COUNSELING SKILLS SESSION 8 1 - UWSP 101.pdf · 2019-09-17 · Jeff Lewis COUNSELING SKILLS SESSION 8 3 What is Mental Illness A DISEASE PROCESS CHARACTERIZED BY IMPAIRMENTS IN THOUGHT

Jeff Lewis

COUNSELING SKILLS SESSION 8 1

Welcome! Crisis 101

https://www.youtube.com/watch?v=rj2CD5xgpNY

HTTPS://WWW.YOUTUBE.COM/WATCH?V=XE3RQGNXAT4

What makes a good Crisis Worker?

What makes a good Crisis Worker

Jeff Lewis


What Mental Health?

What do you think of when you hear the term Mental Health?

What Mental Health?

Mental health includes our emotional, psychological, and social well-being. It affects how we think, feel, and act. It also helps determine how we handle stress, relate to others, and make choices.

What is a Crisis?

Chapter 34 defines a crisis as: A person shall be in a mental health crisis or the

situation will likely develop into a crisis if supports are not provided

Jeff Lewis


What is Mental Illness

A DISEASE PROCESS CHARACTERIZED BY IMPAIRMENTS IN THOUGHT AND OR MOOD MANIFESTED THROUGH BEHAVIORS

Paul Paul is a 24 year old man who comes to you with

complaints that he is hearing voices. In your assessment you interview Paul and his mother. You learn that Paul has been hearing voices for about a year. He does not use drugs on occasion he may drink help settle his nerves. After all the voices are not friendly.

Paul is having a hard time following the conversation and at times seems quite distracted. He will stop his conversation and appears to be giving directions to someone who is not present.

Paul's mother reports Paul had to drop out of school last year because he could not follow what was happening in his classes, Since then he has been spending much of his time in his room and seems to be avoiding contact with other people

Mother has taken Paul to a doctor and a preliminary exam revealed no brain trauma or disease

What is a Schizophrenia

Beliefs that have no basis in reality (delusions) Hearing, seeing, feeling, smelling, or tasting things

that have no basis in reality (hallucinations) Disorganized speech Disorganized behaviors Negative, potentially less overt psychotic symptoms Inhibition of facial expressions (Flattened affect) Catatonic behaviors Self neglect, poor grooming and hygiene Lack of speech Lack of motivation

Jeff Lewis



Schizophrenia is a chronic, severe, debilitating mental illness that affects about 1% of the population, more than 2 million people in the United States alone.

With the sudden onset of severe psychotic symptoms, the individual is said to be experiencing acute psychosis. Psychotic means out of touch with reality or unable to separate real from unreal experiences.

There is no known single cause of schizophrenia, it appears that genetic factors produce a vulnerability to schizophrenia, with environmental factors contributing to different degrees in different individuals.

There are a number of various treatments for schizophrenia. Given the complexity of schizophrenia, the major questions about this disorder (its cause or causes, prevention, and treatment) are unlikely to be resolved in the near future. The public should beware of those offering "the cure" for (or "the cause" of) schizophrenia.

Schizophrenia is one of the psychotic mental disorders and is affecting individual's thoughts, behaviors, and social functioning.


In addition to providing treatment that is appropriate to the diagnosis, professionals attempt to determine the presence of mental illnesses that may co-occur.

People with schizophrenia are at increased risk of having a number of other mental-health conditions, committing suicide, and otherwise dying earlier than people without this disorder.

Medications that have been found to be most effective in treating the positive symptoms of schizophrenia are first- and second-generation antipsychotics.

Psychosocial interventions for schizophrenia include education of family members, assertive community treatment, substance-abuse treatment, social-skills training, supported employment, cognitive behavioral therapy, and weight management.

Cognitive remediation, peer-to-peer treatment, and weight-management interventions remain the focus topics for research.

