BHA/P Services and Common Interventions

Prepare any required documents, such as Consent to Treatment or Release of Information, if they have not yet been completed.

Make sure the meeting area is safe and confidential. Refer to Confidentiality and Release of Information.

Depending on your level of certification, you may be required to review your intervention plan with your supervisor before the session.

Review the treatment plan for an existing client.

• If there is a current treatment plan, refer to it first. It is possible, if not likely, that a community member will show up to your office asking for services without having a scheduled appointment. In these instances, follow your organization's policies and procedure for working with a new client.
• Work with your clinical team to determine the most relevant and appropriate interventions to use for this client's treatment.
• Integrate the information you gathered from the client and/or caregiver and other sources.
• Request collateral information, including reports or records from other sources.
• Identify ways to use the client's personal strengths and abilities.
• Consult with your clinical supervisor if needed.

Review treatment goals for an existing client.

• Revisit the original referral question (i.e., why did this person come in for services?).
• What signs, symptoms, and risk factors require immediate attention? What can be addressed over the course of treatment?
• What positive factors can be increased, such as social supports or medication management? See Self-Care for BHA/Ps and Clients and Wellness and Prevention.
• What signs, symptoms and risk factors can be decreased, such as the frequency of coping behaviors or hopeless feelings?

When working with minors, make sure the meeting environment is appropriate for the client’s age. Include some appropriate activities and toys, such as the following.

• All ages: Art and craft supplies, age-appropriate board games, kinetic sand.
• Ages 3-5: Large hand-held toys, play dough, small chairs and tables. If small chairs and tables are not available, use the floor.
• Ages 5-10: Clay, putty, play dough, large puzzles.
• Ages 10 and up: Puzzles, books.
• Adolescents: Table games such as Uno or other card games. May respond better to non-verbal techniques, but may also respond to verbal interactions.

There are many laws that govern and guide your work with minors.

• Be aware of all agency, state, federal, local,and Indian Child Welfare Act (ICWA) requirements of working with a minor. This includes obtaining any required treatment authorizations from the legal guardian. A summary of this information can be found in Chapter B-3: Consent to Treatment.

Safety should always come first. Be aware of and operate within ethical boundaries. See Chapter B-1: Values and Ethics for BHA/Ps.

• For your own safety, whenever possible, schedule client visits with minors during regular business hours and when there are other people in the building and accessible.
• Maintain appropriate physical boundaries when working with children.
• Remember that abused children can easily misinterpret physical touch, and you may not know whether a child has been abused.

There are some things a client tells you that cannot be kept confidential.

• As a behavioral health provider, you are a mandated reporter and must make a report to the appropriate authorities if you suspect abuse or neglect or if a client tells you about plans to harm the self or others.
• See Chapter B-5: Mandatory Reporting and Duty to Warn and consult with your supervisor regarding your agency’s protocols for reporting.

Start with a warm greeting to begin building a trusting relationship.

Take time to orient your client to behavioral health services. Make sure he has completed all required paperwork and answer any questions he may have about the forms or process of behavioral health treatment.

Allow the client to express her feelings, including her hopes for how behavioral health services can help her address her presenting problems. Use the techniques described below to provide the client with opportunities to express feelings and needs without being judged.

• Be open and ready to listen and help. Acknowledge and praise successes, big and small.
• Be careful not to shame the client. Never express shock, argue, tease, or tell the client that her thoughts or feelings are wrong or incorrect.
• Be careful to not take sides if a client and family member or caregiver have a disagreement.
• Be alert and observant. For client and staff safety, set and maintain professional boundaries.
• Remember that there are many ways to be an effective counselor; regardless of your approach to treatment, you should always be respectful and ethical.

When possible, especially with older clients (adolescents and adults), allow the client to decide what problem to work on in the session. If a client does not have full capacity to make independent decisions due to age or disability, develop the plan with the parent or guardian.

As part of your professional boundaries, keep in mind that the problem is the client’s, not yours. You can help the client problem-solve, but it is up to the client (and caregiver) to decide how to manage it.

Explain your plan of action to the client. Don’t promise the client or caregiver an answer to the problem.

Remind your client that healing takes time. Help him to develop coping strategies to support his interim success while he works toward healing.

During the appointment, provide a service that aligns with those assigned to you in the treatment plan. If there is no treatment plan, provide a service that aligns with your scope of practice. Throughout the appointment, look for opportunities to identify any additional needs client may have, including referrals to other possible intervention services. Depending on the client's presenting problems and level of risk, you may consider a range of interventions individually or together.

Clinical Interventions are processes used to improve a client’s behavior, thinking, or emotional state. The type of interventions used will vary depending on the issue and severity of the problem. They may also vary based on the type of treatment or treatment setting (e.g., outpatient, inpatient, residential, or detoxification ).

