Profile of A Treatment Plan:: Early Stage Middle Stage Late Stage

Profile of a Treatment Plan:
Early Stage Middle Stage Late Stage

Rapport Active Stage of Change Goals Met?
Unit of Treatment Deal with Underlying Loss of Therapy
Collaborative Goals Themes and Dynamics Anticipate Future Problems
Symptom Reduction Collateral Resources Resources
Collateral Resources (Thematic) Open Door Policy
(Symptomatic)
Psychodynamic Therapy (Freud, Jung, Erikson, Framo, Sager):

Acronym:
D – Deficiencies in the Holding Environment Role of the Therapist:
U2 – Unresolved Past Issues / Unconscious - Neutral, non-reactive participant
R – Recapitulation of Past Issues in Present - “Blank slate” – allows client to project transferences onto
P – Projection and Projective Identification us
I – Introjection - Therapist serves as a container for strong feelings
S – Splitting
Timeframe: Past and the Present
General Concepts: Duration: Long Term
- Focus: Past’s influence on present, unconscious past Unit of Treatment: Individuals, Couples, Families
dynamics and the effect on present How Change Occurs: Insight and working through transference
- Emphasis on intrapsychic structure formed as a result of Termination Criteria:
relationships with primary caregivers (e.g. attachment) - Symptoms have been connected with a cause
- External holding environment becomes internalized by - Original conflicts have been worked through
client - Object relations have been improved
- Improve holding capacity and ability to self-soothe - Family’s holding capacity allows members’ needs to be
- Develop ability to distinguish past/present/fantasy/reality met satisfactorily. (Separation – Individuation)
Early Stage Goals: Early Stage Interventions:

- Provide a safe holding environment - Establish and model boundaries
- Establish therapeutic relationship - Use Empathic Listening
- Explore presenting problems and establish goals - Ask questions that clarify and amplify issues / begin to put
- Symptom reduction and reframe role of identified patient language to feelings
- Psychoeducate and normalize to promote symptom
reduction
Middle Stage Goals:
- Identify and interrupt dysfunctional patterns (e.g. Middle Stage Interventions:
projective identification) - Continued use of clarification and amplification
- Make unconscious dynamics conscious - Interpretation and linking the past to the present
- Explore and reframe defense mechanisms (e.g. splits, - Reframe the adaptive purpose of defense mechanisms
repression, etc) - Identify and educate about defenses
- Promote insight - Explore and interrupt the projective identification process
- Promote and emotionally corrective experience - Interpret and explore transferences and projections
- Help clients recognize and integrate split-off aspects of the - Identify and increase tolerance of split-off parts
personality - Continue psychoeducation when relevant
- Develop ability to distinguish between the past and - Use of objective countertransference (therapist aware of
present own feelings to aid in therapy)
- Increase the level of individuation and promote the
development of a cohesive self
Late Stage Goals: Late Stage Interventions:

- Symptoms have been connected with a cause - Interpret and explore recapitulated issues / loss of
- Client has become conscious of defense mechanism therapeutic relationship
- Transference of past issues to present relationships has - Review and consolidate self-soothing and other coping
been brought to awareness mechanisms
- Restructuring of object relations for each family member
- Family members act in an authentic and adaptive manner
- Work through termination issues – loss of the therapeutic
relationship
Existential Theory: (Gestalt – Client Centered) (Yalom, Frankl, May)

General Concepts: - Creating treatment stages objectifies the client by
- A person is free to choose behavior determining how the therapy “should” progress
- Life has no meaning other than what each person ascribes - Assessment is viewed as quantifying human existence
to it Role of the Therapist:
- Importance of awareness, genuine encounters - Non-directive
- Client must assume responsibility of one’s life - A Separate and Free Being
- “Neurotic anxiety” occurs when individual doesn’t accept - Uses Self with Client to Model Authentic Relating
responsibility - Not an Expert
- Human beings are whole and united entities. All parts of Timeframe: Here and Now (in the room)
self are available and present for interacting if one chooses Duration: Client determined
- Denial and repression are viewed as a choice not to know Unit of Treatment: Individuals, Couples Families
a truth (bad faith)
- Intentionality: the ways in which people create meaning How Change Occurs: Through Client’s Awareness
for themselves
- Project: one’s basic goals and aims in life Termination Criteria:
- Existential conflicts causing anxiety: death, isolation, - The Client is aware of his/her choices
freedom and meaninglessness - The Client is living “in the moment”
- Goals are defined by client, not therapist - The Client accepts anxiety as a basic human characteristic
- Satisfaction of needs is central
Early / Middle / Late Stage Goals:
- Develop therapeutic relationship as microcosm of other
healthy relationships
- Facilitate awareness of:
o One’s parts that are out of awareness
o One’s unique, subjective experience
- Facilitate client’s search for personal meaning and life
goals Treatment Interventions:
- No stages - Therapist’s Use of Self as person in response to the client
- Therapist’s role as Facilitator - Clarifying
- Affirm personal choices and responsibilities - Identifying
- Acceptance of anxiety as a basic human characteristic - Guiding
- Acceptance of responsibility - Exploration of client’s internal world
- Increase personal choice - Noting metacommunication (body language)
- Assume responsibility for and ownership of one’s life - Experimenting
o From “Victim” to “Chooser”
Reviewing Family Systems Concepts:

Nonsummativity – A system cannot be analyzed by isolated segments. The whole is greater than the sum of the parts.
Wholeness – There is interdependence between the parts of a system. Change in one person results in change in the
system.
Circular Causality – Each person is organizing and being organized by others in repeating feedback loops
Equifinality – Same results may spring from different origins
Triangulation – Two people under stress recruit a third person to lower anxiety
Homeostasis – A system’s balance point
Positive Feedback – Occurs when the system experiences a change of homeostasis
Negative Feedback – Occurs when the system reverts to homeostasis; there is no change in the system
Boundaries – Invisible barriers regulating contact with others
Subsystems – Alignments between family members based on generation, developmental tasks, etc
Unit of Treatment: Whole Family
- Take focus off of IP; symptoms belong to the system
- Focus is on the process; not the content
- No belief in linear causality
- Content not the concern
- Sequence of transactions = process “conflict detour mechanism”
Experiential (Satir) Theory:
Acronym: Timeframe: Here and Now; Honors past influences
Duration: Varies, more brief than psychodynamic
F - Feelings
R - Rules and Roles Dysfunctional Communication Stances:
G - Growth - Placator
S - Self Esteem - Computer
C - Communication - Blamer
- Distractor
General Concepts:
- Free choice and Conscious Self Determination Functional Communication Stance: Leveler
- Self-awareness leads to the ability to make decisions and Unit of Treatment: Entire family system preferred; will work with
take responsibility (“self actualizing”) individuals and couples
- Based on “Seed Model” – Innate self-actuating tendencies How Change Occurs:
need to be nourished for people to flourish - Individuals in the family become aware of feelings, faulty
- Premise: Faulty communication and/or inappropriate roles communication patterns, inappropriate roles, restrictive
and/or inappropriate rules and/or unrealistic expectations rules and/or unrealistic expectations and take
= Dysfunctional relationships responsibility to make new choices that maintain healthy
- Low self-esteem and defensive behavior result from relationships
dysfunctional family systems
- Growth is facilitated by intervening at the level of process Termination Criteria:
rather than content - Clients are aware of their choices / can express feelings
- (Content is superficial) - Partners operate as separate individuals
- Children are not drawn into the parents’ pain
Role of the Therapist: - Family adapts more easily to change
- Directive - Balance between sharing and autonomy
- Active/Educator - Family can communicate clearly and congruently
- Provides for new experiences by being a foreign element - Personality parts are integrated into a whole
in the system

- Make contact - Use congruent behavior and authenticity to establish
- Create alliance with part(s) that want to change contact with each family member
- Shift focus from IP to family system - Use circular questioning to facilitate a supportive
- Facilitate awareness environment
- Creation of systemic hypothesis (what do we see going in) - Ask the family about their therapeutic goals
- Ask questions to explore expectations, beliefs, yearnings,
and meanings
- (Yearning = experience of self actuating tendencies)
- Construct self-mandate to assess areas of strength and
challenge
- Note communication patterns, roles, rules, survival
stances, levels of self esteem
- Reframe / relabel the problem
- Family Life Chronology
- Family Sculpting (Person’s view)
- Self Mandalas – difference parts of self
Middle Stage Goals: Middle Stage Interventions:

- Unblock defenses - Model congruent (level) communication by using “I”
- Promote congruent communication, openness and statements, active listening
flexibility in the family - Discuss significant events in the family life chronology
- Enhance self-esteem, acceptance of self and others - Direct family members to speak for themselves
- Reflection is always good - Use a feelings chart and sentence stems
- Use a “temperature” reading to allow family members to
express feelings and aspirations
- Point out positive intentions (even when perceived bad or
is bad, the intention is good)
- Role play / Empty Chair
- “Parts Party” – to help family members see how their parts
interact with each other
- Anchor self-worth, maturation (separation, individuation, - Coach the practice of new behaviors
differentiation), and gains client has made - Sculpt new behavioral patterns and compare to old
- Affirm strengths sculptures
- Increase personal integrity and decrease dependence - Recount the new family life story (by therapist or family)
- Facility termination – closure - Discuss and compliment growth and change
- Identify new metaphors and names to describe new rules
and roles
- Imagery rehearsal of new relational dynamics
Multigenerational Family Systems (Bowen):

Acronym:
Role of the Therapist:
A - Anxiety - A coach, researcher of family functioning; neutral
S - Solid self / pseudo self - Healthy point of triangle / reduces emotional reactivity
T - Triangles Timeframe: Past’s influence on present functioning
O - Over / under functioning (relationship load uneven) Duration: Long Term
P - Projection Unit of Treatment: Initially the family, but will frequently
F - Fusion (interpersonal / intrapsychic – merging thoughts see just the couple. Will also work
and feelings) with the most differentiated family
E - Emotional Reactivity / Cut off / Knee-jerk member on an individual basis.
D - Differentiation
M - Multigenerational Patterns (history of family issues) How Change Occurs:
- Through insight into how the client’s current relationship
General Concepts: dynamics are impacted by family-of-origin
intergenerational processes
Differentiation: intrapsychic (separate thoughts from feelings) and
interpersonal (self and other; ability to hold beliefs and values Termination Criteria:
regardless of other’s emotional pressure) - Emotional reactivity has been reduced
Anxiety: the tension between the competing pulls of togetherness - Family members respond rather than react
and individuality creates emotional arousal and reactivity which - Conflicts are resolved without projection / triangulation
overwhelms the cognition system and leads to automatic, - Solid self (differentiated self) has been developed
thoughtless behavior - Person-to-person relationships are established
Pathology: seen as developing through generational patterns - Multi-generational transmission process is disrupted
Insight: into present relationship dynamics, relationship to family-of-
origin and intergenerational processes = key to change and required
for differentiation
- Form the therapeutic relationship - Maintain therapeutic neutrality
- Assess levels of differentiation and anxiety - Direct clients to talk to the therapist, not each other
- Reduce emotional reactivity and fusion - Educate about triangles
- Remove IP label - Educate regarding family life cycle tasks
- Define nature of problem and set goals - Use of Bibliotherapy and Cinema Therapy (displacement
techniques)
- Introduction to “I” statements and journaling
- Introduction to Genogram
- Identify sibling positions and their impact on current
family relationships

