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GLOSSARY Absolute efficacy: One of two types of evidential counseling outcome research. Refers to the overall effectiveness of counseling and psychotherapy in general. Adjustment disorders: A class of disorders appearing in the DSM-IV-TR system which have in common clinically significant emotional or behavioral symptoms that occur in response to an identifiable psychosocial or environmental stressor. Age, gender, SES, and cultural differences in making diagnoses: Information about common demographic differences associated with specific mental disorders provided in the DSM-IV-TR when such information is known. Analyzer: The natural helper style in which the individual likes to explore, probe, and offer a critical analysis of a situation. Areas of dysfunction approach: One of four approaches to intuitive-logical clinical. thinking at Step 2 of the inverted pyramid method of case conceptualization. Using this approach, the counselor looks for life roles and themes. Clinical thinking using this approach organizes client issues by common denominators according to problematic themes of every day life. Associated features: Clinical features that are not part of the diagnostic criteria for a particular mental disorder, but may frequently occur in association with the disorder. Attitudes of helper: Specific personality characteristics that have been theoretically or empirically shown to be critical to the effective helping relationship. Include being empathic, genuine, accepting, open-minded, cognitively complex, adjusted psychologically, able to build a relationship, and competent. One of the eight core areas of knowledge and skills Accountability: The increased emphasis by health care organizations and others to have clinicians show that what they are doing is working. Some say accountability has become more important than one’s theoretical orientation when working with clients. Acceptance: The ability to regard clients unconditionally, despite differences in cultural heritage, values, or beliefs. One of the eight critical attitudes of the helper. Advice-giving: The most potentially harmful of three problem-focused, commonly used, skills in which the clinician offers expert opinion in hopes client will follow suggestions. Also see offering alternatives and information giving. Advanced empathic responses: After becoming proficient at conversational empathic responses, clinicians are encouraged to make these kinds of responses which often bring about deeper levels of understanding for the client. They include the use of analogies, metaphors, visual images, and the pointing out of contrasting feelings. Affirmations: Genuine and caring responses on the part of the clinician that says to the client that he or she likes a behavior or statement the client has expressed. A commonly used skill. Appearance and behavior: This part of the mental status exam reports the client’s observable appearance and behaviors during the clinical interview. Often includes manner of dress, hygiene, body posture, tics, significant nonverbals (eye contact, wringing of hands, swaying), and manner of speech (e.g., stuttering, tone). Assessment techniques: Formal and informal assessment instruments helpful in information gathering. Axis I: Axis II: Using the DSM-IV-TR classification system, all clinical disorders and other conditions that may be a focus of clinical attention with the exception of personality disorders and mental retardation are recorded on Axis I. Using the DSM-IV-TR classification system, personality disorders and mental retardation are recorded on Axis II. Axis III: Using the DSM-IV-TR classification system, general medical conditions are recorded on Axis III. Axis IV: Using the DSM-IV-TR classification system, psychosocial and environmental problems are recorded on Axis IV. Axis V: Using the DSM-IV-TR classification system, the Global Assessment of Functioning, or GAF, score is recorded on Axis V. Behaviorally stated treatment approach: Preparing the treatment plan in such a manner that it is clear what will take place during the working stage of the counseling relationship. Breach of confidentiality: A critical ethical and legal issue that addresses the importance of the confidential nature of the helping relationship and that confidentiality should only be broken under extreme circumstances such as when there is a “duty to warn.” See Tarasoff case. Buckley Amendment (FERPA): Also known as the Family Rights and Privacy Act of 1974, this law affirms the right of all individuals to have access to their educational records. Business-related activities: The management of the professional counseling office, such as documentation of contacts, billing, and interacting with third-payers. Case conceptualization [Definition 1]: The process that allows the clinician to understand, through his or her unique theoretical perspective, a client's presenting problems and subsequently apply appropriate counseling skills and treatment strategies. One of the eight core areas of knowledge and skills. [Definition 2]: A clinical thought process that provides a framework to assess, appraise, and make sense of client needs. Involves three elements: assessing client behaviors, thoughts, feelings, and physiology; using this assessment to determine patterns and themes among the client’s concerns; and then, as a function of the clinician’s theoretical orientation, using the patterns or themes to make clinical judgments about etiology and sustaining factors associated with the client’s concerns. Case management: The overall process involved in maintaining the optimal functioning of clients. Includes: documentation; consultation, supervision, and collaboration; communicating with stakeholders; business-related activities; and caseload management. One of the eight core areas of knowledge and skills. Case notes: A record, prepared by the clinician, of how counseling proceeds. A key part of the client’s record, providing a clinical reference for professional use and a mechanism or showing accountability. Also referred to as “progress notes.” Case reports: Reports used to summarize client sessions. Such reports are often the reflection of information gathered during a structured interview or during daily client contacts. Caseload management: Directing