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ICD-10-CM Compliance date is
October 1st 2015

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Payers will only accept claims with ICD-10 codes with dates of service (or dates of discharge) on or after October 1st, 2015.  Payers will deny claims with invalid codes based on date of service or discharge. ICD-9 codes will be accepted on claims with dates of service (or dates of discharge) through September 30th, 2015.
The transition to ICD-10 is required for everyone covered by the Health Insurance Portability Act (HIPAA). Please note, the change to ICD-10 does not affect CPT or HCPCS level II coding for outpatient procedures and physician services.

Major Differences Between
ICD-9-CM & ICD-10-CM

Comparison of ICD-9-CM
& ICD-10-CM
ICD-9-CM Code
A – Category of code
B – Etiology, anatomical site, and manifestation
XXX.XX
A B
ICD-10-CM Code
A – Category of code
B – Etiology, anatomical site, and/or severity
C – Extension
7th character for obstetrics, injuries, and external causes of injury
XXX.XXXX
A B C

Examples of ICD-9-CM vs
& ICD-10-CM
Description ICD-9 code ICD-10 code
Chronic motor or vocal tic disorder 307.22 F95.1
Psychotic disorder with delusions 293.81 F06.2
Mood disorder due to known physiological condition unspecified 293.83 F06.30
Unspecified schizophrenia unspecified 295.90 F20.9
Schizoaffective disorder, unspecified 295.70 F25.9
     

Let’s Review some ICD-10-CM
Psychiatric Conditions

DSM-V
Psychiatrists generally state diagnoses in accordance with the nomenclature used in the Diagnostic and Statistical Manual of Mental Disorders.
Most of these codes are the same as those used in ICD-10-CM, but the terminology may differ.
Actual coding assignments are made according to the classifications in ICD-10-CM.

Major Difference between DSM-V
and ICD-10
The Substance Use Section. While the DSM-5 eliminates the distinction between chemical abuse and dependence, the ICD-10 retains the categories of use, abuse, and dependence.
There are significantly more substance use diagnoses in the ICD-10 than there are in the DSM-5.
Because diagnoses in the DSM-5 have numerous possible iterations in the ICD-10, clinicians expecting a one-to-one code match need to be aware this is not the case.

ICD-10 Challenges
The number of actual diagnoses in each category has jumped significantly in the ICD-10 coding system
Another concern is that a single diagnosis code may represent very different conditions, ultimately necessitating more detailed clinician documentation
Improving clinical documentation requirements will be important for regulatory and auditing purposes. Given the inherent differences in the DSM-5 versus the ICD-10, decisions will need to be made about coding, diagnosing, terminology, and clinical documentation.

Crosswalks
In order to help providers arrive at the correct diagnosis in the ICD-10, “crosswalks” have been developed to help bridge the translation between the DSM and ICD.
Crosswalks typically map between the DSM and the ICD-10 codes to enable the clinician to pick the right code for billing purposes.
However, simply cross-walking between DSM-5 to the corresponding ICD-10 code will not produce an accurate code number.
The ICD-10 is more specific and contains many more diagnoses in the behavioral health section than the DSM-5 contains.

The code on the left is an ICD-9 code. The code on the right is an ICD-10 code. Beginning Oct. 1, 2015, you will need to use the code on the right.
Here is an excerpt from a page of
DSM-5 for post traumatic stress disorder
Where do you find the ICD-10
codes in DSM-5?

How do you code disorders that
now have multiple coding options?
Below is an illustration taken from the DSM-5.
The code on the left is an ICD-9 code. The code on the right is an ICD-10 code. Beginning Oct. 1, 2015, you will need to use the code on the right.

Organic Brain Syndrome
Since organic brain syndrome is used to describe a decrease in mental function due to a medical disease other than a psychiatric condition, it is coded to F09, Unspecified mental disorder due to known physiological condition.
The underlying physiological condition should be coded first

Altered Mental State
An alteration in level of consciousness not associated with delirium or another identified condition, is classified to category R40.

Mental Disorders Due to Known Physiological Conditions—F01-F09
Conditions reported in this ICD-10 code range include (when documented):
Dementia
Amnestic disorder due to known physiological condition
Delirium due to known physiological condition
Personality and behavioral disorders due to known physiological condition

Categories F01 – F09
This category reports mental disorders due to known physiological conditions grouped together on the basis of having a demonstrable etiology in cerebral disease, brain injury or other insult leading to cerebral dysfunction.
The cerebral dysfunction may be reported as either a primary or secondary diagnosis.

Primary Cerebral dysfunction
Primary cerebral dysfunction includes diseases, injuries and insults affecting the brain directly and selectively.

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Secondary Cerebral Dysfunction
Secondary cerebral dysfunction includes systemic diseases and disorders which attack the brain only as one of the multiple organs or body systems involved.

ICD10 and Instructional Notes
You will encounter “instructional notes” intended to guide you to documentation which needs to be evident in the record to report the underlying physiological condition.
Example
Vascular dementia has an instructional note to code first the underlying physiological condition or sequelae of cerebrovascular disease.

An alteration in level of consciousness not associated with delirium or another identified condition is classified to category R40.
Category R40 in Chapter 18 of ICD-10-CM is further subdivided to indicate whether it is identified as somnolence, stupor, coma, persistent vegetative state or transient alteration of awareness.
Recording the Altered Mental
State ICD10 Category R40

An altered mental status or change in mental status of unknown etiology is coded to R41.82 “Altered mental status, unspecified”.
If the condition causing the change in mental status is known (and documented), do not assign code R41.82 – code the condition instead – if it recorded in the patient’s chart.
Unknown Etiology

Schizophrenic Disorders
Schizophrenic disorders are classified in ICD-10-CM in category F20 – with a 4th character indicating the type of schizophrenia
4th Character Options to Specify Schizophrenia
F20.0 Paranoid Schizophrenia
F20.1 Disorganized Schizophrenia
F20.2 Catatonic Schizophrenia
F20.3 Undifferentiated Schizophrenia
F20.5 Residual Schizophrenia
F20.8 Other
F20.81 Schizophrenia disorder
F20.89 Other Schizophrenia
F20.9 Schizophrenia unspecified

Affective Disorders
Major depressive disorder, bipolar disorders and anxiety disorders are classified under categories F30-F39
We need to code 4th & 5th characters!
Categories F32 and F33 report Major depressive disorders and are subdivided to provide information about the current severity of the disorder – such as mild, moderate, severe, etc.

Bipolar Affective Disorders
Bipolar affective diseases are divided into various types according to the documented symptoms displayed.
ICD-10-CM classifies bipolar disorders according to four categories
F30 Manic episode
F31 Bipolar disorder
F34 Persistent mood disorders
F39 Unspecified mood disorder

Anxiety, Dissociative, Stress-Related, Somatoform, and Other Nonpsychotic Mental Disorders—F40-F48
Diseases documented can be reported in ICD-10 include:
Phobic anxiety and anxiety disorders
Obsessive-compulsive disorders
Reaction to severe stress and adjustment
Dissociative conversion disorders
Somatoform disorders
Other nonpsychotic mental disorders

Behavioral Syndromes Associated with
Physiological Disturbances and Physical
Factors – F50-F59
The following disorders are reported here:
Eating disorders
Sleeping disorders
Sexual dysfunction not due to a substance or known physiological condition
Abuse of nonpsychoactive substances

Disorders of Adult Personality and Behavior— F60-F69
Categories reported here include:
Specific personality disorders—F60
Impulse disorders—F63
Gender identity disorders—F64
Paraphilias and sexual disorders—F65-F66
Other and unspecified disorders of adult personality and behavior—F68-F69

Mental Intellectual Disabilities— F70-F79
This block of codes reports mental Intellectual Disabilities according to severity (when documented):
Mild Intellectual Disabilities F70
Moderate Intellectual Disabilities—F71
Severe Intellectual Disabilities—F72
Profound Intellectual Disabilities—F73
Other and Unspecified Mental Intellectual Disabilities—F78-F79

Pervasive and Specific Developmental Disorders— F80-F89
This block of codes reports specific developmental disorders of:
Speech and language—F80
Scholastic skills—F81
Motor function—F82
Pervasive developmental disorders—F84
Other and unspecified disorders of psychological development—F88-F89

Behavioral and Emotional Disorders with
Onset Usually Occurring in Childhood and
Adolescence— F90-F98
This block of codes reports disorders with onset usually in childhood and adolescence but these codes may be used regardless of the age of the patient.
Code Range F90-F98 These categories report:
Attention-deficit hyperactivity disorders
Conduct disorders
Emotional disorders with onset specific to childhood
Disorders of social functioning with onset specific to childhood and adolescence
Tic disorders
Other behavioral and emotional disorders

Mental and Behavioral Disorders due
to Psychoactive Substance Use— F10-F19
These categories report mental disorders related to excessive use of substances.
Abuse is defined as taking alcohol/drugs to excess.
Dependence is defined as the chronic use of alcohol/drugs creating a dependence.
Alcohol-related disorders—F10
Opioid-related disorders—F11
Cannabis-related disorders—F12
Sedative-, hypnotic-, or anxiolytic-related disorders—F13
Cocaine-related disorders—F14
Other stimulant-related disorders—F15
Hallucinogen-related disorders—F16
Nicotine dependence—F17
Inhalant-related disorders—F18
Other psychoactive substance-related disorders—F19

ICD-10-CM Guidelines
In Remission
Selection of codes for “in remission” for categories F10-F19, Mental and behavioral disorders due to psychoactive substance use (categories F10-F19 with -.21) requires the provider’s clinical judgment.
The appropriate codes for “in remission” are assigned only on the basis of provider documentation.

Psychoactive Substance Use, Abuse
And Dependence
When the provider documentation refers to use, abuse and dependence of the same substance (e.g. alcohol, opioid, cannabis, etc.), only one code should be assigned to identify the pattern of use based on the following hierarchy:
If both use and abuse are documented, assign only the code for abuse
If both abuse and dependence are documented, assign only the code for dependence
If use, abuse and dependence are all documented, assign only the code for dependence
If both use and dependence are documented, assign only the code for dependence

Psychoactive Substance Use
As with all other diagnoses, the codes for psychoactive substance use (F10.9-, F11.9-, F12.9-, F13.9-, F14.9-, F15.9-, F16.9-) should only be assigned based on provider documentation and when they meet the definition of a reportable diagnosis
The codes are to be used only when the psychoactive substance use is associated with a mental or behavioral disorder, and such a relationship is documented by the provider.

Pain disorders related to
psychological factors
Assign code F45.41, for pain that is exclusively related to psychological disorders.
Code F45.42, Pain disorders with related psychological factors, should be used with a code from category G89, Pain, not elsewhere classified, if there is documentation of a psychological component for a patient with acute or chronic pain.

General Equivalence Mappings
(GEMs)
The Centers for Medicare and Medicaid (CMS) and the Centers for Disease Control and prevention (CDC) created GEMs to ensure consistent national data when the U.S. adopts ICD-10.
The GEMs will act as a translation dictionary to bridge the “language gap” between the two code sets and can be used to map an ICD-9 code to an ICD-10 code and vice versa.

Purpose of GEMs
Designed to give all sectors of the healthcare industry that use coded data the tools to:
Convert large databases and test system applications
Link data in long-term clinical studies
Develop application-specific mappings
Analyze data collected before and after the transition to ICD-10-CM

Not a Substitute for Coding
The GEMs should not be used as a substitute for learning how to use the ICD-10-CM code sets.
“GEMs are not a substitute for learning ICD-10-CM coding. They’ll help you convert large data sets.”
Mapping simply links concepts in the two code sets, without consideration of context of specific patient information, whereas coding involves assigning the most appropriate code based on documentation and applicable coding guidelines.

