates caring human connection
        o Therapist work to make client feel deeply understood and accepted.
        o Client focuses on what needs to change in therapy.

■ Explore the psychological dynamic operating in the client
        o Consists of a subjective interview
        o Clients tells own story as expert on own life
        o Therapists listens for cues to client’s coping and approach to life
        o Objective interview
                ■ Family constellation
                ■ Early recollections
                ■ Personal priorities
                ■ Integration and summary

■ Encourage development of self understanding (insight into purpose)
        o Understanding motivates that operate in client’s life
        o Client disclosure and therapist interpretation (open ended manner)
        o Make unconscious into conscious
        o Confront resistance to help client and therapist align
        o Explore purposes of symptoms, feelings, behaviors and human difficulties or block

■ Help client make new choices (reorientation and reeducation)
        o Encouragement process
        o Change and search for new possibilities
        o Make a difference through change in behavior, attitude and perceptions.

Individually based theory and therapy models 05

2007-07-17T07:55:00.000-07:00

Adlerian Therapy 03

Adlerian Concepts

■ Basic Mistake- faulty, self defeating perceptions attitudes and beliefs, personal myths

■ Fictional Finalism- imagined central goal that gives direction to behavior and unity

■ Holism- study of humans as integrated beings

■ Insight- special form of self awareness

■ Style of Life- individual’s ways of thinking feeling and acting

■ Complexes
        o Inferiority complex- normal feelings of incompetence exaggerated, feeling its impossible and hopeless to reach goals
        o Superiority complex- very high opinion of self, bragging, quick to argues often

■ Organ Inferiority- everyone is born with some physical weakness, this motivates life choices

■ Aggression Drive- reaction to perceived helplessness or inferiority, lashing out against the inability to achieve or master

■ Masculine Protest- kids work to become independent from adults and people in power.

■ Perfection striving- people who are not neurotically bound to an inferiority complex spend their lives trying to meet fictional goals
        o Elimination of perceived flaws
        o “As if” philosophy
        o Gives motivation and focus

■ Social responsibility and understanding of social issues
        o Occupation tasks
                ● career,
                ● self worth
        o Societal tasks
                ● Creating friendships
                ● Social networks
        o Love tasks
                ● Life partner

■ Positive and Goal Oriented Humanity
        o People striving to overcome weakness to function productively
        o Urge to contribute to society

Individually based theory and therapy models 04

2007-07-17T07:52:00.000-07:00

Adlerian Therapy 02

Social Interest

■ Adler’s most significant and distinctive concept.
■ Refers to an individual’s attitude toward and awareness of being part of the human community.
■ Mental health is measured by the degree to which we successfully share with others and are concerned with their welfare.
■ Happiness and success are largely related to social connectedness.

Role of Birth Order Psychological Positions

■ Motivates later behavior.
■ First born/ Oldest
        o Favored pseudo-parents, high achievers
        o Receives more attention, spoiled
■ Second born
        o Rivalry and competition
        o Behaves a in a race, often opposite first child
■ Middle Child
        o Often feels squeezed out
■ Last born
        o More pampered, “baby,” creative, rebellious, revolutionary, avant-garde
■ Only Child
        o Does not learn to share or cooperate with other children
        o Learns to deal with adults

Encouragement

■ Encouragement is the most powerful method available for changing a person’s beliefs
■ Helps build self-confidence and stimulates courage
■ Discouragement is the basic condition that prevents people from functioning
■ Clients are encouraged to recognize that they have he power to choose and act differently

5 Basic Tasks

■ Acceptance
■ Achieving Intimacy
■ Work
■ Spiritual Dimension
■ Community/Friendship

Individually based theory and therapy models 02

2007-07-17T07:46:00.000-07:00

Analytic Therapy- Carl Jung

Therapeutic Goals

■ Reintegration
o Merging past and present
o Explore the Conscious/unconscious
o Develop self knowledge
o Individuation- reclaiming undeveloped parts of self through reflection on life/past

