Therapist’s Guide to Clinical Intervention
The 1-2-3’s of Treatment Planning
Third Edition
SHARON L. JOHNSON
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CONTENTS
Introduction xix
Level of Patient Care and Practice Considerations xxi
Decision Tree of Evaluation and Intervention xxiii
Levels of Functioning and Associated Treatment Considerations xxiv
High-Risk Situations in Practice xxv
Treatment Plan xxvi
Solution-Focused Approach to Treatment xxvii
Case Conceptualization xxviii
Common Diagnoses and Associated Codes xxx
Behavioral Health Code Crosswalk From DSM to ICD-10 xxx
Common DSM “V” Codes xxxii
Chapter 1
TREATMENT PLANNING: GOALS, OBJECTIVES, AND INTERVENTIONS
Neurodevelopmental Disorders 2
Intellectual Disability 2 • Intellectual Disability 3 • Autism Spectrum Disorder 6
Disruptive Behavior Disorders 12
Attention-Deficit Hyperactivity Disorder and Oppositional Defiant Disorder 12
Impulse Control Disorders 20
Impulse Control Disorders 21
Separation Anxiety 24
Separation Anxiety 24
Pediatric Generalized Anxiety Disorder 27
Pediatric Generalized Anxiety Disorder 27
Feeding and Eating Disorders 31
Feeding and Eating Disorders 33 • Preventing Weight and Body Image Problems in Children 40
Recommendations for Family Members of Anorexic Individuals 41
Neurocognitive Disorders 42
Dementia 44
Neurocognitive Disorders 44
Substance-Related and Addictive Disorders 50
Substance-Related and Addictive Disorders 52 • Categories of Pharmacological Intervention 57 • Treatment Settings 58 • How to Prevent an Opioid Overdose and Opioid-Related Overdose 58 • How to Prevent an Alcohol Detox Death 58
List of Symptoms Leading to Relapse 59
Schizophrenia Spectrum and Other Psychotic Disorders 61
Schizophrenia Spectrum and Other Psychotic Disorders 62 • Summary of Treatment Recommendations for Patients With Perceptual Disturbances 67
Mood Disorders 69
Depression 70 • Depression Co-Occurring With Other Illness 75
Bipolar Disorder 75
Mania 76 • Children 79
Bipolar Disorder Hypersexuality 80
Antidepressant Medication and Other Treatment for Major Depression 81 Additional Treatment Considerations 82
Anxiety Disorders 83
Anxiety Disorders 83
Cycle of Anxiety-Provoked Emotional Distress 87
Trauma Response 88
Somatic Symptoms and Related Disorders 89
Somatic Symptoms and Related Disorders 90
Dissociative Disorders 93
Dissociative Disorders 94
Sexual Dysfunctions 98
Sexual Dysfunctions 98
Gender Dysphoria 100
Gender Dysphoria 101
Adjustment Disorders 102
Adjustment Disorders 103
Personality Disorders 105
Avoidant Personality Disorder 106 • Avoidant Personality Disorder 106 Borderline Personality Disorder 109 • Borderline Personality Disorder 109
Dependent Personality Disorder 112 • Dependent Personality Disorder 113
Histrionic Personality Disorder 115 • Narcissistic Personality Disorder 116
Narcissistic Personality Disorder 117
Obsessive–Compulsive Personality Disorder 118
Obsessive–Compulsive Personality Disorder 118 • Compulsive Personality Disorder 120
Paranoid Personality Disorder 122 • Paranoid Personality Disorder 122
Schizotypal Personality Disorder 124 • Schizotypal Personality Disorder 124
Schizoid Personality Disorder 125 • Schizoid Personality Disorder 126
Physical Factors Affecting Psychological Functioning 126
Stages of Adjustment 127
Chapter 2
ASSESSING SPECIAL CIRCUMSTANCES
Assessing Special Circumstances 131
Understanding the Individual in Crisis 132 • Understanding the Individualized Journey of Mental Illness 132
The Individualized Journey of Mental Illness 133
General Concept of Intervention 133 • Family and Community Involvement 134
Crisis Assessment 134
Crisis Assessment Outline 134 • Cognitive-Behavioral Assessment 136
Factors to Consider in Evaluating Patients for Brief Cognitive-Behavioral Therapy 137
Depression and Anxiety Screening 139 • Depression 140 • Anxiety 140
Structured Interview for Depression and Anxiety 140
Cycle of Depression and/or Anxiety: A Cognitive-Behavioral Therapy Assessment 142
Cycle of Depression and/or Anxiety: A Cognitive-Behavioral Therapy Assessment 144