ones time and schedule, and tracking and following up ones caseload; carefully monitoring each client’s experience of the counseling relationship, treatment compliance, and progress; and ensuring that ones caseload remains manageable in terms of size, number of weekly client contacts, complexity, challenge, and psycho-emotional demand. Challenger The natural helper style in which the individual likes to push and confront a client into viewing the world differently. Clinical consultation: Occurs when the therapist seeks out another mental health professional in order to discuss a client’s needs, explore treatment options, or gain a better understanding of the dynamics of the counselor-client relationship. Clinical disorders: All childhood and adult mental disorders contained in the DSM-IV-TR with the exception of personality disorders and mental retardation. Clinical skills: The attitudes and techniques used by professional counselors. They include the eight attitudes of the helper, foundational skills, information gathering skills, and commonly used skills. Clinical supervision: An intensive, interpersonally focused relationship in which one person is designated to facilitate the development of therapeutic competence in one or more other persons (Loganbill, Hardy, & Delworth, 1982). Clinical tools: The skills needed for managing the counseling process. They include diagnosis, case conceptualization, treatment planning, and case management. Closed question delimiting affect: A type of information gathering technique that uses questions to force the client to pick between feeling choices assumed by the clinician. Closed question delimiting content: A type of information gathering technique that uses questions to focus on a particular topic or point of view and forces the client to pick between choices given. Closure stage: Stage 5 of the helping relationship, with its primary goal being to summarize, review, and make the transition out of counseling as smooth as possible. See Tables. 2.1-2.3 to review how core areas of knowledge and skills are applied at this stage. Clinical targets approach: One of four approaches to intuitive-logical clinical. thinking at Step 2 of the inverted pyramid method of case conceptualization. Using this approach, the counselor looks at thoughts, feelings, behaviors, and physiology. Clinical thinking using this approach divides client presentations into four domains: irrational thoughts, distressing moods, dysfunctional and maladaptive actions, and problematic physical aspects. Codes of ethics: Documents that guide the ethical practice of mental health professionals. See Appendix A for websites of codes of ethics. Cognitive complexity: A broad range of cognitive skills related to the manner in which one makes sense of the world. The ability to think systemically and understand multiple perspectives. One of the eight critical attitudes. Cognition: The part of the mental status exam that assesses the client’s orientation to time, place, and person; short- and long-term memory; knowledge base and intellectual functioning; and insight and judgment. Collaboration: When the clinician communicates that he or she values the client’s feedback and wants want to come to a mutually agreed upon decision about the next phase in treatment. Most useful at transitional points in the helping relationship. Common outpatient disorders: The Mood Disorders (depressive and bipolar disorders) and Anxiety Disorders follow four red flag chapters in the DSM text and are considered common outpatient disorders. Competence: A thirst for knowledge. Willing to examine new ways of working with clients. Being aware of appropriate techniques. One of the eight critical attitudes. Also, one of the ethical “hot spots” highlighted in many professional ethical codes (see Table 3.1). Communication with stakeholders: Interactions with interested parties who are not mental health professionals, such as the client’s family and friends, courts, schools, employers, and social services. Confidentiality: An ethical “hot spot” that states clients have the right to privacy in their communication with clinicians. Contrast with privileged communication. See Tarasoff. See Table 3.1. Confidentiality of records: The critical ethical and legal issue that address the importance of confidentiality records, the probable right of parents to their children’s records as well as clients to their own records. See Buckley Amendment. Confinement against one’s will: The critical ethical and legal issue that addresses the fact that an individual cannot be hospitalized against his or her will unless he or she is in danger of harming self or another. See Donaldson v. O’Connor. Conflicts of interest: An ethical “hot spot” that suggests that dual relationships can often be problematic in the helping relationship and should be avoided. See Table 3.1. Confrontation: The commonly used skill in which the clinician first builds a trusting relationship then gently encourages the client to change. Based on the clinician recognizing one of four client discrepancies: values and behavior, feelings and behavior, idealized self and real self, and expressed feelings and underlying. Five types: You/but statements, asking client to justify the discrepancy, reframing, irony or satire, and higher level empathy. Conjoint treatment: Occurs when the client is engaged in more than one mode of treatment. Common examples include individual counseling plus a support group, group counseling, or group psychotherapy; individual counseling plus family or couples counseling; and individual or group therapy plus specialized assistance such as stress management training or career counseling. Content self-disclosure: A type of self-disclosure in which the clinician reveals information about himself or herself. Also see process self-disclosure. A commonly used skill. Contents of a client record: Materials comprising a client record vary according to type of professional counseling setting, differences in state and local requirements, and needs and guidelines of the specific agency in which one is employed. Typical contents include: initial contact information, diagnosis and treatment planning notes, progress notes, and termination materials. Consultation, supervision, and collaboration: Use of clinical supervision, clinical