Key Ideas

■ View of Man
o Man’s behavior is conditioned not only by his individual/racial history (causality) but also by aims and aspirations (teleology- explanation of behavior based on future goals)

■ Collective Unconscious
o Shared by all but modified by personal experience

■ Personal Conscious
o Unique life experiences and perceptions

■ Theory of Personality
o Psyche
■ Conscious/unconscious
o Personal Conscious
■ Only understood through dreams and analysis and makes itself known through complexes and emotions
o Personal Shadow
■ Archetypal representing thoughts, feelings, and actions that disown by projecting them outward (contains everything that could or should be part of the ego that the ego denies or refuses to develop, either positive or negative)
■ Reclaiming is an essential task for mature personality.
o Archetype
■ Pathway of communication between unconscious and conscious
■ Understanding archetypes (images of unconscious) helps one to understand the self
o Principles of Opposites
■ Animus vs. Over Characteristics
■ Conscious vs. Unconscious
■ Personal vs. Shadow
■ Mind vs. Body

Individually based theory and therapy models 01

2007-07-17T07:42:00.000-07:00

Psychoanalysis- Freud/Erikson/Mahler

Role of Therapist

■ Invisible- Blank Screen (detachment)
■ Fosters transference
■ Focus on Resistance

Therapeutic Goals

■ Bringing the unconscious to the conscious
■ Strengthen the ego

Key Ideas

■ Deterministic- problems are rooted in the first six years of life and trapped in unconscious motivations
■ Reality Principle- maximize gratification minimize punishment
■ Biological Drives- sex and instincts
■ Parts of Personality- Id/Ego/Superego
■ Id- Pleasure principle, “Demanding Child,” deterministic, unconscious, satisfy basic survival
■ Ego- Reality principle, “Traffic Cop,” mediator between Id and Superego
■ Superego- Moral Principle, “The Judge,” strive for perfection

Psychosexual Stages of Development

■ Oral Phase- 0-1 years, greedy, mistrust, unable to form intimate relationships
■ Anal Phase- 1-3 years, anal retentive, aggressive
■ Phallic Phase- 3-6 years, identity disturbance (Oedipal/ Electra complex)
■ Latency- 6-12 years, Socialization stage
■ Genital- 12+, Interpersonal relations freedom to love/work

Techniques

■ Brief psychodynamic therapy (BPT)- treating selective disorders within an established time.
■ Hypnosis
■ Dream Interpretation
■ Free Association
■ Projective Techniques
■ Freudian Slips

Individually based theory and therapy models 03

2007-07-13T11:03:00.000-07:00

Adlerian Therapy 01

Therapy Focus

●        Importance of the feelings of self (ego) that arise from interactions and conflicts.

●        The sense of self, or The Ego is the core individuality/personality of a person

●        Adlerian therapy got its start from psychoanalysis.

●        It places emphasis on motivation and social interaction

●        A phenomenological approach

●        Social interest is stressed

●        Study of birth order and sibling relationships.

●        Purpose of therapy is teaching, informing, and encouraging.

●        Basic mistakes of client logic
        o        Overgeneralization
        o        Exaggerated need for security
        o        Misperceptions of life
        o        Denial of ones worth
        o        Faulty values

●        The therapeutic relationship is a collaborative partnership.

●        Focus on the importance of each person’s:
        o        Unique motivations
        o        Perceived niche in society
        o        Goal directedness

Phenomenological Approach

●        Adlerian's attempt to view the world from the client’s subjective frame of reference.

●        Belief in how life in reality is less important than how the individual believes life to be.

●        Belief that it is not the childhood experiences that are crucial, but rather our present interpretation of these events.

●        Belief that unconscious instincts and our past do not determine our behavior.

Standardized psychological assessment tests

2007-07-09T13:22:00.000-07:00

● Achievement and aptitude tests
        o Seen in educational or employment settings
        o Attempt to measure either
                ■ Achieved knowledge- particular subjects
                ■ Aptitude or ability to master material in a particular area.

