V. Recommended AMHCA Training
AMHCA recommends that clinical mental health counselors have specialized training in addition to the generally agreed upon course areas endorsed by CACREP. These include the biological bases of behavior, clinical assessment, trauma, and co-occurring disorders. Knowledge and skills related to the biological bases of behavior may be covered in a single course or more commonly across several courses or domains of inquiry. The skills outlined in this document can be measured through standardized testing, participation in class or team role-playing exercises, reviews of treatment plans, and reviews of progress notes in field work settings. It is recommended that the following be addressed for students in mental health counseling programs of study.
A. Biological Bases of Behavior
The origins of most mental health disorders are currently thought to be related to some combination of genetic and environmental factors. There is increasing consensus that biological factors exert especially pronounced influences on several disorders not limited to depression and attention deficit disorders, for example. Biological irregularities or anomalies of the central nervous system that influence behavior can be caused by genetic predisposition, injury or infection. A number of biological risk factors exert important effects on the brain structure and its functioning, and increase the likelihood of developing subsequent mental health disorders, either short or long term.
a. Understand the organization of the central nervous system.
b. Understand the role of plasticity and recovery of the brain across the lifespan.
c. Possess introductory knowledge of the neurobiology of thinking, emotion, and memory.
d. Understand current information about the neurobiology of mental health disorders (mood, anxiety and psychotic disorders) across the lifespan.
e. Possess an awareness of basic screening tools used to assess CNS functioning.
f. Possess basic understanding of reproductive health and prenatal development and how the brain changes across the lifespan.
g. Understand the process of early development including attachment and social environmental factors that influence brain development.
h. Possess knowledge about dementia, delirium and amnesia.
i. Understand how drugs are absorbed, metabolized and eliminated.
j. Possess knowledge about disorders and symptoms that may indicate the need for medication.
k. Possess working knowledge about antidepressants, antipsychotics, anxiolytics, mood stabilizers, cognitive enhancers and drugs of abuse.
a. Demonstrate the ability to counsel clients and describe to colleagues the basic organization of the brain as it may relate to mental health.
b. Demonstrate the ability to counsel clients and work with colleagues to understand the ability of the CNS to change and adapt to life circumstances including traumatic brain injury, physical and sexual abuse and substance abuse.
c. Discuss with clients and colleagues how the neurobiology of thinking, emotion, and memory can impact behavior.
d. Identify current research findings and resources about the neurobiology of mental disorders and discuss these findings with clients and colleagues.
e. Identify and briefly describe common assessment instruments used in brief neuropsychological screening instruments.
f. Demonstrate a working knowledge of the biology of reproduction and prenatal development and discuss with clients and colleagues.
g. Counsel clients from a biologically grounded lifespan developmental approach.
h. Understand and describe the aging brain and how it may change across the lifespan.
i. Understand and explain to clients, family and colleagues the most common signs and symptoms of dementia and strategies to improve functioning.
j. Describe how the body metabolizes drugs and the names of drugs commonly used to treat mental disorders and drugs of abuse.
k. Identify the most common side effects for the most commonly used medications.
l. Counsel clients about how to communicate with providers regarding the risks and benefits of medication, method of adherence, and common side effects.
B. Specialized Clinical Assessment
(Summarized and adapted from the AMHCA-AACE joint agreement 2009)
At the heart of clinical mental health counseling, in both theory and practice, is the process of comprehensive individual assessment. A fundamental belief held by clinical mental health counselors is that each client, regardless of presenting problem or circumstance, brings to counseling a unique pattern of traits, characteristics, and qualities that have evolved as a combination of genetic endowment and life experience. Through the use of assessment techniques, both client and counselor can gain an awareness of the unique constellation of traits, qualities, abilities, and characteristics that defines each individual as unique. The assessment process considers mental and emotional well-being, physiological health, as well as relationship and contextual concerns.
a. Identify the purposes, strengths and limitations of objective clinical mental health assessment instruments including:
- Advantages and disadvantages of qualitative assessment procedures.
- Differences and advantages of structured and semi-structured clinical interviews.
- The use of structured and semi-structured clinical interviews to develop goal setting and treatment plans in clinical mental health counseling practice.