consultation, medical consult, referral, co-therapists, conjoint treatment, and other professional relationships when assisting clients. Conversational empathic responses: The infusion of one’s natural personality style into the response while maintaining the critical components of an empathic response: reflection of feelings and content. Core areas of knowledge and skills: Eight areas, identified by the authors, which professional counselors should master. Include: ethical, professional, and cross-cultural issues; helper attitudes; techniques; diagnosis; case conceptualization; treatment planning; case management; and theory. Corey’s model of ethical decision-making: A seven step ethical decision-making model. Includes: identifying the problem; identifying the potential issues involved; reviewing the relevant ethical guidelines; obtaining consultation; considering possible and probable courses of action; enumerating the consequences of various decisions; and deciding on the best course of action. Co-therapy: Occurs when two (or more) clinicians work directly together. Common examples include group, couples, or family therapy conducted by a pair of therapists. Countertransference: Classic definition: “The positive or negative wishes, fantasies, and feelings that the counselor unconsciously directs or transfers to the client, stemming from his or her own unresolved conflicts” (Gladding, 2001). Modernday definition: When a client’s behavior touches a clinician’s “sore spot,” that clinician may respond in ways that can have a deleterious affect on the client. A common concern of beginning counselors. Courts and criminal justice mandates: One important exception to confidentiality, courts in the United States typically may demand information or clinician communication about a client’s background, current functioning, compliance with treatment, clinician’s assessment, or other professional data. Criterion-referenced approach: A categorical system of diagnosis, stemming from the traditional medical-scientific method of organizing, naming, and communicating information as objectively as possible, which requires matching client presentations to sets of observation criteria. Critical ethical and legal issues: Those ethical concerns that have significantly impacted the work of the clinician and are often found to be associated with important legal issues. Include: breach of confidentiality, confidentiality of records, privileged communication, confinement against one’s will, and the importance of malpractice insurance. Cross-cultural issues: The acknowledgement that counseling is not working for many clients of color and that clinicians need to be vigilant about having an ever increasing awareness of their own assumptions, values, and biases; an understanding of the worldview of the culturally different client; and the ability to apply adequate intervention strategies when working with culturally different clients Cross-cultural myths: Eight myths/attitudes that some clinicians hold that deleteriously affects their work with minority clients. Include: melting pot myth, differing expectations about counseling, not understanding impact of social forces, ethnocentric worldview, ignorance of own racist attitudes and prejudices, not understanding cultural differences in expression of symptomatology, not realizing bias in assessment and research instruments, and being unaware of institutional racism. Culturally appropriate reactions: From a diagnostic standpoint, culturally appropriate reactions to life events usually are not diagnosable as mental disorders, even when they cause distress or dysfunction in the client’s life. Decision-making model: A model that suggests a process for helping to resolve difficult ethical dilemmas. One such model, suggested by Corey, et al. (2003) has seven steps. See Corey’s model of ethical decision-making. Descriptive-diagnosis approach: One of four approach to intuitive-logical clinical. thinking at Step 2 of the inverted pyramid method of case conceptualization. Using this approach, the counselor looks for mental disorders. Clinical thinking using this approach leads toward inferences and treatment planning based on the diagnoses or disorders identified. Destructive attitudes: Attitudes that can have a deleterious effect on the helping relationship, such as being critical, disapproving, disbelieving, scolding, threatening, discounting, ridiculing, punishing, sexist, prejudice, and rejecting. Determining treatment: The second aspect of treatment planning. Includes decision-making about: who will be the service provider, what treatment formats will be employed, what therapeutic approach will be used, which specific interventions will be employed, and what the duration of the counseling relationship will be. Developmental models: Models that address ethical dilemmas and suggest that clinicians at lower developmental levels are dualistic and likely to adhere rigidly to ethical code while clinicians at higher levels are apt to use such codes in a deeply reflective decision-making process. Diagnosis: How the professional counselor comes to understand and categorize client issues, usually using DSM-IV-TR, in case conceptualization and treatment planning. One of the eight core areas of knowledge and skills. Differential diagnoses: Competing diagnoses the clinician should consider before settling on a particular mental disorder diagnosis. These are listed in the DSM text for every disorder to help to clinician avoid overlooking other possible mental disorders the client might be experiencing. Direct question: A type of information gathering technique that uses a question to focus on specific content in an effort to obtain information quickly. Disorders organized by shared similarity: Seven DSM chapters organized into classes of disorders by shared similarity of symptoms, also referred to as shared phenomenology of features. These include: Somatoform, Factitious, Dissociative, Sexual and Gender Identity, Eating, Sleep, and Impulse Control disorders. Documentation: Record-keeping, note-taking, monitoring, and notations of all client information, including pre-interview and intake materials, case notes, termination materials, and storage of records. Documenting the attainment of goals: The third aspect of treatment planning. Provides the clinician with