Cognitive-Behavioral Therapy Individualized Assessment 144
Cognitive-Behavioral Therapy Assessment 144
Psychiatric Crisis Evaluation 144
Essential Factors to Consider 145 • The Assessment Frame 146
Risk Management 147
Danger to Self, Others, or Gravely Disabled 147
Summary of Lanterman–Petris–Short Act 148
Clarifying Risk of Harm 149 • Basic Documentation 149 Suicide 150
SAMHSA Screening Tools for Suicide 151 • Department of Health and Human Services Suicide Assessment 152 • SAFE-T: Suicide Assessment Five-Step Evaluation and Triage 152
Suicide Risk Assessment Pocket Card 153 • Look for the Warning Signs 154
Specific Factors That May Increase or Decrease Risk for Suicide 155 • Ask the Questions 156 Responding to Suicide Risk 158 • Immediate Psychopharmacological Interventions 159
Myths About Suicide 159 • Suicide Assessment Outline 160 • Motivational Interviewing 162
Adolescent Suicide 162 • Adolescent Suicide Assessment 163
ASQ: Suicide-Screening Questionnaire 165 • Tools for Suicide Assessment and Screening 166 • Treatment Focus and Objectives 166 • Depression Relapse and Suicide Risk 167
Dangerousness 168
Dangerousness Assessment Outline 169 • Forensic Psychiatrist Dangerousness and Risk Assessment (The Forensic Panel) 170 • Treatment Focus and Objectives 170 Gravely Disabled 171
Foundation of Gravely Disabled 172 • Treatment Focus and Objectives 172
Living Situation 174 • Self-Care Skills 174
• Level of Required Assistance 174
Care of Environment and Chore Responsibilities 175
Crisis Assessment 175
Guidelines for Crisis Intervention 175 • Crisis Assessment Outline 176
Crisis Assessment, Intervention, and Traumatic Exposure 178
Traumatic Stress and Physical Injury 179
Critical Incident Stress Debriefing 181 • Screening for Survivors 182
Recovering From Traumatic Stress 182
Obsessional Disorders: An Overview 182
Assessment of Obsessional Disorders 182
Obsessional Disorders Assessment Outline 183
Cycle of Phobic Anxiety 185
Assessment of Phobic Behavior 185
Phobia Assessment Outline 186
Postpartum Depression, Anxiety, and Psychosis 188
Postpartum Psychosis 190 • Breaking the Postpartum Spiral 191
Chronic Mental Illness 192
General Guidelines for Assessing the Chronic Mentally Ill 193
Self-Care Behaviors 194
Medical Crisis Assessment and Counseling 195
Treatment Framework and Conceptualization 196 • The Central Crisis Issues 197
Dealing With the Challenges of Long-Term Illness 199
Working Through the Challenges and Fears Associated With Long-Term Illness 201
Chronic Pain: Assessment and Intervention 204
Factors Affecting the Experience of Pain 205 • Clinical Interview 205
Assessing and Measuring Pain 205
The Pain Scale 206
Pain Management Diary 206
Daily Pain Diary Worksheet 207
Daily Pain Journal 207 • Interventions for Chronic Pain 209 • Six Stages of Treatment 209 • Interventions 209
Somatic Problems: A Brief Review 211
The Patient With Psychosomatic Illness Who Has an Underlying Personality Disorder 212
Eating Disorder Screening and Assessment 213
Eating Disorders Screening Questionnaire 214
The SCOFF Questionnaire 215
The SCOFF Questions 215
The Mood Eating Scale 215
Eating History 216
Checklist of Observable Eating Disorder Behaviors 217
Eating Disorder Evaluation: Anorexia 218
Eating Disorder Evaluation: Bulimia 219
Attention-Deficit Disorder 220
Adult Attention-Deficit Disorder Screening 221
Attention-Deficit/Hyperactivity Disorder Behavioral Review (Child) 224
Substance Use Screening and Assessment 225
The CAGE and CAGE-AID Questionnaire 226 • The CAGE and CAGE-AID Questions 226
Substance Use Assessment 227
Substance Use Psychological Assessment 229
Substance Use History 231
Substance Use Disorders Withdrawal 232
Withdrawal Symptoms Checklist 232
Common Postacute Withdrawal Syndrome Symptoms 233 • Coping With Postacute Withdrawal Syndrome 233
Domestic Violence 233
The Family Systems Model of Domestic Violence 234
The Cycle of Violence 235
The Domestic Violence Assessment Process 236
Indicators of Domestic Violence 236 • Core Factors of Domestic Violence Assessment 236