The level of available care and services differs by community and region within the tribal health system. Some types of interventions may not be available in your region, though clients may be able to access such services through the referral process. It is important to know what resources are available to your community members locally, regionally, and throughout Alaska.

Sometimes, clients may need or benefit from interventions that extend beyond the services you can provide within your BHA/P certification level. If you are uncertain about what services you can provide, consult with your supervisor. Additionally, if the client is being referred to the BHA/P for services, communication between the BHA/P and referring clinician is essential to identify the most appropriate interventions. For more information on people who can help support your work with clients, See Chapter B-7: Supervision and Support.

Minor clients. A team approach is essential to work effectively with a child. The team often includes:

• The client (a child or youth).
• Parents or guardians.
• Supportive family members and friends.
• Teachers and other school personnel.
• Elders.
• The BHA/P.
• One or more behavioral health clinicians.

Therapeutic Frameworks

As a BHA/P, you will work with people who experience a wide range of presenting problems. The Unified Protocol for Transdiagnostic Treatment of Emotional Disorders (Barlow et al.) is a useful tool to use with clients whose presenting problems are related to their experiences with and management of different emotions. This framework provides a foundational understanding of antecedents (what happens before the emotional reaction), responses, and consequences ( ARCs ) of emotional experiences and how to understand and change emotion-driven behaviors (EDBs).

Based on a similar understanding of EDBs, the core skills and activities outlined in the Dialectical-Behavioral Therapy (DBT) Skills Training Manual can help you to plan for and provide interventions with clients in four categories:

• Emotional regulation skills focus on increasing the level of control a person has over her experiences with and expression of emotions.
• Interpersonal effectiveness skills help to improve and maintain existing relationships as well as establish and build new relationships.
• Mindfulness skills help focus attention on the present moment, including what is going on internally and in our surroundings.
• Distress tolerance skills help people to increase their tolerance of and ability to survive and manage crisis situations.

Remember to only apply interventions you have been trained in and practiced already.

Most BHA/Ps serve their clients in outpatient treatment settings, wherein clients can walk into a clinic, see their behavioral health provider, and leave under their own free will. Depending on the agency, outpatient services may also be provided outside of the clinic when it is clinically appropriate to do so (e.g., conducting an elder visit or taking a client berry picking to develop and practice healthy activities).

Outpatient care is used for individuals who are experiencing distress at a level that requires less intensive treatment and supports. It is provided by a wide variety of professionals, including clinicians, psychiatrists, and BHA/Ps. In an outpatient treatment setting, clients have access to a wide range of services. The most common outpatient services are described below.

Behavioral health screenings and assessments are used to identify the psychological, behavioral, emotional, cognitive, and social factors important to the prevention, treatment, or management of a client's presenting problems. Many organizations screen all new clients for specific presenting problems, such as those related to substance use, suicidal thoughts, or problems related to memory. A client who screens positive for a presenting problem will likely be referred for additional services, including a more complete assessment. Assessments are usually conducted with a focus on Substance Abuse or Mental Health, though sometimes they are conducted together using an Integrated Assessment. Qualified BHA/Ps can conduct a Substance Abuse Assessment, but not a Mental Health or Integrated Assessment.

Assessments can also include Psychological Testing, which evaluates a person's behaviors and cognitive (brain) functioning. This helps a treatment team explore hypotheses about a person and her behavior, personality, and capabilities, including levels of intelligence. Psychological assessments are commonly referred to as psychological testing and can only be conducted by a psychologist.

Individual counseling helps the client better understand himself and his problems in order to cope with the stress of daily life. It typically takes place between one client and one BHA/P or clinician, though the client can involve a support person in the session if he chooses. The focus of the session is on the individual client's presenting problems and treatment goals. Individual sessions are usually scheduled for 45-50 minutes.

Rehabilitation services are similar to individual counseling sessions, though they have a specific focus on the client's development of life skills and coping strategies to improve or manage symptoms or the presenting problem. These sessions may include counseling focused on the improvement of day-to-day functioning, recovery, and relapse prevention, as well as encouragement and coaching.

Play therapy is a form of individual counseling that is geared towards helping children and youth cope with emotional stress or trauma. It helps them express their feelings and brings emotions to the surface. It can be used for a wide variety of issues, including:

• Nail biting.
• Bed wetting.
• Aggressive or cruel behaviors.
• Social underdevelopment.
• Child abuse.
• Disabilities that are a source of anxiety or emotional stress.
• Family problems such as domestic violence, substance abuse, or death.

Family counseling and couples' therapy may be used when a client has a problem that is influenced by or affects family and social functioning.

It can help family members improve communication, understand and handle specific family situations (such as death, serious physical or mental illness, or child or adolescent issues), and solve family and relationship problems.

