Monthly Archives: November 2010

Comparing Parnaoid Schizophrenia and Delusional Disorder

In comparing delusional disorder and paranoid schizophrenia I noticed that paranoid schizophrenia is actually a step or two further than delusional disorder, even though these two disorders are not related.

The delusions in delusional disorder are not out of the ordinary meaning the delusion a person is currently suffering from could actually happen, but is still considered to be slightly farfetched.  Generally the delusion is something that does not happen to a large amount of people.  The disorder is generally undetectable until the person suffering from it decides to talk about what they feel is happening to them.  This is because the person suffering from delusional disorder had no abnormal behavior and there are either no or very minimal hallucinations.  People suffering from this disorder usually have a scapegoat.  That is, they can always find a way for things that go wrong to be someone else’s fault rather than accept responsibility.  There are several subtypes of delusional disorder.  People suffering from persecutory delusional disorder believe other people are out to get them.

Erotomanic sufferers walk around proclaiming that there is someone of importance is secretly in love with them.  The grandiose delusion disorder causes a person to believe that they are extremely important, or that they have some type of super human powers.  Where the somatic delusion disorder occurs the person believes there is something significantly wrong with their own body, and with the jealous subtype the person believes their spouse has cheated on them even when there is no evidence to support that.

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Research supports findings that a genetic link to a close relative who suffers from delusional disorder is possible.  Another cause could be dysfunctional cognitive processing, in which the patient has a indistinguishable way of looking at life.  The speculations they develop are by assuming everything instead of fact checking.  Another cause could be through stress, through being unable to handle stressful situations.  Treatment for delusional disorder most often involves an antipsychotic medication and sometimes involves therapy either on an individual level or on a familiar level, but treatment is only as successful as the patient allows it to be.

Paranoid schizophrenia patients do not have hallucinations that are possible, the hallucinations these patients suffer from are a much distorted view of their own reality.  There are various symptoms for paranoid schizophrenia patients; these can include auditory hallucinations, anxiety, anger, having a patronizing manner and serious thoughts of suicide, along with suicidal behavior.  These people are less affected by these kinds of symptoms and are generally more affected by what are known as positive symptoms, which are symptoms that are point toward a loss of the knowledge of what reality is.  This usually involves an abnormal view.  While the cause of this disorder is unknown, there is evidence to imply that it is caused by a brain dysfunction and that there are factors which increase the likely hood of paranoid schizophrenia.  These factors seem to be things that people would be unable to avoid, like having a family history or being exposed to viruses in the womb or being malnourished in the womb, or having severe trauma such as childhood abuse.  Even with such early risk factors taking place, paranoid schizophrenia is not generally seen until sometime between the teenage years and the mid-thirties.

Several treatments are available for this disorder but there is no cure, so treatment is there to help people learn how to cope and to learn life skills so they can have a full and productive life.  There are medications which are antipsychotics and they have two different levels.  Tier one medications are typical and have been found to be effective in helping a patient with the positive symptoms such as delusions and hallucination.  There is a side effect of some movements which are completely uncontrolled and seem erratic.  The second generation antipsychotics are atypical and help the patient cope with hallucinations and delusions as well as helping with increasing drive.  The side effect for these medications however is a slow in the metabolism, resulting in weight gain, or worse.  Other treatments available are psychotherapy which is usually recommended with the use of medications and can include social and vocational skills training.  ECT or electroconvulsive therapy and hospitalization are also available if the patient and the therapist feel they are appropriate.  If this disorder is left untreated, adverse affects may start to become visible.  Symptoms become much worse and turn into dangerous and/or deviant behavior.  Abuse of alcohol or drugs may become prevalent, family conflicts, self destructive behavior which can then lead to poverty, homelessness and health problems.  Any of these behaviors can lead to incarceration.

These two disorders seem to have a lot of similarities but in reality they are very different in almost every way including the outcomes of each one.  A more in depth article would be able to show the variations of each in a much better light.

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Child and Adolescent Psychological Disorders.

Oxford Textbook of Psychopathology.

Delusional Disorder.

Paranoid Schizophrenia.