● Intelligence tests
        o Measure basic ability to understand the world, assimilate to functioning, and apply knowledge to enhance the quality of life.
        o Intelligence is a measure of a potential, not a measure of what one has learned (as in an achievement test)
        o It is supposed to be independent of culture.
        o However, most intelligence are not culturally unaffected.

● Neuropsychological tests
        o Measure deficits in cognitive functioning- ability to think, speak, reason which may result from brain damage, such as a stroke or a brain injury.

● Personality tests
        o Measure basic personality style
        o Most used in research or forensic settings to help with clinical diagnoses.
        o Two of the most well-known personality tests are
                ■ Minnesota Multiphasic Personality Inventory (MMPI), or the revised MMPI-2,
                        ◊ Composed of several hundred “yes or no” questions\
                ■ Rorschach (the “inkblot test”),
                        ◊ Composed of several cards of inkblots
                        ◊ Clients give a description of the images and feelings experienced by looking at the blots.

● Psychological tests
        o Administered and interpreted by a psychologist
        o Counselors who have appropriate academic courses and supervision may administer occupational tests or achievement and aptitude tests.

Anticipatory Trauma

2007-07-02T07:16:00.000-07:00

◆ Reactions to anticipatory trauma:
        o Emotional
                ■ Fear
                ■ Anger
                ■ Confusion
                ■ Hopelessness
                ■ Loss of control
                ■ Numbness
                ■ Moodiness
                ■ Irritability
                ■ Guilt
        o Behavioral
                ■ Social withdrawal
                ■ Disruption of daily activities
                ■ Easily startled or jumpy
                ■ Easily cry
        o Cognitive
                ■ Thoughts preoccupied with anticipation of trauma
                ■ Difficulty concentrating
                ■ Low self esteem
                ■ Indecisiveness
                ■ Poor memory recall
        o Somatic
                ■ Muscle tension
                ■ Headaches
                ■ Gastric problems
                ■ Irregular sleep and appetite
                ■ Fatigue

◆ Treatment Techniques
        o Social support:
        o Physical self-care
                ■ Exercise
                ■ Eating healthy
                ■ Regular sleep
        o Spirituality
        o Meditation or Guided Relaxation
        o Positive self talk
        o Humor

Crisis Intervention Models

2007-06-20T08:19:00.000-07:00

Crisis intervention with date rape, school violence, substance abuse, and adolescent suicide.

Step #1: Listen
- Establish therapeutic relationship.
- Identify precipitating problems.
- Explore emotions.

Step #2: Assessment
- Determine the severity of the crisis.
- Assess potential lethality or physical harm to the person or others.
- Identify past coping skills, strengths and supportive resources.
- Suicide/Homicide assessment
- Determine client’s perception of reality.
- Discuss cultural beliefs about handling trauma.
- Find out if family and social resources are potential resources. Are the resources positive or negative?

Step #3: Treatment Plan
- Selectively choose and use appropriate approaches to action planning.
- Modify or eliminate past coping skills.
- Create a contract or have client sign treatment plan.
- Identify useful referral resources.
- Use three basic approaches:
        i. Start by being non-directive.
        ii. Be collaborative by working together on a joint plan.
        iii. Be directive if the person does not or will not make a plan.
- During crisis, have only short term objectives.

Step #4: Termination
- Review progress on treatment plan.
- Plan for expanding resources and support system.
- Schedule a follow up session.

DSM Health Problems

2007-06-11T09:08:00.000-07:00

Diagnostic and Statistical Manual of Mental Disorders (DSM) and International Statistical Classification of Diseases

Diagnostic and Statistical Manual of Mental Disorders (DSM)

o Handbook for mental health professionals.
o Includes all categories of mental disorders and their corresponding diagnosable criteria.
o Intended to be used by those with clinical training.
o In accordance with the American Psychiatric Association.
o Uniform criteria for diagnosing.
o Includes sociological, psychological, biological, criteria.
o Each revision has discarded some previously diagnosable disorders such as pre-menstrual dysphoric disorder and masochistic personality disorder to show the manual is contemporary with social times.
o It now no longer includes homosexuality as a mental disorder, replacing it with sexual orientation disturbance, though still controversial.

