Chapter 4 of 530% of exam

Counseling Skills and Interventions

The largest domain asks what the counselor should do or say next. It spans motivational interviewing, crisis and safety work, trauma-informed responses, evidence-based techniques for specific disorders, family systems, and group leadership.

Motivational interviewing and stages of change

MI is a collaborative style for resolving ambivalence. It relies on open questions, affirmations, reflections, and summaries, and it responds to sustain talk and discord without arguing. Matching the intervention to the client's stage of change is a frequent test point.

OARS

Open questions, affirming, reflective listening, and summarizing are the core skills; follow each question with two or more reflections.

SAMHSA TIP 35 (2019)

Change talk

DARN-CAT: desire, ability, reasons, need, commitment, activation, taking steps.

SAMHSA TIP 35 (2019)

Reflections for sustain talk

Double-sided reflections join both sides with 'and', ending on change talk; amplified reflections overstate the client's view without sarcasm.

SAMHSA TIP 35 (2019)

Match the stage

In precontemplation, build rapport and raise doubt; in contemplation, normalize ambivalence and evoke reasons; save detailed plans for preparation and action.

SAMHSA TIP 35 (2019)

Discord

Discord is a relationship signal; resist the righting reflex, emphasize autonomy, or shift focus.

SAMHSA TIP 35 (2019)

Crisis, suicide, and trauma-informed responses

When risk is acute, safety comes before everything else, and the counselor does not act alone. In trauma work, the counselor watches for dissociation and destabilization and keeps the client grounded.

Safety plans, not contracts

No-suicide contracts are not recommended and never sufficient; build a personalized safety card or plan with the client, including 988.

SAMHSA TIP 50 (2009); SAMHSA 988 Lifeline

Reduce access to means

Restricting access to the method, such as arranging safe storage of a gun, is a core responsible action.

SAMHSA TIP 50 (2009)

Acute risk

For a plan, a method, and intent, obtain immediate supervision and arrange emergency evaluation; call 911 when life is in danger.

SAMHSA TIP 50 (2009); NIMH

Grounding and stability

Use grounding for dissociation; stop trauma exploration if the client destabilizes; make sure the client is grounded before leaving.

SAMHSA TIP 57 (2014)

After disasters

Psychological first aid covers safety, comfort, and practical help; single-session debriefing is not supported.

SAMHSA TIP 57 (2014)

Evidence-based techniques and family systems

Several disorders have a named first-line psychotherapy in the federal summaries. Family questions use systems concepts: boundaries, triangles, and homeostasis.

Exposure-based CBT

Graded exposure for PTSD avoidance, ERP for OCD, and interoceptive exposure for panic.

NIMH PTSD, OCD, and Panic Disorder publications

Cognitive restructuring

CBT helps clients notice inaccurate automatic thoughts and test them.

NIMH, Psychotherapies

DBT

Dialectical behavior therapy teaches mindfulness and emotion-management skills for borderline personality disorder; medication is not first-line.

NIMH, Borderline Personality Disorder

Family systems

Triangulation routes a two-person conflict through a third person; structural work marks boundaries; families resist change (homeostasis) even when it is positive.

SAMHSA TIP 39 (2004)

Solution-focused exceptions

Ask about times when the problem was absent or less severe, and build on what was different.

SAMHSA TIP 39 (2004)

Group leadership

Group items ask about screening and preparation, stage-appropriate work, protecting members, and using the group's own interactions. The leader's first job is safety and cohesion; highly charged work comes later.

Prepare members

Meet with prospective members individually to review the group agreement before they join.

SAMHSA TIP 41 (2005)

Early stage

Emphasize hope, universality, and cohesion; defer catharsis and family-of-origin reenactment.

SAMHSA TIP 41 (2005)

Protect members

Take reasonable precautions to protect members from emotional or psychological trauma; respond quickly to harmful norms such as scapegoating.

ACA Code of Ethics (2014) A.9.b; SAMHSA TIP 41 (2005)

Here and now

Invite members to put their reactions to one another into words in the moment.

SAMHSA TIP 41 (2005)

Outside contact

Discourage outside relationships, and discuss any outside contact openly in the group.

SAMHSA TIP 41 (2005)

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