Paranoid Schizophrenia.

What Kind of Therapy is Out There?

In reviewing treatments for depression, it seems the three most common, two of which are very broad, treatments are anti depressant medications, electro-convulsive therapy or ECT, and psychotherapy. Each of these treatments has their own purpose and regimen and can be combined in various ways even though they are different. In fact it is most likely because they are so different that they work well together.

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Antidepressant medication gives a therapist and a patient many options. These options have both positive and negative effects. There are different side effects with each type of medication, some tolerable, some need to be managed with other medications. It is different for everyone; this is why it is important to continue trying different combinations until an agreeable treatment plan is found. One example of medication is SSRIS, which are Selective Serotonin Reuptake Inhibitors. This medication is usually the first choice for treatment. The reasoning behind this is that SSRI’s are the most tolerated with very little side effects and most people find they work very well for them. Some side effects are headache or insomnia, but often any side effects subside in the first month. This medication allows a high amount of serotonin to be blocked in the synapse. By doing this, the cells that are neglected are resaturated allowing relief from depression symptoms.

Tricyclic anti-depressants or TCAs are a second choice in medications, if for some reason the SSRI is unable to help the patient. This medication was developed sometime during the 1950’s and 60’s. TCAs seem to be used for more moderate or severe depression because the side effects are more likely to be serious. TCAs work in the brain synapses and increase norepinephrine. Some of the side effects include dry mouth or visual focus, but the more serious side effects include things such as urinary obstruction or delirium. People who have had a lot of strokes or have been diagnosed as having seizure disorders should not be given any TCAs as medication.

MAOIs or monoamine oxidase inhibitors are another common medication prescribed to depression patients. These are generally a last choice because the side effects are often serious. MAOIs are usually effective in treating depression and were actually the first anti-depressant. It works by blocking monoamine oxidase in the brain synapses and increasing norepinephrine. MAOIs inhibit the body’s ability to break down tyramine which is found in very common foods such as wine, nuts, and chocolate. When this food is consumed while the person is taking an MAOI, it is possible for the tyramine to cause blood pressure to rise to dangerous levels.

While anti-depressants can be mixed or left as a single treatment, they do provide a lot of options to help deal with side effects or other issues that may come up.  They are always the best option; another treatment option for depression is electroconvulsive therapy or ECT.

When electroconvulsive therapy is chosen as treatment the patient receives an electrical current which is passed through the brain causing a seizure. The seizure usually continues for twenty to ninety seconds. This treatment is said to offer a patient a quick relief of their depression symptoms. A common side effect of this treatment is confusion that can last up to several hours and short term memory loss, both of which are short term.

Psychotherapy is the last type of treatment discussed and is often referred to as talk therapy. There are various types of psychotherapy such as cognitive behavioral therapy, interpersonal therapy, and psychodynamic therapy. The most common type of talk therapy is the cognitive behavioral therapy. During sessions a patient not only talks about their depression, they have the opportunity to learn more about it. The patient is then able to focus on knowing what their negative patterns are and changing those into positive behaviors. Interpersonal therapists’ help their patients look at the destructive relationships a person is in that may be helping to grow the depression instead of helping to keep it at bay. Psychodynamic therapy helps a patient work through and resolves whatever internal conflicts the patient may be living with.

All of these types of psychotherapy focus on one thing, helping the patient talk through and learn how to deal with events in their lives so they don’t feel like they are drowning in depression.

Out of all of these treatments I would actually think electroconvulsive therapy to be the quickest and most effective. I can’t imagine going under sedation in order to endure treatment and then waking up not only with memory loss but also being confused about your whereabouts, among other things, even if only temporarily.

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Child and Adolescent Psychological Disorders.

Oxford Textbook of Psychopathology.


Depression (Major Depression).