Diagnosing Categories

o Axis I: Clinical disorders, including major mental disorders, as well as developmental and learning disorders
o Axis II: Underlying pervasive or personality conditions, as well as mental retardation
o Axis III: Acute medical conditions and Physical disorders.
o Axis IV: Psychosocial and environmental factors contributing to the disorder
o Axis V: Global Assessment of Functioning GAF score
o A scale from 100 (good functioning) to 0 (several dysfunction)

Diagnostic interviewing techniques

2007-06-06T07:26:00.000-07:00

Questioning:
o Client asked direct questions in areas determined by interviewer
o Questioning may be open or closed.
Open= unlimited answer options
Closed= Yes, No, or one word questions

Reflection:
o Restate the clients cognitive or emotional material
o Demonstrate empathic understanding
o Rogerian Client-Centered Therapists rely heavily on reflection
o Overuse is counterproductive - important areas are left unaddressed

Restatement (Paraphrasing):
o Rephrase what client says.
o Demonstrates active listening.
o Reflection is type of intervention, clarifies and joins themes.

Clarification:
o Accompanied by utilizing other techniques such as questioning, paraphrasing, restating
o Shows understanding of client in the interview
o If done from a not knowing stance, should not invoke defensive response.

Confrontation:
o May be used to call client out on discrepancies
o Is often used with substance abusers in order to break denial and/or rigid defenses
o This may increase anxiety and avoidance but is necessary and can be constructive.

Self-disclosure
o The sharing of personal experiences by the therapist to the client relative to the session with the purpose of helping.
o Intended to facilitate client disclosure.
o Should be used minimally
o Must be careful not to cross boundaries.

Silence:
o While this may occur unintentionally there are many benefits if used correctly.
o Provides both client and therapist time to process what is being understood.
o Timing is essential
o Promotes introspection

Exploration:
o Therapist test the limits of what client is willing to process.
o May be used to determine clients level of insight.

Reframing (Cognitive reframing):
o This allows for a different perspective
o Used to challenge negative self concepts and harmful thinking patterns.
o The purpose is to lead to behavioral change.

Statutes, case law and regulations

2007-06-05T12:43:00.000-07:00

Professional disclosure statement tells clients about:

o Informed Consent/parent notification for counseling or assessment
o Parent, legal guardians, and appointed surrogates
o Document parent notifications
o Rights to educational records FERPA
o Procedural Safeguards
o Document parent notifications
o HIPAA

Confidentiality
o Ethical obligation of therapist to keep communications and protocols private.
o May be charged in contempt of court if psychologist refuses to testify about a client.

Exceptions:
o Child abuse reporting laws: mandated to report the suspicion of child abuse or neglect. (in some states this is required of all citizens not just counselors)
o Duty to warn: if therapist establishes there is a likelihood that client will cause harm to him/herself or to someone else and the therapist knows who that victim may be.
o Baker Act

Privilege- Legal right, owned by the client, which is an exception to the general rule that the public has a right to relevant knowledge in court proceedings. This means information revealed in session is not permitted in court. Procedural safeguards.

Appropriate standard of care- how most therapists would treat a case under similar circumstances. Those who do not follow this are at risk for malpractice.

Dual relationship- occur when Psychologist does not keep appropriate boundaries and thereby blends personal or business relationships with the therapeutic/evaluation relationship.

Secret policies- written statements about how information shared privately will be handled by the therapist. Must be signed by both parties. If counseling a minor he/she must be informed that information discussed will not be confidential.