- Limitations of clinical mental health assessment instruments in diagnosing thoughts, emotions, behavior or psychopathology of socially and culturally diverse clients across the lifespan. Defines and describes the various types of reliability and validity, as well as measures of error, in clinical mental health assessment instruments.
b. Identify acceptable levels of reliability and validity for personality, projective, intelligence, career and specialty assessment instruments.
c. Identify where and how to locate and obtain information about assessment instruments commonly used within clinical mental health counseling.
d. Identify the means to locate and obtain clinical mental health assessment instruments for special populations (e.g. visually impaired persons, non-readers).
e. Understand how to use assessment instruments according to the intended purpose of the instrument.
f. Understand how to use assessment instruments in research according to legal and ethical practices to protect participants.
g. Understand the use of clinical assessment instruments and procedures in the evaluation of treatment outcomes and mental health treatment programs.
a. Demonstrate the ability to select, administer, score, analyze, and interpret clinical mental health assessment instruments.
b. Demonstrate the ability to use computer-administered and scored assessment instruments.
c. Demonstrate the ability to use the mental status examination, interviewing procedures, and formal clinical assessment instruments to assess psychopathology among socially and culturally diverse clients across the lifespan.
d. Demonstrate the ability to use personality, projective, intelligence, career, and specialty instruments to develop counseling plans and clinical interventions.
e. Develop mental health evaluation reports, diagnosis, and treatment plans from multiple assessment sources (e.g. direct observation, assessment instruments, and structured clinical interviews).
f. Demonstrate the ability to follow legal and ethical principles for informed consent and confidentiality when using assessments.
g. Communicate assessment instrument results in a manner that benefits clients.
h. Present assessment results to clients and other nonprofessional audiences using clear, unambiguous, jargon-free language that recognizes both client strengths and client problems, and communicates respect and compassion.
i. Demonstrate the ability to select standardized instruments that can measure treatment outcomes and design evaluations to assess mental health treatment program efficacy.
j. Comply with the most recent codes of ethics of the American Mental Health Counselors Association (AMHCA), American Counseling Association (ACA), and National Board for Certified Counselors (NBCC) (if certified), and with the laws and regulations of the licensing board in any state in which the counselor is licensed to practice clinical mental health counseling.
k. Practice in accordance with the Code of Fair Testing Practices in Education, Standards for Educational and Psychological Testing, Responsibilities of User of Standardized Tests, and Rights and of Test Takers: Guidelines and Expectations.
C. Trauma Training Standards
The treatment of trauma and chronic traumatic distress is essential for the practice of clinical mental health. Many clients/patients seeking counseling deal with symptoms associated with traumatic experiences. Patients who suffer from the aftereffects of traumatic events or related chronic distress can develop a variety of related disorders and often form negative core self-beliefs. The U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration (SAMHSA) has addressed trauma in the publication, Concept of Trauma and Guidance for a Trauma Informed Approach. All competent clinical mental health counselors possess the knowledge and skills necessary to offer trauma assessment, diagnosis, and effective treatment while utilizing techniques that emerge from evidence-based practices and best practices.
a. Recognize that the type and context of trauma has important implications for its etiology, diagnosis and treatment (e.g. ongoing sexual abuse in childhood is qualitatively different from war trauma for young adult soldiers).
b. Know how trauma-causing events may impact individuals differently in relation to social context, age, gender, and culture/ethnicity.
c. Understand the distinctions among relational, acute, chronic, episodic, and developmental traumas, and the implications of these for treatment.
d. Understand the impact of various types of trauma (e.g. sexual and physical abuse, war, chronic verbal/emotional abuse, neglect) may have on the central nervous system and how this might impact attachment styles, affect regulation, personality functioning, self-identity, and trauma re-enactment.
e. Recognize the long-term consequences of trauma-causing events on communities and cultures.
f. Understand resiliency factors for individuals, groups and communities that diminish the risk of trauma related disorders.
g. Understand the application of established counseling theories to trauma treatment.
h. Recognize differential strategies and approaches necessary to work with children and adolescents in trauma treatment.
a. Demonstrate the ability to assess and differentiate the clinical impact of various trauma-causing events.