ICD-10-CMS Resources
ICD-10-CM Official Guidelines for Coding and Reporting FY 2016
https://www.cms.gov/Medicare/Coding/ICD10/Downloads/2016-ICD-10-CM-Guidelines
Free lists of codes and ICD-9/ICD-10 mappings are available from CMS
https://www.cms.gov/Medicare/Coding/ICD10/2016-ICD-10-CM-and-GEMs.html

This has 3 assignments; please cite relevant sources; assignments will be submitted through safe assign for plagiarism

Assignment 1: at least 250 words; APA format; please see powerpoint attachment

Respond to the following questions from your future position as a mental health counselor.    Be sure to follow the instructions below! 

Your textbook is your best source to start with.   Use of 2 additional professional sources is required.

1.  How does society define “abnormal behavior”?  How is “abnormal behavior” treated?  Other than counseling/psychotherapy, and medications, what other forms can treatment take?  

2.  Define in moderate detail, each of the following:  a one-dimensional model of conceptualizing abnormal behavior, and the multipath model of conceptualizing abnormal behavior.   Include the impact on treatment of each type of model.  Be clear and specific.

3.  What personal concerns do you have when you think about working with individuals who display abnormal behavior/mental illness?  What thoughts and feelings does this stir within you?

Assignment 2: at least a paragraph; APA format; see AMHCA attachment

Read through the AMHCA (American Mental Health Counseling Association) Standards posted in the Courseweek and discuss what kinds of specialized training is recommended for mental health counselors.

Assignment 3:

Please see power point attachment

1. In a paper of not less than 3 double spaced typed pages (NOT including Title Page and Reference Page; must be APA style),  using a minimum of 5 professional resources, complete the following in a well-thought out paper:

1.  Define the types and specific roles of behavioral health practitioners, including that of the clinical Mental Health Counselor.  

2.  What is collaborative mental health care?  Why is professional collaboration crucial to the treatment of mental health issues and disorders?  Give a specific case example.

3.  How do knowledge and usage of the DSM 5 and the ICD 10 diagnostic systems promote successful collaboration among mental health professionals,  as well as human service and integrated behavioral health care systems?

4.  Your textbook addresses some basic psychopharmacological information under the topic of “Biology-Based Treatment Techniques.”  What are the major classifications of medication used to treat mental health issues and disorders?  Define each one and list the name of a commonly prescribed medication in each classification.

What DSM 5 mean:

Abnormal Behavior

1

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1

Psychopathology
Study of symptoms and causes of mental disorders
Objectives: describing, explaining, predicting, and modifying behaviors associated with mental disorders
People who work in the field strive to alleviate distress and life disruption of those with mental disorders
The Field of Abnormal Psychology

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Mental health professionals
Health care practitioners
Assists in diagnosis of a patient’s mental health
Psychodiagnosis
Attempts to describe, assess, and understand the situation
Treatment plan
Proposes course of therapy
Focuses first on most distressing symptoms
Describing Behavior

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Determine etiology (possible causes)
High priority for mental health professionals
Human behavior is complex
Multiple contributing factors
Explaining Behavior

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Various risk factors for violent behavior
Civil commitment (involuntary confinement)
Extreme decision impacting an individual’s civil liberties
Predicting Behavior

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5

Psychotherapy
Program of systematic intervention
Objective: improve a person’s behavioral, emotional, or cognitive state
Many types of therapies and professional helpers
Modifying Behavior

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Group therapy is one type of evidence-based therapy described in Chapter 1.
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The Mental Health Professions

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Table 1.1 The mental health professions
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The Mental Health Professions (cont’d.)

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Table 1.1 The mental health professions
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The most widely used classification system
Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5)
A mental disorder is characterized by:
Disturbance in thinking, emotion, or behavior
Distress or difficulty with daily functioning
Not being culturally expected, not explained by religious or political beliefs
Views of Abnormality

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DSM Definitions
Questions to raise
When are symptoms or behavior significant enough to have meaning?
Is it possible to have a mental disorder without distress or discomfort?
What criteria are to be used in assessing symptoms?

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What is culture?
Learned behavior that members of a group transmit to the next generation
Viewpoints
Expression/determination of behaviors depends on lifestyles, cultural values, and worldviews
Symptoms and causes of mental disorders are independent of culture
Cultural Considerations in Abnormal Behavior

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E.g., hallucinations are considered normal and appropriate in some cultures whereas they are generally viewed as abnormal in American culture
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Opinions of Thomas Szasz (1987)
A society labels behavior that is different as abnormal
Unusual belief systems are not necessarily wrong
Abnormal behavior a reflection of something wrong with society
Sociopolitical Considerations in Abnormality

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A Sampling of Lifetime Prevalence

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Figure 1.1 Lifetime prevalence of mental disorders in a sample of 10,000 U.S. adolescents
Source: Merikangas et al., 2010
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Prevalence
Percentage of people in a population who have the disorder during a given interval of time
Dept. of Health and Human Services study
24.8 percent of U.S. adults have experienced a mental disorder in the past 12 months, excluding drug and alcohol disorders
Lifetime prevalence
Existence of a disorder during a person’s life
How Common Are Mental Disorders?

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$135 billion a year spent on mental health and substance abuse services in U.S.
25 percent of adults have a diagnosable mental health condition
Many more experience mental health problems not meeting criteria for disorder
57 percent of adults with severe mental health conditions not receiving treatment
Implications to Society

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Mentally ill are frequently stereotyped and stigmatized
Prejudice
Belief in negative stereotypes
Discrimination
Action based on prejudice
Self-stigma
Undermines self-worth and self-efficacy
Hinders recovery
Overcoming Social Stigma and Stereotypes

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National Alliance on Mental Illness (NAMI)
“You Are Not Alone” campaign
Goals: educating the public and reducing stigma
Commending more accurate portrayals of mental disorders in movies and TV
Efforts to Increase Public Awareness

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Public disclosures from well-known people such as actors and sports figures
Open acknowledgment and discussion of struggles
Reduces public social stigma
What you can do:
Be respectful when describing others in mental distress, choose words carefully
Encourage family and friends to seek help early
Decreasing Social Stigma

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Prehistoric and ancient beliefs
Evil spirits residing in a person’s body
Trephining
Exorcism
Naturalistic explanations: Greco-Roman thought
Early thinkers: Hippocrates (460-370 B.C.)
Brain pathology
Historical Perspectives on Abnormal Behavior – Ancient and Naturalistic

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Middle Ages
Reversion to supernatural explanations
Exorcism
Group hysteria
Tarantism
Witchcraft: 15th through 17th centuries
Period of social and religious reformers
Witch hunts
100,000 people (mostly women) executed
The Middle Ages Through the 17th Century

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14th through 16th centuries
Horrendous conditions in asylums
The rise of humanism
Philosophical movement emphasizing uniqueness and worth of the individual
Johann Weyer, German physician
Challenged prevailing beliefs of witchcraft
Sixteenth Century Perspectives

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Shift to more humane treatment of mentally disturbed people
Philippe Pinel (1745-1826)
Took charge of mental hospital in Paris
Removed chains, replaced dungeons with sunny rooms, and encouraged exercise
Changes shown to foster recovery
The Moral Treatment Movement
(18th and 19th Centuries)

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Benjamin Rush
“Father of U.S. Psychiatry”
Patients treated with respect and dignity, and gainfully employed during treatment
Dorothea Dix
Campaigned for better treatment of mentally ill
Clifford Beers
Wrote book on his experience with mental illness
Humane Treatment Movement in the U.S.

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The biological viewpoint
Mental disorders have a physical or physiological basis (Griesinger)
Idea flourished in the 19th century
Kraepelin (1856-1926)
Defined syndromes based on clusters of symptoms
Foundation for DSM used today
Causes of Mental Illness: Early Viewpoints

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Louis Pasteur’s germ theory of disease
Biological view gained greater strength
Discovery of general paresis
Degenerative physical and mental disorder
von Kfrafft-Ebing
Proved that mental symptoms of general paresis are linked to syphilis bacteria
Schaudinn
Isolated microorganism of general paresis
Causes: Early Viewpoints (cont’d.)

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Belief that mental disorders are caused by psychological and emotional factors
Friedrich Anton Mesmer (1734-1815)
Practiced therapies that evolved into modern hypnotism
Mesmer was discredited
Idea that suggestion could treat hysteria
Liébeault and Bernheim demonstrated psychological basis of mental illness
The Psychological Viewpoint

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Breuer
Discovered symptoms disappeared after female patient spoke about past trauma while in a trance
Freud (1856-1939)
Technique of psychoanalysis
Built on practices of Breuer
Cathartic method
Therapeutic use of verbal expression
Breuer and Freud

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Viewpoint rooted in laboratory science
Focus on directly observable behaviors
Also conditions that evoke, reinforce, and extinguish them
Alternative explanation
Offered successful procedures for treating some psychological conditions
Behaviorism

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The influence of multicultural psychology
Culture, race, ethnicity, gender, age, and socio-economic class relevant to understanding and treating abnormal behavior
Mental health professionals need to:
Increase cultural sensitivity
Acquire knowledge of diversity
Develop culturally relevant therapy approaches
Contemporary Trends in Abnormal Psychology

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29

Racial and Ethnic Composition of the U.S.

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Figure 1.2 2013 Census Projections: Racial and Ethnic Composition of the United States
Minorities now constitute an increasing proportion of the U.S. population. Mental health providers will increasingly encounter clients who differ from them in race, ethnicity, and culture.Source: http://quickfacts.census.gov/qfd/ states/00000.html
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Cultural values and influences
Sociopolitical influences
Cultural and ethnic bias in diagnosis (e.g., the tendency to overpathologize)

Dimensions Related to Cultural Diversity

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31

Objectives
Study, develop, and achieve scientific understanding of positive human qualities that build thriving individuals, families, and communities
Focuses on human strength and capacity for resilience
Psychological resilience
Prevention
Positive Psychology

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32

Perspective that people with mental illness can recover
Live satisfying, hopeful, and contributing lives
Some of the recovery model assumptions
Recovery is possible and begins when person realizes that positive change is possible
Recovery involves occasional setbacks
Healing involves separating one’s identity from the illness
Recovery Movement

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The drug revolution in psychiatry
Introduction of psychotropic medications in the 1950s
Considered one of the great medical advances in the 20th century
Naturally occurring lithium found to radically calm some mental patients
Many drugs made available for different disorders
Resulted in depopulation of mental hospitals
Changes in the Therapeutic Landscape

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Some changes brought about by industrialization of health care
Business interests of insurers influence treatment duration
Cost-cutting focus affects hiring
Increased appreciation for research
Denial of coverage for unproven treatments
Technology-assisted therapy
Online programs
The Development of Managed Health Care

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What is abnormal psychology?
How do we differentiate between normal and abnormal behaviors?
What societal factors affect definitions of abnormality?
How common are mental disorders?
Review

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Why is it important to confront the stigma and stereotyping associated with mental illness?
How have explanations of abnormal behavior changed over time?
What were early explanations regarding the causes of mental disorders?
What are some contemporary trends in abnormal psychology?
Review (cont’d.)