Risk-Identifying Instruments 237
Meeting the Patient Where They Are 238
Assessment Challenges 238 • Immediate Interventions 239 • Two Components for Assessing the Perpetrator of Domestic Violence 240
Counseling Victims of Domestic Violence 241
Objectives 242 • Intervention for Couples of Domestic Violence 242
Compulsory Psychological Evaluation Referral 243
Compulsory Psychological Evaluation 243
Psychiatric Work-Related Disability Evaluation 244
Identifying Information 244 • Description of Client at Time of Interview 244
Descriptions of Client’s Current Complaints 245 • History of Present Illness 245
Occupational History 245 • Past Psychiatric History and Relevant Medical History 245
Family History *As It Applies With Pertinence 245 • Developmental History *As It Applies With Pertinence 246 • Social History (Distinguish Prior to Disability, Disability Concurrent, After Injury) 246 • Mental Status Exam 246 • Review of Medical Record 246 • Findings From Psychological Assessment 246 • Interviews With Collateral Sources and Review of Employment or Personnel Records (Compare Description of Industrial Injury With Clients Description) 246 • ICD-10 Diagnosis With Appropriate Modifiers 246 • Summary and Conclusions 247
Functional Capacity Evaluation 248
Indications 248 • Contraindications 248
Consultive Examination 248
Consultative Examination Outline 248 • Evidence Relating to Symptoms 249
Child Abuse and Neglect 250
Prevention 250 • Indicators of Abuse 250
Child Custody Evaluation 252
Guidelines for Psychological Evaluation 252 • Bonding 253 • Ability of the Child to Bond 255 • Ability of the Parent to Bond and Other Pertinent Information 255
Parental Behavior 256 • Interaction Between Parent–Child(ren) 256
Child Custody Evaluation Report Outline 256
Attachment Study Versus Custody Evaluation 257
Parental Alienation Syndrome 258
Parental Programming 258 • Subtle and Unconscious Influencing 259
Child’s Own Scenarios 259 • Family Dynamics and Environment/Situational Issues 259
Six Signs of Parental Alienation Syndrome 260 • Three Categories of Parental Alienation 260
Criteria for Establishing Primary Custody 262
Basis for Family Court Child Custody Recommendations 262
Behaviors of the Parents 263 • Children and Custody 265
Preparing a Parent for Child Custody Evaluation Process 266
Preparing Parents for the Child Custody Evaluation: A Checklist of Do’s and Don’ts 268
Evaluation and Disposition Considerations for Families Where Parental Alienation Occurs 269
Questions to Ask Children 269 • Questions to Ask the Parents 270
Parental Alienation Syndrome Intervention 270
Visitation Rights Report 272
Visitation Rights Report Outline 272
Dispositional Review: Foster Placement; Temporary Placement 272
Dispositional Review Report Outline 273
Learning Disabilities Assessment and Evaluation 275
Role of Legislation 276
Differential Diagnosis (Learning Disabilities vs. Other Conditions) 276
Chapter 3
SKILL BUILDING RESOURCES FOR INCREASING SOCIAL COMPETENCY
What Is Stress? 279
Stress Review 281 • Stress Toolbox 281
Stress Management 283
Early Warning Signs of Stress 285 • Stress Signals 285 • Stress Busting—Five Quick Tips 286
Effective Management of Stress 286
Critical Problem Solving 287 • Assertiveness 287 • Conflict Resolution 287
Time Management 287 • Self-Care 287
Tips for Stress Management 288
Simplifying Life as a Means to Decrease Stress 289
Ten Rules for Emotional Health 290
Individualized Time Management for Decreasing Stress 290
Self-Care Plan 291
How to Get the Most Out of Your Day 292
Relaxation Exercises 293
Deep Breathing (5 Min) 293 • Mental Relaxation (5–10 Min) 293
Tensing Muscles (5–10 Min) 294 • Mental Imagery (10–15 Min) 294
Brief Relaxation (5–10 Min) 295 • Brief Progressive Muscle Relaxation 296
Progressive Muscle Relaxation (20–25 Min) 296 • Preparing for the Provocation 298
It’s Time to Talk to Yourself 299 • A Guide to Meditation (The Time for Meditation Is Decided by the Individual) 299
Managing Depression and Anxiety 300
The Overlap Between Depression and Anxiety 301 • Eight Steps of Taking Responsibility 302