b. Demonstrate the ability to use established counseling theories, and evidence-based trauma resolution practices, to promote the integration of brain functioning and help resolve cognitive, emotional, sensory, and behavioral symptoms related to trauma-causing events for socially and culturally diverse clients across the lifespan.
c. Demonstrate the ability to facilitate client resilience and to resolve long-term alterations in attributions and expectancies.
d. Demonstrate sensitivity to individual and psychosocial factors that interact with trauma-causing events in counseling and treatment planning.
e. Demonstrate the ability to recognize that the impact of his/her trauma may impact counseling trauma survivors.
f. Use differentially appropriate strategies and approaches in assessing and working with children and adolescents in trauma treatment.
g. Use differentially appropriate counseling and other treatment interventions in the treatment of developmental and chronic traumas.Knowledge
D. Co-‐Occurring Disorders
Substance-related and addictive disorders are most commonly comorbid with other mental health disorders. In other words, individuals with substance use normally have a mental health condition at the same time and vice versa. For example, unresolved PTSD is frequently a significant contributing factor to an addictive disorder. Failure to address both the mental health disorder as well as the substance-related disorder will frequently result in ineffective and incomplete treatment. There are many consequences of undiagnosed, untreated, or undertreated comorbid disorders including: higher likelihood of experiencing homelessness, incarceration, medical illnesses, suicide, and premature death and it is incumbent upon CMHCs to apply thorough and comprehensive assessment and treatment for co-occurring disorders to prevent neglect, harm and possible death.
a. Understand the epidemiology of substance use and co-occurring disorders for socially and culturally diverse populations at risk across the lifespan.
b. Understand theories about the etiology of substance use and co-occurring disorders including risk and resiliency factors for individuals, groups and communities.
c. Possess a working knowledge of the neurobiological basis of addiction, and the mechanisms that underlie substance use disorders.
d. Understand how drugs work including routes of administration, drug distribution, elimination, dependence, withdrawal, dose response interaction, and how to interpret basic lab results.
e. Recognize the potentials for addictive disorders to mimic a variety of medical and psychological disorders and to cause such disorders.
f. Understand treatment and clinical management of common co-occurring disorders (anxiety, depression, PTSD and trauma-related disorders, dissociative disorders, personality disorders, eating disorders, psychotic disorders, disruptive behavior, and mood disorders) with substance use disorders.
g. Understand the current history, philosophy, and trends in substance abuse counseling including treatment relying on stages of change (e.g. (motivational interviewing) and self-help (AA and NA).
h. Understand ethical and legal considerations related to the practice of addiction, and co-occurring disorders in diverse settings including inpatient units and the criminal justice system.
a. Demonstrate the ability to screen clients’ stage of readiness for change and gauge the severity of their co-occurring disorders.
b. Conceptualize cases using stage-wise approach to addiction and mental health treatment, and develop a treatment plan based on the conceptualization that addresses mental health and addiction issues simultaneously.
c. Demonstrate skills in applying motivational enhancement strategies to engage clients.
d. Provide appropriate counseling strategies when working with clients co-occurring disorders.
e. Demonstrate the ability to provide counseling and education about substance use disorders, and mental/emotional disorders to families and others who are affected by clients with co-occurring disorders.
f. Demonstrate the ability to modify counseling systems, theories, techniques, and interventions for socially and culturally diverse clients across the lifespan with co-occurring disorders.
g. Demonstrate the ability to recognize his/her own limitations as a co-occurring disorder counselor and to seek supervision or refer clients when appropriate.
h. Demonstrate the ability to apply and adhere to ethical and legal standards in addiction and co-occurring disorder counseling.
E. Technology Assisted Counseling (TAC)
Technology assisted counseling or TAC (also has been described as tele-mental health, distance counseling, etc.) is an intentionally broad term referring to the provision of mental health and substance abuse services from a distance. TAC occurs when the counselor and the client/patient are in two different physical locations.
Mental health is adapting to the use of advanced communication technologies and the Internet for delivery of care and care support. By using advanced communication technologies, clinical mental health counselors (CMHCs) are able to widen their reach to clients/patients in a cost-effective manner, ameliorating the mal-distribution of specialty care. Establishing guidelines for TAC improves clinical outcomes and promotes informed as well as reasonable patient expectations.