State of the Mental Health Union



The first ever surgeon general’s report on the “state of the union” in mental health was issued in 1999.  David Satcher, then the reigning surgeon general, emphasized the importance of adopting a national mental health agenda that acknowledges the effect that mental illness has on public health.  He encouraged the general population to acknowledge that that mental illness is both disabling to the individual and costly to the public health system as a whole.  He advocated for increased use of differential diagnosis by emphasizing the concept that both mental health and mental illness are “points on a continuum.”  David Satcher charged us as a profession with reducing and eliminating the stigma associated with mental illness.  He also highlighted the importance of a solid research base to evaluate the practicality and effectiveness of new approaches and overall accountability to the individuals for whom the interventions are intended.  Satcher’s submission represents a blueprint for change.  It’s been 10 years since this comprehensive report. This essay will attempt to access the following question: “How have we done?”


State of the Mental Health Union


The first ever surgeon general’s report on the “state of the union” in mental health was issued in 1999.  David Satcher, (now former) Surgeon General of the United States, emphasized the importance of adopting a public health perspective, accepting that mental disorders are disabling, and seeing both mental health and mental illness as points on a continuum.  (U.S. Department of Health and Human Services, 1999)  He highlighted overarching themes of reducing and eliminating the stigma associated with mental illness, the importance of a solid research base to evaluate the practicality and effectiveness of new approaches, and overall accountability to the individuals for whom and intervention is intended.  (Satcher, 2000)  Satcher’s submission represents a blueprint for change.  It’s been 10 years since this comprehensive report. This essay will attempt to access the following question: “How have we done?”

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The foundation of Satcher’s public health perspective was rooted in the concept of preventive interventions.  Since 1999 we have made significant progress in developing family-focused preventative interventions (Redmond, Spoth, Shin, & Lepper, 1999) including mother and mother-child programs for children of divorce (Wolchik et al., 2000).  We have adopted an early intervention strategy and attempted to focus our preventative efforts on the individuals who have the most to gain/lose, children.  Preventative efforts focused on coping with anger and stress, family bereavement, bullying, early conduct disorder, social relations, stress inoculation, and suicide prevention are yielding significant results among school-aged children.  (Greenberg, Domitrovich, & Bumbarger, 2001; Shaw, Dishion, Supplee, Gardner, & Arnds, 2006; Weissberg, Kumpfer, & Seligman, 2003)  The underlying theory of many, if not most, of these research efforts is that “prevention programs enhance children’s socio-emotional competence and prevent the emergence of behavior problems.”  (Webster-Stratton, 2003)

Although research suggests that there are correlates of life satisfaction in those with disabling conditions, much of the work has been focused on physical disabilities as opposed to mental illness.  (Mehnert, Krauss, Nadler, & Boyd, 1990; Schröder et al., 2007)  More work remains to be done regarding overall public awareness of exactly how debilitating mental illness can be.  This is particularly true in the cases where individuals whom are heavily medicated may be more disabled by their medication than by the mental illness itself.  (Waldman, 1999)

If we consider seeing mental health and mental illness as points on a continuum a goal, then we should consider ourselves closer to that goal then we were 10 years ago.  (American Psychiatric Association, Diagnostic and statistical manual of mental disorders, 2000)  Differential diagnosis is more prominent in the DSM-IV-TR than it was in any previous revision of the DSM, and we have every expectation that we will continue to see movement towards continuum based differential diagnosis in the upcoming DSM-V.    As a profession, we can expect that the differentiation between normal psychological functioning and pathological functioning will continue to be defined, or redefined.  (Widiger & Clark, 2000)  We can expect that diagnostic categories be removed, added, merged, linked, or otherwise cross referenced to reflect the “points on a continuum” perspective.  If I could predict the specific changes we should expect I wouldn’t be here, but I can be fairly certain that we should expect change in general.

Reducing and eliminating the stigma associated with mental illness is a tall order that is constantly in the process of fulfillment.  Despite persistent efforts, anti-stigma campaigns have not yet resulted in the desired changes in public attitudes and perceptions.  (McNulty, 2004)  “Many people who would benefit from mental health services opt not to pursue them or fail to fully participate once they have begun.  One of the reasons for this disconnect is stigma; namely, to avoid the label of mental illness and the harm it brings, people decide not to seek or fully participate in care.”  (Corrigan, 2004, p. 614)  The availability of accurate information, persistent social marketing, and direct contact with the mentally ill can effectively combat the negative stereotypes associated with individuals who suffer from mental illness.  (Kirkwood & Hudnall, 2006)  Nonetheless, there is much work to be done… it is certainly a work in progress.  Furthermore, the DSM has made an effort to reduce stigma by changing verbiage.  For example, people who suffer from alcoholism are no longer referred to as “alcoholics” in an effort to focus on the disease, not the deficiency of the individual.