Using a Mood and Thought Chart as a Management Tool 302
Depression Symptom Checklist 303
Managing Depression 304
Challenging Depression 305
Decreasing the Intensity of Depression 305 • Breaking the Depression Cycle 306
Surviving the Holiday Blues 307
What Is Mania? 308
10 Points for Managing Mania 309
Anxiety Symptom List 310
Decreasing or Eliminating the Intensity of Anxiety Symptoms 311
25 Ways to Relieve Anxiety 312
Managing Anxiety 313
Improving Anxiety Management Effectiveness 314
Dealing With Fear Associated With Anxiety 314
Stopping the Anxiety Cycle 315
Plan of Action for Dealing With Anxiety 315
Relapse—Symptom Reoccurrence 317
Intervening in the Relapse Cycle 317
Warning Signs of Relapse 318
Systematic Desensitization 319
The Ten Steps of Systematic Desensitization 319
What Is Panic Anxiety? 320
Symptoms of Panic Anxiety 321 • Defeating Panic Attacks 321
Exposure Therapy 322
Effective Coping Strategies for Defeating Panic Attacks 324 • Making My Own Toolbox for Defeating Panic Attacks 325
Posttraumatic Stress Disorder 325
What Is Posttraumatic Stress Disorder? 325
Treating Posttraumatic Stress Disorder 328
Defeating Posttraumatic Stress Disorder 329
Stabilization and Grounding Techniques 329 • Identifying Triggers 330
Avoidance and Safety Behaviors 331 • Learning to Breath (Equal Effort Breathing In and Out) 331 • Learning What Works and What Doesn’t—Refining Information to Use in Your Personal Posttraumatic Stress Disorder Toolbox 332
Making My Own Posttraumatic Stress Disorder Toolbox 332
Substance Abuse, Relapse, and Codependency 334
Substance Abuse 334 • List of Symptoms Leading to Relapse 335
Working a Program and Making My Recovery Toolbox 336
Enabling and Codependency 337
What Is Codependency? 337
The Classic Situation 338
Some Characteristics of Codependence 338
The Rules of Codependency 339
How Does Codependency Work 339
How Codependency Affects One’s Life 341
The Enabler—The Companion to the Dysfunctional/Substance-Abusing Person 341
Characteristics of Adult Children of Alcoholics 343
Symptoms/Effects in Children of Codependents 344
Challenging Codependency 344
Guidelines for Family Members/Significant Others of Alcoholic/Chemically Dependent Individuals 345
Stages of Recovery 346
Detaching With Love Versus Controlling 346
Personality Disorders 347
The Relationship Between a Person Who Has a Personality Disorder and a Person Who Doesn’t (Nonpersonality Disorder) 347
Making My Own Toolbox 347 • Landmines in Personality Disorder Relationship 347
Toolbox for the Nonpersonality-Disordered Individual and Coping in a Relationship With a Personality-Disordered Individual 348
Making My Own Toolbox 348
Personality Disorder Toolbox 349
Making My Own Toolbox 349
Dementia 350
Ten Warning Signs of Alzheimer Disease 351 • Preparing for a Doctor Visit 352
Caregiver Education 352
Caregiving of Elderly Parents 352 • Common Problems Experienced by Caregivers 355 Effective Coping Strategies for the Caregivers 355 • Advice for Others Close to the Situation 355
Ten Warning Signs of Caregiver Stress 356
Mental Health Crisis Planning 356
Developing a Wellness Recovery Program (Lifestyle and Self-Care) 356
Your Social Support Network 356 • A New Beginning: Getting Started 357
Six-Part Action Plan 358 • Surviving the Crisis—What to Do After a Mental Health Crisis 359
Recovering From a Mental Health Crisis 361
Things to Do When You Are Feeling Better 361 • Regaining Control of Your Life 362
Suicide 362
Confronting and Understanding Suicide 362 • Suicide Warning Signs (www.cdc.gov) 363
Level of Suicide Risk (www.cdc.gov) 364 • Supporting a Suicidal Person 364
Feeling Overwhelmed and Desperate 365
Feeling Like Your Life Is Out of Control 366
Loneliness 368
General Management Skills 369
Emotional First Step 369 • Guidelines for Completing Your First Step Toward
Emotional Health 369
Building a Strong Support System 372
Developing and Utilizing Social Supports 372 • Characteristics of a Supportive Relationship 372
How to Build and Keep a Support System 373