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Understanding and Treating Mental Disorders

2

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1

One-Dimensional Models of Mental Disorders
Model
Attempts to describe a phenomenon that cannot be directly observed
Models are intrinsically limited and cannot explain every aspect of a disorder
Human behaviors are complex
Models of psychopathology
Biological, psychological, social, and socio-cultural

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2

Multipath Model
Considers the multitude of factors researchers have confirmed are associated with each disorder
Views disorders from a holistic framework
Some assumptions of the multipath model
Multiple pathways and influences contribute to the development of any single disorder
Not all dimensions contribute equally

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3

The Multipath Model

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Figure 2.1 The Multipath Model Each dimension of the multipath model contains factors found to be important in explaining mental disorders. Reciprocal interactions involving factors within and between any of these dimensions can also influence the development of mental disorders.
4

The Four Dimensions and Possible Pathways of Influence

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Figure 2.2 The Four Dimensions and Possible Pathways of Influence Conceptually, mental disorders arise from four possible dimensions (biological, psychological, social, and sociocultural) and from reciprocal interactions between factors within a dimension or among factors in multiple dimensions.
5

Aspects of the Multipath Model
Many disorders tend to be heterogeneous in nature
Different combinations within the four dimensions may influence development of a particular condition
Within each dimension, distinct theories exist
Same triggers or vulnerabilities may cause different disorders

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6

Dimension One: Biological Factors
The human brain
Forebrain controls all higher mental functions
Cerebrum
Cerebral cortex
Prefrontal cortex helps manage attention, behavior, and emotions
Limbic system
Role in emotions, decision-making, and memories

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7

Structures in the Limbic System

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Figure 2.5 The limbic system, comprised of an interconnected group of brain structures, controls emotional reactions and basic human drives. It is also involved in motivation, decision making, and the formation of memories.
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Multipath Implications
Biological explanations are best considered in the context of other factors
Science suggests that most individual differences result from some combination of genetic and environment variations
People do not inherit a particular abnormality but rather, a predisposition to develop illness
Environmental forces (stressors) may activate the predisposition, resulting in a disorder

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9

Biochemical Processes within
the Brain and Body
The brain is composed of:
Neurons (nerve cells)
Dendrites
Axon
Glia cells that act in supporting roles

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10

Synaptic Transmission

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Figure 2.6 Synaptic Transmission Electrical impulses travel along the axon, through the synapse, and to the dendrites of the next neuron. Neurotransmitters facilitate the transmission of the impulse across the synapse.
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Major Neurotransmitters
and Their Functions

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Table 2.2 Major neurotransmitters and their functions
12

Major Neurotransmitters
and Their Functions (cont’d.)

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Table 2.2 Major neurotransmitters and their functions
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Neuroplasticity
Ability of the brain to evolve and adapt
The brain reacts to environmental circumstances by making new neural circuits and pruning old ones
“Neurons that fire together, wire together”
Chronic stress results in negative changes in brain activity
Exercise can produce positive changes

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Neurons that fire together, wire together: Nerve pathways that we used frequently become mylienated which makes them stronger and more efficient. When we practice a behavior it becomes more hard-wired over time.
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Genetics and Heredity
Heredity: genetic transmission of traits
Chemical compounds outside the genome control gene expression
Whether genes are “turned on” or “turned off”
Genotype and phenotype
Genetic mutations
Epigenetics
Environmental factors trigger biochemical processes that affect gene expression

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Biology-Based Treatment Techniques
Psychopharmacology
Study of effects of psychotropic medications
Medication categories
Antianxiety drugs (e.g., benzodiazepines like Valium)
Antipsychotics (e.g., chlorpromazine)
Antidepressants (e.g., selective serotonin reuptake inhibitors like fluoxetine)
Mood stabilizers (e.g., lithium)

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Other Biological Approaches
Electroconvulsive therapy
Induce small seizures with electricity or magnetism
Can change brain chemistry and reverse some symptoms
Reserved for those not responding to other treatments

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Other Biological Approaches (cont’d.)
Neurosurgical and brain stimulation treatments
Psychosurgery (removing parts of brain)
Very uncommon today
Repetitive transcranial magnetic stimulation
Deep brain stimulation

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Criticisms of Biological Models and Therapies
Drugs are not always effective
Drugs do not cure mental illness
Side effects and interactions are possible

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Dimension Two: Psychological Factors
Four major perspectives
Psychodynamic
Behavioral
Cognitive
Humanistic-existential

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20

Psychodynamic Models
The components of personality
Id: pleasure principle
Ego: realistic and rational
Superego: moral considerations (conscience)
Psychosexual stages
Freud proposed that human personality largely developed during first five years of life
Defense mechanisms
Protect us from anxiety

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Contemporary Psychodynamic Theories
Adler and Erickson
Suggested that the ego has adaptive abilities
With the ability to function separately from the id
Bowlby and Mahler
Proposed that the need to be loved, accepted, and emotionally supported is of primary importance in childhood

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22

Therapies Based on the Psychodynamic Model (cont’d.)
Psychoanalysis
Objective: uncover material blocked from consciousness
Free association
Dream analysis
Effect of experiences with early attachment figures

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Theories Based on the Psychodynamic Model
Interpersonal psychotherapy
Links childhood experiences with current relational patterns
Focus on current relational patterns
Helps clients learn more effective interaction strategies

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Behavioral Models
Concerned with the role of learning in development of mental disorders
Based on experimental research
Three paradigms
Classical conditioning (Ivan Pavlov)
Operant conditioning (B. F. Skinner)
Observational learning (Albert Bandura)

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25

Classical Conditioning Example

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Figure 2.8 A basic classical conditioning process: Dogs normally salivate when food is provided (left). With his laboratory dogs, Ivan Pavlov paired the ringing of a bell with the
presentation of food (middle). Eventually, the dogs would salivate to the ringing of the bell alone, when no food was near (right).
26

Behavioral Therapies
Exposure therapy
Graduated exposure
Flooding
Systematic desensitization
Social skills training
Criticisms of behavioral models and therapies
Often neglect inner determinants of behavior

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Cognitive-Behavioral Models
Thoughts profoundly affect emotions and behaviors
Beck and Ellis
A-B-C theory of emotional disturbance
A is an event
C is a person’s reaction
B are the person’s beliefs about A, which causes reaction C

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Ellis’s A-B-C Theory of Personality

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Figure 2.9 Ellis’s A-B-C Theory of Personality The development of emotional and behavioral problems is often linked to dysfunctional thinking. Cognitive psychologists assist their clients to identify and modify irrational thoughts and beliefs.
29

Third-Wave Cognitive-Behavioral Therapies
Nonreactive attention to emotions can reduce their power to create distress
Mindfulness
Conscious attention to the present
Dialectical behavior therapy (DBT)
Supportive and collaborative therapy
Reinforce positive actions
Acceptance and commitment therapy (ACT)

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Humanistic Models
Humans need unconditional positive regard
Person-centered therapy focuses on facilitating conditions that allow clients to grow and fulfill their potential
Maslow’s concept of self-actualization
The inherent tendency to strive for full potential

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Humanistic Therapies
Communicating respect, understanding, and acceptance are more important than techniques
Unconditional positive regard fosters self-acceptance
Self-growth aids in present and future problem solving
The relationship between client and therapist is critically important to outcome

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Dimension Three: Social Factors
Social-relational models
Healthy relationships are important for human development and functioning
Provide many intangible benefits
When relationships are dysfunctional or absent, individuals are more vulnerable to mental distress

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33

Family, Couples, and Group Perspectives
Family systems model
Behavior of one family member affects entire family system
Characteristics
Personality development strongly influenced by family characteristics
Mental illness reflects unhealthy family dynamics and poor communication
Therapist must focus on family system, not just an individual

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34

Social-Relational Treatment Approaches
Conjoint family therapeutic approach
Stresses importance of teaching message-sending and message-receiving skills to family members
Strategic family approaches
Consider family power struggles and move towards more healthy distribution
Structural family approaches
Reorganizes family in relation to level of involvement with each other

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35

Couples and Group Therapy
Couples therapy
Aimed at helping couples understand and clarify their communication, needs, roles, and expectations
Group therapy
Initially strangers
Share certain life stressors
Provides supportive environment
Allows therapist to observe patient’s actual social interactions

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36

Dimension Four: Sociocultural Factors
Emphasizes importance of several factors in explaining mental disorders
Race
Ethnicity
Gender
Sexual orientation
Religious preference
Socioeconomic status
Other factors

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37

Gender Factors
Higher prevalence of depression, anxiety, and eating disorders among women
Women experience greater stress in certain areas:
Lower wages;, less decision-making power
Expectations of combining chores, childcare, and paid work
Exposure to sexual harassment, interpersonal violence
Affects well-being and learning

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Socioeconomic Class
Lower socioeconomic class associated with:
Limited sense of personal control
Poorer physical health
Higher incidence of depression
Life in poverty subjects people to multiple stressors
Fulfilling life’s basic needs

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Immigration and Acculturative Stress
Acculturative stress
Associated with challenges of moving to a new country
Loss of social support
Hostile reception
Educational and employment challenges
Most common among first generation immigrants and their children

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Race and Ethnicity
Two early inaccurate, biased models:
Inferiority model
Deficit model
Multicultural model
Emerged in the 1980s and 1990s
A contemporary view that emphasizes the importance of considering a person’s cultural background and related experiences when determining normality and abnormality

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Sociocultural Conditions in Treatment
Multicultural counseling is the “fourth force” in psychotherapy
Multicultural counseling is assuming greater importance as our population becomes more diverse
Cultural factors, such as family experience and degree of assimilation, are important in assessment and intervention

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Review
What models of psychopathology have been used to explain abnormal behavior?
What is the multipath model of mental disorders?
How is biology involved in mental disorders?
How do psychological models explain mental disorders?

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Review (cont’d.)
What role do social factors play in psychopathology?
What sociocultural factors influence mental health?
Why is it important to consider mental disorders from a multipath perspective?

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AMHCA Standards for the
Practice of Clinical Mental
Health Counseling
Adopted 1979
Revised 1992, 1993, 1999, 2003, 2011, 2015, 2016, 2017,
and 2018

I. Introduction……………………………………………………………………………………………..1
A. Scope of Practice………………………………………………………………………………..2
B. Standards of Practice and Research……………………………………………………..3

II. Educational and Pre-degree Clinical Training Standards………………………..4
A. Program……………………………………………………………………………………………….4
B. Curriculum…………………………………………………………………………………………..4
C. Specialized Clinical Mental Health Counseling Training………………………5
D. Pre-degree Clinical Mental Health Counseling Field Work
Guidelines……………………………………………………………………………………………….5

III. Faculty and Supervisor Standards………………………………………………………….6
A. Faculty Standards…………………………………………………………………………………6
B. Supervisor Standards……………………………………………………………………………8

IV. Clinical Practice Standards……………………………………………………………………11
A. Post-degree/Pre-licensure………………………………………………………………….11
B. Peer Review and Supervision……………………………………………………………..11
C. Continuing Education………………………………………………………………………..11
D. Legal and Ethical Issues…………………………………………………………………….12

V. Recommend AMHCA Training…………………………………………………………….13
A. Biological Bases of Behavior……………………………………………………………..14
B. Specialized Clinical Assessment………………………………………………………….19
C. Trauma Informed Care……………………………………………………………………..21
D. Substance Use Disorders and Co-occurring Disorders…………………….27
E. Technology Assisted Counseling (TAC) …………………………………………..32
F. Integrated Behavioral Health Care Counseling…………………………..38
G. Aging and Older Adults Standards and Competencies………………………44
H. Child and Adolescent Standards and Competencies………………………….47

AMHCA Standards for the Practice of Clinical Mental Health Counseling
(Revised 2018) 1

I. Introduction
Since its formation as a professional organization in 1976, the
American Mental Health Counselors Association, AMHCA, has
been committed to establishing and promoting vigorous standards
for education and training, professional practice, and professional
ethics for clinical mental health counselors. Initially, AMHCA sought
to define and promote the professional identity of mental health
counselors. Today, with licensure laws in all 50 states, AMHCA
strives to enhance the practice of clinical mental health counseling
and to promote standards for clinical education and clinical practice
that anticipate the future roles of clinical mental health counselors
within the broader health care system. As a professional association,
AMHCA affiliated with APGA (a precursor to the American
Counseling Association [ACA]) as a division in 1978; in 1998,
AMHCA became a separate not- for-profit organization, but retained
its status as a division of ACA.

In 1976, a group of community mental health, community
agency and private practice counselors founded AMHCA as the
professional association for the newly emerging group of counselors
who identified their practice as “mental health counseling.” Without
credentialing, licensure, education and training standards, or other
marks of a clinical profession, these early mental health counselors
worked alongside social workers and psychologists in the developing
community mental health service system as “paraprofessionals” or
“allied health professionals” despite the fact that they held master’s
or doctoral degrees. By 1979, the early founders of AMHCA
had organized four key mechanisms for defining the new clinical
professional specialty:

1) identifying a definition of mental health counseling;
2) setting standards for education and training, clinical practice,
and professional ethics;
3) creating a national credentialing system; and
4) starting a professional journal, which included research and
clinical practice content.