Nowhere have we made more progress than in the arena of developing a solid research base.  Never before in human history have individual clinicians had access to the depth, breadth, and quality of research that we have today.  This is due, in large part, to technology and the advent of reference-able online material.  Scholars are no longer required to scour books at the library in search of support… we simply find a keyword and plug it into resources like Google, ProQuest, PsycARTICLES, WilsonWeb, ERIC or MEDLINE.  The efficient dissemination of information is critical to our success as a mental health community because it prevents duplicate research efforts.  It also provides instant access to research that can justify both diagnosis and treatment modalities.

We have also made significant progress in the form of accountability.  Federal and state regulatory authorities are constantly reviewing, revising, and reinforcing quality control practices with regard to education and credentialing of mental health professionals.  (Nelson, 2007)  Despite the fact that outcome evaluation programs are becoming more common with regard to child welfare services, they are still lacking in the field of mental health as a whole.  (Wall et al., 2005)  Informed consent is now mandatory in most states, although there is a definitive lack of consistency in terms of what that informed consent document should contain, or how clearly it should be worded.  (Walfish & Ducey, 2007)

There’s more work to be done, so the progress doesn’t stop here.  Our profession is currently being assaulted by rigorous cost control efforts in the form of managed care.  Increasingly, insurance companies are making the decision what is best for clients, not their caregivers… or, if the caregivers do weigh in on the decision, it is with the constraints of a limited number of sessions or available treatments.  Although we have made considerable progress on a number of fronts, including information dissemination, accountability efforts, reducing stigmas, and prevention… all of these avenues of progress will need continued emphasis into the 22nd century in order to have a lasting effect on the profession as a whole.

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American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Washington, DC: Author.

Corrigan, P. (2004, Oct). How stigma interferes with mental health care. American Psychologist, 59(7), 614-625. doi: 10.1037/0003-066X.59.7.614

Greenberg, M. T., Domitrovich, C., & Bumbarger, B. (2001, March). The prevention of mental disorders in school-aged children: Current state of the field. Prevention & Treatment, 4(1), [np]. doi: 10.1037/1522-3736.4.1.41a

Kirkwood, A. D., & Hudnall, S. B. (2006, Oct). A social marketing approach to challenging stigma. Professional Psychology, 37(5), 472-476. doi: 10.1037/0735-7028.37.5.472

McNulty, J. P. (2004). mmentary: Mental illness, society, stigma, and research. NIMH, Schizophrenia Bulletin, 30(3), 573-575. Retrieved from

Mehnert, T., Krauss, H. H., Nadler, R., & Boyd, M. (1990). Correlates of life satisfaction in those with disabling conditions. Rehabilitation Psychology, 35(1), 3-17. doi: 10.1037/h0079046

Nelson, P. D. (2007, Feb). Striving for competence in the assessment of competence: Psychology’s professional education and credentialing journey of public accountability. Training and Education in Professional Psychology, 1(1), 3-12. doi: 10.1037/1931-3918.1.1.3

Redmond, C., Spoth, R., Shin, C., & Lepper, H. S. (1999, Dec). Modeling long-term parent outcomes of two universal family-focused preventive interventions: One-year follow-up results. Journal of Consulting and Clinical Psychology, 67(6), 975-984. doi: 10.1037/0022-006X.67.6.975

Satcher, D. (2000, Feb). Mental health: A report of the Surgeon General–Executive summary. Professional Psychology, 31(1), 5-13. doi: 10.1037/0735-7028.31.1.5