• It may include multiple sessions to deal with many different issues.
• It may involve all members of a biological family, stepfamily, foster family, or adopted family. It may also include extended family members (such as grandparents) in some cases.

Group therapy involves meetings between a BHA/P or clinician and three or more clients who have similar presenting problems (e.g., substance abuse problems). The BHA/P or clinician facilitates the sessions while the clients actively participate. These meetings are usually held in person, though the geographic distance between clients who need this service has led to the development of some distance-delivered groups (using teleconference or videoteleconference equipment to connect clients in different locations).

Some groups provide time for open discussion, while others focus on specific topics. Group members are encouraged to interact with each other and to express their feelings. Whether the group meets in person or via distance-delivered mentions, the group format:

• Creates a safe environment, allowing clients to build trust and have open and honest discussions.
• Allows clients to develop new ways of relating to people.
• Demonstrates to clients that they are not alone and that there is hope and help.

Peer support is the process of giving and receiving information and support between people who share common experiences, situations, or problems. It can come in many forms, from one-on-one encounters to formal or informal groups.

Peer support groups can take on many forms, including talking circles, sewing groups, sweat lodges, beading groups, church groups, drumming groups, and many others. Groups are led by and attended by peers. Alcoholics Anonymous (AA) is an example of a peer-led support group.

Peer support groups provide:

• Encouragement from people who have been in a similar situation.
• Information about common concerns and coping strategies.
• The opportunity to use one’s experience in a positive way to help others.
• The opportunity to learn from how others cope.

They offer members:

• A sense of belonging (others are going through similar situations).
• A sense of confidentiality (an environment where people can safely get things off their chests).
• Affordability (peer support is free).
• The fun of new friendships.

You can help by:

• Giving potential peers information about setting up groups.
• Encouraging the formation of groups.
• Exploring training for Peer Support specialists if you have a lived behavioral health experience. For more information, contact the Alaska Peer Support Consortium.
• Facilitating meeting space.

Education and counseling can help people cope with existing problems, prevent future problems, and make life-altering changes. Knowledge is power, and with more knowledge about behavioral health problems and treatment, clients and community members can make informed decisions about their behavioral health care. Education and counseling will likely be regular parts of the services you provide. For example, you might help educate your clients about medication, substance abuse, mental illness, family interactions, and many other topics. Education may be provided in schools and clinics as well as at community events and other places depending on your employer's policies. It can be provided one-to-one or in group settings, such as anger management or parenting classes.

Case management is used to help clients access and coordinate additional services they may need in order to work towards their treatment goals. Case management involves a referral to or coordination of services with an outside entity. These entities may include schools, housing authorities, public assistance programs, or external treatment agencies.

Crisis Stabilization is a service provided to an individual or family actively experiencing a crisis or emergency situation. This service is designed to help the person or family to:

• Stabilize the crisis or emergency situation within a safe environment that affords the person respect and dignity.
• Obtain consultation.
• Locate other services and resources.
• Obtain follow-up services to assist in resolving the crisis.

These services are provided with the intention of preventing the client and/or family from requiring a higher level of treatment.

Inpatient treatmentis the treatment setting used for clients in crisis who have any of the following:

• Suicidal gestures, attempts, or thoughts with a plan.
• Psychotic symptoms such as hallucinations or delusions.
• Symptoms that require constant monitoring and medical interventions in order for them to be stabilized.
• Plans to harm someone else.

Inpatient treatment includes a variety of services, such as:

• Psychiatric evaluation.
• Medication stabilization.
• Behavioral stabilization.
• Individual, group, and family therapy.

Inpatient treatment is provided at a restricted inpatient setting or hospital, such as the Alaska Psychiatric Institute (API). North Star Behavioral Hospital and Providence Hospital (in Anchorage) both have separate inpatient units for adults (Mental Health Unit) and adolescents (Discovery Unit).

Treatment in inpatient settings can be involuntary if the person at risk is unwilling to sign herself in for treatment. For more information, see Chapter E-6: Involuntary Commitment of a Mentally Ill Person.

Residential treatment is long-term care that is helpful in changing behaviors that have not responded to other types of treatment. It can take place in both secure and unsecure facilities. Staffing levels, intensity of treatment, and length of stay may vary according to the severity of the client’s symptoms and behavioral problems.

Residential treatment may be used for mental health issues, substance abuse issues, and co-occurring disorders. It can be effective for clients with symptoms, behaviors, or personality traits that are difficult to manage or have not been successfully treated in an outpatient setting.

Detoxification (i.e., "detox") is a process that helps stop the intake of drugs or alcohol in people who are dependent. The goal of detox is to safely rid the body of drugs or alcohol that build up.

• Delirium tremens is a severe form of alcohol withdrawal that includes sudden and severe mental or neurological changes. It is serious and may be life-threatening.
• It is considered a medical emergency requiring medical personnel.