Risk factors for and patterns of abuse

2007-06-04T07:17:00.000-07:00

Recognizing sings of abuse

In the child:
o Sudden changes in behavior or school performance
o Not medical attention for problems brought to parents attention.
o Learning problems, difficulty concentrating, that cannot be attributed to specific disabilities.
o Tends to be watchful, expecting something to happen.
o Lacks adult supervision.
o Overly compliant, passive, or withdrawn.
o Comes to school or other activities early, stays late, does not want to go home.

The Parent:
o Shows little concern.
o Denise existence of, or blames the child, for problems at school or home.
o Asks teachers to use physical discipline.
o Describes child as bad or burdensome.
o Demanding high levels of academic and physical performance.
o Relies on child for care, attention, emotional needs.

Parent and Child:
o Do not look or touch each other.
o View of relationship is only negative.
o State they do not like each other.

Pattern of Abuse

Tension building
o Anger builds.
o Poor communication.
o Victim feels the need to keep the abuser calm.
o Tension mounts.
o Victim constantly feels weary of abuser.
o Abuse (physical, emotional, or sexual) takes place.
Making up:
o Apology may be made.
o Promise of the last time.
o Victim blaming.
o Denial of abuse.
o Calm
o Abuser acts as if nothing has happened.
o Some promises may be met, during this time.
o Victim may believe the abuse is truly over.
o Abuser may give gifts to victim.

Risk factors, stages and patterns of grief response

2007-05-23T20:59:00.000-07:00

•        DSM Diagnosis under Other Conditions That May be Focus of Clinical Attention, V62.82, Bereavement- used for death of a loved one.
•        Depression in this case is considered “normal” but individual my be seeking treatment to relieve symptoms such as insomnia or anorexia.
•        Expression of “normal” bereavement time is relative to different cultures.
•        Major Depressive disorder is not diagnosed unless symptoms last longer than two months after loss.

Stages of Grief:
•        Denial
•        Anger
•        Bargaining
•        Depression
•        Acceptance

Reactions commonly seen in children:
        o        Disbelief- children may act as if it did not happen.
        o        Complain of headaches, stomachaches, or fear of their own death.
        o        Anger- concern over own needs and about being alone, or with God.
        o        Guilt- feelings of causing death, or not having been “better”
        o        Anxiety/Fear: may become clingy and need validation of love.
        o        Regression: revert to bed wetting or thumb sucking
        o        Sadness: lethargy and isolation

Short Term Treatment Goals
•        Express fear and anger, grieve in a healthy way.
•        Loss and Grief Counseling Group
•        Recall fond memories
•        Create a phone list of supportive people to call
•        New coping techniques
•        Find a “safe place” to spend limited time thinking about deceased
•        Exercise regiment
•        Relaxation techniques- progressive muscle relaxation, guided imagery

Long Term Treatment Goals
•        Reach a point of coping without being overcome with grief.
•        Regain normal activity.
•        Reduce feelings of guilt and anger towards self, others, and God.
•        Re-mature over regressed behaviors
•        Understanding of death and life.

Therapeutic Interventions
•        Writing Activities
        o        Letter to deceased for closure
        o        Journal of thoughts (may be shared in counseling, in group, or with family members)
•        Art therapy:
        o        Finger paints are useful in expressing feelings
        o        Draw pictures of activities enjoyed with deceased (useful with children).
        o        Collage on a theme
        o        Splatter room: area where (particularly children) are free to throw violent splotches of paint to get anger out.
•        Play Therapy:
        o        Model clay or dough to vent anger or create ritual objects
        o        Puppetry- to express feelings
        o        Sand tray to play out themes, “burry” deceased for closure, or rake sand for relaxation or meditation.
•        Bibliotherapy:
        o        Appropriate self help books
        o        Books related to symptoms client is displaying
•        Loss Graph or Timeline:
        o        Used to discuss types of loss
        o        Used to recall fond memories and celebrate life
•        Storytelling:
        o        Fantasy monologues
        o        Mutual storytelling
•        Therapeutic Metaphors
        o        Helpful in understanding concept of death
•        Empty Chair
        o        Gestalt technique
        o        Imagine deceased in chair and speak to them for closure