- Decrease anxiety - Ask process questions about the dynamics of the marital
- De-triangulate dyad
- Increase differentiation – development of Solid Self - Ask process questions about the extended family dynamics
- Use the Genogram to explore toxic patterns
- Teach anxiety management techniques such as deep
breathing techniques
- Coach regarding 1:1 relationships; detriangulation
- Role-Play differentiated positions (e.g. Empty Chair)
- Explain about the difference between thoughts and
feelings
- Promote autonomy with “I” statements
- Continuation of Bibliotherapy, Cinema Therapy, and
Journaling
- Discuss how family members see their role in family
conflict
- Homework to explore and establish ties with community
- Letter writing / Phone calls to Extended Family

- Resolve family-of-origin relationships - Assign visits to family of origin
- Highlight newly established differentiation and ability to - Coach members to maintain differentiated stance, a non-
balance individuality and togetherness anxious presence, and to avoid triangles and change-back
- Work through loss of therapy – related issues maneuvers
- (First order change – In the system) - Identify and discuss learning about Triangles, the family
- (Second order change – OF the system) Projection Process, and Anxiety
- Discuss and anticipate reactions to the loss of therapy
- Discuss and anticipate reactions to family life cycle
transitions
Strategic Family Systems (Haley):
Acronym: - Symptoms serve a function in the homeostasis of the
family system
P - Power - Goals are not collaborative; set by therapist to manipulate
C - Communication change
P - Paradoxical Interventions - Change occurs by carrying out therapist’s directives, not by
P - Presenting Problem insight
D - Directives - Interventions shift the family organization so presenting
problems no longer serve a function
• All about Power Dynamics - Therapy is concluded when presenting problem is resolved
- Symptoms keep a family in balance
General Concepts:
- Symptoms represent a power struggle in the relationship Role of the Therapist:
- Therapy focuses on communication and interactions that - Adaptive, Active, Directive
perpetuate problems - Determines the Direction of Treatment
- One cannot NOT communicate and all communications are Timeframe: Present – No History Taking
multi-layered Unit of Treatment: Whole Family
- Difficulties occur when stressors converge and overwhelm
family’s coping mechanism How Change Occurs:
- Family systems resist change and fight to maintain - By family carrying out therapist’s directives
homeostasis
o Developmental Stressor Termination Criteria:
o Situational Stressor - Presenting problem has been resolved
- Power struggle among family members no longer serves a
purpose

- Join the family - Observe family dynamics and communication patterns
- Identify the problem - Assume a leadership role with the family
- Reframe symptom as belonging to the system - Use circular questioning to get a specific behavioral picture
- Explore interpersonal payoff of problem behavior of the problem
- Plan strategy for solving the presenting problem - Reframe / Relabel dysfunctional behavior
- Explore solutions previously tried

- Produce change within the family system - Comment on family’s attempt to control therapist and
- Prevent repetition of dysfunctional patterns so the each other
presenting problem no longer serves a function - Move between coalitions
- Move the family to a more adaptive homeostatic level - Emphasize the positives (Relabel dysfunctional behavior)
- Facilitate improved family communication - Use directives, both compliance-based and paradoxical:
- Help family to next stage of family life cycle Positioning Strategy, Pretend Technique, Restraining
Strategy, Metaphorical Tasks, Prescribing Ordeals
- Create a new problem and have the family solve it in a way
that will lead to the solution of the presenting problem
- Teach communication skills, e.g. “I” statements; speak to,
not about each other

- Once problem is resolved, treatment is terminated - Emphasize gains
- Power struggle among family members no longer needed - Identify system changes; anticipate problems
Structural Family Systems (Minuchin):
Role of the Therapist:
General Concepts: - Stage director; observer; educator
- Symptoms are the result of dysfunctional role assignments - Active in making interventions to uncover & modify
and overly rigid or overly diffuse boundaries underlying structure of family
- The focus is change in the family structure, not the
presenting problem Timeframe: Here and now
- Dysfunctional families lack alternatives resulting from Duration: Short term
inflexible family structure Unit of Treatment: Whole Family
- Action-oriented, not insight-oriented
- Healthy subsystems are free of interference from other How Change Occurs:
subsystems - Through Restructuring and Realigning the Hierarchy
- Attention paid to cultural considerations and family
metaphors Termination Criteria:
- Focuses on family life cycle adjustments - Presenting problem is resolved
- Family system restructured to allow problem-solving
- Family has skills to resolve future conflicts

- Form therapeutic subsystem (Joining) - Joining, accommodating, mimesis
- Assess boundaries, alliances, coalitions - Confirmation and empathy
- Symptom reduction - Reframe Problem as family problem
- Relabel the presenting problem and reframe the family’s - Enactments: e.g. draw picture of family – shows power
view of it distribution
- Remove the IP label - Tracking
- Set goals - Family Mapping: look for alliances and splits

- Change underlying family structure and patterns that - Re-enactment
maintain symptoms - Manipulate intensity – e.g. repetition of themes, blocking
- Strengthen boundaries between subsystems or encouraging interactions, modulating voice
- Restructure: boundaries, hierarchy, alignments - Boundary making – e.g. changing the placement of people
- Create a cohesive executive subsystem in the room
- Educate about development issues - Paradoxical interventions – if clients aren’t compliant – do
more of what doesn’t
- Unbalance the system – e.g. support “one down” person
- Teach conflict resolution skills (communication skills,
parenting skills)
- Psychoeducation – regarding family patterns and
developmental issues
- Shaping competence – by highlighting strengths and
progress

- Consolidate Gains - Highlight therapeutic progress
- Mark structural alterations
- Emphasize strengths
- Discontinue sessions digressively
Cognitive Theory (Beck, Meichenbaum, Ellis):
Acronym: Automatic thoughts –immediate, situation-specific
S - Systematic bias (error in processing information, lenses cognitions (instant reaction)
distorted, selective attending to negative, discounting the Underlying assumption – cross-situational belief
positive) Schemas (core beliefs) – beliefs formed
U - Underlying assumptions early in childhood
C - Cognitive distortions (errors in evaluating information,
overgeneralization, black/white thinking) Cognitive Distortions:
S - Schema (belief of world) (refers to the Cognitive Triad of - Cognitive Distortions are errors in information evaluation
self, world, future) - Selective Abstraction: taking a detail out of context,
missing the significance of the total situation
General Concepts: - Catastrophizing: anticipation of unfavorable outcomes
- Self-defeating ideas are learned and can be unlearned - Arbitrary Inference: jumping to a conclusion without
- Thoughts and beliefs determine affect and behavior evidence to support it
- Dysfunctional beliefs about events – not the events – are - Labeling: extreme form of overgeneralization
the basis of emotionally charged consequences - Polarized Thinking: thinking in extremes with events
- Cognitive triad – beliefs about self, world, future labeled as “good” or “bad”
- Systematic bias – error in information processing - Disqualifying the Positive: rejecting positive experiences
- Overgeneralizations: an unjustified generalization based
on a single incident
- Personalization: a person seeing him or herself as the
cause of a negative external event when this isn’t so
Role of the Therapist: Active collaborator; trainer/educator; Termination Criteria:

directive - Dysfunctional thought patterns impacting
Timeframe: Present and Future emotional/behavioral disturbances have been recognized
Duration: 12 – 16 week model with Booster session and corrected
Unit of Treatment: Individuals, Couples, Families - New cognitive and behavioral patterns which are more
How Change Occurs: By altering dysfunctional thought patterns adaptive have been established
- Clients demonstrate flexibility, self-acceptance, and
responsibility for own life

- Form a collaborative therapeutic relationship - Conduct a structured interview to clarify problem
- Set collaborative goals - Create a problem list
- Symptom reduction - Develop a therapeutic contract of goals and
- Socialize to the cognitive model responsibilities
- Ask clients to chart and track problem behavior
- Teach relaxation; develop action plan, e.g. activity
schedule
- Activate collateral resources
- Explain theoretical model, teach automatic thought record
Middle Stage Goals:

- Establish more balanced ways of thinking Middle Stage Interventions:
- Correct faulty cognitions - Use automatic thought record and downward arrow
- Improve communication skills technique to facilitate the guided discovery of underlying
- Evaluate underlying assumptions and schemas assumptions and schema
- Teach thought stopping and other diversion techniques
- Teach communication skills (“I” statements, role playing)
- Assign homework, e.g. journaling, automatic thought
records, Bibliotherapy, etc
- Shape desired behavior by identifying positive and
negative behavioral reinforcers in the family
- Systematic desensitization
- Negotiate quid pro quo and contingency contracts
- Specific discernable acts
- Downward arrow – auto thoughts to schema
- Evaluate therapeutic progress - Review the problem list
- Strategize to prevent symptom reoccurrence - Highlight therapeutic gains
- Cognitive rehearsal: anticipate future obstacles and
rehearse ways to cope with them
- Identify behavioral reinforcers likely to maintain changes
- Establish booster session schedule
Narrative Therapy (White, Epston):

Acronym:
I - Invitations of the problem Role of the Therapist:
S - Separate the person from the problem - Takes a NOT KNOWING stance
E - Externalizing the problem - The therapist is NOT the expert
E - Exceptions to the problem - Therapist asks questions to elicit client resources
D - Deconstruction of the problem Timeframe: Present
U - Unique outcomes Duration: Therapy is usually short term
R - Re-Authoring Unit of Treatment: Individuals, Couples, Families
C - Circulation of the new story
How Change Occurs:
General Concepts: - Through externalization and deconstruction, the client is
- Realities are socially constructed empowered to develop alternative stories that include
- Experience is shaped by language new options/strategies for living
- Reality lends itself to multiple interpretations (e.g. stage
fright vs. anticipation) Termination Criteria:
- There are no absolute truths or one universally accurate - The problem is no longer a problem
description of people or problems - The client has re-authored a preferred story
- Focus is on client resources and not on problem saturated - Client as accessed resources, allowing him/her to reinforce
stories the new story
Early Stage Goals:

- Establish collaborative relationship and goals Early Stage Interventions:
- Create openings for the client’s story to be told - Ask permission to pursue sensitive lines of questioning
- Map the effects and history of the problem - Ask questions that personify the problem
- Map family members’ influence on the problem - Ask questions to learn about client apart from the problem
- Identify factors that support the problem - Ask how the problem invites the client’s participation
- Begin separating the client from the problem - Utilize externalizing language
- Deconstruct context in which problem occurs - Note unique outcomes and exceptions to the problem
- Help clients develop a new relationship to the problem - Explore the client’s internal resources and strengths
- Locate and thicken alternative story or narrative - Ask questions to elicit preferred selves and stories
- Help client to uncover competencies and self-knowledge - Ask externalizing questions
- Ask deconstruction questions
- Facilitate re-authoring of the client’s new narrative
- Assess client’s week to week progress

- Reinforce the client’s new story - Recruit problem fighters and a community of concern
- Circulate client’s new, alternate, or preferred story - Encourage letter writing to circulate the new story
- Extend the new story into the future - Ask questions to extend the story into the future
- Process the end of therapy - Identify rituals and traditions that support the new story
- Celebrations and certificates to thicken the alternative
story
Solution-Focused Therapy (DeShazer, Berg):
Acronym:
R - Resources Within
E - Expert
S - Solution Talk
S - Small Steps Lead to Bigger Steps Role of the Therapist:
D - Different Interventions - Collaborative, cheerleader of the belief that the
client has the wisdom, power and agency
General Concepts: Timeframe: Present and Future
- Cause of the problem is not important to dissolving the Duration: Usually Brief
problem Unit of Treatment: Whoever attends the therapy session is the
- Client is the expert on his or her own life “customer”
- Client has already existing strengths and abilities; strength-
based How Change Occurs:
- “There are no resistant clients, only inflexible therapists” - Client learns to access inner resources
- Small changes leads to larger changes (snowball effect) - Only small change is necessary
- Central Philosophy:
o If it’s not broken, don’t fix it Termination Criteria:
o If it’s working, do more of it - Client is effectively accessing his or her resources
o If it’s not working, do something different
Early Stage Goals:
- Determine if the client is a customer Early Stage Interventions:
- Elicit client goals / description of complaint - Ask “What’s changed since you made the appointment?”
- Introduction and explanation of the therapy process - Miracle Question to set goals and establish future
- Formation of a solution orientation
- Establish therapist’s role as helper, cheerleader - Describe the philosophy and procedures of the model
Middle Stage Goals:

Middle Stage Interventions:
- Elicit client strengths - Coping questions to elicit strengths
- Facilitate and encourage solution talk - Scaling questions to notice what’s working
- Encourage what is working - Scaling questions to facilitate solution talk
- Promote ideas to replace what isn’t working - Relationship questions to promote “something different”
- Compliments
- Assign noticing tasks
- Assign homework to do more of same or to do something
different

- Notice and reinforce accomplishments and new skills - Compliments and encouragement
- Questions about how client would know when to come
back to therapy
- Questions about how client would know how to solve
future problems
ISSUE GOAL INTERVENTION LANGUAGE
Grief and Loss Facilitate Grieving Process Educate
re DABDA Process
Listen; Letter to Deceased
Acting Out Child Increase Effective Parenting Educate
Teach Parenting Skills
Review Natural and Logical
Substance Abuse Promote Sobriety Link Past to Present
Explore Triggers
Teach Alternative Coping Skills
Divorce Clarify Post-Divorce Relationship Explore Rules and Roles
Reverse Role Play
Explore Areas of Commonality
Differing Expectations and/or
Conflicted Values (Be Specific) Negotiate Differences Explore Rules and Roles
Family of Origin Patterns
Teach Communication Skills
Move from Blame to Problem
Solving
Poorly Integrated Blended Family Promote Integration Explore Rules and Roles
Teach Communication
Discuss Conflicting Loyalties

Discrimination Rally Internal Strength and External
Support Process Assumptions
Affirmations
Abusive Family System Increase Impulse Control Teach Cycle of Violence
Bolster Self-Esteem Explore Triggers
Abused: Teach Boundary Setting
Abuser: Timeouts
Difficulty with Life Cycle Transition
(Be Specific) (e.g. Intimacy vs.
Isolation) Facilitate Development Transition Depends on the Development Stage
Current Trauma Re-Activating Past
Trauma Promote Insight Link Past to Present
Reflective Listening
Clarification
Coping with Issues of Being Gay or Facilitate Self Acceptance and
Lesbian Acceptance with Family Explore Internalized Homophobia
Identify Positive Role Models
Discuss "Coming Out" Process
Gay and Lesbian Support Groups
Achieve a Desired Balance Between
Acculturation Difficulties the New Culture and the Culture of
Origin Educate about Acculturation
Process
Referral in (TYPE) Community
Identify Cultural Values
Generational Role Reversal
(Surrogate Spouse) Establish Appropriate Hierarchy Educate About Family Roles
Educate About Developmental Needs

Role-playing Exercise
Survival Guilt Facilitate Grieving Process Explain About Survivor Guilt
Normalize Feelings
Responsibility Pie
Bereavement Group
Distorted Body Image Promote Healthy Relationship With

Body; Increase Self-Esteem Emphasize Other Aspects of Identity
Explore Legitimate Express of Power

Mirroring
Weak Parental Subsystem Strength Parental Subsystem Teach and Model Parenting Skills

Low Self-Esteem Bolster Self-Esteem Identify Strengths
Reflective Listening
Empathy
Family Dealing with Chronic or
Terminal Medical Condition, Or
Mental Illness Promote Healthy Adjustment Family Meeting
Process Expectations of Self and Others
Educate About Changing Roles and Process Losses
Support Group for Caregiver and Those Affected

Coping with Special Needs Child Promote Adjustment Educate
Teach Skills
Explore Expectations
Referral: Regional Center
Trauma (e.g. Rape) Promote Adjustment Educate about Trauma Reactions
Teach
Explore
Process
Denial
Increase Awareness and Insight Encourage Personal Responsibility
Cost / Benefit Analysis
Confrontation
Loss of Autonomy Promote Self-Acceptance Identify Existing Independence
Process Issues of Loss (DABDA)
Model Positive Statements
Explore Changing Identity
Overwhelmed Single Parent Effectively Manage Parental

Responsibilities Teach Parental Skills
Activate Support System
Explore How They Were Parented
Convergence of a Situational
Stressor (e.g. - Job Loss) On Top of
a Development Transition (e.g.
Launching) Promote Healthy Coping Teach Stress Management
Educate (re: Development)
Situational Stressors
Support Group

Family Secrecy Promote Clear and Distinct
Communication Teach "I" Statements
Active Listening
Block Conflict Avoidance
Explore Underlying Process
Normalize Feelings
Betrayal of Trust Process the Betrayal Validate Experience
"I" Statements
Letter Writing
Empty Chair Technique
Inappropriate Sexual Boundaries
within Family Establish Clear Boundaries Teach Appropriate Touch
Developmental Education
Raise Parental Supervision
Set Clear Boundaries
Family Proximity Issues:
Estrangement / Disengagement Increase Contact Create Caring Lists
Block Conflict Avoidance
Family Proximity Issues: Over-
Involvement / Enmeshment Set Clear Boundaries "I" Statements
Stop Interruptions
Process Past Control Issues
Crisis Issues
- Crisis issues are those which impact the safety, functioning
and/or well-being of the client.
- They must be addressed first either because:
o Treatment cannot reasonably proceed until Mandates:
safety is assured or the crisis issue has been
- Child Abuse
stabilized
o PU2NS
o Treatment cannot proceed until legal duties Physical Abuse
(mandates) have been discharged Unlawful Corporal Punishment
Unjustified punishment or willful
cruelty
Neglect
M - Mandates Sexual Abuse
- Child Abuse
- Dependent Adult / Elder Abuse - Elder / Dependence Adult Abuse
D - Duty to Warn (Tarasoff) and Danger to Others o PAINFA
S - Spousal Abuse / Domestic Violence Physical Abuse
P - Physical Crises Abandonment
A - Alcohol or Substance Abuse / Dependence Isolation
A - Anxiety Neglect
D - Depression Financial abuse
S - Suicide Abduction
Tarasoff: Duty to Warn Spousal Abuse / Domestic Violence:
- You have a Tarasoff Duty to Warn when: Indicators:

o Your client (or another person in relationship to - Marks and bruises
this client) - Anger and hostility, high level of conflict
o Communicates to you - Startle response around spouse
o Your client’s serious, imminent intent - Cycle of violence
o To do physical violence - Power imbalance in the relationship
o To a reasonably identifiable other - Substance use increases the risk
- D.V. families are often isolated
- If you believe that your client is dangerous to another,
regardless of whether your client has communicated to Physical Factors:
you an intent to physically harm the person, you have a - Untreated physical symptoms, ailments or conditions
Tarasoff Duty to Warn - May be a presenting problem or otherwise obvious issue:
o Headaches, bruises, cuts, welts, or other injuries
Danger to Others: o Feeling faint, dizzy, glassy-eyed, stomach ache,
etc
- If a client is dangerous to others in general, you have the - May be inferred or underlying:
right to break confidentiality to prevent harm to the other o Effects of substance abuse, ailments related to
in accordance with Evidence Code 1024 an eating disorder, STDs or HIV
Alcohol or Substance Abuse / Dependence:
Drug or alcohol use resulting in:

- Slurred speech, lack of coordination
- Hand tremors, unsteady gait
- Sweating
- Impairment in attention or memory
- Relationship or legal problems
- Impaired social or occupational functioning
Signs of Anxiety:
Suicidal Indicators:
- Feelings of hopelessness, helplessness, despair
T - Tension - Suicidal ideation, plan, means
J - Jitteriness - Loss of a relationship
S - Sweaty palms, sleep disturbance - Anniversary of a traumatic event
D - Difficulty breathing - Putting affairs in order
L - Light headedness - Giving away prized possessions
I - Increased heart rate (tachycardia) - Shift in behavior or mood
F - Flushed cheeks - Period of potential increased risk when depression lifts
- Impaired social or occupational functioning

- Fear of leaving the house (agoraphobia)
Psychosocial Stressors and Environmental Problems:
Depression: - “A psychosocial or environmental problem may be a
negative life event, an environmental difficulty or
L - Libido (low) deficiency, a familial or other interpersonal stress, an
A - Appetite inadequacy of social support or personal resources, or
A - Ahedonia (lack of pleasure) other problem relating to the context in which a person’s
C - Concentration difficulties have developed.” (DSM-IV-TR)
E - Energy - “In general, the clinician should note only those
S - Sleep psychosocial and environmental problems that have been
S - Self-worthlessness present during the year preceding the current evaluation.
S - Suicidal thoughts The clinician may choose to note psychosocial and
S - Social / occupational functioning environmental problems occurring prior to the previous
year if these clearly contribute to the mental disorder or
(Vegetative signs of depression) have become the focus of treatment.” (DSM-IV-TR)
Psychosocial Stressors:
Social Stressors include:
F - Problems with primary support group (Family) - Death or loss of friend
S - Problems related to Social environment - Inadequate social support
O - Occupational / Educational - Living alone
$ - Economic Problems - Difficulty with Acculturation
H2 - Health care access / Housing problems - Discrimination
L - Problems related to Legal system / crime - Adjustment to life-cycle transition (such as retirement)
O - Other psychosocial problems
Occupational problems include:
Family Stressors include: - Unemployment
- Death of a family member - Threat of job loss
- Health problems - Stressful work schedule
- Separation, divorce, estrangement - Difficult work conditions
- Removal from the home - Job dissatisfaction
- Remarriage of parent - Job change
- Neglect, sexual or physical abuse - Discord with boss or co-workers
- Parental overprotection
- Inadequate discipline Educational problems include:
- Discord with siblings - Illiteracy
- Birth of sibling - Academic problems
- Discord with teachers or classmates
Health care problems include: - Inadequate school environment
- Inadequate health care services
- Lack of transportation to health facilities Economic problems include:
- Inadequate health insurance - Extreme poverty
- Inadequate finances
- Insufficient welfare support
Housing problems include: (Beck Depression Inventory)
- Homelessness (Burns Anxiety Scale)
- Inadequate housing
- Unsafe neighborhood Managing a Stressor:
- Discord with neighbors or landlord
N - Normalize, contextualize, reframe
Legal / Crime problems include: F - Process Feelings
- Arrest S - Elicit Strengths
- Incarceration S - Teach Skills
- Litigation C - Collateral resources / referrals / support group
- Victim of crime A - Develop (collaborate on) an Action plan
- Parole or probation M - Break the action plan down into Manageable parts
(clearly defined objectives)
Other psychosocial / environmental problems include:
- Exposure to disasters, war or other hostilities Human Diversity Issues:
- Exposure to traumatic events
- Discord with non-family caregivers such as counselor, S - Socioeconomic, class, education
social worker, or physician C - Culture, race, ethnicity, national origin
- Unavailability of social service agencies A - Age, developmental stage
G - Gender, sexual orientation
ASSESSMENT: S - Spirituality, religion
O - Other (disability or physical difference, circumstantial –
Q - Questions the lived experience, occupational, etc)
R - Releases
M - Mental Status Exam - How might behaviors and symptoms in the vignette
O - Observation translate into diagnoses?
T - Tests - Look for words that point to DSM-IV-TR disorder
H - History categories (mood disorders, anxiety disorders, eating
S - Strengths disorders, etc) or specific diagnoses
ASPERGER’S DISORDER:
Impairment in social interactions, and repetitive, stereotyped ENURESIS:
behaviors and interests Voiding of urine into bed or clothes, involuntary or
intentional, at least 2 times a week for at least 3 month OR
ATTENTION-DEFICIT / HYPERACTIVITY DISORDER: causing clinically significant distress. Onset: 5 years or mental
Symptoms of inattention and/or hyperactivity before age 7, age of 5 years
for at least 6 months, in 2 or more settings - Primary: never had control of bladder
- Secondary: develops after period of urinary continence
CONDUCT DISORDER:
3 or more anti-social acts (lying, fire setting, stealing, truancy) SEPARATION ANXIETY DISORDER:
within 1 year; 1 of those acts occurs within the last 6 months Persistent and excessive worry about being separated from
major attachment figures. Must persist for at least 4 weeks.
OPPOSITIONAL DEFIANT DISORDER: (“Failure to thrive”)
Negativistic, hostile and defiant behavior, lasts at least 6
months, becomes evident before age 8, and not later than REACTIVE ATTACHMENT DISORDER OF INFANCY OR
early adolescence CHILDHOOD:
Bonding failure often associated with multiple early
ENCOPRESIS: caregivers or disruption in caretaking. Onset: Begins before
Repeated passage of feces in clothing or on floor, involuntary age 5
or intentional, at least once a month for at least 3 months. - Disinhibited Type: Diffuse and indiscriminate sociability and
Onset: 4 years or a mental age of 4 years. attachments with a lack of selectivity
- Primary: never had control of bowels - Inhibited Type: Failure to initiate or respond to social
- Secondary: develops after a period of fecal continence interactions
DELIRIUM:
Disturbance of consciousness, change in cognition, impaired
recent memory, disorientation, language disturbance, SUBSTANCE ABUSE:
presence of illusions and hallucinations. Occurs usually in the Only requires 1 symptom – does not meet the criteria for
elderly or very young children. May resolve in hours or Substance Dependence; no tolerance or withdrawal; no
persist for weeks. desire to quit (a DUI can occur)
DEMENTIA: PSYCHOTIC DISORDERS:

Multiple cognitive deficits, coded based on etiology (e.g. Psychotic refers to loss of boundaries or gross impairment in
Alzheimer’s Type, Due to Head Injury, HIV, TB, Cancer, etc). reality testing Involves bizarre delusions or hallucinations
Usually occurs among the elderly. Onset is gradual. Course Involves disorganized speech, thought and behavior
can be progressive, static or remitting.
SCHIZOPHRENIA:
SUBSTANCE DEPENDENCE: Two or more of the following symptoms: Delusions,
3 or more of the following symptoms within a 12 month hallucinations, disorganized speech, grossly disorganized or
period: catatonic behavior, affect flattening, alogia, avolition. If
- Tolerance delusions are bizarre or auditory hallucinations are chronic,
- Withdrawal the diagnosis is met.
- Use of larger amounts or over a longer time than intended - Brief Psychotic Disorder: 1 day to 1 month (only 1 symptom
- Persistent desire but unsuccessful attempts to quit necessary)
- Much time spent in obtaining the substance or recovering - Schizophreniform Disorder: 1 month to 6 months
from its use - Schizophrenia: more than 6 months
- Social, occupational, or recreational activities are given up
SCHIZOAFFECTIVE DISORDER:
Delusions, hallucinations, disorganized speech, grossly BIPOLAR II DISORDER:
disorganized or catatonic behavior PLUS a Major Depressive, At least 1 Hypomanic Episode (lasting at least 4 days) PLUS
Manic or Mixed Episode. Delusions or hallucinations are the presence or history of 1 or more Major Depressive
present for at least 2 weeks in the absence of prominent Episodes
mood symptoms
PANIC DISORDER WITHOUT AGORAPHOBIA:
DELUSIONAL DISORDER: Recurrent, unexpected Panic Attacks
Non-bizarre delusions. No history of bizarre delusions,
hallucinations, disorganized speech and behavior. Apart from PANIC DISORDER WITH AGORAPHOBIA:
delusions, functioning and behavior are not impaired. At Recurrent, unexpected Panic Attacks AND the presence of
least 1 month duration. Agoraphobia
MAJOR DEPRESSIVE DISORDER: OBSESSIVE-COMPULSIVE DISORDER:

5 or more depressive symptoms for at least 2 weeks, (in For at least 1 hour per day a person experiences Obsessions
children and adolescents, the mood can be irritable) (intrusive thoughts) and/or Compulsions (ritualistic
behaviors)
DYSTHYMIC DISORDER:
Less severe depressive symptoms than in Major Depressive PTSD / ACUTE STRESS DISORDER:
Disorder, which have been present for at least 2 years Following exposure to a traumatic / life threatening event,
(adults) or 1 year (children, adolescents) person experiences intrusive recollections, startle response,
hypervigilance,
BIPOLAR I DISORDER: nightmares
At least 1 manic or mixed episode (lasting at least 1 week); - Acute Stress Disorder = 2 days to 4 weeks
with or without a history of depressive episodes - PTSD = 1 month or longer (can be years after the events)
GENERALIZED ANXIETY DISORDER: PERSONALITY DISORDERS (AXIS II):

At least 6 months of excessive anxiety and worry about a -All involve an enduring, persisting pattern of disturbance or
number of events. 3 or more symptoms for Adults, 1 or more inner experience and behavior that deviates markedly from
for Children cultural expectations
ANOREXIA NERVOSA: Antisocial Personality Disorder:

Body weight less than 85% of what is expected; Amenorrhea A pervasive pattern of disregard for and violations of the
– absence of at least 3 consecutive periods rights of others, occurring since the age of 15. Lying,
- Restricted Type: no binging or purging aggressiveness, fights, assaults and a lack of remorse. Person
- Binge-Eating / Purging Type must be at least 18.
BULIMIA NERVOSA: Borderline Personality Disorder:

Recurrent episodes of Binge Eating (2 times / week for 3 Unstable and intense relationships with alternation between
months) coupled with inappropriate compensatory behavior extremes of idealization and devaluation; fear of
to prevent weight gain abandonment; unstable sense of self with feelings of
abandonment; unstable sense of self with feelings of
ADJUSTMENT DISORDERS: emptiness; inappropriate, intense anger or difficulty
Development of symptoms in excess of what would be controlling anger; suicide threats.
expected in response to a stressor. Occurs within 3 months
of the stressor; once stressor has terminated, the symptoms Histrionic Personality Disorder:
do not persist for more than 6 additional months. (May be Interactiosn characterized by inappropriate, sexually
diagnosed “Chronic” if symptoms occur in response to a seductive behavior; exaggerated expression of shallow
chronic stressor) emotions; attention attracting behavior and appearance.
Schizoid Personality Disorder: Obsessive-Compulsive Personality Disorder:
Detachment from social relationships and a restricted range Preoccupation with orderliness, perfectionism, and control;
of expression of emotions in interpersonal settings; chooses prone to repetition, and excessive attention to detail and
solitary activities; little if any interest in sexual experiences checking for mistakes; oblivious to the impact of their
with another person; appears indifferent to praise or criticism behavior on others. (Ego-syntonic)
from others. (Ego-syntonic)
Narcissistic Personality Disorder:
Dependent Personality Disorder: A pervasive and pattern of grandiosity, need for admiration,
A pervasive and excessive need to be taken care of that leads and lack of empathy; boastful and pretentious
to submissive and clinging behavior and fears of separation;
difficulty making everyday decisions; difficulty expressing Avoidant Personality Disorder:
disagreement; passivity in relationships Pervasive pattern of social inhibition, feelings of inadequacy,
and hypersensitivity to negative evaluation; avoidance of
activities that involve significant interpersonal contact for
fear of criticism, disapproval, or rejection. (Ego dystonic)
V-CODES: RELATIONAL PROBLEMS:
Patterns of interaction associated with clinically significant impairment in functioning If they are not the focus of clinical attention,
they should be listed on Axis IV
- Relational Problem Related to a General Medical Condition or Mental Disorder

- Parent-Child Relational Problem
- Partner Relational Problem
- Sibling Relational Problem
- Relational Problem NOS
V-Code applies if the FOCUS of attention is on the PERPETRATOR or the abuse or neglect or on the relational unit in which it occurs
The VICTIM of abuse or neglect is coded 995.5 if a Child, 995.81 if an Adult
Problems Related to Abuse or Neglect:
- Physical Abuse of Child

- Sexual Abuse of Child
- Neglect of Child
- Physical Abuse of Adult
- Sexual Abuse of Adult
Additional conditions - focus of clinical attention:
- Noncompliance with Treatment

- Malingering (making oneself sick for money)
- Adult Antisocial Behavior
- Child or Adolescent Antisocial Behavior
- Age-Related Cognitive Decline
- Bereavement
- Academic Problem
- Occupational Problem
- Identity Problem
- Acculturation Problem
- Phase of Life Problem
DSM-IV
MULTI-AXIAL SYSTEM:
Axis I:
- Clinical Disorders
- Other conditions that may be the focus of clinical attention
(V-Codes)
Axis II:
- Personality Disorders
- Mental Retardation Axis IV:
- Borderline Intellectual Functioning - Psychosocial and Environmental Problems
o This is the only V-Code to be coded on Axis II o As many psychosocial stressors as are present
should be noted on Axis IV
Axis III: o When a psychosocial stressor is the primary
- General Medical Conditions focus of clinical attention, it should be recorded
o Medical conditions potentially relevant to the on Axis I
understanding or management of an individual’s Axis V:
mental disorder - Global Assessment of Functioning (GAF Scale)
o A general medical condition directly causing a o 51-100: Ranging from moderate symptoms to
mental disorder is coded on Axis I (e.g. “Mood superior functioning
Disorder Due to Hypothyroidism, With o 1 – 50: Ranging from persistent danger to self or
Depressive Features”) and Axis III others to serious symptoms
(“Hypothyroidism”)
ASPERGER’S DISORDER: Key Descriptive Words:

- Restless
Criteria: Impairment in social interactions, and repetitive, - Fidgety
stereotyped behaviors and interests - Easily distracted
- Talks a lot
Key Descriptive Words: - Interrupts
- Obsession with certain topics (trains, cars, games) - Can’t sit still
- Engages in repetitive behaviors – lines objects and knocks - Doesn’t finish things
them down
- Flaps hands Differential diagnosis: Environmental, ODD, social skills
- Bangs head deficit related to Autistic Disorder / Asperger’s
- Difficulty socializing with peers
- Lack age-appropriate social skills CONDUCT DISORDER:
Differential diagnosis: In Asperger’s, there is no impairment Criteria: 3 or more anti-social acts (lying, fire setting, stealing,
in the development of language and cognition. In Autistic Disorder, truancy) within 1 year; 1 of those acts occurs within the last 6
there is impairment in both. months
ATTENTION-DEFICIT / HYPERACTIVITY DISORDER: Key Descriptive Words:

- Sets fires
Criteria: Symptoms of inattention and/or hyperactivity before age - Hurts animals
7, for at least 6 months, in 2 or more settings - Doesn’t care about consequences
- In trouble with the law
- Gets in fights
- Lacks empathy
- Bullies
- Truant
Differential Diagnosis: ODD, Substance Abuse

OPPOSITIONAL DEFIANT DISORDER: Key Descriptive Words:
- Frequent accidents
Criteria: Negativistic, hostile and defiant behavior, lasts at least 6 - Parents thought child had grown out of this
months, becomes evident before age 8, and not later than early - Embarrassment / shame
adolescence - Avoids sleepovers
Key Descriptive Words: Differential Diagnosis: Organic Cause (refer to physician),