This section provides guidance on the clinical, technical, administrative and ethical issues as related to electronic communication between CMHCs and clients/patients using advances in TAC. These guidelines also serve as a companion document to AMHCA’s Code of Ethics.
a. Possess a strong working knowledge of technology assisted counseling (TAC) between clinical mental health counselors (CMHCs) and clients/patients which can include the use of:
i. synchronous modalities (telephone, videoconferencing, e-mail), and
ii. non-synchronous modalities (e-mail, chatting, texting, and fax).
b. Recognize that CMHCs and their clients/patients must be technologically competent in the modality of communication being used.
c. Understand that TAC is changing rapidly and anticipates that new modalities of communication with clients/patients will continuously emerge and require clinical, ethical and legal guidance.
d. Understand and complies with all state laws governing or relating to TAC which may include the following considerations:
i. Emerging state laws commonly require that mental health professionals must be licensed in the state in which a client is receiving counseling.
ii. CMHCs who regularly provide mental health counseling across state borders should be fully compliant with all applicable state laws where the client/patient resides.
iii. However, ethical consideration should be given to providing reasonable continuing care for counseling services when:
1. Individuals who temporarily travel out of their state for businesses or other purposes need to receive services from their CMHCs.
2. Individuals who relocate to another state who require continuing care until they have obtained the services of a new CMHC if the current practitioner is not licensed in the client’s new state of residence. This should be for a limited time as agreed to by the client/patient and CMHC.
3. Individuals who are relocating to another country where psychotherapy services may not be available, may warrant continuing treatment.
iv. CMHCs will provide ample informed consent to clients who change residences or locations about the need for referral if distance counseling is not possible with the existing credentials of the CMHC.
e. Stay up to date with relevant changes to laws and continuously consult with ethical and legal experts.
f. Have a working knowledge of how TAC adheres to policies within the Americans for Disabilities Act (ADA). CMHCs will find ways to make appropriate accommodations.
g. Understand that, whenever possible, CMHC’s will meet in a face-to-face session to assess client needs prior to utilizing TAC.
h. Know the need to obtain written informed consent for all TAC modalities utilized, understand how to adhere to all ethical and legal guidelines for counseling, and provide informed consent with appropriate matters to include confidentiality specifically with TAC, encryption, availability, determination of emergency intervention measures if needed, etc.
i. Know that provisions for emergency intervention will include as a priority face-to-face counseling or the provision of a geographically accessible CMHC or other mental health provider, in addition to the inclusion of TAC as part of a comprehensive care management plan.
j. Recognize that synchronous or live communication counseling modalities compared to non-synchronous communication are generally easier to monitor and therefore preferable in the interest of quality assurance.
k. Recognize the importance of keeping records and copies of all correspondence in regard to text-based communications and related electronic information in a manner that protects privacy and meets the standards of HIPAA regulations.
l. Know that confidential and privileged communications using text-based communication TAC should be encrypted whenever possible.
m. Understand the importance of maintaining boundaries in the use of social media which should be continuously monitored and updated, including privacy settings in all social media. CMHCs should differentiate personal and professional forms of social media and keep these separate
i. Demonstrate competence with technological modalities being used such as synchronous modalities (e.g., video-conferencing) and non-synchronous modalities (e.g., texting).
ii. Demonstrate competence and the ability to anticipate and adapt to emerging technologies, and adopt those techniques to address the needs of clients/patients.
iii. Possess the ability to carefully examine the unique benefits of delivering TAC services (e.g., access to care) relative to the unique risks (e.g., information security) when determining whether or not to offer TAC services.
iv. Demonstrate the ability to communicate any risks and benefits of the TAC services to the client/patient, and document such communication preferably during in-person contact with the client/patient, in order to facilitate an active discussion on these issues when conducting screening, intake, and initial assessment.