These mechanisms have significantly contributed to the professional
development of clinical mental health counseling and merit further
explication.

AMHCA Standards for the Practice of Clinical Mental Health Counseling
(Revised 2018) 2

A. Scope of Practice
A crucial development in mental health counseling has been
defining the roles and functions of the profession. The initial
issue of AMHCA’s Journal of Mental Health Counseling included
the first published definition of mental health counseling as
“an interdisciplinary, multifaceted, holistic process of: 1) the
promotion of healthy lifestyles; 2) identification of individual
stressors and personal levels of functioning; and 3) the preservation
or restoration of mental health” (Seiler & Messina, 1979). In
1986, the AMHCA Board of Directors adopted a more formal,
comprehensive definition: “clinical mental health counseling is
the provision of professional counseling services involving the
application of principles of psychotherapy, human development,
learning theory, group dynamics, and the etiology of mental
illness and dysfunctional behavior to individuals, couples,
families and groups, for the purpose of promoting optimal
mental health, dealing with normal problems of living and
treating psychopathology. The practice of clinical mental health
counseling includes, but is not limited to, diagnosis and treatment
of mental and emotional disorders, psycho- educational techniques
aimed at the prevention of mental and emotional disorders,
consultations to individuals, couples, families, groups, organizations
and communities, and clinical research into more effective
psychotherapeutic treatment modalities.”

Clinical mental health counselors have always understood that
their professional work encompasses a broad range of clinical
practice, including dealing with normal problems of living and
promoting optimal mental health in addition to the prevention,
intervention and treatment of mental and emotional disorders.
This work of clinical mental health counselors serves the needs
of socially and culturally diverse clients (e.g. age, gender, race/
ethnicity, socio- economic status, sexual orientation, etc.) across
the lifespan (i.e. children, adolescents and adults including
older adults and geriatric populations). Clinical mental health
counselors have developed a strong sense of professional
identity since 1976. AMHCA has sought to support this sense of
professional identity through legislative and professional advocacy,

AMHCA Standards for the Practice of Clinical Mental Health Counseling
(Revised 2018) 3

professional standards, a code of ethics, continuing education,
and clinical educational resources, and support for evidence-
based best practices, research and peer-reviewed dissemination of
developments in the field.

B. Standards of Practice and Research
A key development for the profession was AMHCA’s creation of
education and training standards for mental health counselors in
1979. The Council for Accreditation of Counseling and Related
Educational Programs (CACREP) adopted and adapted these
AMHCA training standards in 1988 when it established the first
set of accreditation standards for master’s programs in clinical
mental health counseling. In keeping with AMHCA standards,
CACREP accreditation standards for the mental health counseling
specialty have consistently required 60 semester hours of graduate
coursework. AMHCA remained an active advocate for vigorous
clinical training standards through the 2009 CACREP accreditation
standards revision process, during which community counseling
accreditation standards were merged into the new clinical mental
health counseling standards. After careful review, AMHCA
endorsed the clinical mental health counseling standards.

Another important step in the further professionalization
of clinical mental health counseling, AMHCA established the
National Academy of Certified Mental Health Counselors, the
first credentialing body for clinical mental health counselors,
and gave its first certification examination in 1979. In 1993, this
certified clinical mental health counselor credential (CCMHC)
was transferred to the National Board for Certified Counselors
(NBCC). NBCC provides the Board Certification fo CCMHCs.
AMHCA clinical standards have always recognized and
incorporated the CCMHC credential as an important means
of recognizing that a clinical mental health counselor has met
independent clinical practice standards, despite significant
differences that exist among state counselor licensure laws, as well
as among educational and training programs.

Finally, since 1979, AMHCA published the Journal of Mental
Health Counseling, which has become widely recognized and cited

AMHCA Standards for the Practice of Clinical Mental Health Counseling
(Revised 2018) 4

as an important contributor to the research and professional
literature on clinical mental health counseling.

Taken together, these four mechanisms (definition of scope
of practice; educational and training standards, professional
practice standards and code of ethics; credentialing; and
professional journal) resulted in the recognition of clinical mental
health counseling as an important profession to be included in
our health care system. In recognition of the central importance
of vigorous professional educational and clinical practice
standards, AMHCA has periodically revised its professional
standards in 1993- 94, 1999, 2003, and 2010- 11 to reflect evolving
practice requirements. These professional standards, as well as
the 2015 AMHCA Code of Ethics, constitute the basis from which
AMHCA continues to advocate for, and seek to advance, the
practice of clinical mental health counseling.

II. Educational and Pre- degree Clinical Training Standards
Required Education: Master’s in Clinical Mental Health Counseling
(60 semester hours)

A. Program
CACREP- accredited clinical mental health counseling program –
based on 2009 standards (endorsed by AMHCA Board) or master’s
degree in counseling (minimum of 48 semester hours) from a
regionally accredited institution. The 48 semester- hour minimum
will increase to 60 semester hours in January 2016.

B. Curriculum
Consistent with 2009 CACREP standards, clinical mental health
counseling programs should include the core CACREP areas and
specialized training in clinical mental health counseling. The core
CACREP areas include:

• Professional Orientation and Ethical Practice;
• Social and Cultural Diversity;
• Human Growth and Development across the lifespan;
• Career Development;
• Counseling theories and Helping Relationships;
• Group Work;

AMHCA Standards for the Practice of Clinical Mental Health Counseling
(Revised 2018) 5

• Assessment;
• Research and Program Evaluation.

C. Specialized Clinical Mental Health Counseling Training:
These areas of Clinical mental health counselor preparation
address the clinical mental health needs across the lifespan
(children, adolescents, adults and older adults) and across socially
and culturally diverse populations:

• Ethical, Legal and Practice Foundations of Clinical Mental
Health Counseling;

• Prevention and Clinical Intervention;
• Clinical Assessment;
• Diagnosis and Treatment of Mental Disorders;
• Diversity and Advocacy in Clinical Mental Health

Counseling; and
• Clinical Mental Health Counseling Research and Outcome

Evaluation.
AMHCA recommends additional training in Clinical Mental

Health Counseling described in the following standards:
• Biological Bases of Behavior (including psychopathology

and psychopharmacology);
• Trauma Informed Care and;
• Co- occurring Disorders and Substance Use Disorders (mental

disorders and substance abuse).
This training may be completed as part of the degree program, in
post- master’s coursework, or as part of a certificate or continuing
education or CCMHC credential.

D. Pre- degree Clinical Mental Health Counseling Field Work
Guidelines

• Students’ pre- degree clinical experiences meet the minimum
training standards of 100 Practicum and 600 Internship hours.

• Students receive an hour of clinical supervision by an
independently and approved licensed supervisor for every
20 hours of client direct care. This field work supervision is
in addition to the practicum and internship requirements for
their academic program.

AMHCA Standards for the Practice of Clinical Mental Health Counseling
(Revised 2018) 6

• Students are individually supervised by a supervisor with no
more than 6 (FTE) or 12 total supervisees.

III. Faculty and Supervisor Standards
A. Faculty Standards
Faculty with primary responsibility for clinical mental health
counseling programs should have an earned doctorate in a field
related to clinical mental health counseling and identify with
the field of clinical mental health counseling. While AMHCA
recognizes that clinical mental health counseling programs have
the need for diverse non- primary faculty who may not meet all
of the following criteria, the following knowledge and skills are
required for faculty with primary responsibility for clinical mental
health counseling programs.

1. Knowledge
a. Demonstrate expertise in the content areas in which they teach
and have a thorough understanding of client populations served.

b. Involved in clinical supervision either as instructors or in the
field have a working knowledge of current supervision models
and apply them to the supervisory

process.

c. Understand that clinical mental health counselors are asked
to provide a range of services including counseling clients
about problems of living, promoting optimal mental health, and
treatment of mental and emotional disorders across the lifespan.

d. Demonstrate training in the following:
• Evidence- based best practices
• Differential diagnosis and treatment planning
• Co- occurring disorders and substance use disorders
• Trauma, and its related forms (developmental, complex,

situation, chronic or toxic distress, moreal trauma,
historical trauma, etc.)

• Biological bases of behavior including
psychopharmacology

AMHCA Standards for the Practice of Clinical Mental Health Counseling
(Revised 2018) 7

• Social and cultural foundations of behavior
• Individual family and group counseling
• Clinical assessment and testing
• Professional orientation and ethics
• Advocacy and leadership
• Case consultation and supervision with peers or

specialists, and
• Clinical supervision with a hierarchical or regulatory

supervisor.

e. Possess knowledge about professional boundaries as well
as professional behavior in all interactions with students
and colleagues.

2. Skills
a. Demonstrate clinical mental health skills by completing
licensure requirements including successful completion of
coursework, fieldwork requirements, licensure exams, and
licensure renewal requirements.

b. Demonstrate identification with the field of clinical mental
health counseling by their academic credentials, scholarship
and professional affiliations including their participation in
organizations which promote clinical mental health counseling
including AMHCA, ACA and ACES etc. Faculty who provide
clinical supervision in the program or on site are able to lead
supervision seminars which promote case analysis, small group
process and critical thinking.

c. Complete the equivalent of 15 semester hours of coursework
at the doctoral level in the clinical mental health specialty area or
a comparable amount of scholarship in this area.

d. Possess expertise in working with diverse client populations
in areas they teach including clients across the spectrum of
social class, ethnic/racial groups, lesbian, gay, bisexual and
transgendered communities, etc.

AMHCA Standards for the Practice of Clinical Mental Health Counseling
(Revised 2018) 8

e. Demonstrate and model the ability to develop and maintain
clear role boundaries within the teaching relationship.

f. Demonstrate the ability to analyze and evaluate skills and
performance of students.

B. Supervisor Standards
AMHCA recommends at least 24 continuing education hours or
equivalent graduate credit hours of training in the theory and practice
of clinical supervision for those clinical mental health counselors
who provide pre- or post-degree clinical supervision to CMHC
students or trainees. AMHCA recommends that clinical supervisors
obtain, on the average, at least 3 continuing education hours in
supervision per year as part of their overall program of continuing
education. Clinical supervisors should meet the following knowledge
and skills criteria.

1. Knowledge
a. Possess a strong working knowledge of evidence based and
best practices orientation with clinical theory and interventions
and application to the clinical process.

b. Understand the client population and the practice setting of
the supervisee.

c. Understand and have a working knowledge of current
supervision models and their application to the supervisory
process. Maintain a working knowledge of the most current
methods and techniques in clinical supervision knowledge of
group supervision methodology including the appropriate use
and limits of this modality.

d. Identify and understand the roles, functions and
responsibilities of clinical supervisors including liability in the
supervisory process. Communicates expectations and nature and
extent of the supervision relationship.