- Argues with authority highly correlated with sexual abuse and marital discord,
- Pesters Oppositional Defiant Disorder traits
- Defiant
- Talks back ENURESIS:
- Flies off the handle
- Annoying Criteria: Voiding of urine into bed or clothes, involuntary or
- Bratty intentional, at least 2 times a week for at least 3 month OR causing
clinically significant distress. Onset: 5 years or mental age of 5 years
Differential Diagnosis: Parent-Child Relational Problem, - Primary: never had control of bladder
Conduct Disorder, AD/HD, Learning Disability, Autistic Disorder, - Secondary: develops after period of urinary continence
Asperger’s
Key Descriptive Words:
ENCOPRESIS: - Frequent accidents
- New baby in the house
Criteria: Repeated passage of feces in clothing or on floor, - Parents thought child had grown out of this
involuntary or intentional, at least once a month for at least 3 - Embarrassment / shame
months. Onset: 4 years or a mental age of 4 years. - Avoids sleepovers
- Primary: never had control of bowels
- Secondary: develops after a period of fecal continence Differential diagnosis: Organic Cause (refer to physician),
highly correlated with sexual abuse and marital discord
SEPARATION ANXIETY DISORDER: Key Descriptive Words:

- Inhibited:
Criteria: Persistent and excessive worry about being separated o Apathetic / Distrustful / Hypervigilant
from major attachment figures. Must persist for at least 4 weeks. o Does not respond to comforting
(“Failure to thrive”) o No desire to connect
- Disinhibited:
Key Descriptive Words: o Asks, “Can I come home with you?”
- Refuses to go to school o Attaches easily to most anyone
- Afraid to go to bed alone
- Cries when separated from primary caregiver Differential Diagnosis: Autistic Disorder / Asperger’s, Social
- Complains of illness in order to avoid having to leave Phobia, ODD, Conduct Disorder
primary caregiver
- Recent life stressor (death, illness, moving) DELIRIUM:
- Afraid of losing primary caregiver
Criteria: Disturbance of consciousness, change in cognition,
Differential diagnosis: Generalized Anxiety Disorder, Social impaired recent memory, disorientation, language disturbance,
Phobia, Adjustment Disorder presence of illusions and hallucinations. Occurs usually in the
elderly or very young children. May resolve in hours or persist for
REACTIVE ATTACHMENT DISORDER OF INFANCY OR CHILDHOOD: weeks.
Criteria: Bonding failure often associated with multiple early Key Descriptive Words:
caregivers or disruption in caretaking. Onset: Begins before age 5 - Sudden onset
- Disinhibited Type: Diffuse and indiscriminate sociability - Hallucinations / Delusions
and attachments with a lack of selectivity - Disorganized Thinking
- Inhibited Type: Failure to initiate or respond to social - Suffered from a high fever
interactions - Loss of RECENT memory
- Disoriented
- Taking medications / drugs
Differential diagnosis: Dementia, Substance Intoxication /

Withdrawal
DEMENTIA: Key Descriptive Words:
- Slurred speech
Criteria: Multiple cognitive deficits, coded based on etiology (e.g. - Poor coordination / Shaking
Alzheimer’s Type, Due to Head Injury, HIV, TB, Cancer, etc). Usually - Dilated pupils
occurs among the elderly. Onset is gradual. Course can be - Lost jobs / relationships
progressive, static or remitting. - Says they have tried to quit in the past
- Claim that they no longer derive pleasure from it – using
Key Descriptive Words: the substance to avoid withdrawals
- Impaired long AND short term memory - Need to use more to get same effect
- Change in personality
- Impaired thinking / judgment Differentia Diagnosis: General Medical Condition, Bipolar
- Problems with language / motor skills / recognition Disorder, Substance Abuse
Differential Diagnosis: Delirium, Substance Intoxication / SUBSTANCE ABUSE:

Withdrawal
Criteria: Only requires 1 symptom – does not meet the criteria for
SUBSTANCE DEPENDENCE: Substance Dependence; no tolerance or withdrawal; no desire to
quit (a DUI can occur)
Criteria: 3 or more of the following symptoms within a 12 month
period: Key Descriptive Words:
- Tolerance - Occupational / educational / legal / social problems
- Withdrawal - Correlated with Domestic Violence
- Use of larger amounts or over a longer time than intended - Symptoms of intoxication (slurred speech, poor
- Persistent desire but unsuccessful attempts to quit coordination, dry mouth, etc)
- Much time spent in obtaining the substance or recovering - Do not want to quit / do not believe they have a problem
from its use - Acting out behaviors in youth
- Social, occupational, or recreational activities are given up
Differential Diagnosis: General Medical Condition, Bipolar
Disorder, Substance Dependence, Conduct Disorder (in youth)
PSYCHOTIC DISORDERS: Key Descriptive Words:

- Hallucinations (auditory, olfactory, kinesthetic)
- Psychotic refers to loss of boundaries or gross impairment - Delusions
in reality testing - Poor hygiene
- Involves bizarre delusions or hallucinations - Paranoia
- Involves disorganized speech, thought and behavior - Onset often occurs in young, college age men
SCHIZOPHRENIA: Differential Diagnosis: Substance-Induced Psychotic Disorder,

Mood Disorder with Psychotic Features, Delusional Disorder,
Criteria: Two or more of the following symptoms: Delusions, Psychotic Disorder due to a General Medical Condition
hallucinations, disorganized speech, grossly disorganized or
catatonic behavior, affect flattening, alogia, avolition. If delusions SCHIZOAFFECTIVE DISORDER:
are bizarre or auditory hallucinations are chronic, the diagnosis is
met. Criteria: Delusions, hallucinations, disorganized speech,
- Brief Psychotic Disorder: 1 day to 1 month (only 1 grossly disorganized or catatonic behavior PLUS a Major Depressive,
symptom necessary) Manic or Mixed Episode. Delusions or hallucinations are present for
- Schizophreniform Disorder: 1 month to 6 months at least 2 weeks in the absence of prominent mood symptoms
- Schizophrenia: more than 6 months
- Hallucinations (auditory, olfactory, kinesthetic)
- Delusions
- Mania (spending sprees, impulsivity, grandiosity, etc)
- Depression (tearful, hopeless, anhedonia, etc)
Differential Diagnosis: Schizophrenia, Mood Disorder with

Psychotic Features
DELUSIONAL DISORDER: - Loss of appetite
- Missing work
Criteria: Non-bizarre delusions. No history of bizarre delusions, - Loss of interest in friends, staying home
hallucinations, disorganized speech and behavior. Apart from - Hopelessness / suicidality
delusions, functioning and behavior are not impaired. At least 1
month duration. Differential Diagnosis: Dysthymic Disorder, Depressive
Disorder NOS, Mood Disorder due to a Medical Condition,
Key Descriptive Words: Substance-Induced Mood Disorder, Bipolar Disorder
- Delusions are the primary symptom
- The client may appear normal otherwise (employed, good DYSTHYMIC DISORDER:
hygiene)
- Client’s claim may be conceivable, therapist may have Criteria: Less severe depressive symptoms than in Major
difficulty determining validity of claim Depressive Disorder, which have been present for at least 2 years
(adults) or 1 year (children, adolescents)
Differential Diagnosis: Same differentials as Schizophrenia, as
well as: Body Dysmorphic Disorder, OCD, and Paranoid Personality Key Descriptive Words:
Disorder - Lack of motivation
- Irritability (in children)
MAJOR DEPRESSIVE DISORDER: - Feeling “blah”
- Poor appetite
Criteria: 5 or more depressive symptoms for at least 2 weeks, (in - Trouble concentrating
children and adolescents, the mood can be irritable) - Down in the dumps
- “I’m not myself”
Key Descriptive Words: - Lack of energy
- Crying / tearful
- Unable to get out of bed Differential Diagnosis: Major Depressive Disorder, Depressive
- Poor hygiene Disorder NOS, Cyclothymic Disorder
BIPOLAR I DISORDER:
Criteria: At least 1 manic or mixed episode (lasting at least 1 week); Key Descriptive Words:
with or without a history of depressive episodes - Inflated Self-Esteem
- Decreased need for sleep
Key Descriptive Words: - Pressured speech
- Out of control - Increased involvement in activities
- Grandiosity - Note the timeframe
- Pressured Speech - Not severe enough to require hospitalization
- Hyper-sexual
- Not sleeping Differential Diagnosis: Substance Abuse, Substance
- Huge spending sprees Intoxication, Bipolar I, Cyclothymic Disorder
- Calling friends in the middle of the night
- Note the timeframe PANIC DISORDER WITHOUT AGORAPHOBIA:
Differential Diagnosis: Substance Abuse, Substance Criteria: Recurrent, unexpected Panic Attacks
Intoxification, Bipolar II, Cyclothymic Disorder
BIPOLAR II DISORDER: - Intense feelings of fear, terror or impending doom
- Shortness of breath
Criteria: At least 1 Hypomanic Episode (lasting at least 4 days) PLUS - Heart palpitations
the presence or history of 1 or more Major Depressive Episodes - Sweating
- Fear of losing control
- Fear of going crazy
- Fear of dying
Differential Diagnosis: PTSD / Acute Stress Disorder,

Generalized Anxiety Disorder, Substance-Induced Anxiety Disorder,
OCD
PANIC DISORDER WITH AGORAPHOBIA: - Repeated doubts or thoughts about contamination
- Engages in rituals (hand washing, showering, cleaning,
Criteria: Recurrent, unexpected Panic Attacks AND the presence of counting)
Agoraphobia - Feel they must follow certain rules
- Dislikes the intrusive thoughts / compulsive behaviors
Key Descriptive Words: (Ego-Dystonic)
- Intense feelings of fear, terror or impending doom
- Shortness of breath Differential Diagnosis: Obsessive Compulsive Personality
- Heart palpitations Disorder, Generalized Anxiety Disorder
- Sweating
- Fear of losing control PTSD / ACUTE STRESS DISORDER:
- Fear of going crazy
- Fear of dying Criteria: Following exposure to a traumatic / life threatening event,
- Fear or anxiety about or avoidance of places or situations person experiences intrusive recollections, startle response,
in which escape might be difficult: airplanes, buses, cars, hypervigilance, nightmares
movie theaters, elevators, tunnels, bridges
- Acute Stress Disorder = 2 days to 4 weeks
Differential Diagnosis: Social Phobia, Specific Phobia, PTSD / - PTSD = 1 month or longer (can be years after the events)
Acute Stress Disorder, Generalized Anxiety Disorder, Substance-
Induced Anxiety Disorder, OCD Key Descriptive Words:
- Identifiable trauma (rape, combat, severe accident)
OBSESSIVE-COMPULSIVE DISORDER: - Event is persistently re-experienced
- Symptoms of arousal
Criteria: For at least 1 hour per day a person experiences - Difficulty falling asleep
Obsessions (intrusive thoughts) and/or Compulsions (ritualistic - Hypervigilance, exaggerated startle response
behaviors) - Avoidance of stimuli associated with the trauma
- Dissociative symptoms
- Persistent, distressing, intrusive ideas or thoughts Differential Diagnosis: Brief Psychotic Disorder, Adjustment
- Feelings of loss of control Disorder, Major Depressive Disorder
GENERALIZED ANXIETY DISORDER: Key Descriptive Words:

- Thinks that they’re fat
Criteria: At least 6 months of excessive anxiety and worry about a - Fear of gaining weight
number of events. 3 or more symptoms for Adults, 1 or more for - Food rituals
Children - Throwing up / Excessive exercise
- Poor self-esteem
Key Descriptive Words: - Extremely thin
- Restlessness, feeling keyed up, or on edge - Missed periods
- Easily fatigued
- Unrealistic worries Differential Diagnosis: Organic cause-refer to physician, OCD,
- Difficulty concentrating, mind going blank Mood Disorder, Body Dysmorphic Disorder, Borderline Personality
- Irritability Disorder
- Muscle tension
- Sleep disturbance BULIMIA NERVOSA:
Differential Diagnosis: Panic Disorder, OCD, Somatization
Disorder, Adjustment Disorder Criteria: Recurrent episodes of Binge Eating (2 times / week for 3
months) coupled with inappropriate compensatory behavior to
ANOREXIA NERVOSA: prevent weight gain
Criteria: Body weight less than 85% of what is expected; Key Descriptive Words:
Amenorrhea – absence of at least 3 consecutive periods - Thinks that they are fat
- Restricted Type: no binging or purging - Fear of gaining weight
- Binge-Eating / Purging Type - Food rituals
- Throwing up / Excessive exercise
- Poor self-esteem
- May appear to be of normal weight
- No missed periods
Differential Diagnosis: OCD, Mood Disorder, Body

Dysmorphic Disorder, Borderline Personality Disorder
ADJUSTMENT DISORDERS: PERSONALITY DISORDERS (AXIS II):
Criteria: Development of symptoms in excess of what All involve an enduring, persisting pattern of disturbance or inner
would be expected in response to a stressor. Occurs within 3 experience and behavior that deviates markedly from cultural
months of the stressor; once stressor has terminated, the symptoms expectations
do not persist for more than 6 additional months. (May be
diagnosed “Chronic” if symptoms occur in response to a chronic Antisocial Personality Disorder:
stressor) - A pervasive pattern of disregard for and violations of the
rights of others, occurring since the age of 15. Lying,
Key Descriptive Words: aggressiveness, fights, assaults and a lack of remorse.
- Identifiable stressor: divorce, minor car accident, recent Person must be at least 18.
move, lawsuit
- Resulting symptoms: depressions, anxiety, behavior Borderline Personality Disorder:
problem - Unstable and intense relationships with alternation
between extremes of idealization and devaluation; fear of
Differential Diagnosis: PTSD / Acute Stress Disorder, Major abandonment; unstable sense of self with feelings of
Depressive Disorder, Conduct Disorder abandonment; unstable sense of self with feelings of
emptiness; inappropriate, intense anger or difficulty
Adjustment Disorders Timeline: controlling anger; suicide threats.
Stressor Histrionic Personality Disorder:

Symptoms Begin (must occur within 3 months of - Interactiosn characterized by inappropriate, sexually
stressor) seductive behavior; exaggerated expression of shallow
Symptoms Stop (6 months after stressor has emotions; attention attracting behavior and appearance.
terminated)
Schizoid Personality Disorder:
Detachment from social relationships and a restricted
range of expression of emotions in interpersonal settings;
chooses solitary activities; little if any interest in sexual
experiences with another person; appears indifferent to
praise or criticism from others. (Ego-syntonic)
Dependent Personality Disorder: o Relational Problem Related to a General

- A pervasive and excessive need to be taken care of that Medical Condition or Mental Disorder
leads to submissive and clinging behavior and fears of o Parent-Child Relational Problem
separation; difficulty making everyday decisions; difficulty o Partner Relational Problem
expressing disagreement; passivity in relationships o Sibling Relational Problem
o Relational Problem NOS
Obsessive-Compulsive Personality Disorder:
- Preoccupation with orderliness, perfectionism, and - V-Code applies if the FOCUS of attention is on the
control; prone to repetition, and excessive attention to PERPETRATOR or the abuse or neglect or on the relational
detail and checking for mistakes; oblivious to the impact of unit in which it occurs
their behavior on others. (Ego-syntonic) - The VICTIM of abuse or neglect is coded 995.5 if a Child,
995.81 if an Adult
Narcissistic Personality Disorder: - Problems Related to Abuse or Neglect:
- A pervasive and pattern of grandiosity, need for o Physical Abuse of Child
admiration, and lack of empathy; boastful and pretentious o Sexual Abuse of Child
o Neglect of Child
Avoidant Personality Disorder: o Physical Abuse of Adult
- Pervasive pattern of social inhibition, feelings of o Sexual Abuse of Adult
inadequacy, and hypersensitivity to negative evaluation;
avoidance of activities that involve significant - Additional conditions - focus of clinical attention:
interpersonal contact for fear of criticism, disapproval, or o Noncompliance with Treatment
rejection. (Ego dystonic) o Malingering (making oneself sick for money)
o Adult Antisocial Behavior
V-CODES: RELATIONAL PROBLEMS: o Child or Adolescent Antisocial Behavior
o Age-Related Cognitive Decline
- Patterns of interaction associated with clinically significant o Bereavement
impairment in functioning o Academic Problem
- If they are not the focus of clinical attention, they should o Occupational Problem
be listed on Axis IV o Identity Problem
o Acculturation Problem
o Phase of Life Problem
Law and Ethics:
Ethics:
C - Countertransference CAMFT Ethical Standard 3.4 States:

I - Informed Consent
L - Limits of Confidentiality - “Marriage and family therapists seek appropriate
E - Expectations of Therapy professional assistance for their personal problems or
B - Boundaries
conflicts that impair work performance or clinical
judgment.”
Countertransference:
The BBS Handbook says MFT Candidates must demonstrate the Managing Countertransference:
ability to:
- Journal to gain clarity on personal reactions to a particular
- “Manage countertransference to maintain integrity of the issue or client that interfere with the integrity of the
therapeutic relationship” and demonstrate the knowledge therapeutic relationship
of “strategies to manage countertransference issues.” - Seek professional supervision or consultation with
colleagues or mentors
- Use one’s own personal therapy
- If unable to maintain the integrity of the therapeutic
relationship, make reasonable arrangement for
continuation of necessary treatment with another
therapist
Informed Consent: - Therapist’s responsibility to allow clients to make their

own decision on the status of relationships
- The BBS Handbook says that candidates must be able to - The limits of confidentiality
address client expectations about therapy to promote - The fee and any fee arrangements before therapy
understanding of the therapeutic process and discuss fees - Therapist’s experience, education, specialties, theoretical
and office policies to promote understanding of the and professional orientation
treatment process
- Clients have the right to consent or refuse consent to Limits of Confidentiality:
treatment, and must have the information on which to
base such decisions The BBS Handbook says candidates must demonstrate the
- Informed consent assists clients and therapists in avoiding ability to manage confidentiality issues to maintain the
misunderstandings integrity of the therapeutic contract, and knowledge of
- Legal Requirements: confidentiality issues in therapy. It also stresses
o Fee for treatment must be disclosed prior to knowledge of approaches to address expectations of
treatment therapy, which includes where confidentiality does and
o (California Business and Professional Code 4982) does not apply
o Therapists must disclose the name of the owner
of any fictitiously named business Clients should be advised that:
- Fee is Legal.
- Discussing Fee is Ethical. “The information disclosed by you during the course of
your therapy is generally confidential. However, there are
Ethical Aspects of Informed Consent: exceptions to confidentiality including, but not limited to,
reporting child, dependent adult, and elder abuse,
- Potential risks and benefits of therapy expressed threats of violence towards an ascertainable
- Therapist’s availability for emergencies and between (intended) victim, and where you make your mental or
sessions emotional state an issue in a legal proceeding.” (CAMFT
Legal and Ethical Practices, 2004)
Expectations about Therapy: o The implications of sexual feeling / contact
within the context of therapy
- The BBS Handbook lists tasks and knowledge that should o Strategies to maintain therapeutic boundaries
be demonstrated by MFT candidates
- Task one = Address client’s expectations about therapy to Managing Boundaries:
promote understanding of the therapeutic process
- Knowledge task = Approaches to address expectations of - Obtain informed consent to prevent misunderstandings
the therapeutic process - Sessions start and stop on time
- Brief, limited phone contact between sessions
- Clarifying misconceptions of therapeutic process or goals - Sessions held at therapist’s place of business
- Clarifying misconceptions of the therapist’s role - Regular and consistent payment of fees
- Dual relationships - No bartering fees
- Risks and benefits of therapy - No dual relationships or extra-therapeutic contact with
- We do NOT make decisions for our clients clients outside of sessions
- Limits of confidentiality - No sexualized behavior on therapist’s part
- No-secrets policy
- Records are kept and client has right to inspect MDS2$C2P2R2 – LAW:
- Accurate representation of therapist competence,
education, training, and experience M - Mandates
D - Duty to warn / Danger to Others
Boundaries: S1 - Suicide (Bellah vs. Greenson)
S2 - Scope of practice
- The BBS Handbook states that candidates should $ - Fees
demonstrate a knowledge of: C1 - Confidentiality
o Strategies to manage countertransference issues C2 - Consent to treat a minor
o The impact of gift giving and receiving on the P1 - Privilege
therapeutic relationship P2 - Professional Therapy Never Includes Sex
o Business, personal, professional, and social R1 - Releases
relationships that create a conflict of interest R2 - Records
within the therapeutic relationship
Legal Obligations about Child Abuse: Legal Obligations about Dependent Adult and Elder Abuse:
Upon knowledge or reasonable suspicion, a therapist must: Upon knowledge or reasonable suspicion of dependent adult or
- Notify a child protective services agency within the state of elder abuse, a therapist must:
California as soon as possible - Report by phone to Adult Protect Services within the state
- Follow up with a written report within 36 hours of California as soon as practicably possible
- Maintain confidentiality if the client reporting his or her - Follow up with a written report within 2 working days
own abuse is 18 or older UNLESS the therapist has
knowledge or reasonable suspicion that the perpetrator Tarasoff Statute 43.92:
has abused others who are currently under the age of 18
If your client communicates to you a serious, imminent
What is a Dependent Adult? An Elder? threat of physical violence to a reasonably identifiable
other, you must make reasonable efforts to contact law
- A dependent adult is anyone residing in California enforcement and the intended victim, and document in
between the ages of 18 and 64 who has a physical, mental, your notes the reason you believe the threat to be credible
or financial limitation which restricts the ability to carry and your attempts at notification.
out normal activities of living, or is unable to protect his or
her rights Tarasoff “Duty to Warn” Pursuant to “Ewing vs. Goldstein”:
- An elder is anyone age 65 or older, residing in the state of If you believe your client is dangerous to another,
California regardless of whether your client has communicated to
you an intent to physically harm the person, you must take
reasonable steps to protect the safety of the person
Reasonable precautions include:

- Notifying the police
- Notifying the intended victim
- Notifying someone likely to warn the intended victim
- Arranging for your client to be hospitalized
- Anything else you deem reasonable under the
circumstances
Hedlund Decision: Increased phone contact
o Have client dispose of means
- Therapists who do not carry out their duty under Tarasoff o Have client voluntarily hospitalize self
are liable for damages or injuries to bystanders harmed by
their client - Interventions that BREAK Confidentiality:
o Evidence Code 1024:
What is the therapist’s legal responsibility under the Gives therapist the right to make
Hedlund decision? disclosures deemed appropriate by the
o None. If the therapist has a Tarasoff situation, therapist to prevent threatened
the therapist must simply make reasonable danger, e.g. warning parent, spouse,
efforts to notify the police and warn the etc
intended victim Therapist must have solid reasons to
o Hedlund imposes no additional responsibilities, break confidentiality under E.C. 1024
but rather increases the liability for therapists o Warning parent, spouse, etc
who don’t carry out their Tarasoff duty to warn o Help family and friends organize a 24-hour watch
o Have client voluntarily hospitalized by initiating a
Suicide – Bellah vs. Greenson: 5150
Call 911
- Establishes the legal precedent that therapists must take Or Call the county Psychiatric
reasonable steps to prevent clients from committing Emergency Team (the PET team)
suicide
- Reasonable steps are clinical interventions a reasonably Fees:
prudent therapist would use under similar circumstances
- California Business and Professional Code 4982(n) says
- Interventions that do not break Confidentiality: that it is unprofessional conduct for a therapist to:
o No suicide contract o Prior to the commencement of treatment, fail to
Suicide prevention hotline number disclose to the client or prospective client the
Promises to call friends, family fee to be charged for the professional services,
o Increased contact with client or the basis upon which that fee will be
Extra sessions computed
Confidentiality: Privilege:
- Confidentiality is both a legal and an ethical requirement - Privilege is a client’s right to refuse to disclose and to
placed on the therapist restricting the volunteering of prevent others from disclosing a confidential
information received in the context of the therapeutic communication between patient and psychotherapist in a
relationship legal proceeding
- Psychotherapists have the right and duty to claim (or
Consent to Treat a Minor: assert) the privilege whenever the communication is
sought to be disclosed
- Generally speaking, therapists must obtain the consent of - Subpoena = assert privilege
a parent or guardian to treat a minor
- Legally, either parent in an intact marriage may consent to Professional Therapy Never Includes Sex:
treatment, but it is advisable to have the consent of both
parents - Upon learning of a client’s sexual contact with a former
- In families where there is a divorce or separation, either therapist or current therapist, the therapist receiving this
parent with joint custody can consent to treatment, unless information is required by law to give the client the
the custody agreement indicates otherwise. Ask to see Department of Consumer Affairs’ brochure “Professional
the custody agreement before proceeding with treatment Therapy Never Includes Sex”
- Minors age 12 and older who are victims of abuse or a - The BBS will NOT accept complaints from one therapist
danger to self or others without treatment may qualify to about another therapist’s alleged sexual contact with a
consent for their own treatment client
Records: Releases:
- California Business and Professional Code 4982(v) states - California Civil Code 56.11 generally prohibits the release
that it is unprofessional for a therapist to of confidential information without a valid authorization
o Fail to keep records consistent with sound - All members of the treatment unit competent to do so
clinical judgment, the standards of the must sign the release in order for confidential information
profession, and the nature of the services being about any one member of the treatment unit to be
rendered disclosed
General Exceptions to Privilege: What are the Mandatory Exceptions to Confidentiality?
- The client waives privilege - Child Abuse
- The client introduces his/her emotional condition into a - Elder Abuse
legal proceeding - Dependent Adult Abuse
- The client treated confidential information as if it were not - Tarasoff (Duty to Warn)
confidential - Patriot Act
- The client signed a health insurance claim or other waiver
- The client has sought psychotherapy to commit or escape What are the Permitted Exceptions to Confidentiality?
punishment for a crime - Evidence Code 1024
- Release Authorizations
Who is the Holder of Privilege? - Certain Professional Consultations
- The client, regardless of age (unless there is a guardian or - Breaches of Duty
conservator) o Client sues therapist
- The guardian or conservator when there is a guardian or o Client commits a crime against therapist
conservator o Client fails to pay the therapist
- The personal representative of the patient (if the patient
has died) When can a Minor be treated without Parental Consent?
- Parents do NOT hold privilege for their children UNLESS - A minor must be 12 years of age or older
they have been accorded “guardian ad litem” status by the - Therapy must be on an outpatient basis
court - The minor must be mature enough to participate
meaningfully in the therapeutic process
Who can Exercise a Minor’s Privilege? - There must be documented in the records a good reason
- Minors who have (or who could have) consented to their why parental involvement is not advisable
own treatment - Minor IS responsible for payment of fees
- The state when the minor client is a ward of the state (an - The minor is:
attorney is usually appointed to determine whether o A serious danger of physical or mental harm to
privilege should be waived) self or others without treatment
- A Guardian Ad Litem appointed by the court (could be the o Or, an alleged victim of child abuse (which
parents or could be an attorney) includes rape and incest)
What are the Legal Obligations regarding Spousal Abuse? What is the Therapist’s Role in a 5150?
- There are NO legal obligations or mandate - To initiate a 5150 by calling 911 or PET
- The therapist does not “report” spousal abuse unless the - A 5150 may be INVOLKED by the police, an evaluation
spouse is in a protected class of individuals team member, or by someone designated by the county
- The therapist would take steps to advance the welfare of
the client Legal Responsibility if Minor Client is engaged in Consensual Sexual
Activity?
What is a 5150? - Sexual activity involving minors is generally not reportable
- California Welfare and Institutions Code 5150, allowing for with four (4) exceptions:
a 72 hour hold (involuntary confined) for treatment and 1. The minor is under the age of 16 and the
evaluation of a person who is gravely disabled or is a adult is 21 years or older
serious threat of physical or mental harm to self or others 2. The minor is 14 or 15 and the adult is at
least 10 years older
3. Any sexual activity between a minor under
the age of 14 and a person of disparate age
4. All oral and anal sex involving any minor is
reportable
COUNTERTRANSFERENCE: Managing Countertransference:
The BBS Handbook says MFT Candidates must demonstrate the 1. Journal to gain clarity on personal reactions to a particular issue
ability to: “Manage countertransference to maintain integrity of the or client that interfere with the integrity of the therapeutic
therapeutic relationship” and demonstrate the knowledge of relationship
“strategies to manage countertransference issues.” 2. Seek professional supervision or consultation with colleagues or
mentors
CAMFT Ethical Standard 3.4 States: 3. Use one’s own personal therapy
“Marriage and family therapists seek appropriate professional 4. If unable to maintain the integrity of the therapeutic relationship,
assistance for their personal problems or conflicts that impair work make reasonable arrangement for continuation of necessary
performance or clinical judgment.” treatment with another therapist
INFORMED CONSENT: Legal Requirements of Informed Consent:

The BBS Handbook says that candidates must be able to address • Fee for treatment must be disclosed prior to treatment (California
client expectations about therapy to promote understanding of the Business and Professional Code 4982)
therapeutic process and discuss fees and office policies to promote • Therapists must disclose the name of the owner of any fictitiously
understanding of the treatment process. Clients have the right to named business
consent or refuse consent to treatment, and must have the • Fee is Legal.
information on which to base such decisions. Informed consent • Discussing Fee is Ethical.
assists clients and therapists in avoiding misunderstandings
Ethical Aspects of Informed Consent:
• Potential risks and benefits of therapy
• Therapist’s availability for emergencies and between sessions
• Therapist’s responsibility to allow clients to make their own
decision on the status of relationships
• The limits of confidentiality
• The fee and any fee arrangements before therapy
• Therapist’s experience, education, specialties, theoretical and
professional orientation
CONSENT TO TREAT A MINOR: When can a Minor be treated without Parental Consent?
• Generally speaking, therapists must obtain the consent of a • A minor must be 12 years of age or older
parent or guardian to treat a minor • Therapy must be on an outpatient basis
• Legally, either parent in an intact marriage may consent to • The minor must be mature enough to participate meaningfully in
treatment, but it is advisable to have the consent of both parents the therapeutic process
• In families where there is a divorce or separation, either parent • There must be documented in the records a good reason why
with joint custody can consent to treatment, unless the custody parental involvement is not advisable
agreement indicates otherwise. Ask to see the custody • Minor IS responsible for payment of fees
agreement before proceeding with treatment The minor is:
• Minors age 12 and older who are victims of abuse or a danger to • A serious danger of physical or mental harm to self or others
self or others without treatment may qualify to consent for their without treatment
own treatment • Or, an alleged victim of child abuse (which includes rape and
incest)
LIMITS OF CONFIDENTIALITY: Clients should be advised that: “The information disclosed by you
The BBS Handbook says candidates must demonstrate the ability to during the course of your therapy is generally confidential.
manage confidentiality issues to maintain the integrity of the However, there are exceptions to confidentiality including, but not
therapeutic contract, and knowledge of confidentiality issues in limited to, reporting child, dependent adult, and elder abuse,
therapy. It also stresses knowledge of approaches to address expressed threats of violence towards an ascertainable (intended)
expectations of therapy, which includes where confidentiality does victim, and where you make your mental or emotional state an
and does not apply. issue in a legal proceeding.” (CAMFT Legal and Ethical Practices,
2004)
EXPECTATIONS ABOUT THERAPY: • Clarifying misconceptions of therapeutic process or goals
The BBS Handbook lists tasks and knowledge that should be • Clarifying misconceptions of the therapist’s role
demonstrated by MFT candidates • Dual relationships
Task one = Address client’s expectations about therapy to promote • Risks and benefits of therapy
understanding of the therapeutic process • We do NOT make decisions for our clients
Knowledge task = Approaches to address expectations of the • Limits of confidentiality
therapeutic process • No-secrets policy
• Records are kept and client has right to inspect
• Accurate representation of therapist competence, education,
training, and experience
BOUNDARIES: Managing Boundaries:

The BBS Handbook states that candidates should demonstrate a • Obtain informed consent to prevent misunderstandings
knowledge of: • Sessions start and stop on time
• Strategies to manage countertransference issues • Brief, limited phone contact between sessions
• The impact of gift giving and receiving on the therapeutic • Sessions held at therapist’s place of business
relationship • Regular and consistent payment of fees
• Business, personal, professional, and social relationships that • No bartering fees
create a conflict of interest within the therapeutic relationship • No dual relationships or extra-therapeutic contact with clients
• The implications of sexual feeling / contact within the context of outside of sessions
therapy • No sexualized behavior on therapist’s part
• Strategies to maintain therapeutic boundaries
LEGAL OBLIGATIONS ABOUT CHILD ABUSE: WHAT IS A DEPENDENT ADULT? AN ELDER?

Upon knowledge or reasonable suspicion, a therapist must: • A dependent adult is anyone residing in California between the
• Notify a child protective services agency within the state of ages of 18 and 64 who has a physical, mental, or financial
California as soon as possible limitation which restricts the ability to carry out normal activities
• Follow up with a written report within 36 hours of living, or is unable to protect his or her rights
• Maintain confidentiality if the client reporting his or her own • An elder is anyone age 65 or older, residing in the state of
abuse is 18 or older UNLESS the therapist has knowledge or California
reasonable suspicion that the perpetrator has abused others who
are currently under the age of 18 LEGAL OBLIGATIONS ABOUT DEPENDENT ADULT AND ELDER
ABUSE:
Upon knowledge or reasonable suspicion of dependent adult or
elder abuse, a therapist must:
• Report by phone to Adult Protect Services within the state of
California as soon as practicably possible
• Follow up with a written report within 2 working days
TARASOFF STATUTE 43.92: • Notifying someone likely to warn the intended victim
If your client communicates to you a serious, imminent threat of • Arranging for your client to be hospitalized
physical violence to a reasonably identifiable other, you must make • Anything else you deem reasonable under the circumstances
reasonable efforts to contact law enforcement and the intended Hedlund Decision:
victim, and document in your notes the reason you believe the Therapists who do not carry out their duty under Tarasoff are liable
threat to be credible and your attempts at notification. for damages or injuries to bystanders harmed by their client
What is the therapist’s legal responsibility under the Hedlund
Tarasoff “Duty to Warn” Pursuant to “Ewing vs. Goldstein”: decision?
If you believe your client is dangerous to another, regardless of None. If the therapist has a Tarasoff situation, the therapist must
whether your client has communicated to you an intent to physically simply make reasonable efforts to notify the police and warn the
harm the person, you must take reasonable steps to protect the intended victim. Hedlund imposes no additional responsibilities, but
safety of the person: rather increases the liability for therapists who don’t carry out their
• Notifying the police Tarasoff duty to warn
• Notifying the intended victim
SUICIDE – BELLAH VS. GREENSON:
Establishes the legal precedent that therapists must take reasonable
steps to prevent clients from committing suicide
Reasonable steps are clinical interventions a reasonably prudent
therapist would use under similar circumstances Interventions that BREAK Confidentiality:
• Evidence Code 1024: Gives therapist the right to make disclosures
Interventions that do not break Confidentiality: deemed appropriate by the therapist to prevent threatened
• No suicide contract danger, e.g. warning parent, spouse, etc / Therapist must have
• Suicide prevention hotline number solid reasons to break confidentiality under E.C. 1024
• Promises to call friends, family • Warning parent, spouse, etc
• Increased contact with client • Help family and friends organize a 24-hour watch
• Extra sessions • Have client voluntarily hospitalized by initiating a 5150
• Increased phone contact • Call 911 Or Call the county Psychiatric Emergency Team (the PET
• Have client dispose of means team)
• Have client voluntarily hospitalize self
FEES: Prior to the commencement of treatment, fail to disclose to the