Self-Monitoring Checklist 374
Management Behaviors 374 • Daily Activities 375
Daily Activity Schedule 376
Challenging Negative and Irrational Self-Talk 377
Rational Thinking 377
Thinking Distortions 379
Realistic Self-Talk 379
Thought Stopping 380 • Reframing 381 • Steps to Successful Reframing 382
Practice Reframing How You Interpret Situations 383
Defense Mechanisms 383
Defense Mechanism Definitions 384
Defense Mechanisms 384
Overcoming Worry 385
Anger Management 387
Anger 101 387 • Understanding Anger 387 • Consequences for Not Expressing Anger 389 Stuck on Anger 389 • Anger and Self-Responsibility 390 • Steps of Anger Management 390 Decrease the Intensity of Anger 392 • Letting Go of Anger 393
How to Handle Angry People 393
Boundaries 394
Defining Boundaries 394
Establishing Healthy Boundaries 395
The Consequences of Unhealthy Boundaries and Healthy Boundaries 396
Marital Boundaries 397
Death of a Marriage 399
Assertive Communication Defined 400
Personal Bill of Rights 400
Assertiveness Inventory 401
Assertiveness Checklist 402
Assertive Communication 403
The Steps of Positive Assertiveness 404 • Practicing Assertive Responses 405
The Consequences of “No” 405
Ten Ways of Responding to Aggression 406
Building Self-Esteem 407
Characteristics of Self-Esteem 407
The Self-Esteem Review 407
Characteristics of Low Self-Esteem 408
Low Self-Esteem 410
Ten Self-Esteem Boosters 411
Affirmations for Building Self-Esteem 412
Self-Nurturing: A Component of Self-Esteem 412
Characteristics of High Self-Esteem 413
Self-Confidence 414
Building Self-Confidence 414
Programming Self-Confidence (Richard Bandler, Alessio Roberti, and Owen Fitzpatick) 415
How to Take Charge of Your Life: The User’s Guide to NLP 415
Personal Empowerment 416
Resilience 417
Resilient Living 417 • Raising Resilient Children 418
Self-Determination 421
Building Self-Advocacy Skills in Children 422
Goals and Motivation 423
What Motivates Me? 423 • Questions to Ask Yourself 423 • Setting Priorities 424 Steps for Setting Priorities 424
Journal Writing 424
Self-Monitoring 426
Goal Development 426 Steps for Developing Goals 426
Goal Setting 427
Accomplishments 428
Strengths 428
Resources 429
Problem Solving 429
Preparing to Learn Problem-Solving Skills 429 • Managing Interaction During Problem Solving 429 Developing Good Problem-Solving Skills Equips Individuals to 430 • Stages of Problem Solving (As Therapist Facilitates Skill Development in Individual) 430 • Steps for Problem Solving 430
Problem-Solving Process 430
Assignment 1 431
Sample Problems 431
Assignment 2 432
Assignment 3 432
Risks 432
Decision Making 433 Steps for Decision Making 433
Time Management 434
Four Central Steps to Effective Time Management 434 • Starting Your Time Management Program 434
Examples of Individualized Time Management Options 435
Mindfulness 435
How to Practice Mindfulness 436
Planning 437 • Posture 437 • Thoughts 437 • Breathing 437
Seven Basic and Easy Mindfulness Exercises 437
Dealing With Loss and Grief 438
Adjusting/Adapting: Life Changes 438 • Adjusting/Adapting: Developmental Perspective 439
Learning History 440
Losses/Opportunities 441
Grief 441
Never Happened 442 • Bargaining 443 • Depression 443 • Acceptance 443
What Is Meant by Resolving Grief/Loss? 444 • Common Symptoms of Grief 444
What Are the Myths of Dealing With Loss? 445
Grief Cycle (Where Are You Stuck?) 446
Definition: The Natural Emotional Response to the Loss of a Cherished Idea, Person, or Thing 446
History of Loss Graph 446
Coping With Loss and Grief 447
Losing a Family Member or Friend to Suicide 448
Physical Health 450
Health Inventory 450 • Assessing Lifestyle and Health 451
Assuming the Patient Role: The Benefits of Being Sick 452
Improving Your Health 453
Sleep 455
Sleep Disorders 455 • Treatment Focus and Objectives 455
Ten Tips for Better Sleep and Recovery 455
Eating and Nutrition 457
Eating History 457
Stop Using Food as a Coping Mechanism 457
Preventing Weight and Body Image Problems in Children 458
Obsession With Weight 459 • Obesity and Self-Esteem 459 • What Parents Can Do 459