i. Demonstrate competence in assessing the appropriateness of the TAC services to be provided for the client/patient. Assessment may include:
1. the examination of the potential risks and benefits of TAC services for the client’s/patient’s particular needs;
2. a review of the most appropriate medium (e.g., video teleconference, text, email, etc.);
3. the client’s/patient’s situation within the home or within an organizational context;
4. service delivery options (e.g., if in-person services are available);
5. the availability of emergency or technical personnel or supports;
6. the multicultural and ethical issues that may arise;
7. risk of distractions or possible technological limitations or failures in session related to reception, band width, streaming, power sources, etc.;
8. potential for privacy breaches, and
9. other impediments that may impact the effective delivery of TAC services.
ii. Demonstrate the ability to monitor and engage in the continual assessment of the client/patient progress when offering TAC services to determine if the provision of services is appropriate and beneficial to the client/patient.
c. Emergency Considerations
i. Demonstrate reasonable efforts, at the onset of service, to identify and learn how to access relevant and appropriate emergency resources in the client’s/patients local area. These should include:
1. emergency response contacts;
2. emergency telephone numbers;
3. hospital admissions and/or emergency department;
4. local referral resources;
5. patient-safety advocate (clinical champion) at a partner clinic where services are delivered, and
6. other support individuals in the client’s/patient’s life when available.
ii. Make a reasonable effort to discuss with and provide all clients/patients with clear written instructions as to what to do in an emergency.
iii. Demonstrate the ability to prepare a plan to address any lack of appropriate resources, particularly those necessary in an emergency, and other relevant factors which may impact the efficacy and safety of the service.
d. Multicultural Considerations
i. Demonstrate understanding of best practices of service delivery described in the empirical literature and professional standards – including multicultural considerations – relevant to the TAC service modality being offered.
ii. Demonstrate understanding of specific issues that may arise with diverse populations and which could impact assessment when providing TAC. CMHCs should make appropriate arrangements to address those concerns including but not limited to language or cultural issues; cognitive, physical or sensory skills or impairments; transportation needs; rural resident needs; elderly considerations, and needs for appropriate adaptive technology.
e. Special Needs
i. Have a reasonable skill in accepting and addressing special needs of clients in adhering to appropriate ADA provisions.
ii. Make appropriate arrangements for disabled individuals to accommodate special needs such as sight and hearing impairments.
F. Integrated Behavioral Health Care Counseling
The integration of clinical mental health counseling with primary care and other medical services is required to achieve better patient health outcomes. Integrated systems of medical and behavioral care are comprehensive, coordinated, multi-disciplinary, and co-located through the latest technologies. Clinical mental health counselors must continually increase their knowledge and skills to participate in these emerging practices and systems through the use of evidence-based treatment approaches. In order to stress the vital importance of integrated behavioral health counseling, please see the AMHCA white paper entitled Behavioral Health Counseling in Health Care Integration Practices and Health Care Systems.
Integrated health care is the systematic coordination of behavioral health care with primary care medical services. Episodic and point-of-service treatment which has not included behavioral health care has proven to be ineffective, inefficient, and costly for chronic behavioral and medical illnesses. By contrast, the integrated behavioral health care assessment and treatment of patient psychiatric disorders strongly correlates with positive medical health outcomes. For example, many gastro-intestinal health outcomes rely on the effective treatment of anxiety disorders. By employing all-inclusive behavioral health interventions, skilled CMHCs assist patients to realize optimal human functioning as they alleviate emotional and mental distress.
CMHCs have the ethical responsibility to possess the training and experience to promote health from their unique perspective of prevention, wellness, and personal growth. They must be able to work as members of multi-disciplinary treatment teams and provide holistic behavioral health interventions. Integrated care models hold the promise of addressing many of the challenges facing our health care system. CMHCs as “primary care providers” are invaluable in developing innovations in integrated public health. These knowledgeable and skilled CMHCs will be prepared to dramatically reduce the high rates of morbidity and mortality experienced by Americans with mental illness.
a. Understand the anatomy and physiology of the brain with particular relevance to mental health.
b. Gain a working understanding of the most common medical risks and illnesses confronted by patients (e.g. obesity related diseases, substance use disorder related diseases, cardiovascular disease, cancer, diabetes, COPD, etc.)