Schröder, C., Johnston, M., Morrison, V., Teunissen, L., Notermans, N., & Van Meeteren, N. (2007, Aug). Health condition, impairment, activity limitations: Relationships with emotions and control cognitions in people with disabling conditions. Rehabilitation Psychology, 52(3), 280-289. doi: 10.1037/0090-5550.52.3.280

Shaw, D. S., Dishion, T. J., Supplee, L., Gardner, F., & Arnds, K. (2006, Feb). Randomized trial of a family-centered approach to the prevention of early conduct problems: 2-year effects of the family check-up in early childhood. Journal of Consulting and Clinical Psychology, 74(1), 1-9. doi: 10.1037/0022-006X.74.1.1

U.S. Department of Health and Human Services. (1999). Mental health: A report of the surgeon general. Retrieved from

Waldman, E. (1999, Dec). Substituting needs for rights in mediation: Therapeutic or disabling?. Psychology, Public Policy, and Law, 5(4), 1103-1122. doi: 10.1037/1076-8971.5.4.1103

Walfish, S., & Ducey, B. B. (2007, April). Readability level of Health Insurance Portability and Accountability Act notices of privacy practices used by psychologists in clinical practice. Professional Psychology, 38(2), 203-207. doi: 10.1037/0735-7028.38.2.203

Wall, J. R., Busch, M., Koch, S. M., Alexander, G., Minnich, H., & Jackson-Walker, S. (2005). Accountability in child welfare services: Developing a statewide outcome evaluation program. Psychological Services, 2(1), 39-53. doi: 10.1037/1541-1559.2.1.39

Webster-Stratton, C. (2003). Aggression in young children services proven to be effective in reducing aggression. Retrieved August 8, 2010, from

Weissberg, R. P., Kumpfer, K. L., & Seligman, M. E. (2003, June/July). Prevention that works for children and youth: An introduction. American Psychologist, 58(6-7), 425-432. doi: 10.1037/0003-066X.58.6-7.425

Widiger, T. A., & Clark, L. (2000, Nov). Toward DSM—V and the classification of psychopathology. Psychological Bulletin, 126(6), 946-963. doi: 10.1037/0033-2909.126.6.946

Wolchik, S. A., West, S. G., Sandler, I. N., Twin, J., Coatsworth, D., Lengua, L., … Griffin, W. A. (2000, Oct). An experimental evaluation of theory-based mother and mother–child programs for children of divorce. Journal of Consulting and Clinical Psychology, 68(5), 843-856. doi: 10.1037/0022-006X.68.5.84



Some counseling approaches use more confrontation than others. What is the function of confrontation and give an example of positive confrontation.


More often than not, a client comes to us because they are having difficulty resolving issues, or incongruities, in their lives.  Positive confrontation is a process whereby a therapist will highlight discrepancies and then feed them back to the client.  Once recognition is achieved, the mutual task is the work though the discrepancy to resolution.

The process is relatively simple… first, we attempt to listen to the client and identify any mixed messages or incongruities between what the client says and what the client actually does.  An example might include a recovering alcoholic who insists that they want to quit drinking, yet persists with the behavior.  Next, we should make an attempt to work the mixed message or incongruity through to resolution.  In the case of the example, we should reassure and reaffirm the recovering individual that they have repeatedly stated that they desire to quit drinking, despite repeated relapses.  Personally, I would focus on the power of “now” and move forward, emphasizing that we can’t change the past.  Finally, we evaluate the effectiveness of our confrontation intervention.  (Ivey, Ivey, & Zalaquett, 2010, p. 243)  This would be done on an ongoing basis as the session proceeds, with modifications to our method being made along the way to maximize benefits for the individual with whom we are working.

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Ivey, A. E., Ivey, M. B., & Zalaquett, C. P. (2010). Intentional interviewing & counseling (7th ed.). Belmont, CA: Brooks/Cole.