AMHCA Standards for the Practice of Clinical Mental Health Counseling
(Revised 2018) 9

e. Maintain a working knowledge of appropriate professional
development activities for supervisees. These activities should be
focused on empirically based scientific knowledge.

f. Show a strong understanding of the supervisory relationship
and related issues, not limited to power differential, evaluation,
parallel process and isomorphic similarities and differences
between supervision and counseling, and qualities that enhance
the supervisor/supervisee working alliance for the benefit of
clients served.

g. Identify and define the cultural issues that arise in clinical
supervision and be able to routinely incorporate cultural
sensitivity into the supervisory process.

h. Understand and define the legal and ethical issues in clinical
supervision including:

• applicable laws, licensure rules and the AMHCA Code of
Ethics specifically as they relate to supervision;

• supervisory liability, respondent superior, and fiduciary
responsibility; and

• risk management models and processes as they relate to
the clinical process and to supervision.

i. Possess a working understanding of the evaluation process
in clinical supervision including evaluating supervisee
competence and remediation of supervisee skill development.
This includes initial, formative and summative assessment of
supervisee knowledge, skills and self- awareness with provisions
for clearly stated expectations, fair delivery of feedback and
due process. Supervision includes both formal and informal
feedback mechanisms.

j. Maintain a working knowledge of industry recognized financial
management processes and required recordkeeping practices
including electronic records and transmission of records

AMHCA Standards for the Practice of Clinical Mental Health Counseling
(Revised 2018) 10

2. Skills
a. Possess a thorough understanding and experience in working
with the supervisees’ client populations. Be able to demonstrate
and explain the counselor role and appropriate clinical
interventions within the cultural and clinical context.

b. Develop, maintain and explain the supervision contract to
manage supervisee relationships with clear expectations including:
• frequency, location, length and duration of supervision meetings;
• supervision models and expectations of the supervisee and

the supervisor;
• liability and fiduciary responsibility of the supervisor;
• the evaluation process, instruments used and frequency of

evaluation; and
• emergency and critical incident procedures.

c. Demonstrate and model the ability to develop and maintain
clear role boundaries and an appropriate balance between
consultation and training within the supervisory relationship.

d. Demonstrate the ability to analyze and evaluate skills and
performance of supervisees including the ability to confront and
correct unsuitable actions and interventions on the part of the
supervisees. Provide timely substantive and formative feedback
to supervisees, along with providing cumulative feedback and to
train supervisees in techniques and methods in self-appraisal.

e. Present strong problem-solving and dilemma resolution skills
and practice skills with supervisees.

f. Develop and demonstrate the ability to implement risk
management strategies.

g. Practice and model self-assessment. Seek consultation as needed.

h. Conceptualize cultural differences in therapy and in supervision.
Incorporate and model this understanding into the supervisory

AMHCA Standards for the Practice of Clinical Mental Health Counseling
(Revised 2018) 11

process.

i. Possess an understanding of group supervision techniques and
the role of group supervision in the supervision process.

j. Comply with applicable federal, state, and local law. Take
responsibility for supervisees’ actions, which include an
understanding of recordkeeping and financial management rules
and practice.

IV. Clinical Practice Standards
A. Post-degree/Pre-licensure
Clinical mental health counselors have a minimum of 3,000
hours of supervised clinical practice post-degree over a period
of at least two years. In the process of acquiring the first 3,000
hours of client direct and indirect contact in postgraduate
clinical experience, AMHCA recommends a ratio of one hour
of supervision for every 20 hours of on-site work hours with a
combination of individual, triadic and group supervision.

B. Peer Review and Supervision
Clinical mental health counselors maintain a program of
peer review, supervision and consultation even after they are
independently licensed. It is expected that clinical mental health
counselors seek additional supervision or consultation to respond
to the needs of individual clients, as difficulties beyond their range
of expertise arise. While need is to be determined individually,
independently licensed clinical mental health counselors must
ensure an optimal level of consultation and supervision to meet
client needs.

C. Continuing Education
Clinical mental health counselors at the post- degree and
independently licensed level must comply with state regulations,
certification and credentialing requirements to obtain and maintain
continuing educational requirements related to the practice of
clinical mental health counseling. Clinical mental health counselors

AMHCA Standards for the Practice of Clinical Mental Health Counseling
(Revised 2018) 12

maintain a repertoire of specialized counseling skills and
participate in continuing education to enhance their knowledge of
the practice of clinical mental health counseling.

In accordance with state law, AMHCA recommends that in
order to acquire, maintain and enhance skills, counselors actively
participate in a formal professional development and continuing
education program. This formal professional development
ordinarily addresses peer review and consultation, continuum
of care, best practices and evidence-based research; advocacy;
counselor self-care and impairment, and AMHCA Code of
Ethics. Clinical mental health counselors who are involved in
independent clinical practice also receive ongoing training relating
to independent practice management, accessibility, accurate
representation, office procedures, service environment, and
reimbursement for services.

D. Legal and Ethical Issues
Clinical mental health counselors who deliver clinical services
comply with state statutes and regulations governing the practice
of clinical mental health counseling. Clinical mental health
counselors adhere to all state laws governing the practice of
clinical mental health counseling. In addition, they adhere to all
administrative rules, ethical standards, and other requirements of
state clinical mental health counseling or other regulatory boards.
Counselors obtain competent legal advice concerning compliance
with all relevant statutes and regulations. Where state laws lack
governing the practice of counseling, counselors strictly adhere
to the national standards of care and ethics codes for the clinical
practice of mental health counseling and obtain competent legal
advice concerning compliance with these standards.

Clinical mental health counselors who deliver clinical services
comply with the codes of ethics specific to the practice of clinical
mental health counseling. The AMHCA Code of Ethics outline
behavior which must be adhered to regarding commitment to
clients; counselor-client relationship; counselor responsibility
and integrity; assessment and diagnosis; recordkeeping, fee
arrangements and bartering; consultant and advocate roles;

AMHCA Standards for the Practice of Clinical Mental Health Counseling
(Revised 2018) 13

commitment to other professionals; commitment to students,
supervisees and employee relationships.

Clinical mental health counselors are first responsible to
society, second to consumers, third to the profession, and last to
themselves. Clinical mental health counselors identify themselves
as members of the counseling profession. They adhere to the
codes of ethics mandated by state boards regulating counseling
and by the clinical organizations in which they hold membership
and certification. They also adhere to ethical standards endorsed
by state boards regulating counseling, and cooperate fully with the
adjudication procedures of ethics committees, peer review teams,
and state boards. All clinical mental health counselors willingly
participate in a formal review of their clinical work, as needed.
They provide clients appropriate information on filing complaints
alleging unethical behavior and respond in a timely manner to a
client request to review records.

Of particular concern to AMHCA is that clinical mental health
counselors who deliver clinical services respond in a professional
manner to all who seek their services. Clinical mental health
counselors provide services to each client requesting services
regardless of lifestyle, origin, race, color, age, handicap, sex, religion,
or sexual orientation. They are knowledgeable and sensitive to
cultural diversity and the multicultural issues of clients. Counselors
have a duty to acquire the knowledge, skills, and resources to assist
diverse clients. If, after seeking increased knowledge and supervision,
counselors are still unable to meet the needs of a particular client,
they do what is necessary to put the client in contact with an
appropriate mental health resource.

V. Recommended AMHCA Training
AMHCA recommends that clinical mental health counselors have
specialized training in addition to the generally agreed upon courses
and curricula endorsed by CACREP. These include the biological
bases of behavior, clinical assessment, trauma, and co- occurring
disorders technology assisted counseling, and integrated behavioral
health care counseling, working with children and adolescents,
and working with older persons. Knowledge and skills related to

AMHCA Standards for the Practice of Clinical Mental Health Counseling
(Revised 2018) 14

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, case studies, research papers, 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 human thought, feeling, and behavior, from the
more to the less adaptive, are the result of complex interactions
between biological, psychological, and social factors. There is an
increased need for an expanded exploration and understanding
of the biological factors as well as the way that they influence and
are influenced by the psychological and social factors. A deeper
understanding of the biological bases of behavior helps clinical
mental health counselors not only be more precise in our diagnosis
and treatment of mental disorders, but also in the promotion of
wellness, peak performance, and quality of life.

1. Knowledge
a. Understand the structure and function of the central
nervous system (CNS) (brain, spinal cord) and the peripheral
nervous system (PNS) (somatic, autonomic, sympathetic, and
parasympathetic).

b. Understand how the human nervous system interacts
with other physiological systems (endocrine, immune,
gastrointestinal, etc.).

c. Possess a basic understanding of neural development across
the lifespan (e.g. genetic, social, and/or environmental factors
that influence the development of the human nervous system).

d. Comprehend structural and functional neuroanatomy as well
as physiology of the sympathetic and parasympathetic nervous
systems.

AMHCA Standards for the Practice of Clinical Mental Health Counseling
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e. Understand physiological and biochemical mechanisms of
interneuronal communication (e.g. neurotransmission).

f. Comprehend methods used to evaluate functioning in the
central and peripheral nervous systems (e.g., quantitative
electroencephalography, MRI, galvanic skin response).

g. Possess an introductory knowledge of the neurocognitive
processes underlying executive function, feelings, learning,
memory, sensation, and perception across the lifespan.

h. Understand the neurobiological mechanisms underlying
neurodevelopmental, neurodegenerative, and psychiatric
disorders.

i. Comprehend the neurophysiological causes and behavioral
implications of various medical conditions (e.g. autoimmune
disorders, epilepsy, stroke, obesity) and traumatic brain injury.

j. Understand current research (e.g. mechanisms, efficacy,
effectiveness) related to the use of biofeedback (e.g.
neurofeedback, actigraphy data) for enhancing therapeutic
outcomes in clinical mental health counseling.

k. Understand how drugs are absorbed, metabolized and
eliminated.

l. Understand the pharmacokinetics and pharmacodynamics
of psychotropic drugs used in the treatment of mental health
disorders and neurodegenerative diseases.

m. Understand how psychotropic medications influence
behavior change and is able to identify possible
contraindications and adverse effects.

n. Understand the biological components of the therapeutic
relationship.

AMHCA Standards for the Practice of Clinical Mental Health Counseling
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2. Skills

a. Integrating Research into Practice
i. Acknowledge how science and evidence-based practice
may be leveraged to improve outcomes and increase
collaboration in integrated care settings.

ii. Identify the limits of one’s knowledge and professional
expertise and regularly engage in ongoing continuing
education and certification for additional specialty practice
(e.g., biofeedback, neurofeedback).

iii. Is able to locate, appraise, and assimilate research
from allied fields such as neuroscience, endocrinology,
immunology, nutrition, and psychiatry into clinical practice.

iv. Critically evaluate peer-reviewed literature, communicates
findings in a clear and accurate manner, and avoids
overstating or overgeneralizing research findings.

v. Demonstrate the ability to discuss the biology of
reproduction and prenatal development with both clients
and colleagues.

vi. Describe the aging brain and how it may change across
the lifespan.

vii. Explore the mechanisms and common clinical features
of neurocognitive disorders in addition to offering
strategies designed to improve functioning (e.g. agitation
and anxiety, cognitive function, caregiver support) with
clients, family and colleagues.

viii. Articulate how physiological (e.g. genes, molecules,
circuits, immune functioning, endocrinology, gut
microbiome), psychological (e.g. neurocognitive, personality,
symptom), and environmental (e.g. individual, family,

AMHCA Standards for the Practice of Clinical Mental Health Counseling
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community, society, cultural) factors may interact to
modulate human behavior.

ix. Articulate the basic principles of pharmacology (e.g.
dose-response, side-effects, interactions pharmacokinetics,
pharmacodynamics, routes of administration, distribution)
and adaptation (e.g. tolerance, sensitization, withdrawal,
placebo, nocebo) associated with commonly used drugs.

x. Review and critically appraise all research investigating
the reliability and validity of any diagnostic and/or
interventional technology intended to augment the
practice of clinical mental health counseling, which may
include emerging tools/methods used for collecting data
from self-report or laboratory tests, mobile devices, and/
or other methods of physiological data collection (e.g.,
electroencephalography).

b. Clinical Intervention
i. Counsel clients from a biologically grounded lifespan
developmental approach In concert with one’s theoretical
orientation.

ii. Acknowledge the strengths and limitations of drugs
commonly used to treat major psychiatric disorders.

iii. Counsel clients about how to communicate with
providers regarding the risks and benefits of medication,
method of adherence, and common adverse effects.

iv. Effectively and accurately translate mental health
information into plain language, without using scientific
jargon, while also communicating empathy and ensuring a
warm, non-judgmental, and supportive therapeutic alliance.

v. Render suitable diagnoses grounded in the synthesis
of assessment data obtained from various methods (e.g.,

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clinical interview, psychometric instruments, quantitative
EEG) across multiple levels of explanation (e.g., genetic,
molecular, cellular, neurocircuitry, physiology, behavior, and
self-report).

vi. Produce timely, detailed, and accurate clinical reports
which demonstrate: (1) the use of appropriate clinical
terminology; (2) a commitment to ethical practice; (3) the
ability to systematically collect and synthesize relevant data,
and (4) how treatment is routinely refined and/or modified
over time.

vii. Implement, at a minimum, formative and summative
assessments to monitor progress and outcomes.

viii. Effectively communicates and collaborates with medical
and other allied health professionals.

ix. Use an appropriate biopsychosocial assessment to
explore and enhance the quality of the therapeutic
relationship.

c. Professional Advocacy
i. Consult with clients, the public, the media, and
other professionals regarding the neurophysiological
underpinnings of behavior and how the human nervous
system adapts to life circumstances including traumatic
brain injury, physical and sexual abuse and substance use.

ii. Remain up to date on emerging trends in mental health
research (e.g. Research Domain Criteria) and practice (e.g.
neurofeedback, precision psychiatry) so as to ensure that
assessment, diagnosis, and interventions are continuously
aligned to evidence-based treatments.

iii. Critically analyze emerging developments in mental
health and social policy and engage in professional advocacy

AMHCA Standards for the Practice of Clinical Mental Health Counseling
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efforts to ensure that all clients have equitable access to
ethical, sensitive, timely, and effective services.

iv. Partner with professional associations to offer ethical
guidance and professional expertise to policy makers, the
public, and colleagues from allied disciplines on emerging
issues related to mental health policy.