Depression

https://www.youtube.com/watch?v=eRXGwffy_90

Jeff Lewis


What is Depression

Depressed mood most of the day, particularly in the morning, and a loss of interest in normal activities and relationships -- symptoms that are present every day for at least 2 weeks used to diagnose other symptoms might include:

Fatigue or loss of energy almost every day Feelings of worthlessness or guilt almost every day Impaired concentration, indecisiveness Insomnia or hypersomnia (excessive sleeping) almost every day Markedly diminished interest or pleasure in almost all activities nearly

every day (called anhedonia, this symptom can be indicated by reports from significant others)

Restlessness or feeling slowed down Recurring thoughts of death or suicide Significant weight loss or gain (a change of more than 5% of body

weight in a month) Loss of Hope

What is Bi Polar Disorder

Depressive episode along with a episode of “mania”Three of the following must be present: Elevated expansive or irritable mood Increased energy accompanied by:

Poor sleepGrandiosityFlight of ideasDistractibilityPurposeless behaviorRisk taking (Sex, spending foolish investments)

What is Bi Polar Disorder

Person does not perceive a problem Speech can be rapid, difficult to follow and

impossible to interrupt Behavior more volatile There is impairment in social and occupational

functioning Rule out drugs as a cause.

Jeff Lewis


What does Bi Polar Look like?

https://www.youtube.com/watch?v=AhiU1m9UNs0

7:00 -10:00

Personality Disorders

Normal: Can pretty much function in environment independently

Abnormal: Typically emotionally unstable, self defeating or self destructive under stress

Differential Diagnosis

When a mood disorder or substance abuse is present, clinicians should make sure personality symptoms preceded these disorders.

Jeff Lewis


Other Common Disorders

Anti Social Personality Disorder is about power and control. This person has an intense need to stay in control and feel a sense of power. (Even when it is self defeating)

Aggression is more commonly associated with this disorder. The antisocial personality will manipulate, but not to gain

concern from caretakers

DSM-5 Does this sound familiar?

1) frantic efforts to avoid real or imagined abandonment2) a pattern of unstable and intense interpersonal relationships characterized by alternating

between extremes of idealization and devaluation

3) identity disturbance: markedly and persistently unstable self-image or sense of self

4) impulsiveness in at least two areas that are potentially life damaging

5) recurrent suicidal behavior, gestures, threats, or self-mutilating behavior

6) affective instability due to marked reactivity of mood

7) chronic feelings of emptiness

8) inappropriate intense anger or difficulty controlling anger

9) transient stress related paranoid ideation or severe dissociative symptoms

Borderline Personality Disorder

Jeff Lewis


DSM-5

A pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked by impulsivity beginning by early adulthood and present in a variety of contexts, as indicated by 5 (or more) of the nine items listed in DSM5:

Interpersonal Agenda

“There is a morbid fear of abandonment and a wish for protective nurturance, preferably received by constant physical proximity to the rescuer. The baseline position is friendly dependence on a nurturer, which becomes hostile control if the caregiver or lover fails to deliver enough (and there is never enough.) There is a belief that the caregiver secretly if not overtly likes dependency and neediness, and a vicious interject attacks the self if there are signs of happiness or success.” (Benjamin 2003)

Description

Affective instability

Reactivity, rage, idealization and devaluation Behavioral difficulties

Impulsive, self-destructive Cognitive problems

Preoccupation with loss and abandonment, psychosis and dissociation

Co morbidity

AODA, impulse control disorders, mood disorders, eating disorders, anxiety disorders

Jeff Lewis



Knowing this we should bear in mind with our responses

There may be a strong sense of urgencyWhat is urgent may not be importantWhat is important may not be urgentSlow downUse Others (peers, supervisors)They may be more objective in responding since they are not so closely involved


In other words…… There are reasons people act the way they do. It is not a well conceived plot to make everyone’s life chaotic

Bias and values What are your values? How do you cope with crisis? How do you react in a personal crisis? Do you

yell? remain quiet? Engage others? Become sarcastic?

What is your culture? Does race matter? What is your understanding of a family?