Guidelines to Follow if Someone You Know Has an Eating Disorder 460
Relationships 460
Relationship Questionnaire 460
Healthy Adult Relationships: Being a Couple 461
Improved Coping Skills for Happier Couples 462
Evaluate the Problem 462
Couple’s Conflict: Rules for Fighting Fair 463
Problem Resolution 464
Be Clear About What You Want 465
Domestic Violence 466
How to Predict the Potentially Violent Relationship 466
Domestic Violence: Safety Planning 467
Most Important to Remember 468 • Document the Abuse 468 • Find a Safe Place to Go 468
Create a Safe Room in Your Home 468 • Have Money and Keys 469
Chapter 4
Create a File With Your Important Documents (If You Are Taking Your Children, Also Put Their Documents) 469 • Pack a Suitcase 469 • Know When and How to Leave 470
Why Victims of Domestic Violence Struggle With Leaving 470
Surviving Divorce 471
Self-Care 471
Letting Go of the Past 472
Families and Children 472
Parenting a Healthy Family 472
Creating Effective Family Rules 472 • Effective Coparenting 473 • Maintain the Parent Role 473 • Be an Active Parent 473 • A Healthy Family Means All of Its Members Are Involved 473 • Encourage Communication 474
Guiding Your Child to Appropriately Express Anger 474
The Family Meeting 475
Guidelines for the Family Meeting 476 • Developing Positive Self-Esteem in Children and Adolescents 476
Family Facing a Crisis 477
What Happens During a Crisis 478
Understanding and Dealing With Life Crises of Childhood 478
Crisis Resolution 479
Helping a Child Deal With a Crisis 479
Your Child’s Mental Health 481
Warning Signs of Teen Mental Health Problems 481
Talking to Children 483
Demonstrating Respect 483 • Rules for Listening 484 • Rules for Problem Solving and Expressing Your Thoughts and Feelings to Children 484 • Do’s 484 • Don’ts 485
Boundaries With Children 485
Guidelines for Discipline That Develops Responsibility 486
Helpful Hints 486
Children Surviving Divorce 487
The Children’s Bill of Rights in a Divorce 488 • Parent-Centered Structure 489
Helping Children Cope With Scheduling Changes 489
Is Your Behavior in the Best Interest of Your Children? 490
Successful Stepfamily Characteristics 491
Honor 492 • Validation 492 • Respect 492 • Responsibility 492
Communication 492 • Discipline 492
PROFESSIONAL PRACTICE FORMS CLINICAL FORMS BUSINESS FORMS
Clinical Forms 495
Case Formulation 497
General Consult Information 497
Initial Patient Evaluation Consultation Note to Primary Care Physician 498
Brief Consultation Note to Physician 500
General
Evaluation 500
Treatment Plan 502
Difficulties Experienced 503
Mental Status Exam 505
Mental Status Examination Content 505
Mental Status Exam 507
Brief Mental Status Exam Form 508
Mental Status Exam 509
Initial Case Assessment 511
Initial Evaluation 513
Brief Mental Health Evaluation Review 514
Life History Questionnaire 516
Please Completely Fill Out the Following Pages 516
Adult Psychosocial 524
Family History 525 • Drug and Alcohol Abuse 526 • Educational History 526
Employment History 526 • Socialization Skills 526
Summary 527
Treatment Plans and Recommendations 527
Child/Adolescent Psychosocial 528
Identifying Information 528 • Chief Complaint 528 • Psychosocial History 529
Current Family Situation 529 • Child Health Information 531 • Developmental History 532
Developmental Milestones 532 • Early Social Development 533 • Educational History 533
Academic Performance 533 • Additional Comments 534
Parent’s Questionnaire 536
Question 536
Self-Assessment 538
Chief Complaint (Check All That Apply to You) 538
Brief Medical History 539
Illnesses and Medical Problems 540
Medical Review Consult Request for Primary Care Physician of an Eating Disorder Patient 541
Substance Used and Psychosocial Questionnaire 542
Treatment History 543 • Family History 543 • Social History 544 • Medical Problems 545
Chemical Dependency Psychosocial Assessment 546
Brief Consultation Note to Physician 549
Outpatient Treatment Progress Report 550
Progress Note for Individual With Anxiety and/or Depression 553
Clinical Notes 555