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.

1. Knowledge
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

AMHCA Standards for the Practice of Clinical Mental Health Counseling
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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.

2. Skills
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

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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 Informed Care
Many individuals seek counseling to resolve symptoms associated with
traumatic or chronically distressful experiences. Those experiences

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may include single-episode traumatic events (such as a mugging,
assault, tornado, etc.), or complex trauma (sometimes referred to as
developmental trauma or poly-victimization) experienced in childhood,
adolescence, or adulthood featuring chronic abuse, neglect, or exposure
to other harsh adversities.

The types of traumatic or persistently distressful experiences that
can result in symptoms and disorders are many. As more is learned
about the causes of trauma-related symptoms, the nomenclature within
a trauma informed care approach has grown, and the descriptors for
trauma are numerous. Some examples in this non-exhaustive list that
are based on existing literature, research, models and methods might
include betrayal trauma, domestic trauma, forced displacement trauma,
historical trauma, military trauma, moral trauma, polytrauma, system-
induced trauma and re-traumatization, refugee and/or war zone trauma,
medical trauma, and more. For the purposes of this standard, the
terms trauma, chronic distress, and/or complex trauma will be used to
encompass the meaning of all types and causes of trauma.

CMHCs obtain knowledge and skills to treat clients who
experience(d) traumatic events or conditions, chronic distress, and
complex trauma; this preparation is essential for the practice of clinical
mental health due to the high incidence of trauma and distressful
events or contexts. Individuals who have the symptoms of unresolved
complex trauma, chronic distress, or other traumas are at risk for a
variety of emotional, cognitive, and physical illnesses that can potentially
last throughout their lives. Therefore, these individuals frequently
present with related co-occurring disorders, such as anxiety, depression,
and substance abuse, and often form negative core self-beliefs. Recent
research reveals that physical health later in one’s lifespan may be
compromised due to trauma. The presence of resilience is an important
mitigating variable in the progression of symptoms related to traumatic
experiences. Complex trauma can often compromise an individual’s
resilience or capacity to thrive after traumatic experiences compared
to persons who survived a single-episode traumatic event such as a car
accident.

It is important to note that the traumatic event is a cause of the
related disorders or symptoms as contrasted with unwittingly regarding
the client as the cause of the symptoms. Though the aftereffects of

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traumatic experiences can be very profound and experienced internally
within traumatized individuals, the cause of the trauma is almost
always related to external events, actions, or contexts that are outside
of the individual. CMHCs also want to note if the cause(s) of the
trauma are natural (e.g. a tornado or hurricane) or human caused (e.g.
domestic violence, maltreatment, terrorism). Human-caused traumas
frequently create more vexing emotional repercussions. Additionally,
clinicians should remain well-informed about neurological effects of
chronic distress or exposure to repeated traumatic experiences which
compromise a person’s ability to develop effective coping measures.

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.

1. Knowledge
a. Recognize that the type and context of trauma has
important implications for the etiology, sequelae of symptoms,
diagnosis, and treatment of symptoms (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, prior history of
traumatic experiences, age, gender, sexual orientation,
developmental level, culture, ethnicity, access to care, resilience,
etc.

c. Understand that symptoms faced as a result of traumatic
experiences can be multi-faceted and therefore CMHCs should
be familiar with its many forms including relational, acute,
chronic, episodic, and complex, as well as the implications for
effective, evidenced-based treatment approaches.

d. Recognize the circumstances or indicators when a referral to
a more qualified mental health professional who specializes in
trauma is warranted. Indications that a more trauma-focused

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approach is needed may be related to severity, complexity,
responsiveness of the client to lower-level of care, capacity of
the CMHC to provide specialized care, etc. More specialized
care may be found in services such as inpatient care, trauma
intensive-care, Eye Movement Desensitization Reprocessing,
Trauma-Focused CBT, and other recognized evidence-based
approaches.

e. Understand the impact of various types of trauma (e.g.
sexual and physical abuse, war, chronic verbal/emotional
abuse, neglect, natural disasters, etc.) may have on the Central
Nervous System (CNS) and the Autonomic Nervous System
(ANS) and how this might impact one’s sense of secure
attachment, affect regulation, personality functioning, self-
beliefs and self-identity, self-care, etc., as well as the potential
for trauma-related re-enactment in relationships.

f. Recognize the long-term consequences of trauma-causing
events on social groups, communities, and cultures, including
the incidence of collective trauma, generationally-transmitted
and “historical” trauma. CMHCs may serve communities
and assist with the impact of collective trauma in a variety
of formats or settings, such as with families, agencies and
organizations, municipalities, multi-systemic collaborations,
etc., through various modalities such as psychoeducation,
consultation, information provision with the media, follow-up
initiatives, preventative initiatives, etc.

g. Understand how promoting and developing resiliency
and other protective factors for individuals, groups, and
communities can diminish the risk and impact of trauma
related disorders.

h. Recognize differential strategies and approaches necessary
to work with children, adolescents, adults, couples, and families
in trauma treatment.

AMHCA Standards for the Practice of Clinical Mental Health Counseling
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i. Recognize, from an organizational or management
perspective, the need to design, train, and implement trauma-
informed care policies and practices for a systemically-
responsive approach to serving clients impacted by traumatic
experiences (e.g., train the Security Guards who work in a
domestic violence shelter how to carry out their duties with
trauma-informed-awareness).

j. Understand familiarity with trauma stewardship and effective
practices for self-care, as well as strategies to protect from
secondary or vicarious traumatization.

k. Understand the indicators or target outcomes of effective
and enduring trauma resolution (e.g. the integration of
traumatic memory into the client’s regular memory, traumatic
event recall without debilitating emotional distress, individual
generalized affect regulation, the alleviation of traumatic
triggers, posttraumatic growth, etc.).

l. Understand the well-timed exploration of the potential
for and themes for posttraumatic growth (PTG) among
traumatized clients after effective counseling and symptom
reduction. CMHCs may assist clients to discover ways in which
a survivor may change for the positive (e.g., changes in one’s
sense of priorities, a greater appreciation of life, a deepened
sense of personal strength, more meaningful relationships,
a sense of new possibilities for oneself, developing views
and philosophy about life, and/or the meaning of suffering,
perspective, or a strengthened belief system).

2. Skills
a. Demonstrate the ability to use evidence-based assessment
measures to evaluate and differentiate the clinical impact
of various trauma-causing events, not limited to evaluation
measures/resources focused on early life trauma and distress,
such as the Adverse Childhood Experiences Survey, along with
the many other trauma assessment tools available for type-of-

AMHCA Standards for the Practice of Clinical Mental Health Counseling
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trauma measures throughout the life span.

b. Demonstrate the ability to apply established counseling
theories that are evidence-based or best trauma resolution
practices. Best practices promote the integration of brain
functioning and resolution of cognitive, emotional, sensory,
and behavioral symptoms related to trauma-causing events for
socially and culturally diverse clients across the lifespan.

c. Demonstrate sensitivity to individual and psychosocial
factors that interact with trauma-causing events in counseling
and treatment planning.

d. Demonstrate familiarity with trauma stewardship and
effective practices for self-care, and for protection from
secondary or vicarious traumatization.

e. Demonstrate the ability to recognize that any of the clinical
mental health counselor’s traumatic experiences may impact
his or her trauma-surviving-clients and the counseling process.
CMHCs should seek appropriate trauma resolution counseling
and/or consultation as necessary.

f. Apply age-appropriate strategies and approaches in
assessing and counseling children and adolescents and
modify these techniques when working with adults.

g. Use differentially appropriate counseling and other
treatment interventions in the treatment of couples who
encounter re-enactment trauma, trauma of a partner, or
secondary trauma from traumatized family members.

h. Demonstrate the ability to advocate with payors of
counseling fees (e.g., insurance companies, treatment centers,
etc.) by monitoring diagnosis and treatment needs with
utilization review of sessions allotment. Clinicians may
have to advocate rigorously for the client with the payor of

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counseling fees and itemize thoroughly all diagnosed comorbid
disorders while also assuring the client about the differences
of “what’s wrong with me” vs. “what happened to me.”

i. Demonstrate how to comprehensively assess the degree
of trauma resolution as a measure of client recovery as
well as an indicator of therapeutic efficacy. CMHCs should
monitor ongoing clinical progress toward target outcomes,
using assessment measures, and client self-report to ensure
that mutual counselor/client termination of care (contrasted
with premature cessation of counseling by either party) yields
healthy and positive outcomes.

j. Demonstrate the ability to facilitate the development of
clients’ sense of safety and resilience.

k. Provide assessment and guidance with a traumatized client
related to posttraumatic growth (PTG) in a clinically time-
sensitive manner (after symptom reduction) to explore possible
avenues for the client to discover personal changes or qualities
within oneself, in relationships, or in belief systems and
meaning-making that may have emerged from the traumatic
experience(s) and its impact on self.

D. Substance Use Disorders and Co-occurring Disorders
Substance use disorders (SUDs) are commonly comorbid with
other mental health disorders. In other words, individuals with
substance use often have a mental health condition concurrently.
For example, having Post Traumatic Stress Disorder (PTSD) is
frequently a significant contributing factor to the development
of a substance use disorder. Failure to address both the mental
health disorder as well as the substance-related disorder can result
in ineffective and incomplete treatment, stabilization, or recovery.
There are many consequences of undiagnosed, untreated, or
undertreated comorbid disorders including a higher potential for
homelessness, incarceration, medical illnesses, suicide, danger to
others, and premature death, to name a few. It is incumbent on

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CMHCs to apply thorough and comprehensive assessment and
treatment for co-occurring disorders to prevent such neglect,
harm, and possible death.

1. Knowledge
a. Understand the epidemiology (incidence, distribution, and
control) of substance use and co-occurring disorders for
socially and culturally diverse populations at risk across the
lifespan.

b. Understand theories and models about the etiology of
substance use and co-occurring disorders including risk and
resiliency factors for individuals, groups, and communities.
Explanations for the development of SUDs are multiple
including Psychological Models [behavioral, learning, cognitive,
psychoanalytic, personality, social learning]; Multi-causal Models
[biopsychosocial, syndrome, integral]; Biological/Physiological
Models [disease, genetic predisposition, co-occurring];
Educational/Knowledge Models [educational, public health,
developmental]; Psychosocial Model [peer-cluster, problem-
behavior]; Sociocultural Models [sociocultural, culture-specific,
prescriptive, sanctioned-use]; Family Models [general systems,
parental influence]; Lifestyle/Coping Models [stress-coping,
lifestyle, spiritual]; Progression Models [gateway, final common
pathway]; and the choice/moral model. Additionally, CMHCs
should become familiar with “abstinence-focused” and “harm-
reduction-focused” views of and approaches for understanding
and treating substance use.

c. Possess a working knowledge of the neurological and
biological aspects of SUDs, both related to the causes and
treatment implications for SUDs.

d. Possess a working knowledge of SUDs including drug
types, routes of administration, drug distribution, elimination,
dependence, tolerance, withdrawal, dose response interaction,
and how to interpret basic lab results.