a tool to substantiate the work being done and confirm the efficacy of one’s work. Includes showing what goals were set, what interventions were used, what milestones were reached along the way, and whether the goals were ultimately reached. Besides demonstrating that client needs are met, also provides support for third-party payments and safeguards in the case of liability challenges. Donaldson v. O’Connor: The Supreme Court decision that unanimously upheld lower court decisions stating that a hospital could not hold a patient against his will if he was not in danger of harming himself or others. Led to deinstitutionalization of state hospitals. DSM-IV-TR: The Diagnostic and Statistical Manual-IV-TR (DSM-IV-TR), published by American Psychiatric Association, is the primary classification system of mental health diagnoses in use today and contains about 300 separate diagnoses. DSM-IV-TR Diagnosis: Description of a client’s mental health concerns using a classification system of mental disorders that is based on sets of criteria made up of observable features. Dual relationships: An ethical “hot spot” that states clinicians should avoid not having other relationships outside the professional arena with clients. See Table 3.1. Duty to warn: The legal assumption that a clinician must make all efforts to prevent a client from danger to another or to self. Emotional state: Part of the mental status exam that assesses the client’s affect and mood. Affect is the client’s current, prevailing feeling state (e.g., happy, sad, joyful, angry, depressed, etc.), and may also be reported as constricted or full, appropriate or inappropriate to content, labile, flat, blunted, exaggerated, and so forth. Mood represents the long-term, underlying emotional well-being of the client. Empathy: The ability to have deep understanding toward a client. May be more important as a function of the stage of the counseling relationship. Classic definition developed by Carl Rogers. Robert Carkhuff created a scale to measure empathy. Three kinds of responses: formula, conversational, advanced. Both a critical attitude and an important skill for effective counseling. A foundational skill. Employment checks and background investigations: Clinicians may receive requests to communicate about clients and former clients with employers or potential employers, and generally may do so with the client’s written authorization. Encouragement: When the clinician tells the client he or she has faith that the client can achieve a certain goal or be successful in trying out a new behavior. A commonly used skill. Establishing how change will be measured: Included in a completed treatment plan, this is a specification of the methods to be used to assess client progress. Change may be assessed by a combination of subjective and objective measures such as: client records and self-report, in-session observation, clinical rating and clinical estimate, pre-post comparisons, and achievement of milestones or short-term gains. Ethical “hot spots”: Ethical issues that have been particularly focused upon over the recent years and addressed in varying professional codes of ethics. Include: confidentiality, competence, dual relationships and conflicts of interest, inappropriate fee assessment, informed consent, misrepresentation of credentials, and sexual relationships with clients. See Table 3.1. Ethical, professional, and cross-cultural issues: Those ethical, professional, and cross-cultural issues that are critical to the helping relationship and affect how the clinician works with his or her client. One of the eight core areas of knowledge and skill. Ethics: Generally describes the collectively agreed upon “correct” behaviors within the context of a professional group. Existential model of cross-cultural counseling: As suggested by Speight, Myers, Cox, and Highlen (1991), in trying to understand clients, clinicians should be aware of their uniqueness (Eigenwelt), their common experiences held in groups and cultures (Mitwelt), and their shared universal experiences (Umwelt). Evidence-based treatment: Selection of treatment mode and specific interventions on the basis of efficacy research regarding the most effective approaches associated with various client needs. Eysenck: Known for flawed research on counseling that showed little results. His research spurred new research that showed effectiveness of counseling. Family Rights and Privacy Act (FERPA): See Buckley Amendment. Formal assessment techniques: Tests that are valid, reliable, practical, cross-culturally fair, and specific to the issue at hand. Often used to assist in information gathering. Freedom of Information Act: This law assures the right of individuals to access their federal records. Most states have similar laws that assure access to state records. Formula empathic responses: Important in the learning of empathic responses, it involves using the following formula when first making empathic responses: “You feel place feeling word here because (or “and”) place content here. Functional, normal, and ordered behavior: From a diagnostic standpoint, most human behavior is functional, normal, and ordered, rather than dysfunctional, abnormal, or disordered. Such behaviors do not cause significant distress or impairment beyond normal expectations. Gelso and Carter: See “relationship building.” General medical conditions: Physical and medical problems, especially those that might be associated with a client’s mental health concerns. These are recorded on Axis III. Genuineness: The willingness to be authentic, real, open, and periodically self-disclosing within the helping relationship. One of the eight critical attitudes. Genogram: An informal assessment tool that examines the family's functioning over a number of generations. Often includes such items as dates of birth and death, names, major relationships, scapegoats, identified patient, mental illness, disabilities, cultural or ethnic issues, physical diseases, affairs, abortions, and stillbirths Glasser, William: Founder of reality therapy and spoke to the importance of the relationship in counseling. Global Assessment of Functioning: The GAF Scale ranges from 1 – 100, is used by the clinician to estimate the client’s overall functioning in everyday life, and is recorded on Axis V of the DSM-IV-TR system. Goal setting and treatment planning stage: Stage 3 of the helping relationship, with its primary goal being to specify expected outcomes of the counseling process. See Tables. 