Outline for Diagnostic Summary 556
Diagnostic Summary 556
Discharge Summary 558
Reports Associated With Disability or Workers’ Compensation 559
Disability/Worker’s Compensation 559
Social Security Evaluation Medical Source Statement, Psychiatric/Psychological 560
Worker’s Compensation Attending Therapist’s Report 561
Progress 561 • Treatment 561 • Work Status 561 • Disability Status 562
Brief Psychiatric Evaluation for Industrial Injury 563
Treatment Progress and Prognosis 564 • Alcohol and Drug Abuse 564
Current Work-Related Skills 564
Brief Level of Functioning Review for Industrial Injury 566
Business Forms 571
Patient Registration 573
Insured/Responsible Party Information 573 • Office Billing and Insurance Policy 573
Contract for Services Without Using Insurance 575
Fee Agreement for Deposition and Court Appearance 575
Limits on Patient Confidentiality 577
Release of Information 577
Treatment Contract 578
Contract for Group Therapy 579
Authorization for the Release or Exchange of Information 580
Pediatric Patient Registration 581
Client Information 581 • Clinical Intake Form (for Children) 584
Release for the Evaluation and Treatment of a Minor 589
Client Messages 590
Affidavit of the Custodian of Mental Health Records to Accompany Copy of Records 591
Referral for Psychological 592
Psychiatric History 592
Release to Return to Work or School 594
Notice of Discharge for Noncompliance of Treatment 595
Duty to Warn 596
Missed Appointment 597
Receipt 598
Receipt 598
Receipt 599
Receipt 599
Balance Statement 600
Client Satisfaction Survey 601
Form for Checking Out Audio CDS, DVDS, and Books 603
Mental Health Record Review 604
Chart Content Review 604
References 607
Index 627
INTRODUCTION
THIS third edition, like the first and second, is intended to serve as a comprehensive resource tool. Behavioral health industry changes continue to evolve with the development of evidence-based treatment, DSM 5, electronic health care records, telepsychology, and the documentation transition for clinicians to the diagnostic coding of the ICD-10 system of the World Health Organization. Regardless of the continuing evolution, the clinician providing behavioral health services operates within a formal ethical framework. It is likely that no other health treatment is so stringently founded on privacy and confidentiality than psychotherapy. Providing behavioral health interventions is a complex process that takes into consideration evidence-based practices, multifaceted individualized aspects of the individual, and institutional demands of the insurance industry.
Clinicians are sensitive to the needs of the individual, and the Therapist’s Guide to Clinical Intervention provides best practice interventions in an easy-to-use manner that provides the clinician the evidence-based treatment necessary to meet the patient where they are while respectfully incorporating personal need/desire, time, and resources. Case management demands continue to increase with documentation being more important than ever resulting in potentially more indirect service required by the clinician. Additionally, the consumer has become more sophisticated—often inquiring about the type(s) of interventions a clinician uses, thus making commensurate educated decisions regarding the type of therapy they are seeking for a specific problem. Therefore, in many cases, both the consumer of services and the contractor of services expect the therapist to provide refined diagnostic skills, brief evidence-based treatment planning with defined goals and objectives, crisis intervention, case management with collateral contacts, contracting with the client for various reasons, and discharge planning that is well documented and research supported. The Therapist’s Guide to Clinical Intervention facilitates the ease of accomplishing these expectations by combining the aforementioned significant aspects of practice. All of this is provided in a single resource, versus a considerable number of review texts necessary to encompass a commensurate amount of information.