California Business and Professional Code 4982(n) says that it is client or prospective client the fee to be charged for the professional
unprofessional conduct for a therapist to: services, or the basis upon which that fee will be computed
CONFIDENTIALITY:Confidentiality is both a legal and an ethical

requirement placed on the therapist restricting the volunteering of What are the Permitted Exceptions to Confidentiality?
information received in the context of the therapeutic relationship • Evidence Code 1024
• Release Authorizations
What are the Mandatory Exceptions to Confidentiality? • Certain Professional Consultations
• Child Abuse • Breaches of Duty
• Elder Abuse • Client sues therapist
• Dependent Adult Abuse • Client commits a crime against therapist
• Tarasoff (Duty to Warn) • Client fails to pay the therapist
• Patriot Act
RECORDS:
California Business and Professional Code 4982(v) states that it is unprofessional for a therapist to Fail to keep records consistent with sound
clinical judgment, the standards of the profession, and the nature of the services being rendered
PRIVILEGE: Who is the Holder of Privilege?

Privilege is a client’s right to refuse to disclose and to prevent others • The client, regardless of age (unless there is a guardian or
from disclosing a confidential communication between patient and conservator)
psychotherapist in a legal proceeding • The guardian or conservator when there is a guardian or
Psychotherapists have the right and duty to claim (or assert) the conservator
privilege whenever the communication is sought to be disclosed • The personal representative of the patient (if the patient has died)
Subpoena = assert privilege • Parents do NOT hold privilege for their children UNLESS they have
been accorded “guardian ad litem” status by the court
General Exceptions to Privilege:
• The client waives privilege Who can Exercise a Minor’s Privilege?
• The client introduces his/her emotional condition into a legal • Minors who have (or who could have) consented to their own
proceeding treatment
• The client treated confidential information as if it were not • The state when the minor client is a ward of the state (an attorney
confidential is usually appointed to determine whether privilege should be
• The client signed a health insurance claim or other waiver waived)
• The client has sought psychotherapy to commit or escape • A Guardian Ad Litem appointed by the court (could be the parents
punishment for a crime or could be an attorney)
PROFESSIONAL THERAPY NEVER INCLUDES SEX:

Upon learning of a client’s sexual contact with a former therapist or current therapist, the therapist receiving this information is required by law to
give the client the Department of Consumer Affairs’ brochure “Professional Therapy Never Includes Sex”
The BBS will NOT accept complaints from one therapist about another therapist’s alleged sexual contact with a client
RELEASES:
California Civil Code 56.11 generally prohibits the release of confidential information without a valid authorization
All members of the treatment unit competent to do so must sign the release in order for confidential information about any one member of the
treatment unit to be disclosed
WHAT ARE THE LEGAL OBLIGATIONS REGARDING SPOUSAL ABUSE?

• There are NO legal obligations or mandate
• The therapist does not “report” spousal abuse unless the spouse is in a protected class of individuals
• The therapist would take steps to advance the welfare of the client
WHAT IS A 5150? LEGAL RESPONSIBILITY IF MINOR CLIENT IS ENGAGED IN

California Welfare and Institutions Code 5150, allowing for a 72 hour CONSENSUAL SEXUAL ACTIVITY?
hold (involuntary confined) for treatment and evaluation of a person • Sexual activity involving minors is generally not reportable with
who is gravely disabled or is a serious threat of physical or mental four (4) exceptions:
harm to self or others • The minor is under the age of 16 and the adult is 21 years or older
• The minor is 14 or 15 and the adult is at least 10 years older
WHAT IS THE THERAPIST’S ROLE IN A 5150? • Any sexual activity between a minor under the age of 14 and a
• To initiate a 5150 by calling 911 or PET person of disparate age
• A 5150 may be INVOLKED by the police, an evaluation team • All oral and anal sex involving any minor is reportable
member, or by someone designated by the county
Human Diversity in a Treatment Plan:
E - Empathy Rapport building is accomplished through a genuine interest in
R - Respect understanding the world from the client’s point of view and
R - Rapport conveying a respect for the client’s experiences of difference and
C - Curiosity otherness
E2 - Educate Yourself and Educate the Client
P - Personal Bias Curiosity means staying open to the client and not making
T - Treatment Plan assumptions
Empathy is particularly important when dealing with human The proper source of information about our clients should be our
diversity issues and clients whose difference often causes them to clients, and not, for example, books that tell us about who our
feel alienated clients should be based upon a particular aspect of their inclusion in
a particular diversity group
Mirroring, and careful, reflective listening to stories of difference,
otherness, and alienation builds empathy and is in itself therapeutic In the exam, avoid answers in which the therapist knows what the
and healing client needs or in which the therapist tells the clients how they must
be feeling
Demonstrating respect means being aware of your cultural values
and taking care not to impose them on others who may have Educate yourself by asking the client:
different but equally valid cultural values - Taking a genuine interest in understanding what it is like to
be in the client’s shoes builds rapport and provides the
Demonstrating respect means openly addressing differences as they therapist with information
arise in the room and incorporating them into treatment - Being open to learning about the client’s unique
experience of difference conveys respect
- Seeking to see, feel and understand the lived experience
of another builds rapport
Educate yourself:
- Ethical standards require therapists to actively strive to Treatment Plan:
understand the diverse cultural backgrounds of their - Treatment goals must be sensitive in the context of human
patients by: diversity
o Consulting with other therapists who have - Assumptions about what the client needs may be
experience or expertise in the particular human irrelevant or contrary to the client’s goals, based upon a
diversity issue you are working with lived experience the therapist cannot presume to know
o Reading books about the diversity issue - In the WCV exam, avoid answer that establish goals
o Reading peer review literature about research in without collaborating with the client
working with the diversity issue
How to Proceed if an Intervention Did Not Work:
Educate The Client:
- Share relevant information from self-education about C - Client Reaction
diversity issue about which client may be unaware A - Alliance
- Provide relevant resources V - Values Differences
- Must be done with sensitivity so as not to presume or L - Lifestyle
imply an expert stance with someone who has genuine T - Timing
expertise by virtue of the lived experience D - Different Interventions
Personal Bias: Client Reaction:

- The therapist must be aware where he or she is culturally - Why did the client not respond or not respond favorably to
situated the intervention?
- The therapist must be aware of his or her cultural values, - In the WCV exam, look for answers that respect the
beliefs, customs, and norms client’s unfavorable reaction
- The therapist stays aware of these elements of culture to - In the WCV exam, avoid answers that make assumptions
avoid imposing them on the client about why an intervention did not work
Alliance:
- Does the client’s reaction indicate a problem with the therapeutic alliance?
- Did the intervention not work because the client was reactive to something going on between therapist and client?
Values Differences:
- Are you asking psychodynamic questions of a client who is more interested in life coaching?
- Is your intervention subtly promoting heterosexual values with a gay or lesbian couple?
Lifestyle:
- Are you assigning homework to a harried single mother?
- Are you making geographically difficult referrals for a client who doesn’t have a car?
- Are you assuming gay relationships have the equivalent of masculine / feminine roles?
Timing:
- Was the intervention attempted before there was adequate trust in the therapeutic relationship?
- Were you too far ahead of the client in the session? Did you move too quickly to use your intervention?
Different Interventions:
- Therapists must be flexible and adaptable to client needs, values and lifestyles
- In considering alternative interventions, be sure they achieve the same goal as the one that didn’t work
- In considering alternative interventions, be sure it will not evoke the same client reaction as the one that didn’t work
- Consider interventions from another theoretical orientation

Profile of A Treatment Plan:: Early Stage Middle Stage Late Stage

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Profile of a Treatment Plan:

Early Stage Middle Stage Late Stage

Psychodynamic Therapy (Freud, Jung, Erikson, Framo, Sager):

Early Stage Goals: Early Stage Interventions:

Late Stage Goals: Late Stage Interventions:

Existential Theory: (Gestalt – Client Centered) (Yalom, Frankl, May)

Reviewing Family Systems Concepts:

Early Stage Goals: Early Stage Interventions:

Middle Stage Goals: Middle Stage Interventions:

Multigenerational Family Systems (Bowen):

Middle Stage Goals: Middle Stage Interventions:

Late Stage Goals: Late Stage Interventions:

Early Stage Goals: Early Stage Interventions:

Middle Stage Goals: Middle Stage Interventions:

Late Stage Goals: Late Stage Interventions:

Early Stage Goals: Early Stage Interventions:

Middle Stage Goals: Middle Stage Interventions:

Late Stage Goals: Late Stage Interventions:

Role of the Therapist: Active collaborator; trainer/educator; Termination Criteria:

Early Stage Goals: Early Stage Interventions:

Middle Stage Goals:

Narrative Therapy (White, Epston):

Early Stage Goals:

Late Stage Goals: Late Stage Interventions:

Solution-Focused Therapy (DeShazer, Berg):

Middle Stage Goals:

Late Stage Goals: Late Stage Interventions:

ISSUE GOAL INTERVENTION LANGUAGE

Educate About Developmental Needs

Distorted Body Image Promote Healthy Relationship With

Explore Legitimate Express of Power

ISSUE GOAL INTERVENTION LANGUAGE

Process Expectations of Self and Others

Educate About Changing Roles and Process Losses

Support Group for Caregiver and Those Affected

Overwhelmed Single Parent Effectively Manage Parental

ISSUE GOAL INTERVENTION LANGUAGE

Tarasoff: Duty to Warn Spousal Abuse / Domestic Violence:

- You have a Tarasoff Duty to Warn when: Indicators:

Alcohol or Substance Abuse / Dependence:

Drug or alcohol use resulting in:

- Impaired social or occupational functioning

DEMENTIA: PSYCHOTIC DISORDERS:

MAJOR DEPRESSIVE DISORDER: OBSESSIVE-COMPULSIVE DISORDER:

GENERALIZED ANXIETY DISORDER: PERSONALITY DISORDERS (AXIS II):

ANOREXIA NERVOSA: Antisocial Personality Disorder:

BULIMIA NERVOSA: Borderline Personality Disorder:

V-CODES: RELATIONAL PROBLEMS:

- Relational Problem Related to a General Medical Condition or Mental Disorder

- Physical Abuse of Child

Additional conditions - focus of clinical attention:

- Noncompliance with Treatment

ASPERGER’S DISORDER: Key Descriptive Words:

ATTENTION-DEFICIT / HYPERACTIVITY DISORDER: Key Descriptive Words:

Differential Diagnosis: ODD, Substance Abuse

Key Descriptive Words: Differential Diagnosis: Organic Cause (refer to physician),

SEPARATION ANXIETY DISORDER: Key Descriptive Words:

Differential diagnosis: Dementia, Substance Intoxication /