2.1-2.3 to review how core areas of knowledge and skills are applied at this stage. Hackney and Cormier: Presented eight characteristics of effective helping: self-awareness and understanding, good psychological health, sensitivity, open-mindedness, objectivity, competence, trustworthiness, and interpersonal attractiveness. Health Insurance Portability and Accountability Act (HIPAA): Ensures the privacy of client records and the sharing of such information. In general, HIPAA restricts the amount of information that can be shared without client consent and allows clients to have access to their records, except for process notes used in counseling. Health maintenance organization (HMO): A managed health care organization. Inadvertent modeling. The unplanned adoption of behaviors exhibited by the clinician on the part of the client. Also see intentional modeling. A commonly used skill. Imposter syndrome: The feeling that although we have gained expertise in a particular area, we still feel as if we are “faking it” or not worthy of what we have accomplished. A common concern of beginning counselors. Inappropriate fee assessment: An ethical “hotspot” that suggests clinicians need to be vigilant about how they charge for services. See Table 3.1. See Table 3.1. Informal assessment instruments: Instruments that allow a client a wide-range of responses and often used in information gathering. A few examples include: clinician made ratings scales, sentence completions, client diaries, client autobiographies, observation of clients, interviewing others about clients, the use of drawings, and genograms. Information gathering: The skills used to gather information from clients. Includes the use of questions, conducting a structured interview, and assessment techniques. Information giving. One of three problem-focused skills, commonly used skills, in which the clinician offers “objective” information of which the client is truly unaware in an effort to help the client reach his or her goals. More potentially harmful than offering alternatives but less than advice giving. Also see offering alternatives and advice giving. Informed consent: The client’s verbal or written permission to participate in the helping interview. Generally given after the client has received a professional disclosure statement. Also considered an ethical “hot spot” (see Table 3.1). Initial contact information: Generally includes data obtained prior to the first interview as well as intake materials. Typically included are such items as information on record, intake data, psychological testing results, and the intake summary. Intake summary: A report written by the clinician that provides a detailed snapshot of all the basic information gathered from the client’s initial contact. Typically includes identifying information, presenting concerns, background history, problem and counseling history, mental status exam, and goals for counseling and course of counseling to date. Intentional modeling: The planned viewing and subsequent practice then adoption of desired behaviors by clients. Also see inadvertent modeling. A commonly used skill. Inter-chapter organization: The DSM-IV-TR’s inter-chapter organization is designed to assist the clinician in making an appropriate diagnosis. The text begins with childhood disorders, follows with four “red flag” classes of disorders and two most common disorders (mood and anxiety disorders), next presents a series of phenomenologically similar classes of disorders, then presents adjustment disorders, follows with Axis II personality disorders, and finally presents other conditions. Intrapsychic approach: One of four approaches to intuitive-logical clinical. thinking at Step 2 of the inverted pyramid method of case conceptualization. Using this approach, the counselor looks for intrapersonal life themes. Clinical thinking using this approach divides client issues by common denominators according to the intrapsychic roles they play. Inverted pyramid method: A step-by-step approach to case conceptualization that gives students and beginning clinicians a specific plan to identify and understand client concerns. Involves four steps: problem identification; thematic grouping; formation of theoretical inferences; and formation of deeper theoretical inferences. Joining: See “relationship building.” Jaffee v. Redmond: The 1996 Supreme Court ruling that held the right of a licensed social worker to keep her case records confidential. Likely to apply to all licensed clinicians. Kitchener’s moral model: Describes the role of five moral principles in the making of ethical decisions. Include autonomy, beneficence, nonmaleficence, justice, and fidelity. Lambert and Cattani-Thompson: Conducted research that showed effectiveness of counseling. Lambert and Ogles: Conducted research that showed effectiveness of counseling. Listener: The natural helper style in which the individual likes to understand another‘s point of view by listening and showing empathy. Listening: A foundational skill that helps build the relationship and tells the client the clinician is wanting to learn more about him or her. Good listeners don’t interrupt, show interest, don’t jump to conclusions, and have good non-verbals. Malpractice insurance: A critical ethical and legal issues which suggests that all clinicians need to purchase insurance to protect them from potential lawsuits. Managed care: Includes HMOs, PPOs and other organizations that are designed to help contain health care costs and provide evidence of accountability from providers. Matching problem with intervention strategy: An important professional issue, that addresses the research that suggests that adherence to one theoretical orientation may be less important than matching the client’s problem with an intervention strategy that has been shown to be effective. Mental disorder: A clinically significant pattern that occurs in an individual and is associated with present distress, impairment in one or more important areas of functioning , or significantly increased risk of distress or dysfunction (APA, 1994). Mental retardation: This mental disorder is presented in