c. Understand the processes of stress which relate to impaired immune systems as well as its affects regarding depression and anxiety.
d. Understand the correlation of trauma, chronic distress, and anxiety with medical health issues, medical diagnoses, medical treatment, and recovery (e.g. post-surgical trauma).
e. Understand how to triage patients with severe or high-risk behavioral problems to other community resources for specialty mental health services.
f. Understand and address stressors which lead individuals to seek medical care.
g. Understand primary (preventing disease) and secondary (coping and ameliorating symptoms) prevention interventions for patients at risk for or with medical and mental health disorders.
h. Understand and conduct depression, anxiety, and mental health assessments.
i. Understand and provide cognitive-behavioral interventions.
j. Understand and assist clients to cope with the medical conditions for which they are receiving medical attention.
k. Understand and operate in a consultative role within primary care team.
l. Understand and provide recommendations regarding behavioral interventions to referring medical providers.
m. Understand and conduct brief interventions with referred patients on behalf of referring medical providers.
n. Understand the importance of being available for initial patient consultations.
o. Understand the importance of maintaining a visible presence with medical providers during clinic operating hours.
p. Understand and provide a range of services including screening for common conditions, assessments, including risk assessments, and interventions related to chronic disease management programs.
q. Understand and assist in the development of behavioral health interventions (e.g. clinical pathway programs, educational classes, and behavior focused practice protocols).
r. Understand medical concepts needed to effectively function on an integrated health team including these topics and others:
s. Understand the basic knowledge about key health behaviors and physical health indicators (e.g. normal, risk, and disease level blood chemistry measures) which are routinely assessed and addressed in an integrated system of care, including but not limited to:
- body mass index
- blood pressure
- glucose levels
- lipid levels
- smoking effect on respiration (e.g., carbon monoxide levels)
- exercise habits
- nutritional habits
- substance use frequency (where applicable)
- alcohol use (where applicable)
- subjective report of physical discomfort, pain or general complaints
t. Understand psychopharmacological treatment of mental health disorders.
a. Demonstrate the ability to understand the dynamics of human development to capture good psychosocial histories of patients.
b. Diagnose and treat for behavioral pathology.
c. Provide evidenced-based psychotherapy practices to provide credible treatment to patients.
d. Facilitate and oversee referrals to specialty mental health and substance abuse (MH/SA) services and when appropriate, support a smooth transition from specialty MH/SA services to primary care.
e. Support collaboration of primary care providers with psychiatrists or other prescribing professionals concerning medication protocols.
f. Monitor psychopharmacological treatment of mental health disorders.
g. Apply motivational interviewing skills.
h. Demonstrate consultation liaison skills with other primary care providers.
i. Provide teaching skills and impart information based on the principles of adult education.
j. Provide comprehensive integrated screening and assessment skills.
k. Provide brief behavioral health and substance use intervention and referral skills. Coordinate the treatment of trauma, chronic distress, and anxiety with medical health issues, medical diagnoses, medical treatment, and recovery (e.g. post-surgical trauma).
l. Provide triage for patients with severe or high-risk behavioral problems to other community resources for specialty mental health services.
m. Identify and address stressors which lead individuals to seek medical care.
n. Provide comprehensive care coordination skills.
o. Provide health promotion, wellness, and whole health self-management skills in individual and group modalities.
p. Apply brief interventions using abbreviated evidence-based treatment strategies including but not limited to:
- solution-focused therapy
- behavioral activation
- cognitive behavioral therapy
- motivational interviewing
q. Employ behavioral health care techniques to address the needs of geriatric population to address their chronic health issues, disabilities, and deteriorating cognitive needs.
r. Treat the full spectrum of behavioral health needs which minimally include:
- common mental health conditions (depression, anxiety),
- lifestyle behaviors (self-care, social engagement, relaxation, sleep hygiene, diet, exercise, etc.)
- substance use disorders
s. Coordinate overall patient care in coordination with the treatment team including:
- reinforce care plan with other primary care providers
- summarize goals and next steps with patient
t. Lead group sessions for patients (e.g. pain groups, diabetes management, etc.).
u. Provide concise information to the primary care team verbally, through EHR notes, and other appropriate communication channels.