Observation and Reflection on Affective Experience and Communication

“Civilization seems to require that we inhibit the free play of our emotions, and many have wondered what consequences such emotional inhibition might have.”  (Gross & Levenson, 1997, p. 95)  The word feeling is another word for emotion, and emotions represent the well from which many of our thoughts and actions flow.  “If we can identify and sort out clients’ feelings, we have a foundation for further action.”  (Ivey, Ivey, & Zalaquett, 2010, p. 190)  That further action, if there is to be any, should represent clarification of what has been dubbed “affective experience.”  In my view, that affective experience, properly channeled, is like channeling the flow from an artesian well.  If we are successful “the client will experience and understand their emotional state more fully and talk in more depth about feelings” or emotions.  (Ivey et al., 2010, p. 172)  In essence, clients tap the well of emotion that swells up inside of them… and the release of that pressure will result in both verbal and nonverbal expression.

If we succeed in tapping the well of emotion, the resulting flow of verbal and nonverbal expression of emotion allows us to functionally guide a client through a liquid reenactment of emotion experience.  “Human change and development is often rooted in emotional experience.”  (Ivey et al., 2010, p. 180)  Meaningful change, in my opinion, is difficult to obtain without addressing the emotions that will be leveraged to drive and guide that change… although difficulty dealing with emotions is not an insurmountable issue.  Research seems to support the view that difficulty or discomfort with emotional expression is less important than the bond between therapist and client.  In the same study, perception of treatment helpfulness was also capable of overcoming discomfort with emotional expression. (Cusack, Deane, Wilson, & Ciarrochi, 2006)  While emotions and feelings remain central to our profession, the efficacy of the treatment and the professional relationship continue to trump their significance in some circles.

As a client, I know when a therapy session goes well… it “just feels right.”  “Like other aspects of the non-sensory fringe of consciousness (e.g., feelings of familiarity, knowing, or causation), feelings of rightness are evident instantly, although they may be amorphous and fuzzy.  (Hicks, Cicero, Trent, Burton, & King, 2010, p. 967)  In my view, observing and reflecting feelings make it possible to be “right” more often, at least as it relates to tapping the our clients emotional wells and channeling that emotion to positive ends.

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Cusack, J., Deane, F. P., Wilson, C. J., & Ciarrochi, J. (2006, April). Emotional expression, perceptions of therapy, and help-seeking intentions in men attending therapy services. Psychology of Men & Masculinity, 7(2), 69-82. doi: 10.1037/1524-9220.7.2.69

Gross, J. J., & Levenson, R. W. (1997, Feb). Hiding feelings: The acute effects of inhibiting negative and positive emotion. Journal of Abnormal Psychology, 106(1), 95-103. doi: 10.1037/0021-843X.106.1.95

Hicks, J. A., Cicero, D. C., Trent, J., Burton, C. M., & King, L. A. (2010, June). Positive affect, intuition, and feelings of meaning. Journal of Personality and Social Psychology, 98(6), 967-979. doi: 10.1037/a0019377

Ivey, A. E., Ivey, M. B., & Zalaquett, C. P. (2010). Intentional interviewing & counseling (7th ed.). Belmont, CA: Brooks/Cole.

Active Listening

Active listening is the process by which we communicate to our clients that they are heard and understood.  There are three specific micro-skills included in the text that all serve this purpose, included among them are encouraging, paraphrasing, and summarizing.  Encouraging can be either verbal or non-verbal, although my personal style is mostly non-verbal.  For me, it’s as simple as a head-not or strategically placed “I understand.”  Restatements are a form of encouraging that I will definitely need to work on, although it is evident to me that restatement is a valuable skill and one that will most certainly be used often.  “Key word encouragers contain one, two, or three words, while restatements are longer.”  (Ivey, Ivey, & Zalaquett, 2010, p. 157)

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“The goal of paraphrasing is facilitating client exploration and clarification of issues.”  (Ivey et al., 2010, p. 158)  Paraphrasing represents an opportunity for the therapist to verify that they have heard and understood what the client has said, as well as to focus (or refocus) conversation on a specific element of the dialogue.  I well designed paraphrase utilizes key word that were used by the client previously, captures the essence of what they client has communicated, and gives the therapist an opportunity to ‘check out’ and verify that they did in fact understand the dialogue correctly.