the DSM-IV-TR’s first chapter, Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence. Criteria include significantly subaverage measured intellectual functioning, deficits in everyday adaptive functioning, and onset before age 18. Mental retardation is recorded on Axis II of the system. Mental status exam: An assessment of the client’s appearance and behavior, emotional state, thought components, and cognitive functioning. Used to assist the clinician in making a diagnosis and in treatment planning. Minuchin, Salvadore: Well-known family therapist who stressed the importance of “joining” with clients. Similar to the concept of relationship building. Misrepresentation of credentials: The “ethical hotspot” that speaks to the issue of the importance of claiming only those credentials for which one has legitimately achieved. See Table 3.1. Modeling: The demonstration of a behavior which a client views and later exhibits. Modeling can be inadvertent or intentional. A commonly used skill. Moral models: Ethical decision-making models that stress the role of moral principles when faced with difficult ethical dilemmas. See Kitchener’s moral model and Rest’s moral model. Morality: Generally concerned with how an individual conducts oneself and is often the reflection of values of a group, such as an individual’s family, religious sect, culture, or nationality. Multi-axial diagnostic system of the DSM-IV-TR: A system of five “axes,” or mechanisms for gathering and recording data, currently in use by the mental health profession. Narrowed inferences: Step 4 of the inverted pyramid method of case conceptualization. Requires applying the same theoretical orientation used in Step 3 of the method to identify still-deeper, more encompassing, or more central, causal themes, when they are present. At Step 4, these themes are distilled or narrowed further into existential, fundamental, or underlying questions of life and death (suicidal and homicidal thoughts and meaning of life issues), deep-rooted shame or rage, extreme loss of identity, fragile personality structures, or other deep concerns. Natural helping: The informal style of the untrained lay helper. Natural helpers rely on intuition, familiarity, natural responsiveness, and personal opinions. Four different styles: listener, analyzer, problem solver, and challenger. Non-diagnosable client presentations: Functional, normal, and ordered behavior, or expected and culturally appropriate reactions to life events and developmental challenges. Non-verbal behaviors: The often unconscious behaviors exhibited during communication. As much as eight percent of communicate. Varies across culture. Includes: attire, eye contact, body positioning, facial expressions, personal space, touch, voice intonations and tone. A foundational skill. Offering alternatives: The least potentially harmful of three problem-focused, commonly used, skills in which a number of options toward working on identified problems are given. Also see information-giving and advice-giving. Open-mindedness: Freedom from fixed preconceptions and an attitude of open receptivity to what the client is expressing. One of the eight critical attitudes. Open question: A type of information gathering technique in which a question is used to allow the client to respond in a myriad of ways. Other conditions that may be a focus of treatment: Problem areas that are not considered mental disorders appear together in the DSM-IV-TR under this heading. This section lists various issues, problems, areas of growth and development, and other counseling themes and topics that may be a focus of treatment, but are not causing enough clinically significant symptoms or distress to warrant a mental disorder diagnosis. Paraphrasing: Repeating back to the client, in condensed form, what you heard the client say. An important skill prior to being empathic. A foundational skill. Pause time: The amount of silence between responses. Varies as a function of culture. Some suggest allowing for 30 seconds of pause time. Personality disorders: These disorders are presented in the DSM-IV-TRs’ last chapter of mental disorders. Personality disorders are characterized by “an enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual’s culture” (APA, 1994; p. 633). Three clusters of personality disorders are included: Odd-Eccentric (Paranoid, Schizoid, and Schizotypal), Dramatic-Emotional (Antisocial, Borderline, Histrionic, and Narcissistic), and Anxious-Fearful (Avoidant, Dependent, and Obsessive-Compulsive). Parents and legal guardians: As a general rule, in the United States the parent or legal guardian of a minor under age 18 has “ownership” of the client’s confidentiality. Post-interview stage: Stage 6 of the helping relationship, with its primary goal being to maintain appropriate availability. See Tables. 2.1-2.3 to review how core areas of knowledge and skills are applied at this stage. Pre-interview stage: ”Stage 0” of the helping relationship, with its primary goal being to prepare for an optimal first professional encounter with the client. See Tables. 2.1-2.3 to review how core areas of knowledge and skills are applied at this stage. Privileged communication: The critical ethical and legal issue that asserts the right to confidentiality of a conversation conducted with someone that state or federal law identifies as a person with whom conversations may be privileged; that is, legally kept confidential. Generally given to licensed clinicians. See Jaffee v. Redmond. Contrast with confidentiality. Problem identification: Step 1 of the inverted pyramid method of case conceptualization. Requires using wide latitude to identify and list the client’s presenting concerns, associated concerns, and relevant aspects of the person’s functioning. More specifically, involves exploring the presenting problem, additional areas of concern, parental and family relationships, experiences and reactions during sessions, health-related issues, as well as formal psychological assessment. Problem identification stage: Stage 2 of the helping relationship, with its primary goal being to identify, describe, and understand the client’s concerns. See Tables. 