AMHCA Standards for the Practice of Clinical Mental Health Counseling
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e. Recognize the capacity for substance abuse to present as one
of a range of psychological or medical disorders, to cause such
disorders, and understand effective assessment and differential
diagnosis among SUDs and other diagnoses.

f. Understand treatment and clinical management of SUDs with
the presence of co-occurring mental health disorders with an
emphasis on best practices, risk management and prioritization
of clinical goals, medication management, and theory/method/
approach match for each condition (such as cognitive behavioral,
trauma-focused, dialectical behavioral, etc.).

g. Possess a working knowledge of how prevention,
treatment, aftercare, and recovery policies and programs
function.

h. Understand the working definition of recovery and recovery-
oriented systems of care for mental illness and SUDs with
familiarity and promotion of recovery support strategic initiatives
that focus on health (physical and emotional well-being), home
(stable, safe living arrangements), purpose (meaningful daily
activities to participate in society), and community (social
relationships involving support, friendship, love and hope).

i. Possess a working knowledge of the ten guiding principles
for recovery from mental illness and SUDs (hope, person-
driven, many pathways, holistic, peer support, relational,
culturally-based, addresses trauma, strengths and responsibility,
and respect).

j. Possess a working knowledge of recovery support tools and
resources that include peer support programs or models that
demonstrate peer-navigators’ competencies, decision-making
tools, use of narratives and stories, parents and families,
communities and social resources, and other training tools.

k. Study the rapidly developing facts and emerging community

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and clinical responses related to the current opioid and
prescription drug abuse epidemic along with emerging
initiatives and response strategies, such as the emerging
evidenced-based publications from researchers, experts,
foundations, and advocacy groups.

l. Understand which medications and psychopharmacological
treatments may be effective for the treatment of alcohol
use disorder, opioid and prescription drug abuse, along with
pharmacological treatments of other co-morbid conditions
(such as mood and anxiety disorders, etc.).

m. Understand the current history, philosophy, and trends
in substance abuse counseling including treatments
that incorporate 1. stages of change (e.g. motivational
interviewing), 2. self-help, spiritual, and secular groups and
communities (not limited to 12-step groups, Self-Management
and Recovery Training [SMART], Secular Organizations for
Sobriety [SOS], Refuge Recovery, LifeRing Secular Recovery,
Moderation Management, Celebrate Recovery, etc.), and 3.
medication-assisted treatment in conjunction with clinical
mental health counseling.

n. Understand the application of existing therapeutic
approaches and counseling techniques empirically-validated
for addictions counseling, such as Motivational Interviewing,
Cognitive Behavioral, Contingency Management, Motivational
Enhancement Therapy, Life Skills Training, Acceptance
and Commitment Therapy, Dialectical Behavioral Therapy,
Functional Analytic Therapy, Mindfulness Based Cognitive
Behavioral Therapy, etc.

o. Understand ethical and legal implications related to
counseling practice for substance use disorders and co-
occurring disorders in diverse settings, particularly, including
familiarity with the co-occurrence of legal problems with
SUDs. CMHCs should be familiar with addiction-oriented

AMHCA Standards for the Practice of Clinical Mental Health Counseling
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treatment options for legal difficulties, inpatient or outpatient
units, partial or day programs, recovery houses or sober living
communities. CMHCs are advised to be aware of criminal
justice system options, with attention to community “mental
health courts” or “drug courts” that encourage alternative
sentencing as a treatment strategy in lieu of incarceration and
should be familiar with Title 42 Code of Federal Regulations
(42 CFR) when working with individuals that have protection
under this code.

2. Skills
a. Demonstrate the ability to effectively assess and screen for
unhealthy substance use such as but not limited to alcohol,
marijuana, tobacco, and other licit and illicit drugs, that relies
on validated screening and assessment procedures, including
recommendations for placement criteria.

b. Demonstrate the ability to gauge the severity of clients’ co-
occurring disorders and to assess their stage of readiness for
change.

c. Demonstrate the ability to provide brief interventions and
counseling, care management, for unhealthy alcohol, tobacco,
prescription drug and opioid use disorders.

d. Conceptualize cases and develop treatment plans based on
stages of change that address mental health and substance use
disorders simultaneously.

e. Demonstrate skills in applying motivational enhancement
strategies to engage clients.

f. Provide appropriate counseling strategies when working with
clients who have co-occurring disorders while first prioritizing
symptom reduction or symptom management in order of most
dangerous (if left untreated) to client or others.

AMHCA Standards for the Practice of Clinical Mental Health Counseling
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g. 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, including incorporating systemically-
oriented family counseling into treatment planning and/or
providing appropriate referrals.

h. Demonstrate the ability to modify counseling systems,
theories, techniques, and interventions for socially and culturally
diverse clients with co-occurring disorders across the lifespan
that are consistent with evidence-based best practices.

i. Demonstrate the ability to recognize one’s own limitations
when treating co-occurring disorders and to seek collaboration,
consultation, training, supervision appropriately, and/or one’s
own therapy, or refer clients as needed.

j. Demonstrate the ability to apply and adhere to ethical and
legal standards in substance use disorders and co-occurring
disorder counseling. This includes competence related
to assisting clients who navigate the legal implications of
SUDs and systems such as drug courts, mental health courts,
legal case management, court-recommended treatment,
incarceration and sentencing trends, 42 CFR, etc.

k. Broaden counseling and therapy skills to provide multiple
modalities of counseling-related functions not limited to
psychoeducation and client education, case management,
multi-system collaboration (for example, with “Drug Courts,”
housing, women and infant care resources, group counseling
and support group provisioning, sober living and independent
living resourcing, etc.).

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

AMHCA Standards for the Practice of Clinical Mental Health Counseling
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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.

1. Knowledge
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:

AMHCA Standards for the Practice of Clinical Mental Health Counseling
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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.

AMHCA Standards for the Practice of Clinical Mental Health Counseling
(Revised 2018) 35

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

AMHCA Standards for the Practice of Clinical Mental Health Counseling
(Revised 2018) 36

2. Skills
a. General

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.

b. 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

AMHCA Standards for the Practice of Clinical Mental Health Counseling
(Revised 2018) 37

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

AMHCA Standards for the Practice of Clinical Mental Health Counseling
(Revised 2018) 38

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

AMHCA Standards for the Practice of Clinical Mental Health Counseling
(Revised 2018) 39

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.

1. Knowledge
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

AMHCA Standards for the Practice of Clinical Mental Health Counseling
(Revised 2018) 40

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.

AMHCA Standards for the Practice of Clinical Mental Health Counseling
(Revised 2018) 41

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:

• medical literacy
• population screening
• chronic disease management
• educating medical staff about integrated care
• group interventions
• evidence-based interventions (See the AMHCA white
paper entitled Behavioral Health Counseling in Health Care
Integration Practices and Health Care Systems)

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

AMHCA Standards for the Practice of Clinical Mental Health Counseling
(Revised 2018) 42

• 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.

2. Skills
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

AMHCA Standards for the Practice of Clinical Mental Health Counseling
(Revised 2018) 43

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.

AMHCA Standards for the Practice of Clinical Mental Health Counseling
(Revised 2018) 44

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 treat-
ment 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.

G. Aging and Older Adults Standards and Competencies
Older adults, those aged 60 or above, make important contributions
to society as family members, volunteers and as active participants
in the workforce. While most have good mental health, many older
adults are at risk of developing mental disorders, neurological
disorders or substance use problems as well as other health
conditions such as diabetes, hearing loss, and osteoarthritis.
Furthermore, as people age, they are more likely to experience
several conditions at the same time.

The key components to successful aging include physical health,
mental activity, social engagement, productivity and life satisfaction.
When any one of these components are compromised, it can have
a negative impact on quality of life. MHC’s must understand and
address the interaction of these components when working with
aging adults.

In addition, older adults are more likely to experience events
such as bereavement, a drop in socioeconomic status with
retirement, or a disability. All of these factors can result in isolation,

AMHCA Standards for the Practice of Clinical Mental Health Counseling
(Revised 2018) 45

loss of independence, loneliness and psychological distress in older
adults.

Mental health problems can be under-identified by health-
care professionals and older adults themselves, and the stigma
surrounding mental illness can make older adults reluctant to seek
help. Substance abuse problems among the elderly can also be
overlooked or misdiagnosed.

1. Knowledge
CMHC’s must demonstrate knowledge of the following physical
and mental health subject areas specific to working with older
adults:

a. Understanding of lifespan developmental theories relating to
older adults

b. Understanding of social processes, including topics such as
the cultural context of relationships, social engagement and
support, leisure and recreation, isolation, productivity (i.e.,
retirement, loss of identity), sexuality, intimacy, caregiving, self-
care, stress relief, abuse and neglect, victimization, and loss and
grief.

c. Understanding of skills necessary to cope with the emotional
and physical challenges associated with the aging process,
including how society responds to older adults

d. Appreciation of psychological aspects of aging, including
topics related to the meaning and end of human life according
to various religious and cultural viewpoints in relation to topics
such as the quality and sacredness of life, end of life moral
issues, grief and mourning, satisfaction and regret, suicide, and
perspectives on life after death.

e. Recognition of and knowledge of the incidence of suicide
among older persons, including warnings signs, risk factors,
protective factors, acute vs. chronic risk, the ability to formulate
the level of suicidal risk (none, low, moderate, high) using
qualified assessment techniques, and managing risk.

AMHCA Standards for the Practice of Clinical Mental Health Counseling
(Revised 2018) 46

f. Appreciation of cultural and ethnic differences among
older adults including culturally relevant strategies to promote
resilience and wellness in older adults.

g. Understanding the integration and adjustment of life
transitions that occur as part of normal aging (i.e., functional
mobility, family constellation, housing, health care, level of care
etc.)

h. Recognition of the comorbidity of aging related and health-
related vulnerabilities and strengths

i. Recognition of the interplay between general medical
conditions and mental health including an understanding
of common medications, side effects, drug interactions and
presentation.

j. Understanding of drug use and abuse amongst older adults

2. Skills
a. Ability to assess the various presentations of mental health
disorders (e.g., mood disorders and cognitive and thought
disorders, etc.) in older adults and their impact on functional
status, morbidity and mortality.

b. Demonstrate the ability to communicate respectfully and
effectively with older adults and their families, accommodating
for hearing, visual and cognitive deficits.

c. Demonstrate the ability to communicate respectfully with
older adults and their families, recognizing all multicultural
considerations unique to older adults, particularly generational
values and age-related abilities.

d. Demonstrate the ability to navigate and address issues
associated with the emotional and physical challenges of the

AMHCA Standards for the Practice of Clinical Mental Health Counseling
(Revised 2018) 47

aging process, including how society responds to older adults
using appropriate counseling strategies.

e. Demonstrate an ability to navigate the unique challenges
related to confidentiality of patient information, informed
consent, competence, guardianship, advance directives, wills,
and elder abuse.

f. Demonstrate the ability to plan treatment, including
a biopsychosocial conceptualization of predisposing,
precipitating, and protective factors, mental status evaluation,
diagnosis, and mental health assessment as it pertains to older
adults.

g. Demonstrate familiarity with the diverse systems of care for
patients and their families, and how to use and integrate these
resources into a comprehensive treatment plan.

h. Demonstrate the ability to effectively interface with
integrated healthcare professional and collateral sources,
enlisting a multidisciplinary approach to the treatment of older
adults.