The third edition of the Therapist’s Guide to Clinical Intervention has retained the original format while updating organization to improve utility and evidence-based treatment supported by a thorough literature review. Changes in the DSM 5 played a role in both the organization associated with diagnostic categorization as well as diagnostic criteria. However, from a common sense perspective, specifically with regards to pediatrics, there was a break from DSM 5. The divergence in no way interferes with treatment planning, but it did increase ease of developmental clinical treatment planning and intervention with maximum ease of utilization. Additionally, the third edition will be structured into four sections consistent with prior editions.
The first chapter of the book is an outline of evidence-based cognitive behavioral treatment planning. This organization of goals and objectives associated with specific, identified problems supports thoroughness in developing an effective intervention formulation that is individualized to each client. The treatment planning section was designed to be user-friendly and to save time. There is a list of central goals derived from identified diagnostic symptoms and the associated treatment objectives for reaching those goals from a cognitive behavioral perspective. It goes without saying that not all individuals or diagnoses are amenable to brief therapy interventions. However, cognitive behavioral interventions can still be very useful in the limited time frame for developing appropriate structure and facilitating stabilization. Often the brief intervention will be used as a time for initiating necessary longer-term treatment or making a referral to an appropriate therapeutic group or psychoeducational group.
The second chapter of the book offers a framework for assessing special circumstances, such as those involving a danger to self, danger to others, danger to the gravely disabled, spousal abuse/domestic violence, and so forth. Additionally, this section offers numerous report outlines for various assessments with a brief explanation of their intended use. The assessment outlines provide a thorough, well-organized approach resulting in the clinical clarity necessary for immediate intervention, appropriate referrals, and treatment planning. The goal is to save the general clinical practitioner time needed for direct services by providing adaptable assessment formats to fulfill the demand of a variety of clinical demands.
The third chapter of the book offers skill-building resources for increasing client competency. The information in this section is to be used as an educational resource and as homework related to various issues and needs presented by clients. This information is designed to support cognitive behavioral therapeutic interventions, to facilitate the client’s increased understanding of problematic issues and to serve as a conduit for clients to acknowledge and accept their responsibility for further personal growth and self-management. Skillbuilding resources, whether offered verbally or given in written form, promote the use of client motivation between sessions, enhancing goal-directed thoughts and behaviors.
The fourth chapter of the book offers a continuum of clinical/business forms. The time-consuming endeavor of creating forms is eliminated by the presentation of basic forms necessary for a clinical practice. Some of the forms have only minor variations due to their specificity, and in some cases they simply offer the therapist the option of choosing a format that better suits his or her professional needs. Many of the forms can be utilized as is, directly from the text. However, if there is a need for modification to suit specific or special needs associated with one’s practice beyond what is presented, having the basic framework of such forms continues to offer a substantial time-saving advantage. This text is a compilation of the most frequently needed and useful information for the time-conscious therapist in a general clinical practice.
To obtain thorough utilization of the resources provided in this text, familiarize yourself with all of its contents. This will expedite the use of the most practical aspects of this resource to suit your general needs and apprise you of the remaining contents, which may be helpful to you under other, more specific circumstances.
While the breadth of the information contained in this book is substantial, each user of this text must consider his or her own expertise in providing any services. Professional and ethical guidelines require that any therapist providing clinical services be competent and have appropriate education, training, supervision, and experience. This would include a professional ability to determine which individuals and conditions are amenable to brief therapy and under what circumstances. There also needs to be knowledge of current scientific and professional standards of practice and familiarity with associated legal standards and procedures. Additionally, it is the responsibility of the provider of psychological services to have a thorough appreciation and understanding of the influence of ethnic and cultural differences in one’s case conceptualization and treatment and to see that such sensitivity is always utilized.