2.12.3 to review how core areas of knowledge and skills are applied at this stage. Problem solver: The natural helper style in which the individual likes to define the problem, set goals, and take action to reach a solution. Problem-focused skills: One of three types of commonly used skills in which the clinician either offers alternatives, provides information, or gives advice. See offering alternatives, information-giving, or advice giving. Process self-disclosure: When the clinician expresses how he or she feels about the client in the moment. Also see content self-disclosure. A commonly used skill. Professional counseling: The term used to describe the highly trained clinician who deliberately applies a broad range of critical skills in a systematic fashion within the counseling relationship. Professional disclosure statement: A verbal or written statement given near the beginning of the helping relationship that describes a number of counseling related issues such as the helper’s theoretical orientation, credentials held, the purpose of the interview, relevant agency rules, limits to confidentiality, legal issues, and fees for service. Progress notes: A record, prepared by the clinician, of how counseling proceeds. A key part of the client’s record, providing a clinical reference for professional use and a mechanism or showing accountability. Also referred to as “case notes.” Professional provider organization (PPO): A managed health care organization. Psychiatric consultation: Either discussing a case directly with a psychiatrist, usually to explore diagnoses or pharmacological interventions, or referring a client to a psychiatrist for diagnostic or medical evaluation. Psychological adjustment: The willingness to undertake activities, such as counseling, in order to assure that the clinician is well-balanced and able to work effectively with clients. One of the eight critical attitudes. Psychosocial and environmental problems: Problems the client is experiencing with his or her primary support group, social environment, educational situation, occupational situation, housing, economics, access to health care services, the legal system, and similar issues, especially those that might be associated with the client’s mental health concerns. These are recorded on Axis IV. Psychotropic medications: Medications used in the treatment of mental health problems. Purkey and Schmidt: Identified four characteristics of the effective helper: being personally inviting with oneself, being personally inviting with others, being professionally inviting with oneself, and being professionally inviting with others. Questions: One of the information gathering skills, questions come in a variety of forms, including: direct questions, closed questions delimiting affect, closed questions delimiting content, open questions, tentative questions, and why questions. Rapport and trust building: Stage 1 of the helping relationship that begins with the actual interview. The primary goal is to gather initial information about the client and establish a trusting, facilitative, therapeutic alliance. See Tables. 2.1-2.3 to review how core areas of knowledge and skills are applied at this stage. Recording procedures: Provided in the DSM-IV-TR text for each mental disorder, these are instructions for documenting subtypes and specifiers as well as for writing out the numerical code associated with the diagnosis. Red flag chapters: Four red flag classes of disorders appear early in the diagnostic system text and should be immediately ruled out by the clinician. These include: delirium, dementia, amnestic disorders and other severe cognitive disturbances; general medical conditions; substance use disorders; and schizophrenia and other psychotic disorders. Relationship building: The manner in which clinicians brings themselves into the counseling relationship and relate with the client. Gelso and Carter state that this working alliance exist throughout the stages of the counseling relationship, regardless of whether it is explicitly acknowledged by the counselor and the client. One of the eight critical attitudes. Relative efficacy: One of two types of evidential counseling outcome research. Refers to the comparative study of the effectiveness of different theoretical approaches, for example psychoanalytic versus behavior treatment, to help understand which approaches are best for which client needs. Resistance: “Any behavior that moves a client away from areas of discomfort or conflict and prevents the client from developing.” (Gladding, 2001). A common concern of beginning counselors. Resolving ethical dilemmas: Three methods suggested for resolving difficult ethical concerns: decision-making models, moral models, and developmental models. Rest’s moral model: Suggests following a critical decision-making path that includes: making an interpretation about the situation, gauging and selecting the moral principles that underlie the decision to be made (e.g., a person should not murder), and acting on the basis of the selected moral principle(s). Rogers, Carl: Defined empathy, genuineness, and unconditional positive regard as core conditions to the counseling relationship. Stressed the importance of the relationship in the counseling process. Selecting achievable goals: The first aspect of treatment planning. Involves determining specific objectives for change from among the presenting concerns, associated concerns, etiological factors, and/or sustaining factors which are causing the client distress or dysfunction. Involves the following considerations: selecting the problems, urgency and dysfunction, case conceptualization, client motivation, real world influences, and setting behaviorally measurable goals. Self-disclosure: When the clinician reveals parts of himself or herself in an effort to strengthen the counseling relationship, help client feel comfortable with selfdisclosure, and/or offer a new way of being in relationships. Two types: content self-disclosure and process self-disclosure. A commonly used skill. Sexton: Researcher who found that "counseling outcome research findings are so compelling that the debate regarding whether counseling is effective is no longer a major issue." Sexual relationships with clients: The ethical “hot spot” that states clinicians must not have sexual relationships with clients. See Table 3.1. Silence: An important foundational skill that gives the client and the clinician time to reflect on what has been