H. Child and Adolescent Standards and Competencies
An estimated one in five youth struggles with mental health
challenges. Like adults, children and adolescents struggle with
mental disorders that include anxiety, depression, obsessive-
compulsive disorder, and posttraumatic stress. Children and
adolescents often present different symptomatic presentations
of these disorders compared with adults, requiring specialized
knowledge of diagnosis and treatment. Several notable
neurodevelopmental conditions emerge during early childhood,
including autism and spectrum disorders and attention-deficit/
hyperactivity disorder. Late adolescence is also the time when
major mental disorders such as bipolar disorder and schizophrenia
develop, with prodromal symptoms often appearing earlier in

AMHCA Standards for the Practice of Clinical Mental Health Counseling
(Revised 2018) 48

adolescence. The teenage years are a time of experimentation,
identity formation and exploration that can have lasting
implications throughout the lifespan (e.g. risk-taking related
injuries, substance use and experimentation, sexual experiences, and
possible pregnancy).

Clinical mental health counselors (CMHCs) can provide more
effective services to youth after obtaining knowledge and skill
in assessing, diagnosing, and treating these conditions during
childhood and adolescence while also remaining informed about
developmental neurodevelopmental conditions and other issues
that occur during the process of child development.

Treatment approaches to counseling youth can vary
substantially, depending on their developmental level and age.
For example, younger children do not have the capacity for
higher-order cognition and are more likely to benefit from play
therapy, and interventions that address parent-child interaction.
Mentalization abilities, sometimes referred to as metacognition and
theory of mind, develop during adolescence, and this new ability
to “think about thinking” provides foundational ability for talk
therapy approaches such as cognitive-behavioral therapies, among
others.

Early intervention has the potential to improve prognosis of
mental disorders over the course of the lifespan. For example,
early behavioral intervention for children with autism spectrum
disorders at 2 or 3 years of age can have a greater impact on the
acquisition of social skills and language development compared
with later remediation. Early intervention with many disorders
often yields better prognosis over time.

Family involvement is often a crucial component of treatment
for children and adolescents with mental health struggles. Working
with parents/guardians to address family dynamics and interactions
through family counseling can often facilitate sustained treatment
gains and prevent recurrent episodes of symptoms. CMHCs also
need to understand minors’ rights in the state that they currently
reside, pertinent to the age of consent for adolescents, and parent/
guardian rights to see the treatment record. Knowledge and skills

AMHCA Standards for the Practice of Clinical Mental Health Counseling
(Revised 2018) 49

pertinent to assessing for child abuse and neglect are also crucial.
CMHCs working with children and adolescents require

specialized culturally competent knowledge and skills pertinent to
the inter-related domains of development–cognitive, neurological,
physical, sexual, and social development. Additionally, CMHCs
need to understand the educational and academic requirements
of P-12 education, the rights and responsibilities of students in
their educational systems, the impact of mental health challenges
on academic achievement and vice-versa, and study skills required
to enhance academic achievement. CMHCs also need specialized
knowledge and skills in working with family systems that support
and promote child and adolescent development. An understanding
of social influence from peer relationships is also important,
particularly during adolescence.

1. Knowledge
CMHCs must demonstrate knowledge of the following subject
areas specific to working with children and adolescents:

Neurophysiological Development
a. Understanding of post-natal and infant mental health.

b. Understanding of developmental milestones, transitions, and
lifespan theories relating to children and adolescents.

c. Understanding of neurological brain development during
childhood and adolescence, and its impact on executive
functioning and decision-making.

d. Understanding of physical and sexual development during
childhood and adolescence.

e. Understanding of the development of sexual/affective
orientation, including the exploration and questioning of sexual
and gender identity.

Social, Cultural, and Familial Influences
f. Understanding of role of gender and gender identity
on development, including the influence of gender role

AMHCA Standards for the Practice of Clinical Mental Health Counseling
(Revised 2018) 50

socialization practices.

g. Appreciation of socio-cultural differences among children
and adolescents, including race/ethnicity, acculturation level,
family background, and culturally relevant strategies to promote
resilience and wellness.

h. Understanding of socio-economic influences on
development, including the impact of poverty, homelessness,
and displacement.

i. Understanding of social support system in childhood and
adolescence, including family, peer, community, and school-
based supports.

j. Understanding of impact of bullying experiences and stigma.

k. Understanding of family relationships, including parent-child
relationships, sibling relationships, relationships with extended
family, and the impact of domestic violence.

l. Understanding of family events that can generate distress
in childhood and adolescence, including parental divorce, and
transitions such as stepfamily integration.

m. Understanding of technology and social media use among
children and adolescents, including healthy limits with mobile
technology use, internet safety, cyber bullying, and appropriate
parent/guardian involvement.

n. Understanding of risk factors for externalizing problems
such as school truancy, peer influence, substance use, high risk
behavior, gang involvement.

Diagnosis and Treatment Planning
o. Understanding of risk factors for internalizing problems
such as adjustment problems, anxiety, depression.

AMHCA Standards for the Practice of Clinical Mental Health Counseling
(Revised 2018) 51

p. Understanding of pre-morbid factors associated with the
development of severe and persistent mental disorders such as
schizophrenia, bipolar disorder.

q. Understanding of behaviors associated with
neurodevelopmental disorders that include autism, particularly
during crucial early developmental period (< 3 years of age).

r. Understanding of differential diagnosis for mental disorders
that can have similar presentations in children, such as anxiety
and attention-deficit/hyperactivity disorders.

s. Understanding of risk factors for suicide attempts by children
and adolescence, and differentiating suicidal from non-suicidal
self-injury.

t. Recognition of when referrals are needed for evaluation by a
psycho-pharmacologist.

u. Recognition of how psychopharmacological medication
prescribing may differ between children/adolescents and adults,
such as dosing.

v. Recognition for when consulting with school-based
professionals is indicated to inform the treatment process
when counseling children and adolescents, including school
counselors, psychologists, social workers, teachers, and other
school-based mental health professionals.

w. Understanding of specialized personality, psychopathology,
intelligence, and aptitude assessments for children and
adolescents, compared with adults.

x. Understanding of drug use among children and adolescents,
and its impact on development.

AMHCA Standards for the Practice of Clinical Mental Health Counseling
(Revised 2018) 52

Academic, Vocational, and Career Development
y. Understanding of factors associated with academic
achievement and underachievement.

z. Understanding of school-based legal rights of minors
pertinent to special education services and academic
accommodations.

aa. Understanding of career development and vocational
aspirations during childhood and adolescence, including early
career exploration, influence of social environment on career
choice, and impact of school environment on college readiness
and vocational training.

Legal and Ethical Considerations
bb. Understanding of parent/guardian rights during childhood
and adolescence, including minors independently seeking
healthcare services in the U.S. state where the counselor and
client reside.

cc. Understanding of state-based laws pertinent to adolescent
emancipation and removal of parental/guardian rights.

dd. Understanding of physical and emotional signs of child
abuse and neglect, interviewing procedures, and appropriate
steps required to report such abuse/neglect within timeframes
established by state law.

2. Skills
CMHCs must demonstrate skills in the following subject areas
specific to working with children and adolescents:

Neurophysiological Development
a. Demonstrate the ability to help children and adolescents
explore their emerging identity, including cultural, sexual,
gender, and vocational identities.

b. Implement developmentally-appropriate practices when

AMHCA Standards for the Practice of Clinical Mental Health Counseling
(Revised 2018) 53

counseling youth, such as using play therapy approaches.

c. Implement theoretical approaches that are evidence-based
practices when counseling child and adolescent clients, not
limited to, for example, parent-child interaction therapy,
cognitive-behavior therapy, multisystemic family therapy,
applied behavior analysis and video modeling (recommended
for the care of youth who have autism).

Social, Cultural, and Familial Influences
d. Demonstrate the ability to communicate respectfully and
effectively with children, adolescents, and their families,
adjusting communication style to match developmental level
and considering ethnic, racial, cultural, gender, socioeconomic,
and educational backgrounds.

e. Demonstrate sensitivity and responsiveness to the child and
adolescent’s individual and family culture, age, gender, ethnicity,
disabilities, socioeconomic background, religious beliefs, and
sexual orientation.
f. Advocate for the prevention of mental health problems
through the creation of social environments in schools and
community settings that support optimal mental health and
wellness.

g. Directly address social problems facing children and
adolescents, including intervention related to peer pressure,
bullying, gang involvement, and stigmatization.

h. Support children and adolescents in the aftermath of a crisis,
disaster, or other trauma-causing event, including deaths within
the local community; prevents contagion of suicidal behavior
through public advocacy related to media coverage and
responses (e.g., public memorials) of schools and communities.

i. Demonstrate the ability to address social problems facing
children and adolescents, including bullying, gang involvement,

AMHCA Standards for the Practice of Clinical Mental Health Counseling
(Revised 2018) 54

peer pressure, and stigma.

j. Demonstrate the ability to strengthen healthy family
functioning that impact child and adolescent development,
including, inter-parental conflict, domestic violence, parent-
child relational problems, parental/guardian over- or under-
involvement, authoritarian or passive parenting styles, and
addiction in the family.

k. Demonstrate ability to address problematic technology and
social media use by children and adolescents, including setting
healthy limits with mobile technology use, internet safety, cyber
bullying, and appropriate parent/guardian involvement.

l. Demonstrate an ability to assist youth in the development
of face-to-face and technology-based social interaction
skills, and address adverse effects of social media dominated
communication systems.

Diagnosis and Treatment Planning
m. Demonstrate the ability to assess the various presentations
of mental health disorders in children and adolescents, with
consideration for developmentally typical and atypical behavior.

n. Conduct developmentally appropriate interviewing
procedures for assessing suicide risk, homicide risk, and child
abuse/neglect.

o. Demonstrate ability to assess and treat attachment distress
and relational patterns, including attachment-based disorders.

p. Demonstrate the ability to plan treatment, including a
biopsychosocial formulation, mental status examination,
diagnosis, and psychological assessment as it pertains to
children and adolescents.

q. Demonstrate familiarity with the diverse micro, meso, and

AMHCA Standards for the Practice of Clinical Mental Health Counseling
(Revised 2018) 55

macro systems within the community that are involved in the
care of children, adolescents, and their families

r. Demonstrate the ability to effectively interface with integrated
healthcare professional and collateral sources, enlisting a
multidisciplinary approach to the treatment of children and
adolescents.

s. Demonstrate ability to effectively consult with school-based
professionals, for example school counselors, psychologists,
social workers, teachers, and school-based mental health
professionals.

t. Implement parent education programs and family therapy
when indicated.

u. Implement operant conditioning procedures when
appropriate, including behavioral modification and token
economy programs.

v. Demonstrate ability to deliver effective psychoeducation
to children, adolescents, and families that is matched to
developmental level, heeding adaptations designed for
adolescents and youth, specifically when available (for example,
DBT, CBT, etc.)

w. Demonstrate ability to form groups that are considerate of
developmental level, such as smaller sizes for younger children,
and excluding younger children in adolescent groups.

Academic, Vocational, and Career Development
x. Demonstrate the ability to assist children and adolescents
with strategies (e.g., self-efficacy, planning, organization, etc.)
to improve academic performance that is affected by clinical
diagnoses and/or concerns, for example autism and spectrum
disorder difficulties, ADHD, etc.

AMHCA Standards for the Practice of Clinical Mental Health Counseling
(Revised 2018) 56

Legal and Ethical Considerations
y. Navigate the unique legal challenges related to counseling
children, such as age of consent and assent, confidentiality,
competence, parental involvement, guardianship, and state laws
related to the reporting of child abuse/neglect.

American Mental Health Counselors Association
107 S. West St, Suite 779

Alexandria, VA 22314
info@amhca.org

703-548-6002
www.amhca.org

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