Jeff Lewis


Impairments vs. “Attitude”Brain Injury Association of Missouri

Our ATTITUDE ISSUE STRATEGYpoor motivation laziness

poor initiation of tasksfatigue

structure, routine schedule rest time

noncompliance poor listening

concentration and attention concerns

quiet, uncluttered environment

stubborn mental inflexibility predictable routinetransition time

unreasonable behavior

impaired reasoning structure, patience, diversion

trouble maker impaired judgment clear rules and expectations

Boundaries

People will consciously and unconsciously do what they can to get what they think they need.

This can convey a sense of entitlement

The sense of entitlement can lead staff to grant favors and cross boundaries that they normally would not.

Impulsivity may precipitate staff having to act immediately with phone calls, extended visits, etc.

The traumatic history may bring out rescue fantasies fed by the clients idealizing transference

“It’s all about them”How can we help “fix” this?

What are your perceptions and biases?

Jeff Lewis


Ok maybe it’s not all about them

How we describe clients, how we discuss cases reflect biases that can contribute to our own interactions with clients.

Strengths verses Deficits Which do you prefer? The basis for our work is relationships.

Mental Health Crisis

Assessment What do I do?

Jeff Lewis


Measure your response

First reactions are feeling before thinking Our reptilian brain functions dominate We want to take the time to address things on a

rational basis Time to think

Mental Health CrisisFirst order of business…..

The first contact is often from Law Enforcement They are a treasure of information and should be seen as an ally. Get collateral information (What when why how) Ask: Are you requesting authorization for a 51:15 Are you requesting consultation on this case? Where are you? What are the circumstances? Is the person able to participate in an assessment? (if not obtain

collateral)

Talk to the client

If the first contact is with the client you have more to learn….

Assessment/Intervention

Your assessment is also an intervention Ask questions “WHAT BRINGS YOU HERE TODAY” Ask questions about symptoms (Now that you

know about diagnosis and what could be) Ask about circumstance and current stress Use familiar language

Jeff Lewis


Assessment/Intervention

Think of the Frank Zappa Question

Steps of Assessment/Intervention

Define the Problem (Listen, validate) “Listen with your eyes” Ensure Safety Provide Support Examine Alternatives (What has worked) Make Plans Safety Plan Obtain Commitment

WHAT TO DOAssessment/Intervention options

Pose open ended questions Allow timeSet Limits (Person with mania)Terminate (abusive inappropriate)Switch (Divert attention focus on strengths)Slow Person Down (Angry, anxious person)Realistic Expectations (The problem won’t be solved

in 30 minutesAssess SafetySafety Plan

Jeff Lewis


Assessment/intervention can “slow the person down”

What is the precipitating event? (Non Directive (Rogerian) Collaborative (“We statements”) Be aware of the language style the person uses

Questions to ask yourself

What has worked before? WWYD? What would you do if you were in crisis?

How would you want the crisis staff to respond to you?

Behavior and coping is usually based on something even if it is not working

How to respond to certain behaviors

Jeff Lewis


Crisis Prevention Intervention model

Crisis Development Staff Response1. Anxiety Supportive2. Defensive Directive3. Acting-Out Physical

Response4. Tension Reduction Therapeutic

ReportCaraulia and Steiger: Nonviolent Crisis Intervention 1997

What if the person is Angry? Remain calm, model calm behavior Do not try to reason or argue with person Redirect attention to something they are interested in Remove person from situation, go to neutral ground Remove other people from area, if that seems better

Remove yourself if threatened Help person see anger coming: physical signs When calm, provide feedback on consequences

What is the person is withdrawn?

Make sure the individual has real choices Encourage and cue to Try varying modes of

stimulation: sights, sounds, smells Help individual establish and maintain relationships

with peers Give them time to answer

Jeff Lewis


What if the person can’t focus? Use eye contact, touch and verbal cues to get

attention Minimize distractions Work on one thing at a time

Things to remember

What is the basis for my reaction?