said. Also, see “pause time.” SOAP: A common template for writing case notes, including the following information: Subjective Client Report, Clinician Observations, Current Assessment, and Current Plan. Speight, Myers, Cox, and Highlen: See existential model of cross-cultural counseling. Stages of the counseling relationship: The natural unfolding progression of the helping relationship. Core areas of knowledge and skills should be applied to them in a systematic fashion (See Tables 2.1–2.3). The stages include: The Pre-Interview; Rapport and Trust-Building; Problem Identification; Goal-Setting; Work; Closure; and The Post-Relationship. Storing of records: Safeguarding of client files and materials during and after a course of professional counseling. Must be done in a secure and confidential manner in compliance with ethical and legal guidelines. Structured interviews: An information gathering technique that gives the clinician a mechanism to gather information in a consistent and expeditious manner. An important precursor to developing treatment plans. Questions are often used to facilitate this process. Often includes: demographic information, reason for referral or contact, family of origin background, current family background, cross-cultural issues, educational and vocational background, medical/psychiatric history, substance abuse history, legal issues and history, and mental status. Tarasoff case: The landmark case that set a precedent for the responsibility that clinicians have regarding confidentiality and acting to prevent a client from harming self for others. See “duty to warn.” Techniques: The type of helping skills that have been shown to be effective in assisting the client through the stages of the helping relationship. Includes foundational skills, information gathering skills, and commonly used skills. One of the eight core areas of knowledge and skills. Tentative question: A type of information gathering technique in which a question is asked in a manner that invites the client to tell the clinician if he or she is on target with the response made. Empathic responses can be made into tentative questions or other kinds of questions can be asked in a tentative fashion. Termination summary: A part of the client record associated with the Closure Stage of the helping relationship. Describes the overall progress made in implementing the treatment plan and achieving stated goals for change. Typically includes four components: Reason for Termination, Treatment Plan Compliance, Progress Summary, and Post-Termination After-Plan. Thematic groupings: Step 2 of the inverted pyramid method of case conceptualization. Requires organizing all identified client problem and symptoms into intuitivelogical groupings or constellations. Four types of intuitive-logical judgment may be applied: descriptive-diagnosis, clinical targets, areas of dysfunction, or intrapsychic. Theoretical inferences: Step 3 of the inverted pyramid method of case conceptualization. Requires attempting to tentatively match client themes developed in previous steps of the process to areas of difficulty according to the counselor’s theoretical orientation. At this step, previously identified symptom constellations are refined to reflect inferences about deeper aspects or causal roots of the client’s difficulties. Theoretical orientation: System of understanding human functioning and dysfunction applied by the clinician to his or her understanding of client needs. Commonly used traditional theoretical orientations include: behavioral, brief solutionfocused, cognitive, cognitive-behavioral, humanistic, and psychodynamic. Others include existential, feminist psychology of women, reality, and gestalt. Theories often are combined to form eclectic or integrative orientations. Theory: The template for conceptualizing client problems. Theories are heuristic, based one’s view of human nature, and typically take into account the effects of biology, genetics, and environment. One of the eight core areas of knowledge and skills. Thought components: The part of the mental status exam that looks at the content and the process of thinking. Content includes delusions, distortions of body image, hallucinations, obsessions, suicidal or homicidal ideation, and so forth. Process includes circumstantially, coherence, flight of ideas, logical thinking, intact as opposed to loose associations, organization, and tangentiality. Time management: Being on time, keeping appointments, meeting deadlines, staying as expected during assigned office hours; and being present, timely, and conscientious regarding all clinical duties, including individual, group, and other counseling assignments, as well as intake duty, on call and emergency staffing, phoneline responsibilities and similar tasks; and being present, timely, and active in all clinically related activities, such as attending supervision, consultation meetings, case staffings, and other meetings. Such work habits take on special meaning and importance in the context of providing professional counseling services. Treatment planning [Definition 1]: The process used to address identified client concerns, and is based on one’s conceptualization of client problems and on the diagnosis. One of the eight core areas of knowledge and skills. Treatment planning [Definition 2]: The process of plotting out the counseling process by delineating the path from the client’s presenting concerns and underlying difficulties to alleviation of these concerns. Treatment planning stems from the clinician’s conceptualization of client needs and includes three aspects: selecting achievable goals, determining treatment modes, and documenting attainment of goals. White knight syndrome: The feeling that we need to rescue others. A common concern of beginning counselors. Why question: A type of information gathering technique in which a “Why” question is asked with the intent to have the client delve deeply into self. However, clients often feel defensive with why questions and they should generally be avoided. Work stage: Stage 4 of the helping relationship, with its primary goal being to facilitate progress toward specified treatment goals. See Tables. 2.1-2.3 to review how core areas of knowledge and skills are applied at this stage. Working alliance: See “relationship building.”