Summarizing can be employed at the beginning, the end, or during the course of a topic transition.  Summarization is a form of selective attending in which the therapist picks out multiple key points and attempts to restate them as accurately as possible.  (Ivey et al., 2010, p. 159)  The bottom line is that it is absolutely necessary that we continue to be ‘active participants’ in the conversation and that we attend to the details of said conversation so that we are better able to detect slight movement in mood or affect.



Ivey, A. E., Ivey, M. B., & Zalaquett, C. P. (2010). Intentional interviewing & counseling (7th ed.). Belmont, CA: Brooks/Cole.


Observation Skills

(Pfäfflin & Adshead, 2004) suggest that from a neurobiological perspective the process of affect regulation inexorably links nonverbal and verbal representational domains in the human brain.  This relationship may serve to facilitate the transfer of implicit information in the right hemisphere to explicit or declarative systems in the left.  (Pfäfflin & Adshead, 2004, p. 136)  One might deduce that it would be subsequently impossible to separate verbal behavior from nonverbal behavior.  Recognizing this connection, in my opinion, is the key to improving our observational skills.  No action, verbal or nonverbal, should go un-scrutinized… every action (no matter how small) means something.

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Despite our recognition that nonverbal communication is as important, or more important, than verbal communication; “there is no dictionary of nonverbal communication.”  (Riggio & Feldman, 2005, p. xiii)  There is no standard by which we can judge the inherent meaning of an averted gaze.  Even basic facial expressions that convey emotion are subject to the trials of context and individual differences.  And so, we would be well served to recognize that individual and multicultural issues are paramount in the interpretation of behavior.  Furthermore, the interpretations of those expressions are governed by our own selective attention.  (Ivey, Ivey, & Zalaquett, 2010, p. 124)  “Be careful not to assign your own ideas about what is ‘standard’ and appropriate nonverbal communication.”  (Ivey et al., 2010, p. 125)

I would suggest that we be cognizant of the perceived deficits that our potential clients bring to the table, especially if they have a history of interpersonal problems.  We should approach our observations with a healthy scientific skepticism and mindful that we can not always trust what we see.  Furthermore, we would be well served to approach the perspectives of our clients with the same distance and objectivity.  Take the case a client whom demonstrates deficits in decoding facial expressions…

One can speculate that many interpersonal problems might result from a deficit in decoding facial expression… the most obvious problem is the difficulty in identifying the internal states of others: their desires, emotions, or intentions.  Such information is essential for the understanding of others, of the meaning of their behavior in general as well as during social interaction.  Relating to someone whose intentions and emotions are obscure is virtually impossible.  (Philippot, Douilliez, Pham, Foisy, & Kornreich, 2004, p. 18)

Furthermore, research suggests that both nonverbal and paralinguistic communication play an important role in the retrieval of knowledge in trans-active memory systems.  (Borman, Ilgen, & Klimoski, 2003, p. 348)  Almost invariably, it seems as though individuals will “look up and to their left” when they are retrieving information from long-term memory.  Although I do not recall the specific source, I recall that left handed people actually do the opposite (look up and to their right).  When interpreting the memory retrieval of our clients, we would be well served to know which hand they write with.

You mentioned note taking… which is important not only for our benefit of reviewing previous sessions, but for our ability to self access and determine if we have left a stone unturned.  Process notes really are an art, not a science.  In his blog, Bowden Mcelroy (2005) suggests a couple of different formats for process notes that you may find helpful in your practice.  He terms the first one ‘BIRP.’

B: Behavior. What did the client do?

I: Intervention. How did the therapist intervene?

R: What was the client’s Response to the intervention?

P: What is the Plan? Where does treatment go from here?

A second suggestion, one that is in relatively wide use in the field, is called ‘SOAP.’  (As a sidebar, this is also a great method for self-assessment) (Mcelroy, 2005)

S: Subjective: What did the client say?

O: Objective: What did the therapist observe?

A: Assessment (or, Analysis): What does the therapist think is going on?

P: As always, P stands for Plan.

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Borman, W. C., Ilgen, D. R., & Klimoski, R. J. (Eds.). (2003). Handbook of psychology (Vols. 1-12). Hoboken, NJ: John Wiley & Sons.

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