A outside person, supervisor, team can be more objective and help me problem solve

DON’T WORRY ALONE

How would I want to be treated?

Cookie?

One approach

Jeff Lewis


Transactional Analysis

TA is a theory of personality and a systematic for personal growth and personal change.

1. This is a description of how we communicate to each other

2. Parent3. Child 4. Adult

What about Suicide?

Is this acute verses persistent?

Getting the story

What about Suicide? DON’T WORRY ALONE (Seek consultation)

Columbia Suicide Severity Raring Scale http://cssrs.columbia.edu/scales_practice_cssrs.html

Jeff Lewis


CASE

Chronological Assessment Suicide Events http://socialworkpodcast.blogspot.com/2012/09/t

he-chronological-assessment-of-suicide.html

CASE

First step is to build rapport. Give the person your attention. Be interested in

the story.

CASE techniques

Gentle Assumption: You assume the person will have suicidal thoughts based on the trauma and what they describe they are dealing with

Normalization: You normalize the behavior: It is quite common for people who have struggled with anxiety to have thoughts of suicide do you?

Symptom amplification- This techniques is based on the evidence that shows that patients tend to minimize "bad behaviors" when asked about frequency or quantity. The therapist sets the upper limits to a frequency or quantity so high that even if the client downplays the amount, the therapist still knows there is a problem. An example might be to say to an adolescent " Would you say that you have attempted to kill yourself about forty times?"

Denial of the specific

Jeff Lewis


CASE techniques

Attenuate the Shame: “you know people who experience this much loss often have thoughts of ending it all. Has that been true for you? “

Behavioral Incident (Make a movie be a detective)

Look for risk factors

Current thinking about SuicideA suicidal person has his own logic

Suicidal thoughts have a purpose: Pain reliefHopelessnessAnxietyPresence of drugs /alcoholHistoryIntentAccess to means to suicide

Look for protective factors

Hope and plans for future Supports in place to assure safety No intention Religion or cultural connection that prohibits

suicide Connected to professional help (and willingness

to follow up

Jeff Lewis


Suicidal Clients

Document your reasoning and actions REMEMBER A CONTRACT FOR SAFTEY IS NOT

VALID. IT IS BEST TO NOT USE THIS LANGUAGE! Follow up! Close the loop, Do the hand off E.g Someone gets a wellness check document

your response and the result

Persistent Suicidal thinking

There is risk for traumatizing the patient. Counter transference “Why are you suicidal again?

Don’t look for Brady Bunch solutions 3rd heart attack example Use feelings as barometer Chronic Pain model

Questions to askWhen there is persistent Suicidal thinking

WHAT IS GOING ON TODAY? WHAT BRINGS YOU HERE?HOW LONG HAS THIS BEEN A PROBLEM?WHAT IS THE NATURE OF THE CRISIS?

Jeff Lewis


Documentation

Cases that are well documented will be much less likely to end up in court.

Write what you are thinking and why. Keep professional in your documentation.

Consult and document that as well.

Remember

You are allowed to make mistakes Our clients are allowed to make mistakes It is ok not to know We can not solve all the problems

Remember

You are probably helping more than you know Your client may be more resourceful than she

knows You do not have superpowers

Jeff Lewis


Resources

Dr David Mays “Personality Disorders handouts DSMV Brain Injury Association of Minnesota Brain Injury Association of Missouri CPI Institute Transactional Analysis in Psychotherapy. ISBN 0-

285-64776-8. Dr Shawn Shea “Psychiatric Interviewing”Columbia Suicide Severity Raring Scale http://cssrs.columbia.edu/scales_practice_cssrs.html

COUNSELING SKILLS SESSION 8 1 - UWSP 101.pdf · 2019-09-17 · Jeff Lewis COUNSELING SKILLS SESSION 8 3 What is Mental Illness A DISEASE PROCESS CHARACTERIZED BY IMPAIRMENTS IN THOUGHT

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